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In fast-changing Western healthcare systems, to what extent has the idea of a ‘market’ come into play? And how has this affected and redefined healthcare?
A new book edited by Oxford academics – Marketisation, Ethics and Healthcare: Policy, Practice and Moral Formation – attempts to answer these questions.
The book’s three editors, Dr Joshua Hordern (Faculty of Theology and Religion), Dr Therese Feiler (formerly of the Faculty of Theology and Religion) and Dr Andrew Papanikitas (Nuffield Department of Primary Care Health Sciences), talk to Arts Blog about their work, which was highly commended in the recent British Medical Association book awards.
The project forms part of the Oxford Healthcare Values Partnership.
Where did the idea for the book come from?
The idea for the book came out of conversations with doctors and others working in healthcare. We wanted to work together on understanding the changing ethos of the NHS and other health and care institutions nationally and internationally. So we formed a partnership with the Royal Society of Medicine and approached the British Academy for funding. They were excited about the project and awarded funding which was then renewed for a second year to enable us to bring the different strands of our work together in the book. We ran a conference and some workshops to bring people together and set up some conversations.
Core emphases for us and the British Academy have been on involving early career researchers at every stage and on developing enduring partnerships between healthcare practitioners, social science experts and humanities researchers, drawing especially on those working in theology and religion. From the start we wanted to find out the real issues which were shaping the practice of healthcare and then resituate them in ways which would open up new lines of inquiry.
How do you define a ‘market’ in relation to healthcare?
In the book we tend to talk about marketisation and market-type processes operative in health and care. Broadly speaking, we’re talking about mechanisms of packaging, selling and paying for healthcare that are neither state-distribution nor solidarity- or charity-based forms of exchange. These are always mixed in with each other. So the key is to discern by which principles a given policy or system is governed.
Examples perhaps bring this out best – more obvious ones include the changing face of general practice with GPs running pharmacies to the role of private hospitals or doctors offering their services in private practice. But there are other important factors in the mix, including the efforts to create a functioning market in personalised social care through initiatives like personal independence payments; the role of pharmaceutical companies in contributing to and shaping the culture of healthcare; and the significance of diagnosis-related groups as a form of financial coding which has all sorts of intriguing implications for the ethos of healthcare.
What were your aims in carrying out this work?
We asked 12 authors from round the world – influenced by everyone from Marx to free market economics; Christian moral theology to analytic moral philosophy – to think together about the place and influence of market-type processes on policy and practice in healthcare. We wanted to look at institutions as organisations and examine the kind of ethic they embody and depend upon; but we also wanted to examine the way that people’s moral outlook and behaviour are shaped by marketisation processes within those institutions – questions of personal and professional formation. Think of trends like ‘defensive medicine’ which emerge for a variety of factors, but which impact medical professionalism at a deep level. All in all, we wanted to stimulate a conversation about policy, practice and moral formation which is worthy of the deep and existential questions that healthcare raises.
What were the key findings?
There weren’t any findings which all the authors shared. We as editors gave our own views in the epilogue of areas for further research. There’s a further clue, though, in the aphorism in Greek we quote at the start of the book – check it out to see what we think. If we are sincere in our respect for people, which is the ostensible basis for democratic society and healthcare ethics, then money should be a means and people should be ends in themselves. And if we understand how the things that should never be bought and sold connect with the material world, there is a chance they remain visible – even to those who now see the price of everything and the value of nothing.
One overall point which Muir Gray highlighted in the foreword was the question of what will keep money and markets in position to serve health and care rather than distort people’s attention from what matters. A conceptual and policy theme which emerges is the idea of a healthcare covenant, akin to, but distinct from, the military covenant between the people of the UK and armed forces. That’s an idea to be taken into practice in the future. Other approaches include incentives and education.
How can the humanities interact with the medical sciences?
The best way for humanities researchers to make a contribution is in close learning partnerships with medical science researchers and others working in healthcare. Where that is happening, humanities researchers are increasingly in demand for the ways they frame challenges in healthcare. This is partly because of broad cultural transitions in healthcare ecologies which represent a turn from a dependence on a largely or even exclusively biomedical model of conceiving healthcare towards a greater balance between biomedical and social conceptions of healthcare. At the same time, the trajectory towards an ever more high-tech approach to healthcare, with a particular emphasis on the biosciences as key to the UK’s offering to the world post-Brexit, is provoking critical reflection on the very purpose of healthcare. In this context humanities disciplines have the capacity to provide historical perspective, conceptual understanding and other kinds of insight into what helps sustain and restore health for people and communities. Humanities scholars are able to examine and question an entire conceptual edifice that is often taken for granted. Not: ‘How can we solve problem X?’ but rather: ‘Is this even the right way to put the problem?’ When that kind of questioning is done in partnership, everyone may be prompted to try a different path.
All this means there’s a tremendous opportunity for healthcare and humanities researchers to find new and creative ways of understanding the challenges of our time. Humanities researchers are becoming more capable in developing these partnerships and shared agendas with colleagues in healthcare locally, nationally and globally. Mutually beneficial collaborations are enabling more focused and better-informed research which can target the needs and concerns of healthcare organisations. But there remains the strategic need to interweave the agendas of humanities researchers and medical researchers, alongside colleagues in other relevant disciplines, to address challenges which are best tackled in interdisciplinary ways, in partnership with patients, public bodies and private enterprise.
The book's editors express particular thanks to the British Academy for the British Academy Rising Star Engagement Award which made this project possible. They are also grateful for funding from the AHRC (grant AH/N009770/1) and the Sir Halley Stewart Trust.