Archives For consensus

Author information: Jeroen Van Bouwel, Ghent University, Belgium, jeroen.vanbouwel@ugent.be; Michiel Van Oudheusden, SKC-CEN Belgian Nuclear Research Centre and University of Leuven, Belgium.

Van Bouwel, Jeroen and and Michiel Van Oudheusden. “Beyond Consensus? A Reply to Alan Irwin.” Social Epistemology Review and Reply Collective 6, no. 10 (2017): 48-53.

The pdf of the article includes specific page numbers. Shortlink: http://wp.me/p1Bfg0-3Pq

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Image from Alex Brown via Flickr

 

We are grateful to Alan Irwin for his constructive response, “Agreeing to Differ?” to our paper and, notwithstanding differences between his view and ours, we agree with many of his comments. In this short rejoinder, we zoom in on the three main issues Irwin raises. We also use this opportunity to highlight and further develop some of our ideas.

The three issues Irwin brings up are:

How to understand consensus? Rather than, or along with, a thin ‘Anglo-Saxon’ sense of consensus as mutual agreement, one could adopt a thick conception of consensus, implying “faith in the common good and commitment to building a shared culture” (Irwin 2017). The thick sense (as enacted in Danish culture) suggests that disagreement is an integral part of consensus. Therefore, we would do well to pay more attention to conflict handling and disagreement within consensus-oriented discourse.

Why are so many public participation activities consensus-driven? We should question the institutional and political contexts within which consensus-seeking arises and how these contexts urge us to turn away from conflict and disagreement. And, why do public participation activities persist at all, given all the criticism they receive from various sides?

Should we not value the art of closure, of finding ways to make agreements, particularly in view of the dire state of world politics today?

These are legitimate questions and concerns, and Irwin is right to point them out. However, we believe some of the concepts discussed in our paper are helpful in addressing them. Let us start with the first issue Irwin raises, which we will link to the concept of meta-consensus.

Meta-Consensus

It is indeed helpful to draw a distinction between the thinner Anglo-Saxon sense of consensus and the thicker sense of consensus as faith in the common good, as Irwin suggests. In the latter sense, disagreement and dissensus can be seen as part of the consensus. We fully agree with Irwin that consensus and dissensus should be thought together rather than presented only in terms of contradiction and opposition. This is why we analytically distinguish a (simple) consensus from a meta-consensus.

As we sketch in our article, at the simple level, we might encounter disagreement and value pluralism, whereas at the meta-level, the meta-consensus provides a common ground for participation by explicitly or implicitly laying out the rules of engagement, the collective ways to handle conflict, and how to close or disclose discussion. The meta-consensus also impinges on the scope of issues that is opened to discussion, who may or may not participate, the stopping rules, the structure of interaction, and the rationales and procedures that guide participation in general.

We have sought to put this meta-consensus center stage by comparing and contrasting how it is enacted in, or through, two participation cases (participatory TA and the NIH consensus conference). In this way, we seek to give due attention to the common ground that enables and constrains consensus and dissensus formation, and to different institutional designs impinging on participation, without insisting on the necessity of a simple consensus or the need for closure.

Drawing attention to the meta-consensus that governs participation may help to facilitate more reflexive modes of engagement that can be opened to joint discussion rather than imposed on participants. It should also help participants to better understand when and why they are in disagreement and determine courses of action when this is the case. As such, it may contribute to “building a shared culture” by facilitating and by establishing a shared adhesion to the principles of inclusion, mutual listening, and respect (cf. Horst and Irwin 2010; Irwin 2017). However, we believe it is equally important to emphasize that there is always the possibility of dissensus, irreconciliation, and further conflict.

As we see it, entertaining this possibility is an important prerequisite or condition for genuine participation, as it creates an open and contested space in which participants can think, and engage, as adversaries. Thus, we concur with Irwin that consensus and dissensus both have a place in public participatory exercises (and in the public sphere more generally). However, when we are faced with a choice between them (as with fundamental disputes, such as those over abortion or human enhancement), we must carefully consider how, whether, and why we seek (dis)agreement. This is not to argue against consensus-seeking, but to insist on the importance of constructing and sustaining an agonistic, contestable order within participation.

Different Democratic Models of Participation

Irwin appropriately proposes to reflect more on the institutional and political contexts in which participation is organized. The question why we aim for consensus in public participation activities, as well as the broader question of why public participation activities persist at all, do indeed deserve more attention. We have not addressed these questions in our paper, but we do think being more explicit about the aims of participation is an integral part of the approach that we are advocating. In order to discuss and choose among the different democratic models of participation (aggregative, deliberative, participatory, and agonistic), it is imperative that we understand their political, economic, and social purposes or roles and make these explicit.

Similarly, we may ask how the models serve different aims within specific institutional and political contexts. Here, the notion of political culture springs to mind, as in our region (Flanders) and country (Belgium), conflicts and divisions between groups are often managed through social concertation between trade unions, employers’ organizations, and governments. This collective bargaining approach both challenges and complements more participatory modes of decision making (Van Oudheusden et al. 2015). As mentioned earlier, we do not consider this issue in our paper but it is well worthy of further reflection and consideration.

Irwin also wonders whether policy makers might think our concepts and models of participation miss the point as many of them see it. It is an interesting question (we wonder whether Irwin has any particular cases in mind), but one thing we can do is to insist that there is no one-size-fits-all approach to participation. Different options are available, as each participation model has strengths and weaknesses. It seems important to us to attend to these strengths and weaknesses, as the models designate roles and responsibilities (e.g. by specifying who is included in participation and how), foresee how the collective should interact and indicate what kinds of results may ensue from participatory practice. By juxtaposing them, we get a better picture of how problems, contexts, and challenges are framed and handled differently within each participatory setting. As making trade-offs between approaches is at the heart of policymaking, we invite policy makers (and decision makers more broadly) to explore these settings with us, and carefully consider how they embed multiple social and techno-scientific values and orientations.

Disclosure

As Irwin rightly notes in his reply, we do not propose one final alternative to existing practice but entertain the possibility of mobilizing more than one model of democracy in participation. This implies that we also allow for a consensual approach when it is warranted. However, in developing ideals that contrast with consensus, we open onto disclosure and a more agonistic appraisal of participation, thereby abandoning the ideal, and appeal, of final closure. In response to this move, Irwin wonders whether we should not value the art of closure, especially in these times. While we agree on the dire state of world politics, we are not convinced that replacing closure by disclosure would aggravate the present situation. Perhaps the contrary is true. What if the quest for consensus brought us to this situation in the first place?

As the political theorist Chantal Mouffe argues, in a world of consensual politics (also characterized as neoliberal, de-politicized or post-political, or in Mouffe’s words as a “politics of the center”), many voters turn to populists to voice their dissatisfaction (Mouffe 2005: 228). Populists build on this dissatisfaction, publicly presenting themselves as the only real alternative to the status quo. Thus, consensual politics contributes to hardening the opposition between those who are in (the establishment) and those who are out (the outsiders). In this antagonistic relation, the insiders carry the blame for the present state of affairs.

This tension is exacerbated through the blurring of the boundaries between the political left and right, as conflicts can no longer be expressed through the traditional democratic channels hitherto provided by party politics. Thus, well-intentioned attempts by “Third Way” thinkers, among others, to transcend left/right oppositions eventually give rise to antagonism, with populists (and other outsiders) denouncing the search for common ground. Instead, these outsiders seek to conquer more ground, to annex or colonize, typically at the expense of others.

Whether one agrees with Mouffe’s analysis of recent political developments or not, it is instructive to consider her vision of radical, agonistic (rather than antagonistic) politics. Contrary to antagonists, agonistic pluralists do seek some form of common ground; albeit a contested one that is negotiated politically. In this way, agonists “domesticate” antagonism, so that opposing parties confront each other as adversaries who respect the right to differ, rather than as enemies who seek to obliterate one another. Thus, an agonistic democracy enables a confrontation among adversaries – for instance, among liberal-conservative, social-democratic, neo-liberal and radical-democratic factions. A common ground (or meta-consensus) is established between these adversaries through party identification around clearly differentiated positions and by offering citizens a choice between political alternatives.

To reiterate, antagonistic democracy is characterised by the lack of a shared contested symbolic space (in other words, a meta-consensus) and the lack of agonistic channels through which grievances can be legitimately expressed. This lack emerges when there is too much consensus and consensus-seeking, as is arguably now the case in many (but not all) Western democracies. We therefore need to be explicit about the many aspects and different possible democratic models of participation. Rather than emphasize the need for more consensus and for closure, we would do well to engage with the notions of dissensus and disclosure.

This, in our mind, seems to be a more fruitful venue to sort out various political problems in the long run than attaching to the ideal of consensus and consensus-seeking. Disclosure keeps the channels open. It is a form of opening joint discussion on the various models of participation, not with the aim of inciting endless debate but of making the most of them by reflectively probing their strengths and weaknesses in specific situations and contexts. Rather than aiming for closure beyond plurality, it urges us to articulate what is at stake, for whom, and why, and what types of learning emerge in and through participation. It should also increase our understanding of what “game” – participatory model – we are enacting.

Beyond Consensus?

At the end of his response, Irwin raises the very pertinent question as to whether we need more disclosure now around climate change. For Irwin, “certain consensual ideals seem more important” (Irwin 2017). There are many aspects to Irwin’s big question, but let us pick out a couple and start sketching an answer.

First, calling for a consensual approach or a consensus regarding climate change risks backfiring. A demand for consensus in science may lead to more doubt mongering (cf. Oreskes & Conway 2010), not so much because of disagreement among scientists, but due to external pressures from various lobby or pressure groups that gain from manufacturing controversy (e.g. industry players and environmental NGOs). A lack of scientific consensus (within a framework that emphasizes the importance of achieving a scientific consensus) might, in turn, be used by politicians to undercut or criticize science or policies based on scientific evidence and consensus. Even the slightest doubt about a claimed consensus may erode public trust in climate science and scientists, as was the case in 2009 with Climategate.

Second, the demand for consensus in science might also set too high expectations for scientists (neglecting constraints on all sides, such as lack of time, scientific pluralism, and so on) and suggest that dissent in science is a marker of science failing to deliver.

Third, granting too much importance to scientific consensus risks silencing legitimate dissent (e.g. controversial alternative theories), whereas dissent and controversies also drive science and innovation. (There are, as we all know, many important scientific discoveries, paradigms, and theories that were for a long time ignored or suppressed because they went against the prevailing consensus.)

We are thus led to say that seeking a consensus on climate change does not result in effective policies and policymaking. Taking to heart Irwin’s plea “to imagine the kinds of closure which might be fruitfully established,” we think it is important to ask if closure here necessarily unfolds with consensus seeking, and if so, how consensus is best understood. Finding ways to break the antagonism invoked by a (depoliticized) scientific consensus on climate change may ultimately be more fruitful to forge long-term durable solutions among particular groups of actors, something that might be done by publicly disclosing the divergent agendas, stakes, and power mechanisms at play in “climate change.” (A scientific consensus does not tell us what to do about climate change anyway.)

Seen in this way, and again drawing on Mouffe, an agonistic constellation might have to be put in place, where disclosure challenges, or even breaks, the sterile opposition between outsiders and insiders. This is because disclosure requires that insiders clearly distinguish and differentiate their policies from one another, which urges them to develop real alternatives to existing problems. Ideally, these alternatives would embed a diversity of values around climate change and engender solutions that make use of the best available science without threatening a group’s core values (cf. Bolsen, Druckman & Cook 2015).

To give some quick examples, a first example could center on reducing the amount of carbon dioxide and other greenhouse gases by adjusting consumption patterns; a second could insist on private enterprise-driven geo-engineering to mitigate global warming and its effects (e.g. technology to deflect heat away from the earth’s surface); a third alternative on making cash from carbon by emission-trading systems; a fourth on moving to Mars, etc.

Whichever political options are decided on, we again emphasize the importance of questioning the rationales and processes of consensus-seeking, which to our mind, are too often taken for granted. Creating a more agonistic setting might change the current stalemate around climate change (and related wicked problems), by re-imagining the relationships between insider and outsider groups, by insisting that different alternatives are articulated and heard, and by publicly disclosing the divergent agendas, stakes, and power mechanisms in the construction of problems and their solutions.

Conclusion

Thanks in large part to Alan Irwin’s thoughtful and carefully written response to our article, we are led to reflect on, and develop, the concepts of meta-consensus, disclosure, and democratic models of participation. We are also led to question the ideals of consensus and dissensus, as well as the processes that drive and sustain them, and to find meaningful and productive ways to disclose our similarities and differences. By highlighting different models of democracy and how these models are enacted in participation, we want to encourage reflection upon the different implications of participatory consensus-seeking. We hope our article and our conversation with Irwin facilitates further reflection of this kind, to the benefit of participation scholars, practitioners, and decision makers.

References

Bolsen, Toby; James Druckman, and Fay Lomax Cook. “Citizens’, Scientists’ and Policy Advisors’ Beliefs about Global Warming.” Annals of the AAPSS 658 (2015): 271-295.

Horst, Maja; and Alan Irwin. “Nations at Ease with Radical Knowledge: on Consensus, Consensusing and False Consensusness.” Social Studies of Science 40, no. 1 (2010): 105-126.

Irwin, Alan. 2017. “Agreeing to Differ? A Response to Van Bouwel and Van Oudheusden.” Social Epistemology Review and Reply Collective 6, no. 10 (2017): 11-14.

Oreskes, Naomi and Erik Conway. 2010. Merchants of Doubt: How a Handful of Scientists Obscured the Truth on Issues from Tobacco Smoke to Global Warming. London: Bloomsbury Press.

Mouffe, Chantal. “The Limits of John Rawls’ Pluralism.” Politics, Philosophy and Economics 4, no. 2 (2005): 221-31.

Van Bouwel, Jeroen and Michiel Van Oudheusden. 2017. “Participation Beyond Consensus? Technology Assessments, Consensus Conferences and Democratic Modulation.” Social Epistemology 31(6): 497-513.

Van Oudheusden, Michiel, Charlier, Nathan, Rosskamp, Benedikt & Pierre Delvenne. 2015. “Broadening, Deepening, and Governing Innovation: Flemish Technology Assessment in Historical and Socio-Political Perspective.” Research Policy 44(10): 1877-1886.”

Author Information: Alan Irwin, Copenhagen Business School, ai.ioa@cbs.dk

Irwin, Alan. “Agreeing to Differ? A Response to Van Bouwel and Van Oudheusden.” Social Epistemology Review and Reply Collective 6, no. 10 (2017): 11-14.

The PDF of the article gives specific page numbers. Shortlink: http://wp.me/p1Bfg0-3Lf

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Image credit: Broo_am (Andy B), via flickr

What is the purpose of criticism? Is it to challenge and provoke, to establish new kinds of dialogue and mutual learning, to silence or to give voice? And what happens when we do not agree? Is disagreement an impediment or a driver to change? Is it a way of testing out arguments and building a mutually-enlightening dialectic? Or is open disagreement a fundamental problem which makes further discussion impossible?

I should quickly say that I do not write in these terms because I feel criticized or especially disagreed with by Van Bouwel and Van Oudheusden’s very fine and reflective paper—nor do I have devastating criticisms and disagreements to offer them.  But I am struck by the parallels between writing a critical response to academic colleagues and the handling of criticism and disagreement within public participatory exercises. To move to the main theme of these comments, should agreement be the purpose of academic/public debate or does this imply a stepping away from difficult issues, a failure of nerve or even a form of manipulation?  Should one focus on what we share or on what divides us?

The Value of Disagreement

With inevitable irony, I think one important area of agreement between myself and these two authors is that we all value disagreement and have a suspicion of public participatory processes which seek to push this aside or to conceal the existence of contradictory views. As I read Jeroen Van Bouwel and Michiel Van Oudheusden, there is a basic problem with many participatory formats which seek agreement (or what they call ‘consensus’) and serve to delegitimize conflict and disagreement. In a careful analysis, they present different models of democracy but also critically (that word again) reflect upon the ‘consensual-deliberative model of public participation in technoscience’.

From their perspective, ‘consensus is enacted as an epistemic and political ideal that, implicitly or explicitly, renders undesirable the prospect of protracted conflict and the unfeasibility of conflict resolution. Nonconsensual conceptions and possibilities of change, conflict and democracy are thereby mostly left out of the equation.’ (Van Bouwel and Van Oudheusden 2017, 3) Instead, they are drawn to more agonistic ways of thinking. They also challenge the current ‘meta-consensus’ around public engagement ie the consensus over the ways such exercises are theorized and invoked—or perhaps the ‘consensus over consensus’ (my awkward formulation not theirs).

There is much more to say about Van Bouwel and Van Oudheusden’s thoughtful discussion than I can summarize here, including the presentation of two cases, a reflection on different models of democracy and an important inter-connection of STS and political theory. I strongly invite the reader to read their paper on these and other points. Certainly, I think the authors succeed in bringing new perspectives to what has often been a rather stale discussion of ‘public engagement—democracy or disappointment?’ within the academic literature (on this see Irwin et al 2012).

In critical response, I will—in the most constructive interpretation of ‘criticism’—focus on the relationship Van Bouwel and Van Oudheusden present between disagreement and consensus-seeking within participatory exercises. To bring in one further aspect of their discussion, how should we think about the role of ‘closure’ in this context and also their proposed notion of ‘disclosure’? In line with the positive valuation of disagreement and conflict, ‘disclosure’ is seen as opening up a fresh perspective on participation: ‘disclosure does not imply a begrudging acceptance of the impossibility of actors to reach a shared solution for a social problem; rather, conflict between them is valued positively as the guarantor of political struggle.’ (Van Bouwel and Van Oudheusden 2017, 10) Their argument, as I see it, is not necessarily in favour of disclosure over closure, but rather that we need to augment our ways of thinking and acknowledge the possibility of protracted conflict as well as agreement.

So how does the constructively-minded critic react to all this? My response—apart from the previous appreciative summary—is to point to three issues which I think deserve to be discussed in greater depth. It may be that my comments are more normatively-inclined than Van Bouwel and Van Oudheusden’s rather balanced paper. Instead, my thoughts are best read as reflections stimulated by their text rather than disagreements with it. All are intended to move the field of ‘public engagement: studies and practice’ further forward.

On Consensus

First of all, I think the authors do well to portray consensus not simply in the common ‘Anglo-Saxon’ sense of a rather weak state of agreement but also as a faith in the common good and a commitment to building a shared culture. In fact, it is one of my own publications (with Maja Horst) that is drawn upon here so it is hard for me to differ (Horst and Irwin 2010). However, and in contrast to the approach taken in Van Bouwel and Van Oudheusden’s paper, the Danish ideal of consensus (at least from our perspective) does involve the acceptance both of fundamental disagreement and of the inability to achieve resolution on every issue (see Horst 2010). It asks what are for me some key questions: ‘how do we proceed when we are not in agreement?’; ‘how do we live together with conflict?’; and, not least in current troubled times, ‘how can we face disagreement directly and without fear of negative consequences?’.  This is of course an ideal and not necessarily what one sees at a daily level within the Danish state—although notice the relative stability in that country of multi-party governments whose internal disagreements are at least as important as what they have in common. My point is that an orientation to consensus-seeking does not have to mean a ‘begrudging acceptance’ of disagreement. It can be that it starts with this acceptance and builds from there.

The authors’ approach to these issues is to put forward new conceptions and ideals that contrast with ‘consensus discourse’. My own argument is, firstly, to acknowledge that ‘consensus’ can take several different forms but, secondly, to suggest that we may have much more to learn from previous experience of ‘consensual’ conflict handling than the authors’ approach implies. For me, concepts like dissensus, disclosure, conflictual consensus and agonism are valuable—but they should be seen as part of the consensual ideal rather than a contrast to it. Of course, here I also reveal my own commitment both to vigorous (dis)agreement and to finding collective ways of handling conflict—and even being made stronger by it.

On Institutional and Political Contexts

This takes me to my second point of discussion. If we accept the argument that official approaches to public engagement around the world often back away from disagreement and conflict, then it is also necessary for us as ‘critical’ scholars to consider the institutional and political contexts within which such assumptions are generated and performed. Why this persistent pattern? Is it caused by a culture of ‘scientism’ whereby complex socio-technical issues are reduced to a reductionist matrix of risk? Is it due to a deeper institutional urge for control, and resistance to the troublesome uncertainties often emphasized within public discussion? Is it because issues such as nanotechnologies and new approaches to healthcare have the potential to become ‘wicked problems’ for government institutions in particular: crossing departmental jurisdictions, spinning in several directions at once, easy to open up but hard to close down? Or is it because there are economic pressures at work which make it difficult even to imagine that the answer to any proposed innovation will be ‘no thanks’?

Having observed civil servants struggling both to ‘make space’ for participation activities in the face of sceptical ministers and suspicious stakeholders, and to move forward with what are often ‘hot’ issues in a distinctly ‘cold’ environment, it seems to me vital that we understand the institutional and cultural forces at work. We should also ask why, after so much criticism from all sides, initiatives in public participation actually persist. Without examining the relevant organizational and political contexts, it seems to me that we are doomed to a not very subtle revision of the old deficit model: why don’t policy makers understand? What if they understand more than we acknowledge, but simply find that our concepts and models miss the point as they see it?

On Opening and Closing

My third observation is the most general of all. And I have to say that it is influenced by a mood of pessimism concerning the current state of world politics (I am hoping this will pass—both the politics and my mood). I too share the enthusiasm for opening problems up rather than closing them prematurely down (Stirling 2008), for challenging the manner in which issues are framed for debate, and for bringing criticism and disagreement forward more visibly, directly and vigorously. Our critical training as social scientists and humanities scholars encourages this and (although I can’t speak for everyone here) our own political sensibilities have often been sharpened by critique of the orthodoxy, the closed agreement and the establishment stitch-up.

But does this lead us to under-value the art of closure, the process of finding ways to make agreements, understandings and policies stick even when the disagreements persist and the uncertainties show no sign of dissipating? To take an obvious example, does the world need more ‘disclosure’ right now around climate change or is it actually more interesting (and challenging) to imagine the kinds of closure which might be fruitfully established—and the acknowledgements of dispute and difference upon which these should be built? In the era of Brexit, starkly-polarized US politics and global warming, certain consensual ideals seem more important and powerful than ever.

Should we focus on what we share or what divides us? The answer for me can only be ‘both’. I am grateful to Jeroen Van Bouwel and Michiel Van Oudheusden for providing us with the foundation for doing exactly that.

References

Horst, Maja. “Collective Closure? Public Debate as the Solution to Controversies about Science and Technology.” Acta Sociologica 53, no. 3 (2010): 195-211.

Horst, Maja and Alan Irwin. “Nations at Ease with Radical Knowledge: on Consensus, Consensusing and False Consensusness.” Social Studies of Science 40, no. 1 (2010): 105-126.

Irwin, Alan, Torben Elgaard Jensen, and Kevin Edson Jones. “The Good, The Bad and The Perfect: Criticizing Engagement Practice.” Social Studies of Science 43, no. 1 (2012): 118-135.

Stirling, Andrew. “‘Opening Up’ and ‘Closing Down’: Power, Participation, and Pluralism in the Social Appraisal of Technology.” Science, Technology, & Human Values 33, no. 2 (2008): 262-294.

Van Bouwel, Jeroen and Michiel Van Oudheusden. “Participation Beyond Consensus? Technology Assessments, Consensus Conferences and Democratic Modulation.” Social Epistemology (2017): 1-17. doi:10.1080/02691728.2017.1352624.

Author Information: Clarissa Ai Ling Lee, National University of Malaysia, call@ukm.edu.my

Lee, Clarissa Ai Ling. “Review of Making Medical Knowledge by Miriam Solomon.” Social Epistemology Review and Reply Collective 6, no. 1 (2017): 1-8.

The PDF of the article gives specific page numbers. Shortlink: http://wp.me/p1Bfg0-3oA

solomon_mmk

Image credit: Oxford University Press

Making Medical Knowledge
Miriam Solomon
Oxford University Press, 2015
224 pp.

Miriam Solomon’s Making Medical Knowledge is an important contribution to the oeuvre of philosophy of practice in medicine for interrogating medical practices while highlighting many of the ethical and scientific gray areas in the social-epistemological character of medical intervention. The findings of basic science are resituated into a messy chain of causal mechanisms represented by various phases of clinical trials. The production of evidence could be parlayed into the negotiation of guidelines for governing medical situations where consensus over intervention is lacking, and also for the development of a personalized approach in favor of the ‘cookbook’ approach in medical treatments. She highlights some contradictions and miscomprehensions regarding the interpretation of quantitative and qualitative medical evidence, while arguing for need to make a clear distinction between the practice of basic science and medicine.

“Disrespecting” Disciplinary Boundaries

Solomon keeps her philosophical intervention closely situated to the not-always-predictable and non-linear movements of medical discoveries, and their potential for heralding new treatments, as they go from the lab to clinical trials to the stage of treatment interventions; her critical descriptions continuously remind of the importance of not overemphasizing theoretical rigor at the expense of practical applications, while reminding us of the need to encourage strong science for successful interventions to happen. She refuses to play to the dichotomy of art and science in medicine, not because she rejects medicine as bearing both characteristics, but because she chooses to operate from a perspective that both are equally crucial but not the limits by which medicine operates. She also seems to subscribe to the opinion that a reduction of medical knowledge to a dualist representation is merely a submission to a traditional logical-positivist empiricist philosophy of science, and to eschew such dualism is to transcend the binary of “soft” versus “hard”, “precise” versus “mess”, and “reductionistic” versus “holistic”.

Beyond claiming that she intends to go beyond the art and science divide in her analysis of medical epistemology, which is also part of her mission to “disrespect” disciplinary boundaries, she declares in the first chapter that she will be providing a pluralistic account of methodologies that bring together the “naturalistic, normative, applied, pluralist, social epistemology” in an integrated manner, especially through a selection of case studies such as that involving cystic fibrosis, treatment of heart diseases, and use of mammography for women between ages 40 and 49 as part of early screening for breast cancer that she uses to highlight a methodologically plural approach in the penultimate (ninth) chapter of the book that considers the integration of the methodologies discussed throughout the book.  She is upfront about the STS and HPS traditions that inform her work, even though as a philosopher and lacking formal training in social scientific methods, she acknowledges where her alliance is with philosophy, and to a lesser degree, history of medicine.

That said, the methodologies discussed in the book are the consensus conferences for group deliberation among a group of experts (although non-expert stakeholders are also sometimes involved); evidence-based medicine (which some equate with “cookbook medicine” (meaning medicine that prescribes a general intervention for every patient facing the same ailment) and the problem of bias (or assumption of lack of bias) in randomized control trials, the hierarchies of evidence, scientific inadequacy, and unreliability; translational medicine that involves the translation of basic biomedical research to application to patients; and medical humanities exploration in the form of narrative medicine for exploring professional empathy and the phenomenological aspect of the relation between physicians and their patients.

On Consensus Conferences

The methodology she spends the most time exploring is that of the consensus conferences followed by that of evidence medicine, with only single chapters, each, dedicated to translational and narrative medicine. Her reason is that medical consensus conferences are under-considered. However, the details she provides are useful for presenting the mechanics underlying a movement as heavy in the politics as it is in juggling multiple epistemic commitments and priorities, and which, to my mind, contains narratives that should be of interest even to those in the medical humanities. Solomon claims that there has not been much interest by historians and sociologists of medicine to investigate this area, which is puzzling, given that the question of authority and expertise, together with the political history involved in the development of the conference consensus program globally, should be of interest to them.

Solomon limits her case studies to the development of the program and movement in the UK, North America (particularly the US), and Scandinavia Europe, although every country that practices modern medicine obviously will have their own form of consensus conferences; therefore the philosophical generalizations that are derived from the study of these cases could be apply, with some caveats and modifications, to other local settings.

The case studies that inform her story provide a case of binary tensions that she does not want embodied by her analyses of the situations, but which she acknowledges to be an unavoidable consequence of competing epistemic and social priorities involved in generating consensus, in addition to meeting the expectations of the medical community and non-medical stakeholders that include administrators, policy-makers, insurance companies (or whoever that pays the medical bills), technologists, and perhaps even some members of the public (which include patient advocates and patients). Each of these stakeholders will have their own opinion over what is considered epistemically authoritative, credible, and objective, even if the point of consensus seeking is to break away from over reliance on arbitrary designation of authority. Using the example of the US-based NIH Consensus Development Conferences, she argues that the justification for the conferences is the production of credibility in translating research findings to the general health care providers and members of the public. Solomon considers knowledge dissemination and changing how practices of the medical professionals transmit trust as much as it does results, such as trust in the researchers, the review processes, and incentives that will change practices for the better.

The rhetoric of consensus, according to Solomon, aims to dissuade other interested groups from manufacturing doubt on decisions made through the generation of authoritative sources of knowledge. However, the NIH Consensus Development Conference Program has since been retired, and evidence-based medicine apparently had taken over, although Solomon regrets that this potentially leads to the over-reliance of evidence-based medicine methods of more formalized knowledge assessment techniques rather than group knowledge assessment, which means giving evidence-based medicine a dominant position. At the same time, she acknowledges that there is a blackbox to the process of achieving consensus to hide the more ‘doubtful’ practices from public view, thereby maintaining a credible appearance. However, the Institute of Medicine (IOM) runs a modified version of the NIH program, which it claims will produce an “arguably” attainable and useful form of objectivity by not trying to eliminate intellectual bias, but rather, seeks for balance of expertise.  She also cites other US bodies, which are variations to the NIH model, such as the Medicare Coverage Advisory Committee (MedCAC) and the US Preventive Services Task Force (USPSTF). The difference with the USPSTF model is that attention is also given to interface (socio-economic level) consensus to get as many different organizations and experts as they are able, to commit.

Public Deliberation

She gives as a counter to the NIH consensus program, the ‘Danish model’ that takes on a public deliberative approach compared to the group expert judgment of the NIH model. She also looks at countries where health care is universal and centralized, such as in Canada and Europe; the differences in the system also change how the consensus conferences operate in these countries. The Canadian Task Force for Preventive Health Care has a permanent panel, rather than different panels for different topics, mainly because the evaluation is centered on primary care rather than the NIH model of evaluating specialty care.

The European consensus model focuses more on developing interface rather than technical consensus, therefore focusing more on the social, ethical, and financial consequences of reaching a medical decision, even though they also preserve certain features of the NIH model such as a neutral (rather than ‘balances of biases’) panel, half-day of expert presentation and questions, with the production of a public statement the following day. Solomon points to the difficulties of producing mutually agree-upon guidelines, since different panels could arrive upon different guidelines within the same country and with regard to the same medical technology; moreover, the expert composition of the panel (whether they be disciplinarily homogenous or interdisciplinary) skews support for forms of interventions and therefore, the guidelines for the interventions.

Solomon follows through this controversy with a more detailed philosophical discussion in chapter four, on the topic of consensus practices, including the difference between achieving consensus in science and medicine. As far as Solomon is concerned, consensus in science is merely aimed at achieving a semblance of united front on an issue that members of the scientific community agree on even if they might have different reasoning and interpretive processes for arriving at the same conclusion, such as in the case of climate change and their representation at the Intergovernmental Panel on Climate Change; consensus negotiation should not be utilized for negating controversy from developing due to conflicting views.  However, I am not persuaded by Solomon’s claim that the Strong Programme, as advanced by the Edinburgh Science Studies unit, subscribes to a simplistic acceptance of negotiation to get to truths; if one were to read chapter seven of David Bloor’s Knowledge and Social Imagery, the argument appears to be that what is being negotiated is not the syllogistic rule of formal reasoning, but rather the application of that syllogistic rule; the negotiation takes place when the informal process of reasoning is applied to problematic cases that do not fit the mold at content level, even if the logical form appears to prevail. Bloor uses examples in mathematics, particularly arithmetic, to demonstrate his arguments. Therefore, the form of scientific (or mathematical) consensus Solomon attributes to the Strong Programme is not so much a case of scientific consensus in the literal sense of attaining agreement through discussions, but rather, to find ways for explaining seemingly illogical contradictions.

Group Deliberation and Judgment

Solomon ventures into discussions concerning different philosophical views surrounding group judgment, such as the usual assumptions regarding how group deliberations could be sufficiently robust and rigorous to withstand individual bias and error while including different points of views through relevant data and considerations. Group deliberation is seen as a way for uncovering presuppositions, and transmitting further evidence from some members of the group to the rest of the group, from the perspectives of internalist and externalist views. The core belief of internalist approach is that justification of belief is internal to each individual owner and available for reflection whereas the externalist approach allows one to have knowledge without being able to explain how one is justified or in possession of that knowledge. Her core thesis in this chapter concerns the potential for group think as a fallible point during group deliberation, on the premise that cognitive and motivational bias will always be present regardless of attempts at eliminating them.

The problem of group-think persists due to factors such as the tyranny of majority (that led to the ignoring of dissenting views) and omission of relevant information.  However the manner group think operates, Solomon is right in suggesting that factors such as peer pressure, pressure from authorities, pressure to reach consensus, time pressure, and obviously, the presence of particularly domineering members of the group (who are also the more privileged members of the group) can skew how decision-making is made, given that the fallibility of the parts (individual members) that constitute the whole (group) would hold under such conditions. Moreover, the desire for standardization through consensus also brings on the problem of the loss of autonomy for individual professionals who may not even have a say in the process. Even if the consensus method is not eschewed, Solomon suggests that the process involved is still work in progress for which no final judgment could be attained.

Evidence-based medicine has much more literature that contributes to an exploration of its discourse, especially as it is a continuation of the empirical medicine discourse, such as in the context of clinical application. When different trials of the same intervention produce different results, an overall evidence assessment is made through the consensus conferences. Without rehearsing the evaluation of the practice of evidence-based medicine that Solomon provides, I venture that her most interesting contribution to the discourse is in taking out the usual assignment of mechanistic evidence (stemming from mechanistic reasoning), which she discusses in detail in chapter five, from within the evidence hierarchy because high-quality mechanistic reasoning is deemed to be logical and deductive (though she does not quite say why other than that mechanistic reasoning presupposes that one has complete knowledge for enabling that form of reasoning) rather than mechanistic reasoning. However, even if complete knowledge is available, it does not presupposes that the intervention proposed for applying knowledge of that mechanism will work; hence, mechanistic reasoning provides weak evidence while remaining useful as an instrument of discovery.

Regarding Cystic Fibrosis

Solomon uses the case of cystic fibrosis to illuminate her argument concerning application of mechanistic/causal knowledge and experimental heuristics come together. She argues that the case of treatment for cystic fibrosis is an example of evidence-base medicine through the deployment of a multidisciplinary medical team, with therapies that are discovered at distal or proximate ends of a causal chain such as in the case of the CFTR (cystic fibrosis transmembrane conductance regulator) gene; she claims that a treatment might not have been created specifically to address cystic fibrosis but rather conditions similar to the problem; nevertheless, regardless of the original intention of the treatments, they could still be put to test to see which are effective for dealing with cystic fibrosis. However, even with evidence of effectiveness (by the standards of evidence-based medicine), the question of why certain therapies work while others do not is not answered.

The trials deployed are a mix of randomized double-masked, observational, as well as other methods. In addition, even the identification of genetic mechanisms underlying cystic fibrosis are successful in the early stages of genetic testing, the improved information produces more uncertainty because more variables are now at play. Although she acknowledges a more complex consideration is needed, I would suggest that the nested problem of mechanisms could be laid out through a cybernetic systems approach, a system which has been deployed in other forms of psycho-social therapies, such as family therapy and counseling.

Chapter six sees Solomon returning to the problem of biases and of confounding factors (being factors that affect experimental and control groups in a sufficiently major way as to skew results); I agree with her argument that the hierarchy of absences of biases does not translate into a corresponding hierarchy pertaining to the reliability of evidence because any presence or potential for bias indicates a possibility for errors. Moreover, even a double-masked randomized controlled trial could fall apart when large differences are being measured, since this allow trial subjects to guess which intervention arm they have been assigned to.

Solomon argues that external validity could serve as a check to ameliorating the problem of bias and weak evidence even in double-masked randomized trials through the deployment of background knowledge and judgment based on context of those targeted for intervention and the ensuring of common traits between trial participants and the rest of the larger population. Further, there is difficulty in generalizing the findings from trials due to biological and cultural variations and complexities (which inform much of the discourse in the anthropology of medicine). In addition, the trial may be designed to demonstrate a particular effect, and therefore, is controlled to the point of excluding the possibility for illuminating another important, even if seemingly irrelevant, condition. An important point for Solomon is that evidence-based medicine does not constitute an algorithmic or infallible scientific methodology; and her recommendation for dealing with this epistemic fallibility is to apply social interventions such as the setting up of trial registries with the aim of preventing manipulation of data, publication bias, bias resulting from time to publication, and conflict of interest, among issues that could potentially arise.

Translational Medicine

Translational medicine, considered as a translation of pure science knowledge into effective healthcare application Solomon divides into T1, “applied research from bench to bedside (and back)” and T2 “moving successful new therapies from research to clinical context” (159), contains many historical cases that demonstrated the messiness, the timely arrival of a technology that could facilitated the operationalization of basic research after years of being stymied, and of course, the right team of people that all come together in the transformation from the lab bench up to the clinical stages. Due to some affinity and overlaps that one can find between evidence-based medicine and translational medicine, with evidence-based medicine requires a complementing methodology that could take on the risk, through the process of problem solving, careful observation, and tinkering needed to move the implementation of clinical intervention into the next level, even with success not assured and failure a strong possibility.

For Solomon, translation medicine is that level before evidence-based medicine as it occupies the place in the context of discovery, while the more prestigious evidence-based medicine is located within the context of justification. However, given the underdevelopment of translational medicine at this point, Solomon has not too much to suggest from a philosophical viewpoint. However, she offers possibilities for how the methodology of translational medicine could be strengthened within the causal chain of various therapies to be applied, such as in the case of the CFTR gene. Her most interesting contribution in this regard would be to show how that is put to practice in her chapter on the pluralism of methods in chapter nine.

In her appraisal of narrative medicine in chapter eight, Solomon does not offer as much philosophical insight into the contents of the narrative. Instead, she focuses her evaluation to the causality and effects of the deployment of narrative medicine, which provides a useful reflection on the intent behind the deployment of narrative medicine in the first place: forms of listening that need not be confined to the verbal, the creation of empathy at the experiential level (through an invocation of the aforementioned phenomenological method of eliciting the full spectrum of patient experiences), making the right diagnosis (through a close-reading of the narrative between the physicians and their patient), and making meaning out of the information compiled from the three aforementioned techniques. She also brings up historical precedents to narrative medicine that had other fallibilities, such as biopsychosocial model considered as lacking in intimacy, empathy, democracy, and attention to the dyadic relation between individual physicians and their patients; while deconstructing certain assumptions regarding the efficacy of narrative medicine in entering zones untouched by the biomedical-scientific method.

Obviously, the philosophical insight that comes out of this investigation could go even further when paired with the technique of narrative deconstruction found in literary and other areas of inquiry attending more to the problem of narrative contexts and non-evident subjectivities. Philosophy may identify such possibilities, but its current deployment through philosophy of science and medicine lacks the capacity for deeper penetration. Philosophically, it would appear that narrative medicine has only a limited role to play in medicine by being confined to deployment in primary care and psychiatry; but cultural angle, there is much more that could be offered even to specialized medicine.

The Importance of Dissent

What I find most compelling about the book is its advocacy of pluralism that is not merely a composition of multidisciplinary or multi-modal methodologies, but for how they could be integrated most effectively. Such pluralistic considerations have not have been given as much attention in the literature of medical humanities, or social-cultural studies of medicine. This book, perhaps, could open up more possibilities for such developments, especially for the examination of the development of medical infrastructures and practices outside of the Western world. The penultimate chapter takes a philosophical reconsideration of how certain traits deem crucial in the practice of science might work in reverse in medicine, such as that of dissent. However, I argue that the avoidance of dissent in medical practice will produce its own form of dogmatism, such as when less orthodox approaches of a yet unknown value are put forward, which happens more frequently than acknowledged. While I believe that the arguments she offers are important considerations for medical practitioners and not only to philosophers, the density of the material and the lack of clear prescription to practice would require patience from the practitioner-reader in their contemplation of how they could best profit from the discussions in the book.

References

Bloor, David. Knowledge and Social Imagery: Second. Chicago & London: Chicago University Press, 1991.

Solomon, Miriam. Making Medical Knowledge. Oxford: Oxford University Press, 2015.