Editorial
I know, some jobs are harder, lower paid, and generally less rewarding than those in Academe. But keeping up with academic work can also be quite stressful. Now in the first weeks of summer, if you’re like me, you are imagining that this summer you’ll find time to catch up. Don’t let me be the one to disillusion you (as if you really needed disillusionment). Spend your summer as best you can – catching up not only on reading, writing, and presenting papers, but also on sleeping, socializing, travelling, and … well, simply enjoying life.
I plan to do the same – catch up as best I can with work tasks while also spending plenty of leisure time at home, in the garden, out on my bike, and in the woods. This issue is a first step in catching up at work. What with so many events scheduled in the summer, we need to get the announcements out. Book reviews also have a limited shelf life. And we need to lend our showcase spot to recent graduates looking for jobs come fall. So without spending overmuch time recruiting in further reviews and comments, I’ll send this short, summer issue on its way. Look for another issue in early fall, short or long depending on what you readers/contributors send me. Then look for a double-issue around the New Year. By then I also hope to have an open forum up and running, at least on a trial basis, for discussion of matters taken up in the Review. Depending, of course, on my getting caught up on that task this summer.
Meanwhile, I think I’ll leave you guessing about the same cover illustration one more round. Is there really nobody who dares to venture a guess? Here’s one idea to get you started: Envision this in its full original colour – gold-speckled yellow and dark-outlined electric blue. Now wouldn’t this make a lovely dinner plate design for the Royal Horological Society?
Technology has a prominent position in current discussions about the future development of health care. At the same time, however, health technology has proved to be an area which political, medical, scientific and patient audiences have found hard to come to terms with. The problem of health technology clarifies some of the key issues that make health technology such a complex and elusive topic. The book aims to “illuminate the main layers of scientific and policy arguments about the ‘problem of health technology’ that are currently deployed in various industrialized countries and to show why and how they are misleading” (xviii). By bridging the fields of health technology assessment (HTA) and science and technology studies (S&TS), Lehoux further seeks “to develop an alternative conceptualization of health technology as it is used in industrialized health care systems”(Ibid). Indeed, the chosen starting points provide two articulated, yet rather different rationales for trying to come to terms with the complexity of technical change in health care settings.
The book begins by setting out the concerns that spurred HTA and the promises it suggests. The constantly rising costs of health care create ambitions for and debates about the role of technology. It is commonly argued that new technology lowers costs, but it is almost as regularly claimed that it merely leads to more sophisticated and expensive treatments. Issues of patient safety, a flood of new candidates for future health technology, uneven rates of adoption and so on all contribute to the mandate of somehow trying to gain evidence about which technologies and treatments are effective and which are not. In Lehoux’s view, the answer that HTA provides rests on several common conceptions about how technologies and scientific evaluation are understood. HTA views technologies as neutral tools, which can be sorted into good ones (to be supported and diffused) and bad ones (to be limited) on the basis of their cost, efficiency, and safety. This is done preferably by accumulating rigorous evidence, such as that produced in gold standard randomized clinical trials.
Lehoux provides a clear round-up of empirical facts about health technology that undermine such a view. Various rationing and ethical issues related to health technologies complicate apparently clear cut cost-benefit classifications and further decision making. Denying access to health technology is a highly contested policy option: some effective technologies have few beneficiaries; other life-prolonging ones may lead to poor quality of life, and so on. HTA’s understanding of its societal purpose—revolving around rational, collective use of health technology—leads to another set of pitfalls. In reality there are multiple goals for health provision that are variable and can conflict on both individual and organizational levels. Furthermore, the desirability of technology hinges on clinical and social practices, which, Lehoux argues, calls for integrating several different disciplinary perspectives into the current epistemic basis of HTA, as do issues concerning the decision-making process and the interrelation of and institutional links between HTA producers and the range of stakeholders in the evaluations.
The empirical criticism is intertwined well with conceptual clarifications based on ethnographic S&TS work on implementing, using and evaluating health technologies. For an S&TS reader, a great part of the attraction of the book is that it reviews in great clarity several strands of S&TS literature, which tend to remain somewhat isolated due to different debates, data, theories, style of argumentation. These strands include: a) critique of narrow positivistic scientific rationality in evaluation (for example in HTA and health economics); b) analyzing “what technologies do” both in the sense of the huge range of different functions, activities and issues there are with different “technology” as well as how various health technologies affect people and how they do not (as an antidote to piecemeal and overly simplistic accounts of technology); c) an analysis of stakeholder groups, their commitments, resources, and interests, and patterns of interaction around health technology; d) engaging with political theory about what should be discussed in relation to change and transformation of work, treatment and resource allocation.
While the book is primarily a critique of HTA, it is in many ways a healthy critique of S&TS as well, particularly with regard to the questions about the ability of S&TS to engage productively with real-life problems. Lehoux’s overarching and explicit question is, after all, the normative “how and when do we know a given innovation is better?” Her answer is, in short, an outline of how to turn the above fields of inquiry into an integrated alternative framework for thinking about evaluation of and deliberations related to health technology. 1) As technology embodies and reinforces values, evaluation is a process that requires making values explicit. 2) As innovations can perform effectively only as part of socio-technical networks that embody multiple norms, the enabling/constraining effects of technology need to be articulated jointly in relation to both current and potential practice. 3) As health technology is a public-private good that is open to public policy interventions, reflexive science is produced within socio-political projects. 4) As the framing of policy is vital, civil society should be made a pivotal locus of transparent and public deliberations. 5) As industry develops health technology largely on the basis of its own logic, the role of the private sector within publicly-funded health care systems needs to be made explicit.
This message is hopeful. Even in highly complex matters such as health technology, fair and open deliberation can do better than the opaque dealings of an expert elite. While it is easy to hope sincerely that this optimism is warranted, the book suffers from a slight lack of reflection on the limits and pitfalls of the proposed approach. The basis for a positive stance towards political processes, and seeing health technology as being a fundamentally governable process should perhaps have been discussed more explicitly and thoroughly. For instance, arguing for an expansion of the disciplinary basis of HTA requires a more thorough discussion of the potential risks involved in such a diversification of what counts as evidence. This is underscored by how the book stresses that HTA is being used as just one resource in political decisions and industry actions. When diverse political interests, different sets of arguments and of information are contrasted, something that bears resemblance to randomized clinical trial is likely to be a trump-card in arguing for or against decisions. Such HTA evidence is harder, relatively, to debunk (by politicians, laity as well as experts) than is empirical ethics or S&TS ethnography, regardless how those of us doing such research would perceive its evidentiary value. Thus, while arguing for a broadening of evaluation methods, and recognizing the political connections of HTA, one would expect discussion of to what extent such broadening is sensible practically and how it is not, in the context of policy processes between stakeholder groups.
There is also a relative neglect of dynamics upstream of evaluation, and how HTA effects actual company practices (as opposed to their discourse about it). Industry is discussed only in terms of characteristics of “design” and as the “big bad wolf”, the multinational, multibillion-dollar enterprises in the pharmaceuticals and medical equipment. The majority of medical technology companies, excluding pharmaceuticals, are SMEs, throughout the Western world. The rationality and calculability of innovation can easily get over-emphasized when “industry” equals companies that can choose from hundreds of promising projects those few that have the greatest commercial potential and happen to fit their own product portfolios. This rationality is also emphasized by focussing on “design” rather than “development of health technology innovation”, as if artefacts were produced during a singular process of designing. Here the book neglects work done in S&TS on innovation trajectories and other detailed case histories of the development of new technology. These insights about uncertainty about the stakeholders and their requirements and the technical shape of an eventually realizable and viable innovation would have brought in an important nuance to the book. The ways HTA – and its potential improvements – is linked to the upstream of producing desirable health technology is importantly affected by how the upstream processes are shaped and how HTA features there.
As is the explicit aim of The problem of health technology, the multiple perspectives covered make the book valuable for many different audiences, ranging from HTA practitioners to policymakers, and from patient-advocacy groups to people pursuing research in several areas of S&TS. Lehoux presents a range of topics and debates around health technology in a careful and instructive manner, which increases the value of the book as course material on health technology. Due to the broad scope covered, the discussion risks being trivial at times for a specialist in any one of the topics it covers, but nevertheless, the book has the appealing quality (and ample capacity!) of offering a fresh perspective on a less familiar body of knowledge on the very next page.
Sampsa Hyysalo is affiliated with the Helsinki Collegium for Advanced Studies, University of Helsinki, Finland