In the 19 years of care section and in this Marketplace section I have written about the patterns of thinking that have been imposed on aged care and the changes that have resulted. These have all of the characteristics of an ideology - the appication of a one size fits all pattern of ideas to situations where they are not applicable.
In the next section I will be arguing that the aged care system has been harmed by this and that it is simply an example of a common occurence. As frail humans in a complex world we too often come to believe implicitly in what we are doing and fail to recognise that this is harmful.
I am going to call it “culturopathy” because it needs to be seen as cultural pathology and not as some wicked plan by evil people. These are well meaning people and their indignation and anger is genuine. This is why it is such a difficult problem to deal with.
On this web page I am going to step back and look at this in two ways.
- Firstly a broad look at issues in the broader society of which aged care is a part and which therefore impact on aged care
- Secondly I want to look at ourselves - the nature of man. The way we develop our patterns of thinking and why we so desperately strive to find simple universal truths and if we can’t find them then create them. Then I look at the consequences for aged care.
I will return to some of these issues in later pages but this is a good place to introduce them.
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Oddities like civil society, the common good and the proposed community aged care hub
Civil society: We should not be surprised by the way the market and the political system has behaved and at the consequences for the aged care system. It is happening because we have a hollowed out, disorganised and fragmented civil society which is unable to structure and organise itself as an effective force. It has been unable to fulfill its role in containing the excesses of politicians and markets. It is not organised or structured to fulfil its function in our democracy. A core role of civil society is to uphold our morality, our humanity and set the ethical standards for our society.
Civil society is the totality of that part of each of us where we develop our social selves and fullfill our responsibilities in our democracy by meeting our obligations to others and to society as citizens. Its a greater or lesser part of all of us and all of us together constitute civil society. Its what we do as we serve society and are involved in managing its activities. It is the social self within us, the societal patterns of belief we develop in our activities that makes us reflect on what we do, challenge ideology and apply an ethical filter to those actions that are driven by self interest to be sure that they are appropriate and do not impact adversely on society or other citizens.
Depriving civil society of the best minds: John Ralston Saul raised an interesting issue in regard to the confidentially and loyalty requirements of corporate structures including government. Much of the knowledge, skills, intellect and ethical muscle of civil society he suggests is locked into these organisations through employment contracts, loyalties and social pressures often compounded by legal restraints. The corporations own our intellectual contributions. Most of this vast resource of knowledge, skill, intelligence and humanity is not available to civil society leaving it deprived and weak. These people are denied the opportunity to develop their social selves. Civil society is deprived of the skills and knowledge of the best of its citizens and their participation in ethical issues is contained by the law. There is a revealing example of the way the marketplace sees and justifies just this in Australia.
The HIH insurance scandal and the One Tel collapse were two very public scandals at the turn of the century with much to suggest a culturopathy. The leaders of the business sector in Australia were involved. One HIH director went to prison. The government responded by proposing changes that tried to make business more accountable and encourage staff to report unsavoury behaviour.
The marketplace angrily objected. The president of the Business Council of Australia (BCA) showed just how right Saul was. Not only did he admit that corporate malfeasance was an inevitable consequence of the corporate market but he demanded that employees loyalty should be to the corporation and they should not be encouraged to be socially responsible and become “state informers”. In orher words the BCA considered that corporate interest should be placed above responsibility to the community.
He said it would put employees in conflict with the interests of their organisations and would turn them into "state informers".
Business has been furiously lobbying for parts of the bill to be watered down.
The most important present problem, which the members of the BCA face - and with them, everyone involved in commercial and business life in Australia - is the attack on the corporation as a vital institution in our economic life," Mr Mxxxx said.
He (Mxxx) suggested corporate misbehaviour was an inevitable outcome of the rapid growth in capital markets, with the owners or shareholders of a company becoming more numerous and distanced from the managers - the so-called "agency problem" identified by economist Adam Smith.
Source: Laws an attack on way of life. The Australian December 2, 2003
In his argument Mxxx convenietly forgot that Adam Smith's also warned society that any proposal "which comes from this order ... ought never to be adopted, till after having been long and carefully examined ... with the most suspicious attention". He clearly felt that citizens had a duty to carefully watch what corporations were doing.
We need to ask whether the business establishment and the Business Council still thinks this way. Do aged care providers as a group consider that those in the industry who speak out about failures in care are morally at fault because they should put their duty to the corporation above their responsibility as citizens to the community and its members? Business today employs probably a majority of citizens. Their right to citizenship and civil responsibilities is costrained and limited by their loyalty to an impersonal social structure than constrains their freedom.
Saul blames much of this on the legal strategy introduced 200 years ago to treat corporations as if they are a person and so eserving of loyalty which clearly they are not. He refers to the threat of litigation that is so commonly used by corporate interests to suppress the disclosure of information.
Take the libel laws - an ethical tool for citizens to use to protect their freedom of speech. Today the fictive corporate humans are able to combine deep pockets and these libel laws in order to discourage, even prevent, real citizens from questioning the companies’ methods and products, to decrease transparency, to discourage debate, to hide errors and to justify price fixing.
Source: On Equilibrium page 110, John Ralston Saul 2001 Penguin Books
He was talking about North America. I am not sure how much of it is valid, particularly in Australia in 2016 but it is food for thought.
Developments in civil society: The internet and social media are restructuring civil society in very different ways building disseminated communities, even global communities. This provides fascinating opportunities for rebuilding and reorganising civil society in many ways to make it effective in the 21st century.
We already have activities like the crowd-sourced lobbying through change.org but that is just a small beginning when we consider what is possible if civil society seizes the opportunity to form groups that can network and contribute expertise and breadth of perspectives then pass the fruits of these deliberations into the political mix.The global open government and participatory democracy movements are already experimenting and ways of rebuilding civil society are being explored.
Instead of selling policies to citizens, knowledgeable citizen groups whose only interest is the welfare of society (and not their political future) will be able to take the initiative, formulate well informed policy options and then feed them into the political debate. This will bring the vast intellectual resources of the nation to the political table. The public debate might be led by groups within the community and politicians would be participants and not salesmen as everyone worked towards an agreed course of action. It could become a better democracy, more in the spirit of the Athenian ideal and one in which society would be educating and building itself in an ongoing manner.
We need as a society to establish ourselves and take charge of this sphere before government and markets appropriate the medium for themselves and use it to control us. There are exciting opportunities for a better world but we need the courage and the interest to pursue them.
The public good: Currently advice and consultation embraces stakeholders, who by definition have a stake, ie. a personal or corporate interest in the outcome. They are not there to look after the interests of civil society and the "common good". The public good, the welfare of society and the interests of its citizens, are not at the top of their lists.
The role of civil society in a capitalist democracy is to protect and nurture the public good, what is best for citizens and society. Those with interests in the outcome and expertise should be contributing their individual ideas but these need to be subservient to the common good. It is civil society’s role to ensure that and protect society from lobby groups and large polittical donors..
The Community Aged Care Hub: The proposed hub can be seen as a unit of civil society which focuses on aged care issues. It will focus on the common good and the welfare of elderly citizens in its discourse with markets and government. This will occur during the everyday operation of aged care services in the community and nursing homes as as well as in the hierarchy of central organisations. The broad range of experience and opinion will protect the common good and the frail elderly from self-interest as well as the vagaries of the alternating belief systems that politics has been so vulnerable to.
Our complexity: Humanity and inhumanity
The nature of care
Aged care is essentially a personal and intimate matter and something that a caring society provides. It has to deal with the complexities of a myriad different lives all with different priorities - a myriad intimate and vulnerable universes. Those who provide care need to enter into cherish, nurture and maintain each of these universes and help them to build on each as universes are never static.
To maintain identity and strive to hold on to a meaningful life even as it steadily slips through their fingers these universes must change and restructure. Of all our community services aged care is the most personal, the most empathic and the most in need of our time and our patience. It requires much more from those who care. The end of life is confronting and emotionally draining on all those who are close to it. Each person confronts their own mortality in the presence of another who is dying.
Consider what sometimes happens
An article in the Guardian describes how home care in the UK has simply become an uncaring routine and how care is delivered (and in many instances not delivered) without any sort of personal contact with the person they are caring for. When secretly monitored carers ignore faeces on the floor and don’t give the baths they are supposed to give. They don't bother to talk to the person that they are supposed to be looking after. The carers are poorly paid and clearly get little support. A culture of disinterest and disengagement develops. They simply don't see or acknowledge what is in front of them.
The person is treated as an object and their is no attempt to imagine what their life is like and reflect on it. Carers refer to them as a "feed" or a "shower". There is a barrier between the carers and their humanity. They simply don’t engage it. Management are very well paid and clearly think that they are doing a good job.
In Belgium, they address the problem by sending carers to an ethics laboratory where they become residents and have to endure poor care themselves. A UK manager who went to the laboratory said that “I felt hideous. I didn’t feel clean enough. I think it needs to be mandatory.” But first you have to recognise the problem and that does not seem to be happening.
If these are “bad apples”, there are an awful lot of them.
You’d have thought you wouldn’t need to be told that if someone isn’t washed they will feel dirty, or that if they aren’t fed they will feel hungry, or that if they are made to feel like a nuisance they will be really quite upset. You’d have thought people could exercise something called imagination.
Source: We hear a lot about compassion for the elderly. Isn’t it time we showed some? The Guardian, 6 Apr 2016
How often do we all do this? Not perhaps to the same degree. We are not prepared or are prevented by the system from giving that most valuable of all gifts, our time.
Examples of similar situations in Australia are given in the section 19 years of care. Widespread problems are also documented in disability services. It occurs whenever marginalised groups are subjected to the sort of process driven care that disconnects their carers from their humanity. Many disabled have been abused in aged care facilities.
- Abuse in Victorian disability services widespread, report finds ABC News, 26 May 2016
Our intellectual heritage
Chaos was the law of nature; Order was the dream of man.
Source: Henry Adams quoted by Wallace Stegner in his award winning “Crossing to Safety” 1987
When it comes to life and what it means there is much to learn from our heritage. In looking at this issue I hope that I am not too long winded and patronising. It is simply to put a point of view that fits with and explains what is happening at another level - placing some order on it to raise the issues. I hope any one who reads this will consider, criticise and make up their own minds.
John Ralston Saul argues that common sense has its roots in our own past and in the history of our culture. People in the past seem to have had much more time to think about mankind and its place in the world than we do now. People who write about these issues track back into the past usually to Socrates and beyond. I don't have that classical education so must depend on others who have done so - a long line of men and women who were educated and brought their learning to the debate. Saul is one of those who have looked at what the world has been saying and used that to provide an insight into our civilisation. But clearly he is not alone.
Insights from our human heritage: Henry Adams, a 19th century US historian and politician, quoted above indicates that mankind, in searching for meaning, tries to find order and structure in nature and in what we do. If order is not there mankind seeks to impose its own in order to survive there. Mankind must create meaning in order to contemplate any sort of action and that requires some sort of order.
Adams has also said “anarchy and chaos are the habit of nature, and law and order its accident” and also “Chaos often breeds life, when order breeds habit.” He saw the order that we impose as an accident and not an accurate reflection of nature - or we would say reality. He also repeats Adam Smith’s assertion made in the previous century “It's always the good men who do the most harm in the world” and that as I have made clear is our big problem in aged care. In our criticism we are criticising good people who have devoted their lives to what they considered was good for the aged. We should not forget that criticism can be very stressful for them and while we must confront and challenge if we are to change we need to be mindful of what we are doing.
What we have in aged care is an order that originated elsewhere that does not fit, imposed on the system and that is an accident in more ways than one. The extent to which the aged care system is process driven can be seen as the extent to which it is a habit. It becomes something we do mechanically like a habit as we follow the prescribed processes. We do so without engaging or reflecting. When not engaged our humanity is suspended because humanity requires imagination and reflection before it can enter the life of others. Both require engagement and are elsewhere at this time. Consider the home care example in the UK above.
The nature of order and structure
To be effective as humans we need an organised view of the world. When we struggle to create an ordered universe for ourselves, when our universe is challenged or when it starts to fall apart and we need to rebuild it we experience emotional stress. Philosophers have long recognised that we live in a complex universe which we understand in a limited way through our senses and then see through a multitude of tinted glasses - the meaning systems that we have created. Yet even with these filtered glasses our preconceptions are challenged and this stress causes us to build or modify our personal universes - the process of personal development.
Angst: The anxiety experienced has many names depending on where we experience it. Philosophers talk about this as existential angst, psychologists about dissonance. Sociologist Peter Berger writing about religion called it “anomy” (a disordered and frightening world) in order to contrast it with “nomos” or order such as when we have a belief system. Whatever actually exists outside this complex world the multiple religions that we have created since the earliest times have provided that safe haven or nomos where everything can have an ordered place.
Seeking simplicity: That search for simplicity and order in a complex world leads us to find secular ways of ordering the world as well as or instead of religion. When we find something simple we can latch on to we embrace it and frequently vast numbers of us get on board and use it to build our lives. This becomes so important to us that we sometimes go out and cause chaos and harm to thousands of others in its name. But even when it works for large sections of society there will be other sections big or small that are impacted and to various degrees harmed.
Politics and simplicity: When selling a political policy it has become important to use only one simple pattern of thought and keep repeating it over and over again. We easily manage simple arguments but struggle when they are multifaceted. If you argue a policy from more than one point of view you create doubt and that doubt causes angst and you fail to sell the policy. But good policies need to be looked at and debated from multiple points of view.
This is one of the reasons why our democracy is in such a parlous state and why our sort of democracy is so vulnerable to ideology. Technology which has the capacity to broaden debate has become the tool of public relations experts whose objective is to serve the self-interested and limit debate.
These are some of the problems that the open government and participatory democracy movements are trying to address. They are trying to create a context where we will debate and consider policies and develop them ourselves and so can can escape the political market where simplistic policies are sold like perfume. In many ways it is what the proposed community aged care hub is also trying to create.
Blindness and humanity
In our determination to hang on to the truth that we believe in we simply do not see what we do not want to see. We cease to see and understand the lives of others. As we strive for order and structure and hold what we have created tightly to our chests we lose our ability to imagine anything outside our ordered system. It is our imagination that allows us to enter the lives of others and give form to the humanity in all of us and we lose that.
How we can escape from the restrictions imposed by belief for long enough to see what we are doing has taxed the minds of many. To embrace our humanity we often need to step outside belief if only briefly. There are many ways of coming at this
- Sociologist Peter Berger used the analogy of primitive man living in a cave. One warrior might go out into the wild night and climb the mountain to stand on top with the storm and hail lashing him, thunder and lightning all around and the wolves howling below. Not understanding any of it, a terrifying and unbelievably exciting view of the world outside the cave, none of it making complete sense. He cannot survive there and scurries back into the cave and snuggles up with the group sleeping around the fire. The title of his book on the sociology of religion was “The Sacred canopy”. The point was that while we have to live with our tribe and its secure ideas we also need to be able step outside it and look more broadly - but that can be challenging.
- John Ralston Saul writes about our weakness for simplistic belief and ideology and our determination to find and embrace universal truths and believe in them and use them to order our lives. These truths are seldom true and often harmful. He sees our way out of this as lying in our capacity to embrace doubt and reject absolute truth - to accept uncertainty and some angst on a recurrent basis. If we accept that the way we think reflects a probability and not a certainty then there is always some doubt and it is always open to challenge. His other thesis is that we need to use not one of our many human attributes when we evaluate our experience (as those who must believe do in order to maintain a universal truth) but all of them including our imagination and common sense, balancing them one against the other.
- On my corporate medicine web site written in 2000 I suggested a way of understanding the corporate marketplace. I borrowed an idea from Rokeach, a US psychologist, and suggested that we all lived along a line with closed minded (hanging on to the beliefs we know) at one end and open minded (challenging our ideas and exploring new beliefs, willing to remain undecided) at the other. At the one end our response to challenge and uncertainty was "responsive" (rationalising, justifying, ridiculing and then anger in order not to confront). At the other it was constructive (reflecting engaging and challenging). If we all move along this line and are at different places on it then what factors in our personalities, but even more importantly in the context in which we find ourselves would move us further towards the constructive end where we accept new ideas, are able to handle multiple conflicting ideas and challenge our own ideas without experiencing too much angst.
Constructivism: And that of course brings us to “constructivism” an approach to education in which we seek to create contexts and groups that come from different places and with different strengths. By involving them in practical situations, knowledge and ideas are debated and challenged, attitudes are defined and concepts of morality, humanity and ethics brought into focus as the problems in those practical or simulated situations are debated. Instead of responsiveness we get constructiveness.
Responsiveness: The things that moves us in the opposite direction are uncertainty, threat, conflict, rhetoric threatening dire consequences and strong pressures in the workplace and elsewhere. Loss of your job, economic disaster, terrorism and hundreds more including the lack of time to reflect critically on your situation.
If you listen to the political debate around elections, including the aged care crisis caused by the baby boomer bulge, then the way this works and the use of this strategy by politicians becomes very obvious. It stops people from challenging, from thinking constructively and from considering new ideas. The political debate and the whole process is trapped and is unable to move ahead . This is political paradigm paralysis seen from another perspective,
On the web page “Speak out if you dare” I quoted from a psychologist who explained why people who were persecuted and discriminated against would vote for the perpetrators because they felt so threatened by the uncertainty of change.
Dr Linda Peeno, a US doctor was rewarded by her Managed Care employer for making a decision to deny care that cost a patient his life. This so disturbed her that she studied ethics and later became a strong critic of managed care.
In her address to a government inquiry in 1996 she described the strategy used to persuade the front line individuals responsible for refusing care. She listed the patterns of thinking, the rationalisations and strategies to cope with the dissonance they experienced when following policies that required them to deny care. It describes what happens particularly well.
When a "system" tightly connects its goals and consequences of non- compliance with economics, predictable behaviors occur. We can see these at work now in health care as:
- Ideological indoctrination, which currently occurs in such rationalizations as, "we are doing this in health care for 'the good of society,'" even if it requires some kind of sacrifice -- even harm -- at level of individual patient;
- Emphasis on "efficiency," which inherently strips complex, human engagements (e.g. what happens between a doctor/patient, and what happens when we need medical care) into artificial delineation, e.g. money involved with patient needs becomes a "loss" or a "savings"; care is divided between "unnecessary" and "necessary," etc.;
- Diffusion of responsibility, such that no one is responsible solely for adverse decisions;
- Fragmentation of behavior, enabling professionals to act one way in their role of work and different ways in other settings;
- Disconnection of conscience from conduct as a means to further insulate oneself from consequences;
- Depersonalization of beings who comprise this context, which here means patients who become a "member per member month"; a statistic on a data sheet fractured into a lab result, an x-ray, a procedure, etc.; a profit "loss" or "savings"; an "approval" or a "denial," etc.; in fact, the entire language used by the managed care industry reflects this -- no personal or human references are made;
- Instrumentalist thinking, i.e. treating every action as a means to something else, rather than an end in itself, e.g. the professional act of caring for a patient becomes a means to keep one's numbers "in line"; a means to increase one's bonus, or the profit of a company; a means to keep one's job, etc.; patient care is no longer an end to itself.
Source: MANAGED CARE ETHICS: THE CLOSE VIEW PREPARED FOR U.S. HOUSE OF REPRESENTATIVES COMMITTEE ON COMMERCE SUBCOMMITTEE ON HEALTH AND ENVIRONMENT BY LINDA PEENO, M.D. The National Coalition of mental Health Professionals and Consumers May 30, 1996
This brings us to the idea of civil society, which Eva Cox wrote about in her Boyer lectures, “A Truly Civil Society”. Here members of society engage in the affairs of that society and have responsibility for them. People with multiple different backgrounds become interested and involved. They then start thinking, learning and questioning as they interact with one another. This creates what is called social capital within society and within people as they build lives and ideas together. This can be contrasted with financial capital and personal wealth and in society balances it so that we get the benefits of a broad society one that capitalises on the life that economic wealth brings.
Our weakness for ideology
At the heart of ideology is belief, a belief in unchallengeable truth. It removes all doubt and cannot be challenged by reason, evidence or common sense. Any unchallengeable truth is an illusion as there is always doubt of some sort. To be truly human and exercise our human potential we have to learn to live with probability rather than truth.
Saul argued that using only one of our qualities was likely to lead to ideology. We should try to avoid this by using a balanced selection of all our other qualities to keep that one on track. We can see the attributes that govern our society in much the same way.
If we use a metaphor then our body consists of multiple chemicals including vitamins and trace elements. If we are ill we get given drugs and are careful to take the right dose. We know that if we take high doses of vitamins, trace elements and drugs we will poison ourselves. We also know they need to be given by the right route so they get to the right place.
Yet that is exactly what we as individuals and as society embracing ideology do. We take something that works and administer massive doses that become harmful and do so in the wrong places. It is not surprising that our society gets sick and behaves harmfully. Competition and efficiency two important personal and group attributes can be seen as useful when balanced and constrained by our other societal considerations and human attributes including common sense, imagination and ethics, and they need to be used in appropriate situations.
But instead we have given them almost divine properties, making competition policy a part of our national identity and appointing a National competition council to drive the process into every vein of our society.
Consider whether the pressures generated by this overuse would increase tension and inhibit constructive behaviour - drive us back into responsive mode.
If we apply a little common sense to aged care we can see that both competition and efficiency have a profoundly negative impact when applied in the excessive and unbalanced manner they have been.
Competition: Competition requires self-interest because we compete for something that benefits us. How could we possibly entice people to compete to care for the frail aged using self-interest when what it actually requires above all else is empathy, a quality directed to helping others. Empathy depends on our ability to imagine others lives and so enter into them.
But true believers found a way. They could do it by getting providers to compete to see who could squeeze the most money from the care of the elderly. Their belief in the infallibility of markets led them to suspend all of their attributes, reason, common sense, imagination, intuition and more. How else could they have done it?
It is pretty obvious that the stronger the competition to be profitable and survive in the marketplace, the greater the pressure on staff and care are going to be. The international evidence is clear. But its heresy to say that in Australia where profit and competition are two "goods" that cannot be questioned. A recent paper says it but in a very roundabout way!
- More competition may not be the answer to reforming the aged care system The Conversation 27 May 2016
Efficiency: Human life and social interaction are very inefficient processes. They take time as we chatter and network with others. This leisurely activity is essential to our lives. The impact of unfettered and unbalanced efficiency in aged care allows no room for this and is devastating for the lives of the struggling humans there! Once again all of the provider's attributes are suspended in order to believe in the truth of their vision.
Accreditation: Consider the accreditation process which is based on an understanding of the way in which we naturally deal with the experience of daily life. We act , then look at the consequences, reflect on them and then incorporate all that into our consciousness and modify our understanding so that we use that experience next time and repeat the process all over again. But taking it out of its context, turning it into a belief system (continuous improvement) and enshrining it as the basis of a complex system of accreditation is a dubious exercise.
It has potential benefit if used in a suitable context. But it has been separated from the experience and data that are integral to its benefits; has been used as a measure of standards of care which it is not; and turned into an oversight and regulatory body in a highly competitive environment, something that it is not structured or capable of doing. But by shrouding it with the word "quality" politicians were able to sell it to the industry and the public as legitimate and effective - an illusion.
In order to do these things it was necessary to suspend common sense and enter a world of illusions and make believe, and then drag the rest of the country in behind them. But the illusions above are simply part of a cascade of illusions. They are there to serve and protect a deeper and more profound illusion.
The illusion of a free-market was not argued and debated. It was presented to the world in 1970 as a fundamental inalienable truth that could not be challenged and its supposed virtues and great potential was then expounded. It caught the imagination of the great and powerful and was given legitimacy by a Nobel prize.
As I will explain on another page every grand illusion requires a cascade of supporting and facilitating illusions to protect itself from its critics and explain away or address its failings.
Like the illusions that saw competition and efficiency as ultimate goods and so distorted the world we live in we need to go back to 1970 to see how the balance of society’s attributes and qualities, the attributes that made it work for society was distorted.
Capitalists Democracy: Core democratic concepts are based on the idea of freedom that is never absolute as it is contained by the requirement of responsibility to others and to society. In the same way the self-interest of individuals which drives the economy is constrained by their responsibility to customers and to society. These are central to our idea of citizenship. The market is intended to serve customers and society. In a functioning capitalist democracy it is constrained and controlled by both.
Milton Friedman: Milton Friedman the Chicago economist turned this on its head. He propounding a new philosophy which first appeared in the New York Times in January 1970. He placed the self-interest of individuals above all else in the marketplace and attacked social responsibility as socialist and essentially evil. He described it as a "fundamentally subversive doctrine”.
“There is one and only one social responsibility of business–to use its resources and engage in activities designed to increase its profits so long as it stays within the rules of the game, which is to say, engages in open and free competition without deception or fraud”
It seems that the world was ripe for a new appealing ideology and Friedman won a Nobel Memorial Prize in Economic Sciences in 1976. These profound truths became political policy when adopted by Reagan in the USA and by the belief driven iron lady, Margaret Thatcher in the UK. Their dementia was only diagnosed some years later!
Contrary arguments made by others at the time including Peter Drucker in 1973 had no impact as belief was soon triumphant. Later critics like Robert Kuttner were also ignored. The progress of Friedman's ideas across the world and into every crevice in our society is history.
Peter Druker 1973
“There is only one valid definition of business purpose: to create a customer. . . . It is the customer who determines what a business is. It is the customer alone whose willingness to pay for a good or for a service converts economic resources into wealth, things into goods. . . . The customer is the foundation of a business and keeps it in existence.”
Friedman’s original article and a 2013 criticism quoting Drucker are at these links
- The Social Responsibility of Business is to Increase its Profits by Milton Friedman The New York Times Magazine, September 13, 1970.
- The Origin Of 'The World's Dumbest Idea': Milton Friedman by Steve Denning Forbes Leadership 26 Jun 2013
So we have a free-market aged care system whose origins are based on self-interest and whose theoretical underpinning considers social responsibility to be a "fundamentally subversive doctrine” - and it has no effective customer. And we poor gullible fools thought aged care was still a social responsibility.
Example: This thinking is illustrated by a current example from the USA. The New Mexico attorney general charged a nursing home owner with providing poor care and harming residents. The state had a 2.5 hours minimum staffing ratio, still below the 2.8 hours considered to be the level below which most residents are at risk of being harmed.
While studies showed that proper care of the residents was impossible with the number of staff the company argued that the minimum was all it was required to provide — and not the amount of staffing the residents needed. They meet the legal requirements and that is all they have to do. Clearly social responsibility is not something that is part of their operation and imagining what it is like for the residents is not their role.
The results showed that it was “physically impossible” for the number of workers employed to provide the care required by the residents, according to the NPR report.
- - an attorney representing the chain - - (claimed) - - the state's formula “reinvents the wheel,” and clashes with the established state standard of 2.5 hours of nursing care per resident per day.
The standards argued by Mann and Preferred Care are the “minimal standards, just a basic floor” and that facilities should be doing “everything they can” to meet residents' needs, New Mexico Attorney General Hector Balderas told NPR.
Source: Report: Data used in NM nursing home lawsuit clashes with industry staffing standards Mcknights.com 3 April 2016
Good men do harm: If we go back to Henry Adams comment that “It's always the good men who do the most harm in the world” and then look at videoclips on Youtube showing Friedman in discussion arguing his points there can be no doubt about his sincerity, his conviction and his desire to change the world for the better. He must qualify as a good man - certainly in the minds of those who have followed him.
Turn to history to see what happened to others who had lightbulb moments. Ideas that they saw as ultimate truths. They were able to sell their countrymen a vision that was embraced They believed in these truths so implicitly that they were prepared to pursue policies that resulted in millions of deaths and even in genocide. Hitler, Stalin, Mao, Verwoed and many more - all committed to ideals and thought by their followers to be good men - but by posterity as evil. If any of them had succeeded in dominating the world we would all admire them and their ideas. If we are honest we must see them as motivated by "great truths" and a desire to create what they saw as a better world- good men in their own way. Was Hitler's book Mein Kamph, propounding his theories, insincere? I don't think so.
Friedman caused fewer blood baths but his ideas have been far more successful and have conquered the world. Friedman’s conquest has been far more low key, far more extensive and far more pervasive. While like the others it has had some successes it has had negative impacts and distorted human activity and human lives in large sections of society. We would have had a very differeent world without them, perhaps less wealthy but we and our society might have been different and probably had fuller lives in other ways.
Marketing and tokenism
Advertising is vital: The two largest fraud prone health care corporations in the USA stated quite openly that marketing was their most important activity and the recipe for their enormous success. In the company NME, whose 1980’s fraud I described earlier, every employee was expected to phone someone daily to sell the company's psychiatric services.
In the service of self-interest everything must be clothed in words. Joseph Goebbels, Hitler's propaganda minister described it as “They are mere words, and words can be molded until they clothe ideas and disguise." Examine the brochures and the web sites of the big listed aged care corporations. To compete all the providers have to market themselves like this. Ask yourself if they are cloaking their self-interest and failure to accept any social responsibility in words that clothe ideas and disguise.
We don't like being liars: But most of us need to believe in what we are doing if we are to consider our lives to be "good lives" and worth living. To maintain our personal integrity we have to believe the words when we sell the aged care services we provide to others.
In a competitive market descriptions given by the words and pictures used in marketing are not attainable with the resources that can be allocated to provide care - not if the business is to be profitable and competitive, prosper and grow, acquire others and not be acquired. But to maintain integrity and to succeed with customers care must be good and be seen to be good. The only way out is for meaning to lie in the words themselves and not in what they refer to. We create a make believe world created by the language we use. We become unconscious of the real world. The way in which we deceive ourselves when we do this has been described by philosophers as "bad faith". I may look at it on another page.
Tokenism: What happens in this situation is that the words become tokens of what should be there and are used and believed in place of the real thing. We talk of tokenism or of something being tokenistic.
If we look at some comments by people from the sector who are critical of what is happening we can see that they are describing tokenism using terms like “smoke and mirrors”, “all show no go” and meaningless babble. The extracts from comments below were in response to an article promoting the aged care guild and its wealthy members.
(Comment 1) As an industry that pumps the rhetoric of positive, active ageing and person centered care, we are all smoke and mirrors.
(Comment 3) As you have both identified, we’ve been hijacked by profit-driven charlatans and funded by one-term bureaucrats who don’t think anyone will notice if Aged Care is all show and no go.
We get thrown the occasional feel-good cliche, the next BIG THING to prove we’re a dynamic and care-focused industry (active ageing and restorative care) but, on closer inspection, is just meaningless babble that wont be funded, wont be practiced and wont ever have a chance of working under our existing model.
Person centered care...hands up all those with staff/resident ratios of 1:3, no daily shower lists or the ability to serve a cooked breakfast at 10:30?
Reablement...how, more heat packs?
Consumer directed care...take it or leave it (there’s your choice)
Source: Comments on Aged Care Guild commissions Deloitte report into ACFI changes Australian Ageing Agenda 18 May 2016
A political example: But consider an example in politics. Helen Polley shadow minister for aged care on her web sites refers to the Living longer Living Better reforms that labour introduced and she claims the Abbott government destroyed, blaming them for the mess,
In Government, Labor made ageing and aged care a national priority, consulted widely, worked collaboratively and introduced the reform package with bipartisan and extensive community support.
Source: Aged Care Reforms - four years on Helen Polley web site accesses 1 June 2016
I described what actually happened on the "Aged Care in the dark" web page under the third slider "The Process: Reform gone wrong". After a few years of doing nothing the labor government finally announced an inquiry. The “consulting widely” and “worked collaboratively” were selective and did not include the wider community or critics of the Productivity Commissions proposals. “Extensive community support” was tokenistic and Polley’s words are a substitute for the real thing that never happened. The policy had been made after the 2010 Productivity Commission which was essentially directed to supporting the market without protecting the interests of the community. The mess was as much labor's as the coalition government's.
Why aged care is like it is?
Is it any wonder that aged care is in crisis and that we are all trapped in this. Little room for our humanity here.
In a submission to the Productivity Commission "Caring for Older Australians" Inquiry in 2010 a nurse academic, who had previously spoken out about what she saw in aged care, put it this way “Instead of a partnership – it becomes a struggle”. That sums up a situation where good care occurs in spite of the system.
The proposed Community Aged Care Hub is suggested as a way to do what Druker suggested - to place the customer and civil society in charge. A free market cannot remain free and serve only the interest of investors when there are customers with knowledge, understanding and power supported by a strong civil society.
The hub is intended to create a situation where instead of a struggle to express our humanity it becomes a partnership. Does anyone have a better idea?
The Community Aged Care Hub
The Community Aged Care Hub is created very specifically within what I consider to be a constructivist (sociology of knowledge) perspective. It is intended to be an expression of civil society, to embrace the idea of citizenship and participatory democracy. Its focus is the common good and social responsibility. It creates a context within which unrealistic concepts can be comfortably challenged and where entrenched beliefs can be abandoned without experiencing too much angst. It is intended to prevent a recurrence of what has happened in aged care.