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This page created October 2000 by Michael Wynne
In his speech
to the World Bank Graham Samuel talks
of the "starting
points" which exist in most countries
and then sets out to promote a system of health care with very
different "starting points". This page examines the nature of
"starting points" and their impact on identity. It attempts to
understand what Samuel is really proposing by examining both starting
points. It concludes that he is telling us how to get from where we
are to somewhere we don't want to be and most certainly should not
be.
Like philosophical systems each ideological system of belief, whether it be religious, secular or political develops on the basis of some fundamental understanding which is a self evident truth within the context in which it arises. These starting points "legitimise" the belief system. Some have some validity outside the context in which they arose. Others do not. Their validity is seldom questioned by believers.
Examples: - Rene Descartes' dualist philosophy was based on the insight "I think therefore I am". Few now accept dualism. Communism was based on Marx's understanding of consciousness - the way in which industrial understandings by the workforce kept them subservient. Hitler's anti-Semitism and apartheid were both based on the obvious physical and cultural differences of Jews and blacks.
The importance of "I am":- In each case the theories which were developed were congruent with the experiences of groups in society and with their personal interests. They seemed self evident - the "AhHa" factor. They struck a chord and were accepted. Each was appropriated and given meaning and identity in action - "I am the person who did this because I believe". Vast numbers identified with these ideologies, fought to impose them. Some died in their defense. Those who adopted alternate systems were seen as evil and threatening. They were blamed for all the wrongs of the world.
Labeling: - This defensive strategy is known as "labeling". Derogatory words were used to describe those who held different views. Under Apartheid those who interceded on behalf of blacks were known as "kaffirboeties: (literally kaffir brothers), a very derogatory term which immediately destroyed credibility in that society. Any opponent became a "communist" and so a threat to the state - someone who could legitimately be detained and imprisoned without trial.
Consequences: - It is now clear to us that all of these starting points and the ideologies expounded by highly intelligent people were incomplete and misleading. Many had disastrous outcomes - some after a period when they benefited the people who adopted them (eg. labour, apartheid). I am not claiming that all belief systems fail society. They work well when used in congruent contexts. Most civilisations and human achievement has been built around belief systems, often religious systems.
I buy therefore I am: - In the first paragraph of the section of his lecture which deals with implementing his model, Samuel shows us that what he is proposing is another belief system. His is a belief in the market. People will realise themselves by buying and selling - "I am the man who bought four hundred hospitals".
Samuel indicates that what he proposes 'represents a very major change from the "starting point" that exists in most countries.' He seeks to impose it on health care on the basis that it has worked in other contexts. He ignores the fact that it has already failed in the health care context.
Comparing paradigms: - If we are to
understand what Samuel proposes then we must examine the paradigms of
understanding which Samuel proposes to use and those which are
already in use in health care in most countries. We can then consider
which is more appropriate.
A market society:- In the 20th century marketplace the starting point for many has become "I buy therefore I am". Descartes ideas influenced human belief systems for several centuries. They have been challenged and shown to be wanting.
Market theory now claims the universal legitimacy which dualism once enjoyed. I have suggested that this is what the young writer Hsu-Ming Teo was talking about when she wrote "The tides of continuity wash over and litter the future with the debris of the past". She was writing about her pessimism for the 21st century. This line followed her description of the horrors of the late 20th century - all in the name of belief systems - among them economic beliefs. ----- (The Australian 1/1/2000)
Competition: - Central to the marketplace thesis expounded by Samuel and Wooldridge is the idea that competition and specifically competition for personal or corporate gain is a "given", all embracing, unchallengeable and overriding good. This is accomplished by competitive bargaining for goods and services. It becomes a universally valid paradigm - the frame within which all human activity can be measured. Identity is attained by gaining personal wealth and by successfully competing to build massive empires. It becomes "I am the competitive entrepreneur who founded this company and built a giant empire".
Competition is the unchallenged ideological rock on which modern market theory is built. It makes it legitimate to act in ones own interests (or those of shareholders) and at the expense of the community. While claiming a commitment to the community it enshrines self rather than community as the driving force in society. It places the rights of the individual well above responsibility to the community. It creates an intense paradigm conflict in contexts where duty to the community is paramount. Outcomes are likely to be unpredictable and dysfunctional.
Historical legitimacy is lacking: - This radical market thinking is quite recent in Western culture. The market was where one went to conduct the business of the community. It was a part of society but It did not dominate the thinking or the lives of the bulk of the community. Marketplace ideology as we now experience it is not a traditional western cultural paradigm.
In the market a price was set and the shopper accepted or rejected it. While in practice competition and bargaining characterised most marketplace activities haggling over costs was not considered socially appropriate. The aggressive commercial practices so admired in the business community were frowned upon. The seller who exploited the weakness of others was intensely disliked. He was objectified negatively in literature (eg.. Charles Dickens' Scrooge).
While bargaining was accepted somewhat shamefacedly in the market it could not be carried over into the other activities of society. It carried a stigma. Aggressive marketplace haggling was a feature of supposedly inferior Eastern countries.
Aggressive commercial practices were seen as a characteristic of the Jews and formed the basis of anti-Semitism. It was used to label them. Respectable people did not behave like this. It was avaricious - not "fit and proper".
While modern marketplace theory originated in the marketplace it does not have a long history to give it the legitimacy which it claims. Its legitimacy is strongly contested by some well trained economists.
Labeling the professions: - It is clearly difficult for Samuel to accept that what he is so concerned about in professionalism was in fact a historical response to exactly what he is proposing - placing self interest and personal gain before duty of care to others and the community - personal greed and personal advancement ahead of Samaritan traditions - competition and market forces ahead of service to the community.
Clearly in the right context personal
interest and the welfare of the community can coincide. The key word
is context and ideologists are universalists who pay little or no
attention to the nuances and contexts of our complex world. This is
how they escape the discomfort generated by paradigm conflicts.
What is Graeme Samuel's ' "starting point" that exists in most countries'. This is, as Samuel acknowledges very different to the market system which he proposes. It starts with the idea of a community, of people sharing responsibility for one another - a sense of duty to the community - a Samaritan tradition of responsibility to others when they are disadvantaged or in trouble - identifying and empathising with the misfortune of others. Participants in the health system identify with these ideas and "realise themselves" by living out these beliefs in their actions - securing an identity - "I serve therefore I am" - "I am the person who saved this life".
Historical legitimacy: - This is a tradition which has grown over the centuries. It was enshrined in the ethical structures of the health professions over 2000 years ago. Communities across the world have encouraged the profession to identify with it. It has an historical legitimacy which has survived many social upheavals.
It is a system which our population and the medical profession still aspire to although they do not yet recognise or confront the paradigm conflicts introduced by the new marketplace beliefs. When the providers of health care fail, citizens are understandably disillusioned and angry. This is clearly evident in both the USA and Australia. When the used car industry short changes them, citizens shrug their shoulders and write it off to experience - the market paradigms and therefore the expectations are different.
Progress and community: - With the exception of the USA the majority of developed countries have until recently continued to support these beliefs. When advances and technology increased costs governments responded to public sentiment. They took over responsibility for the care of citizens in differing ways. In Canada the public won a bitter fight with commercial interests to secure a universal health service.
These systems range from national health
systems in the UK to mixed systems including not for profit partly
government supported systems. The latter were called "private
medicine" and they allowed those who could afford it to pay for
convenience and some luxury. It is only quite recently that people
have been conditioned to the idea of a profit based group providing
care - some citizens benefiting from the misfortune of others.
I believe therefore I know who I am: - Market advocates are asking us to replace our community paradigms with the self serving ideas of the market. To encourage everyone to adopt the new ideology the paradigm conflicts have been carefully concealed. Corporate for profit systems have been marketed to the public as "private medicine" without pointing out the difference between for profit and not for profit medicine. To succeed they must avoid challenges to identity - "I don't know who I am or what to do because I am not sure what I believe". The social and psychological processes involved are interesting. I write about them on a page analysing corporate behaviour and on another in which I develop a paradigm for understanding health care.
Politicians and corporate groups have concentrated the public's attention on who pays and how, instead of who provides and how. At the same time they are changing the way in which care is provided. They are introducing a system which squeezes it for the financial benefit of others. A complex and plausible ideology has been created to make this look not only desirable but essential - urgently needed reform.
Managing paradigm conflicts: - The health professions recognised the paradigm conflicts in the marketplace many hundreds of years ago. They responded to protect citizens. Personal gain at the community's expense was specifically frowned on and forbidden. Competition was controlled and tightly restricted and for good reason. What has happened in the USA and is now happening in Australia serves to show how right they were.
Professionalism and paradigm conflicts: - I am not contesting Samuel's criticism that professionalism has not always worked or that self interest has not bent professionalism - seeming to sometimes double it over. Many in the profession have been very critical over the years. The point I am making is that these failures have been a result of paradigm conflicts - a failure of people to adopt and live out paradigms appropriate to the context in their lives. As a consequence they are unable to say "I am" with confidence and certainty.
It is not logical to correct these problems
by using the dysfunctional processes and practices which
professionalism aims to protect citizens from. It is a strange logic
which seeks to correct professional failure by introducing exactly
those paradigms which are largely responsible for that failure - so
augmenting the paradigm conflict.
Samuel is telling us how to get from here to somewhere we don't want to be and most certainly should not be.
I have suggested how these problems in professionalism might be addressed by the community. I suggest that professionalism should be revitalised by reaffirming its fundamental principles. It should invite citizens to participate in the working and operation of professional practices. If it is to fulfill its social obligations and join with society to protect cherished and valuable facets of our society then it requires the help and support of our citizens.
While professionalism must move into the new 21st century freed from the debris of the 20th, it should capitalise on the lessons of the 20th. Among the most significant of these have been the vulnerability of members of the profession to market forces, particularly their susceptibility to financial arrangements which pit financial gain and professional status against the best interests of their patients and of the society they serve.