02 Mar 2010

Sample Essay: Power. A Look at the Work of Michel Foucault

Michel Foucault was a French thinker and philosopher, who brought a different meaning to word power. He is well known for his thinking and critical appraisal of social institutions. He has done extensive work in the areas of human science, prison systems, psychiatry, and medicine. He is well known for his work on Power and its relationship between Knowledge and Discourse.

One of the key earlier works to Power is the Archeology of Knowledge. It is in this work that Foucault states that “Statement” is the fundamental unit of speech and it has a special meaning in the archeology. Foucault postulates that a statement denotes utterances and/or speech acts. It is in this work that he puts forth the argument that the meaning of semantic elements is in-determinable prior to articulation of the same.

Foucault clearly postulates that statements are a network of rules that establish what is meaningful. And that these rules are the pre-conditions for the speech acts to have meaning. And that the meaning of a statement is contextual and is reliant to the statements that are there before and after it. Foucault ensures that he identifies structures of meaning and truth in his texts; His analysts – Dreyfus and Rainbow – imply that Foucault in his texts prefers to ferret the truth rather than analyzing and hiding it beneath the text in some transcendental text. Foucault, it is said, analyzes the discursive and practical conditions for the existence of truth and meaning. From the style and approach taken by Foucault in this text it is amply clear that Foucault does not want the reader to seek interpretations of the text.

Foucault is also well known for his work on Power. It is in this work that he has almost changed the very definition and the traditional concept of power. Prior to this revolutionary approach to Power it was commonly perceived that power is something in the hands of an individual or a group of individuals who can influence, coax or cajole others to do their bidding or in extreme situations even oppress or dominate others.

Foucault brought in a totally new thinking, newer dimension and perspective – He described “power as capillary or diffuse, ultimately forming a force field detached from any human agency, yet pervading the daily existence of individuals on all steps of the social ladder and ordering their lives in the minutest detail (or affecting the way they regulate their own behavior in similar detail)”. This implies that power is something that power is something that is endowed with power and logic of its own, pretty much independent of social factors.

This is a very different perspective, possibly viewing Power under the dynamics of change of the 19th and 20th centuries. This is different from the definition of Power as made out by Gellner’s dentistry state – where in the rulers inflicted some damage or overuse of power over peasants to extract something extra from the subjects while using violence to pre-empt or punish challengers. While this damage inflict happened on one side the rulers played no role in the regulation of daily life of these subjects. This form of governance fit the well disciplined, traditional societies where rules were clear and natural. Also the issue of compliance was ensured by close-up monitoring. The challenge was when these societies began to break up – This was the situation when there was a need for a new breed of social power that would channelize the energies and entropies and also harmonize of people by the newly disembodied populace.

This was the “New Power” that Foucault refers to as the disciplinary power. This is the newer form of power wherein an individual is constantly under monitoring to ensure compliance of their behavior to scientifically designed and accepted norms. It is in the 19th and the 20th centuries that the need for this new kind of power was felt and it became imperative for the governments to create methods and systems for such constant monitoring and “micro-regulation.”

The governments struggled to ensure implementation of such micro-regulation to whole population whose behavior can be scientifically documented, measured, planned and impressed upon. It is suit this situation that the Foucault coined – “bio-power.” And the need for rethinking on the concept of power.

31 Jan 2010

Sample Essay: Serial Killers In Great Britain: A Structural Condition Rather Than a Medical-Psychological One

Introduction

The dreaded menace called serial killing has been sowing terror in many societies for many decades, yet there has been definitive conclusion to what really causes this scourge.  Basically, a serial killer can be defined as a person who usually kills more than three people on different occasions within a span of 14 days (Leung, 2004, p.1).  Consequently, two dominant schools of thought have emerged to explain the reality of serial killers namely the medical-psychological standpoint and from a structural, environmental perspective.  In particular, the medical-psychological perspective attempts to explain the existence of serial killers within the context of the person’s psyche, while the structural view focuses on particular societal structures or conditions as the causes of serial killing (Grover and Soothill, 1999, p.1).  While the examination of serial killers can be assessed from both perspectives, there is a prevailing view that serial killings perpetrated by British citizens on British soil from 1960 to 2006 may have been  a result of structural factors rather than medical-psychological ones.  This paper examines this view from the studies developed in recent years.

Definitions, Characteristics, and Perspectives of Serial Killing

Before jumping into the assessment of the reasons for the emergence of British serial killers, it is appropriate to first define what serial killing is.  Basically, serial killing involves a specific number of killings or murders and a time period.  For example, Grover and Soothill (1999, p.2) cited the six point identification of a serial killer by Egger (1984) specifically: there must be at least two victims; there is no relationship between the perpetrator and the victim; the murders are committed at different times and have no direct connection to previous or following murders; the murders occur at different locations; the murders are not committed for material gain; subsequent victims have characteristics in common with earlier victims (quoted in Grover and Soothill, 2007, p.2).  However, in line with the British serial killings from 1960 to 2006, David Wilson shares a simpler definition of a serial killer as a murderer who has “killed three or more victims in a period greater than 30 days” (Wilson, 2007, p.34).

Aside from the volume of murders and timeframe, serial killers also display certain mannerisms on personality characteristics.  As derived from the research study by Cindy Pokel entitled A Critical Analysis of Research Related to the Criminal Mind of Serial Killers, she cited Sear’s (1991) description of serial killers as those “suffering from anti-social personality disorder which tend to have the following characteristics: superficial charm, intelligence, absence of delusions or irrational thought, lack of nervousness, unreliable, untruthful and insincere, exhibit poor judgment and fail to learn from experiences, and incapable of love” (Pokel, 2000, p.45).  Consequently, as quoted in Wilson (2007, p.38), Holmes and Deburger (1988) derived four different types of serial killers from a study of 400 serial cases, with each type explained as follows:

Visionary – killer is impelled to murder because he has heard voices or seen visions demanding that he kill a particular person, or category of people.  The voice or vision may be for some a demon, but others may be perceived as coming from God;

Mission – killer has a conscious goal in his life to eliminate a certain identifiable group people.  He does not hear the voices or have visions.  He  mission is self-imposed;

Hedonistic – killer kills simply for the thrill of it – because he enjoys it.  The thrill becomes an end in itself;

Power/Control – killer receives gratification from the complete control of the victim.  This type of murderer experiences pleasure and excitement not from sexual acts carried out on the victim, but from the belief that he has the power to do whatever he wishes to another human being who is completely helpless to stop him.

All the documented British serial killers have manifested at least one of aforementioned manifestations from a period from 1960 to 2006.  As cited from Wilson (2007, p.27), there have been 19 British serial killers with a combined murder count of 326 victims.  Those killed were classified as elderly; women involved in prostitution; homosexual men; runaways and throwaways; and children.

The Medical-Psychological Perspective

As indicated earlier, one of the two main perspectives to explain the development of serial killers stem from medical-psychological factors.  The medical-psychological view can further be divided according to biological, psychological, and sociological causes.  In terms of biological causes, related literature point to physiological factors and human chemistry as factors triggering serial killings.  In particular, Sears (1991) presents several human biological conditions such as brain development, head trauma, heredity, and genetics, and male sex drive as factors that breed serial killers (quoted in Pokel, 2000, p.40).  Meanwhile, Scott (2000) identified extra chromosomes, high testosterone, and heavy metals found in the human body to describe the biological state of serial killers, while Mitchell (1996) identified five biological aspects involving evolutionary/ethological processes; neurological contributions; biochemical approaches; genetics; and race as the main determinants in serial killers (Pokel, 2000, p.40).

From a psychological perspective, Sears (1991) and Mitchell (1996) addressed the issues related to sexual sadism, paraphilias, and gender identity disorders, and both adhered to a Freudian approach to attaching serial killing to sexual impulse (Pokel, 2000, p. 46).  Meanwhile, Mitchell also focused on the aspect of multi-personality disorder of serial killers (Pokel, 2000, p.46).   Furthermore, Scott (2000) viewed serial killers as psychopaths who “often see the victim as a symbolic object and that psychopaths are generally out of touch with reality, but seem to know what is right and wrong with society” (Pokel, 2000, pp.45-46).

The third category under the medical-psychological perspective of serial killing is the sociological aspect.  Specifically, Pokel cites four main areas namely the aspect of power or control; societal norms and culture; and violence, family issues, and issues of self (Pokel, 2000, p46).  Of these factors, the need for power and control was considered by Pokel (2000, p.44) as the most prominent feature.

The Structural Perspective

One of the main proponents of the structural perspective of serial killers is Elliot Leyton who developed an excellent study entitled Hunting Humans: The Rise of the Multiple Murderer (Leyton, 1986).   Fundamentally, Leyton argues that to “truly understand why serial killers kill, we need to investigate the very nature of the social structure – the society – that has created these people whom we label as serial killers” (Wilson, 2007, p.17).  He further declares that “multiple murder is not the province of the mentally disturbed and that one has to look beyond the individual to the society, and in particular, the social structures in which he or she lives of one is to explain more fully multiple killing” (Grover and Soothill, 1999, p. 5).  Consequently, Mitchell (1996) also supports the structural view by theorizing that serial killers are people who are unable to meet the goals and values of society as a whole and consequently turn into outcasts (Pokel, 2000, p.36).  Mitchell also broached the “Strain Theory” that explains the behavior of strained people who are unable to derive achieve and success in society and thus resorts to killing as a means to self-accomplishment (Pokel, 2000, p.36).

The social structures that helped breed serial killers, as developed by Leyton (1986), encompass economic and political systems.  To illustrate the development of serial killers in society, he identified three major historical periods or epochs, each showing significant changes in the socio-economic conditions in society, and explained that in “these three periods, the social genesis of multiple killers and their victims are socially specific” (Grover and Soothill, 1999, p.5).  Furthermore, he theorized that there have been significant changes in the socio-economic background of killers and their victims between the historical epochs” (Grover and Soothill, 1999, p.5)   As seen in Table 1, the historical periods are the pre-industrial age (i.e. pre-late 19th century); the industrial period (i.e. late 19th century); and the modern period (i.e. post World War II).  In gist, the socio-economic conditions prevailing during the three historical epochs spawned serial killers who reacted violently in a term called “Homicidal Protests.”  Leyton explains this term as follows:

In each of the historical periodisations, the configuration of the social structure is such that some persons when faced with their challenges to their position in the social hierarchy react to those challenges the protest of killing members of the threatening group.  Homicidal protest can take different forms (qtd. in Grover and Soothill, 1999, p.5)

Table 1:  Three Historical Epochs, Serial Killers, and their Victims

Pre-Industrial

(Pre-late 19th century)

Industrial

(late 19th century)

Modern

(Post World war II)

Killer Aristocratic Middle Classes

(e.g. doctors, teachers, etc.)

Upper working/lower middle-class;

(e.g. security guards, computer operators)

Victim Peasantry ‘lower orders’

(e.g. prostitutes, housemaids)

Middle classes

(e.g. university students)

Source:  Leyton (1986:269-95)

Ultimately, the structural perspective of Leyton implies that that the “acts of serial killers are not simply the result of deranged or dangerous personality, but more importantly, may be the consequence of a socio-economic system which cannot by its rabidly competitive dynamic reward the efforts of all, and may dangerously marginalize certain people” (Grover and Soothill, 1999, p.2)

The British Experience

The British experience in serial killing is considered by David Wilson in his book entitled Hunting Humans: The Rise of the Modern Multiple Murderer as a product of a structural perspective and reflects a form of “Homicidal protest” to the socio-economic changes in Britain in the last three decades.  However, Grover and Soothill (1999, p.13) does not consider Leyton’s structural analysis as mirroring the British experience since the latter described serial killers based on circumstances in the American setting.  However, they do acknowledge the vital role of Leyton’s structural analysis to serial killers in “understanding the meaning of serial killing at a societal level” (1999, p.13)

In examining serial killing in Britain, this paper turns to the work of David Wilson.  As cited by Wilson (2007, p. 27), serial killing emerged in Britain beginning 1960 and grew in significance in the succeeding years.  In particular, from 1960 until 2006, there have been a total of 19 confirmed serial killers murdering a total of 326 people.  However, Wilson also noted that there were no serial killers in the 1920 until the 1930’s as compared to Germany which had 12 cases (Wilson, 2007, p. 16).  Even up to the 1950’s, Britain was considered to be relatively peaceful and serial killing had still not taken root.  Thus, the question arises – why then did serial killers emerged suddenly beginning 1960?

Wilson answers this question by explaining the social-economic transformation that occurred in the Great Britain beginning 1960.  In particular, prior to 1960’s, the country in the 1950’s was considered as “one of the most conservative, stable, and contended societies in the world” (Wilson, 2007, p.28).  The socio-economic environment of Great Britain prior to the 1960’s was described as follows:

…the vast majority of people continued to go happily about their businesses, large part because of the foundations of the Welfare State laid down by Clement Atlee’s Labour Government of 1945-1951 – known by some historians as the post-war settlement.  By this they mean that there was political commitment from both the left and the right to full employment; state-funded social security; a national health service; free education; health and employment benefits; a mixed, part private, part public economy; and recognition of trade unions…(Wilson, 2007, p. 28)

With a generally stable, peaceful environment in Britain during the mid 1940’s until the 1950’s, there was no marked serial killing activity in the country.  Essentially, the stability in the socio-economic order in the country created a sense of “inclusiveness” in British society characterized by a community bonded in family and work security for everyone (Wilson, 2007, p.29).  By 1960’s and 1970’s, however, the political and economic landscape in the country has changed rapidly.  By this time, new economic demands such as free enterprise, advances in industrialization, and changes in the global labor market have emerged.  A “market society” soon developed whereby employment became a privilege of those who deserve or are qualified for it.  The shift from an “inclusive” environment to that of an individualistic, “every person from himself” mentality became the trend in British society as the economic, market-driven environment fostered by the Thatcher government was installed in 1979.  Eventually, the highly competitive, individualistic socio-economic environment which shattered the reality of job security soon changed the way Britons viewed themselves.  Jock Young, a criminologist who analyzed the historical evolution of British criminality in his book The Exclusive Society: Social Exclusion, Crime and Difference in Late Modernity described the breaking down of societal ties during this period:

The market brings together wide swathes of the population…it creates the practical basis for comparison.  It renders visible inequalities of race, class, age, and gender.  It elevates a universal citizenship of consumption, yet excludes a significant minority from membership (Young, 1999, p.47)

Consequently, Young concludes that the advent of individualism has “undermined “relationships and values needed for a stable social order and hence gives rise to crime and disorder (Young, 1999, p.50).  In this kind of environment, some groups inevitably became marginalized and some individuals who were unable to deal with the new demands of society resorted to violence to fill a need for some kind of achievement.  This scenario ushered in the birth of serial killers in Britain.

Wilson further illustrates the tumultuous period of free enterprise and market-driven principles advocated by British government upon the ascendancy of the Thatcher administration and onwards by citing employment statistics culled from a study done by Will Hutton entitled the State We’re in (5th ed.).  For example, according to Hutton, “one in four of the adult male population were unemployed or idle as of 1995; unemployment had increased six-fold since the oil crisis of 1973; one in three children were living in poverty; and that the state is doing all it can to wash its hands of future generations of old people” (Hutton, 1995, p.199).  Furthermore, Hutton also indicated that the trade unions, which were instrumental in securing job security to union members, weakened considerably from 1979 to 1993; and that the period of the 1980’s was a time when “qualifications unemployment benefits and support became tougher; the state pension became progressively devalued in relation to average earnings; and the distribution of income more unequal” (quoted in Wilson, 2007, p.31).  Amidst this depressed socio-economic environment, Wilson notes that the country in 1986 “produced more serial killers that at any other point in British history” (Wilson, 2007, p.31).

The supremacy of the Structural Perspective versus Medical-Psychological in Britain

The structural, socio-economic perspective was deemed to have significantly accelerated the development of serial killers in Britain.  Although the medical-psychological view was never debunked to explain the serial killer development in the country, the current line of thinking supports the primacy of the structural perspective over medical-psychological explanation when it comes to analyzing the British serial killer cases.  As cited by Grover and Soothill (1999, p.4), “there has been a change within the psychological approach over the past 30 years as contemporary psychologists are willing to recognize the importance of the social context much more readily than formerly” (Grover and Soothill, 1999, p.4).  More significantly, Grover and Soothill (1999, p.4) also expressed the fact that psychiatrists had been unable to reconcile the paradox of correlating mental deviance with psychiatric abnormality when in actuality, “few offender are so psychiatrically disturbed as to be termed mentally ill.”  Furthermore, Mitchell (1996) declared that the link between genes and serial killer has not been proven and that it is “not possible to make a general statement that all serial killers as psychopaths” (Pokel, 2000, p.41).  Instead, Mitchell argues that our current society seems to be moving away from a common societal goal and that serial killers remain outcasts in society and are unable to meet the changing needs of society (Pokel, 2000, p.49)

Conclusion

The spate of serial killings in Britain from 1960 to 2006 can best be explained through the rapid, tumultuous socio-economic changes beginning in the 1960’s.  The breaking down of cherished values such as a sense of community, family, and job security to give way to  a market society driven by free enterprise, individualism and competition has inevitably marginalized some groups and filled others with intense hate and a disposition to kill.  The fact that the highest number of serial killers emerged during a period of intense socio-economic breakdown marked by massive unemployment, poverty, and declining incomes only reinforces the view that environmental, societal influences sparked the development of serial killers in Britain.  However, this paper does not attempt to discredit or nullify the possible link between medical-psychological factors to serial killers.  In fact, future study might derive some biological and psychological influences to explain the emergence of British serial killers.  Nevertheless, the pressing question still remains – if medical-psychological factors do influence serial killing, then the time element should have been rendered insignificant.  In effect, serial killers should have emerged every year in Britain since time immemorial – even in stable, peaceful times – since the causes are internal, biological, and innately psychological, which implies the absence of external causation.  The reality, however, is that serial killings in Britain emerged at a specific period in the country’s history.  In this light, the structural view remains the logical choice.

References:

Grover, C and Soothill, K 1999, ‘British Serial Killing: Towards a Structural Explanation’,

British Society of Criminology, vol. 2, pp.1-17

Holmes, RM & De Burger, J 1988. Serial murder: Studies in crime, law and justice, Vol. 2.

Newbury Park, CA: Sage.

Leyton, E 1986.  Hunting Humans: The Rise of the Modern Multiple Murderer, McClelland and

Stewart, Toronto, Canada

Leung, J 2004, The Personality Profile of a Serial Killer, A research paper in Forensics

Mitchell, EW, 1996, The Actiology of Serial Murder: Towards an Integrated Model,

Unpublished Master’s Thesis, University of Cambridge, United Kingdom

Pokel, C 2000. A Critical Analysis of Research Related to the Criminal Mind of Serial Killers,

Research paper, The Graduate College University of Wisconsin-Stout, United States

Scott, SL 2000. What Makes a Serial Killer Tick? <www.crimelibrary.com>

Sears, DJ 1991.  To Kill Again: The Motivation and Development of Serial Murder, Scholarly

Resources: Wilmington, Delaware

Wilson, D 2007.  Serial Killers: Hunting Britons and Their Victims, 1960-2006, Waterside

Press, United Kingdom

Young, J 1999, The Exclusive Society: Social Exclusion, Crime and Difference in Late

Modernity, Sage Publications, London

26 Jun 2009

Sample Essay: Healthcare Ethics

Introduction

Ethics speaks primarily to the right and wrong in human relationships. It is from the study of ethics and, consequently, a better understanding of moral principles, that society may hope to enhance the sense of tolerance, fairness, compassion, and sensitivity to another’s pain and thereby improve aspects of human behavior that place humans in a separate niche in biological history. Ethical questions, especially as they apply to medicine, have become common topics of discussion during the past twenty years. Bitter disputes have arisen regarding abortion, suicide, human experimentation, as well as the management of the dying patient and the severely disabled newborn. Today, the American health care has grown into a multi-billion dollar industry controlled by large corporations. It is clear that various ethical issues associated with delivering heath care services to patients get overridden by monetary interests.

Economic / Financial

In the past 50 years, few sectors of the U.S. economy have escaped the periodic ravages of recession. The health-care industry is a notable exception. Since 1950 hospitals and other health-related enterprises have experienced uninterrupted, indeed meteoric, expansion. Between 1950 and 1982 national health expenditures increased more than 25-fold, reaching $322 billion per year, and the proportion of the GNP accounted for by the health sector increased from 4.4 to 10.5 percent. During the 1970s health-care employment increased from 4.2 to 7.5 million workers, accounting for one seventh of all new jobs in the United States. Moreover, these trends continued through the recession of the early 1980s and 1990s. The fast pace of hospital expansion is indicated by the fact that in 1980 the average age of hospital capital assets stood at an all time low of 7 years, as compared to 15 years for the service sector as a whole and 23 years for capital in manufacturing industries.

Strikingly, the conquest of the main killers of the young (infectious diseases) was largely complete in the United States by the time the health-care sector began its explosive growth, and was clearly due to improvements in the standard of living and public health measures rather than curative medicine. The spectacular expansion of health facilities which occurred after the era of the main advances in life expectancy has been accompanied by massive government spending on curative medical care, a singular neglect of public health and preventive measures (which currently account for less than 3 percent of health expenditures), and very modest improvements in health. Moreover, many Americans lack access to the most basic medical services. The United States shares with South Africa the dubious distinction of being the only developed countries without universal health insurance. Despite the widely heralded Medicaid and Medicare programs, 25 million Americans lack health insurance of any kind, 40 percent of infants and toddlers are not fully vaccinated, and the elderly now spend as large a proportion of their incomes for health care as they did before the passage of Medicare. The paradox of vast increases in health care resources which are funded largely by the government yet fail to provide the services most critical to the improvement of health puzzles bourgeois health-policy analysts. An understanding of the role of health care in the accumulation of capital can help to unravel this mystery, forecast future trends, and focus the work of the left in this field.

Economics of health care

In the best of all possible worlds both economic efficiency and commitment to the individual patient would govern the delivery of medical care. In the real world the conflict between these two factors is increasingly disrupting the health professions. On the one hand, the traditional primary allegiance of health-care providers is to their individual patients: they cannot deny patients something they think would genuinely help. The doctor’s Hippocratic oath illustrates this. On the other hand, we all endorse the sensible goal of economic efficiency, getting the greatest value from our resources. We want to get the most health for our health-care dollars and to obtain as much value from every extra bit we invest in medicine as we could get by using the required resources on something else entirely. In economists’ jargon, we want to minimize our opportunity costs.

This conflict is sharpened considerably by the financial context of modern medicine. Once a patient is insured, the patient’s interest typically lies in receiving the best possible medical care regardless of whether the resources thus used might produce greater benefit elsewhere. The moral and professional allegiance of clinicians then seems to collide head-on with wider economic efficiency. Efficiency will sooner or later call for restricting care that would benefit individual patients. This is “hard efficiency”: it is surely not just the elimination of waste, and it leaves the health economist at seemingly irreconcilable odds with clinicians and their oath.

When each side in such a stark conflict has so much intuitive appeal, it is hardly surprising that the ensuing debate is heated. The traditional conception of loyalty to the individual patient even if that leads to sacrificing some of the overall value of resources gets ardently defended even by those who call for identifying and curtailing unnecessary procedures.

The push for hard efficiency won’t abate easily. Even if unnecessary procedures are better identified and curtailed, eradicating them is only a onetime saving. All historical trends point to continued growth in doubts about whether any and all care that serves the medical need of the patient is worth the money it costs. Randomized clinical trials will be telling more, not less, about the touch-and-go margins of effective care — what might possibly do a patient some good but is statistically and economically a dubious bargain. Both the range of options provided by medical technology and the age of the population will continue to increase faster than per capita income. Healthcare pressures on government and business budgets will grow, not diminish.

The lines of the continuing prospective debate may thus seem drawn already. Shouldn’t we come clean in our ethics and either honestly sacrifice commitment to the individual patient or frankly relent in the push for efficiency? Yet such a choice is bleak; we will swallow neither option without a moral gasp. Maybe we can avoid having to abandon either side, or perhaps we can at least reduce the force of their collision. Clinicians should be able to keep their oath of commitment to patients while at the same time taking much of larger economic efficiency to heart.

Politics

This century has witnessed the transformation of American medicine from cottage industry to large-scale capitalist enterprise. The health-care industry has received massive government subsidies, and has been largely exempt from the competition characteristic of many other sectors. Until now, any medical product has been guaranteed a virtually unlimited market. However, this expansion is giving rise to a contradiction between the health-care industry and other industries. In the past the capitalist class encouraged the growth of the health sector, but as the health-care industry expands, employee health benefits increase in cost and have by now become a major cost of production. In 1980 U.S. corporations were spending more than $65 billion a year for employee health benefits, and Chrysler executives were complaining that Blue Cross had become that company’s largest supplier. Corporate leaders have also begun to express concern about the increasing proportion of state and federal budgets devoted to Medicaid and Medicare.

Soaring health-care costs thus are becoming a major concern for the capitalist class as a whole. It is moving to curtail the special privileges which have allowed the health-care sector to reap greater profits and expand more rapidly than the rest of capitalist industry. The entry of the Business Roundtable into the health-care scene coincided with the start of government initiatives to end the privileged position enjoyed by the health-care industry. Federal grants for hospital capital projects were phased out starting in 1975, though the hospital industry was easily able to compensate for this loss by increasing its used of tax-exempt bonds. Other early efforts to contain health-care costs under the Nixon and Carter regimes were equally unsuccessful. However, more recent government attempts to rein in the health-care sector have more bite. As a reporter for the Boston Globe remarked, “The Business Roundtable’s decision to get serious about hospital cost control marked the turning point in the debate. Until then, the issue had been the province of insiders, the most influential of whom had more of a stake in the status quo [the continuing expansion of the health-care industry] than in cost containment.”

Under pressure from the business community, New York, New Jersey, and Massachusetts, among other states, have passed legislation sharply limiting hospital revenues. The Reagan administration has proposed the elimination of tax exemptions for health insurance and hospital bonds. Medicaid payments have been drastically cut, making it difficult for hospitals and doctors to profit from Medicaid patients. Perhaps most important, the basic structures of the payment systems for Medicare and Medicaid are being radically altered. Hospitals will no longer be paid for each individual test, procedure, or day of care. Instead, under Medicare the hospital will receive a fixed lump sum determined by the patient’s diagnosis. For instance, Medicare might pay a hospital $2,800 to care for a patient with pneumonia, no matter how long he or she stayed in the hospital or what tests or drugs were used. For the first time hospitals will profit by providing fewer services to each patient.

The incentive to do less is of course not new in health care. It is a central feature of so-called Health Maintenance Organizations (HMOs) which are increasingly popular among large corporate employers. The first, and still largest, HMO was started by Kaiser Industries to lower the costs of health care for its workers in massive New Deal construction projects like the Grand Coulee Dam. HMOs collect a lump sum in advance which covers all services delivered. Physicians are salaried and often share in any profits realized because of savings on patient care. Contrary to much recent propaganda, HMOs usually neglect preventive care, since cost savings due to prevention are most often realized after the patient has retired (either because of age or disability) and hence has lost his/her membership in the HMO. HMOs economize by emphasizing less personal and lower cost “industrial” style care, and erecting barriers to access which discourage members from seeking care.

Thus both government initiatives and corporate policies are forcing changes in the organization of health services. Capitalist rationalization and efficiency is replacing the ideology of “care and cure no matter the cost.” And changes on the horizon promise to complete the transformation of medical care into commodity production. Health care will be a product offered for sale on the market. Hospitals and HMOs will compete in offering corporations, the lowest priced health care which will maintain the productivity of their workers, and government the barest essentials of health care which will keep the unemployed, disabled, and retired from revolt. The state seems ready to forsake its role in assuring that health care resources are provided where needed. As a recent study by the Brookings Institution put it, “Congress has abandoned the principle that medical care should be provided whenever it is needed, that cost should not be considered when life or health is at stake.”

Competition

Medicine will increasingly be asked, “Does your practice improve the productivity and tranquility of the work force?” No more will doctors and hospitals be allowed to collect for every useless operation and superfluous machine. No more will health care for the “non-productive” poor, disabled, and elderly be lavishly financed by the state for the benefit of the private health-care sector. To be sure, the health-care industry will be allowed a handsome profit, but one in line with the rest of capitalists industry.

Already care for patients with a particular diagnosis is referred to as a “product line,” and administrators vie to manipulate these “product lines” to maximize profits and assure the survival of their hospital in the increasingly competitive hospital market. The extent to which the ideology of commodity production has come to dominate health-care administration is evident in the titles of some recent articles in the hospital administration trade journal Modern Healthcare: “Surgical Lasers Can Generate Profit If Volume of Use Can Be Guaranteed,” “Baxter Shows Hospitals How to Use Cost Data to Prepare for Price Competition,” “Managing Along Product Lines Is Key to Hospital Profits Under DRG [Medicare] System,” “Fixed Payment Rates Force Hospitals to Reassess ICUs,” and “Medical Records’ New Financial Role Dramatically Shifts Hospital Priorities.” This last article explains that under new insurance regulations, “The medical records department supplies the base information to interpret the medical stay into a financial picture,” and anticipates that “helping their hospitals collect billions of dollars in federal reimbursement will become the top priority of medical records departments. In the past, the department concentrated on maintaining accurate record for ongoing patient care.”

Social

The commodification of health care will have important repercussion for health-care workers and patients. Competition among health-care institutions will increase and result in the elimination of smaller scale, more personal and human sources of care. Health care will be monopolized by large corporations, employing thousands of workers organized to deliver care in an increasingly mechanized factory-like environment, with little human contact or understanding. Thus the familiar petty-bourgeois local doctor is already being replaced by “MediStop” centers staffed by anonymous employees providing technical interventions which keep working people at work and treat others as cheaply as possible. Care of the “non-productive” poor and elderly, and interventions aimed at improving quality of life or psychological well-being will receive short shrift. Public-health efforts to prevent the main modern-day health problems, such as heart disease and cancer, are likely to be crippled because such chronic diseases primarily affect workers in their non-productive post-retirement years.

Health-care workers will find themselves cogs within huge and growing enterprises. Administrators armed with elaborate computer systems will monitor and control day-to-day medical practice, dictating what tests and treatments are allowed for a given “product line” (disease). Physicians, in the past independent entrepreneurs, will serve as highly paid supervisors. For the first time, in 1982, more doctors in the United States were salaried than self-employed. For non-physician personnel the changes may be more painful if less dramatic. Hospitals will have more incentives to limit labor costs by holding down both wages and the number of workers. The proportion of health spending devoted to labor costs, which fell by more than 10 percent during the 1970s, will fall even more rapidly as machines replace many workers. Unions will increasingly be under attack.

Technology

The complexity of ethical dilemmas and resultant clamor will become more bewildering as technology continues to advance. We are facing a time when an egg and a sperm with desirable genetic attributes will be brought together in a Petri dish, nourished until transplanted into the uterus of a future mother, all according to parameters spelled out in a computer containing lists of potential donors. The ethical issues surrounding a surrogate mother are simple compared to those that all of us will face in the future. It has become a moot point whether ethically we should or should not move along certain potentially dangerous lines of research. The fact is that we will continue all areas of research and thus will be in need of greater understanding of ethics involved in the application of our knowledge. In order to clarify the fundamental premises upon which ethical decisions must rest, we need to stand back and assess our situation, free from the burdens of tradition, dogma, or gut reaction that limit our thinking.

As K. D. Clouser so pointedly expresses it, “Medical ethics is no big deal … it is simply ethics applied to a particular area of our lives … it is the ‘old ethics’ trying to find its way around in new, very puzzling circumstances.”[1]

Conclusion

The health care industry is one of the biggest and profitable business sectors in America. Americans spend more and more money on health care year after year, yet, the quality of services may not increase so dramatically and the ethics of medicine usually tends to be ignored in such a thriving sector of the US economy. The enormous sums now spent on health care are sufficient to assure health workers a decent standard of living, provide high quality curative medical services to all in the United States, enormously increase efforts in prevention and relevant research, and meet our now neglected international responsibilities in health. The issue is not lack of money but capitalist irrationality and waste: the insurance industry and armies of administrators which together devour 25 percent of all health-care spending, the billions of dollars of profits and advertising by drug and equipment suppliers, the massive duplication and maldistribution of facilities, and the greed and ideological bias of physicians which leads to millions of unneeded operations and tests, the proliferation of capital intensive treatments, and the neglect of non-technical (and hence unprofitable) therapies. Still, I sincerely believe that the pressure coming from various social groups is having and will have an even greater impact on the development of health care ethics, therefore, improving the quality of medical services.

Bibliography

K. Danner Clouser, “Medical Ethics: Some Uses, Abuses, and Limitations,” The New England Journal of Medicine 293, no. 8 ( August 21, 1975): 384.

Expenditures by John K Iglehart (The New England Journal Of Medicine, Jan. 7, 1999.  Volume 340:70-76).

Health Premiums to Jump Again Next Year: Insurance Rate Hikes in Area, Nation Likely to Be in Double Digits, Data Suggest by Bill Brubaker (Washington Post, June 24, 2003; PageE04).  Based on data from multiple sources, it appears that this will be the fourth year of premium increases in a row.

Why Are Local Healthcare Costs among the Highest in the Nation?  By John Dorschner (The Miami Herald, July 21, 2003).  An examination of the possible factors involved in high cost of health care in South Florida.

Health-Care Costs to Rise in 2004: Employers are expecting increase of 12%, fifth year in a row of double-digit gains by Vanessa Fuhrmans (The Wall Street Journal, September 29, 2003).  Many employers will shift some of the cost to employees.

Healthcare Costs Are Up.  Here Are The Culprits. By David R. Francis (The Christian Science Monitor, December 15, 2003).  Overview of the parts of the health care system that have become expensive.

Tough Trade-offs: Medical Bills, Family Finances and Access to Care by Jessica H. May and Peter J. Cunningham (Center for Studying Health System Change, Issue Brief number 85, June, 2004).  This study examines the difficulty both insured and uninsured Americans have in paying their medical bills, and how that difficulty affects access to care.


[1] K. Danner Clouser, “Medical Ethics: Some Uses, Abuses, and Limitations,” The New England Journal of Medicine 293, no. 8 ( August 21, 1975): 384.

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