Machiavelli and the Nationalised Health Service
Niccolò Machiavelli (1469 – 1527) was a civil servant of the Florentine Republic, being elected Secretary to the second Chancery of the Republic. In 1523 he wrote a short political treatise, “The Prince”, although this was not officially published until five years after his death. His cynical approach on how to retain political power has been the basis of much government since. His surname has given rise to the word ‘Machiavellianism’, the use of deception and deceit in keeping control.
In “The Prince”, Machiavelli makes a distinction between idealism and realism. He suggests that if a new prince is to keep control he must give the appearance of being pleasant, kind and fair but behind the scenes he must exploit dishonest and deceitful means if he is to maintain authority and power. He recognised that people do not like change so he emphasised the need to keep up the appearance of stability with a leader who is above reproach whilst privately acting ‘amorally’ to achieve his goals. He defines ‘amoral’ behaviour as ‘temporary cruel action’ that is necessary to achieve the goal. What mattered to Machiavelli was success and glory.
This textbook on how to keep power was banned both by the Roman Catholic Church and many early humanists, such as Erasmus. They rejected the brutality of Machiavelli’s combination of patronage and unfair oppression in order to achieve political goals. In contrast Hitler was known to study ‘The Prince’ regularly. The regimes of Stalin and Pol Pot were extreme examples of leaders who thought that a utopian goal was worth the price of short-term inhumanity.
Unfortunately it appears that this approach is now rife both in present governments and, as a consequence, in institutions such as the Health Service. The end seems to justify the means. Can our leaders not understand that the means causes the end? It is inevitable that when discussion occurs amongst members of the public, either through the free press or in quiet talks over coffee that deceit, abuses and unfair practices become known. This gives rise to distrust and eventually revolt.
In the Health Service there are now widespread stories of the abuse of both patients and staff. Are the elderly really being treated as we would want them to be treated? Are workers in the Health Service really feeling as wanted and cared as before? People on the shop floor are now feeling powerless to make any significant improvements in the service they give, because of the system. Are these not the natural consequences when ‘big brother’ takes over from personalised units led by individual consultants and GPs? Could it be that the main problems of Health Service Trusts are basically that its executives have seized control from those on the shop floor and some of them have descended into following Machiavellian principles?
In a company that is facing financial problems, it is common practice to undertake a ‘baseline analysis ‘ of each unit. Thus a shop in a chain of stores would determine what is the minimum number of staff required to do the job effectively and efficiently and work up from there. It is essentially a bottom up approach. The opposite is to work form top down, with tiers of committees that subdivide the budget. This is the system employed in the present health service with all its inefficiencies and abuses. It encourages a Machiavellian approach with its abuses.
Isn’t what we need that glasnost, or openness, that transiently reformed the Soviet Union under Mikhail Gorbachev? This might lead to a return to individual ‘firms’ within hospitals where the consultant and ward sister together are responsible for the standards of care, not the Chief Executives and their carefully selected committees. A lack of integrity eventually causes disintegration; the words are closely connected.
People want to be cared for as individuals. Systems working under Machiavellian principles will inevitably fail to achieve this in the long run.
What protection does the public have against ‘amoral’ or ‘immoral’ practices of those with power? Fortunately the law is still based on principles of truth and honesty, with respect for individuals’ rights. However the law, imperfect as it is, reminds us that real justice will be found at the ultimate judgement. Jesus reminds us that everybody’s actions will be scrutinised then (John 5:28-30).
BVP
