For those who believe in rationality, there is the disappointing message that chance, fate, and just plain politics lurk behind every decision. Only historians will know at what point they play a significant role. The cases also illustrate the fact that putting a “human face ” on a problem means it will probably be solved sooner, if not better. Several cases reveal that precedent setting makes people uncomfortable because they are reluctant to be held responsible for future decisions in which they have no part. Other cases demonstrate that, for some decision makers, making history is important—the positive side to setting precedents. Finally, and fortunately, the selected cases show us that, in general, people want to do the right thing.

Each case is a unique constellation of occurrences. They address issues of equity; strongly held ethical values; trustworthiness of actors, numbers, and techniques; authenticity of experiences; the influence of competition; the dilemma of setting precedents; and the challenge of effectiveness. They are about the search for legitimation and empowerment of the lay public. They illustrate our concern as a society for sufficiency of information and authority. Together the cases illustrate a spectrum of problem solving, ranging from coexistence to conflict to cooperation.


Although there are structural similarities among the six cases in this book, a reliable taxonomy of biomedical decision making failed to emerge from this exercise. This is not to say that one could not be developed. Rather, the case study method militates against a normative approach. A different approach to the study of decision making would be needed to develop a solid theoretical framework. While a rational approach to decision making was not the expected finding of this exercise, themes were anticipated to emerge. And they did. Across the six cases were the complexities of pluralism and democracy, the frustrations of incrementalism, the surprises of chance and fate, the danger of precedents, and the tension between politics and expertise.

Pluralism and Democracy

A significant social trend in this country over the past few decades has been an increase in direct participation by the public in social and organizational decisions. Simultaneously, the problems facing our nation seem to have grown in complexity and volatility. History and the development of social events such as the civil rights and women's movements have sensitized different groups and forever moved certain issues such as reproductive rights, environmental standards, and re-

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