Economic rationality and health and lifestyle choices for people with diabetes
Introduction
Although the rationality principle is fundamental to economics, the familiar character of rational economic man—a maximising, consequentialist individual—has been frequently questioned by those in the profession (Hargreaves Heap, 1989; Hargreaves Heap, Hollis, Lyons, Sugden, & Weale, 1992; Renwick Monroe, 2001; Vanberg, 2004). Much of this critique has been either theoretical (Renwick Monroe, 2001; Zafirovski, 2000) or stemmed from experimental studies to determine whether individuals’ choices are consistent with an economic definition of rationality—usually the axiomatic definition represented by expected utility theory (EUT) (Schoemaker, 1982). Results commonly show such axiomatic models of rationality to be descriptively lacking with consistent violations of the underlying axioms (Schoemaker, 1982; Starmer, 2000; Sugden, 1991) (although some argue that they continue to have normative relevance (Baron, 1996)).The economist who truly believes in individual rationality is as much a fiction as homo economicus himself. (Krugman, 1998, p. 111)
Hargreaves Heap (1992) uses the term ‘instrumental rationality’ to distinguish this tradition of rationality in economics from two others he describes; procedural rationality and expressive rationality. Whilst acknowledging the importance of instrumental rationality, he argues that this represents an incomplete picture. Choices are not only about achieving the best possible outcome but are often influenced by a range of other factors such as social norms and institutions, short cuts and rules of thumb, values and internal conflict.
The research reported in this paper uses Q methodology to examine the relevance of this alternative framework of economic rationality to choices made in a health context. The setting for this study is the health and lifestyle choices of people with type 2 diabetes.
The remainder of this paper is organised in six main sections: the rationality framework is described first and is followed by an introduction to the main characteristics of type 2 diabetes. A summary of Q methodology is then provided before presenting the main body of the paper in terms of the research methods, findings and discussion.
Section snippets
The rationality framework
Hargreaves Heap (1989) questions the consistent and exclusive allegiance to a model of instrumental rationality in economics. He presents an alternative, tri-part picture of rationality, incorporating procedural and expressive forms, drawing on areas of economic theory and literature in order to illustrate his arguments. As such the concepts are not new ones, but he provides a structure for those concepts, identifies differentiating features and commonalities, and supplies a terminology to
The research context: Type 2 diabetes
Type 2 diabetes is a common and growing health problem (World Health Organisation, 2002) Current treatment of type 2 diabetes focuses on the self management of health and lifestyle (Diabetes UK, 2003). Typically, self management programmes comprise advice about diet, exercise, smoking and alcohol consumption together with blood glucose monitoring and possible medication, in order to control blood glucose levels and delay or prevent adverse events (e.g. blindness, renal failure or death).
Methods: Q methodology
Q methodology (Stephenson, 1953) combines qualitative and quantitative methods (Brown, 1996) in the study of ‘subjectivity’. It is appropriate to questions about personal experience (McKeown & Thomas, 1988) and matters of taste, values and beliefs (Stainton Rogers, 1995). Whilst there are several applications in the health field (Eccleston, Willams, & Stainton Rogers, 1997; Risdon, Eccleston, Crombez, & McCracken, 2003; Stainton Rogers, 1991) it is little known in health economics (Baker,
Findings: the factors
A three factor solution emerged4 and factor loadings are shown in Table 3. Of 27 Q sorts, there are three ‘null’ cases (i.e. Q sorts which do not load significantly on any of the three factors) and five confounded sorts (loading significantly on more than one factor).
In the three subsections which follow, each factor
Rationality and diabetes management
This rationality framework has not been applied before in the area of health, and the concepts within it have enabled a new understanding of different types of lifestyle choices and the factors which are important to those choices. The application of rationality in a health context is interesting because the narrow biomedical approach to health choices has much in common with an instrumental rationale; relating cause and prevention, disease and cure in an outcome-oriented manner. This is, of
Acknowledgments
This study was funded by the MRC Health Services Research Collaboration as part of a doctoral studentship. This paper was written while the author was funded through an ESRC postdoctoral fellowship (Ref.: PTA-027-26-0107). I am indebted to the respondents who gave up their time to participate in this study; to my Ph.D. supervisors, Senga Bond and Linda Davies; to session participants at the 20th annual meeting of the International Society for the Scientific Study of Subjectivity 2004; and to
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