How we understand the situations in which we find ourselves has a profound influence on the way in which we behave. This page explores this issue and develops a framework of understanding from which to examine the corporatisation of health care. The page first sketches what has happened in health care, the similarity to many of the other beliefs and major traumas of the 20th century, and the inadequacy of conventional ideas about this. It goes on to explore a different set of ideas which more adequately explains what is happening. This page is pure theory and it is not necessary to read it to understand the web pages. Many will not want to be involved at this depth. Because people visit many of the pages on the web site directly, the ideas are repeated in different ways on many other pages on the web site. At the bottom of this page I have put links to many of them. Most describe real situations and the application of the ideas becomes clearer.
Traditional Understandings (Paradigms)
Developing another paradigm
Health Care and Society
Health care, a humanitarian service to the community is being turned into a marketable product across the world. This progressive marketing of citizens health and well being is further advanced in the USA. The USA consequently provides greater insight onto the consequences.
The introduction of a corporatised market driven health and aged care system in the USA has resulted in a health service which has systematically defrauded government, insurers and patients. The interests of patients have been subjugated to the financial demands of the share market. Patients have been used as the vehicle for generating profit without regard to their welfare or their rights. Marketing has replaced care as the key to success, and the value of stock has replaced it as the measure of success.
Staffing levels have been progressively reduced. There is evidence of widespread neglect in nursing homes, and of poorer results in corporate for profit hospitals. Profit driven and corporatised health systems have become the most expensive in the world, the most inequitable and the most inefficient. Financial and human resources are diverted from the care of patients to the business of health care, marketing, administration and competition. Measures of community health reveal that the US system performs very poorly when compared with other developed nations. There is clear evidence that not for profit health systems, and national health systems of various sorts are cheaper, more equitable, and provide equal and often superior care. They serve the community better.
The health care professions, once proudly independent and the upholders of strong ethical traditions have become party to this. Many have connived in the misuse of their patients for profit.
A leading US editorial puts it this way.
"Something is wrong in our nation's hospitals. While we are fatally injuring more people than are killed by automobiles and firearms, at a cost that is as large as caring for people with HIV/AIDS, hospital managers and even medical staffs appear more preoccupied with survival in the marketplace than the survival of their patients. This is a marketplace where hospitals and health plans would supposedly compete based on quality; where report cards would stimulate zealous efforts to enhance quality. Yet, the signs abound, that such report cards have failed and that the market is blind to all but the financial outcomes. *
Logic flies out of the window
Government agencies in the USA have known of these problems for at least 20 years. Multiple attempts have been made to address them. These have been accompanied by a progressive worsening of the problems. None of these attempts have sought the cause of the problem. None have even considered the possibility that there might be fundamental problems in market theory. Instead market theory has been used to address the problems - often making them worse.
Even though the facts are well known and the cause of the problems obvious countries across the world have, like Australia set about "reforming health care" by introducing health care marketplaces and competition policy. US corporations with tarnished track records have been welcomed with open arms. The world trade organisation is promoting the establishment of health care marketplaces around the world and the World Bank is being urged to follow suit.
To anyone standing outside the system looking in it makes no sense at all, yet to those inside the system it seems logical and the only way to proceed - why?
Setting it in context
Isn't this inability to step outside a belief system and look in the story of religious cults and of ideology - the debris of the 20th century littering the 21st? Germany in the 1930's, South Africa in the 1950's, Communism, China's Mao and then its cultural revolution, Yugoslavia and today fundamentalist terrorism. So it goes on, a bloody and destructive century yet one which has seen miraculous technological advances, many a consequence of these destructive forces.
We have seen millions of people committed to their beliefs, killing others to impose their beliefs, dying to protect them. Powerful empires have fought to impose their belief systems on those who challenge them. To the outsider many of these beliefs seem not only illogical but also monstrously evil. As time passes they become increasingly irrelevant to the lives of individuals - so much wasted energy and life.
Vast amounts have been written about these global events. There are also numerous analysis of health care by people far better trained than I am. I am not aware that any have drawn parallels between the powerful beliefs of the late 20th century and modern economic theory. A sure way of destroying your credibility is to do so - how ridiculous!
My only claim to credibility is a direct and personal involvement in both the grand events of the latter half of the 20th century and in the dramatic changes that are occurring in health care. I have been inside. While gaining the sort of understanding inherent in being a participant, I have succeeded in maintaining the position of an outsider looking in - and have been continuously critical.
I have acted in both situations at times in an attempt to mitigate the consequences and at others to directly confront the logic. I am impressed by the similarities, not of actual events, but of underlying human processes. This is not surprising as humans probably behave humanly wherever they are.
What do we know of the thought processes behind all of this behaviour? What can we learn from it? How do we understand it? What frames of understanding will allow us to grasp the essential features of this side of our humanity?
The Legacy of Historical Beliefs
It is easy to use emotive words like fraud, criminals and crooks and these words are useful when trying to increase public awareness of asocial conduct at a grass roots level. These words reveal black and white patterns of thought which are deeply rooted in our Judeo-Christian culture.
This understanding of the world we live in originates from simple historical concepts of good and evil. They were once personified in the form of God and the Devil. If we lead a good life then we were rewarded. We joined God in heaven - eternal paradise. If we were evil and did evil things then we were punished by being condemned to purgatory - joining the devil in the furnaces of hell. The dichotomy between good and evil still forms the framework within which social dysfunction is debated and policy formulated. It is not that the ideas are wrong, simply that they are limited. They provide no insight into what is happening. A deeper understanding is required.
This limited framework for understanding behaviour leads to solutions to combat "evil". These include increased oversight, policing and punishment. We rely on deterrents such as fines and prison sentences. Governments have targeted the problem of crime in this way both nationally and internationally. They have increased prison sentences and even introducing mandatory sentencing. The responses of both US and Australian governments to the problems created by a corporatised health care system have been to police and penalise.
This simplistic response is costly and at most marginally effective. Criminals become more adept and more selective. It concentrates on the dysfunctional behaviour itself. It does not ask why. It fails to address the more complex factors, which lead to dysfunctional behaviour. This is illogical. The closest we come to addressing the social factors behind the behaviour is a behaviourist discourse about incentives and disincentives. We ignore the systems of thinking which permit and even encourage dysfunctional practices.
Important underlying and potentially remediable causes are ignored. Public policy and belief systems continue to generate pressures that encourage and even mandate dysfunctional behaviour. Situations can be created where success can only be attained by antisocial behaviour. We then attempt to control the consequent antisocial behaviour with increasingly onerous oversight and greater punitive measures. All this is evident in the corporatised health care system. None of it is sensible
The role of oversight and punishment
I am not suggesting that some oversight, and punishment is inappropriate. We will never develop a perfect society. I am suggesting that we should not rely on these processes and that they should not be the primary thrust in addressing dysfunctional or criminal behaviour.
In her Boyer lectures (A Civil Society) Eva Cox suggests that regulation and punishment should rest lightly and be seldom used. They do not as the market believes set the limits of acceptable behaviour, but the limits of society's tolerance. Laws, the courts and public punishment do have an important cultural role in "objectifying" norms. They do not address society's problems.
(When criticised for their conduct corporate leaders are often genuinely indignant claiming that they have done nothing illegal. They have a responsibility to do all they are legally permitted to do for their shareholders. The rest of us see many of their actions as abhorrent, but they do not see their conduct as wrong if they think it is legal. Why? Could it be related to the situation in which they find themselves?)
ETHICAL CONSIDERATION OF CLAIMS BY MANAGED CARE (intervening explanatory text under headings deleted)
1. Resources are scarce so rationing care is necessary.
2. Cost savings occur from cost reduction.
3. Cost-containment measures, however harsh, are for the larger good of society.
5. Medical decisions are made in managed care by physicians of good character and competence, professionals who are committed to the greater needs of health careCharacter and competence become irrelevant when one is guided by a mission independent of these traits. I discovered painfully that my character and competence were incidental to my performance as an employee of a corporation. When my performance is measured in numbers and quotas, my job and character are severed.
In my work as an executive physician, I sat from a desk never facing patients or physicians whose lives I held in my hand. I wielded the power of payment, which translates to the power of life and death. Was I responsible when an adverse consequence occurred? No, never. The physician taking care of the patient would be, never mind that his or her hands may be too shackled to do what was necessary. Was I responsible if the patient did not get something necessary? No, never. I denied payment, not care. Was I responsible for another's suffering? No, never, not when any accountability was canceled out by my greater mission to society.
6. The spiraling health care costs justify anything necessary to control the decision-making of physicians. MANAGED CARE ETHICS: THE CLOSE VIEW PREPARED FOR U.S. HOUSE OF REPRESENTATIVES COMMITTEE ON COMMERCE SUBCOMMITTEE ON HEALTH AND ENVIRONMENT BY LINDA PEENO, M.D. The National Coalition of mental Health Professionals and Consumers May 30, 1996
Dr. Peeno is describing and criticising the ratonalisations and justification she and her colleagues working as gatekeepers for a "for profit" Health Maintenance Organisation (HMO) used when denying physicians requests to treat patients who needed care. When she was rewarded and praised for denying care to a patient who died as a result she developed a deeper understanding of the situation she was involved in and went on to further study in ethics and philosophy, playing a major role in opposing managed care. Her presentation analyses the way these justifications were twisted and misused to make HMO advocates and employees comfortable. The full submission is well worth reading after you have finished this page. It illustrates what I am saying. http://www.nomanagedcare.org/DrPeenotestimony.html I have included a number of quotes on this www site including another revealing quote describing corporate culture and thinking in an HMO.
Dr Peeno is describing the patterns of thought used in managed care and by HMO staff. HMOs make money by denying care and have a well documented track record for denying care to patients who need it. Dr Peeno describes how enthusiastically care is denied and how little discomfort those doing it feel. This is because the systems of thinking used make denial of needed care not only acceptable but necessary - even when patients die as a result.
Lets start with the idea that we humans have no choice but to live our lives -- even if this means deciding to terminate it. We have no choice but to do something in whatever situation we find ourselves. We have to build our lives there and most of us want to be successful in doing that. Provided we are successful most of us will do what we need to do even when this is not in society's best interests. We only rebel when we are unable to live our lives successfully.
People will develop ways of thinking and systems of explanation which allow them to succeed in what they are doing. These become the frames of understanding, or paradigms which are used by the people in this context to live their lives and make decisions. Those who play a big part in developing the ideas which people come to live by in a new area become founding leaders and are revered. Those who identify most strongly with the thinking become leaders and assume senior positions. They subsequently inherit the leaders mantle and pass it on. Those who disagree with what is being done can either look the other way and go along with it, go elsewhere, or else become a rebel and be attacked by the establishment.
If what people are required to do to be successful is functional for society and congruent with prior or outside thinking then it is likely to function well. The problems arise when the things which people are required to do to succeed are not functional for society or conflict with prior belief systems. This is the situation we have in the health care marketplace and both of these distracters operate. To succeed in the market participants must place economic considerations ahead of the care to their patients and their social responsibilities to the community. They must develop patterns of meaning and justifications which allow them to do this. They must somehow make it legitimate.
The founders of the big health care corporations in the USA illustrate the development of marketplace health care abstractions very well. These founding leaders surround themselves with devoted followers who will not challenge what they are saying and doing. If what needs to be done to succeed is socially unpalatable then a particular sort of leader seems to emerge, and the culture which he (usually male) develops has particular characteristics. This is particularly well illustrated in health and aged care.
The problems are exacerbated when competitive pressures and results oriented "behaviourist" economic policies like microeconomic reform are introduced to manage what is happening. Incentives (positive stimuli) and disincentives (negative stimuli) play a powerful supporting role in inducing people to behave in ways which will make them successful. They will adopt patterns of thinking which are dysfunctional. They use these patterns of thinking when they make decisions in their daily lives. This makes what they are doing legitimate. It makes them comfortable in what they are doing.
Typically new words, almost a new language is developed to foster the understandings and distance participants from contradictory evidence and common sense. Dr Peeno in her evidence about managed care given to the a US parliamentary committee in 1996 describes her experiences and analyses the processes at work. She first describes the process like this. "They have a vision for a social good, and are as fanatic in their pursuit of this as any group driven by the fervor of a righteousness cause." The greatest threat to situations like this is doubt and people who question. Those who do are ridiculed and marginalised.
The extract below summarises her description of the thinking used to make it legiimate.
When a "system" tightly connects its goals and consequences of non- compliance with economics, predictable behaviors occur. We can see these at work now in health care as:
* Ideological indoctrination, which currently occurs in such rationalizations as, "we are doing this in health care for 'the good of society,'" even if it requires some kind of sacrifice -- even harm -- at level of individual patient;
* Emphasis on "efficiency," which inherently strips complex, human engagements (e.g. what happens between a doctor/patient, and what happens when we need medical care) into artificial delineation, e.g. money involved with patient needs becomes a "loss" or a "savings"; care is divided between "unnecessary" and "necessary," etc.;
* Diffusion of responsibility, such that no one is responsible solely for adverse decisions;
* Fragmentation of behavior, enabling professionals to act one way in their role of work and different ways in other settings;
* Disconnection of conscience from conduct as a means to further insulate oneself from consequences;
* Depersonalization of beings who comprise this context, which here means patients who become a "member per member month"; a statistic on a data sheet fractured into a lab result, an x-ray, a procedure, etc.; a profit "loss" or "savings"; an "approval" or a "denial," etc.; in fact, the entire language used by the managed care industry reflects this -- no personal or human references are made;
* Instrumentalist thinking, i.e. treating every action as a means to something else, rather than an end in itself, e.g. the professional act of caring for a patient becomes a means to keep one's numbers "in line"; a means to increase one's bonus, or the profit of a company; a means to keep one's job, etc.; patient care is no longer an end to itself. MANAGED CARE ETHICS: THE CLOSE VIEW PREPARED FOR U.S. HOUSE OF REPRESENTATIVES COMMITTEE ON COMMERCE SUBCOMMITTEE ON HEALTH AND ENVIRONMENT BY LINDA PEENO, M.D. The National Coalition of mental Health Professionals and Consumers May 30, 1996 http://www.nomanagedcare.org/DrPeenotestimony.html
In contrast a cognitive approach to management and social structure looks at the patterns of thinking which are desirable for society and which will achieve social objectives. It then attempts to create a real context where these will take root. There is no guarantee that they will do so but it is much more likely.
There are of course no guarantees that a context which requires unsavoury practices will always go this way. A charismatic rebel may carry people with her and reject the undesirable practices and the system of thinking, replacing it with something better. The exact opposite can also occur. Neither of these are the norm and in the health care marketplace, replacing market thinking with a more service oriented approach leads to corporate failure.
The way language is used provides a window into what is happening, particularly that used in business. It is a presupposition to most discourse that you have a point of view and wish to get your way. It is a failing to admit you don't know, don't have a view or are receptive to the views of others. We read positively in business reviews of aggression, assertiveness, effectiveness, efficiency, focussed and similar words. These are all words about persuading, accomplishing and getting our way -- producing outcomes. The words reflective and wisdom, indicating a propensity to look at all sides of an issue and other points of view seldom appear. People who are reflective may be less likely to act decisively but they may act wisely. They seldom make any impact when others with fixed minds are being assertive about simplistic explanations. There is a correspondence here with what I have called open and closed minds (see later).
Both individuals and society are better and more functional for citizens when they have a broad range of abstractions which are soundly based in the real world, to reflect on and then apply wisely and selectively to the different situations encountered in their lives. Responding wisely and being receptive to the perspective's of others is an attribute of a civil society, a place where people lead fulfilling lives. Assertiveness is not.
Instead we live in a world where alternate perspectives are described as obsolete, self serving, or anticompetitive. This is called "labeling" and is one of the "closed minded" strategies I describe elsewhere. By applying a word from within the prevailing ideology which is derogatory the arguments and evidence can be legitimately discounted.
When we talk about frames of interpretation, patterns of thought, or paradigms we are talking about the words we use, the understandings we have, and the everyday theories which determine the way we think. In an earlier section I have suggested that the understandings which we use to deal with dysfunctional or criminal behaviour play a large part in determining how we respond to that behaviour. I want to use this insight to create a new set of understandings from which to examine what is happening in health care today.
The patterns of understanding which people bring to, or which develop in any situation play a major part in determining how they think and how they behave in that situation. To grasp why people behave in dysfunctional ways we should understand the situations within which they find themselves - the context of their lives. The understandings, which they bring with them as well as those, they have developed in response to the particular context provide the clues to their behaviour.
The new breed of health care provider is a businessman with a business training and experience in other businesses. Praise and affirmation comes from the marketplace. He is unlikely to challenge these fundamental beliefs and applies them to health care. Marketplace success is proof of their validity.
Belonging to a culture
No one is an island and no set of ideas can succeed if they stay in one mind. Understandings develop in interaction between people living their lives in the same context. People reinforce one another. They come to share beliefs and understandings which makes them more legitimate. A culture is a group, a society or even a country which shares common ideas about the way the world is and how to behave there. When a culture is successful for its members others adopt that culture. A subculture exists within a broader culture. Corporate health care culture is a subculture of marketplace culture. Each corporation will have its own slightly different subculture.
Doctors who work within the older medical culture will tend to identify with and more readily move towards the marketplace culture because this is advantageous for them personally. Nurses faced by cost cutting and deskilling will see the problems more clearly and will oppose it. It is not surprising that nurses have been most vociferous.
Context, meaning, identity and credibility
Paradigms (meaning patterns of understanding) developed in a particular context may either conflict with or be congruent with prior understandings. These prior paradigms may be culturally acquired. They may have developed in other contexts. The conflicts between different paradigms become acute when individuals and groups act out their understanding in their actions. This is how they "realise" themselves and establish an identity.
Perhaps the key to understanding the events of the 20th century lies in what we do when confronted by contradictory understandings and with hard evidence which challenges the dominant cultural understandings. How do we cope with this? What happens when an illogical culturally approved paradigm fosters our personal well being and allows us to take actions that develop a secure identity? Actions taken within alternate conflicting paradigms do not provide an acceptable identity in the context in which we find ourselves.
What happens for instance when actions beneficial to patients do not allow aspiring businessmen and businesswomen, even doctors to establish themselves as credible business people in the business world - the context of their lives? What strategies do ambitious individuals use to establish themselves as successful in the eyes of their peers? What sorts of people succeed?
In the business context the measure of success is money and not care. What happens to those who fail to make money because they have acted within a paradigm which considers it unethical to profit at the expense of those who are vulnerable? What sort of identity do they have and how much influence will they be able to exert with this identity. In other words how credible will they be?
How will a quietly conscientious doctor, who has been peer reviewed out of his hospital because he spends too much time listening to his patients instead of ordering tests which make money for the hospital stack up in the public debate? This is called economic credentialing and corporations see it as legitimate. What about his colleague who has been "delisted" by her HMO because she gives patients accurate information, which is not in the HMO's economic interests. How do these people get their point across when lobbying politicians? How credible are doctors who have been sanctioned by mighty corporations? How do they take on icons like Murdoch, Gates and Jim Clark, the corporate giants who have founded Healtheon - the new wave of efficient corporate medicine?
Identity is something we claim through our actions. It is something which each of us has. We think of it as entirely ours. It is however, something that is granted by our peers and the community - a social, rather than personal attribute. We cannot have a stable identity in isolation. As social beings identity - who we are - is inseparably from those around us, from the understandings we develop together and from the contexts from which this identity was structured. In a sense we are the person whom others have allowed us to be.
Reform and reformers
Social reformers aim to get individuals to identify with and so come to "own" patterns of ideas - new meanings. They induce individuals to realise themselves by acting out the concepts, which then become integral to who they are. These individuals then become advocates for the ideas and are personally challenged by conflicting evidence or arguments. How do they respond? In one sense they are "owned by" the concepts and become their servants. They go out and sell the ideas.
Corporate businessmen see themselves as reformers and what they are reforming is health care! Their economic success gives them supreme self confidence and credibility in the modern world. They induce health professionals to identify with and own the meanings that make corporate health care legitimate. What has happened in the US is a measure of their success in doing so.
Handling conflicting concepts
To understand dysfunctional behaviour we should consider how individuals and groups respond to conflicts between different paradigms (or understandings). We need to relate this to the psychology of individuals and groups to see how and why some individuals and groups succumb to the pressures surrounding them while others resist - why some individuals succeed in a particular context and others fail.
To understand health care today we need to recognise the conflicts between the marketplace paradigm and the more community orientated and traditional Hippocratic and Samaritan paradigms with which the health care professions and the community have identified. The marketplace paradigm is exemplified in the thrust to "reform" health care using competitive market forces. Proponents of market forces do not acknowledge the conflicts. They have discounted them on the one hand by labeling the health care paradigms as obsolete and criticising those who promote them. On the other they claim a commitment to care and quality on the basis that the two are congruent and that good care increases profits. Customers, they claim, will ensure this. Market proponents claim that marketplace success is proof of good care. people would not pay for it if it wasn't.
They are not being dishonest. They really believe this. Because the paradigms they use have lost contact with reality they can bend them to whatever purpose they wish without noticing any contradiction.
Open and Closed Minds
World views:- The terms open minded and closed minded are used many times on these web pages. I have borrowed them from a book of the same tittle written by Rokeach, a psychologist in the 1960s. Underlying these concepts is the earlier work of two sociologists Berger and Luckman. They examined the world of abstractions which we use to grasp the real world. This is the "canopy" of ideas under which we live and which we use to understand the world. We can also call this complex of ideas a "world view".
Our personal comfort and grasp of the world depends on our world view being reasonably integrated and making logical sense. If it doesn't fit the facts or two sets of ideas conflict then we experience a state of mental discomfort. We call it dissonance. Our worldview contains many conflicting situations and we must all confront them. Marketplace corporate medicine creates many such conflicts. Open and closed minds are descriptive terms which describe two extremes in the way we deal with these conflicts.
Open minds:- An open or reflective person is one who can cope more readily with dissonance. She uses her intelligence to resolve the conflicts, search for explanations, develop new understandings to bridge and understand the conflicts, or modify one or other of the understandings. She can accept more complex ideas. If she is unable to resolve the conflict she is able to live with and acknowledge this uncertainty. In her public presence she will express doubt and uncertainty. She is unlikely to be assertive and aggressive. If a community is under stress her lack of simple answers and the certainty a community requires will keep her out of leadership.
Closed minds:- A closed or one eyed person is someone who tolerates dissonance poorly. He has a far greater need for certainty. He latches onto a set of beliefs and won't let go. Rokeach links this to dogmatism. Typically a person like this compartmentalises conflicts putting them in separate mental compartments and never confronts the conflicts between them. He uses "selective perception", seeing only those things congruent with his ideas. Instead of using his intelligence to challenge and resolve conflicts he uses it to rationalise and justify. When he is challenged he ridicules the messenger and then becomes aggressive and attacks him rather than the evidence. These people have no doubts, They are supremely confident and often very plausible. In an uncertain situation their certainty ensures they become leaders. They simply do not see what they don't want to see and they help others not to look.
A continuum:- None of us are completely open minded or completely closed minded. We lie along a continuum between these two extremes and as individuals and societies we occupy different positions at different times. When we are under pressure and experiencing stress we will look for certainty and swing markedly towards closed mindedness. We hang onto old ideas. We can call this "responsive" behaviour. Under more favourable conditions when we are not threatened we may find the dissonance challenging and the conflicts interesting. We enjoy meeting them in an open minded way. We find it exciting and develop new ideas. We can call this "constructive" behaviour. This is what we strive for in modern education. This is the essence of building ourselves and building society.
Successful sociopaths:- Psychologists deal with psychopaths in prisons. They find that there are greater and lesser degrees of psychopathy and the latter are not in prison. They would classify some of the leaders of health care companies as psychopaths or successful sociopaths. Sociopaths of course are untreatable. We have to live with them, but we don't have to make them leaders.
To be successful sociopaths must acquire a following. In other words a group of perfectly normal people must support the sociopath and embrace his meanings and understandings. I don't think that successful sociopaths and the culture that supports them can really be separated. They employ the same strategies and behave similarly. I have retained the term successful sociopath because it so aptly describes what these people do. However in these pages I have used it to describe the extreme end of the closed minded spectrum of behaviour. We are certainly talking about the same people and at that extreme they probably are untreatable. The extreme end of closed mindedness extends into the more normal end of the psychopath spectrum.
Health care does not operate in a vacuum. What is happening must be seen within the context of the wider society and the changes that are occurring there.
The comfort of all embracing theories
The Canadian John Ralston Saul has drawn attention to our 20th century predilection for simplistic overarching and all embracing theoretical understandings** These make life simple and comfortable. These understandings allow individuals and groups to strut the world stage. By acting out their ideas they realise themselves on a grand scale (Mussolini, Hitler, Stalin, Mao).
The development of all embracing ideologies like fascism, communism, and apartheid has made the 20th century one of the most violent and bloody in human history. In each of these ideologies ideas which appeared self evident in a particular narrow and limited context have been "internalised" and embraced by charismatic leaders and dominant groups in society. They have been generalised ruthlessly and indiscriminately across all situations in the face of reason and evidence.
The 20th century has displayed a propensity to universalise ideas that are discordant with society's view of itself as a human and humane endeavour. This flow on of all embracing but distorted ideas and practices has been described as the debris of the 20th century littering the 21st.*** As we enter the 21st century proponents of universal economic understandings still hold power and dominate, but a challenge is emerging.
Signs of Real Change
There is a new "post modern" intellectual movement. This eschews all embracing theory and sees meaning as integral to context and the way people live. Without denying broad understandings of human behaviour it sees the meanings by which we live as individual and context related. Broad theories may or may not have relevance in a particular context. In other words understandings are seen to relate to particular situations rather than all situations. This movement is young and in a world dominated by an all-embracing corporatised understanding of globalisation it has no power.
We are faced with a set of concepts variously called market theory, competition policy, economic rationalism, corporatism, micro-economic reform, managerialism etc. They reflect a paradigm developed in the corporate marketplace, which now dominates social policy and practice. It has appropriated the language we use, the structures of society, and the process of globalisation as its own. It is based on self interest and personal greed. It is set in stark conflict with traditional social understandings and our sense of mutual responsibility and community.
It does not recognise or acknowledge this. Instead it labels and discounts social discordance as due to a fear of change. Instead of confronting the fundamental problems and the evidence of dysfunction it talks of educating the community to its point of view. It often markets a caring face and tries to identify with it. It even supports and contributes to public and humanitarian activities. Those who accumulate great wealth bask in their philanthropy.
It is not that self interest is wrong but that it is unbalanced. It is not that philanthropy is wrong but that it is used to create an illusion which those who identify with the patterns of thinking can use to sustain their illusions. It is not even that a marketplace is wrong. It is that the a pattern of ideas which has some application in the marketplace context has been developed and exaggerated into an ideology similar to the other 20th century ideologies.
This has been carried to such an extreme that it has lost touch with the real world we live in. This is Saul's unconscious civilisation. Marketplace meanings have been isolated from the community within which the market operates. Commercial decisions like destroying evidence (tobacco companies**** ) are seen to be legitimate business activities even when they are socially atrocious. Successful marketplace thinking has then been generalised to every facet of our society and our lives. It is imposed on areas where it has little relevance and creates extreme conflict with existing understandings. Society itself seems to have become a subset of the marketplace. The consequences are well illustrated in health and aged care, particularly in the US marketplace.
The marketplace is an important part of society. Our complex human western civilisation with all its values rests on the market's successful operation. Controlled self interest works while it is balanced by other values and is a subset of a broader culture of integrity, community and responsibility to others. It is all about balance, insight, perspective and common sense -- something we used to call wisdom!
Using the proposed paradigm
The paradigm of understanding I am promoting indicates that the stresses generated between paradigms will create intense psychological discomfort (called dissonance) across large sections of society. This is reflected in protest movements from both the right (One Nation) and the left (Demonstrations in Seattle and Melbourne). Political lines are being redrawn. Previous opponents are becoming uncomfortable allies. Twentieth century experience suggests that instead of addressing fundamental questions this protest movement will be met by every possible social and corporate strategy, and when all else fails violent repression.
And in Health Care
The application of market theory to health care is most developed in the USA and the dissonance created has similarly generated a strong backlash from all sides of the political spectrum. Despite this fundamental questions are not being confronted.
Purists may accuse me of promoting a deterministic theory of behaviour. Human behaviour can never be determined with certainty. I am not suggesting that context fully determines behaviour. Public spirited and unique individuals may assert their influence in the worst context, develop socially responsible paradigms and secure desirable outcomes. Disturbed individuals and groups may arise in the most favourable context and develop paradigms, which lead to unacceptable conduct.
We also have the ability to "transcend" the situation in which we find ourselves by developing understandings that go beyond the immediate context and its paradigms. Instead of developing another paradigm for health care I am trying to stand back and develop a paradigm which embraces and explains how paradigms develop and how they influence our behaviour - a theory about theories - a way of breaking out of the 20th century ideological loop.
What I am suggesting is that the chances of acceptable behaviour are far greater in a favourable context and markedly reduced when the context creates pressures towards antisocial behaviour. When health care in Australia is subjected to market stresses Australians can and may behave differently to the USA but it is unlikely that this will happen. The signs so far are not encouraging.
We do have the capacity to address the contexts and the paradigms within which we live our lives and so make socially beneficial outcomes more likely. The question is whether we will do so. There is little sign of this.
Until probably the middle of the 20th century the paradigms which governed the provision of health care required that it be provided only in the interests of the individuals who were ill. Those who provided these services on behalf of society were entitled to a reasonable reward for their services. They were ethically bound to place the interests of the ill person ahead of any personal gain. The provision of care for personal benefit or for the benefit of a third party was socially unacceptable. To ensure this providers of health services were required to be socially responsible. Probity was a key licensing requirement.
During the second half of the 20th century commercial forces increasingly impacted on health care and the professions bent before the winds of change. The consequent dysfunction was seen as due to professionalism itself, rather than the impact of market forces on professionalism. The response was to increase market forces. By the end of the 20th century corporatisation was progressing rapidly and health care was increasingly a servant of the stock market.
The corporatisation of health care is a consequence of a new set of universal economic belief systems which have come to dominate social processes. This new belief system has made it socially acceptable and perfectly legitimate for some members of society to profit economically from the miseries and vulnerability of others. Those who provide care are expected to do so for the economic benefit of corporate groups and of third parties who have no direct interest in the patient's welfare. Care for the patient has been replaced by care for the corporation. Patterns of thinking have been developed to make this socially acceptable.
Market theory conflicts directly with norms that have protected vulnerable people from exploitation for over 2000 years. This conflict is not confronted. Instead probity requirements in health care are considered to be obsolete obstructions to legitimate business activities. They have been undermined and even removed from licensing requirements for nursing homes in Australia - our most vulnerable sector.
Originating in the marketplace economic theory has been generalised into a belief system governing all facets of human behaviour.
In this page I have developed a framework of understanding for analysing the impact of these changes in health care. It should provide guidance when creating a more appropriate context for caring for those in society who cannot care for themselves. It may have wider implications but its relevance to other contexts should be assessed first.
I ask you to keep this paradigm in mind as you read the www pages on this site. Please consider the frames of understanding revealed by the material and relate them to the conduct reported.
If you would like to explore specific instances or don't understand this web page then go to some of the links to specific examples on the previous page
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Finance vs. Vigilance in our Nations' Hospitals
Editorial by G. Schiff, JGIM, April 2000
** John Raulston Saul " The Unconscious Civilization"-The Massey lectures Penguin books 1997
***Hsu-Ming Teo "Those who can,do" The Australian Jan 1, 2000
**** Interview previous tobacco executive. ABC Television 7.30 report July 23, 2003