I Thank Dr. Vink for her impressive analysis of design and introducing me to another method in thinking about institutional organization. I also am deeply grateful for Dr. Vink's engagement with my work on “Placental Ethics: Addressing Colonial Legacies and Imagining Culturally Safe Responses to Health Care in Hawaiʻi” (Bardwell-Jones) and responding to the call to re-envision alternative design models in guiding institutional operations that seek community engagement. Responding to this paper helped me to think further about the work I began in that article.Dr. Vink's project carefully reflects on her experience working with communities in Canada on behalf of hospital administration. Seeking input from differently situated communities, she reflects on moments of perplexity and resistance from the community members. Working with members from an Indigenous community, she found that dominant design models “can contribute to the reproduction of coloniality and modernity.” Working with diverse communities in Toronto, she acknowledged the “hypocrisy” of participation when dominant design models failed to acknowledge the ongoing process of local design work within the community.It appears that dominant design within hospital administration understands care as best done by authority. Community members are reduced to data. The cognitive work is done by the experts, who are situated outside the community. There are risks that dominant design models, despite the good intentions motivating the inquiry, may perpetrate unconscious structural gaslighting. Drawing upon Elena Ruiz's notion of settler epistemic economies that generate structural violence, Nora Berenstain identifies the nature of structural gaslighting as forms of violence that are perpetrated by settler administrative systems and their organizing logics [which] inherently depend on what Ruíz refers to as settler epistemic economies—collections of hermeneutical resources specifically engineered to promote, uphold, and entrench colonial epistemic frameworks and forms of domination as the only possible epistemological systems and governance structures while violently foreclosing on alternative epistemologies. (743)Dominant design models go beyond merely asserting hermeneutical dominance, but in so doing enact epistemic erasure. Structural gaslighting undermines autonomous community processes and prevents them from taking shape. Ultimately, the dominant design model, which assumes that the researcher knows best, stunts the necessary resistance to undermine the dominant design models.To avoid these problems, Dr. Vink aims to transform the colonial logics involving hospital administration toward a pluralistic design model. Care, in this framework, is a community endeavor. Community members are active agents involved in all aspects of the cognitive work. The experts’ knowledge is decentralized and is positionally placed among the perspectives of the community. Within this narrow space, experts are part of the crowd and must engage with the conflicting values, the chaotic background, and the turbulence of the community. A pluralistic design model, Vink argues, encourages reflexivity or epistemic perplexity, which causes the necessary friction to unsettle one's own assumptions about care in a hospital setting. Vink points out how individual and social frameworks may elicit epistemic perplexity. First, she discusses aesthetic friction, which aims to encourage individual self-reflection. Part of the intent of the design is to change the way caregivers relate to their patients in a hospital setting. The example of the dual tubing of the stethoscope invites the patient and the caregiver to listen to the patient's heart together. The modified stethoscope aims to open up a space where the caregiver and the patient mutually develop epistemic perplexities, which might bridge diverse perspectives in health. The double stethoscope offers a context of play and experimentation in dialogue with differently situated others. An aesthetic disruption of this sort aims to decentralize the epistemic labor involved in understanding the patient's health. I find this instrument interesting as it opens up a space where the patient is able to understand their bodily health more through modern medical technology, and it allows the caregiver the opportunity to learn more about the patient's values of health through a shared experience of listening to the heartbeat of the patient at the same time.Second, Vink acknowledges the limitations of generating the necessary friction that can take place at the individual level. For José Medina, individual accountability also is not enough in addressing the harms of epistemic injustice. Social institutions embedded within particular communities play a role in perpetuating hermeneutical injustice defined by Medina as “the kind of epistemic injustice that occurs when a subject is unfairly disadvantaged in her capacities to makes sense of her experience” (90). Some examples include the Women's Movement in attempting to draw attention to “the problem that has no name.” Additionally, Indigenous peoples’ activism to protect sacred places, such as mountains, rivers, or oceans, is rendered unintelligible within settler values of progress. In the context of health care, using my placenta example conceived within the hospital's hermeneutical structure, the placenta is dogmatically understood through a biomedical approach in which these alternative epistemologies forever remain inchoate or cast as an anomaly. Vink's use of the concept of the “uncommons” captures this fundamental hermeneutical incommensurability among communities. In developing pluralistic design models, the notion of the uncommons and its accompanying acceptance of ambiguous ends seems to offer opportunities for hospital administrators to interact with the community in ways that challenge the hermeneutical hospital frameworks that may center on a dominant design model.In general, I find Dr. Vink's analysis that encourages design models to facilitate openness and a critical reflexivity important in transforming the epistemic values of hospital administration. In what follows are a few critical comments that aim to draw out theoretical implications and generate discussion.First, from the figure depicting the uncommons, it seems that there are overlapping places that signify where the communities would engage each other; however, it is not clear if the space of engagement is always productive, depending on where one stands in relationships of power. For example, in the case of the placenta, the hospital, in enforcing antiquated rules, perpetrated epistemic injustice in reducing the concept of placentas as “biological human waste.” This very ontological framework imposed on the placenta was perceived by Native Hawaiian families as a type of social and moral death. The child's moral connection to the land is obliterated. While Vink acknowledges the risk of ontological occupation in which one way of viewing things overshadows other ways, the figure may overestimate the productive possibility in these spheres of interaction. This is not to say that resistant imaginations are stifled either, but it may mean that whatever productive interactions emerge may evade dominant ontological frameworks of the institutions. For example, doctors who knew families were taking the placenta home in coolers feigned ignorance of these outlaw tactics in the face of hospital administration. The doctor need not engage the meaning of the request of the families to take the placenta home. They can simply not tell the hospital administration. I suppose I want to emphasize that the spheres of interaction in the uncommons framework may not generate the necessary friction if the hermeneutical context prevents genuine interaction.Second, which relates to the first, it's unclear how epistemic friction is generated on an individual level when the larger hermeneutical framework of hospital administration stifles genuine interactions. Part of Medina's argument is that epistemic friction is experienced as challenging the epistemic agent's authority over knowledge, the burden of knowing best. The privileged epistemic agent would have to experience a loss of control of their authority over knowledge. Vink utilizes the metaphor of the stew, which emphasizes difference and marinated connections or opportunities to stew and interact with the culturally different other. In this example, while difference of the other is recognized by the knower, it is unclear whether there is enough epistemic friction to motivate a privileged knower to recognize their loss of control or authority over knowledge. How might the resistance of the privileged knower emerge if the power dynamics of the stew deeply saturate the very makeup of the stew? Moreover, resistant imaginations in a kaleidoscopic vision tend to resist dominant narratives of control and design. In the context of hospital administration, specific individual representatives of the hospital may need to adopt a resistant vision against the institution that employs them. What would that look like? Again, I am reminded that these resistant acts tend to occur at the subaltern level in which there is no change in the dominant hermeneutical framework rendering any possible individual experience of friction to merely hit an institutional brick wall. As a side note, following Medina's analysis, I prefer Maria Lugones's notion of curdling, in which milk curdles as the water is separated from the emulsion of the milk.Third, as I mentioned earlier, the framework of the uncommons recognizes incommensurability as a starting point. Vink argues, citing a point made in Marisol de la Cadena and Mario Blaser's A World of Many Worlds, that “[t]he uncommons is a coming together of heterogeneous groups where ongoing negotiations can take place toward a commons that never fully manifests, recognizing its ever-divergent starting point” (Vink 65). The framework of the uncommons is appealing, as there is no pre-determined common that is in view. This avoids the problem of ontological occupation leaving open an ambiguous future, which is necessary in cultivating a plurality of design model. However, it seems how the coming together of heterogeneous groups cannot be fully captured by ontologies of divergence and separation. In thinking about heterogeneous groups, it is important to also recognize relationships of dependency and reciprocity that bind communities together. Institutions of care are embedded within a community, and depend on the community in rendering their very practice and profession meaningful. Grace Lee Boggs is a key figure in articulating this relationship (see Boggs). The fact of dependency reveals the precarity and vulnerability between divergent communities and that careful care and attention need to be paid in restoring and replenishing those relationships. The relationships embedded in the uncommons underlie the notion of a broader community that is flexible to adapt to the fluidity of heterogeneous groups as they shift and change. This invites communities to transform, to be willing to transform, when relationships are articulated, recognized, and respected.This brings me to my fourth point. As I mentioned in my “Placental Ethics” article, learning about another culture ought not to take place in the boardroom or a seminar room. Though I appreciate the “Iceberg metaphor” and the “story unwriting” workshops, this, to me, speaks to a dominant mode of diversity or cultural sensitivity training that includes diverse perspectives but does not actively engage. I wonder if reflexive design can be thought of in the context of home or belonging, navigating the politics of care and settlement. How does a hospital care facility establish a place in communities to care for the members of the community? This is where I believe shared projects of hospitals need to emerge within the community. Though service projects that address specific ailments, such as cancer, obesity, and so on, are important, how might these health-related issues intersect with the larger hermeneutical framework of the communities that hospitals serve? Following Manu Meyers, contexts that awaken the sensual knowledge of the environment, through engagements with nature and the land may offer out-of-the-board/training room opportunities to become open to the ontologies or cosmologies of the community. I think this is especially important when serving Indigenous communities. In my article, I wondered: What if hospital administrators established a community garden or joined community leaders in service projects in the area? What if doctors, nurses, or administrators learned the indigenous names of plants, and learned the myths of the place they live in, as well as addressing the health needs of the community? How about creating a meal in the hospital kitchen with the elders? These deeply practical activities place health administrators in actual embodied engagement with the community and may prove to be the context in which hospital administration may confront their privilege and walk humbly, prepare food humbly, or care for a garden humbly in order to sympathetically learn about the health needs/values of a community.Finally, at the heart of pluralistic design models, it is essential to define/understand what well-being means in the community, which will then guide the practices of care. Well-being is a politically contested site that is not as self-evident as hospital administration might like to think it is. I defined placental ethics as “rethinking the conditions of knowledge in hospital settings in Hawaiʻi” (Bardwell-Jones 112). However, I have come to realize that placental epistemology must be placed within a broader context of politics, or placental politics. Chamorran Indigenous scholar Christine Taitano DeLisle examines the epistemic role of the pattera, or the nurse-midwife in conducting pattera ritual practices such as burying the placenta. According to DeLisle, despite the US military's efforts in stamping out Indigenous practices of placental and umbilical cord burying, which offended Western values of hygiene and well-being, patteras resisted these efforts and insistently held on to the “old values” even while integrating modern medical approaches to childbirth. Placental politics enact epistemic resistance in hermeneutically producing generative ontological frameworks that resist the colonial logics of hospital administration.Placental politics is an example of Indigenous feminism in asserting what the very definintions of care would look like. Care, in this sense, is bound up with values of self-determination that arises not from a nation-state identity, but from the land.She argues: the political, social and cultural act of burying the placenta can be regarded as a specific form of indigenous and gendered resistance against US naval colonialism, and that furthermore, such corporeal politics of foregrounding communal relations and stewardship of lands and people can be seen as pattera assertions of cultural self-determination. (DeLisle)Placental politics as a form of Indigenous feminism serves as an alternative epistemology that relates closely to practices of well-being not only for the individual mother and her child, but the wider human and more-than-human community that animates the birthing process. Placental politics when recognized in design models can offer new ways for settler colonial health administration to transform the way well-being is understood, to establish that standards of care may not be the design model to enact, and to be willing to accept and transform hospital ontologies revolving around care.Though I appreciated the modified stethoscope as a way of aesthetically disrupting the individual knower, a more radical metaphor that aesthetically disrupts the dominant hermeneutical framework of hospital administration is the placenta. The umbilical cordage figuratively binds knowers to the land, which in turn informs what values of well-being look like and the types of caring practices that are ritualized and enacted collectively. Similar to the modified stethoscope in which the caregiver and patient share an experience of co-constituting knowledge, the placental cordage extends to the wider community, binding deep moral connections with the land, which in turn guides our values and practices of well-being, health, and care. The resistant imagination necessary for hospital administration to manifest must avoid symbolic acts of inclusion and take up a courageous political stance against asserting settler colonial, capitalistic, racist, and sexist ideologies bound up within the ontologies of the hospital administration.