Policy as product: Morality and metaphor in health policy discourse

Hasting Center Report

Volumn 29, Issue 3, 1999, Pages 16-22

  Malone, Ruth E ^a  

^a NONE

Author keywords

[No Author keywords available]

Indexed keywords

ANALYTICAL APPROACH; ARTICLE; COMMODIFICATION; HEALTH CARE AND PUBLIC HEALTH; HEALTH CARE COST; HEALTH CARE POLICY; HUMAN; LANGUAGE; LITERATURE; MANAGEMENT; MORALITY; PHILOSOPHY; SOCIAL PSYCHOLOGY; UNITED STATES;

ANALYTICAL APPROACH; HEALTH CARE AND PUBLIC HEALTH;

COMMODIFICATION; HEALTH CARE SECTOR; HEALTH POLICY; HUMANS; LANGUAGE; METAPHOR; MORALS; PHILOSOPHY, MEDICAL; POLICY MAKING; SOCIAL VALUES; UNITED STATES;

EID: 0033128866     PISSN: 00930334     EISSN: None     Source Type: Journal    
DOI: 10.2307/3528188     Document Type: Article

References (51)

1. Zygmunt Bauman, Life in Fragments: Essays in Postmodern Morality (Oxford: Blackwell, 1995), p. 35;
2. Dow Jones News, "Ethics Training Grows into a Big Business," San Francisco Chronicle, 10 August 1996.
3. John W. Kingdon, Agendas, Alternatives, and Public Policies (Boston: Little, Brown and Company, 1984);
4. Thomas R. Oliver, "Ideas, Entrepreneurship, and the Politics of Health Care Reform," Stanford Law and Policy Review 3 (1991): 160-80;
5. Thomas R. Oliver and Pamela Paul-Shaheen, "Translating Ideas into Actions: Entrepreneurial Leadership in State Health Reforms," Journal of Health Politics, Policy and Law 22, no. 3 (1997): 721-88;
6. Nancy C. Roberts and Paula J. King, "Policy Entrepreneurs: Their Activity, Structure, and Function in the Policy Process," Journal of Public Administration Research and Theory 1, no. 2 (1991): 147-75;
7. Joseph P. Newhouse, "Economists, Policy Entrepreneurs, and Health Care Reform," Health Affairs 14 (1995): 182-99. I am grateful to my colleague, Harold Luft, for pointing out that the Schumpeterian "entrepreneur" was not just a businessperson, but anyone who was an innovator within the market. This does not, however, alter my basic thesis, namely that this word is deeply embedded within an economic/business language form.
8. For an interesting discussion of how the Rand group's purportedly dispassionate economic analysis of health care reflects a specific set of values, see Evan M. Melhado, "Economists, Public Provision, and the Market: Changing Values in Policy Debate," Journal of Health Politics, Policy and Law 23, no. 2 (1998): 215-63.
9. Deborah Stone's important book, Policy Paradox: The Art of Political Decision Making (New York: Norton, 1997) offers further insights into the way metaphors structure what we see as policy problems. Stone also makes the case that policymaking within the market model of society is regarded as an operation of production.
10. Charles Taylor, "Theories of Meaning," in Human Agency and Language: Philosophical Papers 1 (Cambridge: Cambridge University Press, 1985), pp. 248-92.
11. George Lakoff and Mark Johnson, Metaphors We Live By (Chicago: University of Chicago Press, 1980).
12. George J. Annas, "Reframing the Debate on Health Care Reform by Replacing Our Metaphors," NEJM 332 (1995): 744-47.
13. Thomas R. Oliver, "Ideas, Entrepreneurship."
14. See Wanda K. Mohr and Margaret M. Mahon, "Dirty Hands: The Underside of Marketplace Health Care," Advances in Nursing Science 19, no. 1 (1996): 36;
15. Jerome P. Kassirer, "Managed Care and the Morality of the Marketplace," NEJM 333 (1995): 50-52;
16. Jerome P. Kassirer, "The New Health Care Game," NEJM 335 (1996): 433;
17. Arnold S. Relman, "What Market Values Are Doing to Medicine," The Atlantic Monthly (1992 March): 99-106.
18. Robert N. Bellah, "Understanding Caring in Contemporary America," in The Crisis of Care: Affirming and Restoring Caring Practices in the Helping Professions, ed. Susan S. Phillips and Patricia Benner (Washington, D.C.: Georgetown University Press, 1994), pp. 21-35.
19. Notable exceptions include Daniel M. Fox, "Health Policy and the Politics of Research in the United States," Journal of Health Politics, Policy and Law 15, no. 3 (1990): 481-99;
20. Hank Jenkins-Smith, "The Policy Analysis Paradigm," in Democratic Politics and Policy Analysis, ed. Hank Jenkins-Smith (Pacific Grove, Calif.: Brooks-Cole Publishing, 1990), pp. 9-38;
21. David M. Frankford, "Scientism and Economism in the Regulation of Health Care," Journal of Health Politics, Policy and Law 19, no. 4 (1994): 773-99.
22. Also see Stone, Policy Paradox.
23. Frankford, "Scientism and Economism"; Stone, Policy Paradox.
24. The Oxford English Dictionary (Oxford: Oxford University Press, 1978), s.v. policy.
25. Some argue that not all products are traded in markets, pointing to garbage, pollution, and scientific findings as examples. Aside from the fact that at least the first two are actually traded in markets (pollution credits, for example, are bought and sold in some industries), I take this common understanding to be another illustration of the pervasiveness of the metaphor. Increasingly, even scientific findings have become commodified, as illustrated by the phenomenon of patent disputes between universities and individual scientists.
26. Arne Johan Vetlesen, Perception, Empathy, and Judgment: An Inquiry into the Preconditions of Moral Performance (University Park, Penn.: Pennsylvania State University Press, 1994).
27. See Alan Wolfe, Whose Keeper? Social Science and Moral Obligation (Berkeley: University of California Press, 1989) for a fuller discussion of these issues.
28. Knud E. Logstrup, The Ethical Demand, trans. T. I. Jensen (Philadelphia: Fortress Press, 1971).
29. Also see Bauman, Life in Fragments. In discussing agency, I make a distinction between moral agency as the term is used in philosophy to describe one capable of conscious moral action, and the concept of agency as used in economics, of an agent who acts on another's behalf.
30. Wolfe, Whose Keeper? Deborah Gordon shows how this has been true for medicine as well.
31. See Deborah R. Gordon, "Tenacious Assumptions in Western Medicine," in Biomedicine Examined, ed. Margaret Lock and Deborah Gordon (Dordrecht: Kluwer Academic Publishers, 1988), pp. 19-56.
32. See Mohr and Mahon, "Dirty Hands."
33. Lakoff and Johnson, Metaphors We Live By.
34. Robert L Heilbroner, "Rhetoric and Ideology," in The Consequences of Economic Rhetoric, ed. Arjo Klamer, Donald N. McCloskey, and Robert M. Solow (Cambridge: Cambridge University Press, 1988), pp. 38-43.
35. Steven Rathgeb Smith and Michael Lipsky, "Privatization in Health and Human Services: A Critique," Journal of Health Politics, Policy and Law 17, no. 2 (1992): 233-53.
36. See, for example, Peter Conrad and Joseph W. Schneider, Deviance and Medicalization: From Badness to Sickness (Philadelphia: Temple University Press, 1992);
37. Laurence J. Kirmayer, "Mind and Body as Metaphors: Hidden Values in Biomedicine," in Biomedicine Examined, ed. Margaret Lock and Deborah R. Gordon (Dordrecht: Kluwer Academic Publishers, 1988), pp. 57-93;
38. Arthur Kleinman, The Illness Narratives: Suffering, Healing, and the Human Condition (New York: Basic Books, 1988);
39. Margaret Lock and Nancy Scheper-Hughes, "A Critical-Interpretive Approach in Medical Anthropology. Rituals and Routines of Discipline and Dissent," in Medical Anthropology: Contemporary Theory and Method, ed. Thomas M. Johnson and Carolyn F. Sargent (New York: Praeger, 1990), pp. 47-72.
40. Herbert Blumer, "Social Problems as Collective Behavior," Social Problems 18 (1971): 298-306.
41. See Conrad and Schneider, Deviance and Medicalization;
42. Peter Conrad, "Medicalization and Social Control," Annual Review of Sociology 18 (1992): 209-232;
43. C. L. Estes and E. A. Binney, "The Biomedicalization of Aging: Dangers and Dilemmas," The Gerontologist 29, no. 5 (1989): 587-96;
44. Deborah Padgett and Thomas M. Johnson, "Somatizing Distress: Hospital Treatment of Psychiatric Co-Morbidity and the Limitations of Biomedicine," Social Science and Medicine 30, no. 2 (1990): 205-209;
45. Irving Kenneth Zola, "Medicine as an Institution of Social Control," in The Sociology of Health and Illness: Critical Perspectives, ed. Peter Conrad and Rochelle Kern (New York: St. Martin's Press, 1994), pp. 392-402;
46. and Irving Kenneth Zola, "In the Name of Health and Illness: On Some Socio-Political Consequences of Medical Influence," Social Science and Medicine 9 (1975): 83-87.
47. Kenneth J. Arrow, "The Organization of Economic Activity: Issues Pertinent to the Choice of Market versus Nonmarket Allocation," in Public Expenditure and Policy Analysis, ed. Robert H. Haveman and Julius Margolis (Boston: Houghton Mifflin, 1983), pp. 42-55.
48. Heilbroner, "Rhetoric and Ideology."
49. Taylor, "Theories of Meaning."
50. Wolfe, Whose Keeper? p. 214.
51. Annas, "Refraining the Debate."