On Human Conduct

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It’s been 40 years since one of Oakeshott’s masterpieces, On Human Conduct, was published. Despite being an “old man’s” book, dense and highly qualified, it contains some of the most melliflous writing Oakeshott ever did.

Religious faith is the evocation of a sentiment (the love, the glory, or the honour of God, for example, or even a humble caritas), to be added to all others as the motive of all motives in terms of which the fugitive adventures of human conduct, without being released from their mortal and their moral conditions, are graced with an intimation of immortality: the sharpness of death and the deadliness of doing overcome, and the transitory sweetness of the mortal affection, the tumult of grief and the passing of beauty of a May morning recognized neither as merely evanescent adventures or emblems of better things to come, but as adventures, themselves encounters with eternity.

Here is the very excellent David Lloyd Thomas’ review in MIND New Series, Vol. 86, No. 343 (Jul., 1977), pp. 453-456

It would be understandable if a reader’s first impression were that this is a book from another age, largely irrelevant to contemporary philosophical discussions of politics. One will find no reference to Barry, Nozick, Rawls or Sen: only the great dead philosophers are both discussed and named. The lack of ‘engagement’ (to use one of the author’s favourite words) with current discussion may suggest a certain aloofness from, and disdain for, recent work. Such an impression, then, would be understandable, but it would also be wrong. Professor Oakeshott’s book is a major contribution to recent attempts to emancipate political thought from the neo-egalitarianism to which it has been largely confined during the past decade. The ideas, if not the packaging, are very contemporary indeed. Where, for example, has one recently encountered a view of justice like this? ‘(T)he term so frelationship are exclusively the rules of a practice which may concern any and every transaction between agents and is indifferen to the outcome of any such transaction:the practice of being “just” to one another’ (p. I28).

The first essay is principally concerned to defend the thesis that the ‘theoretical understanding of a substantive action or utterance is . . . in principle, a “historical” understanding’ (pp. I06-I07). It is not clear that discussion of the issues raised by this main thesis is much advanced, in part, perhaps, because recent debate on this matter is ignored. The part of this essay of most intrinsic interest and aloof most relevance to what is to follow, is a brief account of morality based upon the analogue of language. ‘A morality, then, is neither a system of general principles nor a code of rules, but a vernacular language. General principles and even rules may be elicited from it, but (like other languages) it is not the creation of grammarians; it is made by speakers’ (p. 78). Besides containing the germ of the idea of ‘the civil condition’, to be developed in the second essay, this account of morality reveals a tension which, in different forms and with respect to several matters, is to persist: are we being given a normatively neutral account of morality or not? On the one hand we are told ‘(that) there should be many such languages in the world . . . is intrinsic to their character. This plurality cannot be resolved by being understood as so many contingent and regrettable divergencies from a fancied perfect and universal language of moral intercourse’ (p. 80). But it also appears that for anything to count as a morality it must be ‘a practice without any extrinsic purpose’ (p. 62), and one may wonder whether some of the ‘vernacular languages’ would in fact satisfy that condition.

The ‘civil condition’, which is the subject of these essays, is an ideal ‘mode of association’.It is referred to as civitas, and is described in terms of its relationship to other idealized notions. The civil condition holds between cives who are subject to a system of rules, lex, which authorizes a procedure of adjudication in which ‘uncertainties and disputes are resolved and the conditions of association in contingent situations ascertained’ (p. I3). The account of civitas is not intended to represent civil society as it actually is, but to be a model to which political communities have approximated in varying degrees. Similarly, lex is not intended to be an account of law as it actually is in any particular state. The principal theme of the essay is to contrast the civil condition with an ‘enterprise association’, which is specified by ‘a common substantive purpose and the choice of each of the agents concerned to be related in terms of it’ (p.  114). But the civil condition is not to be understood in terms of a substantive purpose by which cives are related, nor is lex a system of common rules adopted to further some purpose,nor are the ruler sofa civitas the managers of a collective enterprise.

This essay, the core of the book, presents a lucid model of a conception of political life which many (though not Oakeshott himself, apparently) would call ‘liberal’. Elegant though it is as an intellectual construction, it is not without some obscurities, one being the relationship of civitas to morality. It resembles morality in that both are practices without a goal or purpose. Civil association is also said to be a ‘moral condition’ (p. 174). Nevertheless civitas is not co-extensive with a moral community: moral duties need not be civil obligations. Possibly the answer is that in the civil condition’s system of lex and a procedure of adjudication . . . are necessarily partnered by a procedure of legislation’ (p. I38), whereas there is no such requirement in the case of morality. This could be the starting point for developing an account of ‘the political’. The extent to which civitas is a formally defined relationship is also unclear. Presumably there are many possible variants of civitas all satisfying the formal requirements. ‘The terms of a practice of civility, then, are not conclusions inferred from the postulates of civil association’ (p. 176). On the other hand it appears that the formal requirements of the civil condition can sometimes have impressively strong implications. For example, of a proposal to prescribe that a certain opinion be believed it is said that such a proposal ‘is excluded from politics because such a rule is incompatible with the character of respublica as a system of rules to be subscribed to in conduct’ (p. I7I).

Near the end of this essay Oakeshott says of the civil condition that (one is not astonished to find this mode of human relationship to be as rare as it is excellent’ (p. 180). How is its excellence to be shown? Not, of course, by reference to the purpose it serves, for it has none, nor is it to be justified by contractor consent. Does Oakeshott believe that current orthodoxy simply ignores the distinction between the civil condition and an enterprise association? No doubt it often does, but this is hardly a sufficient argument for the former. Those who conceive of the state as an enterprise association, having become conscious of the alternative, could say ‘Civitas is no doubt an interesting political conception, but we happen to see the state, as an enterprise association devoted to such and such purposes’. It is conceded, apparently, that both models are internally consistent, and Oakeshott cannot say that those who see the state as an enterprise association misunderstand terms such as ‘state’ and ‘law’, for the terms appearing in the model of civitas do not necessarily have the same meaning as ‘state’, ‘law’, etc.

This issue arises again at the end of the third essay. The main task of this essay (entered upon after a delicious debunking of the pretensions of modern European states to either permanence, or national homogeneity, or authority) is to trace the development of two conceptions, societas and universitas in terms of which attempts have been made to understand the state in the course of modern European history. These two conceptions, corresponding to the civil condition and the enterprise association of the preceding essay, are used as poles between which the characters of actual states can be located. There is some brief discussion of particular political theories; for example, of Bodin and Hegel as representatives of the state conceived of as societas, and of Bacon as a representative of the alternative conception. There is also speculation as to the causes of subscription to universitas (though not, significantly, as to the causes of subscription to societas). The causes are said to include familiarity with the exercise of ‘lordly’ power in the administration of colonies, the frequency with which European states go to war, and the prevalence of a certain type of character, those who have an ‘incapacity to sustain an individual life’ (p. 276). In its modern form the state as universitas is seen as the organizer of an economic corporation, managed by the government and directed to exploiting its resources,both human and natural,to provide as many benefits as possible for distribution on some supposed criterion of equality.

Even by the end of the book there is still uncertainty as to whether Oakeshott thinks it proper to argue for the civil condition. Any request for something more than ‘a historical account of how the character of a modern European state . . . came to be understood in terms of the diverse analogies of societas and universitas would be made ‘somewhat improperly’ (p. 326), and yet only a few pages before we have this not altogether uncommitted passage: ‘no European alive to his inheritance of moral understanding has ever found it possible to deny the superior desirability of civil association without a profound feeling of guilt’ (p. 32I). Is it really intended that there should be no argument? Perhaps the outlines of one is to be found in the implausibility of the claims of a state as enterprise association to have authority. ‘(W)hen a state is understood as a purposive association the analogy has been fatally corrupted: association in terms of a common substantive purpose must spring from the choice of each associate to be thus joined with others,a choice which he must be able to revoke,and no modern European state has ever been of this character’ (p. 3I9). By contrast, the authority of the state as a civil association is thought to be (for somewhat mysterious reasons) above reproach. Thus modern anarchism could only apply to the state as an enterprise association, for it has ‘no meaning or relevance whatever in relation to civil association’ (p. 3I9).

This book could be seen as the complement of Professor Nozick’s Anarchy, State, and Utopia. The coyness Oakeshott displays when it comes to revealing arguments for civil association is not a striking characteristic of Nozick’s work: on the other hand, if it is true that Nozick’s book could have more sense of tradition in political thought, that lack is certainly not to be found in Qakeshott’s work. Despite the difficulty one may have in finding specific conclusive arguments, Oakeshott’s defence of the civil condition is both eloquent and persuasive.

BEDFORD COLLEGE, UNIVERSITY OF LONDON

D. A. LLOYD THOMAS

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What Drives Continuing Evolution of Careers in Medicine and Healthcare?

This by my colleague and regular co-author from the UBCMJ | SEPTEMBER 2012 4(1). As you will see, Dave has a rather unusual quality of mind in that he has a philosophical sensibility and so many reference points that typically few with his training would have.

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Two major phenomena have driven dramatic changes in medicine and healthcare careers over the past century. One critical factor has been the almost logarithmic increase in knowledge, a general phenomenon forcefully evident in medicine over the past decades. The other significant phenomenon relates to social and cultural changes with gradual development of more accepting attitudes in a diverse medical and healthcare workforce. Each of these is paralleled by consequential, organizational, family, and institutional changes.

Knowledge has expanded at about 2% per annum, compound, over the past 200 years, according to economic studies using translation of knowledge into productivity increases as a surrogate measure.1 Creation of new knowledge has also led to innovative translation with huge changes in medicine. Whereas 100 years ago a single brain, that of Sir William Osler, could be the primary repository of what was known then in medicine and write the comprehensive textbook “Principles and Practice of Medicine”,2 today, one single mind cannot contain all that is known in medicine. Accrediting bodies such as the Royal College of Physicians and Surgeons of Canada and the American Boards of Medical Specialities in the USA now recognize over two dozen specialities, each of which requires a whole career focus and is in itself a brain full of knowledge. This profound increment in medical specialities continues with new subspecialties proposed each year. Similar proliferation of roles have led to an expanded number of new professional careers in nursing, pharmacy, physiotherapy and occupational therapy, and other healthcare activities — unlike years ago where each was a single profession.

Nowadays, this requires collaboration facilitated by electronic communications with practitioners cooperating as inter–professional “communities of practice” in the best interests of patients. Additionally the patients and practitioners are now exposed to web based knowledge that accentuates the requirement for caregivers to also have immediate access to detailed current knowledge. It also emphasizes the need for all practitioners to use continuing education programs to maintain an up to date knowledge base! This, together with patient-rights initiatives, is gradually leading to a balance with physicians being seen as having expertise and authority over medical therapy and patients exercising more control over which options for care are implemented according to their preferences.3 This is, however, a very complex set of interdependent professional relationships and will continue to evolve long into the future.

Fifty to one hundred years ago, single, apparently omniscient physicians, nurses, or others with comprehensive knowledge in their specialty or practice often presented themselves as authoritative, occasionally irascible bosses with structural authority.4 Such prescriptive behaviours often occurred in operating rooms or emergency rooms where definitive verbal orders were given with instantaneous action and compliance expected of subordinate nurses and others. Nowadays, there are numerous knowledgeable practitioners, each more accustomed to assuming the role of helpful expert to assist their teams, who display their own extensive knowledge as “sapiential” or “personal”4 authority, a much more benign professional presentation.

From a social and cultural perspective over the past century, major cultural shifts in Western-oriented civil societies have occurred: perhaps as a result of two World Wars and post-recession episodic changes. Changes in traditional family roles has been one of these shifts, with more women in the workforce at senior level workforce positions. If one reviews the pictures of UBC Medical graduates over the past 60 years in the Webber MSAC Alumni room, the number of female graduates in the 1950’s was 5-10% each year whereas in current classes 50-60% of graduates are female. Also, the racial makeup of classes has changed to more closely reflect population numbers. To a degree, these shifts seem to reflect a more balanced perspective towards a civil society with a move away from authoritarianism, thus encouraging a more egalitarian professional situation.

All of these social, cultural, and epistemic changes have impacted the overall orientation of healthcare and medical practice. While always required, added emphasis is now placed on empathy, dependability, and integrity as attributes required of our graduates and coworkers in addition to an ongoing need for critical analysis and reasoning skills leading to measurable clinical competence. This is not to imply that a focus on social issues never existed. I can personally recall having a medical school course on social and cultural values in the 1950’s and still remember and utilize the concepts today of a required essay5 where I proposed a balanced civil society that valued individual freedoms. Condemned was the authoritarianism of the “soul–less”, and absolutist anarchic or regimented states!

A further cultural shift has been towards an increasing emphasis on the need for economic efficiencies. Indeed, in medical research, the requirement for effective “bench to bedside” translation is emphasized today with increasing calls for “ROI” or return on investment. This has led to the need for effective ethics review committees to protect patients’ interests6 and reduce pressures on medical researchers from undue market involvement of commercial entities such as pharmaceutical companies.7 A further problem arises with the increasing clash of professional and corporate interests. A professional by definition practices medicine to the standards of their profession in their community—not as an “occupational” working to the imposed standards of a boss!8 Pressure is exerted by some healthcare administrators for doctors to practice according to administrative budgetary requirements, thus being more efficient and perhaps less effective in care of their patients. A number of years ago at the Canadian Red Cross Blood Services, the physician in charge appeared to have rejected blood testing for donor blood infections due to testing costs on the orders of his funding agency bosses—in that case provincial government bureaucrats. His unprofessional behaviour was ultimately outlined in the Krever Commission Report.9 This led to him being professionally discredited, the Red Cross Blood Transfusion Service being terminated, and the Canadian Blood Services Agency being created.

In medicine, a major initiative that has had a profound impact is prevention of infectious diseases by immunization. This and other preventive measures have led to the survival of many who might otherwise have died. Now we are faced with an aging demographic, many of whom through excess nutrition and salt intake,10 suffer from obesity,11 hypertension, diabetes, and major cardiovascular issues. These will require additional attention in the decades to come!

So, what is the ultimate answer to the question posed at the beginning of this polemic? The enormous increase in medical knowledge, adapted to improve the quality of care of patients has led to an essential, major proliferation in types of healthcare providers. This in turn has led to significant shifts in professional relationships, not only of patients and doctors but also among healthcare providers. It is interesting to observe that such interdisciplinary activity is effected, based on a principle outlined by Adam Smith in the 1770’s as a significant concept of the Scottish Enlightenment—the Division of Labour.12 In that description, workers provided a defined activity based on their personal expertise and skill that built upon the different expertise and skill of other providers towards an ideal cooperative outcome. In Smith’s description, that outcome was the efficient manufacture of pins; in our current description for healthcare providers it is towards the optimum outcome of care for our patients in an increasingly complex healthcare environment. Cooperative inter–professional care will require greater provider empathy for all to understand and enable each other’s role in these complex, beneficent patient care related undertakings.

REFERENCES

  1. Taylor T. Thinking about a “New Economy.” The Public Interest. 2001;143: 3-19.
  2. Osler W. Principles and practice of medicine. New York: Appelton;1892.
  3. Truog RD. Patients and doctors—evolution of a relationship. N Engl J Med. 2012 Feb 16;366:581-585.
  4. Paterson TT. Pay for making decisions. Vancouver, Canada: Tantalus Publications; 1981.
  5. Hardwick, D.F. Aldous Huxley and George Orwell: An assessment of their interpretation of their age and prognostications. Social and Cultural values course, unpublished term paper, Faculty of Medicine, The University of British Columbia, 1955.
  6. Millum J. Canada’s new ethical guidelines for research with humans. CMAJ. 2012 Apr 3; 184:657-661.
  7. Hardwick DF, Marsh L. Clash of the titans: when the market and science collide. Advances in Austrian Economics, Vol. 17. Bingley: Emerald;2012.
  8. Friedson E. Professional powers: a study of the institutionalization of formal knowledge. Chicago: University of Chicago Press;1988.
  9. Krever, Mr. Justice Horace. Commission of inquiry on the blood system in Canada (Government of Canada); 1997.
  10. Flegel K, Magner P. Get excess salt out of our diet. CMAJ. 2009 Feb 3.180(3);263.
  11. Eisenberg MJ, Atallah R, Grandi SM, Windle SB, Berry EM. Legislative approaches to tackling the obesity epidemic, CMAJ. 2011 Sep 20. 183(13);1496-1500.
  12. Smith A. An enquiry into the Nature and Cause of the Wealth of Nations – edited with introduction and notes by Edwin Cannan.New York:Modern Library;1994.p.1-13.
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Science, the Market and Iterative Knowledge

The second paper co-authored with Dave Hardwick has now been published in Studies in Emergent Order:

Abstract: In a recent paper (Hardwick & Marsh, in press) we examine the recent tensions between the two broadly successful spontaneous orders, namely the Market and Science. We argued for an epistemic pluralism, the view that freedom and liberty (indeed the very concept of liberalism and civil society) exists at the nexus of a manifold of spontaneous forces, and that no single epistemic system should dominate. We also briefly introduced the concept of “iterative” knowledge to characterize the essentially dynamic nature of scientific knowledge. Herein lies a tension. The Market (and perhaps the prevailing culture at large) sees scientific knowledge in cumulative terms, that is, progressing to a conclusion in a linear fashion. This relatively static understanding of medical science as it relates to pharmaceutical studies can have a corrosive effect on the practice of medicine and ultimately, we believe, on the proper functioning of the market itself. In this paper we examine this tension in much closer detail by focusing upon the demands of the market, specifically the pharmaceutical industry, and the science upon which it is based. In other words, we expound upon a clash of epistemic value – one (science) that sees knowledge as essentially iterative (dynamic yet tentative) and the other (the Market) that harvests conclusive scientific knowledge (ostensibly as a fixed and firm commodity) functional to its own interests. Clinical Trials that are sharply focused with precisely determined deliverables often manifest this tension in the sharpest of relief. As a means of recovering drug development and testing costs, conclusive assessment is required to avoid creating serious financial problems for the companies themselves not to mention issues in the public interest.