Sociological perspectives on the politics of knowledge in health care: introduction to themed issue

Which kinds of knowledge provide valid foundations for healthcare choices and practices, and who decides, is highly contested. From public debates around the safety and efficacy of complementary medicines, vaccinations, new drugs, medical technologies and diets, to private decisions about the who, how, what and where of seeking treatment, the uncertainties of health-related knowledge are woven through our lives. This themed issue offers a sociological analysis of emerging trends and issues in how different knowledges inform, and are legitimated within, contemporary health care.

Although health care (including lay and professional practice, policy, and training/education) may have always been a contentious epistemological space, the questions and dilemmas currently arising reflect larger shifts in the status of knowledge in post-industrial societies, often described as ‘knowledge societies’ in reference to the way that knowledge and expertise have come to govern politics, work and everyday life (Adolf & Stehr, 2014). There is debate over whether a supposed democratisation of knowledge – often linked to the spread of information technology – has decentralised expertise in the knowledge society or reinforced dominant epistemological hierarchies (Broom & Tovey, 2008; Fox, Ward, & O’Rourke, 2005; Nowotny, 2003).

In health care, changes in the status of knowledge have manifested in various ways, including challenging the status of medicine as an expert system. The medical profession rose to dominance partly through gaining access to the specialised knowledge of science (Willis, 1983), but increasingly other health professions have obtained their own forms of scientific expertise. The experiential knowledge of clinical practice has also been partially delegitimated with the rise of evidence-based medicine (EBM) (Pope, 2003). More recently, the patient experience has become a legitimate knowledge resource, with the emergence of the ‘expert patient’ as a stakeholder in health policy and research (Britten & Maguire, 2016; Moreira, 2015).

While reflecting a wider politics of knowledge, debates over knowledge in health care are particularly intense because the stakes are so high. Further signs of a shift in the locus of control over health care, such as increased prominence of complementary medicine, have provoked vehement backlashes in the names of science, evidence and safety (Brosnan, 2015; Vuolanto, 2015). Meanwhile, successive governments must attempt to mediate between patient demands and healthcare supply using scientific evidence, amid lobbying from consumer groups, health professions and skeptic organisations. The five papers in this issue provide a sociological perspective on how epistemological tensions are negotiated, resolved or reinforced within different healthcare practices and contexts, including the implications for professions, patients and publics.

The issue begins with Dew’s exploration of the processes of legitimising health knowledge within three sites, and epistemological spaces: the clinic, the home and the multidisciplinary meeting. Dew’s ethnomethodologically and actor-network theory informed analysis reveals the nuanced ways by which multiple knowledges are produced, highlighting the interplay between forms of authority and interactions between patients, professionals and therapeutic spaces. Dew argues that knowledge is variably produced, enacted and legitimised across therapeutic spaces, contributing new understandings of expertise, medical dominance and subjectivity in everyday healthcare decisions.

Adding to knowledge of how EBM is deployed in practice, Hansen, Walters and Howes explore tensions within general practice around the application of clinical guidelines which aim to standardise diagnosis and treatment. Across three case studies, they show that a key reason GPs resist applying guidelines is their desire to practice holistic, patient-centred care, which entails privileging their knowledge of patients’ life circumstances (though not necessarily patients’ own informed choices) when making clinical decisions.

Brosnan’s paper examines how the challenges of EBM are dealt with in a different context: Australian university departments of complementary medicine, which have recently been accused by sceptics of teaching ‘pseudoscience’. Comparing how academics in Chinese medicine and osteopathy construct and legitimate different forms of evidence, Brosnan argues that responses are shaped by the specific epistemic cultures of these complementary medicine disciplines.

Also on professional knowledge, Smith-Merry and Gillespie explore the notion of embodied knowledge in health care through a qualitative study of Australian mental health policy around the implementation of the Partners in Recovery program. Their analysis reveals the instability of embodied knowledge and the related challenges to successful implementation of health policy in practice, particularly through the structural devaluation of certain types of knowledge over others.

Finally, Willis and colleagues investigate how patients navigate Australia’s complex public and private healthcare system, identifying a significant resource that has been largely overlooked: ‘system knowledge’ – that is, people’s knowledge about the healthcare system itself and how it operates. This may be acquired through online research, social networks and prior healthcare experiences, or conferred through traditional forms of social and economic privilege. Drawing on Bourdieu, the paper mounts a critique of the ‘choice’ assumed to underpin decisions around health care.

Utilising a range of theoretical frameworks and examining different empirical contexts, together these contributions highlight the manifold social dimensions of the politics of knowledge in health care.

Additional information

Funding

This themed issue was conceived during ‘The Politics of Knowledge in Healthcare’ symposium (2015), supported by the Faculty of Education & Arts at the University of Newcastle and the Australian Sociological Association. Caragh Brosnan’s and Emma Kirby’s work is supported by Australian Research Council DECRA grants [DE140100097 and DE150100285].