Time-framing and health risks

Abstract

This special issue is the last in a four-part series Health Care Through the ‘Lens of Risk’, which focuses on risk categorisation, valuing, expecting and time-framing, respectively, and has been published in 2012–2013. The present editorial introduces the issue of time-framing in relation to an interview-based article, a guest editorial and six articles reporting findings from empirical research. The central argument of the editorial concerns the increasing abstractness of time within modernity, which renders risk thinking possible and exists alongside shifting subjectivities regarding time, as futures are increasingly reflected upon. The meaning given to contingent futures intensifies experiences of time in relation to the future and, therefore, the present. This argument is then problematised through reference to empirical studies of more passive attitudes to risk and where future considerations are avoided altogether. Different ways in which past, present and future are related to one another are also considered. We explore these themes before introducing the original research articles, interview-based article and guest editorial in this issue. Each original article explores time-framing within a different context including drinking alcohol away from licensed premises, expecting a baby as an older first-time mother, living with an advanced-stage cancer diagnosis, caring for a close-relative as a young person, long-term self-hurting and the journey towards a skin cancer diagnosis. Each of these contexts can be considered ‘risky’, partially depending on the time-framing invoked. The common theme linking these papers is the analysis of how futures are envisaged and how different approaches to time-framing are fundamental to perceptions and experiences of risk and uncertainty.

Keywords:

• future
• modernity
• past
• present
• risk
• time
• uncertainty

Introduction

In this editorial, we introduce and provide an overview of the fourth and final collection of articles in a series of special issues on the theme Health Care Through the ‘Lens of Risk’, published in Health, Risk & Society in 2012 and 2013. The series focuses on health risk-thinking, with its starting point the Royal Society’s Risk report (1992, p. 2), which defines risk as:

the probability that a particular adverse event occurs during a stated period of time, or results from a particular challenge.

The report framed this definition as the grounding for quantitative risk assessment, portrayed as ‘a powerful tool for investigation and reduction of risk’. The four special issues each offer interpretivist critiques of different elements within the Royal Society report definition, with events recast as categories, adversity as negative value, probabilities as uncertain expectations and time periods as time frames (Heyman et al. 2010, p. 21). As has been acknowledged within earlier editorials in the series, in our deconstruction of ‘risk’ into these four components, we do not mean to suggest that any of these can or should be considered independently of the others. As the authors of articles in this issue note – contrasting their analyses with depictions of time as a universal and standardised continuum – the ways in which people experience uncertainty involve varying modes of valuing or discounting future-time, in relation to the likelihood of a particular category of event taking place within such a frame.

Many influential social theoretical accounts of risk denote the pertinence of technological developments to the emergence and expansion of risk thinking in various societies. Giddens’s (1991) account privileges technologies pertaining to time measurement as especially fundamental to the very nature of modernity. The capturing and standardisation of time through technology, epitomised through the mechanical clock, leads to the separation and disembedding of time from its specific spatial locations (Giddens 1991, p. 16). For example, the development of the English railway network and associated railway timetables in the early nineteenth century required the imposition of standard time, based on Greenwich Mean Time, across all of England. Standardised measurement enables the comparison of time periods across multiple contexts and of the likelihood of certain events occurring within these specific quantities of time, therefore facilitating the generation of large sets of timed observations upon which risk calculations and assessments are based. This universalising tendency, capturing information and events in their relation to time while these are also ‘lifted out’ of distinct local contexts, is fundamental to the development of abstract systems of technical knowledge which define experiences of modernity (Giddens 1991, p. 18). Moreover, the gradual refinement and expansion of such systems – further bracketing off time from space (Giddens 1991) – is integral to the emergence of the more recent era of late-modernity.

Yet this ‘emptying out’ of time through abstraction and standardisation exists alongside growing possibilities and intensities of ‘lived time’ subjectivities (Giddens 1991, p. 17). One important sense in which the intensification of time becomes manifest is in relation to the envisaging of possible futures (Alaszewski and Burgess 2007, Brown and de Graaf 2013). The development of technical knowledge which is harnessed with the aim of making predictions encourages many people within late-modernity to consider their futures and feel a weight of responsibility for these (Luhmann 1988, Giddens 1991). The tendency towards such reflexivity becomes more likely where lived-experiences and narratives across society are heterogeneous and where people have a stronger sense of complex contingencies arising from their decisions (Giddens 1990). Rationalisation, in the sense of the application of technical knowledge for the purposes of planning, thus involves a paradox by which time becomes both more abstract and subjective. Certain forms of medical screening are examples of such a rationalised intervention where patients are provided with risk information, which is generated through, and applied upon, the basis of an abstract period of time – such as risk of aneurism within five years. Correspondingly, this information manufactures new existential-subjective experiences of the present and future for the patients involved (Hansson et al. 2012).

The subjectivities of abstract future-time

As already discussed, time can be measured and quantified in certain obvious ways, but can also become imbued with certain qualitative and value-related characteristics. ‘Future-time’, defined by Brown and de Graaf (2013) in this issue as ‘a specific quantity and quality of time envisaged in the future’ is an especially clear example of this, though a nostalgia for times gone by similarly refers to specific quantities and qualities of time. What future-time and nostalgised time share in common is the actor’s attention focused upon them. For it is this which gives these time periods their qualities – that is to say their social meaning.

Schutz (1972, p. 68) describes the ways in which meaning is given to objects via both a conscious focus upon them with regard to their specific ‘thinghood’, as well as the way these objects are more or less consciously and loosely associated with other entities. These two processes are steps towards meaning construction, and the greater the extent to which our consciousness is directed towards a specific future (or past or present), the more meaningful it becomes for us and the more socio-emotional resonance it has for us (Kierkegaard 1957). Hence, stroke survivors may place great emphasis on a future-time of recovery, imbued with a meaning of ‘business-as-usual’ and many other interwoven considerations of self and others (Alaszewski et al. 2006).

If, as some contend, late-modernity obliges us to consider the future – or the multiple futures which we are increasingly aware of – more than was the case in (pre)modernity, so does it follow that our attention given to these hypothetical futures creates more intense forms of meaning and emotion (Kierkegaard 1957). Affective responses may be especially heightened amidst uncertainty and beliefs that our futures are contingent upon our actions and decision-making (see Wilkinson 2001 for a nuanced discussion of such arguments).

These different intensities of future-time are also reflected in the experiences of time in the ‘present’, as addressed by Henri Bergson’s concept of durée (Schutz 1972) and Giddens’s (1991) notions of ‘killed time’, ‘time-on’ and ‘fateful moments’. Durée, our ‘awareness of the actual or ongoing passage of… life’ (Schutz 1972, p. 36), becomes more intense during fateful moments – when our ability to assume so much of our daily life in a taken-for-granted manner is profoundly destabilised or even shattered (Giddens 1991, Alaszewski et al. 2006). These moments in time are of a profoundly different character and quality to those of killed-time or usual everyday existence. Yet though these moments exist in the here and now of our durée, the past and the future are far from irrelevant. Indeed, it is an awareness of the future and its potential outcomes, which gives certain moments – such as childbirth – their fatefulness (Scamell and Alaszewski 2012). Moreover, we may only come to distinguish fateful moments retrospectively (Schutz 1972). In this sense, it may often be the relating of certain time periods to others, which generates the more or less intense subjective experiences of time in the present, past and future.

The basic arguments rehearsed here, that life within late-modernity is associated with more abstract yet intense experiences of the future, should not be taken as self-evident and require careful empirical examination. Ryan’s (2000) work in this journal provides a useful schema for describing different ways in which the future is confronted or ignored. Ryan investigated the risk approaches of people experiencing severe mental health problems. He concluded that some actors actively considered and planned for the future, others acknowledged potential futures but remained passive due, amongst other factors, to a feeling of powerless to plan and control the future, and yet others were considered to operate a ‘no risk’ strategy – disregarding the future.

This latter mode of bracketing off the future, or at least certain possible or probable futures, can function as a very effective means of avoiding anxiety – not least that relating to death (Kierkegaard 1989). Douglas (1992)  meanwhile argues that such a response may represent a cultural choice; a deliberate decision to reject scientific knowledge. In her study in Brittany of the ways in which individuals threatened by HIV treated expert advice and knowledge she noted: ‘The most baffling thing about the pattern is that a large number of the community at risk are impervious to information; either they know unshakeably that they are immune or recognizing that death is normal they draw the conclusion that to live trying to avoid it is abhorrent’ (Douglas 1992, p. 111).

Other more recent studies also emphasise the socio-cultural factors that shape such different approaches to the future (e.g. Alaszewski et al. 2006). Brown and Vickerstaff (2011) found that experiences across the life course were fundamental in shaping the attitudes of older people towards their retirement. Older people who had experienced limited ability to control and plan for the future, or who had tried to plan only for these arrangements to have been undermined, drew upon such narratives in explaining their more passive attitude towards the future. In contrast, those most proactively planning for their futures were, generally speaking, those whose social experiences, especially within certain education and work related contexts, had imbued them with an ‘Enlightenment’ habitus (a pattern of tendencies and dispositions) for applying technical knowledge to realise their hopes for, and thus attempts to ‘colonise’ (Giddens 1991, p. 125), the future. Meanwhile, others with a ‘no risk’ approach referred to their difficulty in coping day-to-day, financially or health-wise, with the energy consumed by these ongoing preoccupations precluding the luxury of considering the future in any significant detail. Here we see a rather specific type of ‘no risk’ strategy, one more or less necessitated through social context, which is rather different to another possible ‘no risk’ strategy where the future is discounted in favour of enjoying the present. This latter approach was favoured by some of the pregnant women interviewed by Heyman and Henriksen (2001), who consciously chose not to worry about screening for Down’s syndrome in favour of enjoying their pregnancy. Similarly, as recent articles in this journal (Spencer 2013, Thing and Ottesen 2013) show, public health experts may become frustrated that young people do not want to think about their own mortality, and therefore to avoid drinking alcohol and smoking cigarettes or cannabis to protect their health in the future. Rather, they prefer to have fun and enjoy the present. As Thing and Ottesen (2013, p. 6) observed, the young Danish secondary school students who participated in their study ‘did not see information about possible future diseases or the probability of early death as relevant to them. They were interested in the “here and now”’.

Wallman’s (2001) study of migrant sex workers in Europe, in a similar sense to Ryan (2000), identified a range of strategies towards danger adopted by the women participating in her research. Sex workers tended to respond to these dangers in ad hoc and pragmatic ways as the source of the threat was typically beyond their understanding and control. From the point of view of the sex workers, these threats were ‘virtual risks’ or ‘dangers whose magnitude … scientists do not know or cannot agree about’ (p. 78). Only when sex workers accepted that there was relevant knowledge and expertise did such dangers become manageable risks which could be anticipated and planned for (pp. 78–82). Generally speaking though, they focused their attentions on the present.

Different formats for relating past, present and future

‘Active’ approaches to risk, which more or less systematically apply knowledge from the past as a means of planning for the future, are described by Alaszewski and Burgess (2007)  as the traditional risk approach by which large amounts of statistical information are aggregated as a means of considering the likelihood of certain outcomes in the future to assist quality decision-making in the present. Alaszewski and Burgess (2007) then go on to describe other more recent tendencies within policy-making, which reconfigure or warp this distinctly rationalising way of relating past, present and future. The growing political trend towards organising official inquiries into events considered as crises is described by these authors as an emotional revisiting of past events to provide a cathartic experience for those who have suffered, as well as a form of justice through the allocation of blame to the ‘guilty’. So while the clock cannot be turned back, the reliving of these events and the attempt to learn from what happened is nevertheless a politically expedient way of going back in time. Alaszewski and Burgess (2007) point out the danger that certain past decisions, as viewed from the present with hindsight, are problematised in a way that is out of keeping with what was known at the time.

Further problems are associated with the learning of lessons from a single highly atypical case, which are then applied to entire public services in a disproportionate manner. For example, in England, local clinicians initially managed and allocated In Vitro Fertilisation (IVF) treatment. However, in 1993, following IVF treatment in a local hospital, a woman gave birth to sextuplets. Initially, the media represented this as a medical miracle, but as details of the family’s background became more widely known, the case became a scandal. The minster responded to the media coverage with a review that restricted both the availability and location of IVF treatment and placed it under the control of local health authorities (Alaszewski and Brown 2012, p. 226).

Warner (2006), in describing the effects of inquiry reports, goes on to consider the impact of these pasts on activities in the present, which come to be driven by a fear of the future. The unease felt by those working in organisations, not least health and social care professionals, that they could themselves become the subject of a future inquiry creates a particular kind of defensive practice, which undermines effective care provision in the present. The ‘well-known “tombstone” pattern in which risk regulation functions as a monument to public emotions about past tragedies’ (Hood et al. 2001, p. 110) can thus come to bear decisively and destructively upon current practice.

The most problematic reconfiguration of relations between past, present and future for Alaszewski and Burgess (2007) is that typified as the ‘precautionary approach’, by which the possibility of certain events occurring in the future, no matter how remote and rarely seen in the past, has recently started to influence policy-making. This tendency can partly be seen as recognition of pervasive uncertainty and the limited utility of the past for understanding and predicting the future (Aven 2013). The ‘infinite scale of the possible’ means, however, that the creation of and focus upon specific possibilities becomes a potent political tool (Heyman 2012, pp. 607–608), energised by concern about reputational risk to decision-makers if they are retrospectively seen to have neglected the possible (Rothstein 2006). Accordingly, possible but highly improbable futures come to colonise decision-making in the present.

The future and past as inherent drivers of time experienced in the present

A key theme within the two preceding sections has been the extent to which the past, present and future are complexly interwoven with each other. So while analyses of time may try to unpick these relations, it would seem misguided to begin to examine experiences of any one of these time phases in a vacuum. The pervasive way in which the future can be seen as permeating our experiences of the past and present is captured usefully by Jorge Luis Borges¹ (1998, p. 99) in his work The Immortal:

There is nothing very remarkable about being immortal; with the exception of mankind, all creatures are immortal, for they know nothing of death. What is divine, terrible, and incomprehensible is to know oneself immortal... Viewed in that way, all our acts are just, though also unimportant. There are no spiritual or intellectual merits. Homer composed the Odyssey; given infinite time, with infinite circumstances and changes, it is impossible that the Odyssey should not be composed at least once. No one is someone; a single immortal man is all men.

Death, or rather knowledge of this future certainty, vitally shapes the ways in which we live, giving meaning to our actions and identities to our bodies. Giddens (1991, p. 48), similarly, refers to Heidegger’s concept of Dasein in emphasising the challenge of living as a ‘being who not only lives and dies, but is aware of the horizon of its own mortality’. The existential problem of what it means to live the good life within limited time, a finite future, is central to the human condition (Kierkegaard 1989, Giddens 1991) and it is the possibility of regret – which would not exist in unlimited time (Borges 1998) – which is so integral to and defining of social experiences of risk and uncertainty (Luhmann 1988). It is time, as an abstract continuum, which renders past regrets undoable and maintains the unknowableness of the futures. Meanwhile, it is difficult to overstate the extent to which the subjective experiences which emerge out of these pasts and futures play a key role in shaping lived-experiences of the present.

Schutz (1972, pp. 12, 36) argued that a much more meticulously elaborated understanding of ‘internal time consciousness’, building on initial work in this area by Bergson and Husserl, is a necessity for the advancement of the social sciences as a whole. Arguably, given the centrality of futures to our objects of analysis, social-scientific analyses of risk and uncertainty are especially in need of more research in such time-oriented directions. One example, given by Schutz (1972, p. 67), of where greater sensitivity to actors’ experiences within lived time is instructive is in relation to analyses of the nature, format and structuration of decision-making. Rather than seeing a decision between two options X and Y as being made at a specific junction point O, Schutz draws upon Bergson in suggesting that:

the real way in which choice occurs is the following: The Ego imaginatively runs through a series of psychic states in each of which it expands, grows richer and changes... until ‘the free act detaches itself from it like an overripe fruit’. (Schutz 1972, p. 66)

Seeing risk, trust or other related ‘decisions amidst uncertainty in such a light, as unfolding processes involving an envisaging of future-time as an ongoing experience in the present, is integral to accurate analyses of such social phenomena. A sensitivity to the different formats and frames of time involved contributes much towards a more nuanced and detailed analysis of agency in relation to social structure (Schutz 1972, p. 66).

The papers in this special issue

Promising new ways of considering and theorising lived experience and ontologies in relation to time are emerging within risk research (Pierides and Woodman 2012, van Loon 2013), partly drawing upon a post-Actor Network Theory corpus (e.g. Harman 2011). In this issue, the guest editorial of Tom Horlick-Jones (2013) is informed by the interactionist and ethno-methodological tendencies, which are distinctive of his work. In reviewing a range of important risk research texts, especially those oriented towards organisational contexts, he makes a ‘plea for modesty’ within risk management. This modesty is necessary given the unknowability of the future alongside the limitations and short-comings of the Enlightenment project.

The tendency for risk-managers to gradually assume away the possibilities for failure that lurk within the future leads to a risky risk-management whereby the potential for disasters, such as those involving nuclear power or global finance, grow over time. Following Vaughan (1996, p. 394)  and her emphasis upon the ‘taken for granted aspects of organizational life that created a way of seeing that was simultaneously a way of not seeing’, Horlick-Jones draws our attention to the various forms of interpenetration between present and future as an important starting point for analysing effective and problematic approaches to risk and uncertainty.

The final of our four interview-based articles (Heyman and Brown 2013) compiles the views of Tom Horlick-Jones, Paul Slovic and Andy Alaszewski on various issues relating to social-scientific risk research. Though responding to a broader range of questions, which go beyond specific considerations of time-framing, the common theme running across these three experts’ responses is an interest in the collective processes, which lead to risk being defined in particular ways by different groups of actors. These definitions are embedded within certain more or less explicit interests and a particular definition may then become powerful in the way it facilitates and precludes ways of thinking about and addressing possible futures.

Linkages between futures and definitions are apparent within the first of the original research articles in this issue. Foster (2013) analyses qualitative data collected through focus groups, which were conducted in the North East of England around the theme of drinking away from licensed premises. Whether drinking at home (as was typical in the experiences of adults) or drinking in public settings such as parks (as was more commonly referred to by the younger focus group participants), a recurring finding was participants’ focus upon shorter time frames and therefore upon particular risks related to such time frames (injury or vomiting, for example). The absence of longer-term time frames corresponded to a frequent neglect of related potentialities such as health consequences. Meanwhile, other methods of bounding or framing time – through a drinker’s age, the time of day when consuming alcohol or the time between drinks – were all used as reference points when categorising ‘normal’ drinking and distinguishing this from more risky practices.

Age was also a prime consideration within the study of Locke and Budds (2013) into perceptions of fertility of women who had given birth to their first child aged 35 or older. The likelihood of conceiving – or perhaps more specifically the risk of not being able to conceive – alongside health-related risks posed towards unborn children impacted significantly on the timing of pregnancies. Some of the women described making decisions to conceive at times which were seen as non-ideal in respect to broader contextual features such as romantic relationships and workplace demands. Female bodies can thus be seen as being controlled through multiple and often incompatible risk-related discourses of career achievement and knowledge constructed around fertility and foetal health. The demands that emerge from these discourses, rooted importantly around time, can leave women in precarious positions.

Tensions between multiple possible futures and related expectations can thus lead to vulnerability. The participants in the study described by Brown and de Graaf (2013), each diagnosed with advanced-stage cancer, experienced high levels of vulnerability through their compromised futures following diagnosis. These contrasted sharply with previous assumptions about life expectancy and a related ‘bracketing away’ of death. Brown and de Graaf analyse the different ways in which these patients construed future-time. Different quantities and qualities of time were constructed within patients’ expectations, drawing on risk information from interactions with clinicians as well as invoking hopes in possible alternative outcomes. Because of the very nature of hope, whereby high levels of future uncertainty are acknowledged, tensions were apparent between the multiple futures and time frames considered. Some of the participants were seemingly better able to live with these tensions than others because of the influence of past and current social contexts and related habitus.

Multiple futures and time frames are again vividly apparent within the article of Heyman and Heyman (2013), which explores the narratives of young carers as well as professionals working with them. Contrasting time frames and attributions became apparent in analysis of the qualitative interview data. More official understandings of the futures of young carers, grounded in conceptions of youth as a critical phase which defines long-term adult futures, problematised the loss of ‘normal transitions’ and understood this as problematic for long-term outcomes – especially regarding employment. These attributions of risk, involving a particular relationship between a youthful-present and adult-future, stood in contrast to those perceived by the young carers themselves, where long-term futures were less likely to be considered. Where longer-term possible outcomes were envisaged, the young carers saw their futures as much less constrained by the lack of a normal present.

The salience of different lengths of time frames and the way these bear on the considerations of different risks was furthermore a key finding within the study of West et al. (2013). Considering time frames invoked by those reflecting on long-term experiences of self-hurting, short-term time frames were found to encourage a focus on the more direct and palpable effects of their self-hurting, which also included pleasure. Meanwhile, longer-term assessments attended to changing frequencies of the behaviour over the life course, with a certain ambivalence emerging between regret in some contexts alongside a recognition of self-hurting as an important coping mechanism within contexts of extreme vulnerability and emotions. This article also emphasises the need to move away from a ‘one time frame fits all’ approach in clinical practice.

Finally, the article by Topping et al. (2013) provides an insightful interrogation of the development of time frames regarding risks related to skin cancer, as variously interpreted from data emerging within this clinical field. Exploring patients’ journeys towards a diagnosis of cutaneous malignant melanoma, different forms of responsibilised (non-)urgency were apparent based on patients’ understandings of health promotion information and their interactions with family doctors. Vital to experiences of time and exigency within this context are different sources of information linking types of skin, form and extent of melanoma and speed of treatment access to risk of death. Yet these data and their appropriation within health promotion messages, medical understandings and media coverage tend to overlook a range of uncertainties, the impact of increased detection and early treatment on longitudinal trend data, and ways in which these data are modelled into the future. Thus, understandings about risk and time with respect to melanoma are organised around knowledge uncertainties, which are themselves systematically ignored.

Conclusion

This special issue is concerned with the role of time and time-framing within experiences and perceptions of risk and uncertainty. While the time component of risk may often be regarded straightforwardly as existing between two points on a standardised continuum, the earlier sections of this editorial, alongside the special issue articles briefly outlined, each acknowledge various complexities, multiplicities and subjectivities intrinsic to experiences and conceptions of time. Intrinsic to social action amidst uncertainty are various formats for relating pasts, presents and futures. Future-time involves the envisaging of specific quantities and qualities of time which are still to be experienced, with the subjectivities related to such expectations also impacting on lived-experiences within the present. Time, in its framing and as intrinsic to social experiences, is thus constructed within specific contexts. It is this emergence of time within local lifeworlds that forms a vital mechanism by which experiences of vulnerability amidst uncertainty – and related attributions of risk – are shaped and oriented by the social.

The articles in this special issue all explore various such relationships between social contexts, conceptions of time (not least future-time) and experiences and perceptions of risk. Understandings of drinking, child-bearing, living with an advanced-cancer diagnosis, caring as a young person, long-term self-hurting or accessing treatment for skin cancer are each vitally shaped by, and themselves help define, certain time frames within which vulnerability is considered and experienced. An acknowledgement of these different experiences of vulnerability amidst socially constructed time, alongside the different ways in which experiences of pasts, presents and futures are related to one another, is fundamental to effective social-science analyses of risk and uncertainty.

Notes

1. This application of Borges’s work is drawn from an essay entitled ‘Risk and the paradox of life’ by a University of Amsterdam MSc student in 2011, Jenny Schings.