- Restoring Responsibility: Ethics in Government, Business and Healthcare by Dennis Thompson
Cambridge, 349 pp, £16.99, November 2004, ISBN 0 521 54722 9
- NHS plc: The Privatisation of Our Healthcare by Allyson Pollock
Verso, 271 pp, £15.99, September 2004, ISBN 1 84467 011 2
- Brown’s Britain by Robert Peston
Short Books, 369 pp, £14.99, January 2005, ISBN 1 904095 67 4
Hypocrisy is such a ubiquitous feature of democratic politics that it can be hard to take it seriously. Indeed, taking it seriously is sometimes held to be a sign of political immaturity, or worse still, just more hypocrisy. We know that politicians can’t possibly sustain all the absurd contortions we demand of them as the price for securing our votes. In such circumstances, to insist that democratic politicians should honour all their promises, and practise what they preach, is itself absurd, and likely to breed cynicism and contempt. In an essay entitled ‘Hypocrisy and Democracy’ in his wonderfully measured new collection, Dennis Thompson quotes Judith Shklar, who described the politics of anti-hypocrisy as an ‘unending game of mutual unmasking’, in which everyone is bound to lose. Because democracy is a system of government that institutionalises distrust, as the price we pay for handing over so much power to our representatives, it is all the more important that we shouldn’t destroy what little trust remains, by imposing impossibly high standards. ‘We should learn to tolerate some inconsistency between the promises and performances of politicians,’ Thompson writes, ‘and perhaps even more between their private and public lives.’ If we don’t, politics will end up in the hands of the cynics and the prigs.
Thompson does not conclude, however, that we should therefore cease to worry about hypocrisy. He distinguishes between personal and what he calls ‘institutional’ hypocrisy, and suggests that in our preoccupation with the former we have forgotten that it is the latter which really matters. Institutional hypocrisy involves ‘a disparity between the publicly avowed purposes of an institution and its actual performance or function’. Thompson cites the example of the United States Constitution during the early part of its history, when the principles of liberty and equality that it proclaimed had to coexist with the practice of slavery that it also served to legitimise. This, he points out, is a far more significant feature of American politics than the parallel charge of individual hypocrisy routinely levelled against Thomas Jefferson and other champions of liberty, who happened to own slaves. Institutional hypocrisy can coincide with personal hypocrisy, but it doesn’t have to. It is also consistent with deep personal sincerity, and such sincerity will often be one of its causes. Oliver North, for instance, was not a hypocrite in any conventional sense, in that his behaviour was neither primarily self-serving nor inconsistent. It was North’s sincerity that enabled him to subvert the institutions for which he worked, and turn them against their own principles. ‘His main moral fault was not that he failed to be true to himself,’ Thompson writes, ‘but that he failed to be true to those to whom he was accountable. In his individual sincerity, he created and sustained an institutional hypocrisy.’
It is one of the striking features of the current political argument about the way healthcare in Britain should be funded that personal hypocrisy is not much of an issue. Tony Blair may not be able to bring himself to educate his children in the comprehensive system that has to suffice for most parents, but when it comes to health he is happy to take his chances with the NHS (knowing, of course, that he will be well looked after). Equally, Blair does not seem to have mixed motives when it comes to healthcare (in education a preference for selection is almost certainly concealed behind the rhetoric of universal provision). There is no reason to suppose that he doesn’t mean what he says when he talks about maintaining the NHS as a non-discriminatory system that is free at the point of delivery and treats all patients equally regardless of their ability to pay. This government genuinely wants to do its best for the NHS. Like Oliver North, the architects of New Labour’s health policy are nothing if not sincere.
The question, then, is one of institutional hypocrisy: can the NHS be true to itself if the government acts on a sincerely held belief that what it needs is an injection of private capital plus market-style competition to generate patient choice? Allyson Pollock thinks that the answer to this question is an unequivocal no. She argues that New Labour’s reforms of NHS funding, which build on but also threaten to go much further than the Tory reforms of the 1980s and 1990s, constitute a betrayal of the basic principles of a nationalised health service. The most fundamental of these principles is that healthcare should be provided on the basis of patient need, not on the basis of marketability, or cost-efficiency, or the appearance of choice. Her book is a furious denunciation of the institutional hypocrisy that results from seeing the failures of the NHS as competitive failures, rather than as consequences of the failure of successive governments to invest enough money in the service. Pollock believes that New Labour’s reforms will inevitably destroy the capacity of the NHS to meet the goal that it was ‘originally created to achieve’: a system of national healthcare that is publicly funded and, in consequence, fair.
Accusations of institutional hypocrisy can, however, be overplayed. The risk of insisting too strongly on the inviolability of a set of pre-existing commitments is that the charge of hypocrisy can give rise to its opposite, sanctimony. (One only has to think of the sanctimony of some of those who insist on the inviolability of the original purposes of the American Constitution.) Institutions must be allowed to adapt from their original purposes if the circumstances in which they operate have changed. Three things have happened which have altered the task faced by the NHS. First, demand for its services has hugely increased, in line with an ageing population and rising expectations about what healthcare should consist of. Second, the care it is able to offer has been greatly enhanced by progress in medical science. Third, the patients it treats have come to expect a certain level of personal service, as befits their experiences as consumers in other contexts. Taken together, these pressures have made it increasingly difficult to conceive of the NHS as a needs-based institution. It is no longer clear what patients need, or how many of these needs can be met, or whether their needs can be clearly distinguished from what most patients have simply come to want. As a result, the NHS has been forced to change. Needs have given way to rights, and what we have now is what a recent King’s Fund audit of the state of the NHS called ‘a set of rights to treatment, at specified and assured standards, from a widening base of diverse suppliers, public and private’.