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.