“If I were to attempt to put my political philosophy tonight into a single phrase, it would be this: Trust the people.”
This chapter provides a cursory overview of political philosophy, but in no means is meant to be a comprehensive discussion. Readers interested in more detail are encouraged to pursue items on the reference list or consult the Internet Encyclopedia of Philosophy, available online at www.iep.utm.edu.
All of the politics and policies discussed in this book have underlying issues that are infused with some basic understanding of political philosophy. Although most people engaged in health policymaking focus primarily on the strategies used in advocating for a particular issue, it is also important to understand the fundamental themes that structure debates, limit options, and motivate many of those in positions of power. Most of these themes are derived from political philosophy and have historical roots that have evolved over time and assume slightly different meaning in contemporary health policy deliberations.
In this chapter, we present major concepts from political philosophy so that nurses will be mindful of the ideologic, philosophical, and political themes that structure contemporary health policy debates. Such knowledge can enhance the ability of nurses to develop strategies that take into account political and ideologic perspectives, many of which are not always evident but nonetheless often drive political deliberations and outcomes. After an introduction to political philosophy, we present an overview of the state and its relationship with individuals. Next, major political ideologies and their evolution are explained. This leads to a discussion of what policy analysts often refer to as the “welfare state” and its differences across nations in terms of public and private roles and responsibilities. We conclude with a discussion of the implications of political philosophy for nurses involved in health politics and policy.
Political philosophy examines, analyzes, and searches for answers to fundamental questions about the state (discussed later) and its moral and ethical responsibilities. It asks questions such as, “What constitutes the state?” “What rights and privileges should the state protect?” “What laws and regulations should be implemented?” “To what extent should government control people’s lives?” Political philosophy encompasses the goals, rules, or behaviors that citizens, states, and societies ought to pursue. It provides generalizations about proper conduct in political life and the legitimate uses of power (Hacker, 1960). Political philosophers take into account the capabilities of people and societies. Therefore philosophers’ moral assumptions and the realities of their times shape their perceptions and writings. Today’s political philosophers build on the classic works of the past and apply them to contemporary issues, including health policy. From another perspective, political philosophy addresses two issues. The first is about the distribution of material goods, rights, and liberties. It encompasses the rights and responsibilities of residents of a specific geographic locale and how people can exercise those privileges and duties to meet their personal and social needs. The second issue pertains to the possession and determination of political power. It includes questions such as, “Why do others have rights over me?” “Why do I have to obey laws that other people developed and with which I disagree?” “Why do the wealthy often have more power than the majority?” (Wolff, 1996).
Political philosophy is a normative discipline, meaning that it tries to establish how people ought to be, as expressed through rules or laws. It involves making judgments about the world, rather than simply describing or observing people and society. Political philosophers attempt to explain what is right, just, or morally correct. It is a constantly evolving discipline, prompting us to think about how the concerns and questions just described, although as ancient as society, affect us today.
For nurses, political philosophy offers ways of analyzing and handling situations that arise in practice, policy, organizational, and community settings. For example, it helps determine how far government authorities may go in regulating nursing practice. It offers ways of understanding complex ethical situations—such as end-of-life care, the use of technology in clinical settings, and reproductive health—when there is no clear answer regarding what constitutes the rights of individuals, clinicians, government officials, or society at large. Political philosophy offers normative ways of addressing such situations by focusing on the relationships among individuals, government, and society. Finally, political philosophy enables nurses to think about their roles as members of society, organizations, and health care delivery facilities in attempting to attain important health policy goals, such as reducing the number of people without health care coverage and eliminating disparities among ethnic groups. To achieve these goals, nurses also need to address larger issues of poverty, income distribution, and allocation of resources, all of which entail the balance among the rights and responsibilities of individuals, health care professionals, and the state.
The “state” in political philosophy (and political science) does not pertain to the 50 states of the United States. Rather, it is a “particular kind of social group” (Shively, 2005, p. 13). Centuries ago government as we know it today did not exist. Rather, kings and their soldiers held power. Over time, states developed control over war, peace, governance, and industry. The nineteenth century Industrial Revolution greatly contributed to the growth of the modern state. Commerce and industry relied on states to support the expansion of transportation and communication through laws and other policy venues. Conversely, commerce and industry enhanced the development of the state as the latter sought ways to levy taxes, build their defense apparatuses, and develop internal operations.
The state arose from the notion that people cannot rule at their will. As Andrew Levine (2002) explained, “Few, if any, human groupings have persisted for very long without authority relations of some kind” (p. 6). Concentration of power in a “single, centrally controlled mechanism of administration and coercion” characterizes the origins of the modern state (Levine, 2002, p. 6). This coercion or, more precisely, the ability to influence people’s compliance with rules, is necessary for sustaining peace and orderly conduct and for advancing the good of individuals and society as a whole. Political ideologies, described later, provide ways of discerning the best way to achieve those ends.
Today’s modern state is a highly organized government entity that influences many aspects of our lives (Shively, 2005). It typically refers to the “governing apparatus that makes and enforces rules” (Shively, 2005, p. 56). Therefore the terms state and government may be interchangeable. It is the role of the state (or government) in health policy issues—such as licensure of health professionals and institutions, financing care, ensuring adequate environmental quality, protecting against bioterrorist attacks, and subsiding care—that affects nurses in their professional practice and personal lives. Usually people think of national governments as the modern state. However, local and state governments also assume important roles in protecting individuals, regulating trade, and ensuring individual rights and well-being. In distinguishing between a nation and a state, note that a state is a political entity “with sovereignty,” meaning it has responsibility for the conduct of its own affairs. In contrast, a nation is “a large group of people who are bound together, and recognize a similarity among themselves, because of a common culture” (Shively, 2005, p. 51).
Despite these distinctions, the terms state and nation often overlap in common parlance because government leaders often appeal to the “emotional attachment of people in their nation” in building support for the more legal entity, a state (Shively, 2005, p. 52). Furthermore, our global society, with the cultural diversity of most countries, makes claims of common cultural ties as the distinguishing feature of any nation increasingly difficult to uphold. That said, few would dispute that the political culture of the U.S. is different from that of other countries. We pride ourselves on individualism, a laissez-faire approach to government and economics, and a strong belief in the rights of individuals. Policy analysts often point to our unique political culture as an explanation for why U.S. social policy deviates from that of other countries. Two examples are our difficulty in establishing any type of national health insurance program, despite historical progress in the 110th congressional session (2009-1010) and our being one of the last nations to ratify the United Nations Convention on the Rights of the Child. [As of Jan. 20, 2010, the U.S. had yet to ratify the Convention, despite promises from the Obama administration (Carrera, 2009). These policies follow a strong American tradition of a carefully delineated relationship between individuals and the state.
Individuals and the State
One of the major political philosophers to describe the relationship between individuals and the state was Thomas Hobbes (1588-1679). (See Table 6-1 for a summary of the contributions of Hobbes and other major philosophers discussed in this chapter.) Hobbes developed the concept of the “social contract,” which basically claims that “individuals in a hypothetical state of nature would choose to organize their political affairs” (Levine, 2002, p. 18). As Shively succinctly explained, “Of their free will, by a cooperative decision, the people set up a power to dominate them for the common good” (Shively, 2005, p. 38). Hobbes’s theory was intended to defend the rights of kings, but one can use it to justify other forms of government and authority. His thinking was important in establishing governance and authority, without which people would live in a natural state of chaos. To avoid such situations, according to Hobbes, people living in communities voluntarily establish rules by which they abide.
|Political Philosopher||Major Contributions|
|Thomas Hobbes (1588-1679)||Social contract; individuals will voluntarily form governments to provide for common good|
|Thomas Locke (1632-1704)||Individual inalienable rights; different from legal rights|
|Jeremy Bentham (1748-1832)||Utilitarianism—individuals are utility maximizers; government exists to maximize happiness for greater good|
|John Stuart Mill (1806-1873)||Liberalism, but not to the extent that it might harm others|
|Karl Marx (1818-1883)||Socialism—reliance on state policies to protect working class and ensure equity; common ownership of resources|
Nurses can view the social contract as a rationale for government intervention in aspects of practice, public health, and delivery of care. We turn to government to protect us from situations such as unregulated care and unlicensed practice, which might cause harm to patients if professionals and administrators were left to their own devices. We voluntarily adhere to these rules to prevent danger and minimize the consequences of unmonitored care.
Despite its advantages, the social contract doesn’t adequately address the importance of individual rights. British political philosopher John Locke (1632-1704) greatly influenced liberal thinkers, including the writers of the U.S. Constitution, by emphasizing the importance of individual rights in relationship to the state. His defense of individual rights was fundamental to liberalism (discussed later) and the development of democracies around the world. For Locke, individual rights were more important than state power. States exist to protect the “inalienable” rights afforded mankind. One of the premises of Locke’s theories is that people should be free from coercive state institutions. Moreover, the rights inherent in such freedom are different from the legal rights established by governmental authority under a Hobbesian contract. They are basic to the nature of humanity.
Jeremy Bentham (1748-1832), heralded as the father of classic utilitarianism, rejected the natural law tradition. His utilitarianism theory basically asserted that individuals and governments strive to attain pleasure over pain. When applying this “happiness principle” to governments, “it requires us to maximize the greatest happiness of the greatest number in the community” (Shapiro, 2003, p. 19). Instead of relying on natural law, Bentham favored the establishment of legal systems “enforced by the sovereign” (Shapiro, 2003, p. 19). Acknowledging that people are “individual utility-maximizers who care nothing for the overall good of society,” Bentham called for a “robust role for government in computing people’s utilitarian interests and enacting policies to further them” (Shapiro, 2003, pp. 22-23). Therefore quantitative reasoning and cost-benefit calculations to “determine the best course for society” were central to his thinking (Shapiro, 2003, p. 24). Bentham’s utilitarianism has become foundational to many contemporary theories in economics, political science, bioethics, and other disciplines.
The tension between individual rights and the role of the state is inherent in many health policy discussions. Consider, for example, substance abuse. On one hand, individuals have the right to smoke tobacco and drink alcohol. One might even argue that the state should protect individuals’ rights to do so. On the other hand, such freedoms may interfere with others’ rights to fresh air and freedom from harm (e.g., from second-hand smoke inhalation or from incidents related to alcohol use). In such cases, the state has a legitimate role to intervene and protect the rights of others—the greater good. The challenge lies in finding the right balance between the rights of individuals on both sides of the issue and balancing them with the rights of the state.
Hobbes, Locke, and Bentham are among the classic philosophers whose work set the stage for subsequent moral, political, and ethical discourse. Locke’s concepts of liberty, in particular, are basic to other versions of liberalism, a description of which is beyond the scope of this chapter. Liberalism has also been the underlying premise of many contemporary political ideologies.
A political ideology is a “set of ideas about politics, all of which are related to one another and that modify and support each other” (Shively, 2005, p. 19). Political ideologies are characterized by distinctive views on the organization and functioning of the state. Ideologies give people a way of analyzing and making decisions about complex issues on the political agenda. They also provide a way for policymakers to convince others that their position on an issue will advance the public good. Three major political ideologies—liberalism, socialism, and conservatism—originated with eighteenth and nineteenth century European philosophers and are the basis of political deliberations and policies throughout the world (Shively, 2005). Each is described in the following sections, followed by an overview of contemporary American ideologies, which are variations of traditional liberalism and conservatism. It is important to remember that terms and definitions of liberalism and conservatism as they have evolved over time are not necessarily consistent with these two ideologies as they exist today. Nonetheless, without appreciating their origins, the nuances in their rhetoric and their role in health policy cannot be fully understood.
American political thought was greatly influenced by eighteenth century European liberalism and the political thinking of Hobbes, Locke, and others. To fully grasp the impetus for such intellectual revival, one must recall that medieval Europe was a repressive agricultural society with wealthy nobility, monarchs, and clergy (especially the Roman Catholic Church) holding power. The seventeenth and eighteenth centuries brought industrialists, who sought to move goods across land and sea; scientists, who sparked innovation in work and family life; and artists, whose creativity freed the mind from parochialism. Thus, eighteenth century liberalism meshed well with political, economic, scientific, and cultural trends of the time—all of which sought to free people from confining and parochial values. Liberalism relies on the notion that members of a society should be able to “develop their individual capacities to the fullest extent” (emphasis in original) (Shively, 2005, p. 24). People also must be responsible for their actions and must not be dependent on others.
John Stuart Mill.
John Stuart Mill (1806-1873), a British political philosopher, is considered a major force behind contemporary liberalism. His essay On Liberty (1859) is foundational to modern liberal thinking. Mill was committed to individual rights and freedom of thought and expression, but not unconditionally. He based his work on Locke’s philosophies, tempered by Bentham’s utilitarian philosophy.
Mill contended that individuals were sovereign over their own bodies and minds but could not exert such sovereignty if it harmed others. In a sense, Mill provides a way of reconciling Locke’s emphasis on individual rights with Hobbes’ focus on the importance of an authoritarian state. A leading contemporary political philosopher and political scientist, Ian Shapiro, applied Mill’s balancing of individual rights with his “harm principle” as follows:
… although sanitary regulations, workplace safety rules, and the prevention of fraud coerce people and interfere with their liberty, such policies are acceptable because the legitimacy of the ends they serve is “undeniable.” (Shapiro, 2003, p. 60)