Abstract
In this contribution, I wish to explore the potential of health technology assessment and ethics for increasing our capacity to pre-empt the shortcomings and undesired consequences of modern health care while maintaining its benefits. Central is the presumption that in case of some health problems this cannot be done unless we explicitly reconsider some features of the modern health care system, especially those related to its strong reliance on scientific rationality and the strong role played by medical professionals.
So as to both maintain the benefits of advanced health careand ensure that it produces less reason for concern, we need to reconsider our approach to rationality—and maybe even the way in which we build our health care system around that rationality. That is, we need to introduce an element of reflexivity. Two types of circumstances are being explored in which such reflexivity may prove worthwhile: controversies on side effects, and persistent problems encountered in optimising health care. Drawing on brief discussions of typical cases, we explore the potential of reflexive HTA and its methodical prerequisites.
We conclude that ethicists may contribute to reflexive HTA, if they combine a hermeneutic—and often also participative—methodology with a solid understanding of the relation between the health problem under scrutiny and more general critique of the health care system. Insights from the areas of science and technology studies, as well as from social philosophy may be critical items in their tool kit.
Zusammenfassung
In diesem Beitrag untersuche ich das Potential von HTA und Ethik zur Verbesserung unserer Fähigkeit, Mängel und unerwünschte Folgen moderner Gesundheitsversorgung abzuwenden, ohne auf ihren Nutzen verzichten zu müssen. Dabei ist die Annahme zentral, dass dies für manche Gesundheitsprobleme nicht erreicht werden kann, ohne einige der Merkmale des modernen Gesundheitssystems explizit zu überdenken, besonders jene in Zusammenhang mit der starken Abhängigkeit des Systems von wissenschaftlicher Rationalität und der bedeutenden Rolle, die die medizinischen Berufe darin spielen.
Um den Nutzen eines fortgeschrittenen Gesundheitssystems zu erhaltenund zugleich sicherzustellen, dass dieses System weniger Anlass zur Sorge gibt, müssen wir unseren Zugang zu Rationalität – und vielleicht gar die Art, wie wir unser Gesundheitssystem um diese Rationalität herum konstruieren – neu überdenken. Das heißt, wir müssen ein Element von Reflexivität einführen. In diesem Beitrag werden zwei Typen von Umständen untersucht, in denen sich solche Reflexivität als lohnend erweisen könnte: Kontroversen um Nebenwirkungen und anhaltende Probleme im Prozess der Optimierung der Gesundheitsversorgung. Anhand typischer Fälle, die hier kurz diskutiert werden, untersuchen wir das Potential reflexiver HTA and ihre methodischen Voraussetzungen.
Wir folgern, dass Ethiker einen Beitrag zu reflexiver HTA leisten können, wenn sie eine hermeneutische – und oft auch partizipative – Methodologie mit einem soliden Verständnis der Beziehung zwischen dem fraglichen Gesundheitsproblem und einer allgemeineren Kritik des Gesundheitssystems kombinieren. Einsichten aus Studien über Wissenschaft und Technologie und aus der Sozialphilosophie könnten sich hier für den Ethiker als wichtige Instrumente erweisen.
Résumé
Dans cet article, je souhaite explorer la capacité de l’évaluation des technologies médicales et de l’éthique à accroître notre faculté à éviter les insuffisances et les conséquences indésirables des systèmes modernes de santé, tout en conservant leurs bénéfices. Le critère central de ce postulat est que pour un certain nombre de problèmes de santé, ceci n’est pas possible sans que nous reconsidérions de façon explicite certaines caractéristiques du système moderne de la santé, en particulier celles qui dépendent fortement de la rationalité scientifique et du rôle important joué par les professionnels de la médecine.
Pour maintenir l’utilité d’un système de santé progressisteet garantir qu’il donne moins matière à préoccupation, nous devons repenser notre approche de la rationalité, et peut-être même la manière dont nous structurons notre système de santé autour de ce concept de rationalité. Cela signifie que nous devons introduire un élément de réflectivité. Sont étudiés ici deux types de circonstances dans lesquelles une telle réflectivité peut s’avérer utile : les controverses sur les effets secondaires et les problèmes persistants rencontrés dans l’optimisation des prestations de santé. Sur la base d’une brève discussion sur des cas typiques, nous étudions le potentiel d’une ETS réflective et ses prémisses méthodologiques.
Nous en concluons que les éthiciens peuvent contribuer à une ETS réflective s’ils combinent une méthodologie herméneutique, et souvent participative, à une solide compréhension de la relation entre les problèmes de santé faisant l’objet d’un débat et une critique plus générale du système de santé. La connaissance des études réalisées dans les domaines de la science et de la technologie, de même que de la philosophie sociale, peuvent s’avérer pour eux des outils de travail essentiels.
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Notes
I wish to clarify at the outset that the term ‘system’ as I use it does not refer to the more or less rigid, autopoietic type of systems some literature, especially that based on Luhmann or classical system dynamics. Rather, I am using it more loosely to refer to the interconnected whole of actors and structure (including rule, physical infrastructure, knowledge infrastructure, culture) in which action around a particular societal problematic (e.g., health care or agriculture) takes place. Although systems do show relative constancy and are recursive, they are continuously transforming themselves, their (mutual) boundaries may be redefined and their recursive nature does not exclude that this is being done in discursive processes. Thus I adopt a perspective compatible with, for example, Giddens’ (1984) theory of structuration; cf. Fox and Miller (1996).
This need for reflexivity has been a major theme in philosophy and macro-sociology over the past few years. Toulmin (1991, 2001) has argued that we need to “return [from Rationality] to Reason.” Beck (1990, 1997) has argued for a “reflexive modernization” that uses our rationality to maintain the progress and mitigate the side effects brought by simple modernization, while avoiding the pitfalls of post-modernization. Giddens (1991) has also stressed the need for reflexive modernisation, stressing the need to reconsider highly specialized expertise-centred systems and the ways in which they contribute to identity formation. In philosophy, the interest in questioning the implications of all this in terms of reconsidering rationality has expressed itself through a renewed interest in scepticism (e.g., Laursen 1992). Also, as Bernstein (1988) shows in a subtle and thought-provoking quest, the relation between critique and post-modern thought requires a reconsideration of the need for and nature of ‘grounding’ both rationality and critique.
It is important to recognize here that ‘reflexivity’ involves more than merely reflectivity, especially since the two terms are now increasingly being used as synonyms. ‘Reflexive’ denotes that not only a particular medical intervention and its application context should be object of scrutiny, but that also essential features of the wider context, the health care system, should be scrutinised: the assessment ‘bends back’ (re-flexes) onto the system in which it takes place. Reflexivity implies self-criticality.
Grin and van de Graaf (1996a) and Grin et al. (1997) have proposed a method for interactive technology assessment, based on Guba and Lincoln’s (1989) hermeneutic evaluation methodology, which has been further developed and applied to health problems by Reuzel (2002, this issue). Fischer (1991) has proposed a participatory form of risk analysis. For comparative analyses of interactive TA practices, see Hoppe and Grin (1995, 2000); and Joss et al. (2002).
More specifically, in this case, what Achterhuis has called ‘anticipatory regret’ seems to play a role: never discard an option that may help you.
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Second version (April 2003) of a Paper prepared for the Session ‘Integrating Ethical Inquiry and Health Technology Assessment, ISTHAC Conference, Berlin, June 2002.
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Grin, J. Health technology assessment between our health care system and our health. Poiesis Prax 2, 157–174 (2004). https://doi.org/10.1007/s10202-003-0049-y
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DOI: https://doi.org/10.1007/s10202-003-0049-y