Postmodernism, rationality and the evaluation of health care

This paper examines the logic of evaluation of health care services, calling into question the possibility of assessing the extent to which medicine and health care systems are ‘rational’ or ‘irrational’ The paper analyses and rejects claims to rationality made in discourses on evaluation and in particular economic evaluation, by recourse to Weber's distinction between formal and substantive rationalities. The rationality claimed by evaluation is a value-laden and therefore substantive rationality. Similarly, the claims of the rational actor model are seen to over-simplify the ways actors interact in the market. This leads to a postmodernist perspective rejecting the idea of a single rationality, which if it can only be grasped enables the achievement of Truth, and substituting the position of contingent and fragmentary discourse, brought into being to serve the interests of particular groups in determining knowledge and power. With regard to the evaluation of health services, whereas the modernist assumes that the Enlightenment metanarrative of rationality has imbued the provision and delivery of health care, and that the evaluation by another discipline within this metanarrative, for instance health economics, can fine-tune this rational system for efficacy and efficiency, and suggest changes, the postmodern position recognises that both are distinct discursive perspectives, constituted for local reasons. This position is then applied to a case study of the management of surgical services based on ethnographic work conducted by the author. Deconstruction of the ethnography derives an understanding of the disruption of surgery as being a consequence of the arrangements for clinical advice in the committee structure of management.