Abstract
This paper offers critical reflection on the contemporary tendency to approach health care in instrumentalist terms. Instrumentalism is means-ends rationality. In contemporary society, the instrumentalist attitude is exemplified by the relationship between individual consumer and a provider of goods and services. The problematic nature of this attitude is illustrated by Michael Oakeshott’s conceptions of enterprise association and civil association. Enterprise association is instrumental; civil association is association in terms of an ethically delineated realm of practices. The latter offers a richer ethical conception of the relation between person and society than instrumentalism does. Oakeshott’s conception is further illustrated by reflection on the connection between morality and religion that he explores in an early essay concerning “religious sensibility”. Religious sensibility turns on the acknowledgement of the vulnerability of the self to the vicissitudes of life. This vulnerability cannot be bargained over instrumentally without imperilling the self. Religious sensibility is thus a valuable resource for criticising instrumentalist attitudes. It allows for the cultivation of ethical self-understanding that is essential to comprehending the conditions in virtue of which genuine civil life is possible. These conditions need to be taken into account in health care. Health care is not simply about substantive wants. It also necessarily concerns the universal and constant condition of being prey to illness that is the common lot of all citizens.
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Notes
Rationality can mean many things. The meaning of the word “rational” as it is used here is limited to the sense of being “calculative”. This sense is akin to the conception of “subjective rationality” developed by Max Horkheimer in Eclipse of Reason [5]. Horkheimer draws a distinction between subjective and objective rationality. Subjective reason involves calculation with a view to the most efficient means to a given end; objective reason, in contrast concentrates on ends.
One obvious example is utilitarianism, which holds ethical quandaries to be resolvable in terms of the summative calculation of ends.
With the advent of British devolution changes in England no longer have a direct impact on health care in Wales and Scotland. The instrumentalist attitude that has recently driven large changes in the English system remains highly pertinent to these systems, too—not least because of the history of instrumentalism that preceded devolved provision.
Pollock [12, p. vii].
Pollock [12, p. 38].
Pollock notes that this transformation of managerial approach was accompanied by a drastic increase in the number of managers employed within the NHS between 1986 and 1995 (from 1,000 to 26,000) and a consequent rise in expenditure more than doubling administration costs [12, p. 39].
“[T]he PFI programme in healthcare has proved extremely lucrative for a host of banks, private equity financiers, construction companies, and facilities management providers. Treasury figures show that the 106 NHS PFI schemes signed by September 2009 had a total capital value of £11 billion, but ongoing payments to these companies over the next three decades will amount to another £58 billion. Of this, £7.1 billion is due in the 5 years from 2010/11 to 2015/16, which corresponds to almost half the savings the NHS is expected to make in this period” [6, pp. 72–73]. The source cited for this Treasury figure is Shifrin [13], “PFE to cost £40 billion over the next 5 years”.
The fruit of this Board was the 2002 policy document Delivering the NHS Plan: next steps on investment, next steps on reform [2].
Department of Health [3, p. 26].
Department of Health [3, p. 31].
See, Cragg [1, paragraph 5, pp. 1–2].
Oakeshott [7]. My use of Oakeshott, it should be noted here, neither needs nor seeks to be entirely faithful to the politics he overtly endorses or all of his conclusions with regard to this matter.
See, Oakeshott [10]. Some discussion of this essay is offered below.
Oakeshott (1901–1990) might be best described as a political theorist. His background and interests, however, are very broad. Oakeshott initially pursued the study of history, taking a degree in it at Cambridge. At Cambridge, he attended the Hegelian philosopher John McTaggart’s lectures. On a visit to Germany in the late 1920s he also attended theology lectures at Marburg and Tübingen. In the 1930s Oakeshott began to engage in research in political philosophy, concentrating especially on the writings of English Civil War thinker Thomas Hobbes (who, along with figures such as Hegel, Hume, Paine, Burke, and Coleridge he numbers amongst the thinkers who endorse a politics of scepticism). In 1933 he published Experience and Its Modes. After serving in World War II as commander of an intelligence gathering squadron, Oakeshott became Professor of Political Science at the London School of Economics where he taught until his retirement in 1968. Many of Oakeshott’s most important works, including On Human Conduct, were written after his retirement. A conservative thinker in the tradition of Burke and Hegel by inclination, Oakeshott had little sympathy for the neo-liberal free-market culture that has come to dominate British politics since 1979. In 1981 Oakeshott was invited by Prime Minister Margaret Thatcher to become a member of the Order of the Companions of Honour. He declined.
Oakeshott [7, p. 54].
Oakeshott [7, p. 54].
They can be the consequence of performances, but more usually are a by-product of them (i.e. actions are performed a certain way, this becomes generally accepted, and is thereby adopted as a custom or convention) [7, p. 56].
Oakeshott [7, p. 59].
Oakeshott [7, p. 55].
Oakeshott [7, p. 55].
There is thus no ultimate standpoint (no “practice of practices”) with regard to which all others could be assessed. This is explored by Oakeshott in his 1933 volume, Experience and its Modes (see Oakeshott [8]).
Oakeshott [7, p. 58]. It does not follow from this that all practices give rise in a direct manner to transparent self-reflexivity, i.e. that the self-disclosure given rise to in virtue of subscribing to a practice is immediately obvious to the subscriber. Engagement in a practice can disclose who one is without the nature of such disclosure being apparent. For example, the person who worships before the altar of a god need not know what kind of identity is fashioned and disclosed in virtue of subscription to the conditions which characterise such worship. Only after one has acted in such and such a way and thereby become endowed with a specific form of self-understanding is its re-articulation into self-reflexive terms (“We are those who adhere to this act of observance”) a possibility. That it is a “we” at stake here rather than merely an “I” springs from the necessarily shared condition of all forms of practice. There can be no such thing as a “private” practice, since the observance of any practice would be meaningless if taken in such terms. In short, the world of practices is always already a shared world. The self-reflexive “I”, one might add, only gets articulated in virtue of the web of communal relations that forms its precondition. The task of theory is to make manifest these aspects implicit in the notion of practice.
Oakeshott [7, p. 59].
Oakeshott [7, p. 60].
Specific moralities, Oakeshott argues, are not given but made. They are symbols of human achievement that have developed and continue to do so. Any moral discourse is a language of self-disclosure. Such languages are learned.
“There is no agency which is not the acknowledgement of a moral practice, and no moral conduct which is not an exercise of agency” [7, p. 63].
Oakeshott also uses the term “civil relationship”. His acknowledged exemplars in the exploration of this field are Aristotle, Hobbes and Hegel.
Oakeshott [7, p. 112].
Oakeshott [7, p. 114].
Oakeshott [7, p. 116].
If asked to proffer a meaningful account of their relationship the members can do so only by specifying its purpose; it does not make sense to cite the rules that govern it.
A publican’s association, Oakeshott notes, is unlikely to have a rule prohibiting its members from coming into contact with alcohol.
Oakeshott [7, pp. 119, 122].
Oakeshott [7, p. 122].
Oakeshott [7, p. 126, c.f. pp. 124–126].
Oakeshott [7, p. 128]. On such an account, any theory of human action which presupposes an ontology of individual “rational self-interest” as the basis of the social world is delusional. I cannot meaningfully have “self-interest” independently of the non-substantive realm of self-disclosure in virtue of which my actions, attitudes and purposes are endowed with their possibility. The self, to put it another way, is not a discrete, self-seeking atom but rather a self-reflexive bundle of practices composed of may aspects, some of which seek substantive ends, some of which do not (and cannot).
Oakeshott [7, p. 129].
Oakeshott [7, p. 147].
Oakeshott [7, p. 159].
Oakeshott [7, p. 161].
Oakeshott [7, p. 118]. One example of this attitude is the notion that society represents a common enterprise for the betterment of humanity as a whole. Oakeshott rejects this view since it assumes that the realm of a plurality of pursuits which epitomises civil association can be subordinated to a larger purpose. One might add to this that any presupposition that the instrumental pursuit of purposes in any form defines the civil realm in an exhaustive manner is untenable on this account.
The 2005 Department of Health document, Creating a patient-led NHS, does not shy away from such language: its avowed over-riding aims are “to ensure fitness for purpose and maximum efficiency in the way services are planned and run” [3].
Sontag [14].
As Arthur W. Frank observes, this parallel realm is a consequence of the modern process of “colonization” which renders the ill person an example of a “type”, reducing the particularity of individual experience to a bland, formalised generality. See, Frank [4, pp. 9–11].
Oakeshott [9, p. 61].
Oakeshott [9, p. 56]. Bacon conceives of government, Oakeshott adds, as something “almost external to society”—as a giant regulator of relationships driven to supervise the worlds of trade and agriculture, combat “idleness and waste […] regulate prices and consumption, to distribute wealth, to endow learning, to settle religion (so that it should not interfere with the enterprise of mundane salvation) and, of course, to preserve order and guard against a foreign foe […]”. In short, the modern state is conceived of here as an imposer of rules in service of the attainment of a concrete end.
Pattison [11, p. 155].
Oakeshott [10, p. 44].
For the naïve person, this conformist view may appear to be Christian, but it is in reality “both immoral and unChristian” [10, p. 43].
Oakeshott [10, p. 45].
Oakeshott [10, p. 44].
Oakeshott [10, p. 45].
Oakeshott [10, p. 45].
It is in this sense the exponent of a woeful form of empiricism which is inclined to take “how things are” to indicate a contingently given state of affairs.
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Sedgwick, P.R. Instrumentalism, Civil Association and the Ethics of Health Care: Understanding the “Politics of Faith”. Health Care Anal 21, 208–223 (2013). https://doi.org/10.1007/s10728-013-0250-7
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DOI: https://doi.org/10.1007/s10728-013-0250-7