DEFININONAL WORK INAPPLIED SOCTAL SCIENCE:COLLABORATWE ANALYSIS IN HEALTH

ECONOMICS AND SOOOLOCY OF SCIENCE

Malcolm Ashmore, Michael Mulkay,

Trevor Pinch, and HESG

INTRODUCTION

In this paper, we seek to extend recent sociological work on the discourse andinterpretative practices of the physical sciences by studying an area of socialscience and by examining a field of research, namely, health economics, inwhich the production of knowledge is linked closely to its practical application.We also try to build upon recent experiments in new literary forms ofsociological analysis by devising a kind of textual presentation which enablesus to engage more directly than usual with participants, and which is, therefore,particularly appropriate to the collaborative form of analysis that we developbelow. Because some of the health economists we have studied appear as active

Knowledge and Society: Studies in the Sociology of Science Past and PresenlVolume 8, peges 27-55.Copyrighl o f989 by JAI Press Inc.All rights of reproduction in any form reserved.ISBN: 0-89232-910-6

28 MALCOLM ASHMORE, MICHAEL MULKAY, TREVOR PINCH, aNd HESG

contributors to this text, we have included them collectively in the list of authorsas HESG (Health Economists'Study Group).

The specific focus of this paper is upon 'definitional work;' that is, on theinterpretative practices and social actions involved in providing definitions.Some such definitional work is necessarily carried out, sometimes explicitlybut often implicitly, by sociologists of knowledge during their studies of. orcomments on, par t icu lar d isc ip l ines, specia l t ies, networks, bodies ofknowledge, and so on. It seems inevitable that sociologists' definit ions wil lderive in some measure from those of participants. Yet sociologists have givenlittle analytical consideration to the nature of participants'definitional work;and the relationship between participants' and analysts' definitions remainscompletely obscure. We have chosen, therefore, to begin our study of healtheconomics with an examination of health economists'definit ions of their f ield.

The underlying idea behind the present text is that it should provide someanalysis of health economists'definit ional work, while at the same time re-presenting health economists actively involved in the course of definitionalwork and actively engaged in negotiating with the analysts about the natureof both parties'definit ions. ln other words, we have tried to devise a text whichis reflexive in the sense that some of the interpretative social practices whichc<lnstitute all texts are revealed in the text itself, and in the sense that theanalysts' ability to impose their discourse on that of participants is restrictedby the very form of the text. This deliberate restriction on the interpretativedomination of those we study is the essence of the form <lf collaborative analysisexemplif ied here. Our attempt to implement this type of analysis cruciallyinvolves the active recognition of reflexive similarities between our ownknowledge practices and those of our health economist 'subjects.'They, too,may impose their'way of thinking' on health service practit ioners or collaboratewith them in the joint production and application of practical social knowledge.

We attempted to carry out these ideas by presenting an introductory paperon participants'definit ions of 'health' and of 'economics' at the January 1986meeting of the HESG. A shorter version of this paper tit led, "What HealthEconomics Is," forms Part One of the present text. Part Two consists of anedited transcript of first, one of the authors' introductorv remarks at thatmeeting; second, the discussant's presentation of "What Health Economics Is;"and, third, the ensuing discussion. In Part Three, the analysts discussparticipants'responses to "What Health Economics Is." The analysts identifytwo major forms of definitional work and examine their implications for theway in which social science may be put to practical use. In conclusion, theyjustify their choice of an analytical dialogue as the textual medium for theiranalysis as an attempt to devise a form of discourse appropriate to thecollaborative application of social science.

Definihonal Work in Applied Social Science

PART ONE:WHAT HEALTH ECONOMICS IS

An Introduction to Health Economics

In a sense, this paper is part of a'tradition'r of HESG papers in that it iswritten by outsiders to the corpus of texts which is its topic. On (at least) twoprevious occasions the HESG has held joint meetings with, in 1978 the Societyfor Social Medicine and, in 1983, the Medical Sociology Group. On eachoccasion, a member of each group was invited to read 200 pages of the othergroup's work and to write a paper commenting on his reading (Will iams 1979;Acheson 1979; Culyer 1983; Atkinson 1983.) In each case, the author introduceshis paper with a series of comments on the process of coming to terms witha strange2 literature and then uses his "innocence" (Culyer 1983, p. I ; Atkinson1983, p. l) in a positive manner for the purpose of assessing, in terms of hisown discourse, the worth, interest, acceptability, similarity/difference, etc., ofthe foreign corpus.

This paper, then, is the product of a similar process of instant immersion'in the l iterary products of a strange culture (cf. Atkinson 1983; Acheson 1979).However, its purpose and its scope are rather different. No attempt is madeto review,the texts discussed or to compare them to another corpus, that is,'ours.' lnstead, this text can be understood as an extended commentary uponthe brief remarks of the four authors mentioned above on the 'process ofcoming to know,'that is, of introduction. Given this aim, we feel it important(and, indeed, pragmatically necessary) to restrict our attention to a class oftexts in health economics which are engaged, more or less obviously and moreor less explicit ly, in'doing introduction.* One of the features of this class oftext is the frequent appearance of definitions of 'health economics,'of 'health,'

and of 'economics.' The main aim of this paper is an introductory analysisof this definit ional work.

A Typology of Det'initions

Positive Stipulative: 'X is Y'. . . the economics of health is the application of economics to thehealth field (Klarman 1965, p. 1).Negative Stipulative:'X is not Y'. . . money is not the central problem of health economics (Mushkin1958, p.792) .Positive Pluralist: 'X is Y and Z and . . .'Health economics refer[sl to the relationship between economic cir-cumstances and health or disease as well as to the economic aspectsof the health care system . . . (Groot 1980, p. 162).

29

A.

B.

C.

30 MALCOLM ASHMORE, MICHAEL MULKAY TREVOR PINCH and HESG

D. Negative Pluralist: 'X is not Y nor Z nor . . .'

lHealth economists] are neither glorfied cost accountants nor stu-dents only of the market place and market phenomena (Culyer 1981,p . 4 ) .

E. Principled Absent:'X is not defined because . . ./

These hve are the main types of definition which we have found-they formthe basis of the following analysis. However, in the course of the analysis many'mixed'and/ or'uncertain'types wil l be noted. The major classes of such'mixed'definitions are those which are both negative and positive or negative andprincipled absent:

F.

G.

Combined Positive/Negative: 'X is Y (and Z andnor . . . ) 'Combined Negative/Principled absent:'X is notand is not defined because. . . '

. . . ) n o t P ( n o r Q

Y ( n o r Z n o r . . . )

One might object at this point that this so-called'typology'is merely an adhoc collection of descriptions, and that our mistake lies in not correctlyidentifying or rigorously defining the relevant concept, namely'definition.'Butdo we really want a definition of a definition? Or, for that matter a definitionof definitional work? Without giving any explicit attention to the reJlexiveproblem of 'defining definition,r we can say that a refusal to define-or evena simple absence of a recognizable definition can itself be a form ofdefinitional work. (This point is partly recognized in the typology by theinclusion of 'principled absent' (types E and G) definitions.) For instance, theclaim that it is unnecessary to define something, frequently works as a wayof textually strengthening the 'factuality' of that something (Latour andWoolgar 1979).

'Health' and'Economics' in Health Economics:An Analvsis of Definitional Asvmmetrv

Although all the texts in our corpusu have a common identity asintroductions,t they differ in terms of their declared or implied audiences. Someare addressed to (non-health) economistr (e.g., Cullis and West 1979; Williams1977; Cooper and Culyer 1973) while others address themselves to (non-economist)'heahh workers'(e.g., Mooney and Drummond 1982; Jacobs 1980;Rapoport et al. 1982; Culyer 1976; Fuchs 1974), while still others are clearlydesigned for internal consumption by fellow health economists (e.g., Culyerl98l; Engleman 1980; Abel-Smith 1980). Some also declare themselves to havemore than one audience in mind (e.g., Klarman 1965; Lee 1979).8

Definihonal Work in Applied Social Scimce

This paper began with the following dual and symmetrical 'hypothesis:'

When health economists were introducing health economics to others,definitions of 'health' and of 'economics'would be found to vary systematicallywith respect to which of the two major audiences-economists not workingon health or noneconomists who were working in (or on) health--they wereaddressing. Very simply, we expected numerous positive and probablystipulative definitions concerning that part of the subject of which the audiencewere presumed to be ignorant and a dearth of such definitions concerning thepart which the audience presumably already knew. Thus, in the case of textsdirected at (non-health) economists there would be regular stipulations of 'what

health is' but no such corresponding delinit ions of 'what economics is. ' And,in the case of texts designed for (noneconomist) health-ists, there would bean abundance of 'economics is X' one-liners but no such treatment siven tothe concept of health.

Unfortunately, we lbund this starting point to be inadequate. First, fortheoretical reasons the idea of the 'audience'as a textually independent naturalphenomenon was replaced by the idea of a 'preferred reader' posited in thetext. 'The audience' thus becomes a textual product: the result o/ not theoccasion for modes of textual construction." Secondly, and more specifically,across a// the texts examined, positive definitions of 'health' seemed an almostempty category while negative definitions were very prevalent. This contrastedwith definitions of 'economics' which followed the general pattern predictedboth in terms of definitional type (overwhelmingly positive)'0 and audiencedistribution (a general scarcity of definitions in economist-oriented texts). Therest of this paper is concerned with an examination of this asymrnetry.

"What is Economics?""

By way of introduction, here is a selection of some of the more commondefinit ions to be found in the corous:

Economics 1is the science o[ choice . . . (Culyer 1976, p v i i i ) .

Fconornics, the science ofchoice (Yule and Moonev 1984, p 136).

Econumics is concerned with the analysis of choices at all levels ranging from the individual. . . to nat ional pohcy decis ions (Rapoport et a l . 1982, p. 2) .

F,conomics is the science that deals with the consequences of resource scarcity. . . (.lacobs

1980, p. 2) .

. . . the basic economic problem is how to allocate scarce resources so as to best satisfyhuman wants (Fuchs 1974. p. 5) .

. . . the primary interest of economic analysis . . . defined simply, is the appraisal of theal locat ion of resources . . . (Mushkin 1964, p. l3) .

31

JZ MALCOLM ASHMORE, MICHAEL MULKAY TREVOR PINCFI, and HESG

Economics is about getting better value liom the deployment of scarce resources (Mooney

and Drummond 1982, p. 949).

. . . the discipline of economics is essentially about valuation (and not simply valuation

in markets, although as a topic that has been, and still is, our predominant interest). . . .

a l l valuat ion problems are gr is t to our mi l l . . . (Wi l l iams 1979, pp. 5,6.) .

Notice how all these (more-orless) positive stipulative definitions 'shade into'one another in terms of their content. We move from choice through scarcityand resource allocation to valuation.r2 The aspect of these definit ions that wewant to stress, however, is the tension between the representation of economicsas method ("science;" "analysis;" "appraisal') and as topic ("choice;" "scarcity;""value'). 'Economics'describes both an analytical enterprise and an essentialaspect of the problems of the 'real world.' Which of these versions is givendiscurs ive pr ior i ty is h ighly context-dependent ; in these par t icu larnoneconomist directed texts method is depicted as being dependent upon topic.It is the real world economic 'facts' of "resource scarcity" and (therefore)"choice" and (therefore) "valuation" which gives a practical purchase for the"science." And thus, in these writings, the tendency is quickly to move awayfrom any potentially alienating emphasis on the scientificity of the disciplinetowards a concentration on the practical economic problems of participants.This move can also involve reformulating the method of economics assomething which apparently requires little specialist knowledge or training thusmaking it more available 1or participants'own use:

Perhaps it is a clich6 that economics is a way ol thinking about problems rather than asettled body ol'doctrine but in this area of the evaluation of health services it is a clich6which gets very close to the heart ol the matter (Glass 1979, p. 100).

. . . the methodology of economics the thinking underlying this particular disciplineis more important than all the analyses and data arising from it (Mooney and Drummond19u2 , p . 1025 ) .

. . . we stress economics it.s a way o1'thinking. Indeed techniques . . . are much more thansimply mechanical aids; together they provide a framework lbr thinking about . . . problems

. . . (Yule and Mooney 1984, p. 2 l l ) .

Because of its very broad scope, economics does not provide a body of rigid doctrinesabout scarce resources. Rather economics offers an overall viewpoint (Jacobs 1980, p. 2).

This set of combined negative/positive definitions (type F) can be describedas correcting inappropriate characterizations of method. The 'hard'version ofscientific method, which stresses the use of "mechanical aids" for the productionof"analyses and data" constituting a "settled body" of"rigid doctrines" is hererepudiated.

ln the following set of negative pluralist and combined negative/positivedefinitions (types D and F), inappropriate versions of the subject matter ofeconomics are corrected:

Definihonal Work in Apphrd Social Scimce 33

. . . there is an unfortunate tendency to treat economists as ifthey werejust cost-accountants,

and to limit their role accordingly . . . there is more to economics than the calculation

of costs (williams 1979, p. 6).

. . . while many people think of economics as being solely about costs, it is in truth more

about benehts than costs (Yule and Mooney l9tt4, p. 137)-

. . . economics is notiust a sophisticated form ofcost accounting, though costs and prices

are extensively used in economic analysis (Abel-Smith 1980, p. 218).

. . . the suspicions that others entertain about economists Iincludei the widespread belief

that economists have a naive and rather hard-baked system of underlying political values

Iand] the belief that too much of the activity of economists is erected upon excessrvely

simple concepts . . . of the determinants of human action . . . (Culyer 1981, p. 5).

Economics involves finding the alternatives and calculating Ithe opportunityl costs, not

making the actual choices. . . . economics simply points out the consequences (Rapoport

et a l . 1982, p. 5) .

These quotations can be understood as responses to alternative definitionalwork on the substantive concerns of economics. These writers are not onlyconcerned to replace one definition with another, better one; they are also

engaged in disparagin gthe legitimocl of this alternative definitional work itself.The nameless'others'whose formulations of economics are'under review'here,have "unfortunate tendencies," "entertain suspicions," fall victim to"misunderstandings" (Rapoport et al. 1982, p. 5) and hold "common

misconceptions" (Mooney and Drummond 1982, p. 950). It is fortunate thatthese alternative formulations of the concerns of economics are, withoutexcept ion. ( re lat ive ly) 'unat t ract ive. ' r r

To sum up: The work involved in defining'economics'constitutes a preferredreade rsh ip o f ' p rac t i ca l economis t s ' ( choose rs . sca rc i t y expe r i ence rs .evaluators) who, however, lack the "way of thinking" and whose alternativeattempts at definition are, therefore, accorded little or no legitimacy. One could

say that the opportunity cost of this kind of definitional work is the sacrificeof some of the trappings of'special expertise'in exchange for the benefit ofexclusive rights of self-definition.

'"What is Health?

Definitions of health abound. Agreement is hard to tind (Fuchs 1966, p. la4)

In our corpus of texts, positive definitions of health are rare. In fact, wehave only found one which we hereby relegate, undeservedly, to the Notes15in order to concentrate on the relatively large number of negative defrnitionswhere we duly find, as Fuchs' comment perhaps implies, a fair degree ofagreement on the inadequacy of existing (positive) definitions. The standardpositive definit ion taken to task in health economists'negative definit ional

U MALCOLM ASHMORE, MICHAEL MULKAY, TREVOR PINCFi and HESG

work, was formulated by the World Health Organization (WHO) in 1948. Forexample, the above quotation from Fuchs (1966, p. 144) continues thus:

The oft-quoted statement of the [WHO] is framed in positive (some would say lJtopian)termsr6-'A state of complete physical and mental and social well-being.'

Other health economists make similar points:

. . . one of the most popular (and most widely criticized) oneJine definitions is that providedby the [WHO] . . . (Cullis and West 1979, p. \.

The [WHO] has defined [healthl as 'a state of complete physical, mental and social well-being, and not merely the absence of disease or infirmity.' While the elegance of such adefinition can be admired it is less easy to use it in practice (Mooney and Drummond 1982,p . 1 2 6 3 ) .

The WHO definition . . . is insufficiently precise for any operational meaning to be attachedto it (l€e and Mills 1979, p. 170).

The hrst thing to notice about these negative definitions is that they all takethe form of statements about definitions. There are almostrT no equivalentfragments of 'defining talk'in the corpus when the topic is economics. ln fact,a// healthdefinitional formulations which we cite have this feature. It seemsthat it is not only (to anticipate) the nature of health that is problematic; theyery definability of health is also. The final pair of the above quotations givesus a clue as to why this should be so. The concern with "use . . . in practice"and "operational meaning" suggests that definitions of health are beingevaluated for their (possible) utilily (or not) in the practical activity of healtheconomics. As Will iams (1977, p.302) puts it, "the problem [is] of f indingsuitable operational definitions of health that can be used in economicanalysis." And it seems that the portrayal of 'health' €rs resistant to this kindof useful defrnition is a commonplace:

. . . problems surround finding a suitable definition of the commodity 'health'(lre andMills 1979, p. 170).

Even ifdefining health in some appropriate, operarional way is difficult, perhaps none theless we can measure'' it. But again there are . . . problems (Mooney and Drummond 1982,p. 1263).

Common usage leads us to define [health] (unhelpfully) as the absence of ill-health whichof course leaves us still with the problem of determing what deviations from this undefinedstate of perfect health constitute ill-health? (Williams 1977, p. 302\.

At first glance the concept of health seems so familiar to us that we can reach out andtouch it. It seerns easy to distinguish [healthy from unhealthy]. Precise measures are harderto obtain and the two categories of healthy and unheahhy are hardly exact ones. The mainreason for this is we have not defined health precisely; lacking such a definition two peoplecan have very different opinions on whether one person is healthier than another (Jacobs1980, p. 2 l ) .

Definitional Work in Applied Social Scimce 35

These last two selections are interesting for the way that they ironicisetn

"common usage" and the "familiar." In the context of doing definitional work

on health, commonsense is a hindrance to (the right kind of) definitional work.

It tends to "lead us" astray precisely because "at first glance" things "seem [so]easy." As Williams (1977 , p.302) remarks: "To the innocent beginner it hardly

seems necessary to give a moment's thought" to answering this question. After

all everyone knows the answer, donl they? For the practice of health economicshowever, 'what everyone knows about health'is radically insufficient. Or is

it? The following (type E) definition seems in disagreement. Or is it?

No attempt is made to define rigorously what is meant by [the] terms [good and bad health]

on the grounds that to date no really satisfactory definition has been agreed upon. However,

health is something that people have an everyday understanding of, and this is sufficient

for the purposes of this book. . . . This is not to imply that the definition of health is an

inconsequential matter because . . . the definition chosen has widespread consequences

(Cullis and West 1979, pp. 34).

Despite these authors' unusually generous attitude towards mere "everyday

understanding," they proceed to emphasize the consequentiality of Ihe choiceof definition. Apart from the 'everyday'(and the WHO), there appear to be

three other definitions 'on offer,' defined in terms of "whose definition" (Lee

and Mills 1979, p. 170) they are. In Will iams'terms (1977, p. 303), these arethe biomedical (the doctors'definition: absence of disease), the functional (the

patients' definition: ability to function 'normally), and the cultural (the

sociologists'definition: subject to varying cultural and historical perceptions).

Will iams (1977, p.304) comments ruefully:

Economists . . . will, unfortunately, have to be prepared to work with each of these notions

from time to time.

Thus, when it comes to defining'health,'health economists'definitional workincludes the recognition-however "unfortunate" this may be of the

legitimacy of other actors' defrnitional work.

Asymmetry and the Application of Dsciplines to Topics

The major points of contrast between health economists' deitnitions of'economics' and of 'health'-in other words the asymmetry of the respectivedefinitional work--concern the treatment of 'everyday practice' and thelegitimacy granted to the definitional work of others.

Definitions of 'economics'-overwhelmingly positive, or positive/ negative,and which predominantly occur in noneconomist directed texts-tend toengage with practical discourse by emphasizing the everyday nature of itsconcerns and by working to reduce any perceived 'gap of expertise'between

36 MALCOLM ASHMORE, MICHAEL MULKAY. TREVOR PINCH, and HESG

the participant and the professional ('Just a way of thinking'). Alternativedefinitions of economics tend to be unattributed to any specific groups andare dismissed and/or corrected; only (selfdefined) economists are treated ashaving the right to define economics.

Definitions of 'health'-overwhelmingly negative or principled absent, andwhich occur throughout the corpus tend to disparage everyday discourse. Thecommon understanding of health is textually articulated as an obstacle to thedistinctive kind of definitional work required for this topic, which is, quitesimply, that it be put to (professional health economic) work. However, withthe explicit attribution of alternative definitions of health to specified groups(doctors, patients, sociologists), the definitional work of these others on thetopic of health is thereby granted some legitimacy.

An Interim Conclusion

The definitional asymmetry of 'economics' and of 'health'clearly has to dowith the taken-for-granted relation of the two terms in health economics.Health economics is treated as the economics o/ health. 'Health' is topic;'economics' is discipline; their relation is one of the application of the latteronto the former. We take some comfort about temporarily concluding ouranalysis with what seems such an obvious and self-evident point, from beingable to support it with the following statement by Culyer (1981, pp. 3-5), onthis occasion20 writing in a sociology of knowledge vein, who cites as inspirationthat other eminent sociologist (again for this occasion!), Williams. (Actually,of course, Culyer and Williams are both economists.)

'Health'denotes, of course, a topic a set of phenomena amounting to a broad but quitewell{efined area of study. . . . The scope of a topic is however conventional. The topic'health' has not always included all the I'eatures [that it does now]. 'Economics' too rs atopic, broadly construed as'the economy'. The definition of the topic ofeconomics is alsoconven t i ona l . . He re I wan t . . . t o f ocus oneconom ics asad i sc i p l i ne . . . . t he top i cof health and the topic of economics are not the only topics to which the discipline ofeconomics may be applied, nor is the discipline ol economics the sole discipline capableof being applied to the topit health or the topic of economics. . . . Health economics canlikewise in principle be viewed as a discipline, a topic . . . or as the discipline economrcsapplied to the topic health. I believe that only the last view makes any sense at all.rr . ..The distinction between topic and discipline is usefui . . . in reminding us that the topicsof our research are largely conventional, being determined by contingent elements suchas local circumstances and institutions. Dersonal talents and nersonal values. rather thanby our discipline itself.

What is interesting and relevant about this passage in the context of our analysisof definitional asymmetry is the highly asymmetrical way in which the twoterms of our (and Culyer's) analysis are deployed. Whereas topics, such as'health'and 'economics' are repeatedly made out as "conventional," that is,

Defrnihonal Work in Applied Social Scimce 37

contingent, variable, or sociallydetermined; disciplines, such as 'economics,'

are not. And while'economics'lives a double life as both topic cnd discipline,'health' is only a topic. Finally, though Culyer canvasses the "in principle"

possibility of construing health economics as topic, as discipline, and as "the

discipline economics applied to the topic health," he comes down firmly in

favor of the last.We maintain that this asymmetry between disciplines and topics does not

reflect any inherent or natural distinctions between these two categories.

However, we suspect it is impossible 'here and now' to persuade health

economists that discipliner are every bit as open to 'deconstruction' as are

topics. As a very weak indication of this lack of intrinsic asymmetry, consider

this ('passing,"jokey) remark of Mooney and Drummond (1982, p. 1727):

. . . the Heal th Service is nei ther tota l ly 'economic ' in i ts operat ion nor is economics as

a discipline completely 'healthy'in its development.

Here, the relation of application is reversed and 'health' is applied to'economics.'

What is it that prevents this from seeming as natural as the application of'economics' to 'health?' We suggest that it is the result of the asymmetric

definitional work that we have been examining (that has been our topic). A

discipline takes on the appearance of'nondeconstructibility'by virtue of the

insiders or members achieving the exclusive 'right' of disciplinary-definition.

A topic, on the other hand, becomes recognized as "conventional"

(deconstructible) through definitional work which takes account of other

actors' definitions.

PART TWO:AT THE HEALTH ECONOMISTS'STUDY GROUP

Introductiory Presentatiory Discussion'"

l. Michael (Author): What I want to talk about, is not so much this paper

[Part One: What Health Economics Is], but very briefly, the project of

which it is a part. Trevor, Malcolm, and I have been working for a number

of years on various knowledge-producing communities. On the whole,

we have concentrated on what are euphemistically called the hard

sciences; that is, we have looked at physics, chemistry, bio-chemistry.

radio-astronomy, and areas of that kind, but not much attention has been

paid-I am not quite sure why-to the social sciences. Neither has very

much attention been paid to those areas that produce knowledge with

a view to the application of that knowledge, and it seemed to us that

health economics would be a good example of a social science, and a

38

2.

MALCOLM ASHMORE, MICHAEL MULKAY TREVOR PINCFI and HESG

social science which in some way was centrally bound up with theapplication of the knowledge which it produced. So what we have begunwithin the last couple of months is a three-year study of healtheconomics. . . .

Our study is not the kind of study that starts off with a series of hypothesesabout health economists. It is really a kind of descriptive study wherebywe try to enter the culture of health economics and, with the help of peoplelike yourselves, to begin to understand it and to try and describe the kindof culture of health economics as a knowledge-producing community.So we are interested in the nature of health economics knowledge andthe way in which this knowledge is produced. We are particularlyinterested in the part played by considerations of practical usefulness inthe identification and formulation of health economic knowledge. Andlast, we are interested in the kind of use made by practitioners of theend product of health economics study and research. . . .

Just a few more brief remarks. The methods which we intend to employin the course of this study are first, participant observation in variousforms and our presence here today is one part of that participantobservation. Second, the analysis of texts and particularly of the-butnot exclusively the texts which in some way carry or embody theknowledge that health economists produce. And also the use of interviewsof various kinds. . . . The paper that has been distributed and which Ihope many of you have been able to read . . . is an attempt to understandhow health economics is defined by participants and to try to begin tounderstand how these definit ions might change under differentcircumstances. . . . We hope that you will respond . . . by being charitablein telling us where we have not even begun to capture yourunderstanding of what health economics is. And, in this way, we mightbegin to understand more adequately.

One last word about the paper. It is an unusual paper, in that it namesyourselves as joint authors, those of you who have read it may havenoticed that fact. It is also an unusual paper in that it is, by intention,incomplete and further parts of the paper are being written now andthroughout the rest ofthis discussion. . . . It is part ofour style ofresearchthat we try and engage in a kind of active dialogue with the people thatwe are studying, so that they become analysts themselves of their ownculture. . . . And it is for that reason that we have two tape recordersoperating, just to make sure that we do not miss any of the words thatyou have to offer to us this afternoon. Thank you.

J .

4.

Defrnitional Work itt Applied Social Science

7 .

Peter (Discussant): I enjoyed reading the paper. I do not think I have

ever been reminded of so many of the works of Tom Stoppard

simultaneously flaughter] as when I read it. I was reminded of Jumpers,

which, as you may know, has quite of lot of introspection andphilosophical discussion in it. I was reminded of Rosencrantz qnd

Guildenstern in the sense that, from time to time, various actors wanderedinto the script . . . and did a bit and then wandered out again. And, of

course, in the way in which I was set up for being a discussant, I was

reminded of Prcfessional Foul flaughter].

1-he paper concentrates on definitions of economics and definitions of

health . . . and really can be summed up by its focus on what it calls

the asymmetry of the definitional work. And that is to say, when health

economists talk about economics, they have a fairly clear idea of what

they are saying; they spell out what economics is, they are fairly positive

about it. When economists talk about health, they are, on the whole, muchless clear, they are not really saying what health is, they are often rather

saying what health is not, or what may or may not be included. The whole

thing is much more vague, much more general, and the authors point

this out without, in my view, fully coming to terms with some of thereasons why that asymmetry exists, possibly because of the early stage

that their work is at. Certainly I do not think there is any doubt, given

the quotes in here, that there rs an asymmetry, that on the whole the basic

texts of health economics do give a much clearer idea of economics than

they do of health. . . .

The asymmetry seems to me to be . . . to do with, well, very substantiallyto do with, the sorts of things that economics and health are. . . . The

difficulty with health, is knowing where it begins and ends, knowing quite

what it comprises. . . . Economics is ways in which people act, they dothings, you can look at it and observe it. Health is, it seems to me, to

be much less tangible, much less open to that sort of observation and,therefore, much more difficult to define. . . .

It does seem to me that that is one feature. Another one though, I think,is a sort of inevitable professional arroganre that 'you know what you aretalking about,'and so, in some sense, you do not have any problems withyour own field and when you go into the other fteld, you want to try andset up in a way in which you can manage it. And you are actually, in a

sense, colonizing the other peoples'territory and you are trying to put aring around certain topics or certain aspects of what they do, in order toapply your discipline to them. That does not seem to me to be an unreason-able thing to do, but it may be that you get it wrong from time to time.

39

5.

6 .

8.

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MALCOLM ASHMORE, MCFIAEL MULKAY, TREVOR PINCH. and HESG

It does seem to me to be reasonable then . . . that there ls this asymmetryand that it is, I think, partly the nsture of the two things, health andeconomics, that determines it; it is partly the desire to impose a structureon the alien field in order to help you manage it, compared to themanagement of your own field which you know well. I think though,that the economist's problems are partly related to the difficulty ofseparating health from utility. If you say that health is well-being, andwell-being is welfare, and welfare is utility, then you are left with thepossibility that health economics covers everything. . . . Our own difficultyis that we have got some concepts about welfare, and that we are notquite sure ourselves, as a discipline, where they begin and end, where theyoverlap with health or where they are the same as health, which is whatI more and more feel, and so we are in difficulties in addressing, in definingthe health field. . . .

IPause]

10 . Alan: Since there was a large gap, I thought I had better say somethingirrespective of what it is. Really, just in support of what Peter said, aboutthe need not to be bound up with the definition of health per se. Healtheconomics, I mean it is an unfortunate name really, but it deals with amuch wider concept of utility. lt is not really a division by discipline,we are not looking at health, I mean that is the unlbrtunate thing aboutthe name. What we are looking at is the impact of certain facilities, NHS,social services, whatever . . . upon the utility, the welfare of the individualswhich they are supposed to serve. . . . So, really just a word of caution:If you are bound up too much by the definition of health and are lookingfor a definition of health, you may miss a great deal of what healtheconomics and the health economist is trying to look at: this wider areaof utility and welfare.

Jeremy: . . . I think that you need to look at the practice of healtheconomists as well as what they write in the literature. I certainly wouldnot disagree with any of these eminent statements about what healtheconomics is that you have quoted, they all seem fine to me. But I amnot sure that the emphasis is all that apt at the practitioner end of theprofession. . . . I suspect that when you look at the practice of healtheconomics, you will find that it is very closely bound up with theinstitutions of health service delivery and so on, much more so than thedefinitions. In other words, I think there is a bit of a kind of oversellwith calling it heahh economics. It is, most of the time, health serviceeconomics. I would defend to the death the fact that it should be healtheconomics rather than health service economics, but that is alright if you

l l .

Definitional Work in Arylied Social Scimce

are working in the university and you can choose your area of operation,but not necessarily alright if you are working for some customer.

Charles: . . . One of the things that I found extremely typical of thepracticing health economist, working on planning questions in the service,was that there was an enormous difference between what 1 thoughteconomics was about and the popular perception of what economics wasabout; to the extent that you got shuffled into areas where you had nocompetence and kept out of areas where you might possibly have helpedthem and people were persistently trying to turn you into costaccountants. . . . To a very large extent, this obsession with explainingwhat we do, or what we think we do, is in response to the fact that ifyou stop even the average, dare I say lecturer in sociology, you wouldhave some difficulty in getting them to understand at least our perceptionof what the content is. . . .

Michael: Could I link that back to Peter's comments where he wassuggesting that, in some sense, economics was tangible and observable

[para. 6J? Your experience, in a practical situation, is not that; but thatfor various people economics means various different things. Is it thateconomics is tangible and observable for trained economists, but thattheir definition of what this tangible observable activity rs, may be quitedifferent from that of people in other settings, would that be yourobservation?

Charles: I would put it a different way: That people do not understandwhat our activity is about. . . . Any beliefs they have, I would suggest,are based on a lack of knowledge as opposed to a lack of ability tounderstand what you do. . . . This leads to a very keen interest in tryingto explain what it is that we believe we can help with; and trying to shyaway from things that we are not really interested in being seriouslyinvolved with.

Anne: I am not reolly sr,tre to what extent definitions of healtheconomics or what health economists are trying to do, can be understood,really, in isolqtion from the people whose problems we are trying to workon; that is, the health service professionals. Because, most of the timewe are actually part of the way through a dialogue with them when weare trying to present an argument or an idea. . . . The customer has aproblem and he is not really all that interested in what health economistsdo, he is interested in solving a particular problem and, therefore, hisapproach is going to be dominated by trying to get you to work on hisproblem rather than wanting to know what health economics is about.

41

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t 3 .

t4.

1 5 .

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42 MALCOLM ASHMORE, MICHAEL MULKAY, TREVOR PINCH, and HESG

Therefore, a lot of explanatory work, perhaps, is produced for thatreason.

t 1

Alan: Just to come back on that point. I mean. obviously what Anneis saying is true, but it is also important . . for us to advertise whatwe do best, because only in advertising what we do best, will we actuallyget the questions that we are most able to answer correctly. . . . Because,only in that way will we get those in power educated sufliciently to askus the right questions so that we can use our skills appropriately.

Peter: I am a bit concerned about the idea that there might be quitedifferent views of what economists can do, among the different groupswhich we work with. . . . I think we have to be careful in saying thatwhat economists have been doing out there in the system . . . reflectsthe different perceptions of the people about what economics is. Theymay very well knou,, thev may have a quite clear idea of what economicsis . . . but what they need is a spare pair of hands to do some other task.. . . A lso, i f you have an economist who is onyour team. then you canu.re him as a cost accountant because you do not trust or you do notl ike the cost accountants that you are normally dealing with. . . . So.I think there is a difference between what they use us./or, and what theysee economics d.r. . . . Thev may have a better idea than the way in whichthey use us would suggest.

Alan: Is health economics the sole preserve of health economists'JObviously it is not, and we have a question which is also asked in manyother disciplines. What the health economist has perhaps, is a certain wayof looking at that particular question. So, if anvrhing makes us different,it is the type of way in which we look at questions. the analytical tool-kit we use. . . . I think that because of the primary importance of customersin the area where we are working. we are in danger of having a disciplinedefined for us . . " and what we think we should be doing and wherewe should be fitted into this general framework is immaterial.

'fhat is

the theoretical definition, the practical definition will be defined by peopleat DHSS who give us this to do. So, the practical area we are workingin may be very dift'erent than the theoretical area and it may be the caseof 'never the twain shall meet,' I hope not. but it is possible. . . .

Mike; I have a very much more simplistic approach to this. . . . It worriesme slightly to discover my colleagues defining themselves almost as adiscipline. What I expect to find . . . is a common toolkit and a commoninterest in, and hopefully knowledge of, things pertaining to health andheaith services and health care. Those seem to me to be the two thines

1 8 .

t9 .

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Definikonal Work in Applied Social Scimce 43

that bring us all together. . . . I really see health economics and health

economists as nothing more than a shorthand for economists who happen

to have a concern with the health area.

Malcolm: . . . It seems to me, on this asymmetry business, that if you

look at the point of view of the medical profession or hospitals orsomething like that . . . the asymmetry is that health is an important areaof human activity, or medicine is, and you have got this flea bite on its

back, called economics, and that is more like the reality actually. If you

are merely-because you are involved with the university economics all

the time you think the university economics is the important thing, butit is not!

Jaime: About the asymmetry to the definitions, there should beasymmetry mainly because, when talking about economics, I have the

tools which enable me to tackle the problem. Once I have tackled theproblem, or the community has tackled some problems,.then you definewhat you have. . . . Whereas when the work is applied, you need a workingdefinition of health. It should be different because as health is nothingthat you can apprehend, unlike economics, which definition you pick willdepend on the problem that you are working on. But in any case, it hasto be an operative one unlike economics, for economists, of course. lt

would be the other way around if you were to talk about what themedicine of economics is flaughter].

Ken: I took the paper to be an attempt to address two questions. Thefirst is: What are the characteristics of the definitional assumptions whichhealth economists use in their discourse? The second is: Is there anyconsensus about the definitional content? lfthat ls the thrust ofthe paper,

is the way you have done it the right way of doing it, by starting withintroductory texts? Because the point is, almost by definit ion,introductory texts are principally addressed at people who are nothealtheconomists, and, therefore, a different discourse will be applied, and

different definitional assumptions will be applied. . . . It seems to me thatyovr approacft is not wrong, and the question is not wrong, both are

very interesting; it is the starting point that is wrong. You should abandonintroductory texts.

Dave: . . . I think you have to think carefully about the language inwhich those definitions count because people who define economics,however they define it, are not talking to fellow people [laughterl. Sorry-to fellow practitioners. . . . The display that is put forward is a displayfor outsiders. This definition is a definition for outsiders. . . . Now . . .

2 t .

22.

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M MALCOLM ASHMORE, MICHAEL MULKAY TREVOR PINCF' ANd HESG

that must be a common problem for anthropologists and it must be aproblem that you have encountered before, looking at other disciplines,because I would guess, as a hunch, that physicists do not talk basic physics

to each other, they know physics, they do not have to communicate thistype of thing. This is all taken for granted, or is not even discussed, itis not regarded as being a valid source of intellectual debate forpractitioners of a discipline. So, what I am saying is: How dosociologists of science get over this problem that they are not practitionersof the science which they are studying?

Michael: Yes. The definitions, as you say, are for occasions, they arefor use in a particular text or for a particular customer or for some furtherkind of social work. And one of the things that interested us when webegan to look at this material, was, first of all, that economists wereoffering definitions when radio-astronomers, for example, never offereddefinitions. They never had to get into the business of saying what radio-astronomy was. And they certainly never, in my experience. ever saidto some outsider, 'radio-astronomy is a way of thinking' llaughter].

William: What he is really saying is that we are still on the level of beingastrologists Ilaughter].

Graham: Well, I got the impression from what Michael said that hehas noticed in health economics a tendency to declare frequently andpublicly what health economics is in a way in which other disciplines havenot done. And I think that the reason for that is . . . to do with whathe almost suggested, which is that it is a fairly new aclivity, or, at least,it is an area where economists are breaking into a new market. . . . But,in order to get into the market in health, you have to be able to packageyour product and sell it to the people who are already in the market.And that seems to be what the definitions of health economics aredesigned to do, to declare that here are economists who are capable ofadding something to the decisions that are being made in the health field.And in that sense really, if you get a definition of health economics, youare not defining kinds of people, you are just defining a role thateconomists may or may not play. . . .

Clive: I think my experience in the government has led me to believethat you avoid definitions if you want to get on flaughter]. . . . We arein a position where, having recognized that there are problems that wethink some economics could contribute to, we can then say, 'we wantto be in on this'and we will define that as within health economics; and,I think that means [that] until we find that we are far in excess of the

24.

25.

26.

27.

Definihonal Work in Applwd Social Science

area which we can deal with, we do not have to come back to what thecore subject can deal with. Let us place our boundaries, arrogantlyperhaps. as far out as possible and stretch towards them.

28. John: The one point in this paper that intrigued me most was whenyou made the statement,'lt appears that health economists are sacrificingthe claim to special expertise for the sake of self-definition.'Now we have

discussed all around this issue without referring directlv to the paper. quite

a lot this afternoon. [There has beenl all this talk about what health

economists think they are good at and what people employ them to do,which seems bound up very much with this paper. And you also seemto get on to the right l ines, I think, when you adopt this idea of economicsas a way of thinking, which is a very common explanation that economistsuse for saying that economics is really very straightforward, it is not amassively complicated subject. Perhaps it is not followed through in thepaper because of the preliminary nature of the work, but thinking aboutthis further, if you say economics is a way of thinking, vou then takethe next step. that anyone approaching the matter with a set of logicaltenets ought then to be able to do it. There is no specific I'a<'tual bodyof knowledge which you require to do economics. you require theknowledge of the system of thinking. Then, of course, the other thingyou point out is that economists spend a lot of t ime being very crit icalof their colleagues'work and particularly o1 other people from otherdisciplines who try to do economics, I laughter] when they have spent thelast seven years explaining that anyone ought to be able to do it I laughterl.. . " It seems to me that this leads back to this question of self-definitionand: How important is self-definition in deflecting health economists trombeing really useful people?

PART THREE:SOME SOCIOLOGICAL OBSERVATIONS AND

A COLLABORATIVE CONCLUSION

In this section, we, the sociological contributors to this text, present ourobservations on the comments made by members of HESG in Part T'wo" Wealso attempt to link these analytical observations with those in Part One ('WhatHealth Economics ls) in order to produce a conclusion.

Our lirst observation is that in Part Two the health economist'participants'act as 'analysts;' they respond with further analyses of their own to the discourseof health economics presented and analyzed in Part One. Three initialcomments can be made about the analyses provided by the members of theHESG. First, it appears that these participant-analysts experienced ncr

45

M MALCOLM ASHMORE MCFIAEL MULKAY TREVOR PINCH, and HESG

difficulty in accepting that the material we examined in Part One involveddefinitional work. At no point in the discussion were we questioned on thisscore. Second, no doubts were expressed about the existence ofthe dehnitionalasymmetry we had identified. All of those who spoke explicitly about theasymmetry confirmed that it was evident in the material which we had studied.Third, there was no dispute that the particular items we had chosen to examinewere representative of a larger population of introductory texts about healtheconomics.'

Nevertheless, the speakers clearly treated our analysis in Part One as radicallyincomplete and as in need of improvement. For instance, most of theparticipant-analysis in Part Two is concerned not with definitions of'economics' or of 'health,' but with definitions of 'health economics' and/or'health economists.'Indeed, one speaker suggests that "looking for a definitionof health" is a mistake (para. l0). In general, the health economists enthusi-astically accepted our invitation to tell us where we had not "even begun tocapture lparticipants'] understanding of what health economics is" (para. 3).

In correcting our analysis of health economists' definitional work, theparticipant-analysts begin to specify the social and interpretative factors whichinform participants'definitions of health economics. Two rather different linesof analysis can be discerned which we will call the 'disciplinary' and the'practical'.2r Participant-analysts tend to treat these two lines of analysis asdifficult to reconcile.

Disciplinary and Practical Bases for Definitional Work

The first line of analysis to appear in Part Two emphasizes the disciplinarybasis of health economics and the need to provide a definition of healtheconomics which properly reflects a concern with economic phenomena asconceived by professional economists. The major features of the disciplinarl,definilion of health economics, developed above, are as lbllows:

Economics as a discipline is taken to consist of a body of practices anda range of phenomena which can be unproblematically identified byprofessional economists (paras. 6-9, 2l , 23).Moreover, economists are said to have a special approach, skills,expertise, way of thinking, or toolkit, which are available throughoutthe discipline. 'Health economics'thus refers simply to the work of thoseeconomists who make use of these professional resources in relation tohealth care (paras. 16, 18, 19,21,28).The distinctive approach to economic phenomena provided byeconomists can be used, it is said, to solve or help with practical problemsfaced by noneconomists, including medical practitioners and othersworking within the realm of health care (paras. 14, 16).

-).

Det'tnitional Work in Appli"d Social Science

4. However, because noneconomists frequently misunderstand the natureof economics as adiscipline, they must often be persuaded or re-educatedbefore they can benefit from the help potentially available fromeconomists (paras. 12, 14, 16,28).

Participant-analysis along these lines treats the discipline of economics as itsprimary point of reference and, in so doing, provides a clear explanation ofour original asymmetry. For if health econcmics is simply the techniques ofeconomics applied to problems in health care, health economists can only clearlydefine in advance the economic components of their specialty. The health carecomponents cannot be specified in the same way; perhaps because they areintrinsically vague or difficult to apprehend (paras. 7, 2l) but also because theyfall within the province of health care specialists (paras. 15,26). This line ofanalysis treats health economists' asymmetric definitional work as naturallygrowing out of an asymmetric relationship between economics and medicalpractitioners with regard to economic matters; in this sphere, economists seethemselves as intellectually dominant, that is, they "claim the right of self-definition" (para. 28), even though they accept that noneconomists will havea say in defining the parameters of its applicability. Disciplinary definitions,however. attempt to place noneconomists in a relatively subordinate position.This kind of definitional work treats them as the source of vaguely specifiedpractical problems which can be effectively resolved only with the help of thecomparatively rigorous techniques devised within the discipline of economics.

This disciplinary line of analysis, although recurrent in Part Two, does notgo unchallenged. For example, it is suggested that definitional work is seldomnecessary among insiders (paras. 8, 23) and that dehnitions of health economicsare almost entirely produced for specific outside audiences (paras. 22,23).Thisimplies that'textbook'definit ions of health economics, of the kind we examinedin Part One, may bear little resemblance to the actual practice of healtheconomists and more to the supposed requirements of the audience(s) inquestion (paras. 11,22). If this is so, the disciplinary account of definit ionalwork appears to be inadequate, and the definitional asymmetry, found inintroductory texts, is to be explained by reference to the nature of theaudience(s) rather than the nature of the discipline.

In other parts ofthe discussion, participant-analysts pay particular attentionto the important audience of health care practitioners and, in so doing,formulate a practical, as opposed to a disciplinary, account of healtheconomists' definitional work. They propose that definitional work whichoccurs in the course of interaction between health economists and health carepractitioners is not asymmetric, but dialogic (para. 15) or that, if it ,rasymmetric, the asymmetry favors the health care practitioners rather than thehealth economists (para. 20). The central features of the practical deJinitionof health economics, developed above, are as follows:

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48 MALCOLM ASHMORE, MICHAEL MULKAY. T'REVOR PINCH. and HESG

t . "I'here is a significant gap between 'theoretical'and 'practical'defrnitions

of health economics. What health economists do as well as what heciaims to do is greatly influenced by noneconomists (paras. 11, 12, 15,1 7 . l 8 ) .Health economists'definit ions often occur in the course of dialogue withhealth service professionals and vary, to some extent, as a result of thesocial interchange between the parties involved. On some occasiono,health service prof'essionals are able to impose their own conceptionsof the relevant role o1'economics and economists uDon the economists( p a r a s . l l . 1 2 , 1 4 , 1 5 , 1 7 , l 8 ) .Health economists'definit ions are designed to enable them to enter thehealth care market, anC vary in accordance with changes in the marketsituation as economists seelt to persuade practit ioners of the value oftheir product (para. 26).This may mean that the boundary of health econclmics is intentionallyleft unspecified so that economists can take advantage of every possiblemarket opportunity (para. 27).

3.

Both the disciplinary and the practical accounts of detlnitional work in healtheconomics acknowledge that such work is related to the socral relationshipsin which health economists are involved. Within the disciplinary analysis, anasymmetric definition of health economics is regarded as inevitable becausethe definit ions represents a social science which exists in order to apply thedistinctive inteliectual assumptions, techniques and 'ways of thinking,' ofeconomics to the practical diff icult ies experienced by economically less well-informed lay persons. The definit ional asymmetry of the disciplinaryperspective is l inked to an asymmetrical conception of the relationship betweensocial science knowledge and lay knowledge about economic matters, andbetween lay actors and the purveyors cll' social science expertise. We suggestthat. in areas of applied social science, such as health economics, definitionalwork cannot be a socially neutral act. In such trelds, definit ional work is inpart a claim to define how expert knowledge is to be put to use and, at leastpotentially, a claim lor the right to control others'social activit ies. In the caseof economics, defined as 'the science of choice.' disciplinary delinit ion of itsapplied specialties will necessarily imply the need to restrict other social actors'rights to choose tbr themselves. In its strongest form, the disciphnary definitionof health economics implies the need to impose the culture of the disciplineof economics upon any aspects of health care over which the economists claimprofessir:nal j urisdiction.

ln contrast, the practical line of analysis maintains that 'textbook'definitions

of'health economics are, and should be, radically reformulated in the practicalworld and that, in practice, health economics comes to be defined in manydifferent ways as health economists interact and negotiate with the members

2.

Deftnitionnl Wark in Applied Soctal Science

of the various health service professions. According to this latter line of analysis,

health economics cannot be defined by economists alone. Rather, as an applied

social science its definition and effective realization have to be accornplishedin diverse practical settings through collaboration between economists and

health care practitioners. Such collaboration will tend to militate against theproduction of asymmetric definitions. Practical definitions of health economicstreat practit ioners not simply as sources of problems to be solved by the

application of scientific knowledge, but as themselves sources of knowledge

who are fully capable of engaging in analysis of their own choices and actions.

Collaborative Analysis in Social Science

The preceding discussion reveals that in health care and perhaps in othercontexts in which social science is 'applied,' practitioners are necessarilyinvolved in defining the scope of the science. It also shows, however, that therelationship between the supposed knowledge-producers and the recipients of

that knowledge can be conceived in radically di{Ierent ways within the samearea of social practice. Whereas the disciplinary view treats practitioners asthe source of practical problems to be solved or allayed by the application of

social science expertise, the alternative account treats practitioners as activelyinvolved with analysts in the joint creation/ application of practical knowledge.These two views seem to imply significantly difl'erent conceptions of appliedsocial science. On the one hand, the application of social science is a form of

beneficent cultural domination of practitioners by analysts. On the other hand,

it takes the form of a collaborative dialogue.Which of these positions one adopts may well depend in part on one's social

location. For instance, those advocating a relatively collaborative stance in PartJ'wo tended to speak on behalf of health economists directly involved withhealth care practit ioners (paras. l l , 12. i5, l8). However. it may also depend,in part, on one's view of the social production of social science. Our view isthat social scientif ic knowledge in general, whether 'pure' or 'applied,' is, in

all cases. the product of collaboration between analysts and participants. Thisis why we have tried to become participants in order to carry out our analysisand why we have invited participants into our text to help with the analysis.

One major rea^son why the contributions made by participants to socialscientific analysis are not widely recognized is that the conventional textuaiforms of social science, including those of economics, hide them from sightby the use of an impersonal 'scientific' style. Such forms provide a textualwarrant enabling analysts to insist on the analytical primacy o1'their disciplineand to advocate the cultural dominion of that discipline in appropriate practicalmatters; including, especially, the right to define just which matters creappropriate (Strong 1979; Shepard and Hamlin 1986). In the present text, incontrast, we have chosen to include participants as active contributors to our

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50 MALCOLM ASHMORE, MICHAEL MULKAY. TREVOR PINCFI, and HESG

analysis. Our aim is to move towards textual forms which more properlyrepresent the social production of social science and which prepare the wayfor an applied social science that generates, not cultural domination of oursubjects of study, but a fruitful collaboration with them in the production anduse of knowledge. Thus we offer this text to health economists, and to othersocial scientists, as a preliminary, and undoubtedly crude, example of ananalysis produced jointly by analyst-participants and by participant-analystswhich may be of benefit, in as yet unspecified ways, to both parties.

An Appendix by HESG: Some Critical Last Words2a

"Thus we offer this text to health economists . . . "; well, we are sure thatwe and our colleagues are most grateful. However, as official authors of thispaper we claim the right to do more than simply accept the completed text.In fact we feel justified, in the spirit of "fruitful collaboration," to extend ourcontribution beyond the somewhat passive role of heavily edited and analyzed"participant-analysts" which Dr. Ashmore, Professor Mulkay and Dr. Pinchhave been kind enough to write for us. Thus, these'Last Words'are addressednot only to the reader but also to our fellow authors. Our critical remarks willendeavor to show how both their advocacy of"collaborative analysis in appliedsocial science" and their proclaimed attempt to produce a reflexive text, maybenefit from a constructive critique of some of the ways in which this text fallsshort of these goals.

The first and most obvious shortcoming is that the right of analysis is almostentirely reserved for the sociological contributors. We, the health economists,only achieve the status of "participant-analysts" by fiat: We were neverconsulted; our textual collaboration wzrs never asked for; and we are not atall certain that we wish to be protosociologists. Moreover, although Ashmore,Mulkay, and Pinch claim to be "analyst-participants," their degree ofparticipation in our concerns seems to be minimal: They certainly do noeconomics! In short, it would appear that the sociological authors are engagingin some "definitional work" of their own; as analysts they are "claiming theright of selfdefinition;" and as sociologisrr they are invoking a "disciplinaryline of analysis."

'Ihis last point is linked to the authors' stated objective of producing a

reflexive text. Although as economists our interest in and knowledge ofreflexive issues is minimal, it does seem to us that such an objective at leastentails that the 'analyzing discourse'-here, sociology of science-should betreated symmetrically with the 'analyzed discourse'-in this case, healtheconomics. Thus, in Part Three, when Ashmore, Mulkay, and Pinch clearlysuggest that the "practical" mode of definitional work is superior to the"disciplinary," surely one has a right to expect that they themselves shoulddemonstrate their allegiance to the practical mode in their own relations with

Definihonal Work in Applied Social Scimce

health economists. And yet it seems clear that our sociologists'relationshipwith us is not like the kind of relationship between health economist'consultants'and health care'customers'which is said to involve the practical,collaborative mode of definitional work. Our relationship with our fellowauthors is not of this kind: We have not consulted them; we are not customersfor their research; and we have no problems which they are able to help ussolve. Indeed, our relationship with these sociologists seems better placed intheir "disciplinary" category, in which the analyzed (for us, health carepractitioners; for them, health economists) are treated merely as the sourceof data or problems, which the analyst utilizes for purposes internal to, in theone case, economics and in the other, sociology.

A similar criticism of our fellow authors'reflexive ambitions concerns theiruse of the label: "applied social science." Presumably this is supposed todescribe not only health economics but also this sample of sociology of science.Unfortunately, we find it hard to identify the relevant context of applicationfor this present work; unless, heaven forbid, it is science policy!

Another indication of the lack of genuine collaboration is evident from theselectivity of Part Three's analysis of Part Two. Here, no attention whatsoeveris given to any of the author's ('Michael's) comments (paras. 14, 13,24). ltappears to us that if collaborative analysis is to be more than just an emptyc la im, 'analyst -par t ic ipants ' and'par t ic ipant-analysts ' must be t reatedsymmetrically. This requires that the discourse of each party be equallyavailable for analysis just as much as it requires 'equal time' for both to dcranalysis. One example of the analytical uncertainty caused by our sociologists'asymmetric attention concerns the issue of the fruitfulness of analyzingintroductory texts. Although in Part One the authors concentrate their analysisentirely on this kind of text, their failure in Part Three even to mention'Michael's' introductory text (Part Two: paras. 14) suggests that they areequivocal on this point, especially given their lack of any reply to our member'sspecific criticism (Part Two: para.22).

Finally, we would like to comment on a related aspect of Ashmore, Mulkay,and Pinch's selective approach to collaborative analysis, namely their generallack of any serious engagement with our members' attempts to question,criticize, or even comment upon their own project. While there may well beadequate contingent reasons for this lack of engagement in Part Two(concerning both the temporal conditions of the session itself as well as thespatial restrictions on the length of this paper which necessitated some heavycutting of the transcript), no considerations of this kind apply to the analysisin Part Three. We suggest that this absence denies those "health economists,and . . . other social scientists" who have been offered this text any adequateexplanation of its formal structure (why did it remind 'Peter' (para. 5) of theworks of Tom Stoppard?); any exploration of the kind of authority claimedby, or attributed to, sociology of science (why did 'William'(para, 25) take

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52 MALCOLM ASHMORE, MICFIAEL MULKAY, TREVOR PINCH, and HESG

'Michael's'comment about radio-astronomy (para.24) as a denigration of thescientific status of economics?); and most important of all, any answer to thebasic methodological question of a collaborative sociology of knowledge asasked by 'Dave' in paragraph 2-1 (". . . how do sociologists of science get overthis problem that they are not practit ioners of the science which they arestudying?").

ACKNOWLEDGMENTS

This research is funded (grant number 433250004) by the UK ESRC as a part of itsinit iat ive on Science Studies and Science Policy. We would l ike to thank the membersof HESG lor their cooperation and support, nrost especial ly John Hutton, Peter West,and Alan Wil l iams. We would also l ike to thank Tonv Culver lbr extensive commentson the first version ol Part One.

NOTES

l . [n the sense used by C-ul l is and West in their anecdote ol the Vice Chancel lor of a newunivers i ty , who. feel ing that the inst i tut ion lacked t radi t ions. announced that " f rom tomorrowmorning it will be traditional to . . . " (Cullis and West 1979, p. 2l).

2. We were struck by the cvident lack of knowledge of cach other's wurk displayed by alllbur authors, regular 'calls' for an interdisciplinary clfort in the study of the heallh fieldnotwithstanding.

3. Such as the introductory chapters of these monographs: Cullis and West ( 1979), Culyer(1976). Fuchs (1974), Klarman 11965), . lacobs ( l9t t0) , and Rapoport et a l . (1982); and theintroductions to thcse readers: (iooper and Culyer ( 1973). and Lee ( 1979). and these articles: Fuchs(1966), Mooney and Drummond (19821 l9t l l ) , Mushkin (195u. 1964), Wi l l iams (1977). and Yuleand Mooney (19841 1985); as wel l as these: Abel-Smith (1980), Culyer ( l9t t l ) , Engleman ( l9t i0) .Glass ( | 979), Ci root 1 I 980), and l-ee and M ills ( | 979). The last group of texts are less clearly designedas ' in t roduct tons' than the others arc. in that thev seem to be addressed to audiences ol ' ' fe l lowheal th economists ' rather than thc var ious calegor ies of 'outs iders ' that the others c la im to beaddressing. However. s ince their common topic is 'heal th economics ' i tsel l . thev share certa incharacteristics 01'these introductorv te.{ts such as thc regular appearance of (sclt-) dejinitions.

4. l'here is no example here of the 'principled absent' type of definition because we havebeen unablcr to t ind one on'heal th economics ' in the texts we have examined. However. th isdet in i t ional type is important in our analysis of def in i t ions of 'heal th, ' below.

5. For a wide-ranging discussion of reflexive problems rn social science, see Ashmore ( 1989).6. See note 3. Our corpus covers a large range of the relevant literature in both chrorrological

(1958-1985) and geographical (Amcncan, Br i t ish, and European) terms.7. Though see note J lor a caveat.8. I'his rather gross procedure of allying a particular text with a particular audience is clearly

higlrly contestible. Indeed, in the analysis below a subtler notion of'audience' (as a textualconstruct) is deployed. Nevertheless, fbr this preliminary exercise, each text was assigned aparticular audience on the basis of either explicit authorial declaration "This book has beenwritten lbr all those who are concerned with, or about, the NHS" (Culyer 1976, p. vii) or, inthe absence of such explicitness, various relevant textual clues such as the series (or the journal)

in which the book (or the article) appears and the use of certain pronominal formulations likethe f i rs t person plural in Culyer (1981) and l lngleman (1980), or some combinat ion of rhese.

Definitional Work in Applied Social Scimce

9. Thus this work is in the tradition, not only of the sociology of knowledge generally, but

of that 'tradition' see Note I variously known as 'the sociology of reading(s)', 'textsociology'

and/ or'discourse analysis.'For some of your authors'other work in this area, see Ashmore ( 1989);

Pinch and Collins (1984); Gilbert and Mulkay (1984); Mulkay (1985).

10. This includes the partll: positive, that is, type F: combined positive/negative.

I l. See Mooney and Drummond (1982, p. 949) and Rapoport et al. (1982, p. 2).

12. The logically connected as well as the consensual nature of these definitions is given a

historical gloss by Rapoport et al.:

Over the years many dehnitions of'economics' have been offered. Today, all economists

stress the fact of scarcity of productive resources [and therefore that] choices in the use

of scarce resources must be made (Rapoport et al. 1982).

13. At leest , one etssumes, to the audiences of 'educated publ ics 'and/or 'concerned

professionals'at which these texts are aimed.

14 . SeeFuchs (1966 ,p . 144 ) ;W i l l i ams (1977 ,p .302 ) ;MooneyandDrummond (1982 ,p . 1263 ) .

Mooney and Drummond (1982) it will be noticed, is the only text in the corpus to include both

"What is . . .?" headings. The differential prominence accorded to each heading is quite striking:

"What is economics?" is the title of the first article io the series of six which make up'Essentials

of Health Economics.' As such it covers four pages and two separate publication dates. "What

is health?" on the other hand, heads a small one paragraph subsection in Part (article) III. We

examine this series of articles in detail in our analysis of the dilemmas of social science application

(Mulkay, Pinch, and Ashmore 1987).

1 5 .

'Health'is part of an individual's capital, and everyone inherits an initial stock, which

depreciates over time, and at an increasing rate in later life (Williams 1977, p. 305).

Williams claims that this delinition arises liom "an analogy with physical capitai, which is at the

root of 'human capital theory"' (1977 , p. 305). ln this higly signilicant isolated case, 'health' is

defined by direct translation from the economics discourse of'capital' and 'investment,' and of'stocks'and 'flows.'Thus, the'problem'of health-a-s{efined-by-others, which is dealt with shortly,

is solved by bypassing others'delinitions altogether and reformulating the object entirely within

a theoretical and disciplinary-specific discourse.

16. Where'ill-health'is the negative term.

17. For the exception, see the quote from Rapoport et al. (1982) in Note 12.

I8. The relation between 'definition'and 'measurement'is obviously in need of examination.

[Jnfortunately, this cannot be pursued in this introductory text.

19. For discussions of the use of irony in sociological discourse, see Wright (1978): Woolgar

(1983); Brown (1977, 1983); and Anderson and Sharrock (1983).

20. The occasion was the introduction (to a conference of health economists) of the theme--

Health, Economics, and Health Economics of that conference. Culyer ( 198 I, p. 3) himself had

similar reservations about making points "that some of you may think self-evident."

21. 'l 'his

is, of course, essentially an insider's.iudgement. There are ways of treating 'health

economics'as a topic!

22. As we mentioned in the Introduction, this section consists of an edited version ol the

transcript of the authors'introduction, the discussant's presentation and the ensuing discussion

by members of HESG of an earlier draft of 'What Health Economics Is.' In editing this material,

we have tried to preserve the 'flavor'of the occasion as much as possible, despite the reduction

of the transcript to less than one-third of its original length. In addition to this extensive cutting.

we have altered the order of some of the discussion sections in order to enhance the topical

coherence of the talk at various points. However. we have not tamDered with the order of the

53

54 MALCOLM ASHMORE, MICFIAEL MULKAY, TREVOR PINCH, and HESG

talk within any one turn. The points at which major changes to the transcript occur are markedin the text by four dots, thus: . . . .

Such a liberal editorial practice involves certain dangers. For instance, it could permit theaccusation that we have selected the material illegitimately in order to support our analysis inPart Three. You will have to take our assertion that we have not done this on trust. Our methodof guarding against such a possibility was for one of us to edit the material before any analysiswas carried out and for another to do the initial analysis.

It has been suggested that Part Two is a difficult text to read 'in the right way.' We argue in PartThree that this difficulty seems due to its double status as talk which is both subject to analysis anda species of analysis itself. We recommend that it is read with this double nature very much in mind.

23. This dichotomy bears some comparison with the other pairs of interpretative contrasts wehave found analytically useful, namely the empiricist and contingent accounting systems (Gilbert

and Mulkay 1984) and, from another part of our current research, the strong and the weak programsfor health economics (Ashmore, Mulkay, and Pinch 1987). Clearly, this contrast between'disciplinary'and 'practical'modes of definitional work is linked to the distinctions drawn in PartOne between 'discipline' and 'topic' on the one hand, and 'economics'and 'health' on the other.

24. This Appendix is written by Ashmore, Mulkay, and Pinch. It is thus a piece of fiction.This statement, however, should not reduce its epistemological status in comparison to the restof the text; or to 'nonfiction' generally. For advocacy of fiction as social science, see Kreiger ( | 984).For some of your authors'other attempts, see Ashmore (1989), Mulkay (1985), and Pinch andPinch (1988).

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