Technology legitimacy and the legitimacy of technology: The case of chronic kidney disease therapies

This paper explores how the institutional environment in which technologies are embedded serves to select certain technological options while marginalizing others. To do this, the activities occurring among the sponsors and the legitimacy assemblage are traced – that is, the distributed set of actors, materials and methodologies that collectively confer legitimacy to a technology. Specifically, this paper employs an analytic narrative of the evolution of chronic kidney disease (CKD) treatment modalities to demonstrate how dialysis has become an accepted form of treatment while an effective preventative and complementary treatment, dietary protein restriction (DPR), has been marginalized. Our account highlights the emergence of a legitimacy assemblage that establishes the boundaries of what constitutes an appropriate technology, the bandwagon process by which technologies accrue legitimacy, and how actors subsequently engage in legitimacy capture that can further contribute to technology stagnation in a domain. In highlighting these legitimacy dynamics, we provide new insights to the literature on technology selection, develop an expanded elaboration of technology legitimacy, and also offer insights for the medical and healthcare policy domains.