The Paradox of Scientific Authority How is Certainty of Medical Science Constructed?

1. The Paradox of Scientific Authority How is Certainty of Medical Science Constructed? Wiebe E. Bijker Maastricht University Night of Descartes Utrecht, Sept 2009

2. No societal priority for health care, education, research Diminished authority of professor teacher, doctor We live in a technological culture: Modern societycannot exist without science and technology Paradox of scientific authority ?

3. Questions • About character and role of EBM: • Its historical roots (Howick) • Its shaping the medical profession (Porter) • Its epistemological base (Matthews) • Its clinical practices (Timmermans) • About societal functioning of (medical) science: • Societal role of scientific advice (“evidence based policy”) • One example: advisory report on EBM

4. The Health Council of the Netherlands • Task: to advice Dutch government on the ‘state of knowledge’ concerning public health • Established in 1902 • Works mainly through a committee process • Highly respected*: • Amongst politicians and policy makers • Amongst scientists and professionals • Nationally and internationally * Health Council: itself a living paradox?

5. Key concepts of our analysis • Constructed character of scientific knowledge • Frontstage — backstage • Coordination mechanisms • Problem definition • Committee composition • Committee process • Rhetorical and literary techniques • Distribution management and repair work • …

6. backstage interests hearings Civil servant as advisor Coordination- mechanisms policy science frontstage knowledge

7. Committee membership frontstage • members are selected a titre personnel: no representation • only ‘certified experts’ are eligible for committee membership backstage • membership is used for • distancing from the societal problem (‘taking the academic route’) • inducing commitment of the field (by strategically choosing experts)

8. Committee work: organizing disputes to create a ‘serviceable truth’ Committee’s secretary (backed by chair): • …sets the stage for a dispute: “I will send an email to another committee member, saying ‘he said that X, but I think Y’ - and I’ll state my reasons - and ask ‘what do you think?’ And when they concur with my position, I’ll ask ‘can I bring that into the committee?’ And then I’ll say in the committee ‘last time we heard this opinion X, but another committee member says this Y.’ Then I’m no longer involved, although I’ve steered it.” • …and controls dissent “It enriched the discussions very much. He really knows about this subject, like when he criticized the RIVM for not interpreting the tests correctly. But we couldn’t use much of his writings for the actual advice. The trouble with these people is that they have much scientific insights to add, but cannot place it in a policy context.”

9. Case of EBM:(Medisch handelen op een tweesprong, 1991) • Question (1989): which treatments are not scientifically proven effective and can be dropped from the insurance package? • Qualitative research (50 interviews)  annex “medical treatments in practice” • Advice (1991): more focused on medical practice in general than on single treatments  also addressing insurance, multi-disciplinarity, patients’ consumerism, work load, training quality, quality control • Effects: • Very mixed reactions • Leave quality-control to medical profession • “Evidence-based” becomes corner stone Dutch medicine

10. Theory of scientific advising* Specifies scientific advising as: Product Work Process * W.E. Bijker, R. Bal, R. Hendriks. (2009) Paradox of Scientific Authority: the role of scientific advice in democracies. Cambridge, MA: MIT Press.

11. Productof Scientific Advising Advisory report: • Front stage identity • Scientific, but not like research:Serviceable truth: Scientific knowledge, which is tuned to policy making

12. Workof scientific advising • Backstage activities (to produce frontstage product) • Boundary work by coordination mechanisms: Inseparable acts of distinguishing and coordinating

13. Scientific advising in democratic Process How to position scientific advising in the wider process of democratic (risk) governance? Case: risk governance in nanotechnologies

14. Risk Governance: classification

15. Examples of classification(nanotechnologies)

16. Risk Governance

17. But, of course: Who decides?

18. ‘triage’ of risk & expertise Broad monitoring committee Advises government on nanotechnologies’ state of the art and associated risk classification With heterogeneous membership of citizens, stakeholders, scientific & technical experts Health Council Public Debates Sector Councils .....

19. Conclusions • Institutions like the Health Council : • Provide solid scientific expertise while reflexively and consciously recognizing a constructivist epistemology • Serve democracy by providing an (“undemocratically”) secluded space for scientific debate and advising • EBM: • Was asked to solve a financial problem, then used to solve a quality problem

20. References • Bal, R., Bijker, W. E., & Hendriks, R. (2004). Democratisation of scientific advice. British Medical Journal, 329, 1339-1341. • Gezondheidsraad. (2006). Health Significance of Nanotechnologies (No. 2006/06E). Den Haag: Gezondheidsraad. • Bijker, W. E., Beaufort, I. D. d., Berg, A. v. d., Borm, P. J. A., Oyen, W. J. G., Robillard, G. T., et al. (2007). A response to 'Nanotechnology and the need for risk governance', O. Renn & M.C. Roco, 2006. J. Nanoparticle Research 8(2): 153-191. J. Nanoparticle Research, 9(6), 1217-1220. • Bijker, W. E., Bal, R., & Hendriks, R. (2009). Paradox of Scientific Authority: the role of scientific advice in democracies. Cambridge, MA: MIT Press.

21. w.bijker@maastrichtuniversity.nl