Invisible Agency is a sociological work in a specific medical domain, that of dialysis in Taiwan, that forms a set of local knowledge. The author has been in this field of study for more than two decades and continually prompts new theoretical reflections with his empirical observations. The book covers a wide range of issues and detailed information about users of dialysis technology, including both hemodialysis (HD) and peritoneal dialysis (PD), as well as their situations and environments. In this book, readers may witness how the invisible HD and PD community is made visible by the author’s “translation” in the academic sense. Published by the Institute of Sociology, Academia Sinica, the leading organization in sociological research in Taiwan, Invisible Agency reflects the domestic sociological community’s changing attitude toward actor-network theory (ANT), a theoretical framework previously not widely accepted by Taiwanese sociologists.
The book consists of eight chapters. The first sets up a basic framework by presenting the author’s motivations for his long-term research, as well as his data collection methods. Chapter 2 discusses relevant theories in a wider scope, covering various perspectives from different disciplines. Chapter 3 enters into ontological issues, and chapters 4 and 5 review some accounts of the everyday lives of HD and PD users. Moving away from individual strategies, chapter 6 shifts to the group level, examining types of collective action such as formation of patient associations. Chapter 7 describes how the subaltern agency of medical technology users changed the evolution of medical institutions. Finally, chapter 8 is an extended conclusion in which the author offers theoretical reflection and some prospects for the future.
Medical sociology in Taiwan once paid closer attention to doctor-patient relationships, health care institutions, and policy evolution. Thus, most domestic research falls into the structure-agency binary, with special emphasis on the structural side. Moreover, such research used to ignore the technological dimensions or simply put them in a black box, as it were. Inspired by ANT, Lin’s book opens that black box of technology, considering it as an important element of capability in action for both patients and organizations. The technological details are described in comprehensible language for readers, as it is an important part of the ordinary lives of patients rather than of scientists or doctors. According to Lin, some technologies are provided for categorizing agents, and some for characterizing practical procedures; such categories and procedures are also constituents of institutions, so institutions are the practical outcome of heterogeneous or even hybrid interactions among human and nonhuman agents.
Lin argues that there are two levels of agency dynamics in Invisible Agency: the practical level and the institutional level. At the practical level, patients’ agency is situated within an institutional environment where displacement in clinical dialysis and everyday lives takes place. Displacement refers to the action in which a patient transfers his or her interest, attention, and concerns from one area to another, to exercise his or her agency. Lin offers an example to discuss the relationship between patients’ displacement and their agency (180–81): A patient was asked by nurses to reduce water consumption that might have contributed to the frequent failure in her dialysis practice. The patient followed the instruction but did not improve her dialysis. After that, the patient turned to control her diet, as suggested by a Chinese medicine practitioner, so as to change her bodily condition. It worked. To Lin, the patient successfully made a displacement by identifying her bodily condition as the major factor to improve her dialysis, instead of water consumption. The collective effect of displacement contributes to institutional change, the dynamics at the institutional level. What the author calls “driftworks ontology” is possible only when these displacements interact with each other, and very often, it is those at the “weak” practical level that contribute the most to the evolution of the “strong” collective level.
According to Lin, there are three types of displacement throughout this research. The first displacement is from the academic world to various fields where a variety of practical experiences exist beyond scholastic imaginations. The second is the progression from one perspective to another, following the author’s steps in different fields, from the world of patients to that of policy makers. The third is at the theoretical level: his study shifts its theoretical standpoint from occidental to oriental, from central to marginal, from colonizing to colonized, and from strong to weak.
Chapters 3–6 are impressive ethnographic field studies. Interspersed are various actors’ accounts and the author’s field notes, including technological sheets, photos, and diagrams showing how agents and technology interact with one another. The chapters reveal realistic, detailed actions of actors in their daily lives, like motion pictures captured by a video camera.
While Lin has said that “we have never been latecomers” (Lin and Law 2015), Taiwanese HD and PD patients are in a latecomer situation. They are technology users rather than innovators. They are dominated by technology not only because of their technology-dependent health conditions but also because of their social and institutional positions that are subordinated by technocracy. To uncover the real situations of the patients, Lin uses a patient-oriented strategy. This strategy is, however, different from that of Certeau (1984), who explored communities in Lyon, France, and proposed the idea of “the invention of everyday life.” Certeau’s idea was that laypeople have their tactics against the social institutions that subordinate them; the patient-oriented approach is different: patients are agents whose actions coevaluate the institutions via their invisible power.
These HD and PD patients are also different from the participants in the American AIDS movement. Epstein (1996) calls that movement a “credibility struggle” because lay outsiders engaged actively in collective actions that pushed the scientific community to develop effective AIDS treatments. Even though they had no power over the discourse in the scientific world, lay outsiders utilized the visible power of their activism to transform the institutions they needed to reach.
The invisible power of dialysis agency is neither the Foucauldian knowledge-power regime nor hegemonic power. To reflect the real situation of Taiwanese dialysis users, Lin borrows Spivak’s postcolonial concept. This gives the patients a theoretical position—that of subaltern, a critical term in the analysis of invisible power. And Lin also utilizes oriental elements in his study. For example, when talking about power, he uses the phrase “to deal with a man in the way he deals with you” (以其人之道還治其人之身). This kind of power is invisible but powerful. Moreover, it fits well with the notion of displacement, indicating that force is transferable from one agency to another.
Invisible Agency is written in Chinese—it is Lin’s native language, and the field of study is Taiwan. Fortunately, Lin has also published some English-language articles in prestigious STS journals (Lin 2013; Lin and Law 2015), which can help non-Chinese readers access the spirit of this book. However, this also raises a problem: should Taiwanese domestic experiences be written in a European language for better comprehension?
ANT approaches often evolve into a position contrary to the ontology of a presupposed society. Even so, it still sits within the genealogy of the occidental intellectual tradition, proposed by the request of scientific, legal, political, and social institutions characteristic of Western civilization. Users of dialysis technology in Taiwan are often ignored by technology innovators, who are mostly scientists and engineers in the global North. These users are in a situation that cannot be directly analyzed by ANT. Therefore, they are doubly marginalized. They are technological subalterns, as well as theoretical subalterns.
Invisible Agency also suffers from a double marginalization of language: communicative (Chinese rather than English) and theoretical (mostly subordinated by theories and models proposed by Western scholars). With regard to this double marginalization, Lin further emphasizes that a new worldview based on domestic experience is required. A new perspective based on the idea of “provincializing STS” has thus been proposed (Law and Lin 2017). This means that new terms that can better describe local situations must be used in any new domestic research.
Tzung-wen Chen is associate professor in the Department of Sociology at National Chengchi University. His major interests are the social, economic, and political aspects of biomedical technology, the governance of technoscience, and the theorization of innovations.