the problematic relationship between expert and lay knowledge

ARTICLE10.1177/1049732304273927QUALITATIVE HEALTH RESEARCH / July 2005McClean, Shaw / EXPERT AND LAY KNOWLEDGE

From Schism to Continuum?The Problematic Relationship BetweenExpert and Lay Knowledge—An ExploratoryConceptual Synthesis of Two Qualitative Studies

Stuart McCleanAlison Shaw

Ideas about lay and expert knowledge increasingly underscore debates within qualitativehealth research. In this article, the authors develop an exploratory synthesis of two qualita-tive studies in which they critique the lay-expert divide, suggesting instead a spectrum ofknowledge(s) about health and scientific issues. In the original studies, the researchers exam-ined food risks and alternative medicine, and they shared an interest in the lay-expert knowl-edge relationship. Reinterpreting each study in the light of the other led to greater conceptualdevelopment. Three mutual themes emerged and are presented with discussion of their con-tribution to wider theoretical debates. This worked example indicates that researchers canachieve valuable additional conceptual development through the cross-fertilization of ideasacross qualitative studies united not by common health topics but by shared conceptualconcerns.

Keywords: qualitative research; synthesis; risk; food; alternative medicine

What is the nature of the relationship between lay and expert knowledge? Thisquestion has increasingly underscored debates among qualitative social

science researchers in a range of health fields. Qualitative studies of lay knowledgeand experiences of health have been particularly abundant, for example, in thefields of genetics (Kerr, Cunningham-Burley, & Amos, 1998; Parsons & Atkinson,1992), heart disease (Davison, Davey-Smith, & Frankel, 1991), HIV/AIDS (Bloor,Barnard, Finlay, & McKegany, 1993; Rhodes & Cusick, 2002), and drug use and bodybuilding (Monaghan, 1999). In this article, we aim to offer some thoughts inresponse to the lay-expert knowledge question by developing an exploratory con-ceptual synthesis of two qualitative studies that we have undertaken, in which weexplored aspects of the lay-expert relationship in two substantive fields: publicunderstanding of food risks (A. Shaw, 2001) and alternative medicine practice(McClean, 2003b).

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AUTHORS’ NOTE: We thank the research participants who gave their time in the original studies andthe four anonymous reviewers for their helpful comments and suggestions on the first draft of thisarticle.

QUALITATIVE HEALTH RESEARCH, Vol. 15 No. 6, July 2005 729-749DOI: 10.1177/1049732304273927© 2005 Sage Publications

To achieve this, we identify some common thematic concerns across our respec-tive research areas, which, taken together, can be used to build a conceptual argu-ment that goes beyond the understanding of lay-expert knowledge offered by theindividual studies alone. The overarching argument we build from cross-fertilizingideas across our studies is that lay and expert knowledge cannot adequately be con-ceptualized as two distinctly different types of knowledge. We suggest that theboundary between lay and expert knowledge is not fixed and static but fluid andchanging. Rather than a schism, there is a continuum of different forms of knowl-edge(s), reflecting how individuals position themselves in relation to scientific/biomedical discourses.

APPROACHES TO THE SYNTHESIS OFQUALITATIVE RESEARCH

The exploratory conceptual synthesis we present is not a formal metaethnography(Noblit & Hare, 1988), metastudy, or metasynthesis (Paterson, Thorne, Canam, &Jillings, 2001), the language and methods of which are currently being debated anddeveloped within the qualitative health research literature. At present, there is con-siderable variety in qualitative researchers’ understandings of what it means tobring together or synthesize qualitative research. There has been some generalacceptance of Noblit and Hare’s (1988) typology of three ways to relate qualitativestudies to one another: reciprocal translation (similar studies are combined and pre-sented in terms of one another), refutational translation (studies are contrastedshowing how they refute each other), and line of argument (studies are takentogether to develop a line of argument that goes beyond that achieved in the indi-vidual studies). In a general sense, our conceptual synthesis follows the last of thesethree approaches.

However, significant debate continues regarding the appropriate terminol-ogy and the methods to use for synthesizing qualitative research. More fundamen-tally, some question whether it is even appropriate to attempt the task, given thediffering epistemological foundations of qualitative research compared with quan-titative research (within which the roots of meta-analysis lie) and the variety ofphilosophical perspectives within qualitative research. Examples of recent writ-ings on qualitative syntheses include Britten and colleagues (2002), Campbellet al. (2003), Finfgeld (2003), Kearney (2001), and McCormick, Rodney, and Varcoe(2003).

The position we adopt in this article is that the cross-fertilization of conceptualideas across qualitative studies can be conducted in a way that is consistent with aninterpretive paradigm. The reinterpretation and reshaping of knowledge that thisprocess produces has value for conceptual development in two ways. On one level,it allows us to see the bigger picture in terms of where our work is located withina wider theoretical context. In addition, it allows for greater depth, more subtlenuances, and new interrelationships between concepts to be identified, beyondthose developed in individual studies in isolation. As some qualitative researchershave argued (McCormick et al., 2003), the primary aim of qualitative synthesis isnot to lead us closer to some singular and/or objective “truth.” Rather, the processprovides the potential for more sophisticated constructions of substantive and con-

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ceptual issues, which can, in turn, contribute to theoretical, policy, and practicedevelopment in the health field.

In attempting qualitative synthesis, several researchers have drawn primarilyon other authors’ published studies (e.g., Britten et al., 2002; Campbell et al., 2003),whereas others have examined their own work (McCormick et al., 2003; Varcoe,Rodney, & McCormick, 2003). Our approach is aligned more with the latter.Whereas several previous qualitative syntheses seem to have been motivated by aconcern to produce more rounded and integrated knowledge in a specific healthfield (e.g., living with diabetes; Campbell et al., 2003), our synthesis was driven by acommon conceptual or theoretical concern regarding lay-expert knowledge thattranscended the substantive focus of the original studies.

We recognize the inevitable trade-off in depth versus breadth that the decisionto focus in depth on two of our own studies brings. Following Noblit and Hare’s(1988) concern, we want to avoid aiming for too great a breadth of studies, whichcould lead us to make gross (and potentially superficial) generalizations across sev-eral diverse health areas. Our chosen approach allows us to preserve the contextsand specificities of the original studies while making conceptual connections andtranslations across the studies where appropriate.

In the remainder of this article, we provide some background to the originalqualitative studies, sketch how we sought to translate our findings across the twostudies to produce a reinterpretation of common conceptual concerns, and presentkey shared conceptual themes illustrated by verbatim quotes from the originalstudies. We conclude with a discussion of how the conceptual line of argument wedevelop adds to our thinking about the lay-expert knowledge relationship withinthe health field.

THE ORIGINAL QUALITATIVE STUDIES:BACKGROUND, METHODS, FINDINGS,AND COMMON CONCEPTUAL LOCATION

To be explicit about the methodological assumptions of our individual studies, welocated both within an interpretive qualitative paradigm. More specifically, theywere underpinned by a “weak constructionist” position (Schwandt, 2000, p. 198), inwhich social “reality” is viewed as (at least in part) socially constructed, interpretedand negotiated by social actors through mediated understandings, social relation-ships, and interactions in specific social contexts. Through the use of qualitativemethods, we sought in both studies to explore in depth, from the perspective ofthose studied, the diverse ways in which people appreciate what constitutes knowl-edge and expertise in particular settings.

Food Risks Study

The first qualitative study was an interview study of public understandings of foodrisks (A. Shaw, 1999, 2001, 2002, 2003, 2004).1 This was located against a backdrop ofsocial and political debates about food risks in the United Kingdom since the 1980s,such as concerns about bovine spongiform encephalopathy (BSE) in beef and genet-ically modified (GM) foods. It was shaped by theoretical writings on what it means

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to live in a “risk society” (Beck, 1992; Lupton, 1999) and empirical studies of pub-lic understanding of science, health, and food issues (Caplan, Keane, Willets, &Williams, 1998; Grove-White, MacNaghten, Mayer, & Wynne, 1997; Lambert &Rose, 1996). These bodies of literature have common concerns with the nature ofexpertise in late-modern society and the place and value of lay knowledge. Thus,the study was underpinned by a conceptual interest in the relationship between layand expert knowledge and how this is played out in the field of food risks, in whichscientific and biomedical expertise has faced a stern critique from lay communities.In the study, we juxtaposed expert views with lay understandings of food risks toexamine critical issues in this relationship.

The study involved two phases: first, interviews with 17 U.K. food experts fromindustry, government, science, consumer/campaigning groups, and the media;and second, interviews with 32 laypeople from a range of social backgrounds withvarying perspectives on food (from the Bristol area in the southwest of England).These included women with young children from a community cooking club, mem-bers of an older persons’ lunch club, people from an organic food group and thelocal vegetarian society, members of a youth group, and farmers. Data were col-lected between 1998 and 1999. Shaw analyzed the interview data thematically,drawing on techniques derived from grounded theory approaches, in particular theuse of the constant comparative method (Strauss & Corbin, 1998).

In general terms, the interview data were interpreted through a conceptual lenswhich sought to examine how the specificities of public understandings of foodrisks reflected wider theoretical concerns about risk society and the lay-expertknowledge relationship. The findings indicated that laypeople have grown increas-ingly mistrustful of scientific authority on risk and “turn inward” to make highlyindividualized and reflexive judgments about risks from food. They increasinglycreate and rely on their own expertise, as risk is understood and experienced in spe-cific social contexts, and intuitive judgments are made about the extent to whichgeneral population-level statements about risk from scientific experts can be ap-plied to their personal situations. Lay expertise is created not only at an individuallevel but also at a group level, as alternative bodies of expertise develop (such asfood campaigning groups), which are seen as a more trustworthy authorities on riskthan “traditional” experts such as science and government. Furthermore, expertsmight critically self-evaluate their own knowledge and recognize the limits of theirexpertise. Taken together, these findings suggested a problematic boundary be-tween lay-expert knowledge.

Alternative Medicine Study

The second study was an ethnographic study of complementary and alternativemedicine (CAM), which involved an exploration of the practice of spiritual healersat a healing center in the north of England (McClean, 2003a, 2003b).2 The study wasset against the context of continued growth of a varied field of CAM in Western soci-eties (Astin, 1998; Cant & Sharma, 1999; Eisenberg et al., 1998; Kelner, Wellman,Pescosolido, & Saks, 2000; Wiles & Rosenberg, 2001; Zollman & Vickers, 1999). Inte-gral to this widespread growth of alternative health practices has been a prolifera-tion of New Age or spiritual healing activities in both the United States (Brown,


1997; English-Lueck, 1990; Frohock, 1992; Hess, 1993; McGuire, 1988) and theUnited Kingdom (Prince & Riches, 2000).

One key explanation for CAM’s increasing popularity is that it is due, in part, tothe decline of trust in medical expertise and represents dissatisfaction with scien-tific biomedicine (Bakx, 1991; Saks, 1995). Biomedical knowledge reflects a societythat valorizes specialized and systematized knowledge systems; indeed, doctorsbecome socialized into valuing expertise and the subsequent objectification of dis-ease (Good, 1994; Kleinman, 1980). Thus, biomedicine has traditionally neglectedthe personal meaning of illness for the patient (depersonalization), although thissituation is changing and there is increasing recognition within various biomedicalfields that patients are experts in their own health (Department of Health, 2001). Thepanoply of available CAM practices is thereby perceived as an attempt to conveydiffering forms of expertise and knowledge. For example, it is a general view thatalternative medicine concepts, such as those that explore the body, resonate par-ticularly for a large section of the population because they appeal to the lay view(O’Connor, 2000).

Set against this background, this study focused on the views and practices ofalternative medicine practitioners, specifically healers’ activities at the Vital EnergyHealing Centre (VEHC) in Granby, in the northeast of England.3 Data were gatheredprimarily through informal interviews and participant observation between 1996and 1998. The sample included individuals who contributed significantly to theeveryday life of the center. Primarily, it was a snowball sample of healers at the cen-ter, focusing particularly on 5 key healers and 6 trainee healers, but included contactwith a number of regular patients. Informal interviews alongside participant obser-vation were the main data collection methods. Data were collected mainly at peri-ods of key activity, including healings, meditations, free healing evenings, andguest talks. Field notes were taken, and these were analyzed in a broadly thematicway with attention to relationships between emerging concepts and how theyrelated to the theoretical literature on critiques of biomedicine and the rise of CAM.

The findings led to the development of ideas about what constitutes knowledgeand expertise in this setting. A central theme in the original study was that healingpractice and ideas at the center reflected individual concerns, and therefore healingpractices were often highly personalized and influenced by lay agendas. At thesame time, although healers were critical of orthodox medicine, they also soughtforms of legitimacy through a process of incorporating perceived scientific andmedical (expert) practices and terminology. In such ways, laypeople (in this case,healers) are responding in an individualized fashion to the cultural ubiquity of sci-ence. However, instead of seeking universal expertise, the healers’ sought the “self-evident” and “intuitive” truths of individual self-reflexivity.

Common Theoretical Location

Both of our original studies are located within broader theoretical debates aboutthe status of medical and scientific expertise in late-modern society (Beck, 1992;Giddens, 1991), and the value and distinctiveness of ordinary people’s knowledgefor understanding patterns of health and illness (Popay & Williams, 1996; Popay,Williams, Thomas, & Gatrell, 1998).


Both studies explored the issue of declining trust in medical and scientificauthority, which, paradoxically, has emerged at a time when scientific expertise isitself at its most ubiquitous (Nowotny, 2000). The value of subjective and highlypersonal lay knowledge in challenging the objective and depersonalized nature ofexpert knowledge is now of key concern. Indeed, the very division between lay andexpert has been challenged, with critics pointing to a range of knowledge(s) andemphasizing the equal status—if sometimes differing forms—of lay and profes-sional expertise (Kangas, 2002; Williams & Popay, 1994). Questions such as How layare lay beliefs? have been posed, reflecting dissatisfaction with the concept of “alaity who holds a separate and distinctive set of beliefs from expert knowledgesystems” (I. Shaw, 2002, p. 287).

As a whole, these critiques have had political, sociocultural, and methodologi-cal implications, challenging the elevated status of medical and scientific knowl-edge, and questioning the conventions of positivism by focusing on biographicalnarratives and subjective views. However, it should be noted that some authorshave recently raised questions about the limits of lay knowledge and lay exper-tise (Prior, 2003). Therefore, these debates are characterized by diversity, and thenotions of what constitutes lay and/or expert knowledge are contested.

TRANSLATING CONCEPTSACROSS THE STUDIES

The cross-fertilization and translation of concepts across our two studies followed,in a broad sense, qualitative synthesis processes identified in the literature, involv-ing moving from familiarization with others’ work, through an examination of keyconcepts that unite the work, to translation of concepts and the expression of a syn-thesis (Noblit & Hare, 1988).

Our familiarization process initially comprised verbal discussions over aperiod of time, where we made notes about the conceptual connections between ourtwo studies and reflected on how these related to wider debates in this field. Fromthis process, we identified a central conceptual question that united our work andguided the ongoing cross-fertilization of ideas across our studies: What is the natureof the relationship between lay and expert knowledge?

We then examined each other’s work in more depth, including reading aspectsof each other’s doctoral theses, articles in preparation, and published work. In anongoing iterative process, we reexamined our own work, comparing key themesfrom our work with those identified in the other’s work, revisiting our data, ques-tioning and reinterpreting them where appropriate in the light of our developingideas about the conceptual links between our studies. As we “translated” the con-cepts of each study through those identified in the other, we began to see the po-tential for a higher degree of conceptual development than we had achievedin our individual studies. A particular turning point for creating a preliminarysynthesis of our work was a joint conference presentation on the problems ofthe lay-expert knowledge relationship at the British Sociological Association’sMedical Sociology Conference (A. Shaw & McClean, 2002). This presentation,combined with postconference discussions and rewritings, formed the basis for thisarticle.


A PROBLEMATIC LAY-EXPERT DIVIDE?:COMMON THEMES FROM TWOQUALITATIVE STUDIES

In this section, we present three key shared themes relating to lay-expert knowledgethat emerged from the cross-fertilization and conceptual translation process. Theseare illustrated by quotes from the original studies to enhance the transparency andcredibility of our reinterpretations. For the food risks study, data from both theexperts and the lay participants are used; quotes from experts are identified by theperson’s role, and quotes from the laypeople refer to their community group: cook-ing club (C), organic food group (O), vegetarian society (V), lunch club (L), youthgroup (Y), and farmers (F). For the alternative medicine study, quotes from inter-views with healers are used (identified by pseudonyms) interwoven with aninterpretive account of fieldwork observations.

Critique and Distrust ofBiomedical or Scientific Expertise

Food Risks Study

The first theme concerns a questioning and distrust of biomedical and scientificexpertise. In the food risks study, although expert discourses largely focused on lev-els of lay understanding of science and risk, some experts were also self-reflectiveabout the extent to which they possessed expertise. Ideas of expert uncertaintyemerged, particularly from accounts of those from consumer-oriented organiza-tions. These experts acknowledged the complexities of risk in relation to issues suchas BSE, noting that not even “world experts” are able to understand it fully:

It has been impossible for the public to get a good handle on the beef-on-the-bonebusiness. . . . Before, the risk was zero, but now we’re being told that it’s one in how-ever many million, and we don’t have the tools, or the intellectual capacity to reallyassess what that means for us. . . . It’s an incredibly complex area. . . . Even some ofthe world experts grapple with the same problems. (Independent consumerconsultant)

Furthermore, within the expert accounts, there was some reflection on the wayin which public trust in experts had been damaged by a series of highly publicizedfood scares, during which scientific and government experts were seen to have mis-managed events and misled the public. Public mistrust of experts as a result of risk“miscommunication” during the BSE crisis was a recurring theme and was seen ascentral to public concern about later scientific developments relating to geneticmodification:

People now think that they can’t trust scientists, because BSE was a major disas-ter. . . . The public’s view is that we scientists are not capable of giving good and sen-sible advice, and therefore if we say that there might be a risk, they should assumethere will be, and that’s very difficult to overcome. (Government advisory commit-tee on GM food)


The lay people’s accounts mirrored these views, with recurring reflections onthe nature of scientific knowledge and what it means to be an expert. Perceptions ofthe uncertainty of expert knowledge often underpinned their concerns about foodrisks. For example, scientists, industry, and government were frequently blamed fortreating consumers as guinea pigs for an unknown and uncertain technology(genetic modification), and making decisions about the use of this technology with-out knowing the long-term environmental and health risks. Discourses around BSEand GM food were closely intertwined: Although expertise about BSE was seenas lacking but being gradually acquired, GM was perceived as too “young” for thenecessary scientific knowledge to have been accumulated:

The experts really don’t know what the long term effects could be of geneticallymodified food . . . using the human population as guinea pigs is appalling. (V1)

There’s more hard evidence about the effects of BSE, but genetically modified foodsthey haven’t really got any very hard evidence about the effects. (Y4)

Indeed, the notion of an expert was explicitly questioned in several lay dis-courses, and scientific advice about risk was regarded with skepticism. This critiqueof experts was evident in varying degrees. Although the young people expressedgreater faith in science, industry, and government to manage any risks, mistrust ofthe political and commercial vested interests in GM foods was recurring in theadults’ accounts. Furthermore, scientists were mistrusted for being removed fromthe everyday lives of ordinary people (in their “ivory towers”), being prone to sub-jectivity and bias and allowing the desire for scientific advance to cloud consider-ation of risks to public health:

What is an expert? My definition of an expert is somebody who tells you that some-thing can’t be done. . . . My opinion of politicians is practically zero, and as for scien-tists, well, they’re all wrapped up in their little ivory towers. . . . If they told me GMfood is safe, I wouldn’t believe them. (L2)

Scientific experts are humans as well . . . and their expert views are colored by theirsituations. . . . Scientists . . . are not unbiased . . . and they’re liable to ignore possiblehealth risks because of the excitement of the scientific advance. (V1)

However, lay people often seemed more willing to trust in, and credit expertise to,“alternative” experts (organic or “green” campaigning groups), who were per-ceived to have no particular “axe to grind” and thus more likely to provide “unbi-ased” information:

I would probably believe things that were written from an organic background orfrom a non-governmental background. (O4)


Questions about the nature of expertise also emerged from the alternative medicinestudy. The healers at the VEHC were largely ambiguous about the status and legiti-macy of expert systems such as scientific biomedicine. Expert-based knowledgesuch as biomedicine exerts considerable influence in Western societies, so it perhaps


came as no surprise that the healers at the center used or adopted metaphors, idi-oms, and practices that are resonant with medical discourses. For example, duringthe course of the research, some of the healers employed what they call “laser-wand” scalpel crystals, which are long, thin, striated quartz crystals and which,healers argue, help to “draw out” spiritual impurities in the body. Afurther illustra-tion of this appropriation of medical knowledge can be seen in the work of Charlie, ahands-on healer at the center. Charlie drew on spiritual entities to aid him in hishealing work, and he referred to these entities as the “Doctors,” in that each has hisor her own area of expertise (cancer, bones, the heart, and so on).

However, alongside the appropriation of certain biomedical discourses andmetaphors, the healers commonly exerted their distrust of biomedicine in their day-to-day dealings with clients. For example, in addition to holding diverse views onthe spiritual body, healers maintained a position on the material body, althoughunlike medics, they perceived parts of the human body to be uniquely suited to theperson. By this, healers argued that organs, limbs, and blood are peculiar to that per-son and embody their spiritual energies. Therefore, a biomedical practice such asorgan replacement was deemed to be problematic, as it would replace the person’sspiritual energies in addition to a physical organ. The following example showshow Teresa (the owner and principal healer at the center) linked together the bodyand the individual of the person in her response to issues about organ transplants.This can be interpreted as a critique of expert approaches to the body that eschewindividuality.

On this occasion, Teresa was explaining what happens to the energies of a par-ticular organ when transplanted into the body of another. She emphasized thatsuch practices are wrong, as they involve transferring ones spiritual energy intoanother’s aura:

I am completely against these forms of organ transplant, because it means you aredividing up the spirit and I don’t think people know what they are doing. The heartis the chalice for their spiritual energies, so when the heart is put in the body ofanother then the spiritual essence of that person is transferred with the heart . . . I amagainst transplants of the major organs. Also, after death it takes three days for thespirit to totally detach from the body, and look at what’s happening now with ani-mal to human and human to animal transplants, I think it’s disgusting. So you canhave human pigs and pig humans.

In addition, when a question is asked about blood transfusions, Teresa is equallydismissive:

Well, I’m against that also. The blood is the life force and you cannot put that intoanother individual as it will take the life force of the individual into another and willmix up the spiritual energies. You cannot make happiness out of other peoples suf-fering, and that is exactly what they’re trying to do.

Here, the blood of the individual carries with it the spiritual essence of a person.Therefore, transfusion would cause the spiritual energies to be mixed up, therebycomplicating the individual’s nature. The distrust of the expert biomedical systemis clearly signified by Teresa’s remark about the motives and rationale of such trans-plant procedures.


The Role and Meaning of Intuitive,Individuated, and Personalized Knowledge

Food Risks Study

The second theme focuses on the role and meaning of intuitive, individuated, andpersonalized knowledge. In the food risks study, although the lay people partiallyengaged in scientific discourses about risk, they also drew on other discoursesand gave explanations for responses to food risks that were different from scien-tific explanations. For example, discourses about genetic modification were oftenthreaded through with highly personalized “intuition” and “emotional” responsesrather than being characterized by ideas prominent in scientific discourses, such asthe “rational” calculation of risk.

A recurring theme was a distinction between “natural” and “unnatural” food.Comparisons were drawn between “traditional” food produced by tried-and-tested methods over years of production (e.g., bread, beer, cross-pollination ofplants)—seen as scientifically well-known, natural, and acceptable—and “new”methods, such as genetic modification, which were seen as scientifically unknown,untested, unnatural, and sometimes frightening. In particular, scientific interven-tion to move genetic material across species—a process that would not occur natu-rally—and the pace of this genetic change were seen as the crucial problematic dif-ferences between traditional and GM foods. Participants often expressed anintuitive unease about this process, a feeling that was described as going “againstthe grain.” They described their “gut feelings” that the transfer of genes across thespecies barrier was “crossing a line” that should not be crossed:

If they’re joining things together that wouldn’t occur naturally I think that’s danger-ous. I’m quite happy with cross-fertilisation of the same thing, say different toma-toes or different potatoes, to improve the strain. . . . But to actually invent crosses Ithink is incredibly dangerous. (V2)

It just seems to be like a line they’ve crossed, ’cause older methods . . . they’re chang-ing what’s already there, but with GM they’re creating new stuff. (Y4)

Therefore, the laypeople repeatedly questioned the appropriateness of scien-tific intervention in nature, often drawing close parallels between BSE and GMfood. A strong antiscience position was not evident. Admiration for science andtechnology in general, and for specific medical applications of biotechnology, wasoften expressed. However, the application of these techniques to food (GM foods)was intuitively rejected as unnatural, and scientists were described as “playingGod.” Commonly recurring phrases were genetic modification as “fiddling” or“messing around with” nature:

It is totally unnatural . . . it’s very impressive from a scientific point of view,but . . . they haven’t given a lot of thought as to what the end result is . . . genetic mod-ification is tinkering with nature for no particularly good reason. (V3)

Science, technology . . . in some ways it’s good. . . . But other things, like tamperingwith food . . . it’s all interfering with nature really. (L1)


Thus, in their closely interwoven discourses about BSE and GM food, the lay peopleset up a tension between nature and science, with nature seen as fundamentallygood and human intervention through science as undesirable. Nature was oftenpersonified as a powerful “she” who has shown through BSE (and will show in thecase of GM food) that she will “hit back” at inappropriate human intervention.Thus, BSE seemed to act as an initiator and focal point for subsequent concernsabout GM food:

I don’t like nature being interfered with because she always hits back. . . . I don’t holdwith GM food. . . . I don’t think they should interfere with nature to thatdegree . . . nature always gets you back . . . like the beef problem, whoever the stupidpeople were who introduced cannibalism into the beef chain, they wanted theirheads examined, it hit back. (L5)

I’m sure the experts in BSE, they thought then that it was fine . . . there probablywon’t be potential problems with GM food, but you can never be sure. (Y5)


In the alternative medicine study, healers seemed able to maintain differentapproaches to knowledge and thereby displayed both “expert” and “intuitive”knowledge. Being intuitive about the healing process could also be construed as aprerequisite for being expert. For instance, in a therapy like crystal healing, choos-ing crystals for the task is seen by participants as a crucial opportunity to displayeither expert-based or intuitive knowledge. These approaches reflect differentialattitudes to expertise in healing knowledge.

Healers might make an “expert-based” judgment about the appropriate crystalto use. Crystal choice corresponds to parts of the body and to particular conditionsthat require healing. These decisions tend to be based on healing texts that list thekinds of ailments that certain crystals treat. For example, amethyst is widely pre-sented in these texts to be good for the overworked and stressed (Raphaell, 1987).Therefore, crystals embody expert-defined qualities that can be isolated and lookedup in a crystal textbook, and therefore be known by the community of crystal heal-ers. Moreover, there are broader crystal typologies. For example, links are madebetween specific ailments and the physical structure of crystals: shape, color, andspecial markings. As Sally explained,

The crystals work on two vibrational levels, the color and the shape. These are thetwo basic ways in which they act upon us. This is what attracts us to them and makesus choose a particular one.

Teresa frequently adopted this expert-led approach to crystal selection. Oneday, following a healing, Teresa was asked why she chose certain stones. Sheexplained that a wand crystal was used for spine work. A rose quartz, held in herleft hand, generates a calming effect. Based on the properties that key healing textsdescribe, both crystals are used “acceptably.” It is worthwhile noting how in suchinstances, Teresa’s professionalism took precedence. As figurehead of the center,she was the most responsible for establishing a systematized (expert-based) set ofideas regarding crystal properties.

However, the crystal might not be right for a particular patient. Crystal healingtextbook descriptions of crystals list “ideal type” properties, but these might not


suit the individual. As Raphaell (1985), a crystal healer, stated, “[Crystals] may bedifferent for you than for anyone else” (p. 15). Each healer then extracts somethingunique from the crystal. Healers hold the view that crystals have no intrinsic quali-ties but that, instead, their quality changes according to both the healer and thepatient. In this way, healers make intuitive and individual choices over what kind ofcrystal is right. For example, this sentiment can also be identified in Charlie’sstatement,

You usually know what to do at first with a healing. You pick the stones you want bytrying to think of what they’ve said they’re feeling [the patients]—sad, tired,unloved—and then you choose the crystals that you think you need.

Similarly, Jenny (a crystal healer) holds a relatively loose definition of what isacceptable when choosing crystals. In the following quotation, Jenny explains theimportance of contingency in being the crystal expert:

Often the properties in the books for each stone are all vastly different, so you haveto go by what you think. There are guidelines with the colours of the chakrasthough . . . the chakras are divided by colour, although you can place a crystal fromone area into another if it feels right.

The general guiding principle is “if it feels right,” which reflects the core idea ofintuitive-based and individuated rather than systematized and expert-based heal-ing. This emphasis on nonsystematized and personalized knowledge is particu-larly prevalent in a form of healing that engages with spiritual notions of the selfand world. This also led the healers to develop more individuated forms of practice,in which healers used methods of healing that reflected personal concerns. Thisissue is further illustrated by the following example.

One day at the healing course, a healing tutor called Jack was explaining a crys-tal healing technique. He was talking through the process by which the healer inter-prets the “subtle” and intuitive stages of the healing. As Jack started his healingdemonstration, he described what the trainee healer should be looking out for:

Slowly move the crystal over the body from one side to the other. Now, feel any dif-ference. These differences are signals of problem areas, energy blockages or weak-nesses. They may be very subtle. Some detect the sensation as resistance, some asheat. Other people feel it is a sensation of cold. Don’t worry if you feel hot and I feelcold. It doesn’t then mean that I’m right and you’re wrong—you’re individuals.

For Jack, each healer receives different, even contrary, signals and impressions.Jack explained that this does not matter, as the signs are different for each person.There is no expert position to rely on, and the healer has to be sensitive to both thepatient and the healing sensations. Teresa explained this position on sensitivity inthe following statement:

Awareness is listening with all of your inner body, go with the first thing that youget . . . it’s all about listening and going with spirit, you instinctively go with whatyou get first, it goes with a flash, and it’s like directions without words.

As an intuitive process, healing prioritizes the use of the senses, particularly inthe diagnostic process. Also, these data have indicated that there is no objective


diagnosis in spiritual healing, no repeatable outcome that can be tested for its reli-ability. Healing that uses the senses is thereby a counter to the expert-led models ofbiomedical knowledge and diagnosis.

The Potential for Differing Forms of “Lay Expertise”?

Food Risks Study

The third broad theme focuses on the potential for various forms of “lay expertise.”In the food risks study, the experts largely focused on the extent to which lay peoplehad scientific understanding (e.g., about risk) rather than reflecting on other formsof lay knowledge that might be of value. Experts—particularly those from scienceand industry—commonly portrayed “the public” as lacking knowledge of sciencein general, and specifically of science as used in food production. Public “misunder-standing” of science was seen as at the heart of concerns about genetic modification:

Most members of the population are extremely ignorant about science . . . Theydon’t know anything about biology. . . . Biotechnology . . . is quite a difficult con-cept. . . . People are uncertain what’s really involved. (National Farmers’ Union)

A particular shared discourse among the science, industry, and governmentexperts was a tension between the risk expectations of experts and the public. Thepublic was often portrayed as lacking in understanding of risk, misguidedly desir-ing “no risk” and wrongly interpreting risk communication as “absolute truth.” Incontrast, experts were seen as able to recognize risk as inherent to every situationand product, and risk communication as able to give qualified statements basedonly on what is currently known:

The public doesn’t understand the risk in GMOs, and naturally say, “If I don’tunderstand it, I don’t want anything to do with it. Stop.” (Food producer)

In their haste to reassure the public [during the BSE crisis], statements were madewhich were believed to be absolute truth by the consumer, but known to be the bestreasonable statement of accuracy by legislators, doctors and the food chain. . . . Wealways knew that there is risk all the time in everything you do, but had unfortu-nately convinced the consumer that we had virtually eliminated it from the foodchain, so when it became apparent that we hadn’t, all hell broke loose. (Foodproducer)

However, although ideas about the paucity of lay knowledge of science wererecurrent, some expert discourses gave greater credit to public understanding andsuggested other valid and valuable forms of lay knowledge. This was particularlyapparent in the accounts from consumer and campaign group experts, who gavedifferent explanations for public reactions to food risks and were critical of scientificperspectives that treat the public as ill informed and “irrational” in their riskresponses. In contrast to the levels-of-risk approach used by scientists, lay peoplewere portrayed as seeing the “big picture” about risks, which was broader than thescientific issues and included wider social concerns, commercial interests, andpolitical agendas involved in scientific developments and policy decisions. Fur-


thermore, laypeople were seen as able to understand scientific ideas of qualifiedrisk that take into account the limits and uncertainty of scientific knowledge:

People are able to comprehend the idea of a qualified risk . . . that says “As far as weknow” or “We estimate the risk to be” . . . it certainly doesn’t need to be simplified bypoliticians unless they have another agenda. In the case of BSE, there was anotheragenda, to do with the preservation of the meat trade, which shaped the way thatstatements got changed from scientifically qualified ones to politically unqualifiedones. (Food pressure group)

You can say about BSE only 29 people have died, therefore it’s no risk. [But] the pub-lic was absolutely right to be deeply angry . . . there was a much more sophisticatedrange of positions. . . . Using the levels of risk approach you could say “It was only 29deaths, who cares? It is peanuts compared to coronary heart disease, 160,000 ayear . . . you’ve got it out of proportion.” No they haven’t. . . . The public saw the bigpicture . . . it was pretty good understanding. (Food policy academic)

What about the lay people? Mirroring many expert discourses, several lay-people initially denied expertise in relation to issues such as BSE and GM food.Although expressing increased awareness of GM foods through widespread mediacoverage, they felt that they had little detailed knowledge of the science involved.“I’m no expert” was a common response. However, a recurring discourse was thebelief in the potential of ordinary people to understand the basic scientific issues ifgiven more helpful information by scientists, the food industry, and the media:

I don’t really understand [GM food]. . . . I’ve heard about it . . . but I don’t reallyunderstand this one very much. (C5)

I wish the media would give us some decent coverage about what the issues are. Ithink people can understand it, the issues are quite complex, but I think peoplecan understand them if put in a certain way. (O3)

However, claims of lack of knowledge were not evident among all the lay par-ticipants. The accounts from the organic food and vegetarian participants in partic-ular drew in detail on scientific debates about GM food. Their discourses often mir-rored the complexity of expert accounts, pointing to the blurring of boundariesbetween expert and lay knowledge. These lay people engaged with and remoldedscientific discourses about GM food for their purposes: to create an argument aboutthe unacceptability of genetic modification and make a case against GM food. Indoing so, they showed their lay expertise in the science and in the wider social,political, and commercial issues:

The worrying thing is that sixty percent of soya crops in America are GMO and thatinfiltrates into many products. . . . The other issue is that any crop spreads . . . and soyou’ve going to get a transfer of GMOs. . . . The other thing is the power of the bio-technology industry . . . they want it to work, and governments, because of thepower and the money, can’t really see why not . . . [genetic modification] is very ran-dom, in some cases they literally throw genes at an organism and sometimes it willreceive it and sometimes it won’t . . . and if you move on five years, you don’t knowwhether there’s going to be a throw-back. (O4)

In addition, as the interviews progressed, the lay people who initially deniedexpertise showed some engagement with scientific discourses. As people from a


range of backgrounds talked about BSE and GM food, their language often reflectedideas within scientific debates, such as the delayed timescale for the emergence ofrisks:

It may be alright at the time, but what will be the outcome of eating GM food?Because what about BSE? That didn’t happen immediately to a person, if you’deaten it. (L1)

Thus, in the food risks study, the lay critique of expert knowledge and the develop-ment of lay expertise, alongside the reflexive awareness of uncertain knowledgeamong some experts, indicate a blurring of the boundaries between expert and layknowledge.


The potential for lay expertise also emerged from the alternative medicine study. Atthe VEHC, there was some ambiguity about the healers’ professional credentials,which arose partly because the healers’ involvement in the center was often attrib-uted to their negative experiences with conventional medicine. Many of the healershad at one stage been clients at the VEHC, and through their involvement with heal-ing themselves became experts about the healing process. Teresa explained whatthis meant in relation to Charlie:

To understand something like this, you need to experience it. Charlie has had vari-ous experiences in his life that will help him understand various people, which isvery important. You have to understand what people are experiencing to healthem . . . this helps you become more sensitive to the healing energies, both of thecrystals and other people.

This personalized approach to being expert was also important in terms of under-standing how each healer understood what it meant to be an expert. On the whole,each healer perceived his or her activities differently, although the official line fromTeresa was that the healing organization was a professional body that providedexpert views on healing. Various activities that the center was involved in wouldconcur with this view. For example, Teresa allowed the center to form alliances with“professional” healing organizations—in particular the Confederation of CrystalHealing Organisations (CCHI).

The CCHI was established by a group of crystal healing organizations to pro-mote training in crystal healing and to ensure that regulatory standards are metbetween the affiliated schools. Its existence suggests that esoteric healing activitiesare closely regulated and standardized by a national body. Identifying the role ofthe CCHI is significant, as many alternative therapies are conceding to these formsof systematization, a key feature of biomedicine’s hegemonic position within thefield of health. This organization reflects Teresa’s commitment to the project ofprofessionalization.

However, although Teresa did not want to people to view the center as similarto an orthodox medical centre, she felt that the image of being “professional” was animportant one. In the following quotation, Teresa makes this point clear to hertrainee healers:


Don’t be bothered with trying to prove anything. I don’t have to prove anything. It isimportant not to imitate the medical services . . . primarily, it is important to presentyourself as professional and you should not forget this.

On first attending the VEHC, it was expected that healers would claim someright to heal: that they were chosen because they exhibited a special talent. It is truethat some healers do make these claims of this sort, in that there is usually a “story”involving some unpleasant experience with medicine that led the healer to explorehealing, but healers were largely instrumental about their effect on the healing out-come. The various sources of healing alluded to at the center included the healer, thecrystal, the notion of a “higher” source (such as God), and the “channeled” spiritssuch as exhibited in Charlie’s healing. Such inclusion of multiple sources of healinghas been noted in other writing on healing groups (see Benor, 1984).

One particular argument at the center was that the crystals could heal regard-less of the healing ability or expertise of the person using the crystal. This state-ment implied that anyone can be a healer. Despite Teresa’s earlier statement aboutCharlie’s “sensitivity,” Charlie himself emphasized that he has no inner ability toheal. He explained that he attracts the help of his spirit “Doctors,” who operatethrough him and act as expert intermediaries to generate healing energy. As heexplained,

I don’t have any healing ability at all . . . we can’t heal by ourselves, we have to askour spirit guides which will help us. They provide the energies and they do the heal-ing. When I’m healing the spirit guides work on the body while I channel the ener-gies through me, I don’t try to interfere with them.

Uncertainty and ambiguity about healer “ability” arises because of an innatedistrust at being a holder of expert knowledge. In this way, the healers at the VitalEnergy Healing Centre promoted an alternative form of expertise, one that gave cre-dence and trust to individualized knowledge rather than the systematized form ofexpertise prevalent in conventional medicine. Their responses also draw attentionto healing as a “natural” process, which is an interesting take on the interplaybetween science and spirituality. In addition, the idea of anyone becoming a healeris quite different to expert systems of knowledge in which the philosophy is thatsomeone has to be good enough to get through a period of training. These demo-cratic elements in spiritual healing imply that there is no hierarchy of healer ability.What we see here is a shift in forms of knowledge, something between autocraticand democratic modes of knowledge and healing practice.

DISCUSSION

We have presented three broad, unifying themes concerning the lay-expert knowl-edge that emerged from a reinterpretation of concepts across two qualitative stud-ies. These focused on a questioning of biomedical or scientific expertise; the role andmeaning of intuitive, individuated, and personalized knowledge; and the potentialfor differing forms of lay expertise. It is important to locate these within wider theo-retical debates about expert and lay knowledge in late-modern society to illustratehow our conceptual synthesis reflects and adds to this body of work.


Although studying different substantive areas, both of these qualitative studieshighlight the complexity of, and ambiguity between, differing forms of knowledge,conventionally understood as expert and lay. Furthermore, they indicate that a vari-ety of forms of knowledge or understanding—such as systematized/scientific andpersonalized/intuitive—might coexist, and might be differentially engaged withand used by individuals with diverse stakes in health and scientific issues. This flu-idity might equally be indicative of a wider crisis in scientific knowledge per se(Lyotard, 1984).

In many respects, the debate highlights facets of the familiar structure-agencytheme in the social sciences. For example, in taking stock of this uncertainty, somewriters have discussed how the changing relationship between lay and expert isillustrative of a wider sociocultural transformation (Bury, 1998; Giddens, 1991),wherein individuals are perceived as either figures of historical circumstance or ascreative and critical agents. Bury argued that two issues are central to this debate:the encroachment of expert knowledge and systems on ordinary people’s everydaylife, and the fragmented or contested nature of expertise in a postmodern society.

The first issue concerns the importance of the reflexive quality of late-modernlife. For instance, medicine’s forms of rationality have encroached on key areas ofpersonal and social life: the medicalization of everyday life (Zola, 1972) or, inHabermasian terms, a colonization of the lifeworld (Habermas, 1987). Also, thisencroachment can be seen in the ways in which ordinary people absorb expertknowledge. Therefore, increasingly we see lay expertise (Kerr et al., 1998; Popay,Williams, Thomas, et al., 1998), but we can also note expert and scientific uncer-tainty and the social basis of all forms of expertise (Nowotny, 2000; Otway, 1992;Wynne, 1992).

The second issue for Bury (1998) concerns the changing boundary between layand expert knowledge, which, Bury explained, has become more fragmented andcontestable over time. This points to the shift from modernity to postmodernity (orlate modernity):

These [lay experts] transform modernity’s reliance on expertise and the “docile”body into a more fragmented and less authoritative scientific voice on the one hand,and a more active and sometime resistant stance of the lay person on the other.(pp. 11-12)

Broadly speaking, postmodernity is characterized by the privileging of subjec-tivity and, indeed, represents an increasing trend toward a plurality of subjective(lay) discourses. As Smart (1993) said, “We find ourselves living amidst a pluralityof doctrines and styles of reasoning” (p. 120). Giddens (1990), too, emphasized thispoint and outlined the implications for scientific knowledge: “The post-modernoutlook sees a plurality of heterogeneous claims to knowledge, in which sciencedoes not have a privileged place” (p. 2). Although science is the most culturallyembedded and ubiquitous system of knowledge in contemporary society, we notethat changes to the public status of science and medicine have fundamental implica-tions for the legitimacy of knowledge in the postmodern era.

In exploring the conceptual links between our respective qualitative studies,a theme that we found most striking is the way in which laypeople interpolateda privileging of subjectivity and individuation in the construction of knowledgewith a varied understanding of the cultural ubiquity of science in modern life. To


illustrate, in the food risks study, lay individuals who favored organic foodadopted scientific arguments to confer legitimacy on their case against GM foodwhile also drawing on “gut feelings” as a basis for rejection of this technology. Inthe alternative medicine study, healers with highly personalized views on healthengaged with both individualized and systematized approaches to knowledge.Thus, in both research contexts, we see how, in the differential engagement withbiomedical/scientific knowledge, laypeople seek to adopt, mimic, critique, or re-write expert positions. In this sense, we can see the movement in late modernitytoward expert knowledge as highly individualized knowledge. As Nowotny (2000)explained, “The stage is therefore set for everyone to become an expert in somethingof concern to him- or herself” (p. 12). As such, we must note that in a society with no“final authorities” (Giddens, 1991, p. 141), the layperson might find him- or herselfadopting “erroneous” beliefs with some degree of conviction that might be lackingfrom experts, who might be in disagreement.

To conclude, we have illustrated the fruitfulness of critical exchange between,and creative reflection on, qualitative research on two different health topics forexamining a common conceptual concern (lay-expert knowledge). By interweavingtwo qualitative studies, added complexity and a higher level of conceptual abstrac-tion were gained, which was less possible from our individual studies. The studieshighlighted different but complementary facets of the lay-expert continuum. Layand expert are not polarized knowledge positions. It would be naive to suggest thattraditional expert knowledge, as exemplified in scientific and/or medical fields,ever provides absolute certainty, and it is even more unlikely that such knowledgecan be perceived as indubitable. Thus, all expressions of knowledge, whether iden-tified by the scientific community, the community of healers, or organic food advo-cates, whether public or private, expert or lay, are seeking recognition, although notnecessarily in terms of the universality of their claims.

NOTES

1. Subsequent references to the food risks study refer to these sources.2. Subsequent references to the alternative medicine study refer to these sources.3. To ensure the anonymity of research participants, fictional names are used in this article for both

the research setting and individual participants.

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Stuart McClean, Ph.D., is a senior lecturer in health and social care, University of the West of Eng-land, Bristol, United Kingdom.

Alison Shaw, Ph.D., is a lecturer in primary health care, Department of Community-Based Medicine,University of Bristol, United Kingdom.


the problematic relationship between expert and lay knowledge

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