The Situated Complexity of Health Care
In the previous three chapters, I have explored the ways in which the ideal formats of the market, the laboratory and the forum were mobilised and implemented in contemporary health care organisation. In Chapter 3, I suggested that cost-eff ectiveness analysis presented a solution to the political and methodological problems health economists were faced with when considering the design of health care systems in the 1960s. In proposing a ‘mundane economics’, the QALY provided an explicitly normative route to address the ‘economic problem’ of health care. In so doing, it became entangled with cognitivist, information-based models of decision-making and with a political imaginary that emphasised legal authority and bureaucratic hierarchy. In relation to the question of eff ectiveness, I argued that evidence-based medicine and health care have been articulated through recourse to an ‘experimental ideal’ which proposed a tight relationship between controlled, mechanism-based procedures of knowledge-making and the governance of democratic, pluralistic societies. Responding to critiques of the randomised clinical trial, the systematic review formalised practices of reading that enhanced the transportability and calculability of information across contexts and a reliance on a technical repertoire of engagement with decision-makers. Finally, in analysing the issue of deliberation in health care, I suggested that public participation should be viewed within a long history of epistemic attempts to solve the ‘problem of the public’ in modern democracies. I have shown that choreographing publics, however, was not as straightforward as political and social scientists would have us believe, namely because attempts at formalising and indexing deliberation for decision-makers are in tension with the indigenous methods and techniques deliberative groups use to establish themselves as instruments of knowledge-making.