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Dr Paul Grosch Abstract In this paper I am concerned to accomplish
the following six things. First, I examine the
broad view of morality taken by ancient or pre-modern thinkers. The best
known account of this view, based on the notion of virtue or "human excellence",
is that offered by Aristotle in the Nicomachean Ethics. Second,
I describe the contemporary view of morality which, according to MacIntyre,
is largely emotivist. This is characterised by two things: a belief in
the fundamental distinction between facts (knowledge) and values (morality);
and a belief that values are simply and solely expressions of approval
and disapproval and nothing more. Third, I say something
about the rise of a particular kind of "character" in modern society who
is the inevitable product of the fact/value distinction, namely, the "bureaucratic
manager". Fourth, I try to show how the bureaucratic manager
has influenced both theory and practice in the U.K. National Health Service.
I do so by way of an example. This is the invention of the QALY (Quality
Adjusted Life Year Schedule) - an administrative unit of measurement by
which patients' needs are assessed in relation to resource problems. Fifth,
I try to demonstrate, in a similar way, how the manager has dictated issues
in education in the U.K. Here, the example is directly connected to the
recently published document on "values" produced by the "National Forum
for Values in Education and Community". After raising some objections to
the overall view of morality embedded in these examples, I conclude, sixthly,
with a brief comment about the linguistic origins of the term "management".
VIRTUES AND VALUES IN MEDICINE AND EDUCATION l : VIRTUE THEORY IN THE PRE-MODERN AGEIn his influential work, After Virtue : a study in moral theory, (1) Alasdair MacIntyre has systematically charted the gradual disintegration of moral discourse and practice such that now, he claims, we are no longer able to use the language of morality or the concepts governing ethics with any sense of meaning or purpose. We use words like "good" and "bad"; "right" and "wrong"; "values", "morals", "standards" and "ethics" without really knowing any longer what they mean, what their origins are, or even to what uses we might put them. They have become surface words, concealing only confusion, puzzlement and ignorance. Indeed, all of our utterances on matters moral have become philosophically bankrupt and culturally unintelligible. How is this so? MacIntyre's answer is, as one might expect given the nature of the charge, both long and complex. However, the narrative might be summarised thus. Prior to the Enlightenment, that historical period characterised by an unparalleled belief in the power of human reason and empirical investigation, morality was informed by at least three things, all of equal value and importance. First, there was a belief that morality consisted in improving the self, and more specifically, the qualities of mind and character with which one had been born. This, broadly, was the Aristotelian scheme. We are all born with potential qualities or virtues. Our task, as persons, is to develop the moral virtues, such as courage, friendliness, justice and truthfulness through constant habit, and to develop the intellectual virtues, such as understanding, judgment and practical wisdom through instruction and education. Our potential virtues, or human excellences, will then become actual virtues. Consequently, we will then be living according to our telos - our in-built aim or purpose in life - which is to become not just persons, but good persons. The second thing is necessarily related to the first. Aristotle was quite clear about how our identities are fashioned. Identity is partly given to us, and partly forged by us. We are members of a community first and only self-constructed individuals second. Therefore, in developing our virtues to become good persons, we are also developing our virtues in order to become good citizens. As Aristotle famously says, "while it is desirable to secure what is good in the case of an individual, to do so in the case of a people or a state is something finer and more sublime." (2) Modernist and postmodernist culture, in its headlong pursuit of individual liberty and self-fulfilment has tended to reverse that dictum. Third, there is some kind of mystical or
ineffable otherness related to our morality and our ethical concerns; something
that we do not quite understand. Aristotle argued that the purest aspect
of our intelligent mind is divine, and it is this which may live on after
the death of the body. I do not wish to go as far as Aristotle, (indeed,
all physical evidence points to the inadvisability of doing so), but there
is undoubtedly something rather mysterious and deeply unfathomable about
what it means to be a human being endowed with the powers of understanding
and feeling, the capacity to create, question and modify ideas; and about
our capacity to be driven to heights of awareness as well as to depths
of despair. Often, little of this is logical in the final analysis. Consequently,
the virtue of humility in the face of such strangeness and in the acknowledgement
of our insignificance in the cosmos is deemed as important as the virtues
of friendliness and truthfulness.
ll : THE DESCENT INTO EMOTIVISMHowever, as a consequence of the enlightenment, (3) the rich constellation of the virtues was replaced by the singularity of secular reason or rationality; the pre-eminence of the community was substituted by the rise of the liberated individual. Finally, any mystery embedded in the notion of living a human life was expelled from intellectual thought. Hence, one rationally-constructed moral theory after another was erected and then found wanting. Kant's universal dictum of strictly obeying the moral law simply because of its logical nature was too unbending and often inapplicable in the everyday realities of life. Always tell the truth and always keep your promises, irrespective of the outcome, does not match up to the messiness of day to day relationships, where sometimes a white lie or a reluctantly broken promise is an inevitability. Therefore, Bentham's, and subsequently Mill's, more pragmatic ultilitarianism soon prevailed; maximum pleasure and minimum pain, or increased happiness and decreased unhappiness, collectively and individually, were the measures of a moral decision. What was interesting was the rational calculus on which it was all fashioned. The hedonic calculus - the arithmetical means of measuring pleasure - and the utilitarian calculus - the slightly less numerical measure of happiness - both proved to be paradoxical. How can one measure whether or not one hour of Bach is worth more pleasure or happiness than an hour of Shakespeare or an hour spent sailing or playing rugby ? Are they all equal ? Measuring morality according to pleasure and pain, happiness or unhappiness, is fraught with more problems than it is able to solve. When the problems of utilitarianism had
been understood, moral philosophy eventually descended into emotivism:
the bleak doctrine that all moral utterances are simply expressions of
personal approval or disapproval.(4) This soon became known as Boo-Hurrah
theory; if all there is to morality is the emotive response of personal
approval or disapproval, then the debates about abortion, euthanasia, the
moral status of animals, the gap between rich and poor, can all be reduced
to exclamations of "Boo, I disapprove of x" or "Hurrah, I approve of y".
This extreme form of moral subjectivism has reinforced the Humean fact/value
distinction; namely, that we can agree on the truth or falsehood of facts,
such as there are x number of people in a room, but that we could never
agree on the truth or falsehood of values, such as every person has intrinsic
moral worth simply because they are members of a single species. Or, to
take another example, we could all agree on the factual truth of a certain
statement such as x million children die each year through starvation;
but that we could never agree on the moral "truth" that, therefore, we
ought necessarily to do everything in our power to ensure their future
survival. Hence, no ought (statement) from an is (statement).
We could never agree on the truth or falsehood of values or moral positions
- to do with abortion, euthanasia, rich and poor - because, according to
the theory, there are no truths to be had. It is simply a matter of whether
or not one agrees or disagrees, approves or disapproves.
lll : THE BUREAUCRATIC MANAGEROnto this rather alarming cultural stage strut three figures, according to MacIntyre: the bureaucratic manager, the aesthete and the therapist. (5) Briefly speaking, the bureaucratic manager views the world as a collection of facts, facts which have to be arranged in the most efficient manner possible in order to maximise resources, meet pre-specified objectives and evaluate decisions. The world of values or morals is not specifically his concern; that is dealt with by the church or voluntary organisations, or particular public institutions like education. For MacIntyre, the character of the manager is unique in twentieth century culture. "Managers themselves and most writers about management conceive of themselves as morally neutral characters whose skills enable them to devise the most efficient means of achieving whatever end is proposed....(This necessarily involves) .....the manipulation of human beings into compliant patterns of behaviour; and it is by appeal to his own effectiveness in this respect that the manager claims authority within the manipulative mode." (p 74)
MacIntyre's critique is not new, and he acknowledges his debt to Weber, the nineteenth century German sociologist. However, Bertrand Russell, made almost the same point half a century ago. The "bureaucrat" wrote Russell, suffers from the "administrator's fallacy"(6) which involves wedging people into pre-planned orders derived from desk-top blueprints of social reality. If they fit, all well and good; if not, then they become, like the sacked British miners in the 'eighties, sacrificial victims to the manager's morally-neutral world of economic efficiency and entrepreneurial effectiveness. MacIntyre's other two characters who naturally participate in this morally fictional world are the rich aesthete, whose existence is governed by the constant pursuit of more and different pleasures; and the therapist, whose sole task is to keep the whole sorry cultural show on the road. Professional therapists are paid to keep the rich aesthete and the bureaucratic manager mentally fit and alive, whilst the rest of society make do with the television chat-show therapist who helps to massage away the meaninglessness and superficiality of contemporary life lived in a secular and materialist mode. Nowhere is MacIntyre's analysis of managerial efficiency and effectivess more apparent than in the UK National Health Service, with its proliferation of administrators and accountants; and in the UK education system with its emphasis on administrative procedures in order to secure agreement on values, standards and quality. In the former, I claim that the fact/value distinction and the cultural elevation of the character of the manager have led to the bureaucratisation of health; whilst in the latter, the same two movements have led to the bureaucratisation of values. lV : VALUES IN MEDICINE AND HEALTHAmong those who have traditionally had to grapple with the central issue of human values, namely the values attached to life and death, are doctors in particular and the medical profession in general. Where, for example, to draw the delicate line between active and passive euthanasia has always been a problem for doctors. The distinction is a fine one; whether or not to take positive steps to end the life of a patient who may be suffering from a terminal illness, in order perhaps to relieve suffering, or whether to take positive steps to prolong that life. To administer a lethal injection, whatever the humanitarian grounds for doing so, is to engage in active euthanasia and is prohibited, but not to administer life-saving antibiotics to a terminally-ill patient with bronchial pneumonia is to underwrite passive euthanasia - allowing nature to take its course - and is permitted, or at least, not to be condemned. Historically, such fine judgements have been the preserve of medical practitioners, generally informed by social, moral and cultural considersations; and often such judgements have had to be made under difficult circumstances where resources can never keep pace with demand. John Harris, in The Value of Life (7) has illustrated the problem sharply in an example in which, for the sake of argument, we have two patients admitted to an emergency ward, both requiring surgery. Unfortunately, because of cuts and rationalisation, only one remaining theatre is available for use, and so one of the patients has to be transferred to a hospital nearby, but the journey may, itself, be life-threatening to either of the patients. Which patient to choose? According to Harris, two broad criteria come into play: age and quality of life. Suppose our two patients are aged three and eighty respectively. Again, according to Harris, both criteria favour the three year old, and both criteria are expressed as arguments: the fair innings argument and the quality of life argument. First, the fair innings argument claims that the eighty year old has already had a goodly spell at the wicket and, if absolutely necessary, there is the greater moral imperative to allow someone else an opportunity to take up the bat. Second, the quality of life argument suggests that, all things being equal, the three year old is likely to have a better quality of life after invasive surgery than the the eighty year old. The obvious problem with both arguments is that the intrinsic value of life to each of the patients is difficult, if not impossible, to measure or to determine. Presumably, the life to the eighty year old is as important to her as the life is to the three year old. Moreover, the fundamental moral status of the life of granny, presumably, cannot be assumed to be worth less than that of the grandchild. There is no way round this deeply problematic issue, unless, of course, unlimited resources were available. It is, therefore, a matter of deep Aristotelian judgment on the parts of doctors, family and others, agonising and deliberating in each and every case before finally agreeing a course of action. Moreover, their only moral resources are their qualities of mind and character which will help them to face the immensity of the problem squarely and humanely, in the knowledge that our individual and collective grasp of human worth is frail and open to question, and is always tinged with both mystery and anguish. However, in the newly-reformed NHS some
bureaucratic managers have found an ideal solution to the problem. The
solution is a QALY - a unit of measurement which can determine, in advance,
who shall be treated and who shall not, and what kind(s) of treatment are
best suited both to the patient and the hospital purse. (8)
QALY stands for Quality Adjusted Life Year Schedule and works in the following
way. Each patient admitted to hospital is assigned a QALY rating from nought
to one. Nought is equivalent to being dead, namely, there is no quality
of life; and one is equivalent to being healthy, stable and normal. Unsurprisingly,
therefore, it is known as the dead-healthy scale. (9) In between
there are minute gradations based on an assessment of the patient's overall
physical and mental condition, the likely life-style to be enjoyed or endured
post-treatment and, finally, an assessment of the economic costs of different
forms of treatment. This way, all patients can, theoretically, be given
a rank order number and a cost-benefit number, especially when resource
questions are given the same priority as value of life questions. It is
interesting to note, as Haydock does, that :
"the idea of QALYs has been invented and pioneered by a team of economists....in response to the problem of ensuring that 'as much benefit as possible is obtained from the resources devoted to health care'. The QALY is proposed as a unit of currency with which to measure the beneficial consequences of a whole range of medical operations, treatments and interventions." (p 183)To return to the previous example of the three year old and the eighty year old, matters of moral judgement are wholly simplified by the QALY rating procedure. The three year old will automatically have a much higher QALY rating given the number of quality adjusted life years she has ahead of her, whereas our eighty year old will, again automatically, have a much lower QALY rating given her tenuous future measured in life years. Haydock claims that many of the objections raised against QALYs are to do with the promotion of ageist policies in particular and reductivist ethics in general. Moreover, according to the QALY procedure, alternative quality of life schedules can be compared and assessed against costs incurred by the Health Service and a single arithmetical calculation produced which will, or can, dictate the kind of treatment which a patient will receive. However, QALYs do, of course, generate their own kinds of utilitarian problems. For example, with a finite budget, is it better to treat a small proportion of patients with low QALY ratings than a large proportion with high QALY ratings? Similarly, is it better to administer treatment to a patient which will ensure a high QALY rating for only ten years, as opposed to treatment which will lead to a low QALY rating for twenty years. The current position appears to be that by maximising QALYs per se, the amount of good achieved by the NHS will be necessarily improved by a means both precise and measurable. As ever, who makes the final decision - for arithmetical calculations are often followed by a decision rather than a judgment - is of crucial importance. Now, I am not suggesting at all that the
utilitarian invention of the QALY system is the product of a malign imagination
or that the managerial culture of the NHS is in any sense informed by a
set of deliberately sinister or immoral motives. What I am objecting to
is the rapid acceptance of a bureaucratic and managerial climate which
abstracts the value of a human life and places it on an economic balance
sheet in the mistaken belief that it can be measured. Moreover, that it
does so, not from a moral point of view but from a supposed belief that
all it is doing is simply matching ends to means in the most efficient
manner possible.
V : EDUCATION AND VALUESWhat I shall next argue is that the same kind of managerial approach to moral problems has begun to infiltrate education, particularly through the Schools Curriculum and Assessment Authority (SCAA) and other non-elected, politically-appointed groups whose central task, it seems, is to shift the responsibility for making fine educational judgments away from teachers, from the professional practitioners of the art, and place that responsibility in the hands of those, supposedly, skilled in the science of management and decision-making. The new SCAA proposals for values in education make mistakes similar to those in the health service just described. Their hierarchical lists of values and their matrices and calculations for evaluating them are the product of a managerial mindset which wishes to prescribe pre-determined solutions to daily problematic practice. Langford (10) has talked of the shift from a professional model of education in which the overall moral responsibility for children and their learning is located primarily in teachers themselves, to a bureaucratic model in which the main aims and responsibilities are set by others. These are then simply handed to teachers who are themselves demoted, by default, to the role of functionary in a pre-ordained system. The history of the UK National Curriculum and of national testing is clear testimony to this. In September 1997 SCAA set itself the task
of constructing a national school policy on "pupils' spiritual, moral,
social and cultural development". (11) This was to be based on a
"small-scale consultation" process limited to only three hundred
people. Given that there are, at least, four hundred thousand teachers
alone working in England and Wales, this is small-scale indeed. The intention
is to produce a final policy document by the year 2000; presumably to last
for the next millenium. We learn from this consultation document that SCAA
had set up the National Forum for Values in Education and the Community
(p 32) with the express remit of examining two issues. The language here
used in relation to these issues is important. The Forum was to
1. discover whether there are any values upon which there is common agreement within society; andBy all accounts a "a number of values" were quickly identified, and then equally quickly it was discovered that "there was overwhelming agreement" on their nature, function and description. (p 32). Interestingly, the Forum claimed that they were not, in any sense, recommending that certain "values" should be taught, only that they were intent on discovering which values rest on what they call the "authority of consensus" (p 32). (Presumably the moral justification of slavery in the eighteenth century rested on the 'authority of consensus'). Anyhow, included in SCAA's package of consensus values is the "positive promotion of marriage" which is itself defined clearly as "the voluntary union for life of one man and one woman to the exclusion of all others" (p 33). This automatically condemns to silence, and hence to marginalisation, all those households where this ideal of marriage does not correspond. (12) Overall, the Forum has set up a four part "matrix" of values beginning with the "self", followed by "relationships", then "society" and finally "the environment". These are all to be "promoted", as though they are now fully agreed and finalised, and are actively to be taught and encouraged. This in itself ought to be sufficient to give cause for concern. Although the Forum explicitly reject any notion that they are creating a hierarchy of values they simultaneously assert, in contradictory fashion, that values must necessarily start with the self. Although, ideologically, this is an understandable position, philosophically it is a mistake. As MacIntyre, (13) amongst others points out, the rise of the primary self or the individual, is a purely modernist conception, arguably beginning with Descartes, the founding father of modern philosophy. The sovereign authority of the individual is philosophically, but wrongly established as the self in the famous cogito argument, "I think, therefore, I am." From then on, the rise of what Scruton has called "first-person case philosophy" (14) has continued unabated. The assumption is that we are individuals first, and only members of a community or a society second. This is a mistake, as has already been argued with reference to Aristotle. Being a member of a society is logically prior to being an individual self. As members of the species homo sapiens we are inducted and initiated into a variety of communities and societies before we have any notion of who we are as individuals. Such communities are those households, or human groupings into which we are born and which initially confer identity upon us. Our parents, guardians or significant others name us, feed us, protect and train us (with varying degrees of success or failure) long before we have any conscious understanding of who we are as individual selves. Indeed, that notion of what actually constitutes an individual self is largely dictated to us by the kind of community into which we are inducted and initiated. As Langford claims, (15) the concept of a person is whatever a particular society believes such a concept to be, and as long as we continue to build into that concept primary assumptions of extreme individualism, rationality, and liberty then our concept of a person will inevitably be more culture-bound than is, perhaps, necessary. Of course, it is difficult to escape our culture, but the culture that does not examine critically its primary assumptions is one that is destined to stagnate. According to the Forum we must begin with the "self". Here, there are six broad areas which need to be "developed", and these are generally to do with maximising talents, rights and opportunities. In the atomised and individualistic culture of late twentieth century emotivism, this block of values is central to its survival. In terms of "relationships", there are seven broad areas largely to do with upholding semi-Victorian values of public politeness but absolute separateness. We are to "exercise goodwill in our dealings with (others)" and "respect (their) privacy and property" as indeed they are to do with us. This is an unabashed Lockean conception of rights: the right to individual life, the right to individual liberty and the right to individual ownership of property. (16) Philosophically this theory of rights rests on the underlying moral assumption that, provided we exercise those rights with due care and attention to existing law and order then we and our individualist projects of unfettered acquisition and private plunder will not, indeed must not, be interfered with. There is nothing here about the moral obligation to assist those who are worse off than ourselves, (17) although admittedly there is something akin to it in the third "block" of values to do with "Society". But these comprise thirteen broadly innocuous statements about the importance of "truth, integrity, honesty and goodwill", the need to "promote opportunities for all", supporting "the institution of marriage" and the need to understand and carry out our responsibilities as citizens "which include knowing about and respecting the rule of law". If ever there was a charter for the moral support of the status quo then this is it. Society as it is presently conceived and constituted is regarded as a "given", rather than an ideological construct which, as Plato and Aristotle are there to remind us, is forever contestable, always open to radical critiques, conservative responses and bloody conflicts. Finally, the "block" on the environment is simply about a weak thesis version of conservation ethics which sees the environment as a planetary playground to be carefully swept and manicured for future generations of individuals to enjoy and exploit.(18) The bureaucratic manager has a charter here for individual exploitation of persons, communities, objects and surroundings. As long as the veneer of polite respectability is managed and maintained we, as individuals, have the liberty to do what we like unfettered by any fundamental obligation to anyone or anything except ourselves. This is why the outpouring of the Forum is fundamentally flawed. How this lengthy and misconceived list of values (along with an equally byzantine list of spiritual and cultural objectives) is to be promoted is by way of an administrative matrix of seventeen pages, covering the four key stages of schooling (at ages 7, 11, 14 and 16) and the corresponding setting of targets in each of the four blocks previously mentioned. There are nineteen objectives at key stage one and a list of the ways in which these can be met in each of the national curriculum subjects. The Forum is keen to point out that the content of the matrix is simply a set of suggestions and that schools are encouraged to fill in the matrix for themselves. This is very good of them. I should imagine that hopelessly overburdened teachers are only too anxious to fill in a seventeen page complex matrix with four separate blocks of values and x number of objectives at each of the four key stages. This is bureaucracy taken to its absurd limits. I do not doubt the sincerity of the members of the Forum, nor do I doubt the moral health that underpins the desire to promote such a set of values. I do not object to many, if not most, of the kinds of values being commended. What I do object to are the following : first, the philosophical confusion that is at the heart of the document, especially in the ideological commitment to a flawed culture which promotes the individual self above all else. Second, there are no acknowledged sources for much of the conceptual analysis that underpins the document; it is completely unreferenced. One can glimpse a shred of Kantian "respect for persons theory", a nodding acquaintance with Aristotle's "virtue theory"; and a strong version of Lockean political theory. But what is most evident is the basic affirmation of Ayer's and Stevenson's emotivist doctrine that values, divorced from facts, are essentially about the private preferences, wants and desires of individuals, rather than about the deeply problematic moral judgments of particular groups of people in quite specific contexts. Describing the kind of emotivist individual who, I claim, is embedded in the pages of this SCAA document, Murdoch (19) writes that such a person is "rational and totally free except in so far as, in the most ordinary law court and commonsensical sense, his degree of self-awareness may vary. He is morally speaking monarch of all he surveys and totally responsible for all his actions. Nothing transcends him. His moral language is a practical pointer, the instrument of his choices, the indication of his preferences. His inner life is resolved into his acts and choices...... His moral arguments are references to empirical facts backed up by decisions." (p 45)This not only describes the kind of person embedded in the document but also represents the managerial approach to education and the bureaucratisation of values that go with it. Thirdly, and finally, I object to the absolute vacuity of the concept of values as it is here treated. It is at such a high level of generality that its pronouncements appear to be bland and uncontroversial, but this masks its very absurdity and dangerousness. The concept of values here is similar to that other concept of educational bureaucracy, namely, "quality". In the recent past this has generated a vast and self-perpetuating industry of philosophical nonsense, so helpfully analysed and found wanting by Hart in a delightfully refreshing article entitled "The Qualitymongers." (20) All in all, "Values in Education" is a confused and confusing document which, in terms of the history of ideas, seems to come from nowhere and equally goes nowhere. It appears as though, metaphysically and historically, it has simply dropped from the skies without reference to anything. Moreover, it can hardly be said to be essentially about morality or ethics, for it eschews the historical, cultural and philosophical nature of morality altogether. Instead, it is just another managerial guidance document in the overwhelming barrage of matrices, manuals and flow-charts in the growing but self-regarding discipline of decision-making theory. As such, it treats teachers, those remaining three hundred and ninety odd thousand practitioners, as little more than functionaries in a bureaucratically-organised social institution; functionaries who, it is assumed, are unable to make deep moral judgments on their own, nor able to understand why they must make them. Vl : CONCLUSION One final thought which may give us a clue as to the raison d'etre of the bureaucratic manager and his meteoric rise in contemporary culture. The clue lies in the etymological origins of the word itself. The word "manage" referred initially to the training of horses. It comes from the French manage or manege and the Italian maneggiare meaning simply, "the training, handling and directing of a horse in its paces - to put through the exercises of the manege." (21) This, I think, is revealing, for it demonstrates the underlying, but perhaps unintentional, purposes of management and management science as they proliferate in contemporary society. What is clear, however, is that in medicine as in education, there are a range of pre-ordained ends, usually economic and resource-based, which are entrusted to appointed individuals whose sole task is to match means to these ends in the most efficient and effective manner possible. Beware anyone who interferes with this supremely important business! NOTES & REFERENCES 1. A. MacIntyre, After Virtue:
a study in moral theory. (London: Duckworth, 1981). The second edition,
1985, includes an additional chapter in which MacIntyre replies to a number
of his critics.
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