Tag Archives: rational policy process

Debating the merits of Tamiflu

Source: Social Science Space April 15, 2014

Source: Social Science Space April 15, 2014

A few weeks ago, the British medical journal the BMJ published an article that offered a critical appraisal of Tamiflu.  While there have been other bits of research that challenge the efficacy of Tamiflu and the decisions of governments to stockpile the medication in anticipation of a flu pandemic, this most recent article was remarkable because it was a systematic review and was prepared as part of the Cochrane reviews.

For the uninitiated, a systematic review is quite different from an individual study.  Rather, as the Cochrane Library puts it: “A systematic review attempts to identify, appraise and synthesize all the empirical evidence that meets pre-specified eligibility criteria to answer a given research question. Researchers conducting systematic reviews use explicit methods aimed at minimizing bias, in order to produce more reliable findings that can be used to inform decision making.”  And Cochrane reviews have been described as “the highest level of evidence on which to base clinical treatment decisions.”

Serious stuff.  In other words, when a Cochrane review is published, people stand and take notice.

The political result of the publication of the review critical of Tamiflu was a chorus of criticism of governments that had stockpiled the medication at a cost of millions of dollars, pounds, Euros and yen.  Some even have begun to refer to the vaccine as “Scamiflu”.

Source: Twitpic

This does not mean, however, that systematic reviews, be they from Cochrane or elsewhere are faultless.  Therefore, almost as soon as it was published, the article that was so critical of Tamiflu attracted its own chorus of criticism (see also here and here).  Critics pointed to what they saw as flaws in the analysis and argued that the study as such did not justify the conclusion that governments were wrong to stockpile Tamiflu.  Some pointed out that in the real world of policy making governments have to manage risk and that the Cochrane systematic review did little to consider.

I am not qualified to evaluate the claims and counterclaims.  And I am cynical enough to ask about the motives of the various parties in the debate.  Having said that, governments are routinely faced with having to make decisions when the evidence is conflicting and where they must balance clinical effectiveness against public confidence that the health system will be able to protect them from harm.  In this case governments opted to stockpile Tamiflu, knowing it might only be somewhat useful.  However, in the face of the prospect of large number of people dying in the event of a serious pandemic, being able to do something, however limited, is preferable to being able to do nothing. This is the real world of politics and difficult political decision making.

More generally, I think that a systematic review critical of Tamiflu appeals to those of us who are, justifiably I think, quite critical of large pharmaceutical companies and their motives and ultimate goals.  In other words, combine a nascent mistrust of Big Pharma, add a systematic review done by the Cochrane collaboration no less, and you inevitably get a torrent of criticism not only of the drug but of the governments who spent large sums of money acquiring it.

Yet it is in the nature of scientific inquiry to subject any given study to critical appraisal and this case was no different.  Systematic reviews, even the best ones, are not the final word on an issue.  And when it comes to translating scientific research into policy, systematic reviews, be they good, bad or indifferent, are but one factor shaping policy decisions.  And as I and many, many others have argued, this is as it should be. Scientific evidence shapes and informs public policy but does not and indeed cannot determine policy.

Inside the black box: science, politics and healthy public policy Notes for an address to The Ontario Public Health Convention, April 1, 2014

tophc_ca

 

Yesterday I had the honour and the pleasure of speaking to The Ontario Public Health Convention.  The title of my talk, “Inside the black box: science, politics and healthy public policy” gives a good sense of the themes developed in my presentation.  I specifically made an argument about the limits of evidence for making public health policy, presented some key ideas about the policy process arising from political science theories of policy making; and ended with a short defense of “politics”.

A copy of the notes for my presentation is available here.

Policy as Values

In July 2012 I published a short piece entitled “Policy as Values” in the newsletter of the Institute for Science, Society and Policy. While this was a response to an earlier item by my University of Ottawa colleague, Scott Findlay, I think my contribution stands on its own and may have continuing interest to a wider audience.

I am reproducing the piece here since it is no longer avaialble in its entirety from the ISSP.

ISSP logo

Policy as Values

Patrick Fafard

June 2012

Long ago and far away I took a course in philosophy of the social sciences. Surprisingly, this philosophy course involved a field trip and a very peculiar one indeed. On campus there was a small office in a bit of commercial space that housed, if memory serves, Technocracy Inc. The organisation was committed to advancing the cause of a rational and scientific approach to life in general and government in particular.

I have repeatedly encountered variations on this desire for a scientific approach to government, most recently in the blog post by my University of Ottawa colleague Scott Findlay provocatively entitled (at least for me) “Policy as Science”. To summarize and oversimplify, he advocates a rational policy process that selects among candidate policies in a rational manner, using the scientific method. My first inclination was to discount if not dismiss the argument by simply asserting that in real life things are not so simple and grumble about the hubris of scientists.

But the very fact that the desire for a rational approach to policy making is always present and, at first glance, quite seductive, demands a more fulsome response. There are any number of possible objections: much has been written on why policy making is not rational and indeed cannot be so. In fact, I have argued, as have many others, that policy making should not be reduced to rational problem solving.

But for the moment I want to focus on one aspect of the argument for a more rational or scientific approach to policy making. To reduce policy making to problem solving, as Scott suggests, assumes that we can agree on the nature of the problem and on the desired outcome. Let us consider each of these claims in turn.

Before there can be a policy choice there has to be agreement that there is a problem to be solved or at least one that government can do something about. In effect then, the art of governing is to choose the problems that will be addressed and which are to be more or less ignored. However, among the many challenges of governing is the simple fact that we do not always agree on the nature of the problem. I say Canadians eat too much salt, which causes widespread high blood pressure. Others say that there is no scientific consensus on the matter and scoff at the idea that there is a problem to be solved. In effect, fighting over how to define the problem and the science underlying problems is often a big part of the policy process – witness the debates about climate change or drug addiction.

Assuming we can agree on the nature of the problem (or at least most of us can, at least for a time) according to Scott a rational policy process would see us choose the option that is most likely to achieve desired outcomes. However, we are confronted by the reality that we are unlikely to agree on what is desirable. Policymaking is never only about solving a problem. It is addressing a problem in a way that is acceptable to at least some citizens some or most of the time. It is making decisions that advance a broader overall agenda if not a broader philosophy. It is addressing public concerns in a politically prudential way.

To return to the case of dietary sodium, we have no way of demonstrating unequivocally whether what is required is social marketing, industry self-regulation or government regulation of the food industry. And even if it could be shown that government regulation of the food industry is the optimal way to reduce the amount of salt in our diet, small-c conservative governments are unlikely to want to do so on broadly philosophical grounds.   Government regulation of food raises concerns about undue government influence in the lives of citizens. The latter objection cannot be resolved with reference to science alone. It is a normative claim and requires a different kind of reasoning altogether.

In effect, most of the truly interesting and non-trivial policy issues do not lend themselves to rational decision-making. Why? Because they involve disagreements over values and such disagreements, as Hume reminded long ago, cannot be resolved with reference to science alone.

Policy as Values

(This first appeared in the newsletter of the Institute for Science, Society and Policy at the University of Ottawa.)

Image

Long ago and far away I took a course in philosophy of the social sciences.  Surprisingly, this philosophy course involved a field trip and a very peculiar one indeed.  On campus there was a small office in a bit of commercial space that housed, if memory serves, Technocracy Inc.  The organisation was committed to advancing the cause of a rational and scientific approach to life in general and government in particular.

I have repeatedly encountered variations on this desire for a scientific approach to government, most recently in the blog post by my University of Ottawa colleague Scott Findlay provocatively entitled (at least for me) “Policy as Science”.  To summarize and oversimplify, he advocates a rational policy process that selects among candidate policies in a rational manner, using the scientific method.  My first inclination was to discount if not dismiss the argument by simply asserting that in real life things are not so simple and grumble about the hubris of scientists.

But the very fact that the desire for a rational approach to policy making is always present and, at first glance, quite seductive, demands a more fulsome response.  There are any number of possible objections:  much has been written on whether policy making is rational and many have argued that it is not rational and indeed cannot be so.  In fact, I have argued, as have many others, that policy making should not be reduced to rational problem solving.

salt But for the moment I want to focus on one aspect of the argument for a more rational or scientific approach to policy making.  To reduce policy making to problem solving, as Scott suggests, assumes that we can agree on the nature of the problem and on the desired outcome.  Let us consider each of these claims in turn.

Before there can be a policy choice there has to be agreement that there is a problem to be solved or at least one that government can do something about.  In effect then, the art of governing is to choose the problems that will be addressed and which are to be more or less ignored.  However, among the many challenges of governing is the simple fact that we do not always agree on the nature of the problem.  I observe that Canadians eat too much salt, which causes widespread high blood pressure.  Others say that there is no scientific consensus on the matter and scoff at the idea that there is a problem to be solved.  In effect, fighting over how to define the problem and the science underlying problems is often a big part of the policy process – witness the debates about climate change or drug addiction.

Assuming we can agree on the nature of the problem (or at least most of us can, at least for a time) according to Scott a rational policy process would see us choose the option that is most likely to achieve desired outcomes.  However, we are confronted by the reality that we are unlikely to agree on what is desirable.  Policymaking is never only about solving a problem.  It is addressing a problem in a way that is acceptable to at least some citizens some or most of the time.  It is making decisions that advance a broader overall agenda if not a broader philosophy. It is addressing public concerns in a politically prudential way.

To return to the case of dietary sodium, we have no way of demonstrating unequivocally whether what is required is social marketing, industry self-regulation or government regulation of the food industry.  And even if it could be shown that government regulation of the food industry is the optimal way to reduce the amount of salt in our diet, small-c conservative governments are unlikely to want to do so on broadly philosophical grounds.   Government regulation of food raises concerns about undue government influence in the lives of citizens.  The latter objection cannot be resolved with reference to science alone.  It is a normative claim and requires a different kind of reasoning altogether.

In effect, most of the truly interesting and non-trivial policy issues do not lend themselves to rational decision-making.  Why? Because they involve disagreements over values and such disagreements, as Hume reminded long ago, cannot be resolved with reference to science alone.