The trouble with brain imaging: Hope, uncertainty and ambivalence in the neuroscience of autism

The UK COVID-19 contact tracing app as both an emerging technology and public health intervention: The need to consider promissory discourses

The UK's National Health Service (NHS) COVID-19 contact tracing app was announced to the British public on 12th April 2020. The UK government endorsed the app as a public health intervention that would improve public health, protect the NHS and 'save lives'. On 5th May 2020 the technology was released for trial on the Isle of Wight. However, the trial was halted in June 2020, reportedly due to technological issues. The app was later remodelled and launched to the public in September 2020. The rapid development, trial and discontinuation of the app over a short period of a few months meant that the mobilisation and effect of the discourses associated with the app could be traced relatively easily. In this paper we aimed to explore how these discourses were constructed in the media, and their effect on actors - in particular, those who developed and those who trialled the app. Promissory discourses were prevalent, the trajectory of which aligned with theories developed in the sociology of expectations. We describe this trajectory, and then interpret its implications in terms of infectious disease public health practices and responsibilities.

Beyond the hype: 'acceptable futures' for AI and robotic technologies in healthcare

AI and robotic technologies attract much hype, including utopian and dystopian future visions of technologically driven provision in the health and care sectors. Based on 30 interviews with scientists, clinicians and other stakeholders in the UK, Europe, USA, Australia, and New Zealand, this paper interrogates how those engaged in developing and using AI and robotic applications in health and care characterize their future promise, potential and challenges. We explore the ways in which these professionals articulate and navigate a range of high and low expectations, and promissory and cautionary future visions, around AI and robotic technologies. We argue that, through these articulations and navigations, they construct their own perceptions of socially and ethically 'acceptable futures' framed by an 'ethics of expectations.' This imbues the envisioned futures with a normative character, articulated in relation to the present context. We build on existing work in the sociology of expectations, aiming to contribute towards better understanding of how technoscientific expectations are navigated and managed by professionals. This is particularly timely since the COVID-19 pandemic gave further momentum to these technologies.

‘Braining’ psychiatry: an investigation into how complexity is managed in the practice of neuropsychiatric research

Neuropsychiatry searches to understand mental disorders in terms of underlying brain activity by using brain imaging technologies. The field promises to offer a more objective foundation for diagnostic processes and to help developing forms of treatment that target the symptoms of a specific mental disorder. However, brain imaging technologies also reveal the brain as a complex network, suggesting that mental disorders cannot be easily linked to specific brain areas. In this paper, we analyze a case study conducted at a neuropsychiatry laboratory to explore how the complexity of the human brain is managed in light of the project of explaining mental disorders in terms of their neurological substrates. We use a combination of ethnomethodology and conversation analysis to show how previously assigned diagnostic labels are constitutive of interpretations of experimental data and, therefore, remain unchallenged. Furthermore, we show how diagnostic labels become materialized in experimental design, in that the linking of symptoms of mental disorders to specific brain areas is treated as indicative of successfully designed experimental stimuli. In conclusion, we argue that while researchers acknowledge the complexity of the brain on a generic level, they do not grant this complexity to the brains of individuals diagnosed with a mental disorder.

'Not at the diagnosis point': Dealing with contradiction in autism assessment teams

Social science literature has documented how the concept of diagnosis can be seen as an interactive process, imbued with uncertainty and contradiction, which undermines a straightforward notion of diagnosis as a way to identify underlying biological problems that cause disease. We contribute to this body of work by examining the process of resolving contradiction in autism diagnosis for adults and adolescents. Autism is a useful case study as diagnosis can be a complex and protracted process due to the heterogeneity of symptoms and the necessity to interpret behaviours that may be ambiguous. We audio-recorded and transcribed 18 specialist clinical assessment meetings in four teams in England, covering 88 cases in two adult, one child and one adolescent (14+) setting. We undertook a qualitative analysis of discursive processes and narrative case-building structure utilised by clinicians to counteract contradiction.We identified a three-part interactional pattern which allows clinicians to forward evidence for and against a diagnosis, facilitates their collaborative decision-making process and enables them to build a plausible narrative which accounts for the diagnostic decision. Pragmatism was found to operate as a strategy to help assign diagnosis within a condition which, diagnostically, is permeated by uncertainty and contradiction. Resolution of contradiction from different aspects of the assessment serves to create a narratively-coherent, intelligible clinical entity that is autism.

Drawing a line in the sand: affect and testimony in autism assessment teams in the UK

Diagnosis of autism in the UK is generally made within a multidisciplinary team setting and is primarily based on observation and clinical interview. We examined how clinicians diagnose autism in practice by observing post-assessment meetings in specialist autism teams. Eighteen meetings across four teams based in the south of England and covering 88 cases were audio-recorded, transcribed and analysed using thematic analysis. We drew out two themes, related to the way in which clinicians expressed their specialist disciplinary knowledge to come to diagnostic consensus: Feeling Autism in the Encounter; and Evaluating Testimonies of Non-present Actors. We show how clinicians produce objective accounts through their situated practices and perform diagnosis as an act of interpretation, affect and evaluation to meet the institutional demands of the diagnostic setting. Our study contributes to our understanding of how diagnosis is accomplished in practice.

Managing risks or generating uncertainties? Ambiguous ontologies of testing in Australian healthcare

Medical testing promises to establish certainty by providing a definitive assessment of risk or diagnosis. But can those who rely on tests to offer advice or make clinical decisions be assured of this certainty? This article examines how Australian health professionals, namely clinicians, microbiologists, specialist physicians and health policymakers, delineate the boundary between certainty and uncertainty in their accounts of medical testing. Applying concepts from science and technology studies, and drawing on qualitative data from a sociological study of testing in Australian healthcare, we consider how professionals ascribe meaning to testing and test results. As we argue, for these health professionals, the 'evidence' that testing generates has ambiguous ontological significance: while it promises to provide diagnostic certainty and clear direction for advice or treatment, it also generates uncertainties that may lead to yet further tests. Our analysis leads us to question a key premise of testing, namely that it is possible to establish certainty in medical practice via the measurement of individual health risks and disease markers. Against this dominant view, the responses of the health professionals in our study suggest that uncertainty is intrinsic to testing due to the constantly changing, unstable character of 'evidence'. We conclude by considering the implications of our analysis in light of healthcare's increasing reliance on sophisticated technologies of 'personalised' testing using genetic information and data analytics.

Autism Scientists' Reflections on the Opportunities and Challenges of Public Engagement: A Qualitative Analysis

This article draws upon qualitative interviews in order to examine how UK based research psychologists understand public engagement activities and interactions with autistic advocates. Researchers describe public engagement as difficult and understand these difficulties as stemming from autistic impairments. In particular, it is reported that a heterogeneity of autism impairments means there is little agreement on the form research should take, while socio-communicative impairments make interactions difficult. Conversely, researchers describe autistic individuals as having the capacity to positively influence research. In this paper we discuss the nature of these claims and stress the need for autism-specific modes of engagement to be developed.

Failing, hacking, passing: Autism, entanglement, and the ethics of transformation

One of the most notable recent changes in autism science is the belief that autism is a heterogeneous condition with no singular essence. I argue that this notion of 'autistic heterogeneity' can be conceived as an 'agential cut' and traced to uncertainty work conducted by cognitive psychologists during the early 1990s. Researchers at this time overcame uncertainty in scientific theory by locating it within autism itself: epistemological uncertainty was interwoven with ontological indeterminacy and autism became heterogeneous and chance like, a condition determined by indeterminacy. This paper considers not only the conceptual significance of this move but also the impact upon forms of subjectivity. This analysis is undertaken by integrating the agential realism of Karen Barad with the historical ontology of Michel Foucault. I argue that these two approaches are, firstly, concerned with ontologies of emergence and, secondly, foreground the inherently ethical nature of change. As such these theories can be used to articulate an 'ethics of transformation'. I argue that the agential cut which brought about autistic heterogeneity is potentially problematic within an ethics of transformation, limiting the possibility of future change in subjectivity by imagining difference and resistance as properties of autism rather than the individual.

Expectant futures and an early diagnosis of Alzheimer's disease: Knowing and its consequences

Efforts to diagnose Alzheimer's disease (AD) at earlier stages as a means to managing the risks of an ageing population, dominate scientific research and healthcare policy in the UK. It is anticipated that early diagnosis will maximise treatment options and enable patients to 'prepare for their future' in terms of care. Drawing on qualitative data gathered across an out-patient memory service and in-patient hospital in the UK, the purpose of this paper is to examine the ways in which the hopeful promissory claims of early diagnosis as it maintains the dominant biomedical model for managing AD, are negotiated by healthcare practitioners. Developing the analytical standpoint of the sociology of expectations, this paper demonstrates that early diagnosis has the potential to 'close off' hopeful promissory visions of the future in two ways. Firstly, it (re)produces the fearful anticipations of AD built around expectations concerning the ageing future 'self', and secondly it produces uncertainty in terms of the availability of care as material resource. Whilst practitioners account for the uncertainties and anxieties it produces for patients and their families, they also convey a sense of ambivalence concerning early diagnosis. This article captures the internal conflicts and contradictions inherent to practitioners' perspectives regarding the repercussions of early diagnosis and concludes by arguing that it effaces the uncertainties and anxieties that it produces in practice as it restricts the co-existence of narratives for making sense of memory loss beyond 'loss of self', and fails to recognise care as a viable alternative for managing AD.

Charisma and the clinic

Here we argue that 'charisma', a concept widely taken up within geography and the environmental humanities, is of utility to the social studies of medicine. Charisma, we suggest, draws attention to the affective dimensions of medical work, the ways in which these affective relations are structured, and the manner in which they are intimately tied to particular material-discursive contexts. The paper differentiates this notion of charisma from Weber's analyses of the 'charismatic leader' before detailing three forms of charisma - ecological (which relates to the affordances an entity has), corporeal (related to bodily interaction) and aesthetic (pertaining to an entity's initial visual and emotional impact). Drawing on interview data, we then show how this framework can be used to understand the manner in which psychologists and neuroscientists have come to see and act on autism. We conclude the article by suggesting that examining charisma within healthcare settings furthers the concept, in particular by drawing attention to the discursive features of ecologies and the 'non-innocence' of charisma.

Autistic Heterogeneity: Linking Uncertainties and Indeterminacies

Autism is a highly uncertain entity and little is said about it with any degree of certainty. Scientists must, and do, work through these uncertainties in the course of their work. Scientists explain uncertainty in autism research through discussion of epistemological uncertainties which suggest that diverse methods and techniques make results hard to reconcile, ontological uncertainties which suggest doubt over taxonomic coherence, but also through reference to autism's indeterminacy which suggests that the condition is inherently heterogeneous. Indeed, indeterminacy takes two forms-an inter-personal form which suggests that there are fundamental differences between individuals with autism and an intra-personal form which suggests that no one factor is able to explain all features of autism within a given individual. What is apparent in the case of autism is that scientists put uncertainty and indeterminacy into discussion with one another and, rather than a well-policed epistemic-ontic boundary, there is a movement between, and an entwinement of, the two. Understanding scientists' dialogue concerning uncertainty and indeterminacy is of importance for understanding autism and autistic heterogeneity but also for understanding uncertainty and 'uncertainty work' within science more generally.

Asperger's Syndrome, Subjectivity and the Senses

Situated at the intersection of anthropological work on illness narratives and research on the anthropology of autism, this paper is a close reading of an autobiographical narrative recounted by Peter, a young man diagnosed with Asperger's Syndrome, a type of autism spectrum disorder (ASD). Responding to Solomon's (2010a:252) call for phenomenologically grounded accounts of "the subjective, sensory, and perceptual experiences of autism … based on personal narratives and practices of being and self-awareness," this paper calls into question key assumptions in the clinical and popular literature about ASD relating to theory of mind, empathy, capacity for metaphorical thinking, and ASD as a life-long condition.

Hope and doubt in the promise of neuroimaging: The case of autism spectrum disorder

Although neuroimaging is currently not a component of the diagnostic process for autism spectrum disorders, some scientists hail these technologies for their promise to one day replace behaviorally based psychiatric diagnostic techniques. This article examines how psychiatrists understand the potential use of neuroimaging technologies within the context of clinical practice. Drawing on 10 semi-structured interviews with child and adolescent psychiatrists, I describe the hope and doubt that comprise their discourse of ambivalence. This analysis demonstrates that the uses and meanings of neuroimaging technologies are rearticulated in ongoing debates in the field of psychiatry regarding the role of the biopsychiatric model in the diagnosis and treatment of mental illness. This study highlights issues surrounding the perceived biopsychiatric focus of neuroimaging technologies within clinical practice, concerns regarding misdirected research attention, and the ways in which understandings of future utility mediate perceptions of technological utility.

Scepticism and hope in a complex predicament: People with addictions deliberate about neuroscience

BACKGROUND

According to the 'brain disease model of addiction', addiction is a chronic condition the symptoms of which reflect persistent changes in neural functioning produced by long-term drug use. Scholars have argued both for and against the validity and usefulness of this way of conceptualising addiction, which has been variously described as emancipatory and detrimental to addicted persons. In this paper we explore how people with addictions make sense of the brain disease concept and the extent to which they find it useful.

METHODS

We conducted 44 semi-structured interviews with persons in treatment for drug and alcohol addiction recruited through a variety of channels. Transcripts were analysed by combining a health identity approach with thematic analysis.

RESULTS

We describe participants' understandings of how they became addicted and what role, if any, neurobiological conceptions play in their explanations. Our findings highlight the hopeful and sceptical viewpoints of addicted individuals on the value of addiction neuroscience ideas and neurotechnologies.

CONCLUSIONS

These viewpoints shed some light on the diverse and divergent ways that people with addictions make sense of neurobiological ideas and technologies. It also describes when, and how, neurobiological explanations and the 'brain disease' model can be helpful to addicted persons. Some of the limitations of the brain disease model become apparent in the complex ways in which neurobiological explanations and labels are incorporated into lay understandings. In order to be more useful to addicted persons, neurobiological explanations should be provided as part of a more complex explanation of addiction and the brain than the BDMA offers, and should not be given a 'disease' label.

Sociology of Low Expectations: Recalibration as Innovation Work in Biomedicine

Social scientists have drawn attention to the role of hype and optimistic visions of the future in providing momentum to biomedical innovation projects by encouraging innovation alliances. In this article, we show how less optimistic, uncertain, and modest visions of the future can also provide innovation projects with momentum. Scholars have highlighted the need for clinicians to carefully manage the expectations of their prospective patients. Using the example of a pioneering clinical team providing deep brain stimulation to children and young people with movement disorders, we show how clinicians confront this requirement by drawing on their professional knowledge and clinical expertise to construct visions of the future with their prospective patients; visions which are personalized, modest, and tainted with uncertainty. We refer to this vision-constructing work as recalibration, and we argue that recalibration enables clinicians to manage the tension between the highly optimistic and hyped visions of the future that surround novel biomedical interventions, and the exigencies of delivering those interventions in a clinical setting. Drawing on work from science and technology studies, we suggest that recalibration enrolls patients in an innovation alliance by creating a shared understanding of how the "effectiveness" of an innovation shall be judged.