Ebba Sjögren

The study takes its point of departure in a widespread notion that decisions should be based on the ‘facts of the matter’. Normative theories of organizational choice, in particular, encourage organizations to base decisions on facts. Many organizations also face explicit requirements to justify their decision-making with factual knowledge. But what if ‘the facts’ are ambiguous? How do organizations make justifiable decisions with ambiguous knowledge? A study of efforts on the part of the Swedish Pharmaceutical Benefits Board to decide whether prescription drugs are ‘reasonable’ to subsidize, suggests that organizations can employ various methods to remove ambiguity of knowledge. However, such attempts at achieving coherent knowledge on which to base decisions often fail. In these cases, though a decision can be made, the choice of one future action to the exclusion of others is delegated along with the unresolved ambiguity of knowledge. Thus, the study argues that rationalistic demands for ‘knowledgeable’ and ‘justifiable’ decision outcomes, when taken seriously, make it difficult to make choices. Such demands lead to more decisions and fewer choices, since the difficulty in achieving coherence between multiple knowledge claims will delegate the actual choices to practice. Knowledge-based decision-making could therefore tend to be conservative vis-à-vis the practices that it seeks to control. This has, for instance, implications for the possibility of using ‘evidence-based policy-making’ as a means of setting priorities in healthcare.