Adrien Defossez

Pascal Ducournau

Patients receiving ambulatory care: a problematic autonomy situation

Keywords: Autonomy, outpatient, medical care institutions, ambulatory care, patient isolation, sociology

Patients receiving ambulatory care: a problematic autonomy situation

Adrien Defossez, Pascal

Introduction

The number of patients treated as part of a hospital-in-the-home program designed to deliver hospital care, such as palliative care or treatment for neurodegenerative diseases, increased by nearly 80% between 2005 and 2008 in France (National association of French home hospitalisation institutions [FNEHAD], 2009). Concurrently, the availability of outpatient options and the development of different forms of oral chemotherapy have resulted in no more than 9% of cancer patients requiring full hospitalisation (French national cancer institute [START_REF] Inca | Situation de la chimiothérapie des cancers en 2010[END_REF]. Not only has the average length of hospital stay fallen but classic hospitalisation patterns, where care is delivered in a hospital setting, are being replaced by other, more cost-effective ways of providing medical treatment, such as home hospitalisation (HH) or outpatient care for a growing number of pathologies including the most severe kinds (cancer, AIDS, cardiovascular diseases) [START_REF] Carricaburu | Sociologie de la santé. Institutions, professions[END_REF]. According to Schweyer, hospitals, whose initial purpose was to admit patients, now tend to reduce as much as possible their activity as places of care, a structural conversion he describes as shifting "from a stay without care to care without a stay" (Schweyer, 2003, p241).

Due to the emphasis on the cost of health care, the impact of the new care delivery models on the health system has become the focus of much economic research projects. As a consequence, economic literature reviews were conducted as early as the 1980s on this topic (for example, see [START_REF] Berk | Cost and efficacy of the substitution of ambulatory for inpatient care[END_REF]. As for other areas of social sciences, the main studies on care delivery models are more recent and have dealt with the consequences of the 'outpatient shift' and the development of Hospital-in-the-Home on medical staff and care organisation [START_REF] Bonneville | About the Evaluation of Computerised Health Care Services: Some Critical Points[END_REF][START_REF] Diaz | The social organisation of chemotherapy treatment consultations[END_REF]Pérodeau & Côté, 2002). But as indicated in a 2003 review of scientific literature [START_REF] Duke | The impetus for the development of Hospital In The Home (HITH) programs: a literature review[END_REF], few studies have addressed the consequences of these types of systems from the patients' point of view.

A priori the evolution of health care delivery models made possible by technological and medical advances should prove to be a positive factor and an opportunity for users to avoid lengthy stays: hospitals often being described in sociological literature as places of confinement and institutional isolation where patients, faced with the prospect of increased dependency, lose their former "external" status [START_REF] Arras | Bringing the hospital home: Ethical and social implications of High-Tech home care[END_REF][START_REF] Goffman | Asylums: essays on the social situation of mental patients and other inmates[END_REF]. The HH or outpatient models reflects the will to reduce the average length of hospital stays. A 2009 report based on a study by the National Association of HH Institutions on information systems and health technologies, states that HH is "primarily a patient's choice.

It is the response to the wish expressed by a given patient to regain control of his or her illness and treatment and to receive appropriate medical care in a familiar environment" (FNEHAD, 2009, p32). Caplan and other academic researchers with an interest in patient care delivery share this point of view. Caplan stated in a comparative home/hospital study that it is preferable for patients to be spared the need to adapt to the hospital culture, remaining in a familiar environment and keeping some form of routine instead [START_REF] Caplan | Hospital in the home: a randomised controlled trial[END_REF].

However new hospitalisation models are not unanimously acclaimed and some authors note that the urgent need to reduce health costs is taking precedence over any social, ethic or sanitary considerations [START_REF] Duke | The impetus for the development of Hospital In The Home (HITH) programs: a literature review[END_REF][START_REF] Pousada | High-Tech home care for elderly: what, why and how much[END_REF]. Since the existing literature has not dealt extensively with the transformations induced by the new health care delivery models, we decided to focus our attention on the status of patients not confined to a medical institution: Does leaving the hospital premises actually mean reducing their dependency on the institution? Can patients limit their reliance on the hospital by using other available external resources such as family, physicians and the media?

In the first part of our study, based on sociological literature, we identify the constraints imposed by the institution on hospitalised patients and the loss of autonomy they generate. In the second part, we compare these with the results of an interview-based survey of outpatients treated for cancer in a hospital in the South of France. We show that some of the constraints usually encountered by patients receiving care in institutions are also observed in patients receiving ambulatory care: They experience a form of cognitive isolation regarding access to information about their health, and their social life appears to be institutionalised.

From hospitalisation to care outside hospital premises and the likely impact on patient status

Health sociology began to study the role of hospital institutions in the mid 20th century, and while acknowledging that their primary activity consists in delivering care to ill individuals their other functions, such as maintaining social order, also emerged as study topics (for example, see [START_REF] Parsons | The mental hospital as a type of organization[END_REF]. According to Parsons the hospital institution makes it possible to watch and isolate the ill within a closed structure and therefore offers society a form of protection. The approach which consists in alienating the sick from society and consequently keeping them confined has been the object of many studies and works conducted within the framework of a general theory of institutions based on confinement principles. "A large number of like-situated Individuals, cut off from the wider society for an appreciable period of time, together lead an enclosed, formally administered round of life" (Goffman, 1961, p11). This is a typical feature of what Goffman called "total institutions".

Other studies point to strong similarities between hospital institutions and other places of confinement (convents, boarding schools, prisons) from the staff's perspectives [START_REF] Brooks | The geriatric hospital felt like a backwater': Nursing the aged and infirm in Britain, 1955-1980[END_REF][START_REF] Cott | Structure and meaning in multidisciplinary teamwork[END_REF][START_REF] Pearlin | Alienation from work: a study of nursing personnel[END_REF] and the patients' perspectives [START_REF] Clark | Observational study of quality of life in NHS nursing homes and a long stay ward for the elderly[END_REF][START_REF] Quirk | What do we know about life on acute psychiatric wards in the UK? A review of the research evidence[END_REF][START_REF] Wing | Institutionalism in mental hospital[END_REF]. The alienation and ongoing scrutiny experienced by hospital patients results in the alteration of their social status: As they are admitted to hospital patients must give up their autonomy and enter a system which requires them to become strongly dependent on the institution. The change translates into limited contacts with the "outside world", subjection to the rules imposed by the hospital, and the scrutiny and subsequent interpretation of their behaviour according to institutional expectations. Patients also resign from their usual social roles and are relieved of a number of responsibilities [START_REF] Arras | Bringing the hospital home: Ethical and social implications of High-Tech home care[END_REF]. Since Strauss's negotiated order theory [START_REF] Strauss | The hospital and its negotiated order[END_REF] it has been widely accepted that the hospital should not be perceived as a set and immovable organisation where patients are arbitrarily assigned predefined roles and status without the possibility of negotiating. Despite this most of the time hospitalisation does induce a loss of autonomy. As Coenen-Huther put it after a "forced stay" in hospital (he "took advantage" of a hospital stay as a patient to write down observations about the institution and the sociability patterns), the hospital environment "tears patients away from their universe and hurls them into an unfamiliar world where they can only retain a minimal part of their autonomy" (Coenen-Huther, 1991, p141).

The two main types of constraints

Individuals admitted to hospital appear to lose the attributes that typically express autonomy, and acquire others that make them fit to be socialised in the hospital environment.

Two types of constraints imposed on individuals may be taken into consideration to assess patient status within the hospital institution: the first is patient confinement and isolation from the outside world, and the second includes constraints consistent with the institutionalisation of their social life within the hospital premises.

Patient isolation includes being deprived of the privileges afforded by the outside world which seems more instrumental than confinement itself in the loss of their former status. Once hospitalised, individuals can no longer access a number of resources associated with autonomy. Coenen-Huther for instance, showed during his hospital stay that patients were not able to use the telephone at will. His experience dates back to 1991 and nowadays accessing a phone while hospitalised no longer constitutes an issue, but patients wishing to use other means of communication such as the Internet may face the same type of difficulties.

Similarly, prohibiting or limiting visits from relatives to the patient's room also hinders communication with the outside world. Isolation as described here affects any sources of information that may exist concerning patient health. Once within the hospital walls, patients can no longer request the advice and opinion of external professionals they may be acquainted with such as family physicians or specialists. They do not have a choice of persons to talk to, as is the case outside the hospital structure. The variety of external resources [START_REF] Bury | Chronic illness as a biographical disruption[END_REF] that patients may use to effectively deal with their situation is no longer available to them. Care providers are, for the most part, arbitrarily appointed and as a result patients' options appear to be considerably narrowed down. This type of isolation is all the more controversial when patients who express the wish to consult with a different specialist or be transferred to a different place of care encounter a number of obstacles [START_REF] Ménoret | Les temps du cancer[END_REF]. Patient isolation therefore extends to information about their current state of health since individuals are stripped of their former medical resources.

As with isolation, indicators for the second type of constraints -those tied with the institutionalisation of social life -are also frequently quoted in sociological literature. For instance many studies indicate that social temporality in hospitals is structured by medical procedures and their effects, and by encounters with medical care providers (see for example, [START_REF] Jowsey | It hinges on the door: Time, spaces and identity in Australian Aboriginal Health Services[END_REF][START_REF] Naithani | Hospital inpatients experiences of access to food: a qualitative interview and observational study[END_REF]. It is the stream of X-rays, angiographies, cardiac tests, scans and other medical tests which pace the daily lives of patients. It is also the time spent waiting for results, the visits by doctors, nurses and other personnel, and the schedules imposed for getting up, going to bed, taking meals or medication. The imposed social temporality runs parallel with an infantilisation process (Coenen-Huther, 1991) based on rewards and sanctions which induces patients to behave as the institution demands. Even though these obligations may be bypassed, as Goffman suggested with the concept of secondary adjustments [START_REF] Goffman | Asylums: essays on the social situation of mental patients and other inmates[END_REF], it is clearly in the interest of patients to comply with the requests of hospital staff in order to avoid being considered as "bad patients" or "problem patients" [START_REF] Coser | Life in the Ward[END_REF][START_REF] Lorber | Good patients and problem patients: conformity and deviance in a general hospital[END_REF]. Finally, the institutionalisation of social life is made potent through a form of forced sociability where patients are led to interact with individuals they have not chosen to meet (sharing rooms, taking part in collective activities and undergoing tests in the same facilities).

In the light of these observations one may wonder what the patient's status is outside the hospital premises when receiving hospital-in-the-home services? Do the types of constraints usually experienced by patients, according to institutional sociology, disappear in the context of outpatient treatment or HH? One may expect to observe: (i) a drop in manifestations of isolation regarding health information resources (choice of health professionals, exchanges with relatives and access to the media such as the Internet); (ii) a drop in manifestations of institutionalised social life, habitually reflected by imposed social temporality, certain forms of infantilisation and undesired sociability. In the following part, these types of constraints are analysed in the context of outpatient treatment.

Outpatient chemotherapy

The qualitative study

The study was carried out between 2009 and 2010 in a hospital department of a mediumsized city in Southern France where cancer patients are treated using ambulatory chemotherapy. This mode of treatment is favoured by oncologists as it makes it possible for patients to visit the hospital for only a few hours a day to receive intravenous treatment and meet with the oncologist before returning home. According to protocols, chemotherapy is administered one to four times a month. We interviewed 27 persons using semi-structured interview patterns. On the one hand, the interview concerned the issues patients may face as a result of the disease and its treatment (understanding the disease, its evolution, chemotherapy, side effects and nutrition). On the other hand it dealt with the resources mobilised or not by patients to address these issues (medical staff, the media, relatives, support groups), particularly in out-of-hospital situations.

These individuals were approached in the treatment room on the day they were scheduled to receive chemotherapy. Before each interview we introduced ourselves to the patient as sociologists participating with the hospital in a research project essentially centred on patient information. In order to dispel hospital-generated constraints we made it a point of underlining that we were not part of the medical team and that the content of the interviews we requested would remain anonymous. We considered carrying out the interviews in the patients' homes in an attempt to minimise the influence of the hospital setting, but patients repeatedly expressed the wish not to postpone the interviews. This study was conducted in compliance with French legislation and ethical guidelines, which are not as strong as in Anglo-Saxons countries (for example, ethic controls through Institutional Review Boards are scarce for sociological studies in France). Furthermore our methodology was reviewed by the hospital's oncology department. All interviews were electronically recorded and transcribed to conduct a thematic analysis of the data.

Among the patients interviewed there was a slightly larger proportion of women (15 women to 12 men). They ranged in age from 23-82 (the median age being 62 years). All but one were retired or on disability leave. When their latest job was taken into consideration, it was observed that a large proportion of them (three quarters of the sample) belonged to the middle or working classes (textile workers, restaurant employees, warehousemen, daily life auxiliaries and secretaries). How they felt about their conditions varied greatly as some patients had just started treatment while others already had several years' experience with cancer (16 of them had begun their first treatment in the course of the past 12 months and 11 more than one year prior to that date). Five had been receiving treatment for more than three years. Cancers included breast, lung, uterus, pancreas, Hodgkin's disease, leukaemia.

Patients facing a form of cognitive isolation

A number of similarities emerge when the situation of outpatients and inpatients as described in the literature are compared using the elements of institutionalisation and isolation quoted above.

Many interviews indicate that patients rarely mobilise their resources. We observed through analysing the interviews that health professionals such as family physicians, specialists or pharmacists were rarely mobilised by patients for matters directly related to their cancer. Although patients do have contact with these health professionals, they do not seem to seek their advice as medical and health professionals with respect to their disease. The only opinions relevant to them are those of the hospital oncologist and, to a lesser extent, of the nurses working in the department. It appears that many outpatients do not use a source of information that they might have been expected to mobilise as a useful tool to build their independence towards the hospital institution. Even when talking about their disease to their family physicians, their exchanges remain relatively superficial, to which the following testimony by a patient first treated in 2002 attests :

" [about his family physician] To me it's not his thing [oncology]. I let him know what I'm

doing here, last time I saw him I gave him the names of the 4 drugs I was about to take, he was very pleased because he didn't know about them, he wrote the names down. It's almost like I'm the one teaching him things, well if I can say so, I don't mean to imply that I know more than he does. I just consider he is not competent in that area, so I don't ask ". (Patient No 22. 62-year-old man, retired executive) Patients may discuss their situation with their family physicians "to get some comfort, to get it off my chest" as another female patient put it (Patient 21. 68-year-old woman, retired factory worker), but they do not consider them as competent interlocutors where cancer is concerned. While hospital care providers encourage patients attending as outpatients to get in touch with their family physicians in the first place should they experience difficulties in the course of their treatments, our observation is that patients only comply with this instruction during the initial part of treatment, and subsequently largely ignore this resource. We also asked patients about two other possibilities of hospital decompartmentalisation: patient support groups and alternative forms of medicine (healers, for example). The first turned out not to have been used (none of the patients claimed to have attempted to contact a support group and more than half the individuals in our sample were unable to even quote the name of one); as for the second possibility, few patients claimed to have considered it and 2 out of 27 said they had used complementary therapies, but added that they quickly lost interest, as in the case of this patient (Patient No 25. 69-year-old woman, retired factory worker): "You realise that they are wrong [healers], that is not true what they say. Do not go to these people".

Similarly, relatives do not prove to be a helpful resource in improving familiarisation with the range of available medical information sources. Two thirds of the cancer sufferers we interviewed have relatives who, through their personal or professional experience, could, if approached, provide them with information or tips concerning their diseases. A little under half the interviewees have individuals working in the medical field among their relatives (a daughter in her last year at medical school, a sister-in-law who is a nurse, doctors they are friends with). Patients might be expected to approach them for information on side effects or nutrition since relatives can be perceived as relational resources for health questions, as shown by Ferrand in his study on confidants [START_REF] Ferrand | Confidents. Une analyse structurale de réseaux sociaux[END_REF] But we have observed their unwillingness to engage in a patient / care provider relationship. A patient indicated that she does not want to "impose on them [her doctor friends] insofar as they are friends first and foremost". She limits herself to simply "keeping them up to date", like the majority of interviewed patients. She added: "We talk about books, movies, the Avignon festival where we go together and this sort of things, but definitely not... [cancer]." (Patient No 17. 68-year-old woman, retired from a middle-management position). In addition, relatives who are also former cancer sufferers might prove to be a valuable source of information on the disease (1/3 of the patients interviewed are concerned). But we notice that either contact is scarce, or there is an unwillingness to talk about cancer in order to avoid being stigmatised, as this quote indicates (Patient No 18. 40-year-old woman, middle-management position, on sick leave): "I refuse to keep acting as someone who is ill. […] It's important for me to meet with friends, to have conversations about topics other than disease. I also try to keep away from people who are or have been ill".

Although relatives as a major emotional resource may be helpful in dealing with daily obligations [START_REF] Bury | Chronic illness as a biographical disruption[END_REF][START_REF] Carricaburu | From biographical disruption to biographical reinforcement: the case of HIV-positive men[END_REF][START_REF] Smith | The effects of social resources on recovery and perceived sense of control among the disabled[END_REF], they are not instrumental as diversifying sources of information on the disease and do not partake in discussing that information. From this perspective, although outpatients do not experience total physical and emotional isolation, they still face a form of cognitive isolation. Patients are faced with a single source of information originating in the hospital, which they must deal with on their own. Furthermore, certain patients are aware that their disease is, to some extent, a burden to their loved ones, which may be the reason why they choose to set limits to their relatives' involvement. Ambulatory care and HH have caused daily tasks to be transferred from the hospital to the relatives [START_REF] Arras | Bringing the hospital home: Ethical and social implications of High-Tech home care[END_REF]. As a matter of fact, the institution relieves hospitalised patients of part of their responsibilities, while relatives of patients receiving ambulatory care are expected to take charge of the household chores made harder to deal with by the disease.

Over the past few years the Internet as a tool of information has become prominent among the resources available to patients receiving out-of-hospital treatment. In 2011, 36% of the French used the Internet to seek information on diseases, injuries or nutrition against 13% in 2006 (Eurostat figure, 2012). Outpatients with an Internet connection at home might be expected to use this tool to gather information on their pathologies or their treatments, which would not be possible for them to do if hospitalised. But among the 17 patients interviewed who had an Internet connection, 3 of them were unwilling to use this source of information because "you can't do that, [or else] you'll end up ill for good" (Patient no 5. 76-year-old woman, retired employee), and as for the remaining 14, they claim that source of information turned out to be useless, as in the case of a patient in her 4th month of treatment (Patient No 8.

66-year-old woman, retired employee) :

" I looked it up on the Internet but that's dreadful. Whenever he found me on the Web, my husband rushed to see what I was doing. I looked up all my drugs and I thought: "What is all this ?". It doesn't really help, we're not doctors. "

While studies have shown that certain patients do not wish to access all the information they might avail themselves of at every stage of their disease [START_REF] Leydon | Cancer patient's information needs and information seeking behavior: in depth interview study[END_REF],those facing issues raised by cancer and outpatient treatment typically experience a need for information in the early stages. The vast majority of them want to understand how chemotherapy works, what their chances of recovery are and what side effects they should expect [START_REF] Jenkins | Information needs of patients with cancer: results from a large study in UK cancer centres[END_REF]McCaughan & Thompson, 2000). From this perspective, the Internet as a research tool could prove to be a valuable resource. However, except for one individual who, given his job as a nurse, claimed to be able to search through and understand information on the Web, most patients interviewed went "at first", "just to have a look". Even those familiar with this tool experienced difficulties localising the information they were looking for and understanding it, and expressed their lack of confidence in such a source.

They feared the information they accessed might be inaccurate or not consistent with their personal situation. A patient who recently started a chemotherapy protocol expressed those fears (Patient No18. 40-year-old woman, middle-management position, on sick leave): "Dr M. advised me to look up the cancer league website, because it was the most appropriate.

But I can't… I can't find what I want to know, I mean details and… […]. I think on the

Internet one doesn't necessarily use the right words to carry out a search. What's hard actually is that we are individuals but when we face disease we become statistics. […] I didn't look anything up other than the cancer league because I want to avoid the wrong sources. I don't feel like coming across some nonsense, and then again being informed is nice but informed by what?".

Through such comments the uninitiated displayed their basic mistrust of any information available on the Internet, and the reliability of the source being questioned by scholars who had occasion to demonstrate that it varies greatly from one website to the next [START_REF] Friedman | Health literacy and the World Wide Web: Comparing the readability of leading incident cancers on the Internet[END_REF][START_REF] Hargrave | Quality of health information on the internet in pediatric neuro-oncology[END_REF]. The vast majority of patients interviewed stated that even when they understand the information, they still found it difficult to assess its reliability and so to use the Internet with efficiency.

It appears that certain factors that cause hospitalised patients to be isolated also affect outpatients albeit in a different manner: External resources do exist in terms of multiple sources and treatment information (the Internet, relatives, family physicians, associations with individuals affected by a cancer), but are rarely mobilised. From this perspective, the situations of outpatients and confined patients are comparable. While outpatients are not confined properly speaking, they are cognitively isolated since hospitals and their actors remain the sole source of information concerning their disease. Although outside the premises of a health institution, they remain in many respects confined by the hospital system itself.

The institutionalisation of social life "outside hospital premises"

A different set of elements concerns the institutionalisation of patient's social life. The patients interviewed gave evidence of a form of social temporality ruled by hospital life. As in the case of hospitalised patients, those receiving treatment at home are subjected to the pace imposed by an institution which sets their appointments for chemotherapy sessions as well as the dates and places for tests to be carried out, generally leaving little room for negotiation.

Individuals also have to endure the wait for answers (asked by phone or directly to hospital staff), for exam results and the medical decisions that ensue. The overall wait time is " I'll sometimes make a call. Doctor P. will be doing her rounds already or seeing patients in her office and then she needs to call me back. So there I am at home waiting, not taking anybody's calls, people phone me and I hang up in a hurry…that's the most stressful for me, because I want the information and it is hard to get. […] The only time I feel anxiety is when she needs to phone me, to give me a report. I could stand watch all day long beside the phone, and it's not pleasant for me or for anyone else."

The pace of hospital life invades the privacy of the patients' homes. Although they are not confined to a hospital room, they live to the pace of the oncology department and organise their daily lives around the requirements of the institution. Of course the time constraints faced by patients treated at home are not as exacting as the ones hospitalised patients are subjected to, yet they are a constant burden, be they medical constraints (taking prescribed drugs, undergoing tests and receiving care) or constraints coming from the hospital organisation (staff holidays, opening hours, pace of work).

The infantilisation of patients compelled to behave as required by the institution is another indicator of institutionalisation and can to some extent be observed in outpatients. We found no evidence of hospital staff resorting to the praise and threats described by [START_REF] Coenen-Huther | Observations en milieu hospitalier[END_REF] in order to influence the behaviour of hospitalised patients. But patients receiving ambulatory treatment also meet the expectations of their oncology department. They intend to be "good patients", the kind that do not disrupt the pace of the institution and do not The treatment-related issues highlighted by a female patient on chemotherapy for the past three months show how the fear of disturbing hospital staff and coming across as an " annoying " patient compelled her to adapt her behaviour to the institution's expectations.

(Patient No 21. 68-year-old woman, retired worker) :

"Those are things that I wonder about and I don't dare ask the oncologist for fear of being ridiculous, I don't want them to tell me don't be thinking so much or this and that, I just have to cope with it. I guess these poor doctors must be tired of people talking nonsense. […] I don't want to wear them down with questions they must be hearing all day long, I feel like I'm a softy and I sort of demand attention like a child."

" Infantilisation" takes place in a different manner outside the hospital. The institution takes charge of all the patients' needs and brings them step by step to a lower social status, making them dependant on the staff and subjecting them to a system of punishments / rewards [START_REF] Coenen-Huther | Observations en milieu hospitalier[END_REF]. Outside the institution a "paradoxical infantilisation" process can be observed: although patients themselves feel the need to comply with the institution's expectations, such "infantilisation" results from an approach which encourages self-reliance.

Patients will be told by staff at the onset of chemotherapy that should any difficulties arise, they should contact their family physicians rather than the hospital. They are provided with a thin booklet containing information on their disease, their treatment, the potential side effects or nutrition, designed to bring them answers without needing to contact the hospital. So the institution prompts its patients to break free from hospital departments, but this in turn induces self-censorship and patients cease to acknowledge their own expectations as we have seen through the previous quote.

Lastly, where imposed sociability contributes to the institutionalisation of social life, similarities are not obvious between the situations encountered inside and outside the hospital.

In the hospital, patients are bound to interact with individuals they have not chosen to meet and that are imposed on them by the institution on a daily basis. While in shared rooms or exam rooms physical intimacy and personal intimacy (identity, type of pathology, prognosis) are limited, the outpatients we interviewed did not give any evidence of this type of institution-imposed sociability. Outpatients are able to decide whether or not to have contact with the other patients, and so any relationship they may enter will be the result of elective affinities. These situations rarely occur (one female patient out of the 27 interviewed) as most of the individuals taking part in the survey preferred to avoid meeting patients who will inevitably mirror their situation as cancer sufferers. Withdrawing from imposed sociability, a positive experience according to patients, increases their cognitive isolation since they are no longer in contact with other sufferers. So it appears that HH contributes to the fragmentation and individualisation of the hospital experiencea phenomenon already noted by [START_REF] Carricaburu | Sociologie de la santé. Institutions, professions[END_REF]

Discussion and conclusion

This research, prompted by a number of isolation and institutionalisation indicators suggested by the literature, clarifies the particular status of patients receiving treatment outside of a hospital institution.

Firstly, in light of our interviews and findings, it cannot be asserted that HH care delivery models make it possible for patients to remain in their familiar environment as claimed by certain institutional and academic researchers (cf. introduction [START_REF] Caplan | Hospital in the home: a randomised controlled trial[END_REF]FNEHAD, 2009). We have noted that patients receiving care at home experience changes in their environment as the pace of hospital life sets in and informs their daily lives. A certain number of constraints usually encountered in a classic hospitalisation setting arise. It would be more appropriate to state that HH results in the invasion of patients' environments, rather than describing it as a care delivery model that protects patients from the discomfort and inconvenience associated with hospital institutions. The widely positive assessment of these care delivery systems needs to be nuanced as the lived experience of out-of-premises hospitalisation are contrary to those in the institutional rhetoric. Furthermore, we noticed that patient dependence on hospital staff remained very strong, especially when trying to access information about their health. Far from diversifying sources, outpatient treatment models narrow the choices down. It appears that oncology staff remain the sole information providers regarding disease and treatment since patients do not engage with external health professionals such as their family doctor or a relative in patient care discussions. In addition, the Internet is perceived as lacking relevance as an information tool concerning their pathology. Inevitably this leads us to question the conclusions of certain authors who claim that the Internet empowers patients to take control of their disease and negotiate with their doctors [START_REF] Eysenbach | The Impact of the Internet on Cancer Outcomes[END_REF][START_REF] Ziebland | The importance of being expert: the quest for cancer information on the internet[END_REF]. Patients are left to their own devices. Having to process the information provided by hospital staff on their own, a form of cognitive isolation substitutes the physical isolation existing in institutions. HH models were originally designed to decompartmentalise information and enable patients to "regain control over their disease and treatment" (FNEHAD, 2009), but the results of our study did not provide evidence to support this theory.

Additionally, there are conflicting issues related to outpatients suffering the effects of recurring exhortations to autonomy. As stated earlier we have observed that patients tend to practise self-censorship and that they refrain from voicing their needs. These phenomena may be attributed to modern-day domination processes which require individuals to become actors-authors of treatment delivery [START_REF] Martucelli | Figures de la domination[END_REF], and no longer follow the paths of classic disciplines as analysed by Foucault [START_REF] Foucault | Discipline and punish: The birth of the prison[END_REF]. Patients treated outside hospital premises may not be forced to withdraw from the world and may not be infantilised as was the case in the past, but they are expected to develop self-control and self-govern their behaviour [START_REF] Hache | La responsabilité, une technique de gouvernementalité néolibérale ?[END_REF]. This refers to the contemporary forms of power, which were analysed by Foucault through the concept of govermentality [START_REF] Foucault | Security, Territory, Population: Lectures at the Collège de France, 1977-78[END_REF]. From an ethical and political perspective it would seem appropriate to ponder ways to "empower" patients, providing them with practical means to achieve autonomy, so that such exhortations, by definition subjected to the budget constraints of health care management, may actually induce positive changes.

In conclusion, our study fills a major gap in the branch of sociological research specifically devoted to the hospital experience and the alterations induced by the shift towards HH.

However we must make clear that these observations result from the features of our field of study. On the one hand, the patients interviewed live for the most part in rural areas and belong to the lower middle classes, which may partly explain why they seldom resort to the resources available to them (the Internet, external health specialists) for information on their pathologies. The observations we made e.g., on self censorship phenomena regarding the formulation of enquiries addressed to care providers may turn out to be true only in the social environments we surveyed. On the other hand, the particular nature of the disease under study may partly explain the new form of dependence we described since, as Ménoret put it, "oncology transfers little competence to its patients" (Ménoret, 2007, p81). Outpatients may have more difficulty processing information relative to their pathology than other patients facing other types of pathologies, even in the case of patients undergoing cancer treatment for several years. Given the small number of studies dealing with the autonomy of patients treated outside hospital premises, our results need to be compared with the results of other studies based on different environments, e.g. other types of pathologies or individuals issued from more privileged social backgrounds.

  magnified by the wait time associated with phone use, as these two quotes indicate: Patient No 19. 61-year-old woman, retired employee, 3 rd chemotherapy session: " I had a little trouble, I called up the hospital and of course I know, these poor people are working day and night and they kept me waiting with the music for 15 minutes and then I broke down, I hung up and the next day I got through the first time. But I don't judge them because I know…it's always the same, not enough staff, they just can't deal with all the patients ". Patient No 17. 68-year-old woman, mid-management position, first treated for cancer in 2005:

  antagonise staff. Most patients avoid placing what they see as annoying calls and do not ask many questions. As a result, they avoid expressing their anxiety about the physiological changes and constant pain induced by chemotherapy side-effects as stated by this patient (Patient 8. 66-year-old woman, retired employee): "So many strange things happen when you are on chemotherapy, strange side effects, there are many of those […]. It's good that after chemo they tell you you should expect other effects because you'll have been taking drugs for six months and your body still has to get rid of all this crap. It hurts but you don't dare say it, you don't want to be a coward with pain." Another patient expresses the fear of disturbing the care providers (Patient No 22 -62 yearold man, retired executive): "I'm always afraid to disturb. So all right, when I need to set a different date for an appointment or something of the sort I can't really help it, but when I see what happens with the phone, some people will call up for no good reason. […] I try to pay attention, I'm careful about that because I don't want to be a nuisance. […] ". He imagines care providers might complain "Stop being such a damn pain, we have more urgent things to do than answer the phone ".

Acknowledgments

The authors thank Marie-Pierre Bès (LISST, University of Toulouse) and Rémi Bastide (IRIT, University of Toulouse) for their help in the global understanding of the ambulatory model.

A first version of the paper has been reviewed by the participants of the workshop "Knowledges, Networks and Mediations" of the CERS Laboratory, Toulouse University. This work helped the authors to improve the paper.

Thank to Sophie O'Neill-Curato for his contribution to the English version of the paper.

Sources of funding

This study have been conducted with the funding of the Castres-Mazamet Technopole.


Francis Rousseaux
email: francis.rousseaux@ircam.fr

Indira Thouvenin
email: indira.thouvenin@utc.fr

Exploring Informed Virtual Sites through Michel Foucault's Heterotopias

Keywords: Imaginary space, Informed virtual environment, Immersive art, Artificial presence, Michel Foucault's heterotopias, Realism vs. Provocation, Ancient abbey of Compiègne-France

This papers starts with some mysterious contribution by Michel Foucault (1967) about heterotopias as special epistemological sites. With a recent case-study -an immersive virtual reality art project dealing with some ancient abbey reconstruction and managed by a French engineering school -we analyse the successive attempts to satisfy the system users by extending Foucault's heterotopology, which appears to be useful and creative for the Virtual Reality research communities.

INTRODUCTION: MICHEL FOUCAULT'S HETEROTOPIAS

In the twentieth century, many important philosophers worked on human subjectivity with phenomenological considerations relying on space, time or history. Among them are Ernst Cassirer, Gilles Deleuze, Gaston Bachelard, Augustin Berque and many others ([Bachelard07],

[Berque00],

[Cassirer05],

[Deleuze68],

[Deleuze02],

[Fink04], [Heidegger62], [Husserl89], , [Sartre81]). For example, Bachelard's monumental work taught us that we do not live in a homogeneous and empty space, but on the contrary in a space thoroughly imbued with quantities, and perhaps a thoroughly fantasmatic space as well. The space of our primary perception, of our dreams and of our passions holds qualities that seem intrinsic.

But because several ideas that may turn into key concepts for Virtual Reality develop throughout the notion of Heterotopias, we have chosen to concentrate on a short text written by Michel Foucault in 19671 , entitled Of Other Spaces, to give this scientific contribution a philosophical point of view.

In this amazing text, Foucault claims that after history, space is now the main preoccupation of humanity, arguing that we are now in an era of simultaneity, juxtaposition, of proximity and distance, of side-by-side, of the dispersed. Of course, the way we consider space is historical: according to the philosopher, today the site has been replaced by extension (the infinite Galilean space) which has replaced emplacement (the medieval hierarchic ensemble of sacred or secular places): the site is defined by relations of proximity between points or elements; formally, we can describe these relations as series, trees, or grids. Our era is one in which space takes for us the form of relations among sites, knowing what relations of propinquity, what type of storage, circulation, marking, and classification of human elements should be adopted in a given situation in order to achieve a given end.

Foucault was interested in sites that are connected with all the others, but in such a way so as to suspect, neutralize, or invent the set of relations that they happen to designate, mirror, or reflect. These spaces linked with all the others however contradict them. They are of two main types: utopias and heterotopias.

Different from utopias, heterotopias are real places -places that do exist and that are formed in the very founding of society -which are something like counter-sites, a kind of enacted utopia in which real sites, all the other real sites that can be found within the culture, are simultaneously represented, contested, and inverted. Places of this kind are outside of all places, even though it may be possible to indicate their location in reality. And as we may not have reached the point of a practical de-sanctification of space yet (perhaps our life is still governed by a certain number of oppositions that our institutions and practices have not yet dared to break down), our actual heterotopias may keep some trace of this hidden presence of the sacred, that still nurtures them.

Michel Foucault put forward six main principles to build up his emerging theory of heterotopias -named hetero-topology -as a way to organise the simultaneously mythic and real contestation of the space in which we live.

-Principle #1: there is probably not a single culture in the world that fails to constitute heterotopias. But the heterotopias obviously take quite varied forms, and perhaps not one absolutely universal form of heterotopia would be found (developed examples concerning our contemporary cultures are boarding schools, military service or honeymoon trip as heterotopias of crisis, remnants from the so-called primitive societies, or psychiatric hospitals or prisons from emerging heterotopias of deviation);

-Principle #2: each heterotopia has a precise and determined function within a society and the same heterotopia can, according to the synchrony of the culture in which it occurs, have one function or another (developed example is cemetery, as a space connected with all the sites of the city, state or society or village, since each individual has relatives in the cemetery, the type of connexion changing with the resurrection of bodies or immortality of the soul, this influencing the site. The cemeteries then came to constitute, no longer the sacred and immortal heart of the city, but the other city, where each family possesses its dark resting place);

-Principle #3: The heterotopia is capable of juxtaposing in a single real place several spaces, several sites that are in themselves incompatible (developed examples are theatres, cinemas and gardens, as being smaller plots of land and the whole land, our modern zoological gardens springing out from that source);

-Principle #4: Heterotopias are most often linked to slices in time -that is to say that they open onto what might be termed, for the sake of symmetry, heterochronies (developed examples are festivals, libraries and museums, as ideas of accumulating everything, of establishing a sort of general archive, the will to enclose in one place all times, all epochs, all forms, all tastes, the idea of constituting a place of all times that is itself out of time and inaccessible to its ravages, the project of organising in this way a sort of perpetual and indefinite accumulation of time in an immobile place);

-Principle #5: Heterotopias always presuppose a system of opening and closing that both isolates them and makes them penetrable (developed examples are jails, baths for Muslims, or Scandinavian saunas, where the entry is compulsory or submitted to activities of purification or rites);

-Principle #6: The last characteristic of heterotopias is that they have a function in relation to all the space that remains (developed examples are brothel, colony and boat: either their role is to create a space of illusion that exposes every real space, the site inside of which human life is partitioned, as still more illusory (brothels), or else on the contrary, their role is to create a space that is other, another real space as perfect, as meticulous, as well arranged as ours is messy, ill constructed and jumbled (colonies).

Foucault died in 1984, too early to have the opportunity to think about Virtual Reality (VR) as a mature research and experimentation field. In this paper, we aim at presenting a particular VR project (the recent 3D reconstruction of an ancient Abbey in Compiègne-France) from the epistemological point of view that Foucault has offered us with his creative hetero-topology. It is both a way to celebrate the philosopher, and an attempt to benefit from his research, toward the VR community.

EXPERIMENTATION: VIRTUAL REALITY, REALISM AND PROVOCATION

This section is dedicated to the description of a particular VR project, from both technical and management aspects. The accent is put on the contrast between a first spontaneous approach, that basically failed, and a second approach, more provocative but successful, that inherited from the first failure. We are first going to report and describe that case study which is quite typical of an engineering school approach (the action takes place in the Université de Technologie de Compiègne-France -UTC). Then in a second part, we will analyse its epistemological value.

The Project as a Case Study

There is an abbey in Compiègne that was partially destroyed in 1790 ([Bernanos96]). The project we carried out with UTC students consisted of the realization of a model in mixed or augmented virtual reality in order to make inhabitants understand the importance of the abbey in their city.

Virtual reality was instituted as a scientific discipline by researchers and practitioners aiming at producing artificial environments that would simulate the production of such a reality. According to Jacques Tisseau ([Tisseau01]), it should remain a 'dialogue between scientific disciplines'. However, since the first visualizations in the 1980's up to more recent immersive and interactive systems, advances have been mainly technical: worlds similar or close to reality are to be seen, and imaginary or artificial worlds are to be felt.

The realism of experiences, situations and sensations have been essential criteria of performance of VR systems coming from several logics that naturally combined:

-A logic of data reduction and of recomposition with models and algorithm of image synthesis, of illumination, of calculation of details or else of inversed cinematics or dynamics, so as to convey reality as realistically as possible; -A logic of interpretation and amplification in which the operator is to see and feel.

First 'Spontaneous' Approach: Targeting Realism as a 'Must'

The choices made for the project were fast and spontaneous, for they were obvious: -Computer Assisted Modelling (CAO), then transfer of data in 3D; -Addition of textures and materials coming from real photographs of the walls and vestiges of the abbey; -Insertion of virtual characters (monks) walking in the cloister while meditating, with predefined movements; -Free browsing and changes of viewpoints thanks to an appropriate interface and vignettes.

The realism obtained by that kind of method driven by a 3D real time tool, Virtools™, is now classic. Representations are calculated according to the user's position. The following figures illustrate this. The project was formative for students, but when we started the tests on representative samples of the population of the city, it appeared that something was wrong. In fact, either the users criticized the realism of the project to demand more credibility in details, (those were often video game players), or they confessed they didn't find much interest in such a project (those who were used to the abbey neighbourhood).

We thus had to take into account the deception of our future users and radically rethink the foundations of our approach. As a matter of fact, the project became all the more interesting because virtual reality was no longer a simple field of technical feat but sent us back to its pluridisciplinary constitution that Jacques Tisseau held dear.

Second 'Provocative' Approach: Opening to some Rebellious Possibilities

After reading Bachelard's Poetics of Space, we realized that the presence of the visitor was central in the project, and that it would be important to widen his/her imagination and to use it immediately in a lived and felt experience, even though provoking it with some kind of violence. With specialists in synthetic imaging, in conservation of architectural heritage, in augmented reality and in photography, we thought about what the most important was for the building of mental construction the project was to offer. It appeared for example that anachronisms were not necessarily problematic and that an air of fiction or even of scandal could be maintained.

The idea was now to reconstruct the abbey according to what it represented in the city until 1790, while keeping the landmarks of the contemporary city. The inhabitants of Compiègne find themselves in a familiar world where they understand space and accept not to see all the details of the disappeared abbey. They take part in the experience. They can thus explore and deeply understand, get over conventional ideas and arrive at new ones.

We thus chose to show the anachronic presence of the abbey inside the contemporary city.

The abbey in the middle of the city in 2008, where we now have the butcher's shop, the pharmacy, the greengrocer's or the video store appears in its imposing size. Its imposing presence thanks to its two towers is a shock to the inhabitants who can recognize the different reconstituted points of view. This visit into the past is worth it: we will never see the abbey again, even though its role in the community before 1790 was central.

Moreover, choices of simplification and of reinforcement have been suggested. In the second project, textures have been replaced by a diffuse material-a kind of « cartoon » rendering.

The different points of view superimpose real images in QuickTime VR™ panoramic with synthesis images of the abbey. It is an augmented reality, that is to say the addition of virtual objects in a real world. The browsing is no longer continuous with a virtual cameracontrolled mouse but on the contrary with a cognitive map in which a ball will be launched so as to choose the zone to visualize. This 2D simplified map of the city gives an idea of the dimension and disposition of the different parts of the abbey: the cloister, the nave that has become St Corneille street, the monks' housing, the rooms and so on.

Gilles Deleuze ([Deleuze02]), in his work entitled Francis Bacon, The Logic of Sensation, describes very precisely this perception or experience made possible through the image: 'Already when too pious critics reproached Millet for painting peasants who were wearing an offertory like a potato bag, Millet would answer that the heaviness common to both objects was deeper than their figurative distinction. As a painter, he endeavoured to paint the force of heaviness and not the offertory or the potato bag. And isn't Cezanne's genius to have used all the means of painting to this task: make the force of mountains orogeny, the force of potato germination, the thermal force of a landscape visible …?'. It is this gesture that is continued here. It breaks away from realism to go towards fiction and emotion. It can go as far as rebellion.

The following figures give an idea of the proposed visuals. Even before the second version of the project was finished, tests involving the general public were once more organized. This time, the reception by Compiègne inhabitants was more enthusiastic, questions were asked and we also had cooperative responses, in contrast with the apathetic reception of the first version.

Students were now convinced they were on the right track. Then we discovered Foucault's text about heterotopias and we thus decided to use it to systematize our research.

Feed-back analysis/evaluation about the experimentation process in front of the audience

We have attributed enthusiastic response in the second attempt to anachronic settingwhere participants understood where they were, but this has to be examined more carefully because the rendering have also improved since the first attempt, and many other different expressions were also experimented.

Even more, we have to report that the first test sample from the general public (forty five visitors of the abbey were interviewed during five minutes each, based on a Multiple Choice Questionnaire -MCQ) has been partly involved (twenty eight persons from forty five) in the second MCQ test (involving also forty five visitors): i.e. more than half of our second tested sample had already participated to the first test. This is an important bias, because those visitors were already used to test a virtual reality system about the abbey, and were able to manifest a differential view on the two successive projects, by even suggesting some simplification options and/or some reinforcement ones.

Those considerations invite us to carefully interpret the compared results of the two different tests, which are not independent from the sample aspect, and rely on two very different technical configurations, not only differing from 'realism' vs. 'provocation' metaphors.

Nevertheless, as both the authors participated personally to the test campaigns, they can claim for the enthusiastic and cooperative responses to the second test, in contrast with the apathetic reception of the first test campaign.

ANALYSIS: ANCIENT ABBEY, ACTUAL RUINS AND VIRTUAL REALITY

Professionals of national and regional development have taken note of the strong heterotopic character of the ancient abbey to try to convert it into modernity (principle #2): The abbey is thus reinterpreted according to current canons. To succeed in doing the conversion, architects and urbanists have counted on principles of functional conservation, as well as on principles of subversion (principle #6). Let us examine the conversion project in detail.

The Abbey as it was in the Middle Ages

The abbey that used to be a sacred and enclosed place (only for monks in search of God) has now become a secular welcoming place open to the public (museum, library). However, we hope to keep something of its former spirit of meditation, retreat and solitude, a place that would remain favourable for meditation and relaxation. But the liturgical time of monastic life can only give way to the hope of a hybrid time (principle #4) and of a new function, between meditation and efficiency, of such a place that remains indifferent to the swarming activities outside (principle #5). As a matter of fact, the silence of the gardens and of the orchards, in a cosmological connection with the rest of the world, is now in the heart of the noisy city (juxtaposition principle#3), as a kind of ship (the nave), a kind of floating place, a place without a place that would live by itself (principle #6), as if the cultural offer imposed itself within the commercial offer of the modern city.

A heretopia of crisis -the heavenly abbey that used to be at odds with earthly secular order -now gives way to a heterotopia of deviation (principle #1). Everything has changed, but something of the sacred remains in the renewed function of the place: thus, this silent sacred component of former order is still at work in modern spirits, as Foucault already said it.

The conversion of the site had kept a rather classical appearance so far, but it became more complex when the young project team of engineers came with their simulation tools.

What about a VR Model of an Ancient Abbey?

In fact, our first attempt to model the ancient abbey within an informed virtual site was clearly corresponding to the Heterotopia#1, built up from a spontaneous targeting realism approach. We can easily describe the characteristics of System#1:

-Immersion in a virtual imitation of the abbey and more demanding and detailed realism; -The secret of mystical life is unfolded but its symbolic function is gone, desingularized and given like a utopia.

Then, our second attempt to model the actual abbey was clearly corresponding to the Heterotopia#2, built up from a provocative approach opening some rebellious possibilities.

We can describe the characteristics of System#2:

-Superimposing, aporetic and simultaneous juxtaposition of incompatible, impenetrable and heterogeneous places in an implacable neighbourhood; -Rebellion and contradiction, spiritual conflict and suspension of artificial harmony:

Place of leisure or work? Private or public place? Cultural or commercial place? Earthly or heavenly place? Contemporary or medieval place?

The decision to implement an Informed Virtual Site is not neutral, in so far as this option has something to do with heterotopia, which Michel Foucault could not foresee, even though we feel he had the prescience of this technical possibility. In other words, we have to rule on these heterotopias of a different kind that Informed Virtual Sites (IVS) are -and we could thus maybe call them Heterovirtopias as an extension of Foucault's heterotopology.

Heterotopias

The Middle Ages Abbey and its surroundings (as it is supposed it was)

The actual ruins (as they have recently been partly turned into a museum) and their surroundings

Characteristics of the heterotopias

Sacred and enclosed place (for monks in search of God)

Place of retreat, meditation and solitude

Specific liturgy time of monastic life

Silence of the surrounding gardens in a cosmological connection with the rest of the world Heteroptopia of crisis at odds with the profane earthly order

Profane welcoming place open to the public (Museum, library)

Place of sharing and meditation that is hopefully favourable for relaxation

The hope of a hybrid time and of a renewed function, between meditation and efficiency, far from the swarming urban activities around

In the heart of the noisy city, a kind of ship (the nave here has a double meaning), a kind of floating place, a place that would live by itself A cultural offer within the commercial offer of the city

Heterotopia of deviation

Modelling through Virtual Reality approach

Corresponding informed virtual site

System #1: Spontaneous approach targeting realism System #2: Provocative approach opening some rebellious possibilities

Characteristics of the informed virtual site, Heterovirtopias

Immersion in a virtual imitation of the abbey, more demanding and detailed realism

The secret of mystical life is unfolded but its symbolic function is gone, desingularized and given like a utopia Superimposing, aporetic and simultaneous juxtaposition of incompatible, impenetrable and heterogeneous places in an implacable neighbourhood Place of leisure or work? Private or public place? Cultural or useful place? Earthly or heavenly place? Contemporary or medieval place? Rebellion and contradiction, spiritual conflict and suspension of artificial harmony

Virtual Reality as a New Investigation Field for Heterotopias

Michael Wood wrote, about Italo Calvino's M. Palomar, something that makes us think of what we can isolate from reality: 'A fact is something that does not want to go away, that we cannot ignore, as Henry James said about reality. However, when we come close to it, when we stare at it, when we measure our loyalty to it, it becomes more complicated. Without becoming less factual, it slides towards myth. Mr Palomar is looking at the sky, the lawn, the sea, a young girl, giraffes and even more things. He only intends to observe, and learn a modest lesson from creatures and things. But he cannot do it. There is too much to see in them for a beginning… And there is too much in him of his culture in the world he is contemplating anyway: the world is covered with the signs of our needs and with our mythologies'.

Can our IVS help us live singular throbbing? Contrary to the glasses we wore to get into the first virtual worlds, will IVS manage to make us suggest reality, fiction or rebellion glasses that will enable us to get into throbbing facts? As for the past of the Compiègne abbey, let us see what Witold Gombrowicz writes in his work entitled Dante: 'Sharing with the past means elaborating it with difficulty, asking it endlessly to exist… But, we can read the marks the past left us. These marks depend on fate, on the material itself that can be more or less crumbly and dependent on accidents that took place over time. Time brings these marks to us, and the past can be but chaotic, accidental and fragmentary…(…) The past is thus the same scenario made of bits and pieces… Here is what it is… And this gives us enough to think about the desire we have to have at our disposal a whole complete and living past full of concrete characters, and this need is deeply rooted…'.

And if our IVS came with us to the most liberated fiction, even to rebellion? Rebellion could be about historical determinism, which maintains that the abbey will never exist again. Maybe André Breton is the only one to underline the importance of the everlasting presence of a non conditioned rebellion: 'It is at the precise moment when the weight of endured sufferings seems about to engulf everything, that the excess of the ordeal brings a sign change that tends to bring the human being who is unavailable to his most available side, and to afflict this being with a greatness he would never have known without it (…). One needs to have been to the end of human suffering and have discovered its strange capacities to be able to greet what is worth living in the same unlimited way. The only definitive disgrace that could be incurred, for it would make this sign conversion impossible, would be to match it against resignation (…). There is absolutely no more brazen lie than the one which consists in maintaining that rebellion is useless, even and especially in the presence of what cannot be undone. Rebellion justifies itself regardless of the chances it has to modify or not the fact which determines it. It is the spark in the wind, but the spark that is looking for powder'.

CONCLUSION: TOWARD NEW TOOLS FOR FOUCAULT'S HETEROTOPOLOGY?

It's got to be one thing or the other: either our Immersive Virtual, Mixed, or Augmented Reality Art applications are heterotopias of a new kind, or they make us re-evaluate our implicit or explicit heterotopologies. This does not mean that we have to decide between them in general. We do think that an artist sometimes produces a heterotopia of a new kind (a heterovirtopia?) thanks to an IVS device. The artist can also happen to produce a displacement in the dominating heterotopology, or finds new ways of developing it. In both cases however, each contribution is highly valuable, although both of them should not be mixed up.

Why heterotopia concept is useful in designing a virtual reality project?

In the case of our project, things probably occurred that way: a first drafting of the system made the realization of a prototype possible, without deeply thinking about it. Its implementation questioned the heterotopias used more or less implicitly in the definition of the Museum that was to make the ruins of the abbey attractive. It is only at that time that a heterotopia of a new kind could be found. All this makes us consider the use of former sacred places differently, that is to say not only as a realistic evocation.

Because not all virtual reality projects can be heterotopias, since heterotopias (and even heterovirtopias) have to be real (in Foucault's sense, remember our introduction), many of them will only remain virtual heterotopias (which have nothing to do with heterovirtopias). Now the questions are: Can the status of actual heterovirtopia be reduced to some measurable parameters (like continuity, stability, interaction, change, realism, …), that could enable developers to predict and reproduce the status of their IVS systems and then help to standardise their virtual reality projects? Can we generate actual heterotopias by following scrupulously the six principles, considered as specification rules prescribing our design processes? Of course not. The notion of heterotopias is not such an operational concept, that could revolutionize the Knowledge Level [Newell82] of our systems. It is rather an hypothesis than can be compared to the Knowledge Level approach itself, in the sense of a fruitful high level inspiration guide line to elegantly manage the design of our virtual reality projects, like the Knowledge Level heuristic did in its own time.

Heterotopias within virtual reality vs. knowledge level within knowledge-based systems?

Nowadays, everybody agree that there are too few theoretical grounds on how to design a virtual reality project: this was exactly the case at the time Newell felt the necessity to boost knowledge-base systems design by introducing a clever heuristics hypothesis. We argued that Foucault's heterotopias could play an analogous role for virtual reality projects.

TRIBUTE & ACKNOWLEDGEMENTS

Michel Foucault's visionary intuition marked the start of a research that bears unexpected fruit almost half a century after it was written. We are grateful to this great European philosopher.

Figure 1 :

 1 Figure 1: 3D modelling of the cloister.

Figure 2 :

 2 Figure 2: 3d modelled inside stairs.

Figure 3 :

 3 Figure 3: 3D modelled monk.

Figure 4 :

 4 Figure 4: 3DStudioMax™ modelled surrounding wall of the abbey.

Figure 5 :

 5 Figure 5: complete 3D model.

Figure 6 :

 6 Figure 6: Insertion of a 2D sketch in a photograph.

Figure 7 :

 7 Figure 7: Augmented reality shot of the abbey, view of the street.

Figure 8 :

 8 Figure 8: The abbey seen from the town hall.

Figure 9 :

 9 Figure 9: The cloister and the abbey in augmented reality.

Figure 10 :

 10 Figure 10: 'Cartoon' rendering and diffused materials.

First Michel Foucault wrote a text entitled Des espaces autres, published by the French journal Architecture, Mouvement, Continuité in October 1984. It was the basis of a lecture that the famous philosopher gave in March 1967.Although not reviewed for publication by the author and thus not part of the official corpus of his work, the manuscript was released into the public domain for an exhibition in Berlin shortly before Michel Foucault's death. It has been translated by Jay Miskowiec and can be downloaded in both French and English from the Web (<URL: http://foucault.info/documents/heteroTopia/>). An MP3 of the original lecture is also included.

This work has been supported by the city of Compiègne. We thank deeply Mrs Françoise De Buyer and Mrs Juliette Lenoir for their strong investment in this project, particularly on the evaluation aspects. The augmented reality images have been realized with the Institut Image ENSAM (Jean-Michel Sanchez and Antony Charmoillaux) and the UTC students. BIBLIOGRAPHY

> He was born in 1961, became an engineer in 1984, got a PhD in Artificial Intelligence in 1990, and became professor in Computer Science in 1997. Head coordinator of several research project financed by the EC in the interdisciplinary domain of Music & Virtual Reality at IRCAM (<URL: http://www.ircam.fr/?L=1>), he is regularly involved in Philosophy of Computing (within the Collège International de Philosophie) and Computer Art and Music (within the DigiARTS project of UNESCO). Indira Thouvenin, <URL: http://www.hds.utc.fr/~ithouven/perso/doku.php> She was born in 1962, became an engineer in 1984, got a PhD in Biophysics in 1989, became a researcher in virtual reality at the Institut Image/ENSAM in 1998, and has been professor at the University of Technology Compiègne,