Recognizing rhetoric in health care policy analysis

Abstract

Critiques of the 'naïve rationalist' model of policy-making abound in the sociological and political science literature. Yet academic debate on health care policy-making continues to be couched in the dominant discourse of evidence-based medicine, whose underlying assumptions--that policies are driven by facts rather than values and these can be clearly separated; that 'evidence' is context-free, can be objectively weighed up and placed unproblematically in a 'hierarchy'; and that policy-making is essentially an exercise in decision science--have constrained both thinking and practice. In this paper, drawing on theoretical work from political science and philosophy, and innovative empirical work in the health care sector, we argue that health care is well overdue for a re-defining of what policy-making is. Policy-making is the formal struggle over ideas and values, played out by the rhetorical use of language and the enactment of social situations. While the selection, evaluation and implementation of research evidence are important in the policy-making process, they do not equate to that process. The study of argument in the construction of policy has the potential to illuminate dimensions of the process that are systematically occluded when policy-making is studied through a naïve rationalist lens. In particular, a rhetorical perspective highlights the struggle over ideas, the 'naming and framing' of policy problems, the centrality of audience and the rhetorical use of language in discussion to increase the audience's adherence to particular framings and proposals. Rhetorical theory requires us to redefine what counts as 'rationality'--which must extend from what is provably true (by logic) and probably true (by Bayesian reasoning) to embrace, in addition, that which is plausibly true (i.e. can convince a reasonable audience). Future research into health care policy-making needs to move beyond the study of 'getting evidence into practice' and address the language, arguments and discourse through which policy is constructed and enacted.

Puzzling about problems: the ambiguous search for an evidence-based strategy for handling influx of health technology

“…Within the prominent discourse of ''best evidence'', the underlying thought is that policies are value-free, and should be generated by facts, and that these entities can be clearly separated. Hence, evidence is regarded as context free and something that can be classified and weighted (Russell et al 2008). In this rationalistic view, the policy process is about sorting out what is the best evidence, deciding upon it and implementing what is decided.…”

Appeals to evidence for the resolution of wicked problems: the origins and mechanisms of evidentiary bias

“…In contrast, 'hierarchies of evidence' are promoted that emphasize methodological approaches such as randomized controlled trials (RCTs) or systematic reviews to provide relevant evidence in supposedly unbiased ideal ways (Haynes et al 2012;Chalmers 2003). Yet critical policy authors have countered that there is a need to move beyond a 'naïve rationality' (Russell et al 2008) that assumes evidence is somehow outside politics. Instead, these authors point to the reality that public policy decisions fundamentally involve choices between competing social values and competition between interest groups (Head 2010;Lin 2003;Greenhalgh and Wieringa 2011;Russell et al 2008).…”

“…Yet critical policy authors have countered that there is a need to move beyond a 'naïve rationality' (Russell et al 2008) that assumes evidence is somehow outside politics. Instead, these authors point to the reality that public policy decisions fundamentally involve choices between competing social values and competition between interest groups (Head 2010;Lin 2003;Greenhalgh and Wieringa 2011;Russell et al 2008). Appeals to evidence that particularly recommend policymaking be guided by evidence hierarchies have been further critiqued as imposing de facto political priority to those issues where research has already been conducted, or which are conducive to evaluation via experimentation (Barnes and Parkhurst 2014;Parkhurst and Abeysinghe 2016).…”

An inconvenient truth: why evidence-based policies on obesity are failing Māori, Pasifika and the Anglo working class

“…This means that policy-making is a constant process of attempting to reconcile what is actually needed with what can be provided in the way of resources. Shaw (2010) and Russell et al (2008) remain critical of attempts by political rationalists to improve outcomes without engaging in the densely layered and complex interactions of various policy environments.…”