Herein lies the problem: Issues are neither property, nor are they wagers. Stakeholder carries an inherent assumption and value proposition that only those stakes that have monetary worth are legitimate. In the world of healthcare, we hear about stakeholder engagement and delineate the people who we see as affected by certain clinical or research initiatives.5 But I contend this is a projection of who we see as having stakes.
In short, a lot of our beliefs about who should be included get mixed with who needs to be included. Even well-meaning steps toward inclusion may exclude people who don’t seem to be directly invested. In using the term stakeholder engagement, we inadvertently open the door that allows the justification of exclusion.
Stakeholders or Shareholders?
Stakeholder is also remarkably similar to shareholder, and I have witnessed how people sometimes slip between the words with ease. Both words emphasize the commodification of a certain good or service. Shareholder may have a connotation more overtly related to business and the stock market, but stakeholder still has much of the same punch.
Making things worse is that a shareholder is a type of stakeholder, and one that is often prioritized among others.6 Just as modern businesses see themselves as vehicles to keep shareholders happy, we may be lulled into thinking that our primary job is to keep our stakeholders happy. Of course, keeping people happy is a major part of what rheumatologists endeavor to do, but it is not the driving factor.
Similarly, stakeholder puts us in a framework that unintentionally de-emphasizes the power asymmetries and disparities among relevant parties. In the American healthcare system, we know that powerful forces determine agenda and outcomes. It has been a long struggle to make sure that those without adequate representation have a chance to sit at the table, but it is still far from an equitable arrangement.
Whenever I read the phrase “relevant stakeholders were consulted,” I rarely read any follow-up regarding how power disparities were addressed. It raises my suspicion that perhaps this aspect of sharing the stakes was not addressed.
This framework also makes us far too anthropocentric. The generally accepted paradigm is that stakeholders are people, after all, but the general public is an amalgam of all sorts of people and non-people.7 Principles and values, such as environmental conservation, commitment to social equity and preventive health, may get lost, unless there is a particular champion for them as stakeholders. Indeed, even those that are far removed from a clinical or a research initiative are often affected through various indirect effects. By stating that stakeholders were consulted, we may be undercutting these considerations.
