Discussion: The correspondence between position and intentionality is not universal

The residential model is theoretically problematic because it associates a subject’s social position with an intentionality that is assumed to be oriented towards the subject’s own interests. As is known, the assumption of the liberal model is that agents pursue their own interests. That is, the residential model assumes that actors’ intentionalities respond to their own positioned subjectivity.

My theoretical discrepancy is with this assumption that a connection between positioned subjectivity and intentionality is a universal configuration of agency. In principle, I think that the purpose of an action does not have to emerge from the actor’s subjective desires, for instance if the actor is carrying out the desires of others. Such a situation is not always necessarily a form of subjugation or alienation, although it may be so in some cases. It is also the characteristic of people who act as representatives of the interests of others.

A number of studies of agency, such as Mahmood’s for example, focus on groups of informants in which the social actor or subject is the agent. Thus, the connection between subjectivity and agency seems natural because they coincide in these individuals. Yet, informants who act as agents for others have a split between their subjectivity and their agency. Their agency does not emerge from their social constitution as subjects but from the relations they establish with those whom they represent.

In light of this, a discussion of the agency of health workers acquires a dimension of relevance. An examination of the agency of health workers cannot be overlooked or dismissed as unproblematic simply because their position in the power relations is known. Instead, health workers present a problem when the focus is placed on their intentions and intentionality. In principle, health workers do not execute actions for their own benefit. While the issue of power distribution to carry out acts may be important in the discussion of the agency of patients, the problem of the configuration of intentionality is an issue to consider regarding the agency of health workers.

Kowal & Paradies (2005) conducted a workshop among health workers working with Australian Aboriginal communities. They found the health workers insecure, uncomfortable and ambivalent about their identity as benefactors and as agents of health improvement (2005:1353).

The authors say that the “practitioners felt disturbed by their own agency” (2005:1353). The authors explain that the health workers were in an “ambivalent and contradictory subject position vis-à-vis the postcolonial context of Indigenous public health” (2005:1348), due to their White university-educated middle class status. The authors say that the workers’ ambivalence about themselves “points to the inherently problematic nature of practitioner agency in the uneven power relations” (2005:1353) of the former colony. The workers’ seek to maintain their own moral integrity as benefactors while simultaneously asserting a moral similarity with the target population (2005:1353, 1355).

Although Kowal & Paradies express themselves in terms that suggest that they also adhere to the residential model and to the use of the agency concept to explain political behavior, their statements reveal the theoretical problem that I am proposing. Their statements indicate that health workers intuitively perceive that their social position does not match their intentionality.

What Kowal & Paradies identify as ambivalence is the workers’ realization that they identify with the target population in terms of intentions for action, while they are located in an opposing social position that empowers their behaviors. The residential model falters to explain competently this kind of configuration of agency in which social position and intention do not concur.

Ortner and Mahmood ground their theory of agency on the subjective experience of the agent. The authors focus their theory of agency on the formation of the agent. Both authors share the notions that agents are positioned subjects that experience subjective intentions as a personal feature of the intentionality (purposiveness) of their action. That is why agency is imagined as a residential faculty of agents. An association between positioned subjectivity and intentionality characterizes both authors’ understanding of agency. This association characterizes the residential model.

The two authors disagree on the value of intentionality for defining agency. The relative relevance of intentionality in each authors’ position is because they use it to qualify the political value of informants’ actions. Both authors attempt to justify informants’ actions. Ortner represents the liberal model of agency as a source of assertive action, to which Mahmood responds by attempting to argue that her informants should not be judged as subjugated because they attempt to shape themselves according to an agenda that subordinates them.

The debate between Ortner and Mahmood reflects the political utility of the agency concept. The model of agency as a property of individual actors is congruent with agendas that seek to portray social actions as acts of political assertiveness. As an explanatory concept, agency has been especially attractive to scholars of resistance and creativity (Keane 2003).

Keane argues that this trend is associated with a retraction from the concept of culture in social theory and its replacement with power (Keane 2003).

Wisnewski suggests that the major theories of human agency may be politically motivated (Wisnewski 2008:2-3). Agency attribution is a political exercise (Ahearn 2001:124).

The attribution or discussion of agency or degrees of agency has important consequences for political and juridical relations in communities (Kockelman 2007:386).

Wisknewski proposes that theorists of agency may have intended to provide audiences with a particular way of understanding the significance of human actions. Rather than descriptive statements about the nature of being human, theories of agency are political statements that influence an audience’s understanding of themselves as human (Wisnewski 2008:3). Theories of agency should be considered theories that assess the value or significance of human actions (Wisnewski 2008:23).

Therefore, there is room for using the residential model to make informants appear to represent a particular political position. This is potentially why all three studies of patient behavior mentioned above identify agency in such contradictory behaviors. Despite the divergences in patient behavior and the shifting intentions, all three authors concluded that patients had demonstrated autonomy. These three studies may exemplify Mahmood’s alert regarding the teleology of emancipation underlying studies of the agency of subaltern groups (see 2001a:210).

Typically, the main political issue for many such researchers of health care interactions has been the problem of patient autonomy and patient rights. Researchers attribute agency as a device to portray patients as empowered actors despite occupying a subordinate role in

interactions. The use of the agency concept allows researchers to develop an impression that patients are able to navigate the subaltern position with some degree of strategic personal benefit.

Perhaps this may explain why there has been less appeal to use the agency concept for the study of health professionals. It is not as easy to find studies of the agency of health workers as that of patients. Given the common trend to use the agency concept to interpret the behaviors of subaltern populations, perhaps the question of the agency of the powerful may seem insipid and pointless. If health workers are believed to be the intrinsically empowered and dominant actors in the health care relationship, there may seem to be little motive to engage a study that will conclude that their behaviors are an exercise of autonomy. There may not seem to be anything worthy of study if health workers are considered to be able to exercise agency at their discretion.

Yet, the case may not be so simple. The agency of health workers is particularly thorny because even though they ostensibly occupy the dominant position in the health care relation, by definition, they are not primarily acting in their own interests. They are not agents for themselves. The challenging characteristic of their agency is their apparent renunciation of autonomy to benefit another social actor, not its assertion. They occupy a social role in which their agency relies on a collaborative relationship with patients.

The three studies of health care interactions described above show this when they represent the actions of physicians and other health workers. The researchers do not dwell on the agency of the health workers but their descriptions show that, despite the implied assumption, the health workers do not have autonomy for action. Koenig (2011) expresses that physicians are stymied when patients negotiate treatment and cannot proceed until agreement is reached.

Tanassi (2004) similarly shows that physicians use patient compliance to evaluate their relationship with patients and to acquire confidence to proceed.

Therefore, agency is not necessarily a sign of autonomy. It is potentially also a sign of a position in a cooperative relationship. Agency attribution cannot be understood in some cases without observing how it is simultaneously distributed among the different actors in a relationship. This means that some agency configurations cannot be interpreted independently from the particular circumstances of specific relationships.

The difference between Ortner and Mahmood regarding the value of intentionality in the concept of agency occurs because they focus on agency in individual agents, as if agency was not a social condition that is particularized and variable in each social relation. Potentially, the problem of intentionality for the concept of agency is not whether it is present or absent in an actor’s consciousness, as Ortner and Mahmood discuss, but whether it can exist independently from relationships that actors engage with one another.

2.3 REFERENTIAL FUNCTION OF AGENCY IN HEALTH CARE RELATIONS