When thinking about the social and political implications of health innovations, one cannot assume that they solely materialize around technology or after its implementation. Rather, they are part of a given innovation. There is indeed no technology without sociopolitical properties, since both its existence and use require the support of social groups who invest financial and human resources and engage into power relations.
Social and political issues can be examined at two levels: 1) the society-level, which refers to structural issues (education, revenues, demographics), to power relations between groups (for instance, discrimination based on gender and race, the redistribution of wealth across societies) and to democratic principles (for instance, informed consent, fairness and accountability in health care); and 2) the individual-level, which refers to patient-related outcomes (such as length and quality of life, social integration, work opportunities, family/marital life).
Cultural issues (such as ethnicity, norms, beliefs, religion) also play a role at both levels. They shape one’s preferences regarding health care through values that may be related to procreation, life/death, decision-making, sexuality or life-style (diet, physical activity). Some taken for granted practices, values and conceptions of “normality” have to be scrutinized as health innovations profoundly transform social norms over time. Abortion, prenatal testing and the way our societies deal with disability are good illustrations of this phenomenon.
It is therefore not sufficient to be aware of the sociopolitical tensions that surround a particular innovation; the different dynamics by which it can be approved or disapproved by various groups must be considered as well.
A framework to help elicit social and political issues
Lehoux and Blume (2000) developed a framework outlining the social and political issues around two innovations: tele-homecare and the cochlear implant. The framework addresses four sets of issues (see Figure 1).
Figure 1. A framework for eliciting social and political implications of health innovation
The actors (or stakeholders) involved, which include promoters of the innovation, physicians, nurses, other providers, managers, patients, caregivers and the public:
What social groups are involved in, or affected by the use of a given technology?
What is the technology’s significance for each?
Is it dependent on the social context in which it is to be used?
Which actors play a leading role in the innovation’s development?
What are their role, interests, and objectives?
Who are they socially? (expertise, social status, age, gender);
How may cultural issues shape their beliefs and practices?
The implications of the technology for the flow of material and human resources:
Who benefits from this technology?
Who is going to pay?
Who accepts risks associated to its use?
Who endorses responsibilities?
Who is accountable for safety, effectiveness and quality?
Are there economic consequences or impacts on human resources that should be avoided?
The power relations involved:
How does the technology influence actors’ autonomy and freedom?
Is this technology likely to transform (or reinforce) certain social relations on a short- or long-term?
Is this technology likely to transform (or reinforce) certain values of society?
Who is in a position of authority?
Whose decisions/autonomy are constrained?
The production and circulation of knowledge:
What kind of knowledge is available/lacking?
Whose knowledge is it? How could this knowledge be obtained?
How will integration of this knowledge modify one’s assessment?
How will dissemination of this knowledge modify stakeholders’ views and positions?
Applying the framework in your own query about a given health innovation
The framework can be used in small group discussions in order to elicit the social and political implications of various kinds of health innovation. Figure 2 shows some of the issues Johri and Lehoux (2003) explored in the case of the clinical management of very low-birth-weight (VLBW) infants (<1500 g). This case illustrates the dilemmas raised by technologies that prolong life, but are not able to ensure a good quality of life.
Figure 2. Application of the framework: the example of high-tech interventions for low-birth weight babies
Recent advances in perinatal technology have dramatically increased the survival of infants of borderline viability. These improvements have come at a high cost. A California-based study found that average treatment costs per first-year survivor for infants <1500 g was $93,800. For infants less than 750g, these costs were $273,900, while the gradient in cost-effectiveness with respect to birth weight drops to $58,000 per survivor for infants with birth weights between 1250-1499g.
Given the rapid advances in medical knowledge and technology in neonatal care, decisions about aggressive life-sustaining treatments are difficult.
At the policy level, proposals based on restricting care according to birth weight have been criticised on the basis that they would not significantly reduce costs for neonatal intensive care units, and that they would result in denial of care to many infants who would otherwise survive.
From a physician’s point of view, the principal issue evoked relates to the “Rule of Rescue.” This can be defined as “the imperative to rescue endangered life” regardless of the long-term prospects for survival or quality of life, should the means to do so be available. Other factors may also contribute to aggressive treatment: A US survey found that physicians frequently felt pressured to over-treat infants due to federal regulations and fear of legal action.
From the parents’ perspective, a recent open letter paints a dim picture: “As parents of extremely premature infants, we were given little information about probable outcomes and few, if any, choices about the treatment. Instead of being encouraged to limit care, many of us were threatened and made to feel like criminals for questioning even the most extreme medical measures.”
Because such questions are far from easy to tackle, developing tools that can support informed and inclusive debates is a social imperative. These tools could make complex decisions more transparent, less difficult to bear, and would increase an appropriate use of health innovation.
Return to the dossier on: Medical innovations
Johri, M., & Lehoux, P. (2003). The great escape? Health technology assessment as a means of cost control. International Journal of Technology Assessment in Health Care, 19(1), 179-193.
Lehoux, P., & Blume, S.S. (2000). Technology assessment and the sociopolitics of health technologies, Journal of Health Politics, Policy, and Law, 25(6), 1083-1120.