Transcript Slide 1

Policy, Politics
and
Philosophy
Maggie Barker MD MPhil FFPH
31st January 2015
Aim
To signal the close interrelationship
between ethics and political philosophy;
and how political theory - and politics underpin public policy and modern health
systems.
Learning Objectives
• To gain a ‘bird’s eye’ overview of the history
of political philosophy, with some key
landmarks.
• To appreciate the core elements of political
theory, such as political authority,
democracy, freedom, rights, justice.
• To begin to take a political philosophy
perspective on health care provision and to
relate questions of health care ethics to the
broader policy and political context.
History and Politics
• Nietzsche’s approach to philosophy –
‘genealogy’.
• ‘Only what has no history can be defined.’ A
‘triangle’ is a triangle across the centuries.
• Words – like ‘democracy’, ‘liberalism’ - have
shifting constellations of meanings,
contingent on historically inherently variable
configurations of powers, functions,
structures and beliefs.
History, politics and health care
A healthcare system is a structured set of various
powers, agents, functions, and goals. Over time, it
might move through being:
– Founded by a religious order – with physical
health subordinate to salvation and an instrument
of Christian charity
– transformed to an object of liberal universalist
humanitarianism
– Subordinate to other political goals: an instrument
of world proletarian revolution (Bolsheviks); a tool
for preserving the human race – or destroying
sections of it (National Socialists).
‘Our’ time and place …..
• Prevailing assumption in Western Europe is a
single ideal model with five elements:
– democratic liberal state (three separate
elements: liberalism, democracy, the state)
– With a capitalist economy
– And a commitment to a set of human rights
• Conjunction of these five elements is result of a
highly contingent historical process.
• Consistency and practical coherence?
Raymond Geuss suggests this is an illusion.
Tensions are inherent.
Ancient Greece
Period
Year
Archaic
Before 450 BCE
753
530
483
479
(469 – 399 BCE)
Foundation of Rome
Pythagoras active
Death of Buddha
Death of Confucius
Socrates
Classical
450-323 BCE
447
430-380
(430-347 BCE)
(384-322 BCE)
386
335
Parthenon built
Hippocratic Corpus
Plato
Aristotle
Plato founds the Academy
Aristotle founds Lyceum
Hellenistic
323-1 BCE
323
Death of Alexander the
Great
Roman
1 – 300 CE
100 CE
(129-216? CE)
Birth of Julius Caesar
Galen
[404 BCE: End of
Peloponnesian war. Athenian
democracy replaced by
Spartan autocracy .]
Ancient political philosophy
5th century BCE to 5th Century CE
• Invented by Plato (eg in The Republic)
• Reinvented by Aristotle (Politics)
• Covers:
– Origin of political institutions
– Concepts to interpret and organise political
life (justice, equality)
– Relation between ethics and politics
– Relative merit of different constitutional
arrangements or regimes
Ancient political philosophy
• City - state (polis). Acme of human
civilisation, principal domain in which human
fulfilment sought and good life lived.
• ‘Politics’ based on idea that the shared
feature of citizens is rationality, and only
appropriate relation between rational beings
is persuasion – discussion in agora.
• Cf despotism.
• Politics the activity specific to being a citizen.
• Very few political ideas discussed today were
not first recognised by the Greeks.
Ancient political philosophy
• Ancient Greek ‘regimes’ – ‘constitutions’ – set of
offices and laws.
• Belong to the sphere of the rational and
therefore open to scientific enquiry.
• Can be classified:
– Good
• monarchy; aristocracy; democracy
– Poor
• tyranny; oligarchy; bad democracy
Medieval to early modern
• 1000 years: fall of Roman Empire to start of modern
world
– Religion and rise of Christianity
– Feudal order emerging out of violence
– By 11th century – mosaic of principalities – dukes,
counts, kings – and parliaments
– Renaissance 9th to 12th Century. Legal institutions,
universities
• Early modern state – around 16th Century
– Kingdoms fragment or unify - courts
– Emergence of vocabulary of rights
– New politics: First explicit in Italian Cities: Machiavelli
The Prince (1532) – a handbook of the ‘Art of State’.
17th-19th Century landmarks
• Thomas Hobbes: Leviathan (1651)
• John Locke: Second Treatise of
Government (1689)
• Jean-Jacques Rousseau: The Social
Contract (1762)
• Karl Marx and Frederick Engels: The
Communist Manifesto (1848)
• John Stuart Mill: On Liberty (1859)
Some elements of political philosophy
1.
2.
3.
4.
States, political power and authority
Democracy
Freedom and the limits of government
Social justice
1. States, political power and authority
• Hobbes’ Leviathan (1651)painted a bleak
picture of the ‘natural conditions of
mankind’ without political rule - ferocious
competition for the necessities of life …
“and the life of man, solitary, poor, nasty,
brutish, and short.”
• Concludes we must submit to any
established and effective ‘absolute’
government no matter what its credentials.
1. States, political power and authority
• John Locke Second Treatise of
Government (1689)dismisses view of
imposed government: we all accept
benefits from the state and our acceptance
can be treated as a form of consent.
• Jean Jacques Rousseau The Social
Contract (1762)
1. States, political power and authority
• Political authority refers to the authority of the state
– The state has a monopoly on use of coercive power
within its borders (jurisdiction)
– Everyone is subject to this power
– Everyone is obliged to obey this power
• Authority is distinguished from mere power. Authority
indicates a normative relationship between the giver of
orders and the receiver. An authority’s orders are
binding because of who gives them:
– A bully has power over me but no authority
– A team leader may have authority but lack power
1. States, political power and authority
• If the state’s power is legitimate, then we are said
to have an obligation to obey its commands
• Widely understood to be a moral duty
• Applies particularly in the case of one’s own
government, which may impose additional duties payment of taxes or serving in the army
• But one should also obey other countries’ laws
when visiting them
• Typically this will be a prima facie duty
– We may (perhaps) break the law if it goes against
other moral duties, such as not killing others, or in
exceptional circumstances
1. States, political power and authority
• Anarchism denies that the state has legitimate
authority. Social cooperation is possible without
political authority. Broadly two camps.
• Communitarian anarchists – the building blocks of
government are small tightly knit communities,
founded on trust (Russian prince Peter
Kropotkin.)
• Market anarchists – libertarians. Believe the
economic market could replace the state. For
example, Robert Nozick, Anarchy, State and
Utopia 1974.
2. Democracy
• Although there is no agreed definition, the
overall aim of democracy is collective self-rule.
• We can distinguish between
– direct and representative democracies
(do citizens vote directly on issues or elect
representatives to take decisions?)
– aggregative and deliberative democracies
(is democracy a matter of adding up
preferences or about debating issues?)
2. Democracy
Is democracy the best form of government?
• Ruling takes skill
– Government is best left to the experts. Would you
trust a passenger to navigate a ship? (Plato)
• Democracy is inherently unstable
– Individuals’ motivations can be divisive and
produce factions which undermine good
government (Hobbes)
• There are other priorities
– eg authoritarian government is seen as the best
way to deliver economic development
3. Freedom and the limits of government
• Through 18th and early 19th century (with growth
of religious tolerance, and romantic movement)
emergence of view that each person is a unique
individual who can find true fulfilment only if
allowed to choose for themselves how to live.
• Good government is not enough – even the best
constructed, best intentioned government will be
tempted to intrude in areas in which individual
liberty ought to be sacrosanct.
• Liberalism: there is a sphere of personal
freedom that should be protected against the
intrusion of government.
3. Freedom and the limits of government
John Stuart Mill: On Liberty
• Defence of liberty against the state – through
demarcating a sphere of private activity within
which people should have complete freedom to
do as they like.
• When a person’s actions are ‘self-regarding’ – ie
when they cause no harm to the interests of
anyone, except possibly the person themselves they should never be interfered with.
• Is it possible to draw this line?
3. Freedom and the limits of government
Isaiah Berlin: Two Concepts of Liberty
• Positive liberty – the internal aspect of
freedom, a person’s capacity to make
genuine choices among available options.
• Negative liberty – having options that are not
blocked by external forces.
• Berlin was worried about positive liberty
which he believed could be used to justify
authoritarian or totalitarian regimes.
3. Freedom and the limits of government
• Human rights - a different way of restricting - in the
name of individual freedom - what the state may do.
• Concept of natural rights goes back to early liberal
philosophy: eg Locke claimed all men had natural
rights to life, liberty and property Governments
established by social contract undertook to protect
these rights as a condition of having political
authority.
• 1948 Universal Declaration of Human Rights.
Signatory states signed up to much more extensive
list of rights.
• Rights identify certain conditions without which a
human being cannot lead a decent life.
3. Freedom and the limits of government
Emergence of ‘patient choice’ reflects shifting political ideology.
• Post-war NHS designed along egalitarian principles: to meet
collective needs - not individual wants - through a universal, costeffective service, provided free at the point of delivery. Offering
choice not a stated goal.
• ‘Market-reforms’ of public services in the 1990s, driven from an
ideological commitment to the superiority of the market over state
planning in delivering better economic and welfare outcomes.
• Shift to market liberalism brought an emphasis on the individual and
the gradual emergence of the concept of ‘individual patient choice’.
Meanwhile the language of consumers and customer services
became pervasive .
• Shift from paternalistic traditions, in which doctors were the proper
judges of the patient’s best interests, to modern doctor-patient
relationship in which the patient is an equal partner.
• The NHS Constitution (2009) captured this concept of the patient as
a consumer who can expect choice and established a “right to
choice and to information to support that choice”.
4. Social justice
• The idea of social justice is that we can put in place a
set of social and political institutions that will ensure
the just distribution of benefits and costs throughout
society.
• First introduced in late 19th century, and at heart of
political debate in 20th.
• Controversial idea – cf idea of justice as such. Critics
particularly on the libertarian right see it as corrosive of
personal freedom, and especially of the economic
freedom that a market economy requires.
• Freidrich Hayek – claims error in talking about social
justice in the first place.
4. Social justice
Justice in ancient political philosophy
• Either corrective - punishment for offences
• Or distributive – just distribution of good and bad
things.
‘Principle of distributive justice’:
– Equals should be treated equally and
unequals unequally in relevant respects and
in proportion to the relevant inequalities.
• Foundation of civic life - the basis of human
citizenship and civic bonds.
4. Social justice
• Marxism and communitarian anarchism - a just society is one in
which everyone contributes to the best of his or her ability; but
resources are distributed according to need, with any surplus being
shared equally.
• Less radically, democratic socialists view social justice as
– Equal distribution of some social benefits – eg rights of
citizenship
– Some benefits distributed on basis of need, so everyone has
adequate income, housing etc
– But also allows other benefits to be distributed unequally, as long
as there is equal opportunity for everyone to try to acquire a
larger share.
• John Rawls- A Theory of Justice: explicitly makes room for the
market economy. Inequalities of income and wealth are justified
when they work to the benefit of the least advantaged members of
society (the difference principle).
Policy, Politics and Philosophy
and Health
1. The ethics of population health and public
health services: health inequalities
2. Globalism – including global justice
3. Ethics of science and technology
1. Public health ethics
• Public health tends to be a multi-agency
endeavour backed by executive and legislative
powers. Immunisation, screening programmes,
health promotion, infection control (eg quarantine)
– all rich with ethical concerns.
• Public health ethics a relatively recent speciality. A
distinctive aspect is the dilemma that can arise
between individual rights and community benefit.
• Public health cast within a utilitarian paradigm.
But proper ethical assessment requires taking a
variety of perspectives
2. Globalism
• Cosmopolitanism: world government – in literal sense.
Implausible and unattractive. Kant on world
government: “A universal despotism which saps all
man’s energies and ends in the graveyard of
freedom.”
• World citizenship – individuals should think and
behave as citizens of the world – equal responsibilities
to our fellow human beings everywhere. National
boundaries are simply arbitrary.
• Global justice across nation boundaries? Should we
seek to equalize prospects across the entire globe? Or
is the demand for equality limited to fellow citizens
and/or residents of a state? What obligations beyond a
humanitarian minimum do we have at the global level?
3. Ethics of science and technology
• Are science and technology instruments of social
progress and personal liberation? Or are they
instruments of injustice and oppression?
• How can scientific experts help societies make better
collective choices?
• Should the opinions, needs and interests of citizens
determine science policy?
• How can laypersons contribute to debates about science
and technology if such decisions are often on issues that
non-experts do not fully grasp? Should such decisions
be left to scientists? Should they be left to funders?
• How can we avoid elitism, paternalism, the distortions of
commercialisation, and the tyranny of the ignorant?
3. Ethics of science and technology
• Is the politicisation of science a good or a bad thing?
• Are the methods of participatory and deliberative
democracy useful in this context?
• Do the citizens of democratic societies have a duty to
promote and participate in scientific research?
• Should there be mechanisms to ensure that scientific
research contributes to the public good, and that the
benefits and costs of science are distributed according to
correct principles of justice?
• Should there be mechanisms to ensure that the
disadvantaged are not made even worse off by scientific
research and by the introduction of new technologies?
• What if these mechanisms require the imposition of tight
constraints on the freedom of scientists?