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Rapid Responses: Rapid Responses published:
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Scientific advice needs social relevance
- Sethuraman K Raman (3 December 2004)
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This isn't what it's about
- Bebe Loff (3 December 2004)
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Secrecy and democracy don't mix
- John R Kemm (9 December 2004)
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Sethuraman K Raman, Director-Professor of Medicine JIPMER, Pondicherry 605006, India.
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Scientific advice often lacks holistic vision. A respected text-book of Infectious Diseases (1993 edition) had recommended MRI scan as the best way of imaging inflamed sinuses! Such "evidence at any cost" approach is just one example of science without social relevance. Most of the 'Evidence based medicine' has also gone in to such reductionist mode. In India, it is estimated by several surveys that two-thirds of indebtedness is due to health care expenditure. Most of the patients admitted to my wards are such victims who have run out of all their resources half way through the 'initial work up.' At least in the third world, we urgently need scientific guidelines vetted by social scientists and informed members of the public to make it holistic and relevant to their aspirations and capacities. Competing interests: None declared |
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Bebe Loff, Head, Human Rights and Bioethics Monash University, Australia 3181
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Bal et al noted with approval the comment of the House of Lords select committee on science and technology: "framing the problem wrongly by excluding moral, social, ethical and other concerns invites hostility." Who frames the problem, shapes how it is framed and thus how it will be resolved. We know this. We also know that priorities are determined by experts and vested interests, not need. Time and time again transparency and public participation is reduced to the opportunity to respond to a discussion paper, to speak at a public hearing or to be included as a lay person on a committee. There might even be the chance to participate in a focus group. Public input is at the edges. Is this participation? Is this transparency? I think not. Participation is a human right. However it is a right seeking a meaning. What might some alternative options be? Local government in many countries has had long standing responsibilities for the preservation of public health. What if it were the case that before central or provincial governments were entitled to introduce a new public health programme or policy a minimum period of a year had to be set aside for consultation run through the mechanism of local government. Perhaps community health centres might be resourced to fulfill such a function. What might constitute consultation would be strictly set out and it would not be the simple issuing of a paper. Government would need to prioritise the vulnerable and disempowered and physically get out of the office visit, sit down and discuss. A very different decision making process. Much more time and perhaps resource intensive. This probably allows for far fewer significant decisions to be taken over the life of a government. However the current pace of decision making seems to contribute very little to health and wellbeing. We seem to be so wedded to a couple of insufficient options that looking beyond them is too much of a challenge. But there are many small examples that are easily replicated if there was the will. One such example is work by Hannah Walker and Tony LaMontagne to determine how people in a community in Australia viewed asbestos issues and then what they thought should be done about them. Surely the human imagination is not so bereft that we cannot find workable mechanisms for something that more closely resembles what is intended by the word "participation". "Participation" is promoted, indeed required, in just about every significant document dealing with health and with human rights. We should be able to do better. Competing interests: None declared |
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John R Kemm, Public health physician Birmingham
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Bal and colleagues struggle nobly to show that “concealing information from public scrutiny” is a necessary condition for “democratic function” but fail. The fault in their argument is the assumption that an advisory committee should alone decide how the question is framed, how different types of evidence should be privileged and how the “performance” should be presented. Similar debates have been vigorously pursued within the Health Impact Assessment community. Dissention within the scientific community is not a problem that should be hidden from an ignorant public but a fundamental mechanism in the advancement of knowledge. It is true that knowledge of temporary or continued dissention will be used naively or even mischievously and so confuse issues but that is no excuse for hiding the process by which conclusions are reached. Scientific reasoning is a powerful tool for improving public decision making but it is not sufficient. Account has to be taken of lay knowledge. Experiential evidence, which covers far more than experience of disease, is one part of this. “Irrational” concerns (better described as differently rational) and values also have to be taken into account as do all the messy considerations of political possibility. It is understandable that scientists should seek to avoid the complexity of wicked problems by retreating into secrecy but benign paternalism is no answer to mature democratic making of public policy. Competing interests: None declared |
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