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 GreecePeriod Year

ArchaicBefore 450 BCE

753530483479(469 – 399 BCE)

Foundation of RomePythagoras activeDeath of BuddhaDeath of ConfuciusSocrates

Classical450-323 BCE[404 BCE: End of Peloponnesian war. Athenian democracy replaced by Spartan autocracy .]

447430-380(430-347 BCE)(384-322 BCE)386335

Parthenon builtHippocratic CorpusPlatoAristotlePlato founds the AcademyAristotle founds Lyceum

Hellenistic323-1 BCE

323 Death of Alexander the Great

Roman1 – 300 CE

100 CE(129-216? CE)

Birth of Julius CaesarGalen

Ancient political philosophy5th 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.States, political power and authority

2.Democracy

3.Freedom and the limits of government

4.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 governmentEmergence of ‘patient choice’ reflects shifting political ideology. • Post-war NHS designed along egalitarian principles: to meet collective

needs - not individual wants - through a universal, cost-effective 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 Philosophyand 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?