The importance of theories in health careBMJ 1998; 317 doi: https://doi.org/10.1136/bmj.317.7164.1007 (Published 10 October 1998) Cite this as: BMJ 1998;317:1007
- Priscilla Alderson, reader in sociology ()
Series editor: Priscilla Alderson
This is the first in a series of six articles on the importance of theories and valuesin health research
“Medical journals and research funders are mainly concerned with practical factual research, not with research that develops theories.” This widespread view includes several assumptions: that research and facts can be separated from theory; that considering theories is not necessarily practical or useful; and that thinking about theories means developing them.
But theories are at the heart of practice, planning, and research. All thinking involvges theories, and it is not necessary to read academic texts about theories before using them—any more than it is essential to read texts on reproductive medicine before having a baby. Because theories powerfully influence how evidence is collected, analysed, understood, and used, it is practical and scientific to examine them. Hypotheses are explicit, but when theories are implicit their power to clarify or to confuse, and to reveal or obscure new insights, can work unnoticed.
Theories are integral to healthcare practice, promotion, and research
The choice of theory, although often unacknowledged, shapes the way practitioners and researchers collect and interpret evidence
Theories range from explicit hypotheses to working models and frameworks of thinking about reality
It is important, scientifically and practically, to recognise implicit theories: they powerfully influence understandings of health care
A scientist gazing through a microscope symbolises positivist objective examination, the distance and difference between the observer and the observed, the effort to examine intensely the tiniest part isolated from its context, the use of reliable, visible “hard” data. In medicine, the emphasis on specific body parts, conditions, and treatments assumes that these are universally constant, replicable facts. Positivism aims to discover general laws about relations between phenomena, particularly cause and effect. Experiments are designed to measure and explain associations and to test whether a law can be disproved.
Types of theories
Basic beliefs about:
What counts as knowledge and how it is produced
How we can know anything
The meaning and purpose of things
The nature and working of things
Theoretical frameworks about facts and reality, including:
Beliefs about society, policy and relationships, such as:
Disciplines, such as surgery, chemistry, genetics, which each include many theories or ways of seeing things and technical ways of describing them
Theories that explain values and personal aims and motives, priorities, and preferences
Working theories that explain systems and are accepted unless they are superseded by a different explanation1—for example, Harvey's theory of circulation of the blood, Lister's theory of antisepsis, Darwin's theory of evolution, beliefs about how disability is genetically or socially determined
Explicitly stated theories:
Researchers put pain under the microscope when they develop and test analgesics and measure patients' physiological responses. One example is a randomised trial of babies having surgery with or without analgesia.2 Physiological tests showed “massive shock reactions” in the babies not given analgesia. The evidence questioned the standard treatment of withholding analgesia and the theories that babies cannot experience pain.
The four hourly hospital drug round expresses positivist beliefs that clinical norms and standard treatments can be set for effective pain control. Positivism's concentration on the body and brain sees real pain as neurological reactions to visibly damaged tissue, like Descartes's view of a “mechanism” of impulses travelling from the damaged site to the brain, as when “pulling on one end of a cord, one simultaneously rings a bell which hangs at the opposite end.”3
Pain relief has been refined through rigorous experiment and cautious insistence on firm evidence. Yet pain is a paradox: an intense personal sensation, it provides no direct, reliable evidence for the observer. Positivism's strength in precise observation can be a limitation when pain is being assessed. Concern about overestimating pain and overprescribing analgesics deters clinicians from treating pain adequately.4 A possibly greater deterrent is that, to understand pain better, clinicians have also to think partly in non-positivist ways: to accept patients' subjective views and see pain as more than physical, involving the mind as well as the body.
Positivist theories in social medicine
Positivist theories in social medicine take some account of context but tend to see the social in physical terms, like seeing how people's estimations and expressions of pain differ by age, sex, or race. The separate parts are still emphasised, as separate variables, rather than the meanings of all the parts and the whole being connected. Positivist concern with cause and effect, like the pain caused by burns, tends to perceive responses as predictable reactions rather than personal choices and motives. This can make people look rather mindless, passively driven by certain characteristics, superficial beliefs, or brief experiences like a few counselling sessions to reduce depression. Demographic surveys help to predict individuals' likely choices, but do not explain these: why, for example, do women accept or refuse analgesia during childbirth—and how deeply is refusal linked to their values and their beliefs about becoming a mother? Positivist dichotomies also cannot capture ambiguities, such as the way some people dread yet value pain, or fear yet long for recommended surgery.
Groups of people who were once assumed to require punishment are increasingly being treated as sick: alcoholics are given counselling, children with behavioural difficulties are given ritalin. Treatment tends to deal with the individual rather than the context; causes for behaviour are sought within the child's body, rather than in family relationships, education policies, or town planning. Although they originate from personal accounts, medical records of reported pain and distress tend to be treated as firm facts and as the grounds for treatment and research processes—rather like a solid road that supports traffic.
Consensus about the solid facts of positivism fits broadly with the solid morality of functionalism, which sees society as a single organism in which every part functions to the benefit of every other part: doctors are principled and benign, and patients adopt a sick role, wanting to recover and to comply with treatment.5 The deviant minority that does not conform should be reformed or excluded to maintain the status quo. In some societies, an important means of regulation is the use of pain as a punishment and deterrent.
A contrasting approach to positivism is to believe that there is not a single view or truth, and that a range of views can be valid in different ways. It is then possible to attend to different voices. Instead of being treated as agreed facts like a solid road, phenomena are seen as more like part of an ocean affected by tides and currents, shifting lights and opaque depths. People construct evidence through their own experience, and observers inevitably join in this activity—whether they try to take a surface or a submerged view. There is no neutral, objective perspective; whatever the origins of the pain, the experience and the observers' responses are deeply personal. The complex meanings of pain and disease can be seen as questions or problems instead of given facts.
In trying to take nothing for granted and to see reality in a new light, phenomenology or the study of phenomena (one of a range of social construction theories) takes the view of a questioning outsider rather than an accustomed insider. The aim is to see how actors make sense of their experiences, how they try to rationalise and cope with pain. Their reported intentions and motives are seen as more relevant to explanations than are external causes—so, for example, clinicians would discuss with patients their views on possible causes and cures for their suffering. Concepts of individual pain thresholds and innovations like patient controlled analgesia, along with the hospice movement's care for the whole thinking-feeling person, acknowledge that pain is more than physical or generally measurable. The mind's organisation of perceptions, and emotions of fear or hope, affect physical pain in ways that positivism's separation of body from mind cannot address.
Within social construction theories, researchers' and practitioners' relationships with patients, instead of being ignored or being controlled to reduce bias, are seen as areas worth researching in their own right. The words and gestures during interactions are investigated for how they symbolise larger issues, such as the way doctors maintain their professional authority. Patients also influence doctors through spoken and unspoken signals about their health, understanding, and social background and, guided by their interpretation of these signals, doctors tend to adapt their behaviour and language—which in turn alters the patients' responses, in mutually changing perceptions and behaviours. (Positivist blind and double blind trials acknowledge these interactions and try to cancel them out as unwanted variables, such as placebo effects.)
Social construction theories consider how doctors do not simply reveal realities but construct and reconstruct, for example, their patients (as “informed and articulate” or as “that difficult adolescent”), whereas patients reconstruct their doctors (as “caring” or “vague”) and themselves (when they accept or resist becoming the kind of person the doctor supposes them to be). Research within a social construction framework takes account of the expectations and values, backgrounds, and roles of the main groups concerned, as well as the organisation of the clinic or ward; the time, space, and funding allowed; and professional and political influences on how meanings of pain and anxiety are expressed, perceived, and reconstructed.6
Social context and personal identity overlap for both the patient and the doctor. Our beliefs, values, language, and habits cannot easily be detached and changed but are part of our identity, and this raises troubling questions about the extent of free will and autonomy. Attempts to alter people's responses, such as to control chronic pain or to promote a healthier lifestyle, are more likely to succeed when the social context is seen not as a set of separate variables but as a complicated, overlapping mixture of many interacting factors. Pain as partly a social construction, at the intersection of body, mind, and culture, varies according to complex personal differences,7 and effective health care is sensitive to these.
In postmodernism, boundaries are broken down. Three centuries of modern science are founded on sharp dichotomies: the binary system used in computers, life/death, mother/child. Yet life/death certainties are challenged by concepts of persistent vegetative state, and reproductive medicine creates new meanings of motherhood. Doctors have been described as being among the first to create postmodern society in practice and among the last to acknowledge it in theory8; greater use of postmodern thinking could clarify current medical uncertainties. Postmodernists are sceptical about what truth is, what counts as knowledge, and who can determine the validity or worth of any enterprise. They explore how experience and even the apparent fabric of the body are constructed through discourse and power and through changes in medical practice.9 They examine how concepts—masculinity or whiteness, for example—illuminate their supposed opposites but also share characteristics with them, as discussed in later papers in this series. 10 11 They consider the mysterious relations between mind and body, as when intense pain makes the body feel alien: it constricts thought in some ways, but intensifies it in others in the desperate urge to explain the anguish and find relief. Such disruptive pain seems to “shatter the self [into a series of] lived oppositions.”12 This attention to different voices, like those of the “deviant” patients with intractable pain, can help practitioners to give more informed and empathic care.
Showing how people make different but valid sense of experience makes critical theory possible as a rational framework. Critical theory does not see society as a well functioning organism—it sees society as a collection of many factions competing for power and resources. Doctors are partly agents of social control with divided loyalties that face them when, for example, they decide who is eligible for medical or psychiatric treatment for pain, or for sickness benefits. Instead of seeing deviants as a minority of outsiders, critical theorists show how large groups of people are constructed as inadequate or disabled through their circumstances, such as poverty, instead of through their own failings.13 Sick and disabled people are respected as the source of valuable knowledge uniquely gained through adversity. By bridging dualisms between professional and lay knowledge or able and disabled groups, critical theory verges on postmodernism; but postmodernism does not share its radical politics. In contrast to the emphasis in the earlier approaches on treating people who have diseases, critical theorists also look at how political change might prevent and reduce painful disease, such as by reducing inequalities or pollution.
Some of these theories explore new ways of understanding the enigma of pain. The hospice approach could not simply arrive: new theories about bodies, minds, and pain beyond positivism first had to be developed, and recalled from earlier centuries, and accepted. Each approach has strengths and limitations; positivist medicine is effective, for example, in diagnosing and treating angina, whereas within social construction and critical theory, research and practice can look more broadly at how angina is exacerbated, experienced, interpreted, managed, and, in the longer term, prevented.
I am grateful to the other authors in the series, and to David Armstrong, Gillian Bendelow, Tony Delamothe, Richenda Power, and Simon Williams.