ABSTRACT
Health care decision making is not and cannot ever be value free. By its very nature it is a product of, and acts upon, powerful interests. It cannot escape the consequences of the politics of health. As Paul Atkinson points out: ‘Clinical decision making is not the outcome of individual minds, operating in a social vacuum. It is not disinterested, therefore, and is as susceptible to shaping by social influences as any other knowledge’ (Atkinson, 1995: 54). In this chapter I will try to address decision making at a number of levels ranging from the micro-decisions that affect individual patients to the public health decision making that reflects the expansive gaze of medical surveillance in today’s society. I begin by outlining Habermas’ communicative ethics and its relevance to health care. I consider the difficulties this ethics faces when confronted with different understandings of power (particularly medical power). Having set out the theoretical scenery I will address three key areas of health care decision making. First, I will look at changes in the medical encounter. (I will use the term medical encounter throughout this chapter because I am primarily concerned with the doctor–patient relationship and in recent years terms like lay professional relationship and healing relationship have come to the fore partly in recognition of the plastic and open-ended relationships that arise from our increasing concern with health and illness rather than disease.) Secondly, I will examine the rise of managerialism in the NHS, and thirdly I will examine the changing role of public health. Using these exemplars I hope to consider the possibilities and pitfalls of Habermas’ project for health care decision making.
