Class Harmonies in Health Care? The Social-Democratic Way

Researchers in health care, like researchers in education, seem to assume that the current social structures are sacred. They simply research what is there, and assume that any problems must be resolved in terms established by that social structure. There are, of course, possible differences in the way problems are defined or solutions proposed, but there are limits to problem definition or proposed solutions can be forthcoming from the social-democratic point of view. That limit is the class of employers. Social democrats assume–probably without being aware of it–that all problem definitions and proposed solutions must fit into a social structure characterized by a class of employers.

Consider research on what has been called “patient-centred care” (PCC). This idea is similar to the idea of a “child-centred curriculum” that often circulates in school circles.

One researcher, Sara Kreindler  (“The Politics of Patient-Centred Care,”2013, in pages 1139-1150,  Health Expectations, volume 18) argues that there are at least three different groups that argue for PCC, with each one excluding the other two as legitimate representatives of the interests of patients: management, providers (doctors and nurses) and patient advocates outside the health-care system. Each group claims to represent the interests of patients, but they do so by excluding the other interest groups as legitimate representatives of the interests of patients.

Her solution to this problem is to claim that the aspire model (The Actualizing Social and Personal Identity Resources) provides a four-step model that permits the simultaneous recognition of each group’s identity while enabling a synthesis to emerge that incorporates the different views without trampling on each other’s social identity.  The groups are identified through a survey of staff, then each group discusses issues related to its own point of view without the influence of other groups. The third step involves the selection of representatives from each group to come together in order to come to a common vision of what PCC involves. The fourth step is to implement the common vision. Ms. Kreindler argues that it is the process that will lead to change; we should not second-guess the changes required to realize a PCC approach.

Ms. Kreindler, however, argues the following contentious view (page 1147):

While it may be counterproductive to define PCC in terms of taking power or focus away from certain groups, it remains very legitimate to talk about putting patients first.

In the first place, Ms. Kreindler assumes what she needs to prove: that a focus on patient care can exist independently of power relations. She does recognize such power relations when she makes the following assertion (page 1147):

Second, each subgroup discusses the issue separately, defining it in their own terms and using their own language (which may or may not include the term ‘patient-centred care’5). This is very important if staff groups are to have real ownership of the process and make a meaningful contribution; it is even more important for
patients, who have the least power and perceived expertise within the health-care system. Patient/family groups should have a neutral facilitator and not be led (or even frequented) by managers, to avoid the risk of co-optation either by ‘the system’ in general or by whatever subset of managers happens to run the involvement activity.

Ms. Kreindler never questions whether it is really possible to have equality between different “interest groups” in the context of the employer-employee relation and in the  context of the power of a class of employers. We see this problem when Trump argued that workers should go back to work on April 12–despite the biological possibility of many workers being exposed to the coronavirus as a consequence. Workers and many community members in a society dominated by a class of employers are, ultimately, things to be used, and this priority conflicts with any real concept of the patient coming first.

Ms. Kreindler’s belief that somehow managers, as representatives of employers, can somehow be treated at the same level of power as professional groups and patient advocates has little warrant. Since employers have control, in one way or another, over budgeting, finance, health facilities and wages, they ultimately call the shots concerning patient care. This situation does not mean that some of the power of managers cannot be limited. Such a limitation, however, is similar to the limitation of collective bargaining and collective agreements. Employers may be forced to grant some concessions, but this hardly means that they are not the primary power holders in the situation.

One of Ms. Kreindler’s implicit views is that the employers’ interests (represented by management) and the interests of employees can somehow be reconciled. An alternate view argues the contrary:

One highly useful example from the empirical literature that illustrates
the effects of process alienation is that of Whitehall I and Whitehall II studies
of Whitehall civil servants (Marmot et al., 1997, 1999). Forbes and
Wainwright (2001, p. 810) have commented, but do not develop further, that
the evidence and results from the studies appear ‘to be directly related to the
Marxian concepts of alienation and exploitation’. The research has identified
that among civil servants of differing ranks there are decidedly different
experiences of health that appear to relate to how much control a worker has
in their workplace. Looking more squarely at the studies a picture of how
process alienation is at play can be established. In both studies, there is a
clear social gradient in mortality (Marmot et al., 1984) and morbidity
(Marmot et al., 1991). In these studies we see how a worker’s health is
affected by the extent of their control (examples being, choosing what to do at
work, in planning, or in deciding work speed) within their working
environment (Bosma et al., 1997), and how on a variety of measures the health, whether physical (for men and women) or mental (mainly for men),
is influenced by the position or rank that they hold within the organization
(Martikainen et al., 1999). This chimes very much with the alienation that
arises out of the labour process where ‘[i]nstead of developing the potential
inherent in man’s powers, capitalist labour consumes these powers without
replenishing them, burns them up as if they were a fuel, and leaves the
individual worker that much poorer’ (Ollman, 1976, p. 137).

Ms. Kreindler assumes that in a relation characterized by economic dependence, hierarchical authority and detailed division of labour, the interests of management and health employees can somehow converge by putting the patient first. Her assumption reminds me of Professor Noonan’s assumption of class harmony at universities (see The Poverty of Academic Leftism, Part Five: Middle-Class Delusions). Both magically wand away the antagonistic interests of subordinates and superiors in public institutions.

In relation to the principle that patients come first, it is too much to believe that patients will ever really come first when human beings are evaluated on the same level as things: they are a cost, in money terms, and such costs, when set in the context of a society dominated by employers, must always be considered in relation to “alternative use of resources” for such things as buying medical equipment, medication, and so forth, internally, and in relation to the diverse expenditures in other government departments for the maintenance of a society dominated by a class of employers.

Related to this issue is the reason why a hierarchy of skilled and less skilled workers arises in the first place; such a hierarchy has advantages from the point of view of the class of employers. Charles Babbage (a pioneer in developing some principles of computer construction in the nineteenth century), published a book in 1832 titled On the Economy of Machinery and Manufactures, where he pointed out a major advantage for such a hierarchy. From Harry Braverman, Labor and Monopoly Capital: The Degradation of Work in the Twentieth Century, pages 79-80:

In “On the Division of Labour,” Chapter XIX of his On the Economy of Machinery and Manufactures, the first edition of which was published in 1832, Babbage noted that “the most important and influential cause [of savings from the division of labor] has been altogether unnoticed.” He recapitulates the classic arguments of William Petty, Adam Smith, and the other political economists, quotes from Smith the passage
reproduced above about the “three different circumstances” of the division of labor which add to the productivity of labor, and continues:

Now, although all these are important causes, and each has its influence on the result; yet it appears to me, that any explanation of the cheapness of manufactured articles, as consequent upon the division of labour, would be incomplete if the following principle were omitted to be stated.

That the master manufacturer, by dividing the work to be executed into
different processes, each requiring different degrees ef skill or ef farce, can purchase exactly that precise quantity ef both which is necessary for each
process; whereas, if the whole work were executed by one workman, that
person must possess sufficient skill to perform the most difficult, and
sufficient strength to execute the most laborious, ef the operations into which
the art is divided. 13

To put this all-important principle another way, in a society based upon the purchase and sale of labor power [the commodity the worker sells on the market, different from labour since workers, when they labour, have already sold their commodity], dividing the craft cheapens its individual parts.

Ms. Kreindler does not even consider the issue as relevant; indeed, I doubt that she is even aware of the issue. She blindly assumes the permanent status of a hierarchical division of labour.

Of course, there may be other conditions which involve a hierarchical division of labour than the allocation of diverse skills to different individuals for the purpose of cheapening the total wage bill, but this process undoubtedly forms part of the reason why there exists a hierarchical division of labour.

Some workers in that hierarchical division of labour may, on the other hand, be more autonomous than others. Doctors may, for example, be formally employees at hospitals, but their monopoly of certain skills may give them much more autonomy than other employees. Some or even many may form part of the middle class, but other employees in the hierarchy at work have less autonomy–such as nurses, nurses’ aids, food workers and custodians.

In this situation, the idea of patient-centered care will undoubtedly be focal point for diverging definitions of what constitutes such care. That in the struggle over such definitions patients may not be the real focus is possible. On the other hand, given the power advantage of management to regular employees, it is unlikely that their way of defining PCC will be on the same level as management’s definition. The same could be said of patient-advocate groups. Even if her intent is different, Ms. Kreindler’s assumption papers over differential power relations–to the advantage of management undoubtedly.

Another silence in focusing on PCC is the need to look at the relation between health care and prevention of sickness, injury and disease. In a socialist society, health care would still be important. From  Calum Paton (1997),  (pages 205-216), “Necessary Condtions For A Socialist Health Service,” in Health Care Anal., volume 5, page 209:

A socialist health service in a non-socialist society may be forced to stress care and rescue rather than prevention, health maintenance or the promotion of better health and more equal health status. Nevertheless this may be an important role. Even in a utopian society of perfect health promotion and prevention, people are more likely to die of more complex comorbidities at a later stage in the life cycle. The concept of substitute mortality and morbidity is useful here. 5 As a result simplistic trade-offs which suggest that ‘the more primary care there is, the less secondary care will be necessary’, are unlikely to be true either in the here and now or in the perfect society.

To be cared for with dignity, and to suffer with dignity and to die with dignity–these would all be important aspects of socialist health care.

Ms. Kreindler’s focus on PCC also excludes a major issue dealing with health: its prevention. By focusing exclusively on patients, she ignores entirely the need to consider the prevention of disease, injury and sickness in the first place (at least in the article above). What are the social conditions that increase the likelihood that a person would become a patient in the first place? Undoubtedly, as we become old, we will likely become patients at some stage in our lives–there is no getting around this fact. However, there are social determinants of health as well, and consequently becoming a patient is also often a function of social conditions.

In a socialist society, prevention would be a major focus of social policy and would deal with addressing the social determinants of health problems, ranging from health problems linked to the workplace to health problems linked to environmental conditions, including food processing.

Today, though, many social determinants are largely ignored in favour of focusing on caring for those already sick. Consider breast cancer. It arises in many instances from environmental conditions, and yet most money is allocated to caring for those already inflicted with the disease rather than with preventing it from arising in the first place. From Faye Linda Wachs (2007), (pages 929-931), “Review. Pink Ribbons, Inc.: Breast Cancer and the Politics of Philanthropy. By Samantha King,” in Gender & Society, volume 21, number 6 (December), pages 930-931:

Recent studies reveal that simply removing known carcinogens from products and our environment could prevent thousands of cases annually (Brody et al. 2007). However, funding for such research is limited, while the monies for identifying and curing existing cases is the focus of most efforts. Indeed, many of the companies that fund survivorship continue to use known car cinogens in their products. King points to the fact that despite increased awareness, rates of breast cancer have increased from 1 in 22 in the 1940s to 1 in 7 in 2004. Even if one considers women’s increasing longevity, this still indicates an increase in the prevalence of breast cancer. Moreover, structural factors that affect risk and survivorship, such as socioeconomic status, remain woefully understudied.

Personally, the issue of cancer research funding versus caring for cancer patients hits home. In March 2009, I was diagnosed with invasive bladder cancer, and in June 2010 I was informed that I had a 60 percent chance of dying in the next five years (it never happened, of course). The extent of “inquiry” into why I had cancer was a sheet of paper when I was admitted into the hospital for surgery. Two questions related to the causes of the cancer were: Did I smoke? And did I or had I worked in areas that might contribute to cancer. Nothing more. Of course, scientific research is much more extensive and hardly limited to inquiry into specific personal cases. I did find, however, that no qualitative inquiry into possible causes of cancer indicated a lack of a certain kind of cancer research in the area.

Even worse, in December 2015, I was diagnosed with rectal cancer. In 2016, I asked the doctor why I had cancer again. His answer was: Bad luck.

Of course, I would have preferred never to have been a cancer patient at all–patient-centered or otherwise.

Social democrats in various spheres of society (such as the economy, education, health and unions) generally assume the legitimacy of the hierarchical division of labour in society. They seek reforms within such hierarchy–rather than challenging such a hierarchy in the first place. Ms. Kreindler does the same. She, like her fellow social democrats, assumes that such a hierarchy can, ultimately overcome its divisions and serve the public (such as in the idea of patient-centered care).

The focus of social democrats often result in neglect of the wider picture. In the context of health, Ms. Kreindler neglects not only the importance of the employer-employee relation and its power differentials, but she also neglects the importance of preventing disease in the first place. Being a patient is to be avoided, if possible–and that means balancing health prevention and the inevitable need for health care as we age (or are accidentally injured even in a socialist society).

Rather than assuming class harmony between different sectors of health care, we should seek to analyse the class discord in that field and how such discord can lead, ultimately, to a society without classes. Social democrats, however, by assuming the possibility of class harmony within existing economic, political and social conditions, oppose, practically (and often theoretically) such a move.

Health Care: Socialist versus Capitalist Nationalization

Since the coronavirus and health care are undoubtedly on the minds of many people throughout the world, I thought it appropriate to do a bit of research on socialist health care versus present capitalist health-care systems.

Health care even in a nationalized context can easily be an expression of oppression and exploitation. The idealization of nationalization often goes hand in hand with an argument  that we need to extend public services in health and education (as Sam Gindin has argued). However, nationalized health care can easily become an oppressive experience for workers (as well as patients). From Barbara Briggs (1984), “Abolishing a Medical Hierarchy: The Struggle for Socialist Primary Health Care,” pages 83-88, in the journal Critical Social Policy, volume 4, issue #12, page 87:

GPs AND SOCIALISM

Socialists have traditionally argued for state control of key areas of the economy and of the provision of welfare services such as health and education. Socialist health workers have argued for general practitioners to become salaried employees of the Area Health Authorities, along with the ’ancillary workers’, instead of continuing to enjoy the independent self-employed status that they insisted on to protect their status when the NHS [National Health Service of the United Kingdom] was set up.

But the NHS, the largest employer in the country, has shared with nationalised industries the failure to demonstrate any evidence of ’belonging to the people’: because of the backing of the state it has proved a ruthless and powerful employer, keeping the wages of unskilled and many skilled workers also at uniquely low levels; time and again, union members seeking improvements in pay and amelioration of very poor working conditions have been defeated. Nor has the NHS shown any kind of effective accountability to its users. Public spending constraints have hit the NHS not only by causing a decline in working conditions and in the services provided, but also by imposing even more centralised planning priorities based on the need to save money whatever the cost.

This situation likely characterizes the Canadian public health-care system as well.

A word about the Canadian health-care system. One inadequate view on the Canadian health-care system is the social-democratic or social-reformist perspective, which certainly exists in Canada. One definitely inadequate view considers the Canadian health-care system to be socialist (Mary E. Wiktorowicz, pages 264-262, “Health Care Systems in Evolution,” in Staying Alive:  Critical Perspectives on Health,
Illness, and Health Care (2006), page 243):

In many ways, national health insurance symbolizes the great divide between:
liberalism and socialism; the free market and the planned economy (see Box 10.1).

Nationalized health care in no way represents the great divide between liberalism and socialism. An apparently critical form of the analysis of health care–but in reality a variant form of social democracy or social reformism–looks at the inequality in access to health care, according to level of income. Thus, in the edited work Health Promotion in Canada: Critical Perspectives (2007), Denis Raphael, in his article (pages 106-122) “Addressing Health Inequalities in Canada: Little Attention, Inadequate Action, Limited Success,” refers to levels of income as the major social determinant of the level of health. Since income inequalities in Canada are increasing, it follows that health inequalities are also increasing. However, this view defines a social determinant purely in terms of level of income–a typical social-democratic or social reformist method (I will deal with this issue in another post). As Glenn Rikowski (2001) points out (“After the Manuscript Breaks Off: Thoughts on Marx, Social Class and Education”, though, level of income is used instead of social class, or rather level of income is often used as a substitute by the social-democratic left:

… we witness the virtual abandonment of the notion of the working class…. Most people who analyse social class today do no such thing; rather, they have social inequality and stratification in view.

This use of the level of income to evaluate access to adequate health care is useful to a certain extent, but if it is the prime definition of class and inequality, it is far from adequate. It ignores entirely the source of income and exaggerates differences within the working class rather than a shared economic and social situation of being employees (or unemployed or temporary employees) and subject to a hierarchy of power at work (of course, managers are also subject to control from above, but in general it can be safe to assume that they form part of the middle class if not subordinate members of the ruling class).

The situation of the British NHS is typical of what happens when so-called socialist principles are realized in a capitalist context. Two socialist principles in particular fall by the wayside. From Bob Brecher (1997), (pages 217-225), “What Would a Socialist Health Service Look Like?,” in the journal Health Care Analysis,  volume 5, issue #3, page 219:

These principles are: (a) that there by a reasonable degree of equity in respect of outcome concerning the distribution of basic resources, and (b) that people treat each other as ends and not merely as means. The first may perhaps be understood as a political and economic dimension of socialism, while the second constitutes a moral and social element.

The first principle considers that social equity is itself a good in itself or an end at which we should aim. The second principle considers that people deserve to be treated as people in all circumstances and not just outside work or as “consumers.” This second principle, of course, can never be realized in a capitalist society since human beings are necessarily treated as things or objects to be used as means by a class of employers (see The Money Circuit of Capital).

Health care would be just that: health care–not health service. From Brecher, page 221:

‘Service’ implies server and served; consultant and client; provider and consumer. But none of these describes the sort of relationship between carer and person carefd for that the two principles outlined suggest. To take the example of the NHS again: despite the intentions of its founders, it was the connotations of service–by turn beneficently providing for patients and ‘servicing’ them as though they were objects–which helped provide amply justified dissatisfactions with the resultant shortcomings of the NHS treatment: and these have been used to undermine its founding principles. The combination of professional paternalism, especially in respect of senior doctors; an inability or unwillingness to treat people rather than their symptoms; and an attitude of ‘servicing’ and being ‘serviced’ all helped alienate people from what was supposed to be ‘our’ NHS, enabling successive conservative governments to turn what was at its inception at least a ‘social’ health service into an expliictly anti-socialist one. … these are not accidents of the British context: such terms and the attitudes and mores they describe are inimical to a socialist structure, based as that must be on considerations of equity and respect.

It is important to emphasize, as Brecher points out, that the assumption that nationalization is somehow socialist without further ado itself contributes to the Conservative backlash and the emergence of neoliberalism. By indulging the social-democratic or social-reformist left, with their talk of “decent work,” “fair contracts,” “fair share of taxes,” “$15 Minimum Wage and Fairness,” and the like, the so-called radicals have in reality contributed to the neoliberal backlash. What is needed is not indulgence of such talk, but continuous critique of such talk. What is needed is a critical attitude towards the so-called “left” and its associated idealized institutions.

What is needed is critical and hence democratic analysis and discussion of health-care systems. What is absolutely unnecessary is the defense of flaws in various social systems. If we are going to create a socialist society worthy of human beings, we need to be honest about the inadequacies of current social structures and systems.