A Pragmatist
Approach to
the Problem of
Knowledge in
Health Psychology
Journal of Health Psychology
Copyright © 2009 SAGE Publications
Los Angeles, London, New Delhi, Singapore
and Washington DC
www.sagepublications.com
Vol 14(6) 800–809
DOI: 10.1177/1359105309338974
FLO RA C O R N ISH
Glasgow Caledonian University, UK
A LEX GILLESPIE
University of Stirling, UK
Abstract
The multiplicity of forms of healthrelated knowledge, including
biomedical knowledge, lay knowledge
and critical constructionist knowledge,
raises challenges for health
researchers. On one hand, there is a
demand for a pluralist acceptance of
the variety of health-related
knowledge. On the other, the need to
improve health calls for action, and
thus for choices between opposing
forms of knowledge. The present
article proposes a pragmatist approach
to this epistemological problem.
According to pragmatism, knowledge
is a tool for action and as such it
should be evaluated according to
whether it serves our desired interests.
We identify implications for research
methodology and the choice of
research goals.
AC K N O W L E D G E M E N T S . Flora Cornish would like to acknowledge research
funding support from the DFID/ESRC joint scheme (RES-167–25–0193). Alex
Gillespie would like to acknowledge the support of an ESRC research grant.
(RES-000-22-2473)
COMPETING INTERESTS:
None declared.
Correspondence should be directed to:
School of Nursing, Midwifery & Community Health,
Glasgow Caledonian University, Cowcaddens Road, Glasgow, G4 0BA, UK.
[Tel. +44 (0)141 331 3029; Fax +44 (0)141 331 8109;
email: flora.cornish@gcal.ac.uk]
ADDRESS.
FLORA CORNISH,
800
Keywords
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epistemology
lay knowledge
medical knowledge
methodology
pragmatism
CORNISH & GILLESPIE: A PRAGMATIST APPROACH TO THE PROBLEM OF KNOWLEDGE
WORKING in the context of complex real-world health
problems, health psychologists encounter the challenge of a multiplicity of conflicting forms of knowledge. Take an example of working to prevent HIV
transmission in the context of commercial sex (e.g.
Campbell, 2003). Biomedical knowledge about risk
factors and transmission routes suggests promoting
condoms to sex workers. After some qualitative interviewing, it emerges that, according to local knowledge, condoms are for casual sexual relationships and
thus the absence of condoms in a regular relationship
signals closeness and trust. In this situation, emphasizing the medical risks of commercial sex may actually exacerbate the risks in the sexual relationships
with regular partners. Finally, after some critical
reflection, stimulated by theoretical knowledge of
‘victim blaming’ and stigmatization, a researcher
might question the ideological assumptions and
social effects of targeting the sex workers rather than
their clients. In this example we see three forms of
knowledge collide, each indicating a different intervention. How should health psychologists judge the
value of each form of knowledge?
The epistemological assumptions of health psychology research have traditionally been framed as
a choice between the realism of ‘mainstream’ health
psychology and constructionism, often associated
with ‘critical health psychology’ (e.g. Crossley,
2000a). Neither of these approaches has convincingly provided the right answer to health psychology’s epistemological questions (Marks, 2002). On
one hand, the immediacy of suffering and inequality
call for effective action and improved health outcomes, traditionally associated with a realist epistemology. On the other hand, health issues are replete
with political and moral dimensions and thus call for
nuanced constructionist critique (Yardley & Murray,
2003). Realism tends to prioritize a single form of
knowledge as ‘true’, thus being insensitive to alternative forms of knowledge, while the relativism associated with constructionism makes it difficult to give
definitive recommendations for effective action. Is it
possible for research to be pluralist about knowledge,
but at the same time non-relativist and promote positive social action?
In the interest of contributing to the ongoing
debate about the philosophy, scope, values and
methodologies of health psychology (Crossley,
2000a; Hepworth, 2006; Marks, 2002; Murray &
Campbell, 2003; Prilleltensky, 2003), this article
introduces a pragmatist philosophical perspective.
Pragmatism, we shall argue, avoids the problems
of realism and relativism and enables both critique
and action.
The problem of knowledge
in health research
Awareness of the plurality of knowledge is part of
the ‘postmodern condition’ (Lyotard, 1984), in which
‘Grand Narratives’ are no longer convincing. The juxtaposition, in the global age, of multiple contrasting
beliefs undermines our confidence that Science,
Religion or Philosophy holds the key to that which is
True or Good. Historical studies, such as Foucault’s
(1967) pioneering work on scientific discourses of
mental illness, have shown the power-laden effects of
highly contingent, yet so-called scientific, knowledge.
Developing this approach, constructionist researchers
have questioned the dominance of biomedical discourses (e.g. Crossley, 2000a), the governmentality of
health promotion policies and messages (e.g. Sykes,
Willig, & Marks, 2004) and the particular ways in
which research methods such as randomized controlled trials and systematic reviews construct knowledge (Moreira, 2007). Such questioning has been
complemented by alternative positive programmes
of research, including the development of qualitative
research methods (Camic, Rhodes, & Yardley,
2003a), and research interests in other knowledges,
such as community and service user perspectives
(Foster, 2007; Fryer & Fagan, 2003).
However, the constructionist perspective has
itself been subjected to critique (Hepworth, 2006;
Murray & Campbell, 2003). Two major charges are
of particular relevance here. First, a constructionist
position, which claims that all knowledge is constructed from a particular ideological, social or personal position, undermines claims that any one of
these constructions is definitively morally or epistemologically superior to another. Constructionism’s
critics argue that such relativism is not defensible
for a morally responsible science. It is argued that
local knowledge is sometimes simply wrong or
even oppressive (Prior, 2003). In refusing to adjudicate between ‘local truths’, critics argue, constructionism accepts oppressive or false beliefs, and
fosters individualism and fragmentation (Ratner,
2006). Second, constructionism is criticized for
neglecting social action and positive programmes
for intervention (Murray & Campbell, 2003).
Analysis of discourses plays a crucial critical role
in revealing the workings of power in society, but
such analyses rarely lead to specific implications for
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JOURNAL OF HEALTH PSYCHOLOGY 14(6)
health-enhancing action (though see Willig, 1999, for
an exception). The pressing challenge for critical
health psychology, according to Prilleltensky (2003,
p. 2), is ‘to offer alternative practices that go beyond
the status quo and its critique’.
Pragmatism, we shall suggest, takes us beyond
the realism–constructionism divide, providing a
productive approach to evaluating health-related
knowledge. Pragmatism acknowledges the plurality
of knowledges and provides for critical analysis, but,
by focusing on the purposes and consequences of
knowledge, allows for non-relativist positive social
action. We first outline the pragmatist perspective
and then turn to consider some of the consequences
of pragmatism for health research.
Pragmatism: knowledge as a tool
for action
Pragmatism originated over a century ago with the
American philosophers Charles Sanders Peirce,
William James, John Dewey and George Herbert
Mead. Unlike realism, pragmatism does not rest
upon ambitious claims about knowledge reflecting
an underlying reality. Unlike idealism, it rejects the
idea that the mind is the basis of knowledge, and
directly opposed to rationalism, it disagrees that
abstract rationality is the path to reliable knowledge.
For pragmatism, it is practical activity that is the
bedrock and the test of knowledge. Knowledge is
judged according to its consequences in action.
Recently there has been a surge of interest in pragmatism, in philosophy (Kloppenberg, 1996), social
theory (Baert, 2004), law (Posner, 2003), medical
ethics (Hester, 2003), education (Biesta, 2007) and
public administration (Shields, 2003), but as yet, it
has had little impact in psychology or in healthrelated research.
The pragmatist approach to the problem of knowledge is to change the question that we ask about
knowledge. Instead of asking ‘Does this knowledge
accurately reflect the underlying reality?’ the question becomes ‘Does this knowledge serve our purposes?’ (Rorty, 1999). The roots of this shift lie in
a critique of the Platonic idea of Truth. According to
Plato, beyond our flawed human perceptions, there
exists an almost heavenly and timeless realm of
‘ideal forms’ which comprise Truth. In Plato’s allegory of the cave, human perceptions are akin to mere
shadows on a wall, cast by the real ideal forms outside the cave. This Platonic conception of Truth was
carried forward by philosophers such as Descartes
802
(Gillespie, 2006), and underlies contemporary variants
of realism. Realism adheres to a correspondence theory of truth, maintaining that there is a reality ‘behind’
appearances, and that true knowledge is knowledge
which corresponds to that reality.
Pragmatism strongly rejects the correspondence
theory of truth. For pragmatists, knowledge is not
a representation of reality or a ‘mirror of nature’
(Rorty, 1981). Rather, it is a tool for action. Rather
than mirroring reality, knowledge mediates our
relation to the physical and social world. Pragmatists
argue that there is nothing extra to be gained by
positing a reality ‘behind’ appearances and worrying
about whether one’s statements represent that reality
(Rorty, 1999). Lay people and scientists alike construct knowledge in the context of action: knowledge
guides action and action feeds back into knowledge
construction. Thus, for pragmatists, the only sensible
yardstick by which to judge a piece of knowledge is
whether that knowledge is useful for a given interest.
A hammer is useful for striking nails just as knowledge of antibiotics is useful for dealing with bacterial infections, and knowledge about complementary
medicine is useful in cultivating a feeling of wellbeing. None of these tools can be said to ‘better
reflect an underlying reality’, rather, each tool serves
its particular purpose.
Rorty (1998, p. 48) captures the radical novelty
of the pragmatist approach when, in his characteristically provocative way, he states that our vocabularies and concepts ‘have no more of a representational
relation to an intrinsic nature of things than does the
anteater’s snout’. The anteater’s snout is an adaptation to its environment, which mediates between the
anteater’s desire for ants and the existence of ants in
hard to reach places. The ‘goodness’ of the snout
can be judged accordingly. Just as the anteater’s
snout is not a mirror of ants in hard-to-reach places,
human knowledge of horticulture and animal husbandry is not a mirror of plants and animals. It is a
purpose-driven mediator between the human desire
for food and the world as we find it. Its usefulness
is judged, not by whether it ‘mirrors’ reality, but by
whether it successfully enables humans to achieve
their various individual and collective interests.
Pragmatism’s focus on usefulness is sometimes
interpreted (and criticized) as narrow utilitarianism—a position that knowledge should serve very
practical purposes, or should enable the smooth
functioning of society. However, this is misleading.
While one might be able to reduce the anteater’s use
of a snout to reproduction, human interests are much
CORNISH & GILLESPIE: A PRAGMATIST APPROACH TO THE PROBLEM OF KNOWLEDGE
more varied, and may extend from disturbing the
smooth functioning of society to controlling nature,
from poetry to convincing consumers to purchase
cigarettes and, importantly, from individual interests
to collective interests. Indeed, it is the recognition
of the great variety of human interests which makes
pragmatism pluralistic (James, 1977 [1909]).
The rejection of reality behind appearance does
not leave pragmatism in a relativist quagmire. The
existence of activity—mundane here-and-now practical action—is undeniable. While correspondence
theories of truth prioritize reference to reality, considering activity and experience as imperfect reflections of this reality, pragmatism inverts this hierarchy,
placing human activity as primary, and considering
talk of reality ‘behind’ experience as speculative,
vague and untrustworthy. Thus, the criteria for judging good knowledge are in whether it works to solve
the problems of everyday action.
Pragmatism is pluralist (like constructionism), in
that it accepts the variety of competing interests and
forms of knowledge. Accordingly, it is also critical,
in that its focus on the interests served by knowledge
invite questioning of whose interests are being
served. However, it is non-relativist, in that knowledge can be evaluated by reference to its ability to
facilitate successful action. It is action-oriented, in
that everyday problems and actions are the primary
reality, and the test of our knowledge.
Thus far, we have outlined the epistemological
position of pragmatism regarding the nature of
knowledge. But the discussion has been abstract,
focusing on assumptions rather than consequences,
and hence not, in fact, pragmatist. We now turn to
putting pragmatism to its own test of having consequences for action, considering its consequences for
the choice of research methods, and the choice of
interests to pursue.
Choosing research methods:
hierarchy of evidence or diversity
of interests?
Health psychologists are engaged in a wide range of
knowledge-making practices, including randomized
controlled trials (RCTs), surveys, narrative analysis,
discourse analysis, action research and theoretical
work, among others. Researchers in these different
traditions argue over the relative merits of their
approaches, some arguing for the importance of prediction and control, while others argue for the value
of understanding meanings. Arguments between these
different approaches are implicitly predicated on the
non-pragmatist question: Which form of knowledge
making brings us closest to the ‘Truth’?
The dominant way to answer this question has
been to propose a ‘hierarchy of evidence’ to order
the different methods (e.g. Evans, 2003; Harris et al.,
2001). The ‘hierarchy of evidence’ tells us that
systematic reviews of RCTs are the most valuable
forms of evidence, followed by individual RCTs,
uncontrolled studies, cohort studies, descriptive and
case studies. This hierarchy prioritizes experimental,
quantitative methods, and de-legitimizes case studies or qualitative methods. The hierarchy has been
critiqued in critical health literature, on the basis
that RCTs fail to elucidate the processes through
which outcomes were produced (Clark, MacIntyre,
& Cruickshank, 2007; MacPhail & Campbell, 1999),
and are insensitive in instances of complex, multiplydetermined, socially-situated health issues (Clark
et al., 2007; van de Ven & Aggleton, 1999).
A pragmatist approach adds a helpful frame to
such critiques, arguing that there is no absolutely
‘best’ method, but each method is good at achieving
particular ends (Baert, 2004; Camic, Rhodes, &
Yardley, 2003b). To make a judgement about the
relative merits of the diverse knowledge-making
practices, a pragmatist would first ask: In relation
to which interests are we judging these practices?
RCTs are particularly suitable for determining
which of a limited number of interventions is most
effective at producing a pre-determined health outcome within a specific stable context. They answer
to scientific interests in comparing the effects of
different pharmacological treatments, or other clearly
defined interventions, and to health professionals’
interests in choosing between treatments. RCTs are
excellent means of achieving these particular ends,
but these are not the only ends that may be served by
health research. Indeed, to place RCTs at the top
of the hierarchy may be to prioritize certain interests,
and thus, an exercise of power, rather than a reflection
of an objective hierarchy among methods.
The expansion of ‘evidence-based’ approaches,
with their hierarchies of evidence, beyond medicine,
to the now popular notion of ‘evidence-based policy’
points to a key interest served by such hierarchies:
the interest of policymakers and managers in being
able to justify their decisions (Dobrow, Goel, &
Upshur, 2004). Claims about the evidence-base for
the allocation of scarce resources lend decisions the
rhetorical power of accountability, transparency and
fairness. Perhaps the usefulness of RCTs for making
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justifiable policy decisions is the reason for their
being placed at the top of the hierarchy.
This is not to suggest that research ought never to
serve such managerial interests. But it is to be more
specific about what interests RCTs serve. Presenting
RCTs as the ‘gold standard’ for research obstructs the
pursuit of alternative interests, and de-legitimizes
the best methods for meeting these alternative interests. We will consider three alternative interests:
knowledge for taking care of oneself; knowledge
for intervention design; and knowledge for cultural
critique.
Knowledge for taking care of oneself
Health education has been soundly criticized for
taking biomedically accurate information (such as
that provided by RCTs) and assuming that if lay
people are provided with this information, and think
rationally, they will act appropriately (e.g. Campbell,
2004a). From a pragmatist point of view, the key
issue is that biomedical knowledge is often not very
useful or actionable in relation to the needs of lay
people. In situations where people have been diagnosed with a chronic illness, meanings, as much as
facts, comprise useful knowledge (Crossley, 2000a;
Krause, 2003). An illness can change the meaning
of a person’s life, their relationships, their work
and their very self. In creating their health identities, lay people may draw on medical, non-medical
or even anti-medical knowledge (Fox & Ward, 2006).
Accordingly, service users have needs for knowledge
much broader than biomedical knowledge. While
RCTs provide service users with important information about appropriate medical treatments, they offer
few resources for the tasks of making sense of illness
and forging a new identity.
Even for relatively clearly defined objectives,
such as protecting sexual health, giving up smoking
or exercising, actionable knowledge often comes in
the form of strategies and skills, not medical facts
(Lyles et al., 2007). For example, role play may be
used to develop young people’s sexual negotiation
skills, so that they are equipped with interpersonal
skills and discursive strategies enabling them to
deal with situations where they feel under pressure
to have unprotected sex (Laub, Somera, Gowen, &
Diaz, 1999). At meetings of Alcoholics Anonymous,
people actively share strategies for avoiding alcohol
consumption (Makela et al., 1996). They suggest to
each other to avoid certain social situations, to avoid
certain friends and to make sure that wherever they
go, there are alternatives to alcohol. They also prac804
tise how to decline an offer of an alcoholic drink.
In both of these examples the type of knowledge
produced through RCTs takes a backseat, and instead
it is everyday knowledge and social skills that prove
to be most useful and enabling. The proliferation of
service user groups and survivor groups is testament
to the importance of such practical knowledge, and
one role for health research could be to support the
construction of such knowledge.
What methodologies would health researchers
employ to serve the practical interests of lay people
or service users? Such research might begin with
people’s experiences and perspectives. Analytic procedures such as grounded theory (Glaser & Strauss,
1967) and narrative analysis (Crossley, 2000b) can
help researchers to distil strategies, narratives and
heuristics which have proven useful. Strategies, narratives and heuristics are not true or false. They are
resources which can be offered because they have
worked for some people in the past. Alternatively,
action research may be used to create new strategies
or transform service provision to better reflect the
needs of users (Krause, 2003). RCTs, on the other
hand, are not designed to discover or promote skills
or strategies. This is not to say that RCTs are ‘wrong’
or oppressive, but that they answer to different
interests.
Knowledge for intervention design
Health intervention designers face challenges of
implementation. They have to work with the complex, real-world, everyday practicalities of individuals and communities, where familial, financial,
political, cultural and social dimensions are deeply
entwined with health behaviour and outcomes.
Programme success often depends, not only on the
evidence base of the intervention, but also upon skills
of ensuring acceptability to service users, commitment from healthcare workers, and support of
managers or powerful local stakeholders (Campbell,
2004b; Cornish & Ghosh, 2007). RCTs may offer
some confidence that a chosen method has worked
in the past, but a new context will produce uncertainties, obstacles, exceptions and dilemmas that have
to be managed. We cannot expect to map out every
single condition that programme designers might
encounter, in an ever-changing social and historical
context, and create an exhaustive RCT-backed decision tree. Rather, what programme designers need
is generative, adaptive and flexible knowledge to
guide them through novel situations. Theories and
models can provide such flexible knowledge. Richly
CORNISH & GILLESPIE: A PRAGMATIST APPROACH TO THE PROBLEM OF KNOWLEDGE
detailed case studies can support the development of
context-sensitive expertise and skilled decision
making (Flyvbjerg, 2001).
One example of useful knowledge for furthering
the interests of practitioners of community mobilization is Paulo Freire’s (1970) theory of conscientization. The ‘truth’ of this theory has never been
tested by an RCT, and is not amenable to such a test.
As a complex social intervention, conscientization
is not equivalent to a ‘treatment’ to be evaluated.
The theory provides a general orientation to working with communities that can be interpreted, to fit
with the local context, and its utility has been confirmed by its successful usage in a great variety of
settings around the world. A good model can work
in a similar fashion, and Alcoholics Anonymous
again provides an example, whose success has been
facilitated by clear, user-friendly guidelines for the
establishment and running of new groups, provided
in the ‘Twelve Traditions’, and ‘Twelve Steps’,
detailed in The big book (Alcoholics Anonymous,
2007). For those who implement interventions, theories, models and guidelines encapsulate practical
experience and facilitate the design and modification
of projects. Such practical and theoretical knowledge
cannot simply be placed at a low level on a onedimensional hierarchy of evidence.
Knowledge for cultural critique
Finally, research may serve a broader cultural interest of stimulating new interests. Considering knowledge as constitutive of our problems and possibilities
(rather than as a ‘mirror of nature’), a pragmatist
perspective values research activity which creates
new ways of thinking and acting and thus creating
a richer future (Rorty, 1999). As Biesta (2007)
explains, in his pragmatist critique of demands for
‘evidence-based practice’ in education, RCTs are
investigations of alternative means to pre-defined
ends, but they do not problematize the chosen ends,
or envisage new possible ends to pursue.
For health research, the ends are usually defined
in terms of health outcomes, but increasing recognition is being given to competing ends, such as
equality, dignity, tradition, quality of life and ethical
principles. Biesta (2007) gives the example of feminist theory, which has created new awareness of
gender and opened up new important issues and
problems, for educators and healthcare workers (e.g.
Wilkinson & Kitzinger, 1994). Likewise, research
on health inequalities (Wilkinson, 1996) highlights
an interest in ensuring that the impact of health
programmes is evenly distributed through the
diverse groups in society. Feminism and the ideal of
equity in health cannot be subjected to RCTs.
Rather, these are guiding theoretical ideas which
give expression to societal values.
What sorts of methods produce ideas for ‘what
might be’ rather than ‘what is’? Comparative methods, such as Foucault’s genealogical method (e.g.
Foucault, 1967), help to problematize current
assumptions. The value of such work, it has been
argued, is not so much its accurate portrayal of other
cultures or other times, but its creation of a new
point for reflection upon the present (Baert, 2003),
enabling critique of the present and suggesting future
possibilities. For the work of developing new theories or lines of inquiry, Feyerabend (1973) suggests
that methodological proceduralism may be less useful than imagination. Democracy, the welfare state
and universal healthcare were ideas explored through
literature and fictive utopias before they were instituted in reality.
Our argument that there are multiple interests
that may be served by health research leads us to
reject the idea of an absolute hierarchy of evidence.
Since there is no objective way of ordering our different interests into an eternal hierarchy, no method
is intrinsically better than another, though methods
may be better than others in relation to particular
interests. If supporting service users’ practical
needs, or aiding intervention designers, or imagining alternative societal arrangements were prioritized, then theory-building or insightful qualitative
analyses might be considered the ‘gold standard’,
and RCTs a technical necessity, useful for deciding
between comparable alternatives, but silent on the
major questions. Although pluralist, pragmatism is
not epistemologically relativist, since knowledge
can always be evaluated in terms of whether it succeeds in serving a specific interest or not.
Choosing interests: useful for
which end?
Emphasizing the diversity of interests may help to
clarify the usefulness of different methods for different ends, but pragmatism, as described thus far,
does not determine which of these many interests
our research should advance. An individual interest
might be at odds with a collective interest, as when
a public health measure such as a ban on smoking
in public places interferes with an individual’s
choice to smoke. Or an interest in fund-raising to
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provide better services for disabled children, and
thus portraying the children as needy, may be at
odds with an interest in de-stigmatizing disability. If
Truth is not the objective of our knowledge making,
how are we to know which interest our research
should advance? Rather than identifying the content
of the interests to pursue, what we need are means of
collectively deciding between the variety of interests
at stake. We will suggest three means that health
researchers might use to inform their choice of interests to pursue.
Tackle problems defined by people’s
experience
The first suggestion is that we should take our direction from concrete problems in society. Pragmatism
gives priority to people’s everyday experience. As
Rorty (1999, p. xxii) writes, for pragmatists, human
inquiry is ‘an attempt to serve transitory purposes
and solve transitory problems.’ If somebody experiences a problem, we need have no doubt that this is
a real problem. We do not need big ultimate Truths
in order to know what is valuable to pursue, we
just need to listen to people’s problems of living,
and valid lines of inquiry will open up (Glaser &
Strauss, 1967). This approach is well established in
approaches such as Participatory Action Research
and Community Psychology, which pay careful
attention to the perspectives and priorities of local
people, and seek to address them. For example,
Fryer and Fagan (2003), in their work with members of a community with high levels of unemployment, poverty and psychological distress, were
guided by unemployed people’s reports that their
core problems were financial, rather than being
guided by abstract academic hypotheses about psychological impacts of unemployment. Consequently,
their research and action worked to address the
community’s financial problems and access to benefits. Taking people’s problems as the starting point
is not a soft option for a researcher. Their work faces
the most stringent pragmatist criterion: whether it
makes a difference to those problems in practice.
Choose problems through public
deliberation
The second means for choosing problems relies
on democratic debate. Although Rorty (1999) is
adamant that pragmatism does not lead necessarily
to any particular definition of the good, and can as
easily be put to dictatorial as to democratic ends, it is
notable that most pragmatist philosophers (including
806
Dewey, Mead and Rorty himself) are inclined towards
democracy, liberalism, diversity and tolerance. This
is surely related to the anti-foundationalism of pragmatism. As Miller (2004, p. 248) puts it: ‘pragmatists think that democracy is special in that it is the
only belief that does not rest upon the idea that life
must be subjected to some universal standard or
preemptory authority that takes priority over every
lived moment’. Even if all of our knowledge is perspectival and not absolute, shaped for humans in
their diversity, we still have to live together and to
forge collective actions. Inclusive public deliberation is the best means we have developed for identifying collective problems and planning collective
action (Habermas, 1989; Rorty, 1999). Increasing
attention to the participation of service users in health
service decision-making gives greater opportunities
for public deliberation over appropriate action.
Many health-related decisions call for public
deliberation, such as questions about the appropriateness of stem cell research, or equality in the provision of health services, or genetic testing (Gaskell,
2004). No scientist or philosopher can provide a
‘correct’ answer to these issues. Health outcomes
may compete with other ends such as equality, dignity or tradition. For instance, we might know that
reducing contact with tuberculosis patients limits
the spread of the infection, but this fact cannot
determine whether closing international borders to
people with TB is acceptable. Mediating between
these contrasting frames for what is good is an
activity for public deliberation. Likewise, at a more
local level, participation of service users and communities in debate about health service provision
ensures that experiential, local problems are on the
agenda, and that locally appropriate solutions are
generated—rather than these being determined by a
single authority.
Critique the choice of interests
being served
The third suggestion concerns the on-going necessity for critique of the interests served by all knowledge. Supported by the discourse of ‘evidence-based
practice’ and ‘evidence-based policy’, scientific
knowledge is called upon as the basis for decisions
about priorities and allocation of resources (Biesta,
2007). Neo-liberal economic knowledge plays an
important role in society’s understanding of itself
(Nafstad, Blakar, Carlquist, Phelps, & RandHendriksen, 2007), including decision-making
about health services (Pollock, 2004). Each different
CORNISH & GILLESPIE: A PRAGMATIST APPROACH TO THE PROBLEM OF KNOWLEDGE
form of knowledge comes with assumptions about
the way society works, is produced by certain social
groups and advances certain interests at the expense
of others. From a pragmatist point of view, knowledge is never ‘disinterested’. For knowledge to be
worth pursuing, it will be in the interest of those who
are using that knowledge. Accordingly, it is essential
to question which interests are being addressed and
which disregarded or undermined.
A critical perspective in health is often associated
with an anti-biomedical stance. But the pragmatist
perspective reminds us that biomedical knowledge
serves the everyday interests of patients when it cures
an illness, relieves symptoms or helps a person to
avoid a serious medical condition. For certain health
issues, biomedical knowledge is extremely useful
knowledge, and faced with a serious medical condition, many patients and their families will prioritize
interests in physical well-being over other interests
such as equity, identity or meaning. Pragmatism does
not prioritize any of these interests at the outset, but
critically analyses which interests are served in a
particular situation by the application of a particular
kind of knowledge.
Conclusion
Our aim, in this article, has been to introduce a pragmatist way of conceptualizing and evaluating the
knowledge which health psychologists produce and
encounter. We began with the question of whether
research can be pluralist about knowledge, but at the
same time non-relativist and promote positive social
action. We have tried to show that a pragmatist
approach can have each of these three characteristics.
First, pragmatism is deeply pluralist, recognizing
the validity of a variety of interests, perspectives
and forms of knowledge. Being anti-essentialist and
anti-foundationalist, pragmatists are suspicious of
any effort to privilege a single point of view. As
we have argued, RCTs provide crucial information
about the relative efficacy of specific interventions.
This value in no way undermines the position that
ethnographic case studies provide rich understandings of the social dynamics of a community health
intervention, or that action research develops
sophisticated practical knowledge of social change
processes. The pragmatist position is that these methods are not in competition with each other, because
each serves a different purpose.
Second, pragmatism’s pluralism does not result
in epistemological or moral relativism. Viewing
knowledge as a tool that brings us into a more or
less satisfactory relation with the world, knowledge
can be evaluated for whether it works for us in relation to a particular goal or interest. Human interests, from a realist point of view, are considered to
taint knowledge, making it somehow less true. From
a pragmatist point of view, human interests are not
the enemy of productive inquiry but the key to making our inquiry productive and useful, providing the
criteria against which knowledge can be judged.
Making moral choices among these interests is a
social and political activity, which should include
critical assessment of the interests served.
Third, pragmatism is a thoroughly action-focused
perspective. Believing that the grounding for our
knowledge is in concrete human activity, pragmatists do not accept solely intellectual arguments
about concepts dissociated from their practical base.
If the ideas are worth having and worth discussing,
pragmatists argue, they must make a concrete difference for action (Peirce, 1878). The most stringent test of ideas is whether they work in practice,
and so pragmatist health research would prioritize
the creation and evaluation of workable and useful
intervention programmes.
These three characteristics demonstrate the distinctiveness of the pragmatist perspective for health
research. The major contribution of pragmatism is
to bring some clarity to debates over method, by
suggesting that methods, and knowledge, should be
judged, not absolutely according to a ‘hierarchy of
evidence’, but according to how well they serve
specific interests. This brings the user of research—
whether academic, health professional, activist or
service user—to the fore in the evaluation of knowledge. Knowledge is to be evaluated according to
whether it has useful consequences for the user’s
desired action. The criterion of usefulness is then
tempered by the critical analysis of which interests
are being served by that action.
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Author biographies
is a lecturer in the School of
Nursing, Midwifery & Community Health at
Glasgow Caledonian University. Her research is in
community development, participation and
partnerships, with a particular focus on the
interactions between the diverse stakeholders in
health improvement programmes. She has a longstanding research engagement with sex worker led
HIV prevention programmes in India.
FLORA CORNISH
is a lecturer in Social Psychology
at the University of Stirling. His theoretical
interests stem from early American pragmatism
and his empirical research concerns dialogue,
intersubjectivity and identity. Recent publications
include a monograph entitled Becoming other:
From social interaction to self-reflection and a coedited volume entitled Trust & distrust:
Sociocultural perspectives.
ALEX GILLESPIE
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