What happens when a state monopoly provides a service in which users have no power? Ultimately, something like this:
At an institution [in Romania], one nurse and three other staff members were giving round-the-clock care to 65 children. The staff could only keep up with feeding the children and changing diapers. Children did not leave their cribs for years, and sometimes were tied down. They did not cry, because crying did not bring a response. Instead, they sat silently. Investigators also looked at several adult psychiatric facilities that housed children in unspeakable conditions, with teenagers confined to cribs and wearing diapers. (1)
The American Civil Liberties Union put a FOIA suit, a Freedom of Information Act suit, out and pulled down 35,000 records, which actually give a very good picture of the medical system in the war on terror. And that medical system looks very much like, oh, for example, the way physicians were complicit in torturing in Argentina or Paraguay or Chile. Basically they hid torture. They delayed the release or concealed death certificates pertaining to deaths by torture. They helped design and monitor harsh interrogations, and they neglected basic medical needs as they failed to record injuries from torture and failed to report that torture up the chain of command or to places that could stop it. (2)
How could it have happened, people ask after these kinds of event. How could apparently respectable people with no history of sadism or other pathological tendencies have behaved like this? But surely this is being naive about human psychology. If opportunities for abuse exist, there will be people who will exploit them. To have to rely on the benevolent motivation of strangers is a position which should be avoided. Yet this position is precisely what is forced upon us by many of the recent increases in state powers, e.g. with regard to 'child protection'.
We should be extremely wary of interventions that mean we may find ourselves having to rely on the goodwill of government-authorised agents — be they doctors, social workers or teachers. In doing so, it is not necessary to believe anything specific about human nature. On the contrary (as Celia Green has put it) "it is necessary not to believe anything" — in this case, that people are bound to be benevolent, or that enough monitoring or supervision by their colleagues will ensure they do not behave abusively.
Here are some more thoughts.
There has been a massive misdirection of attention towards the harm that may supposedly be done to individuals by individuals acting autonomously, especially if aiming to increase their own autonomy, while the harm being done by people having power over other people’s lives as agents of the collective is completely ignored. There is a tremendous fallacy to the effect that the only motive people have for damaging other people is their own ‘self-interest’ or the ‘profit motive’. Deprived of any opportunity to defend their own interests or extend their territories, and with the exercise of power over other people as the only form of self-assertion easily available, it is implied that people will become benevolent and altruistic. A doctor has a lot more power to do real harm to people, physically and psychologically, than a wealthy businessman. (Celia Green)
"I’m still amazed at how unconcerned the middle classes are about all this 1984 stuff." I think a big part of it comes from the naive belief that everybody in power is nice, will always be nice, isn’t working to any agenda and isn’t utterly incompetent. So when tinfoil hat merchants like me said the terrorism laws would be abused, we were told “Don’t be so silly, dear”. And now, of course, the terrorism laws are used against nice anti-airport-expansion protesters. (Gary Marshall)
One needs to think realistically about what the motivations of those ostensibly providing services to individuals — but employed by and answerable to the state — actually are. Intervention is often predicated on the unexamined assumption that the motivations are no different than if the providers were remunerated directly by the customers. I ask myself: what incentives exist within the state education sector to transmit the same skills which the private sector does? Or to (e.g.) boost the morale of pupils? Especially if they allow themselves to play around with the criteria for success (i.e. exam engineering) in order to minimise, as far as possible, the evidence that the two systems produce a dramatic difference in outcomes. Incentives are relevant because I don't think one should have to rely on the goodwill of teachers. One wouldn't want to have to rely on the goodwill of a solicitor or an accountant, and I don't really see why different principles should apply to education or medicine. (me)
By contrast, we have Stephen Dorrell advocating the current Conservative position on the state professions, which is, apparently, to allow them to go back to running themselves. Trying to control them through targets etc. has "brought short-term benefits" (if the numbers are taken at face value, that is) but "brings the inevitable long-term consequence that discretion is drained from professional structures and centralised in the hands of interventionist ministers."
True, but, in a collectivised system without consumer power, is discretion in the hands of practitioners necessarily any better for patients than discretion in the hands of ministers? Mr Dorrell seems to think so.
The case for strong and independent professions is not the case for a return to the status quo ante. It is the case for challenging the professions to accept their responsibilities — to acknowledge that they, and they alone, are able to ensure the reality of public service excellence matches the rhetoric. ...
It is the essence of good social policy that we should ensure individuals accept responsibility for their actions and are enabled to make the most substantial contribution of which they are capable to the society in which they live.
Which, to my mind, shows just how prone to misuse the concept of 'individualism' has become, if it can be invoked to justify more power for doctors.