Revolutionary breakthroughs in technology, the rise of neoliberalism, and the dazzling progress of medicine have shaped our world like never before. From astonishing advancements to hidden pitfalls, this thrilling exploration delves into the captivating narrative of progress and its unintended consequences. But David Healy argues that amidst the allure, we must confront the ethical dilemmas and societal implications of unchecked advancements, urging us to tread cautiously.
Since the Second World War, we have seen a creation of previously unimaginable armaments, developments in computing and the internet, along with medical advances, including era defining pharmaceuticals. We now face an emergence of Artificial Intelligence (A.I.), which may be the most extraordinary of all, not least in the health domain.
We view these as technologies. Techne originally referred to the principles involved in making something or obtaining an objective, instantiated in machines or code. Techne is also the origin for techniques whose impact on us has been just as profound as that of technologies.
Advances in both our technical and technological capacities and imagination have coincided with political and economic developments often called neoliberalism, and medical developments we might call neomedicalism.
Neoliberalism, for many, is synonymous with capitalism and markets. Its supporters claim that combining capitalism and markets creates a dynamic process that has produced unprecedented innovation. Its doubters point to an ineluctable logic driving extraordinary transfer of wealth from the many to the few.
Many of the ills of modern society are ascribed to neoliberalism but there is no diagnosis, no picking out of an essential and remediable feature. Transposing the dynamics to a medical setting may allow us to make a diagnosis and intervene. But first what is Liberalism?
Liberalism, initially predicated on individual rights, liberty, and choice in respect of religious belief, later endorsed the freedom to choose found in free markets. Adam Smith borrowed the ideas of ‘laissez faire’ and entrepreneurs from French physiocrats, many of them doctors like François Quesnay, who argued that society, like human bodies and nature, could self-regulate. A growing pace of technological developments to supply new markets led to the French revolution, in which modern clinical medicine and public health were born.
After the Revolution, industrialization and urbanization came into the frame, along with a displacement from and alienation from machine-work. In Lyon, Ėtienne Cabet founded a communist party, and research by Louis Villermé on the health of craftsmen transitioning to machinists established public and occupational health. Borrowing from Villermé, Friedrich Engels wrote The Condition of the Working Class in England, more a public health than a political tract.
Government cannot become entirely bureaucratic. It needs an element of leadership.
In 1848, a growing unrest among workers triggered revolutions across Europe. Liberalism and communism joined in a vision of a wealthy land-owning class (State) withering away.
Marx, with Engels as a co-author, borrowing the word communism from Cabet, and capitalism which was linked to market, rushed out a manifesto. Noting the role of technologies in industrialization and alienation, he put more emphasis on capital than technology as the driver of events. He saw a new plutocracy replacing the old aristocracy, but believed this would be unsustainable and that alienation would bring a new class to power.
A science-based medicine, with laboratory technologies and public health techniques, was born in the years leading up to 1848. It used technologies to diagnose biological lesions linked to significant dysfunction, such as tuberculosis or psychosis, in order to justify therapeutic mutilation (surgery) or poisoning (drug treatment).
In Germany and France, doctors rather than economists led the revolutions. Rudolf Virchow, a leading proponent of the new medicine, was one of those who took to the barricades. Declaring politics was medicine on a grand scale, he saw a medical elite, rather than a proletariat, playing a key role in lifting the masses out of misery. As a Liberal politician, Virchow branded the health insurance schemes, introduced by Bismarck, a Conservative Chancellor, as state socialism.
Liberal professionalism was born in these years. It embraced lawyers and doctors, who, independent of State and Church, advised clients. Virchow argued that people would seek out doctors if they clearly offered something useful: medical incomes should not be guaranteed by the State.
In 1848, Marx saw technology as an instrument of a new capitalist class. In 1919, Max Weber, a Liberal politician, claimed government by bureaucratic technique had replaced the aristocracy. He could see no natural limits to this and foresaw an even more profound alienation than happens with technology. Zygmunt Baumann later claimed Weber foresaw the German public health measures that developed into the Holocaust. Bureaucracy, for Weber, was a hazard of a socialist impulse and risked imprisoning us in an Iron Cage.
As with technology, techniques are based in algorithms. These underpin procedures that facilitate bureaucracy, policymaking, regulation, propaganda, and marketing. Everything based on an algorithm has standard effects. As we are often the object of technical procedures, our individuality poses a problem for technicians.
Weber sensed a changing world. After 1900, it was more difficult to be entrepreneurial as was envisaged in 1848. Regulations to support free and responsible rather than just free markets emerged. Regulations promote the development of larger companies, with departments devoted to regulation and also marketing.
Born also around 1900, by the 1960s marketing had become so sophisticated, corporations had the capacity not just to make products but to make markets. Our economies and politics were no longer shaped by our needs; developments were now shaped by the wants we were given. Nowhere is this more clear than in the pharmaceutical domain where companies routinely market less effective and more expensive drugs to displace more effective and less expensive ones.
When it comes to technocracy, especially with the prospect of A.I., it is not clear that Right and Left retain their traditional meanings.
In 1967, a Left leaning American Liberal, JK Galbraith drew attention to the invisible hand of the modern corporation, which generated our wants rather than supplied our needs, and which was run by executives, who were now bureaucrats rather than the entrepreneurs beloved of free marketeers.
Propaganda is another branch of marketing, deployed more by politicians than by companies, the development of which was heavily sponsored by the American military.
The US military also sponsored the emergence of cybernetics, the forerunner of Artificial Intelligence. This entered the frame at a set of Josiah Macy Conferences from 1946 onwards. Its visionaries foresaw a technique delivering technology that could extend beyond simple techniques like algorithms operating to targets, like thermostats in heating systems, to explaining the feedback loops that underpin the homeostasis critical for biological systems, that French physiocrats had noticed, and perhaps explaining how free markets work.
As Denis Gabor put it:
Cybernetics… may have come just in time to harden the regrettably soft social sciences and to save our free industrial society from the twin dangers of drifting into anarchy by its instabilities or stiffening into a totalitarian system.
Heinz von Foerster, another cheerleader, claimed:
We apply the competencies gained in the hard sciences to the solution of the hard problems in the soft sciences. Cybernetics has ultimately come to stand for the science of regulation in the most general sense.
A liberal push-back emerged in mid-century, and this is often called neoliberalism. The origins are traced to meetings of the Mont Pelerin Society and other groups from 1938 onwards. Lippman, Hayek, von Mises and Friedman decried the growing acceptability of State intervention in Western economies and the threat posed by Soviet ‘scientific’ planning (Gosplan). But this wish to shrink government was not distinctively neo.
Milton Friedman echoed Weber’s claim saying we now have “government of the people, by the bureaucrats, for the bureaucrats”. Replacing the Iron Cage with a Deep State, in a later comment on health service corporations, he said:
The intellectuals may have learnt the words, but they do not yet have the tune… On both sides of the Atlantic, it is only a little overstated to say that we preach individualism and competitive capitalism, and practice socialism.
The Liberal advocacy of free markets and a development of technologies was originally a progressive not a conservative cause. Now we have a stand-off branded as conservative free marketeers against progressive socialists. Behind these labels there is discernible difference between those primarily supporting technologies and those supporting technique, paralleled in medicine by a divide between clinical medicine and public health.
The urge of transitional liberals to roll back the State to the mid-nineteenth century appeals to anyone concerned about freedom of choice. The difficulties in doing this are obvious if the proposed program is one of rolling back medical developments to the mid-nineteenth century. Few, other than some doctors practicing in boutique areas of medicine that do not require technical support, would advocate this. On a broader front, pragmatic creativity gave us both technologies and techniques; they are inseparably married.
Health brings one critical other factor into the frame. The 1950s saw the discovery of the greatest number of effective drug technologies we have ever had in one decade – all major classes of drugs, and drugs that are still best in class, all brought to the market without any of the techniques, now seen as essential to drug discovery.
The urge of transitional liberals to roll back the State to the mid-nineteenth century appeals to anyone concerned about freedom of choice.
In 1962, following birth defects caused by a sleeping pill, thalidomide, the most far-reaching regulatory development in any area of life was put in place. A prior 1938 Food and Drugs Act focused on the safety of inevitably risky chemicals, leaving doctors free to practice as they saw fit. This was set aside in favour of a unique regulatory system that stressed efficacy rather than safety. Retrospectively, the new US Food and Drugs Act can be seen to have provided a gateway for drug companies to capture healthcare, displace doctors in the creation of medical knowledge, and seriously limit our freedom.
The Neoliberal Inflection Point
In this picture of a modern complexity not readily managed by traditional political approaches, there was an innovation capable of underpinning a Neo-Liberalism distinct from both transitional and Ur-Liberalism.
In the mid-1970s, Middle Eastern War and an oil crisis gave rise to worrying inflation. In Chile a military dictatorship turned to the Chicago School of Economics for advice on managing the economy. The advice was to adopt monetarism, an idea linked to Milton Friedman, according to which setting a money supply target was all any government need do.
In 1979 Britain and 1980 America, incoming Conservative governments deployed the standard rhetoric of cutting regulation to get government off people’s backs. The Left branded deregulation as neoliberalism, a Thatcher-Reagan ideology. But this branding obscured a new imposition. Both conservatives governments adopted a target based economics - monetarism.
At the time, Friedman’s signature claim was that a freedom to choose was the highest value. But managing an economy in response to a target eliminates choice. Thermostats have targets rather than choices. Applied to people, targets do not support choice, other than the choice to compete to meet it. They replace free markets where companies compete to supply us, with markets in which we compete to fit corporate requirements.
In Chile and Britain, in the face of widespread unemployment and hardship, all was seen as in order if the money supply target was met. Any difficulties, it was claimed, were a necessary short-term corrective to get an inefficient country back on track. The apparent rationality of targets hampered efforts to argue that government involves more than surrendering to a target.
On the Left, Foucault argued that facilitated by technology, and newly able to collect data, we could set targets and adjust course in the light of our efforts to meet those targets – we could replace government with governance. Politicians like Clinton were willing, in the name of efficiency, to outsource public services to private companies, as if government sets the targets, does it matter whether public employees or private companies deliver the services?
Politicians are now openly described as, and praised for being, technocrats. When it comes to technocracy, especially with the prospect of A.I., it is not clear that Right and Left retain their traditional meanings.
At the same time, the duties of company executives were reframed in terms of targets. No longer were executives encouraged to look after the wider interests of a company or consider its social obligations, their duty was to maximize shareholder value.
There is a rationality to setting targets for inflation or share price, but in addition to being essentially algorithmic, getting the numbers right has a hypnotic logic to it. Hypnosis, like algorithms, operates on an If X, then Y basis.
Targets make developments predictable, if not sensible, making it possible to make money by betting on the numbers – not just in terms of immediate changes on a stock market but also by forcing companies and individuals to develop in certain directions. When sufficient financial clout can be brought to bear, the direction of travel even for countries can be shaped.
Weber recognized this problem. Government cannot become entirely bureaucratic. It needs an element of leadership. There are times when a leader, like a doctor, might need to get the country to swallow a medicine it might not like. But no longer are leaders free to do what might seem obviously good for their citizens, in defiance of the capital that can be mobilized against them. No leader now can gainsay a hedge fund, perhaps called Archimedes, that can all but say ‘Give me the right target and I can move the world’.
Could something so simple as targets account for today’s economic ills? Or the ills of medicine, a complex domain, whose practitioners are usually viewed as relatively sophisticated, and conversant with life’s grim realities? Could they too succumb to a target based hypnosis?