Saturday, March 20, 2010

Alternatives to market approaches

Looking for alternatives to neo-liberalism

by Gavin Mooney

One of the issues that must become foremost in any challenging of the market is to imagine alternatives. I am doing this in economics and health policy. My starting point is that health care systems need to be seen as social institutions. Here I spell out some of my thinking. Is there I wonder, merit in running with this idea in a wider context?

There is a need to consider the broad, social role of health care systems as institutions, as part of the fabric of society. Such a focus means trying to devise ways to involve the community as a community in values to underpin these social institutions.

With respect to health care, there is a need for a dual level approach, a personal one nested within a community one. The first is at the level of individual desire for our own health. The other, community level, is concerned with setting the social principles on which health care systems are to be based. At this second community level the individual now is a citizen rather than a patient.

Two potentially important caveats here. First the citizenry will need some education so that they operate on an informed basis. Second there is a risk, that needs to be addressed, that the rights of minority groups will not be adequately recognised by the majority.

What is required to pursue the above proposal is to determine how different levels of preferences might be elicited. Three levels of preferences or interest functions are proposed.

In the context of multiple interests functions it is useful to think of Frankfurt's** first and second order preferences and to develop a third order as well. The first approximates to some notion of desire; the second to what individuals want when they have time to reflect, perhaps embracing the issue of what sorts of individuals they want to be. These may be different not only in being reflective, but also in terms of the object of the preferences. This is inter alia because reflection comes at a cost; time is needed for reflecting (There seems little point in reflecting over long on whether to buy a chocolate bar but we might want to dwell more on preferences about our chocolate dependency.)

Third order preferences are "communitarian". This philosophy recognises that individuals are not free floating atoms. Their identities are embedded in some community/ies. Being active in a community is good in itself and not just instrumental. Institutions such as health care, but also education, are valued not only for producing some narrowly defined outcomes such as health gain and educational human capital gain. They can be valued for other outcomes, in health (e.g.information) or processes (e.g.caring), or as institutions per se which contribute to the decency of a society (e.g such as a tax based universal health care system). These issues are related to what sort of society citizens want.

To advance these third level preferences I have proposed the idea of "communitarian"claims." John Broome proposed the idea that a claim to a good meant that there was a duty owed to a person that she or he have the good.

I have previously suggested moving Broome's concept of claims to make it more relevant to the discussion here in the following way. It is proposed that "communitarian claims" be a sub-set of claims more generally where this sub-set is the responsibility of the community to meet or address. Thus, the duty in the case of communitarian claims is a duty owed by the community.

These are labelled "communitarian claims" reflecting the fact that it is the community who have the task of deciding what constitute claims, the duty to allocate claims and to decide on the relative strengths of different claims. There is value in being part of the process of arbitrating over claims. The more embedded individuals are in a community, the stronger will be communitarian claims in that community.

The strength of a claim is not a function of an individual's ability to manage to feel harmed. Harms and the strength of these harms are for the society to judge not the individual.(In the market, income is the determinant of claims and individual satisfaction is what is to be maximised). Strictly, with respect to claims, the bad feelings arising for the person harmed are only relevant in so far as the society deems them to be relevant. They are a matter for "community conscience".

The actual consumption of the resources however remains determined by how an individual values the options with which he or she is then faced.

Finally it is apparent that there may be problems in advancing the concept of claims and retaining the ability to measure and quantify within whatever set of principles emerges.

I am unsure if the obsession with quantification is a product of the market or not-it is certainly more prevalent in today's neo- liberal societies. On this issue Amartya Sen the Noble laureate in economics argues that measurement can be taken too far and he seeks to guard against 'over completeness'. As Sen sees it:
"Waiting for toto" may not be a cunning strategy in a practical exercise".
He suggests that:
"the nature of interpersonal comparisons of wellbeing.. as a discipline may admit incompleteness as a regular part of the ... exercise.. An approach that can rank the wellbeing of every person against that of every other in a straightforward way.. may well be at odds with the nature of these ideas"
So I don't worry too much about such problems. Maybe others will. More importantly for this blog I wonder if others can see merit in using the idea of communitarian claims in sectors outside of heath care.

* Broome, J (1991) Weighing Goods, Blackwell
**Frankfurt, H (1971) Freedom of the will and the concept of a person, Journal of Philosophy, 68:5-20
*** Mooney, G (2009) Challenging Health Economics, Oxford University Press
**** Sen A (1992) Inequality Re-examined, Clarendon

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