Читать книгу Critical Realism for Health and Illness Research - Alderson Priscilla - Страница 8

Introduction

During 2020, governments faced questions about how they should work to reduce the spread of COVID-19. How should they first impose the lockdown and later manage its gradual ending? How could they protect public health while planning the slow return to ‘normal’ life? How could they best guide the public to cope with differences between pre-and post-pandemic views of what is ‘normal’ and healthy?

The UK government’s Scientific Advisory Group for Emergencies, SAGE, consisted mainly of scientific advisers to government departments, virologists, epidemiologists, statisticians and medical experts with risk management and ‘nudge’ behavioural scientists. Their expert advice varied,¹ and was widely criticised. Just as COVID-19 starkly revealed many problems in our present unequal society, it has highlighted limitations in scientific expertise and its relations to policymaking.

Among innumerable policy decisions, just one example was prisons. There had long been campaigns to close many prisons. England and Wales had the largest prison population in Western Europe in April 2020, when there were plans for the early release of up to 4,000 of the 82,500 prisoners. Prison governors advised that thousands more prisoners should be released early. The aims were to reduce prison overcrowding and thereby reduce COVID-19 infection rates and deaths among prisoners and staff as well as in the communities around the prisons.

Instead, only 33 prisoners were released, and in a double confinement the rest were locked up in their cells for over 23 hours a day. A prison ship and 500 shipping containers were ordered to provide extra cells. The policy increased physical and mental illness and suicide rates among already severely disadvantaged social groups.²

How can researchers best inform governments and the public on questions about health and illness? A first step could be to point out differences between the main versions of science and the contrasting kinds of information, analyses and insights that they offer. It would also help to review contradictions between these different versions of science and consider how to resolve them. Opportunities for transformative health-promoting change could also be researched. These are the major themes in this book.

Valid and convincing research

Chinese doctors, Professor Huang and colleagues, urgently warned in the Lancet in January 2020 that COVID-19 would cause a pandemic.³ The editor of the Lancet, Richard Horton,⁴ pointed out ‘a national scandal’ in contradictions between two reactions to the challenge of COVID-19. The World Health Organization urged all governments immediately to prevent cross-infection, to ‘test, test, test’ and to identify and isolate infected contacts. However, UK experts and politicians delayed their responses. Their initial plan to create ‘herd immunity’, instead of working to suppress and prevent cross-infection, was predicted as likely to cause hundreds of thousands of deaths in Britain alone.⁵ Many people knew at once that herd immunity is built by vaccinations, which did not yet exist. It is not built by exposing everyone to disease and to many deaths, a cull mainly of the old, weak and poor, intended to leave a herd of sufficiently immune survivors.⁶ One researcher concluded: ‘The evidence was not conflicted, it was clear: the Government’s strategy of delaying the peak and inducing herd immunity was unscientific, unfeasible and dangerous.’⁷

I began this book in July 2019 and wrote quite long sections to justify some ideas that used to be widely questioned. Then the COVID-19 pandemic arrived and made these ideas about social reality seem more obvious. Six of them are therefore simply presented here.

1.Health and illness affect every interrelated aspect of all our lives.

2.Many causal influences on health are unseen by the naked eye (such as viruses or the neglect of hygiene) but may be seen in their immense global effects on health and illness.

3.The effects are very varied and partly unpredictable.

4.Health is a process, daily affected by healthy or unhealthy contexts, policies, behaviours and beliefs.

5.Policies and decisions related to health and illness research are practical and ethical as well as scientific.

6.They often fail.

Over the past 150 years, research about health and illness has helped to transform healthcare, survival and quality of life for the better, especially mainstream research such as that reviewed by the Cochrane and Campbell Collaborations.⁸ Yet a summary of mainstream methods shows how they contradict the above six points. The scientists tend to:

1.isolate and examine each element of health and illness, such as each treatment or method of preventing each specific illness;

2.concentrate on measuring, describing and evaluating empirical (experienced) evidence of the effects but not the unseen causal influences;

3.claim to make accurate predictions;

4.treat health as a product and develop treatments and preventions like commodities, concentrating on individuals rather than their contexts;⁹

5.believe that science can be separate from morality, facts from values; and

6.do little work about why so many research reports fail, when they remain unpublished or are disputed, cannot be replicated, and support inefficient healthcare or at least do not challenge it.¹⁰

The government and the mass media favour positivist science that examines specimens through microscopes and other technology, conducts randomised trials, constructs predictive models and runs multivariate statistical analyses. These scientists offer pristine objective evidence to inform policy and tend to work in arcane bounded subspecialties.

Or does positivist science do all these things? Microscopic specimens and randomised trials work brilliantly in biochemistry when testing medicines. Models devised to predict the effects of the climate crisis, such as on melting glaciers, are also invaluable. Records of mortality rates inform policymaking. Yet attempts to apply these methods to much social research often fail. Unlike particles, people are complex and unpredictable. They are entangled within interacting social contexts, relationships and needs, which may not be unravelled usefully into separate variables.

Aware of these problems, many researchers prefer a second interpretive version of social science. Their detailed case studies connect individuals’ views and experiences to their everyday contexts. This can potentially reveal more about varying responses to the pandemic than yes/no replies to hard science surveys could show, by exploring partly conflicting desires for self-preservation, solidarity and liberty.

Yet some interpretivists are so concerned with subjective viewpoints within local contexts and constructions that they deny there are facts or realities and accept only individuals’ views about them. This complicates research about actual bodies, disease and death.

Contradictions between the two version of science and the six pairs of points will be discussed critically throughout this book. Basic new approaches are needed if health and illness research is to be more coordinated, realistic and effective. Critical realism (CR) can assist in this work. Questions remain about why leading scientists and politicians and many journalists and members of the public at first accepted the science about herd immunity. CR promotes habits of critical thinking that can help to increase everyone’s scientific and political literacy and judgement.

CR does not introduce or replace research methods, and fine examples of non-CR research using a range of methods will be discussed in this book. My aim is to show how CR theories and concepts help to clarify researchers’ views about the methods they are using, or could use, and to extend their analyses.

CR does not look for uniform scientific methods or findings. It works to explain how and why there are differences and why some conclusions are more valid and convincing than others. CR’s critical and realistic work responds constantly to each of the above six contradictions. CR helps researchers to:

1.connect each element and treatment of health and illness into many broader interrelated aspects of our lives in the interdependent world;

2.research unseen causal influences and explanations as well as their effects on health and illness;

3.rely less on tracking correlations and making weak predictions;

4.understand health as a process affected by interactions between individuals and their contexts (agents and structures);

5.see how both science and morality affect decisions before, during and after research programmes and how values pervade social and clinical facts; and

6.resolve contradictions and disputes between natural and social scientists, and among social scientists, in order to reduce avoidable failings, promote interdisciplinary research and connect research into effective policies and practices.

These approaches will be explained through the book.

The readers

CR analyses the natural and social sciences,¹¹ so this book is relevant to the whole range of researchers of health and illness, and related disciplines such as healthcare law, ethics and policy. This book is written for sociologists, anthropologists and health geographers.¹² It is also designed for doctors, nurses, psychologists, physiotherapists, radiographers, public health specialists, care workers and many others who study, research and attend to the combined bodily and social needs of their patients, as well as for interested health service users. CR supports ways for social science research to complement and extend the findings of biomedical and clinical research in many ways. Each chapter will end with questions for readers to discuss, potentially with colleagues in other disciplines.

Aims of this book

This practical handbook grew out of a reading group series for doctoral students. The British-Indian philosopher Roy Bhaskar, with the lawyer philosopher Alan Norrie and the philosopher Mervyn Hartwig, started the group in 2007 at the Institute of Education, now part of University College London. The inspiring meetings were based on reading and interpreting Roy Bhaskar’s and Alan Norrie’s texts, supported by Hartwig’s invaluable dictionary.¹³ Students and philosophers from around the world visited and contributed to the free open meetings. Sadly, Roy Bhaskar died in 2014.

Since then, I have convened the meetings and this book is based on the first ten sessions of Bhaskar’s course. As I am a research sociologist, not a philosopher, with the help of the students from a wide range of disciplines the form of the meetings has changed. There is now more practical emphasis on how CR can be applied to research. Each meeting includes a doctoral or postdoctoral researcher who summarises the aims, topics and methods of their work and then explains how specific CR concepts have helped to deepen and extend their analysis. Similarly, in this book, the CR concepts will be illustrated by research examples that concentrate on health and illness.

CR is not a version of sociology but a philosophy of the natural and social sciences. It is a tool kit of practical ideas for researchers. CR is not about research methods but about theories and analysis. Whereas researchers are like skilled specialist workers on a building construction site, CR serves the lowly task of the general ‘under-labourer’. The philosopher John Locke believed: ‘It is ambition enough to be employed as an under-labourer in clearing the ground a little, and removing some of the rubbish that lies in the way to knowledge.’¹⁴

In another builders’ analogy, the philosopher Mary Midgley compared applied philosophy, which all researchers need to do, to plumbing.¹⁵ Everything seems fine until something goes wrong. Then we need to sort out blocked pipes or floods or hidden leaks. These denote confusions or contradictions in our thinking or flowing ideas that seem to lead nowhere. The critical realist Douglas Porpora contends that there is much good sociology, but it is not as good as it could be unless it is informed by CR. And if researchers’ theories are confused or held subconsciously, then they cannot be doing real social science, since science explicitly addresses and clarifies theory.¹⁶ Much CR theory is widely used by non-CR researchers, but studying CR can help them to use the theories more fully and deliberately.

During the reading group sessions, the members talk in pairs and do exercises about their own research and how they have applied, or could apply, CR concepts to their work. The members have shown how CR can apply very broadly within and between a great range of disciplines.¹⁷ They have also shown the value of talking and working through how to apply CR concepts to research, often in response to set questions (see the end of each chapter).

Another key theme will be how to select research theories and methods. Some researchers apply the same ones to most or all of their work. They specialise in questionnaire surveys, randomised controlled trials (RCTs), systematic reviews, in-depth interviews or ethnographic observations. This can be like a carpenter using only a hammer and seeing everything as a nail, a problem that will be considered later. Research method books explain the importance of selecting methods that will most effectively answer the research questions and collecting data to support the conclusions.¹⁸ The choice of theories is also vital.

Examples throughout the book will refer to a wide variety of health-related research disciplines, topics, methods, theories, aims and reports. I have aimed to summarise many of these to assist the general reader while, I hope, not offending the experts in each case. This book is meant to be a resource, with references for readers to follow up if they wish to. My aim is to introduce CR to beginners, or to refresh anyone who has started working on CR and would like some help. Most people find CR very difficult at first. The CR concept of the three levels of reality, for example, is quite simple in some ways but initially it can be confusing. The concept is also complex and can be profoundly and infinitely developed. Confusion may partly arise from the way some CR concepts differ from the beliefs engrained into Western thinking for the past 2,500 years.¹⁹

CR is often dismissed as too dense and jargon-ridden to be worth reading. Bhaskar’s work is challenging. Yet his use of specific terms is not unnecessary jargon because it identifies and clarifies unique concepts in order to understand them in new ways. All disciplines including medicine or law use many specific terms as necessary ‘jargon’. I will use complex terms when they uniquely express specific important concepts, and define them in the glossary. Yet my plan is to avoid over-complex, abstract discussion. Growing numbers of CR researchers write very clearly, besides showing how versatile and useful CR concepts can be. Two of Bhaskar’s final activities were to take part in interviews with Mervyn Hartwig and Gary Hawke,²⁰ and in their edited books he often presents his ideas clearly. Bhaskar’s ‘spiritual turn’ is also criticised as confusing, and it is not covered in this book. I will concentrate on basic CR and dialectical CR. There is not yet an introductory, practical, applied, CR handbook for researchers of health and illness, a gap this book is intended to fill.

CR is like a tall ladder, with philosophers at the upper echelons.²¹ I aim to help researchers on the first few rungs, so that they gain some experience and confidence. I hope they will then feel ready to read more advanced CR texts and learn about many more CR concepts not covered in this book.

A health warning. Readers who are new to CR are advised not to apply too many CR concepts in their research. It is better to concentrate on thoroughly understanding and using a few concepts at first, and not to use a range perhaps superficially and inaccurately – which unfortunately is easily done.

Health and illness are taken to include physical and mental health and wellbeing. Disabled people and people with learning difficulties are also included, to examine critically their equal access to healthcare and how disabilities are seen as medical or social concerns.

The aims of this book include helping to:

•resolve current contradictions and splits between the main traditions in health research;

•show how CR differs from other approaches to health and illness and what it can add;

•explain practical ways to apply CR to health and illness research;

•guide researchers’ initial steps towards understanding and applying CR; and

•encourage readers to become confident and ready to move on to more advanced study of CR.

Summary of the chapters

Chapter 1 considers differences between mainstream research approaches: positivism, a range of interpretive traditions and realist evaluation.²² The questions they raise will be considered through the book. Their strengths and limitations will be considered, in order to compare them to CR and to see what CR can add. Chapter 2 reviews basic CR concepts, including the three levels of reality, closed and open systems and the possibility of naturalism. Naturalism enables closer collaboration between medical and social, positivist and interpretive, qualitative and quantitative research.

Connections and interactions between structures and agents are examined in Chapter 3. Quantitative research provides vital structural background information about health and healthcare. Yet complex individual agency tends to be missed when the emphasis is on large samples and multivariate analysis. Case studies and other qualitative research with individuals and small groups are often seen as unable to support general conclusions. They are also doubted as potentially misleading if they give little sense of where they stand along a broad spectrum of possible positions. CR analysis of large- and small-scale studies examines underlying realities, seeing how ethnographic and case studies can reliably support generalisations, with caution about conclusions and predictions drawn from quantitative research. Margaret Archer’s analysis of structure and agency emphasises interactions, change and resistance to change. Archer explored four detailed ways in which agents draw on social structures and cultural contexts to make sense of their experiences, hopes and identities. Her work offers valuable ways to analyse and evaluate healthcare and health promotion processes.

Chapter 4 questions the centuries-old debates as to whether it is possible for research to be value-free. Can facts be separate from values, as many researchers claim? The critical realist Andrew Sayer contends that social facts are inevitably value-laden and to suppose moral neutrality ignores but cannot remove values.²³ This will be discussed in relation to health and illness, harm and benefit. There will also be reviews of positive and negative power, the relevance and possibility of truth, CR concepts of being serious with theory-practice consistency,²⁴ and why these concepts matter. Ethics has been partly outsourced from being a topic of social research and reduced into procedures to be checked by ethics review committees and boards. Yet ethics pervades every stage of research, from first plans to final dissemination and impact.²⁵ Chapter 4 will consider utilitarian ethics, principles, virtue ethics and human rights and also examine the policies and politics of health research through a CR lens.

The aim of many researchers to isolate and examine each element of health and illness was mentioned earlier, and it underlies much vital research. Critical realists also research connections and complexities interacting on many levels. Much research produces huge amounts of data and Chapter 5 presents examples of CR frameworks for organising and analysing the data. Four planes of social being cover all aspects of social life and health: bodies in material relations with nature; interpersonal relations; social structures and inner being, the mental-social-embodied person.²⁶ The planes relate to health inequality research concerns: material-structural; psycho-social; health behavioural and sometimes genetics analysed through the life course. The four planes and the laminated system are useful for combining clinical and social, qualitative and quantitative research in multitiered analysis. Ways to promote interdisciplinary analysis in many aspects of health and illness will be considered.

Chapter 6 explores processes of transformative change over time through developing sequences. CR theories can assist research about health inequalities and change (or lack of change) over the life course. For this, the CR concepts of absence, change and emergence are relevant, as well as the four-stage dialectic in its benign or malign versions.²⁷ Dialectic is in Chapter 6, in order to follow the programme of Bhaskar’s reading group. Yet dialectic is such a central and major CR concept that some readers may prefer to read Chapter 6 before reading and applying the concepts to Chapters 3 to 5.

The final chapter draws together earlier chapters and shows how CR supports research about the future and about changing the world. It considers how research is always provisional and incomplete, which became especially obvious while this book was being completed in the first stage of the COVID-19 pandemic.

I aim to show how CR assists researchers to be more aware, explicit, judicious and critical in their use of research theories. A wealth of CR concepts, like keys, can open new insights. The final ABCD section – articles, books, commentary and dictionary-glossary – suggests further reading and defines many terms that appear throughout the book.