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6 November 2012
That is why to lie to men, or deceive them, that is, to use them as means for my, not their own, independently conceived ends, even if it is for their own benefit, is, in effect, to treat them as subhuman, to behave as if their ends are less ultimate and sacred than my own. In the name of what can I ever be justified in forcing men to what they have not willed or consented to? Only in the name of some higher value than themselves. But if, as Kant held, all values are made so by the acts of free men, and called values only so for as they are this, there is no higher value than the individual.
Isaiah Berlin Two Concepts of Liberty
The NHS is 'the closest thing the English have to a religion Britain'.
No more. You cannot drug up patients with sedatives and morphine so that they cannot make a choice for the future of their own lives.
As trust ebbs a new culture is badly needed.
(Because of its scale the Liverpool Care Pathway could be considered the greatest disaster to befall Britain since Suez).
15 March 2015
Everyone has a right to an un-sedated and un-institutionalised death if they choose. One has only to read the final volume of the memoirs of Alan Clark to learn of the lengths that some will go to ensure this.
The Liberal Democrats are wont to claim they are defenders of liberties but their record on this liberty will deserve close scrutiny at election time. In these life and death issues a greater standard of openness is required.
BERLIN AND THE NHS
Reviewed by ANDRE BEAUMONT
Not all persons are equal. For too long we have treated non-natural persons on an equal footing with natural persons.
This may have been acceptable when the ethical codes followed by both were similar but, today, non-natural persons are governed by laws, systems and ethical understandings often substantially different from those used by real people.
Corporations have business systems that cannot easily accommodate the fine ethical gradation of actions that comes easily to individuals when not following a system.
Trusts do not die so have tax advantages.
Any claim to erstwhile moral superiority by charities is to be questioned now that they are rigorously governed by law. Their purposes may be benevolent but their modus operandi need not be.
In cases of defamation or breach of privacy people may suffer destroyed lives whilst the loss to non-natural persons can usually be limited to the monetary or reputational.
There is a contemporary need for more ethical considerations to be drawn into decision making.
To assist this there also needs to be a recognition that non-natural persons have different, and often ultimately inferior, ethical make ups to natural persons.
Democracy, being of the people, therefore has a task of continually tilting the rules in favour of natural persons.
This may always have been the case but it now seems more pressing as the number of non-natural persons multiplies and as they demand people follow their rules.
In Two Concepts of Liberty, Isaiah Berlin makes a philosophical case for not having many gatekeepers in life (though the vocabulary used, referring to 'persecution' etc is not really consonant with the subject matter of this review):
The defence of liberty consists in the 'negative' goal of warding off interference. To threaten a man with persecution unless he submits to a life in which he exercises no choice of his goals; to block before him every door but one, no matter how noble the prospect on which it opens, or how benevolent the motives of those who arrange this, is to sin against the truth that he is a man, a being with a life of his own to live.
(Professor Philip Pettit of Princeton University has since elegantly picked up the idea of the gatekeeper in a lecture, The Open-Doors Model of Freedom, of which a podcast is available).
Clearly at times parents act as gatekeepers for children, teachers for pupils and so on but the case for not having many is well enough made out by Berlin.
If there is one reform that the National Health Service would benefit from it would be the removal of its gatekeeping role, at GP level, at hospital level and at administrative levels.
This would put pressure on it to improve at all three levels.
It should not really be for a GP or a hospital to say, for instance, that one cannot have an operation, without the option of attempted recourse elsewhere. It should be commonplace, should one wish, to refer oneself elsewhere to see if opinion or resource differ elsewhere. So called 'post-code lotteries' are diminished if patients make decisions.
In other words, monopoly should be broken.
Of course, problems of finance are very real which is why alternative referral or self-referral could be limited, in the short-term whilst new practice settles down, to once per condition.
However, absolute gatekeeping should be prohibited.
Applying uniquely British standards to healthcare is not working. Accepting some of the plurality of practice and opinion found elsewhere is essential.
Currently, in the NHS, the system (the non-natural person) predominates over natural persons too much.
Berlin was people-centric in his conceptions. Not so some of the increasingly utilitarian economic kites being flown.
The idea, emanating from British social democrats in various forms, that personal capital needs to be rent seeking is a misunderstanding of how capital works best.
Personal capital is often a refuge from rent seeking and performs a social function.
How many families in the past decade have been reduced to having only one income earner but muddle through uncomplainingly because of a capital base built up in previous years?
How many children turn to their grandparents, mortgage paid off, to fund something like a higher degree?
This is a reason incidentally why, in the main, students do not buy into anti-old person rhetoric.
Separating people from their personal capital to put into the productive economy does not add up either.
Once in the financial system the capital might go into government bonds, or into financing private equity takeovers, or overseas but rarely into the micro-enterprises of ten people or less that may be the only guarantors of economic growth in coming years.
Indeed, there needs to be better ways of leveraging personal capital.
Go back a few decades and, in Britain, building societies did the job of borrowing short and lending long. They paid higher interest than banks and they kept up to a third of depositors' funds in liquid or near liquid assets.
They were, literally, as safe as the houses they granted mortgages on.
It should not be forgotten that Britain has not had a real estate triggered financial crisis of its own for 40 years when the secondary banking crisis took place and then the problem was lending to the commercial property sector.
Chronic undersupply of land for residential building has underpinned the value of homes on which mortgages were secured.
Banks largely stuck to lending short to medium term. By lending longer and then securitising they may have created a rod, amongst many, for their own backs.
Individuals were not forced to take mortgages in order to have secured loans.
Now they are because it makes securitisation easier.
People are made to fit the product and this is plainly ridiculous.
For business purposes, people may not wish to borrow medium to long term.
In years of retrenchment, people may not have both the benchmark levels of income and capital that mortgages require though they may easily meet one or the other.
Banks have clearly not grasped the nettle of how to finance recovery from the bottom up rather than from the top down.
Perhaps they should set up subsidiaries with different branding specifically designed to do just this. A bank to lend to people with income, another to lend to those with assets, another to lend to those with profits and cashflow, so the enterprising know where to go.
The universal bank is failing the high street.
For social democracy, one might offer a message: leave natural persons with their money and work out why the non-natural ones are scooping the jackpot.