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On the epistemology of risk: Language, logic and social science
Sm. Sci. Med. Vol. 35, No. 4, pp. 401-407, 1992 Printed in Great Britain. All rights reserved
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0277-9536/92 $5.00 + 0.00 1992 Pergamon Press Ltd
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ON THE EPISTEMOLOGY OF RISK: LANGUAGE, AND SOCIAL SCIENCE
LOGIC
MICHAEL V. HAYES Department of Geography, Simon Fraser University, Burnaby, B.C. Canada V5A lS6
Abstract-‘Risk’ is a widely used concept in literatures related to health, health care and medicine. In recent decades, three bodies of literature have emerged in which ‘risk’ is the primary focus of concern:
Health Risk Appraisal, the Risk Approach and Risk Analysis/Assessment/Management. These literatures overlook important concepts and theoretical developments in contemporary social science. They also lack conceptual coherence. Reduction of incoherence will require re-examination of the epistemology of risk in relation to both its language and its logic in light of developments in social science. Key words-risk, epistemology, ideology, discourse, philosophy
THE
The
programme
CONCEIT
OF RISK
announcement
for
the
XIIth
International Conference on the Social Sciences and Medicine introduces the theme entitled “Concept
of risk and risk taking in health care and health behaviour” with the following sentence: Risk is a pivotal, if neglected, concept in the application of the social sciences to health and medicine. A MEDLINE search for the word ‘risk’ identified 100,898 references made between January 1985 and December 1991-an average of just over 14,400 references per year [l]. This suggests that approx. 5% of the 25,000 references added to MEDLINE every month are associated with some notion of ‘risk’. By comparison, the word ‘neoplasia’ captured 309,008 references, while the labels ‘heart disease’ and ‘cerebrovascular disorders’ captured 103,358 and 29,870 references respectively. It would seem, therefore, that ‘risk’ is in fact a prominent concept in health, health care and medicine which, by definition, involve the application of social sciences. References connected by the tag ‘risk’ reflect the diversity of topics contained within the MEDLINE spectrum of literatures, and include applications to: the evaluation and delivery health care services (patient management, behavioural modification programs and clinical interventions) and formulation of health care policy (both public and private); assessment of technological and natural hazards; public perception of risk; health insurance; investment and financial management of pension plans; social regulation and law; and analyses of culture and ideology. That such diverse literatures are associated with the terms ‘health’ and ‘risk’ is, perhaps, not surprising given the all-encompassing or totalizing meaning that each word has in contemporary society.
As recent models of health [2,3] attempt to illustrate, every aspect of human experience influences health in some way. And, as uncertainty (or indeterminism) is now considered a fundamental and inescapable fact of human experience [4], ‘risk’ to health is inevitable. Analyses of ‘risk’ are typically undertaken to reduce, modify or anticipate the extent or nature of uncertainty in decision-making processes. Widespread application of techniques and methods for the formal analysis of ‘risk’ in the professional literatures on health and health care is a relatively recent phenomenon that has developed primarily over the past 30 years. The term itself is most widely used in the general health literature, in relation to clinical research, to describe units of measurement (relative risk, attributable risk, attributable risk percentage or fraction, and risk ratio for example) [5,6]. However, within this period three spheres of literature have emerged in which ‘risk’ is the primary focus of concern: Health Risk Appraisal, the Risk Approach and Risk Analysis/Assessment/ Management. Health risk appraisal (HRA), variously referred to as health risk assessment, health hazard appraisal or assessment (HHA), personal health risk assessment, and health assessment, developed out of the work of Robbins and Hall [I as a method to help physicians practise preventive medicine by focusing prospectively on the avoidance of premature mortality. “In a conventional HRA, an individual’s health-related practices, habits, lifestyle, personal characteristics, and personal and medical family history are compared with data from epidemiologic studies and vital statistics in an attempt to project the individual’s risk of death over some future period” [8, p. 5541. Thus, attributes of the individual (behaviour and genetic endowment) are cast as the source of ‘risk’ in HRA,
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and the objective of intervention is to reduce the burden of premature death by stimulating individuals to stop or modify ‘risky’ behaviours. The Society for Prospective Medicine, founded by Robbins and Hall, has played an influential role in nurturing HRA, which has been described as “one of the most important innovations in the field of health education and health promotion in more than 20 years” [9, p. 5821. The Risk Approach (RA), also called the Risk Strategy, is a framework for the selective provision of health care services advocated by the WHO in the context of its Maternal and Child Health program [lo, 111.RA is proposed as a strategy to maximize the efficiency of public resource deployment (specifically, delivery of primary health care services) in less developed countries: Its aim is to give special attention to those in greatest need within a framework of improved health care for all. Individuals and groups with an increased expectation of complications or disease are defined as being ‘at risk’ and the aim of the health services should be to identify them as early as possible and to intervene in order to reduce the risk [IO, p. i].
The sources of ‘risk’ in RA are more diffuse than in HRA, and involve attributes of both the individual and her or his socio-ecologic setting. In addition to the publication of two monographs, the WHO has nurtured the development and diffusion of the RA framework by publishing other support materials [ 121, sponsoring research, and holding workshops v31. The sphere of Risk Analysis/Assessment/Management (RA/M) is much more general and amorphous than the two identified above. Much of this research concerns the evaluation of technical hazards, product safety, and public perception of risk, although research is by no means limited to these areas. Here the source of ‘risk’ tends to be external to the individual (the safety of a specific technology), although how the individual perceives and responds to issues of safety is an important stream of this research. The various interests of members of the Society for Risk Analysis and the diversity of research which is published in its journal, Risk Analysis, are indicative of the range of applications of RA/M. A synthesis of methods, techniques and assumptions drawn from various academic and professional disciplines are employed in these analyses of ‘risk’. Fielding [14] attributes the development of HRA to advances made in at least five disciplines-epidemiology, actuarial science, biostatistics, preventive medicine, and health education and behavioural medicine-facilitated by advances in computer science. And Fiksel [IS] writes: Risk analysis is a unique field in that it has no academic boundaries. It admits all creeds. Whereas traditional disciplines tend to specialize, we seek to integrate across disciplines. Our role, viewed broadly, is to draw upon the best available scientific knowledge in pursuit of societal goals-health, safety, and environmental protection [15, p. 1951.
One consequence of the hybrid heritage of the analysis of ‘risk’ is a lack of conceptual coherence both within and between bodies of risk literature. Notions of ‘risk’ vary greatly across operationalized definitions of health, as do the specific motives and purposes of applications, the nature and contextual conditions of relations between ‘risks’ and specific outcomes, and the conditions and methods of measurement. But little has been written about the epistemology of ‘risk’ in general, paradigmatic terms; i.e. about the nature of relations in time and space; the implications of essentially different types of relations for various assumptions, measures and practices of risk analyses; the conceptions of science that underpin these assumptions, measures and practices; or the conceptions of society in which these analyses are embedded. Indeed, a MEDLINE search of the combination ‘risk’ and ‘epistemology’ as key terms failed to capture a single reference. This is not to say that issues of measurement, interpretation or research practice are not discussed in the literature. Very many papers concerned with analyses of ‘risk’ identify such issues and problems. But, by and large, controversy relates to nuance of detail within conventional practices, rather than to more general matters of the theoretical, philosophical and ideological bases of the practices themselves. The state of the art reflects the fact that explicit discussion of the philosophy of science and/or of general social theory is rare in the mainstream health and health care literature, although other realms of social science literature are in ferment with such discussion. To return to the opening sentence of the programme announcement cited above, a more accurate assessment of contemporary practice would be: The social sciences contain pivotal, if neglected, concepts in the application of risk to health and medicine.
The remainder of this paper attempts to illustrate this claim by examining some fundamental issues associated with both the language and logic of analyses of risk. THE LANGUAGE
OF RISK
The lack of conceptual coherence in analyses of risk is reflected in the ambiguity and imprecision of terms used in the language of risk. In his synthesis of recommendations made at the 1986 national invitational conference to discuss and propose a research agenda for HRA, hosted by the Foundation for Health Services Research [16], DeFriese [9] writes: In recognizing the diverse and widespread uses of HHA/ HRA techniques in health promotion and education, conference participants called attention to the absence of a common language and terminology in this field. . Terms such as ‘precursor’, ‘precondition’, ‘risk factor’, ‘risk indicator’, ‘risk ratio’, ‘risk age’, ‘probability’, ‘risk multiplier’, and ‘quality of life’ continue to be used without formal definition among those who write and otherwise communicate about health risk assessment methods [9, p. 5851.
The epistemology of risk Third among the eleven recommendations made at the conference was that “a formal glossary of standardized terms used in the health risk assessment/health hazard appraisal field should be developed and widely disseminated among developers, researchers, and users of these techniques” [9, p. 585]. A guest editorial published simultaneously in Risk Analysis and Risk Management (the journal of the Risk and Insurance Society) suggests the language of RA/M is so incoherent that this field of research is in conflict with itself:
403
sibility for remedial action. Some words imply disorder or chaos, others certainty and scientific precision. Selective use of labels can trivialize an event or render it important; marginalize some groups, empower others; define an issue as a-problem or reduce it to a routine. Is the discovery of PCBs a ‘disaster’ or an ‘incident’? Are certain chemicals ‘doomsday products’ or ‘potential risks’? Are risks unavoidable (‘chemicals are a fact of life’) or a result of deliberate choice? Is fear of risk a ‘phobia’ or a realistic concern? (27, pp. 20--211.
[28] illustrates Nelkin’s point in his analysis of disputes between management and labour over With its multiple definitions and practices, risk management issues of occupational health and safety with respect is in many ways in competition with itself: thus ‘risk to exposure to potentially hazardous substances. management agonistes’ [the title of the editorial] conveys Industry advocates cast ‘risk’ as being unavoidable a sense of struggle or conflict.. . A synthesis-a new form, and illustrate this with reference to everyday activities, definitions, and understanding of risk management-is such as driving a car, taking a bus or crossing a street. needed [17, p. 2011. Thus fears of occupational exposures are irrational Mary Douglas, well known for her work on risk ‘phobias’. To labour advocates, on the other hand, and culture [18, 191, has observed that the connotation occupationally-related diseases have reached ‘epidemic of the word ‘risk’ has changed over time [20]. proportions’. Exposures to various substances have Originally introduced in the seventeenth century in created ‘time bombs’ of human disaster, with ‘tragic’ the context of gambling, risk meant the probability consequences for workers and their families. of an event occurring combined with the magnitude Ideological dimensions of the language of risk of losses or gains that might be entailed. Thus, the have been largely overlooked in the HRA and RA concept itself was neutral. Today, however, the notion literatures. HRA has become “a standard offering of risk tends to be associated only with negative in the health promotion repertoire” [8, p. 5531. The outcomes. This is certainly true of the professional or focus of HRA, which is exclusively upon individual technical usage of the term, as the definition adopted behaviour, is compatible with the definition of health by the Royal Society [21] indicates: promotion proffered by O’Donnell [29] and endorsed Risk is the probability that a particular adverse event occurs by the American Journal of Health Promotion : “health during a stated period of time, or results from a particular promotion is the science and art of helping people challenge [21, p. 221. to change their lifestyle to move toward a state of optimal health” [29, p. 41 (a definition completely In other technical applications, risk is more than the consistent with the American ethos of individualism). probability of occurrence of an adverse or unwanted However, HRA is not entirely consistent with the outcome; it also incorporates some measure of the definition of health promotion contained in the magnitude of impact or consequences [22]. In still Ottawa Charter for Health Promotion [30], proffered other uses, the word risk is applied to attributes which by WHO: “health promotion is the process of differentiate the mortality or morbidity experience enabling people to increase control over, and to between groups of individuals with and without the improve, their health”. Within this definition, “health attribute (e.g. smoking is a risk to health). promotion. . goes beyond healthy life-styles to wellHansson [23] argues that scientific ‘linguistic being”. The WHO definition acknowledges deterimperialism’ treats the word risk as a unidimensional, minants of health that are embedded in social structure technical concept that refers to some numerical proband therefore beyond the individual’s control, in ability value, whereas in everyday popular usage the addition to determinants over which the individual term has many other layers of meaning. Although Hansson does not label it as such, the problem he may have control. It advocates a socio-ecological describes of the different meaning words have in approach to health, and individual and community empowerment to address both types of determinants. scientific and popular uses is referred to as the ‘double HRA’s concern with individual behaviour ignores hermeneutic’ by Giddens (following Winch) [24,25]. structural determinants of health, and places At issue in the double hermeneutic is the translatability responsibility for action solely upon the individualof concepts between scientific and lay language communities, and conflict over authority to declare the effectively endorsing the American Journal’s vision of health promotion. In failing to distinguish between correctness of translation [26]. the competing visions, the HRA literature exerts The ‘double hermeneutic’ exposes ideological dimensions of the language of risk. As Nelkin [27] a strong but subtle ideological influence upon the discourse of health promotion. notes: The WHO intends RA to be an instrument of The language used by different groups to describe risk and to prescribe solutions is judgmental. The terms employed public policy: “if taken seriously, [RA] has the most frame an event; the metaphors and images used to describe important consequences for public policy and can a situation can point the finger of blame and imply responprovide the information necessary for intersectoral Hilgartner
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MICHAEL V. HAYFS
policy decisions which affect health” [l 1, p. 1131. Reducing inequalities in health is identified as the primary motive behind RA. How best to reduce inequalities in health is, of course, fundamentally an ideological issue. RA advocates inequalities be addressed through the provision of health care services: The challenge presented by more accurate knowledge thus consists in how best to use this ‘epidemiology of risk’, how to exploit more of the known causal pathways, and how to improve-even slightly-the effectiveness of prevention (and, of course, promotion) in the domain of maternal and child health care and family planning. Essentially this is a problem of how to enhance and improve coverage, acceptability, efficiency and the effectiveness of primary health care 111, p. 81.
Advocating equality in health through provision of health care services-essentially equating health and health care-focuses the analysis on disease as the cause of inequities in health. Illiteracy, conditions of poverty, lack of access to clean water, and the like are cited as important risk factors for poor health outcomes but there is no discussion of the processes that give rise to these factors, they are simply given. Alternative strategies to primary health care for addressing inequalities in health-improving levels of education, access to water, economic well-being or ‘conditions of daily living’-are not considered. The problem is identified as one of access to health care services, not one of basic distribution of wealth or material comfort, so the solution is to provide more or better health care services (made possible through gains in the economic efficiency of resource deployment realized by analyzing risk). Thus RA as proposed is an inherently conservative strategy that supports the status quo in less developed countries. The negative connotation of the word risk creates a fundamental problem in the notion of ‘risk taking’, namely differences in perception regarding the inherent value or worth of some action or behaviour between the ‘risk taker’ and the risk assessor. Risk taking implies intent on the part of the actor, but the intentions of the action are not fully appreciated or acknowledged with this one-sided view of risk. The risk assessor judges the actions of another individual to be harmful (or bad?). The (real or perceived) benefits to the individual of smoking, eating, drinking, driving, flying, or whatever, are not considered. The health-enhancing aspects of the benefit of some action to the individual may more than compensate for its health-threatening aspects (rational behaviour?). The notion of risk as wager-assessing both losses and gains-would seem a more appropriate conception of risk in relation to ‘risk taking’. Analysis of both positive and negative aspects of behaviour would provide the ‘risk taker’ an opportunity to play an active role in labelling and evaluating ‘risk’, thereby wresting exclusive power to determine ‘risk’ away from an external ‘expert’.
Language is context dependent-the meanings of words derive from the settings and circumstances in which they are used, and shaped by the power relations involved in their use [31]. The essentially problematic nature of language is a much discussed topic in contemporary social science, as popular interest in hermeneutics and deconstruction attest [32,33]. Given differences in individual perception, there will never be universal agreement on the ‘correct’ meaning and use of terms. This does not necessarily imply that formal glossaries of standardized terms called for above cannot be developed within literatures on HRA, RA or RA/M. However, given the hybrid heritage of these bodies of risk literature and the variety of purposes to which analyses of risk are put, one wonders if agreement over the use and meaning of terms or, for that matter, about appropriate application and expectations regarding the utility of risk analyses can be reached in the absence of more explicit theoretical development of other aspects of the epistemology of risk. THE LOGIC OF RISK
Three aspects of the logic of risk requiring greater attention in these literatures will be discussed in this section. These concern: (1) development of a typology of the fundamental properties or characteristics of risk relations; (2) treatment of the time-space dimensions of risk relations; and (3) the prevailing conception of science that guides the analysis of risk. I have explored some of these issues in relation to the RA literature previously in this journal [34]. In this section arguments will be illustrated with particular reference to HRA, especially as discussed in Health Services Research Vol. 22(4), which contains the papers published from the invitational conference identified above, and to RA. Risk relations are defined with respect to specific health outcomes--mortality or morbidity from cancer (more precisely, a specific type of cancer), heart disease, stroke, traffic accidents, etc. The nature of specific ‘risks’ that might be identified in relation to some chosen outcome may vary greatly. One might identify various dimensions across which risk characteristics might be differentiated. Variations are possible with respect to the essential properties of the risk characteristic itself. For example, age, sex, biologic disposition, familial history of disease, and weight are characteristics rooted in the biology of being (‘nature’). Religion, ethnicity, gender, dietary practices, attitudes/values/beliefs, lifestyle, etc. are characteristics that derive from the socio-environmental context of being (‘nurture’). All of these characteristics have been identified as increasing the risk (in the one-sided sense of the word) of, for example, heart disease. Also, in relation to the essential properties of the risk itself, one could consider differences in attributes of the ways in which categorical
ties obtain.
Thus, with respect
to
The epistemology of risk characteristics of the category ‘nature’, biologic disposition is a fixed and unchanging property of biological endowment, as was sex prior to the advent of medical interventions that now allow some flexibility in this regard. Age is a fixed but constantly changing property of biology. Familial history of disease is not necessarily a fixed property of biology because the trajectory of those histories is neither fixed nor predetermined so they do not reveal the entire story of relations between characteristics and specific outcomes. At the same time, one could consider the properties of the relational union between ‘risk’ and outcome. In this regard, risks might be considered modifiable or non-modifiable. Thus, with respect to heart disease, biologic disposition, age and family history are nonmodifiable (even though biologic disposition cannot change but age can), whereas weight is modifiable. Distinction between necessary (i.e. causally related to the outcome) and contingent (empirically associated but not causally related) relations is yet another concurrent dimension of relational union of potential significance. Still another might be primarily within the control of the individual or outside the individual’s sphere of influence. Appropriately identifying all of the potentially important concomitant dimensions of relational union and situating ‘risks’ simultaneously within them is a complex and vexing intellectual challenge. But identfication of relevant dimensions would provide a taxonomic framework for a language of risk. It would also help to clarify potential confusion concerning the policy implications of different types or sources of risk. Such confusion is apparent in the RA literature, which fails to distinguish between socially produced (‘nurture’) and naturally occurring (‘nature’) risks. Thus poverty, short stature and intercurrent illness are all risk markers (factors) for low birth weight, but the implications of each factor for intervention are very different [34]. Paying greater attention to the intrinsic qualities of ‘risks’ and risk relations would also facilitate a richer appreciation of how risk relations might be constituted somewhat differently across dimensions of time and space, the resources through which relations get played out. Theorizing the ways in which highly differentiated relations obtain in specific time-space contexts, and how and why processes vary spatially and temporally, has become a major concern of late among human geographers and sociologists [35-371. In general, risk literatures are insensitive to the dimensions of differentiation of relations in space-time in the lives of specific individuals. The RA literature tends to assume that regularity of empirical effects across time and space will hold almost independently of the specific relations or populations involved, even if these relations are not well understood [34]. With respect to HRA, Spasoff and McDowell [38] note that Applying a risk appraisal model developedin one population to another
group
involves
the assumption
that the causal
405
mechanisms (reflected in the strengths
and relationships of the precursors [risk factors]) are similar in the various groups-an assumption we can rarely test, but one that seems to be generally plausible [38, p. 4731.
Given that “many of the values we measure are probably only surrogates for the true etiologic variables” [38, p. 4861, one wonders if such an assumption is generally plausible. A question that might be fruitfully addressed in this regard is “what must the nature of risk relations be like in order for them to be stable across space and through time (thereby supporting the above assumption)?’ Theoretical development of both the nature of relations and their spatialtemporal context ought to facilitate improved understanding of risk relations, thereby diminishing the prospect of making erroneous assumptions about the general applicability of estimation models. It would also focus attention on the ‘emergent’ nature of risk. As Spasoff and McDowell [38] note, the concept of risk is fundamentally an aggregate notion. At the individual level, events are dichotomous. Probabilities obtain at the group level. Deeper appreciation of the essential qualities of risk relations and their time-space context would necessarily involve consideration of populations of interest, and how these are defined in light of identified characteristics of ‘risk’. Analysis of ‘risk’ necessarily begs the question of interpretation. Guidelines for interpretation follow from the conceptions of science that drive our practice. The hegemonic conception underlying analyses of ‘risk’ is positivist. This is evident in nomothetic treatment of risk relations, general avoidance of normative aspects of science, and the status of prediction in relation to explanation. It is the prospect of being able to predict events (eliminate uncertainty) that is the attraction of risk analyses. Positivist conceptions of science treat prediction and explanation symmetrically. Verification of explanation is provided through accurate prediction. Thus, in discussing composite scoring, methods and predictive validity regarding HRA, Kannel and McGee [39] claim that “for any scientific result to be acceptable, it should be reproducible” [39, p. 5171. Critiques of positivism abound in the social sciences [40-421. Although positivist attitudes are still widely held among social scientists, other attitudes toward science are gaining prominence in related literatures. For example, (transcendental or theoretical) realism has been suggested by some [40,41,43,44] as offering a superior epistemological framework for the practice of social science. One of the fundamental differences between positivist and realist conceptions concerns the status of prediction in relation to explanation. According to the realist what causes something to happen has nothing to do with the matter of the number of times it has happened or been observed to happen and hence whether it constitutes a regularity [45, p. 1621. Within this conception, regularities occur only if the two conditions for closure are met: viz., that
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MICHAELV.HAYES
the internal structure of the mechanisms that allow something to undergo change (i.e. the inherent causal properties or powers of risk relations to lead to specific health outcomes) operate consistently across time and space (termed the intrinsic conditions for closure by Bhaskar [43, pp. 63-142]), and that relationships between the causal mechanisms and external conditions which might make some difference to the operation of internal structures also operate consistently across time and space (the external conditions for closure) [41, p. 1121. Rather than verification, explanation rests on the internal logic and consistency of the theoretical argument establishing the nature of relational powers (both necessary and contingent relations). The more risk relations depart from closure, the less the expected empirical regularity of pattern. But failure to observe regularities does not constitute evidence of disproof of hypothesized relations. In HRA and RA some types of risk may satisfy the conditions for closure (those that relate to genetic disposition, for example) while other types of risk do not (factors related to nurture or social experience). The realist lens frames the question of the practical utility of risk analyses in a somewhat different way from that of the positivist. Rather than discarding hypothesized risk relations that do not display empirical regularity, the realist perspective would hold on to the intrinsic value of knowledge concerning the nature of risk relations. The practical utility of risk analyses (the ability to predict future occurrences) would be limited to those systems of risk relations that approximate the conditions for closure in instances where accuracy of prediction is of great concern (e.g. in the delivery of clinical interventions in the case of RA, or in the precision of estimates deemed important for specific applications of HRA). In other applications of RA and HRA, for example, intersectoral public policy decisions concerning, the impact of poverty upon individual well-being, the fact that conditions for closure would not be met need not deter us from action. Decisions would be based on our theoretical understanding of risk relations, and the multiple pathways to various outcomes that follow from the influence of poverty upon well-being. To contrast the implications for thinking about risk relations from a realist rather than a positivist perspective, consider the illustration Spasoff and McDowell [38] use in their discussion of issues associated with the accuracy of risk estimates (Fig. 1). They write As epidemiologic evidence accumulates, we should be able to move line AA downward, converting the unknown area to known. We shall be unable to move line BB, since chance is chance; its role presumably varies for different causes of death [38, pp. 469-701. The basis upon which line AA moves downward is accurate prediction. From the realist perspective this illustration inadequately represents the issue because knowing a causal pathway does not necessarily mean
KNOWN CAUSAL PATHWAYS A
**t.~t...**t.....*...*...**...,.**.....**....**..*.**~*...
A
UNKNOWN CAUSAL PATHWAYS B
???????????????????????????????????????? B CHANCE
Fig. 1. Determinants of death or disease. Source: Ref. [38]. that its occurrence can be predicted (unless conditions for closure are met). Thus, it does not follow that improved understanding of pathways will necessarily lead to better predictions. Moreover, ‘chance’ is not a phenomenon that affects only unknown pathways. Known pathways that do not satisfy the conditions for closure are always affected by ‘chance’ in the form of contingent relationships that interrupt the causal mechanisms and prevent regularities from obtaining. Of course, the question of what constitutes ‘known’ pathways is addressed in fundamentally different ways by these two conceptions. The realist perspective is not without its shortcomings [37, pp. 166-1691. My purpose here is not necessarily to celebrate realism (although I think it does offer considerable advantage over positivism), but to draw attention to the question ‘science how?. Risk literatures take the question as given and unproblematic, which blinds criticism to fundamental issues of epistemological significance. EPILOGUE
The purpose of this necessarily short and incomplete polemic is to draw attention to the application of social science in thinking about risk in health and medicine. Obviously everyone who writes about this subject engages social science in some manner. At issue is the question ‘what manner?. The epistemological concerns identified here are essentially contestable-there is no single truth. That is why it is so important to scrutinize our science-it will help us maximize the levels of conceptual coherence we are capable of reaching in analyses of risk. Acknowledgements-I am grateful to Lillian Bayne and Nick Blomley for their helpful comments, and to Leslie Butt for her assistance in preparing this paper. REFERENCES 1. The search of MEDLINE file 154 was conducted on 3 January 1992. References either contained the work ‘risk’ in the title, abstract or keywords, or were crossclassified under the section-heading ‘risk’. Both English
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Res. 22, 467-497, 1987. 39. Kannel W. B. and McGee D. L. Composite
scoring -methods and predictive validity: insights from the Framingham study. Hlth Services Rev. 22, 499-535,
1987. 40. Keat R. and Urry J. Social Theory as Science, 2nd edn.
Routledge and Kegan Paul, London, 1982. 41. Sayer A. Method in Social Science: a Realist Approach. Hutchinson, London, 1984. 42. Bryant C. Positivism in Social Theory and Research. Macmillan, London, 1985. 43. Bhaskar R. A Realist Theory of Science, 2nd edn. Harvester Press, Sussex, 1978. 44. Pawson R. A Measure for Measures. Routledge, London, 1989. 45. Sayer A. Realism and geography. In The Future of Geography (Edited by Johnston R. J.). Methuen, London, 1985.
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0277-9536/92 $5.00 + 0.00 1992 Pergamon Press Ltd
C
ON THE EPISTEMOLOGY OF RISK: LANGUAGE, AND SOCIAL SCIENCE
LOGIC
MICHAEL V. HAYES Department of Geography, Simon Fraser University, Burnaby, B.C. Canada V5A lS6
Abstract-‘Risk’ is a widely used concept in literatures related to health, health care and medicine. In recent decades, three bodies of literature have emerged in which ‘risk’ is the primary focus of concern:
Health Risk Appraisal, the Risk Approach and Risk Analysis/Assessment/Management. These literatures overlook important concepts and theoretical developments in contemporary social science. They also lack conceptual coherence. Reduction of incoherence will require re-examination of the epistemology of risk in relation to both its language and its logic in light of developments in social science. Key words-risk, epistemology, ideology, discourse, philosophy
THE
The
programme
CONCEIT
OF RISK
announcement
for
the
XIIth
International Conference on the Social Sciences and Medicine introduces the theme entitled “Concept
of risk and risk taking in health care and health behaviour” with the following sentence: Risk is a pivotal, if neglected, concept in the application of the social sciences to health and medicine. A MEDLINE search for the word ‘risk’ identified 100,898 references made between January 1985 and December 1991-an average of just over 14,400 references per year [l]. This suggests that approx. 5% of the 25,000 references added to MEDLINE every month are associated with some notion of ‘risk’. By comparison, the word ‘neoplasia’ captured 309,008 references, while the labels ‘heart disease’ and ‘cerebrovascular disorders’ captured 103,358 and 29,870 references respectively. It would seem, therefore, that ‘risk’ is in fact a prominent concept in health, health care and medicine which, by definition, involve the application of social sciences. References connected by the tag ‘risk’ reflect the diversity of topics contained within the MEDLINE spectrum of literatures, and include applications to: the evaluation and delivery health care services (patient management, behavioural modification programs and clinical interventions) and formulation of health care policy (both public and private); assessment of technological and natural hazards; public perception of risk; health insurance; investment and financial management of pension plans; social regulation and law; and analyses of culture and ideology. That such diverse literatures are associated with the terms ‘health’ and ‘risk’ is, perhaps, not surprising given the all-encompassing or totalizing meaning that each word has in contemporary society.
As recent models of health [2,3] attempt to illustrate, every aspect of human experience influences health in some way. And, as uncertainty (or indeterminism) is now considered a fundamental and inescapable fact of human experience [4], ‘risk’ to health is inevitable. Analyses of ‘risk’ are typically undertaken to reduce, modify or anticipate the extent or nature of uncertainty in decision-making processes. Widespread application of techniques and methods for the formal analysis of ‘risk’ in the professional literatures on health and health care is a relatively recent phenomenon that has developed primarily over the past 30 years. The term itself is most widely used in the general health literature, in relation to clinical research, to describe units of measurement (relative risk, attributable risk, attributable risk percentage or fraction, and risk ratio for example) [5,6]. However, within this period three spheres of literature have emerged in which ‘risk’ is the primary focus of concern: Health Risk Appraisal, the Risk Approach and Risk Analysis/Assessment/ Management. Health risk appraisal (HRA), variously referred to as health risk assessment, health hazard appraisal or assessment (HHA), personal health risk assessment, and health assessment, developed out of the work of Robbins and Hall [I as a method to help physicians practise preventive medicine by focusing prospectively on the avoidance of premature mortality. “In a conventional HRA, an individual’s health-related practices, habits, lifestyle, personal characteristics, and personal and medical family history are compared with data from epidemiologic studies and vital statistics in an attempt to project the individual’s risk of death over some future period” [8, p. 5541. Thus, attributes of the individual (behaviour and genetic endowment) are cast as the source of ‘risk’ in HRA,
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and the objective of intervention is to reduce the burden of premature death by stimulating individuals to stop or modify ‘risky’ behaviours. The Society for Prospective Medicine, founded by Robbins and Hall, has played an influential role in nurturing HRA, which has been described as “one of the most important innovations in the field of health education and health promotion in more than 20 years” [9, p. 5821. The Risk Approach (RA), also called the Risk Strategy, is a framework for the selective provision of health care services advocated by the WHO in the context of its Maternal and Child Health program [lo, 111.RA is proposed as a strategy to maximize the efficiency of public resource deployment (specifically, delivery of primary health care services) in less developed countries: Its aim is to give special attention to those in greatest need within a framework of improved health care for all. Individuals and groups with an increased expectation of complications or disease are defined as being ‘at risk’ and the aim of the health services should be to identify them as early as possible and to intervene in order to reduce the risk [IO, p. i].
The sources of ‘risk’ in RA are more diffuse than in HRA, and involve attributes of both the individual and her or his socio-ecologic setting. In addition to the publication of two monographs, the WHO has nurtured the development and diffusion of the RA framework by publishing other support materials [ 121, sponsoring research, and holding workshops v31. The sphere of Risk Analysis/Assessment/Management (RA/M) is much more general and amorphous than the two identified above. Much of this research concerns the evaluation of technical hazards, product safety, and public perception of risk, although research is by no means limited to these areas. Here the source of ‘risk’ tends to be external to the individual (the safety of a specific technology), although how the individual perceives and responds to issues of safety is an important stream of this research. The various interests of members of the Society for Risk Analysis and the diversity of research which is published in its journal, Risk Analysis, are indicative of the range of applications of RA/M. A synthesis of methods, techniques and assumptions drawn from various academic and professional disciplines are employed in these analyses of ‘risk’. Fielding [14] attributes the development of HRA to advances made in at least five disciplines-epidemiology, actuarial science, biostatistics, preventive medicine, and health education and behavioural medicine-facilitated by advances in computer science. And Fiksel [IS] writes: Risk analysis is a unique field in that it has no academic boundaries. It admits all creeds. Whereas traditional disciplines tend to specialize, we seek to integrate across disciplines. Our role, viewed broadly, is to draw upon the best available scientific knowledge in pursuit of societal goals-health, safety, and environmental protection [15, p. 1951.
One consequence of the hybrid heritage of the analysis of ‘risk’ is a lack of conceptual coherence both within and between bodies of risk literature. Notions of ‘risk’ vary greatly across operationalized definitions of health, as do the specific motives and purposes of applications, the nature and contextual conditions of relations between ‘risks’ and specific outcomes, and the conditions and methods of measurement. But little has been written about the epistemology of ‘risk’ in general, paradigmatic terms; i.e. about the nature of relations in time and space; the implications of essentially different types of relations for various assumptions, measures and practices of risk analyses; the conceptions of science that underpin these assumptions, measures and practices; or the conceptions of society in which these analyses are embedded. Indeed, a MEDLINE search of the combination ‘risk’ and ‘epistemology’ as key terms failed to capture a single reference. This is not to say that issues of measurement, interpretation or research practice are not discussed in the literature. Very many papers concerned with analyses of ‘risk’ identify such issues and problems. But, by and large, controversy relates to nuance of detail within conventional practices, rather than to more general matters of the theoretical, philosophical and ideological bases of the practices themselves. The state of the art reflects the fact that explicit discussion of the philosophy of science and/or of general social theory is rare in the mainstream health and health care literature, although other realms of social science literature are in ferment with such discussion. To return to the opening sentence of the programme announcement cited above, a more accurate assessment of contemporary practice would be: The social sciences contain pivotal, if neglected, concepts in the application of risk to health and medicine.
The remainder of this paper attempts to illustrate this claim by examining some fundamental issues associated with both the language and logic of analyses of risk. THE LANGUAGE
OF RISK
The lack of conceptual coherence in analyses of risk is reflected in the ambiguity and imprecision of terms used in the language of risk. In his synthesis of recommendations made at the 1986 national invitational conference to discuss and propose a research agenda for HRA, hosted by the Foundation for Health Services Research [16], DeFriese [9] writes: In recognizing the diverse and widespread uses of HHA/ HRA techniques in health promotion and education, conference participants called attention to the absence of a common language and terminology in this field. . Terms such as ‘precursor’, ‘precondition’, ‘risk factor’, ‘risk indicator’, ‘risk ratio’, ‘risk age’, ‘probability’, ‘risk multiplier’, and ‘quality of life’ continue to be used without formal definition among those who write and otherwise communicate about health risk assessment methods [9, p. 5851.
The epistemology of risk Third among the eleven recommendations made at the conference was that “a formal glossary of standardized terms used in the health risk assessment/health hazard appraisal field should be developed and widely disseminated among developers, researchers, and users of these techniques” [9, p. 585]. A guest editorial published simultaneously in Risk Analysis and Risk Management (the journal of the Risk and Insurance Society) suggests the language of RA/M is so incoherent that this field of research is in conflict with itself:
403
sibility for remedial action. Some words imply disorder or chaos, others certainty and scientific precision. Selective use of labels can trivialize an event or render it important; marginalize some groups, empower others; define an issue as a-problem or reduce it to a routine. Is the discovery of PCBs a ‘disaster’ or an ‘incident’? Are certain chemicals ‘doomsday products’ or ‘potential risks’? Are risks unavoidable (‘chemicals are a fact of life’) or a result of deliberate choice? Is fear of risk a ‘phobia’ or a realistic concern? (27, pp. 20--211.
[28] illustrates Nelkin’s point in his analysis of disputes between management and labour over With its multiple definitions and practices, risk management issues of occupational health and safety with respect is in many ways in competition with itself: thus ‘risk to exposure to potentially hazardous substances. management agonistes’ [the title of the editorial] conveys Industry advocates cast ‘risk’ as being unavoidable a sense of struggle or conflict.. . A synthesis-a new form, and illustrate this with reference to everyday activities, definitions, and understanding of risk management-is such as driving a car, taking a bus or crossing a street. needed [17, p. 2011. Thus fears of occupational exposures are irrational Mary Douglas, well known for her work on risk ‘phobias’. To labour advocates, on the other hand, and culture [18, 191, has observed that the connotation occupationally-related diseases have reached ‘epidemic of the word ‘risk’ has changed over time [20]. proportions’. Exposures to various substances have Originally introduced in the seventeenth century in created ‘time bombs’ of human disaster, with ‘tragic’ the context of gambling, risk meant the probability consequences for workers and their families. of an event occurring combined with the magnitude Ideological dimensions of the language of risk of losses or gains that might be entailed. Thus, the have been largely overlooked in the HRA and RA concept itself was neutral. Today, however, the notion literatures. HRA has become “a standard offering of risk tends to be associated only with negative in the health promotion repertoire” [8, p. 5531. The outcomes. This is certainly true of the professional or focus of HRA, which is exclusively upon individual technical usage of the term, as the definition adopted behaviour, is compatible with the definition of health by the Royal Society [21] indicates: promotion proffered by O’Donnell [29] and endorsed Risk is the probability that a particular adverse event occurs by the American Journal of Health Promotion : “health during a stated period of time, or results from a particular promotion is the science and art of helping people challenge [21, p. 221. to change their lifestyle to move toward a state of optimal health” [29, p. 41 (a definition completely In other technical applications, risk is more than the consistent with the American ethos of individualism). probability of occurrence of an adverse or unwanted However, HRA is not entirely consistent with the outcome; it also incorporates some measure of the definition of health promotion contained in the magnitude of impact or consequences [22]. In still Ottawa Charter for Health Promotion [30], proffered other uses, the word risk is applied to attributes which by WHO: “health promotion is the process of differentiate the mortality or morbidity experience enabling people to increase control over, and to between groups of individuals with and without the improve, their health”. Within this definition, “health attribute (e.g. smoking is a risk to health). promotion. . goes beyond healthy life-styles to wellHansson [23] argues that scientific ‘linguistic being”. The WHO definition acknowledges deterimperialism’ treats the word risk as a unidimensional, minants of health that are embedded in social structure technical concept that refers to some numerical proband therefore beyond the individual’s control, in ability value, whereas in everyday popular usage the addition to determinants over which the individual term has many other layers of meaning. Although Hansson does not label it as such, the problem he may have control. It advocates a socio-ecological describes of the different meaning words have in approach to health, and individual and community empowerment to address both types of determinants. scientific and popular uses is referred to as the ‘double HRA’s concern with individual behaviour ignores hermeneutic’ by Giddens (following Winch) [24,25]. structural determinants of health, and places At issue in the double hermeneutic is the translatability responsibility for action solely upon the individualof concepts between scientific and lay language communities, and conflict over authority to declare the effectively endorsing the American Journal’s vision of health promotion. In failing to distinguish between correctness of translation [26]. the competing visions, the HRA literature exerts The ‘double hermeneutic’ exposes ideological dimensions of the language of risk. As Nelkin [27] a strong but subtle ideological influence upon the discourse of health promotion. notes: The WHO intends RA to be an instrument of The language used by different groups to describe risk and to prescribe solutions is judgmental. The terms employed public policy: “if taken seriously, [RA] has the most frame an event; the metaphors and images used to describe important consequences for public policy and can a situation can point the finger of blame and imply responprovide the information necessary for intersectoral Hilgartner
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MICHAEL V. HAYFS
policy decisions which affect health” [l 1, p. 1131. Reducing inequalities in health is identified as the primary motive behind RA. How best to reduce inequalities in health is, of course, fundamentally an ideological issue. RA advocates inequalities be addressed through the provision of health care services: The challenge presented by more accurate knowledge thus consists in how best to use this ‘epidemiology of risk’, how to exploit more of the known causal pathways, and how to improve-even slightly-the effectiveness of prevention (and, of course, promotion) in the domain of maternal and child health care and family planning. Essentially this is a problem of how to enhance and improve coverage, acceptability, efficiency and the effectiveness of primary health care 111, p. 81.
Advocating equality in health through provision of health care services-essentially equating health and health care-focuses the analysis on disease as the cause of inequities in health. Illiteracy, conditions of poverty, lack of access to clean water, and the like are cited as important risk factors for poor health outcomes but there is no discussion of the processes that give rise to these factors, they are simply given. Alternative strategies to primary health care for addressing inequalities in health-improving levels of education, access to water, economic well-being or ‘conditions of daily living’-are not considered. The problem is identified as one of access to health care services, not one of basic distribution of wealth or material comfort, so the solution is to provide more or better health care services (made possible through gains in the economic efficiency of resource deployment realized by analyzing risk). Thus RA as proposed is an inherently conservative strategy that supports the status quo in less developed countries. The negative connotation of the word risk creates a fundamental problem in the notion of ‘risk taking’, namely differences in perception regarding the inherent value or worth of some action or behaviour between the ‘risk taker’ and the risk assessor. Risk taking implies intent on the part of the actor, but the intentions of the action are not fully appreciated or acknowledged with this one-sided view of risk. The risk assessor judges the actions of another individual to be harmful (or bad?). The (real or perceived) benefits to the individual of smoking, eating, drinking, driving, flying, or whatever, are not considered. The health-enhancing aspects of the benefit of some action to the individual may more than compensate for its health-threatening aspects (rational behaviour?). The notion of risk as wager-assessing both losses and gains-would seem a more appropriate conception of risk in relation to ‘risk taking’. Analysis of both positive and negative aspects of behaviour would provide the ‘risk taker’ an opportunity to play an active role in labelling and evaluating ‘risk’, thereby wresting exclusive power to determine ‘risk’ away from an external ‘expert’.
Language is context dependent-the meanings of words derive from the settings and circumstances in which they are used, and shaped by the power relations involved in their use [31]. The essentially problematic nature of language is a much discussed topic in contemporary social science, as popular interest in hermeneutics and deconstruction attest [32,33]. Given differences in individual perception, there will never be universal agreement on the ‘correct’ meaning and use of terms. This does not necessarily imply that formal glossaries of standardized terms called for above cannot be developed within literatures on HRA, RA or RA/M. However, given the hybrid heritage of these bodies of risk literature and the variety of purposes to which analyses of risk are put, one wonders if agreement over the use and meaning of terms or, for that matter, about appropriate application and expectations regarding the utility of risk analyses can be reached in the absence of more explicit theoretical development of other aspects of the epistemology of risk. THE LOGIC OF RISK
Three aspects of the logic of risk requiring greater attention in these literatures will be discussed in this section. These concern: (1) development of a typology of the fundamental properties or characteristics of risk relations; (2) treatment of the time-space dimensions of risk relations; and (3) the prevailing conception of science that guides the analysis of risk. I have explored some of these issues in relation to the RA literature previously in this journal [34]. In this section arguments will be illustrated with particular reference to HRA, especially as discussed in Health Services Research Vol. 22(4), which contains the papers published from the invitational conference identified above, and to RA. Risk relations are defined with respect to specific health outcomes--mortality or morbidity from cancer (more precisely, a specific type of cancer), heart disease, stroke, traffic accidents, etc. The nature of specific ‘risks’ that might be identified in relation to some chosen outcome may vary greatly. One might identify various dimensions across which risk characteristics might be differentiated. Variations are possible with respect to the essential properties of the risk characteristic itself. For example, age, sex, biologic disposition, familial history of disease, and weight are characteristics rooted in the biology of being (‘nature’). Religion, ethnicity, gender, dietary practices, attitudes/values/beliefs, lifestyle, etc. are characteristics that derive from the socio-environmental context of being (‘nurture’). All of these characteristics have been identified as increasing the risk (in the one-sided sense of the word) of, for example, heart disease. Also, in relation to the essential properties of the risk itself, one could consider differences in attributes of the ways in which categorical
ties obtain.
Thus, with respect
to
The epistemology of risk characteristics of the category ‘nature’, biologic disposition is a fixed and unchanging property of biological endowment, as was sex prior to the advent of medical interventions that now allow some flexibility in this regard. Age is a fixed but constantly changing property of biology. Familial history of disease is not necessarily a fixed property of biology because the trajectory of those histories is neither fixed nor predetermined so they do not reveal the entire story of relations between characteristics and specific outcomes. At the same time, one could consider the properties of the relational union between ‘risk’ and outcome. In this regard, risks might be considered modifiable or non-modifiable. Thus, with respect to heart disease, biologic disposition, age and family history are nonmodifiable (even though biologic disposition cannot change but age can), whereas weight is modifiable. Distinction between necessary (i.e. causally related to the outcome) and contingent (empirically associated but not causally related) relations is yet another concurrent dimension of relational union of potential significance. Still another might be primarily within the control of the individual or outside the individual’s sphere of influence. Appropriately identifying all of the potentially important concomitant dimensions of relational union and situating ‘risks’ simultaneously within them is a complex and vexing intellectual challenge. But identfication of relevant dimensions would provide a taxonomic framework for a language of risk. It would also help to clarify potential confusion concerning the policy implications of different types or sources of risk. Such confusion is apparent in the RA literature, which fails to distinguish between socially produced (‘nurture’) and naturally occurring (‘nature’) risks. Thus poverty, short stature and intercurrent illness are all risk markers (factors) for low birth weight, but the implications of each factor for intervention are very different [34]. Paying greater attention to the intrinsic qualities of ‘risks’ and risk relations would also facilitate a richer appreciation of how risk relations might be constituted somewhat differently across dimensions of time and space, the resources through which relations get played out. Theorizing the ways in which highly differentiated relations obtain in specific time-space contexts, and how and why processes vary spatially and temporally, has become a major concern of late among human geographers and sociologists [35-371. In general, risk literatures are insensitive to the dimensions of differentiation of relations in space-time in the lives of specific individuals. The RA literature tends to assume that regularity of empirical effects across time and space will hold almost independently of the specific relations or populations involved, even if these relations are not well understood [34]. With respect to HRA, Spasoff and McDowell [38] note that Applying a risk appraisal model developedin one population to another
group
involves
the assumption
that the causal
405
mechanisms (reflected in the strengths
and relationships of the precursors [risk factors]) are similar in the various groups-an assumption we can rarely test, but one that seems to be generally plausible [38, p. 4731.
Given that “many of the values we measure are probably only surrogates for the true etiologic variables” [38, p. 4861, one wonders if such an assumption is generally plausible. A question that might be fruitfully addressed in this regard is “what must the nature of risk relations be like in order for them to be stable across space and through time (thereby supporting the above assumption)?’ Theoretical development of both the nature of relations and their spatialtemporal context ought to facilitate improved understanding of risk relations, thereby diminishing the prospect of making erroneous assumptions about the general applicability of estimation models. It would also focus attention on the ‘emergent’ nature of risk. As Spasoff and McDowell [38] note, the concept of risk is fundamentally an aggregate notion. At the individual level, events are dichotomous. Probabilities obtain at the group level. Deeper appreciation of the essential qualities of risk relations and their time-space context would necessarily involve consideration of populations of interest, and how these are defined in light of identified characteristics of ‘risk’. Analysis of ‘risk’ necessarily begs the question of interpretation. Guidelines for interpretation follow from the conceptions of science that drive our practice. The hegemonic conception underlying analyses of ‘risk’ is positivist. This is evident in nomothetic treatment of risk relations, general avoidance of normative aspects of science, and the status of prediction in relation to explanation. It is the prospect of being able to predict events (eliminate uncertainty) that is the attraction of risk analyses. Positivist conceptions of science treat prediction and explanation symmetrically. Verification of explanation is provided through accurate prediction. Thus, in discussing composite scoring, methods and predictive validity regarding HRA, Kannel and McGee [39] claim that “for any scientific result to be acceptable, it should be reproducible” [39, p. 5171. Critiques of positivism abound in the social sciences [40-421. Although positivist attitudes are still widely held among social scientists, other attitudes toward science are gaining prominence in related literatures. For example, (transcendental or theoretical) realism has been suggested by some [40,41,43,44] as offering a superior epistemological framework for the practice of social science. One of the fundamental differences between positivist and realist conceptions concerns the status of prediction in relation to explanation. According to the realist what causes something to happen has nothing to do with the matter of the number of times it has happened or been observed to happen and hence whether it constitutes a regularity [45, p. 1621. Within this conception, regularities occur only if the two conditions for closure are met: viz., that
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MICHAELV.HAYES
the internal structure of the mechanisms that allow something to undergo change (i.e. the inherent causal properties or powers of risk relations to lead to specific health outcomes) operate consistently across time and space (termed the intrinsic conditions for closure by Bhaskar [43, pp. 63-142]), and that relationships between the causal mechanisms and external conditions which might make some difference to the operation of internal structures also operate consistently across time and space (the external conditions for closure) [41, p. 1121. Rather than verification, explanation rests on the internal logic and consistency of the theoretical argument establishing the nature of relational powers (both necessary and contingent relations). The more risk relations depart from closure, the less the expected empirical regularity of pattern. But failure to observe regularities does not constitute evidence of disproof of hypothesized relations. In HRA and RA some types of risk may satisfy the conditions for closure (those that relate to genetic disposition, for example) while other types of risk do not (factors related to nurture or social experience). The realist lens frames the question of the practical utility of risk analyses in a somewhat different way from that of the positivist. Rather than discarding hypothesized risk relations that do not display empirical regularity, the realist perspective would hold on to the intrinsic value of knowledge concerning the nature of risk relations. The practical utility of risk analyses (the ability to predict future occurrences) would be limited to those systems of risk relations that approximate the conditions for closure in instances where accuracy of prediction is of great concern (e.g. in the delivery of clinical interventions in the case of RA, or in the precision of estimates deemed important for specific applications of HRA). In other applications of RA and HRA, for example, intersectoral public policy decisions concerning, the impact of poverty upon individual well-being, the fact that conditions for closure would not be met need not deter us from action. Decisions would be based on our theoretical understanding of risk relations, and the multiple pathways to various outcomes that follow from the influence of poverty upon well-being. To contrast the implications for thinking about risk relations from a realist rather than a positivist perspective, consider the illustration Spasoff and McDowell [38] use in their discussion of issues associated with the accuracy of risk estimates (Fig. 1). They write As epidemiologic evidence accumulates, we should be able to move line AA downward, converting the unknown area to known. We shall be unable to move line BB, since chance is chance; its role presumably varies for different causes of death [38, pp. 469-701. The basis upon which line AA moves downward is accurate prediction. From the realist perspective this illustration inadequately represents the issue because knowing a causal pathway does not necessarily mean
KNOWN CAUSAL PATHWAYS A
**t.~t...**t.....*...*...**...,.**.....**....**..*.**~*...
A
UNKNOWN CAUSAL PATHWAYS B
???????????????????????????????????????? B CHANCE
Fig. 1. Determinants of death or disease. Source: Ref. [38]. that its occurrence can be predicted (unless conditions for closure are met). Thus, it does not follow that improved understanding of pathways will necessarily lead to better predictions. Moreover, ‘chance’ is not a phenomenon that affects only unknown pathways. Known pathways that do not satisfy the conditions for closure are always affected by ‘chance’ in the form of contingent relationships that interrupt the causal mechanisms and prevent regularities from obtaining. Of course, the question of what constitutes ‘known’ pathways is addressed in fundamentally different ways by these two conceptions. The realist perspective is not without its shortcomings [37, pp. 166-1691. My purpose here is not necessarily to celebrate realism (although I think it does offer considerable advantage over positivism), but to draw attention to the question ‘science how?. Risk literatures take the question as given and unproblematic, which blinds criticism to fundamental issues of epistemological significance. EPILOGUE
The purpose of this necessarily short and incomplete polemic is to draw attention to the application of social science in thinking about risk in health and medicine. Obviously everyone who writes about this subject engages social science in some manner. At issue is the question ‘what manner?. The epistemological concerns identified here are essentially contestable-there is no single truth. That is why it is so important to scrutinize our science-it will help us maximize the levels of conceptual coherence we are capable of reaching in analyses of risk. Acknowledgements-I am grateful to Lillian Bayne and Nick Blomley for their helpful comments, and to Leslie Butt for her assistance in preparing this paper. REFERENCES 1. The search of MEDLINE file 154 was conducted on 3 January 1992. References either contained the work ‘risk’ in the title, abstract or keywords, or were crossclassified under the section-heading ‘risk’. Both English
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