Healthcare Policy
Commentary: Risk and Causality: The Contribution of Policy Researchers to Public Decisions
Introduction
In his introduction to the translation into French of Max Weber's famous conferences on science and politics, Raymond Aron makes the insightful suggestion that public decisions must start with two distinct conjectures (Aron 1963: 11). One concerns the risks arising from policy action, or inaction, in a situation or context that is always unique and peculiar, and the other, the uncertainty attached to the results of the action. Greatly simplified, because a decision is rarely made by only one person, outside an institution and the constraints that follow, a decision maker's first order of business is to consider the many consequences that may stem from intervening (or not) to change a situation or solve a problem (Tong 1987). In parallel, the decision maker will want evidence that the measures that are considered can succeed, based on experience or by default, on some plausible “theory” of social action (Edenhofer and Kowarsch 2019).
Encounters
The paper by Paprica, Wodchis and McGrail (Paprica et al. 2025) focuses on the sort of encounters between researchers and decision makers in which policy action is considered and decided. The scenario of the virtual experiment that is reported is plausible. Most of the interactions depicted in the story are, in effect, centred around the second of the two conjectures postulated by Aron – the arguments used to promote the (fictional) researcher's intervention are based on an explicit causal model, which emphasizes dimensions such as experience, impact and predictability. Aron's first conjecture, the one associated with the appreciation of risks and consequences, is also referred to more briefly in part 4 of the scenario, in which we are made to understand that the senior decision maker (a fictional deputy minister) had to arbitrate between two possible yet exclusive programs, aimed at distinct health issues. The main features of the story are coherent with the notion that intense policy activity took place upstream, and that the decision framework is largely settled at the time of the exchanges. Such meetings happen all the time, with a few significant variations but, quite evidently, many inflections, depending on the topic and the number and level of players.
The encounters that are described in the paper are mostly working meetings with mid-level bureaucrats. It is a fact that encounters between experts and senior decision makers (those with the actual responsibility to do something about something and facing consequences in case of failure) are sparse and fewer, despite sincere efforts on the part of both groups. The reasons for this situation are well known: busy schedules, social and geographical distance, diverging time horizons, differences in language and, of course, as underlined by our authors, dissonant political and ideological agendas.
To be honest, however, tangible benefits to participants are probably somewhat limited, aside from some symbolic outcomes consequential to the aura that emanates from esoteric scientific activities (quantum computing someone?) or reciprocally, from political activities shrouded in secrecy. It is unusual for individuals from the wider research community to be associated with core policy tasks such as the weighting of risks conducted by political or bureaucratic leaders, with its many nuances and aspects. This would require a panoramic vision of social and economic factors that is often lacking in subject specialists. Moreover, as John W. Kingdon showed a long time ago, political systems tend to segregate “problem” and “solution” experts, which complicates their involvement in conversations regarding probable causes and possible solutions to public issues (Kingdon 2011). To put things differently, and as we see in the paper, researchers' engagement usually comes late in the policy process and happens mostly when decisions have passed the framing stage on elements such as aims, means and resources.
A Case of Severance
One issue with the paper, however, is that it is written primarily from the perspective of the expert, with her or his interest in mind. Involvement must be a precursor to influence. Advice is a prelude to action. Decision is a synonym of validation. In fact, what truly bothers Paprica and her colleagues is the interference of advocacy in these processes, which, otherwise, our authors seem to approve and support (Paprica et al. 2025). Their goal is to have more decisions based on (or informed by) sound research and valid results, and therefore, more fruitful interactions between academic experts and political or bureaucratic actors. They would like open exchanges to happen and are convinced that ideology and hidden agendas constitute a major obstacle to most kinds of productive outcomes. Those researchers who only seek specific policy decisions from governments, leading decision makers to dismiss their advice beforehand, put the full system at risk (Doremus 2006).
At first, following Roger Pielke Jr. (2007) and his large cohort of epigones, who use the term and concept of “honest broker” as if advocacy were just a moral issue that could be resolved with a behaviour change, the paper takes a normative perspective. Similar to the characters in the series Severance, waiting for their personal and professional memories to be surgically divided, researchers are expected to leave their convictions at the door and to adopt (or fake?) a posture of objectivity and neutrality for the duration of their interaction with decision makers. Fortunately, in their conclusion, the authors abandon this absurd position and present a solution based on a broader combination of institutional and functional criteria, which may improve the situation.
A Thought Experiment
If only as a thought experiment, imagine now what the scenario presented in the paper looks like from the perspective of those in charge of the decision. As we suggested previously, the three or four substantive interactions between the researchers and the bureaucrats that are described in the scenario are only a small portion of the policy process. An assessment of government priorities from multiple angles was surely conducted already, and the allocation of marginal dollars to a new health program ought to be the product of a complex appreciation of social, economic and political risks. It is highly probable that these two processes were informed by factors such as public opinion polling, platform commitments, lobbies and policy campaigns, without mentioning fiscal constraints and election cycles. Political advisors have been whispering in the minister's ear. Think tanks of all sorts have made proposals. In this real world, it would then be very unlikely that the choice between diabetes and childhood vaccination proposed in the scenario is the mere product of competing health researchers' representations. It is also very unlikely that ideology would play a large role in the final decision, positive or negative, as most filters have already played their part.
Morris Rosenberg had a distinguished career as a deputy minister with federal departments such as Justice, Health or Global Affairs. His advice to young policy staffers was simple but enlightening.1 The government dislikes hearing about problems without hearing about solutions at the same time – do not bring an issue forward before you have an idea about how to solve it. To build support for the initiative beyond the ranks of the converted, solutions must (also) come with quick results and not only promises of impact in the long term. Results must translate into tangible gains for our political masters, because in a democracy, their support is a necessary condition for action. Finally, though it was the most difficult to accept, some problems take care of themselves; prudence and patience are policy virtues.
There are few studies that look at the questions raised by Paprica and colleagues from the perspective of the Rosenbergs of the world. It is not a new problem. In 1646, in one of his letters to Princess Elisabeth of Bohemia, René Descartes stated that “the principal motives and actions of princes are often such particular circumstances that one can imagine them only if one is a prince oneself, or perhaps if one has been party to their secrets for a very long time” (Pellegrin and Raymond 2024: 227–46; Princess Elisabeth of Bohemia and Descartes 2007: 143). It is not so much that the world of decision makers is opaque than the fact that it would require a distinct anthropology to elucidate how public decisions are “constructed” – more or less along the lines of Latour and Woolgar (1986) in their famous study of laboratory strangeness. When working beside Morris Rosenberg, we did not have issues with the few advocates who had worked their way through the bureaucracy up to the deputy, but with willing contributors struggling with the decision making process and underwhelmed by our pedestrian questions and our objections.
To go back to Max Weber and his vision of the science and politics dyad, the policy world has room for advocates guided by an “ethic of ultimate ends” (Gerth and Mills 1946: 115 et. sq.). Most of them, however, will be politicians, dedicated lobbyists or professional “public intellectuals” such as columnists and influencers. The process leaves limited space for academic improvisers, who may or may not be perceived as the unwanted intruders portrayed in the paper but without much impact. All the other players are expected to follow the norms suggested by the “ethic of responsibility,” with its focus on perspective and consequences. If one wants to join the policy conversation, there is no need to worry so much about “transparency and (value) awareness.” It is essential, however, to be prepared to contribute to the definition of the problem, considering as many dimensions as possibly relevant in that context, and to provide options for solving it, with some probability of success.
Correspondence may be directed to Pierre-Gerlier Forest by e-mail at pierre-gerlier.forest@inspq.qc.ca.
Commentaire : Risque et causalité : l'apport des chercheurs aux décisions publiques
About the Author(s)
Pierre-Gerlier Forest, Phd, FCAHS, President and Chief Executive Officer, Institut national de santé publique du Québec, Québec City, QC
References
Aron, Raymond. 1963. Préface. In M. Weber, ed., Le Savant et le Politique (2nd ed.). UGE.
Doremus, H. 2006. Using Science in a Political World: The Importance of Transparency in Natural Resource Regulation. In W. Wagner and R. Steinzor, eds., Rescuing Science from Politics: Regulation and the Distortion of Scientific Research (pp. 143–64). Cambridge University Press.
Edenhofer, O. and M. Kowarsch. 2019. Pascal's Wager Reframed: Toward Trustworthy Climate Policy Assessments for Risk Societies. In N. Oreskes, ed., Why Trust Science? (pp. 191–201). Princeton University Press.
Gerth, H.H. and C.W. Mills. 1946. From Max Weber: Essays in Sociology. Oxford University Press.
Kingdon, J.W. 2011. Agendas, Alternatives and Public Policies (2nd ed.). Longman.
Latour, B. and S. Woolgar. 1986. Laboratory Life: The Construction of Scientific Facts (2nd ed.). Princeton University Press.
Paprica, P.A., W.P. Wodchis and K.M. McGrail. 2025. Advice or Advocacy – Varying Perceptions of Health Services and Policy Researcher Activities. Healthcare Policy 20(3): 27–34. doi:10.12927/hcpol.2025.27519.
Pellegrin, M.-F. and C. Raymond. 2024. Descartes Politique : Nouvelles considérations sur la pensée cartésienne. Classiques Garnier.
Pielke, R.A. Jr. 2007. The Honest Broker: Making Sense of Science in Policy and Politics. Cambridge University Press.
Princess Elisabeth of Bohemia and R. Descartes. 2007. The Correspondence Between Princess Elisabeth of Bohemia and René Descartes (Trans. Lisa Shapiro). University of Chicago Press.
Tong, R. 1987. Ethics and the Policy Analyst: The Problem of Responsibility. In F. Fisher and J. Forester, eds., Confronting Values in Policy Analysis: The Politics of Criteria. Sage.
Footnotes
1. What follows is a coarse attempt to synthesize many private discussions. Morris's thinking was (and still is) way more subtle and its expression, more elegant. I hope he will forgive me, as he had so often when I was learning the trade under his wing.
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