Healthcare Iron Cage

“There are these two young fish swimming along and they happen to meet an older fish swimming the other way, who nods at them and says “Morning, boys. How’s the water?”

And the two young fish swim on for a bit, and then eventually one of them looks over at the other and goes “What is water?”

— David Foster Wallace, This is Water

Max Weber showed us the water. He said that the most rational way to organize human activity, maximize efficiency and eliminate favouritism was with hierarchical bureaucracy.

The father of sociology, Weber gave us Weberian Civil Service. Weber’s bureaucracy controls medicine, education, all branches of government and most large corporations today.

But Mr. Weber was curiously honest about his bureaucracy. He did not disguise its ugly side.

He predicted it would put an “iron cage” on each of us and, eventually, a “polar night of icy darkness.” Max Weber blamed capitalism for pulling us into bureaucracy. He said it created institutions that limit choice in favour of a “technological utopia”.

Healthcare Iron Cage

The Iron Cage is a “technically ordered, rigid, dehumanized society”, a set of rules for all of us.

A Bureaucracy:

• Concentrates power in a few people that are generally unregulated. (oligarchies)
• Breeds on the fixed belief in its superiority. Spawns more bureaucratization and rationalization.
• Turns individuals into cogs in a machine. People focus their careers on becoming bigger cogs.
• Sees people as units of labour to be bought by the bureaucracy. Others dictate the price of your individual services; the value of your accomplishments.

Weber explained that bureaucracy arises from rational design. He believed it was an inescapable fact of reason. But rational bureaucracy produces irrational results.

Health bureaucracies exist to provide care for the sick but limit access to medical services. National health insurance (Medicare) guaranteed doctors payment for all services, but put doctors out of work by closing operating rooms and blocking them from joining practices. Each industry could add its own stories as the same irrationality happens in agriculture, forestry and education.

“No one knows who will live in this cage (Gehäuse) in the future, or whether at the end of this tremendous development entirely new prophets will arise, or there will be a great rebirth of old ideas and ideals, or, if neither, mechanized petrification, embellished with a sort of convulsive self-importance. For the “last man” (letzten Menschen) of this cultural development, it might well be truly said: “Specialist without spirit, sensualist without heart; this nullity imagines that it has attained a level of humanity (Menschentums) never before achieved.”

Protestant Ethic: [Weber 1904–05/1992, 182: translation altered].

No one talks seriously about bureaucracy anymore, except maybe the anarchists. David Graeber, famous for ‘We are the 99%’ from the Occupy movement, has a new book, The Utopia of Rules: On Technology, Stupidity, and the Secret Joys of Bureaucracy. While I disagree with violent anarchists, I plan to read Graeber’s book.

Have we confused bureaucracy with government, the healthcare iron cage with medicine?

Giles Fraser wrote in the left-leaning Guardian, “…the left has assumed that defending (or being silent about) the smothering prevalence of bureaucracy is all about defending the state.”

Medical associations should challenge the healthcare iron cage. We could use the multi-million dollar medical bureaucracies to build ‘iron cage’ committees. Imagine our association bureaucracy fighting government bureaucracy, bureaucracies attacking bureaucracies.

Maybe that’s dreaming. Maybe the healthcare iron cage, too, must lead to a polar night of icy darkness as Weber predicted.

Photo credit: theunsecretshopper.com