"Some of them are foreign-born and struggle with the language, and all of them are in distress! But I hardly have the time to explain the essentials to them. There's all the paperwork, and we're constantly understaffed.'
Such grievances have become sadly familiar – not only in medicine, but also in education and care-work. Even in more commercial environments, you're liable to hear similar objections: the engineer who wants to deliver quality but is told to focus on efficiency only; the gardener who wants to give the plants time to grow, but is told to focus on speed. The imperatives of productivity, profitability and the market rule.
Complaints come from the other side of the table as well. As patients and students, we want to be treated with care and responsibility, rather than as mere numbers. Wasn't there a time when professionals still knew how to serve us – a cosy, well-ordered world of responsible doctors, wise teachers and caring nurses? In this world, bakers still cared about the quality of their bread, and builders were proud of their constructions. One could trust these professionals; they knew what they were doing and were reliable guardians of their knowledge. Because people poured their souls into it, work was still meaningful – or was it?
In the grip of nostalgia, it's easy to overlook the dark sides of this old vocational model. On top of the fact that professional jobs were structured around hierarchies of gender and race, laypeople were expected to obey expert judgment without even asking questions. Deference to authority was the norm, and there were few ways of holding professionals to account. In Germany, for example, doctors were colloquially called 'demigods in white' because of their status vis-à-vis patients and other staff members. This is not exactly how we might think that citizens of democratic societies should relate to one other now.
Against this backdrop, the call for more autonomy, for more 'choice', seems hard to resist. This is precisely what happened with the rise of neoliberalism after the 1970s, when the advocates of 'New Public Management' promoted the idea that hard-nosed market thinking should be used to structure healthcare, education and other areas that typically belonged to the slow and complicated world of public red tape. In this way, neoliberalism undermined not only public institutions but the very idea of professionalism.
This attack was the culmination of two powerful agendas. The first was an economic argument about the alleged inefficiency of public services or the other non-market structures in which professional knowledge was hosted. Long queues, no choice, no competition, no exit options – that's the chorus that critics of public healthcare systems repeat to this day. The second was an argument about autonomy, about equal status, about liberation – 'Think for yourself!' instead of relying on experts. The advent of the internet seemed to offer perfect conditions for finding information and comparing offers: in short, for acting like a fully informed customer. These two imperatives – the economic and the individualistic – meshed extremely well under neoliberalism. The shift from addressing the needs of citizens to serving the demands of customers or consumers was complete.
We are all customers now; we are all supposed to be kings. But what if 'being a customer' is the wrong model for healthcare, education, and even highly specialised crafts and trades?
What the market-based model overlooks is hyperspecialisation, as the philosopher Elijah Millgram argues in The Great Endarkenment (2015). We depend on other people's knowledge and expertise, because we can learn and study only so many things in our lifetimes. Whenever specialist knowledge is at stake, we are the opposite of a well-informed customer. Often we don't want to have to do our own research, which would be patchy at best; sometimes, we are simply unable to do it, even if we tried. It's much more efficient (yes, efficient!) if we can trust those already in the know.
But it can be hard to trust professionals forced to work in neoliberal regimes. As the political scientist Wendy Brown argued in Undoing the Demos (2015), market logic turns everything, including one's own life, into a question of portfolio management: a series of projects in which you try to maximise the return on investment. By contrast, responsible professionalism imagines work-life as a series of relationships with individuals who are entrusted to you, along with the ethical standards and commitments you uphold as a member of a professional community. But marketisation threatens this collegiality, by introducing competitiveness among workers and undermining the trust that's needed to do a good job.
Is there a way out of this conundrum? Could professionalism be revived? If so, can we avoid its old problems of hierarchy while preserving space for equality and autonomy?
There are some promising proposals and real-life examples of such a revival. In his account of 'civic professionalism', Work and Integrity (2nd ed, 2004), the American education scholar William Sullivan argued that professionals need to be aware of the moral dimensions of their role. They need to be 'experts and citizens alike', and 'learn to think and act cooperatively with us', the non-experts. Similarly, the political theorist Albert Dzur argued in Democratic Professionalism (2008) for a revival of a more self-aware version of 'old' professionalism – one committed to democratic values, and an ongoing dialogue with laypeople. Dzur describes, for example, how experts in the field of bioethics have opened up their discussions to non-experts, reacting to public criticisms, and finding formats for bringing doctors, ethics consultants and laypeople into conversation.
Similar practices could be introduced in many other professions – as well as areas not traditionally understood as specialist vocations, but in which decisionmakers need to draw on highly specialised knowledge. Ideally, this could lead to trust in professionals being not blind, but justified: a trust based on a grasp of the institutional frameworks that hold them accountable, and on an awareness of mechanisms for double-checking and getting additional opinions within the profession.
But in many areas, the pressures of markets or quasi-markets prevail. This leaves our front-line professionals in a difficult spot, as Bernardo Zacka describes in When the State Meets the Street (2017): they are overworked, exhausted, pulled in different directions, and unsure about the whole point of their job. Highly motivated individuals, such as the young doctor I mentioned at the outset, are likely to leave the fields in which they could contribute most. Perhaps this is a price worth paying if it brings huge benefits elsewhere. But that doesn't seem to be happening, and it makes all of us non-experts vulnerable, too. We cannot be informed customers because we know too little – but we can't rely on being simply citizens any longer, either.
Up to a point, professionalisation is built on the persistence of ignorance: specialised knowledge is a form of power, and a form that's rather difficult to control. Yet it's clear that markets and quasi-markets are flawed strategies for dealing with this problem. By continuing to accept them as the only possible models, we forgo the opportunity to imagine and explore alternatives. We must be able to rely on other people's expertise. And for that, as the political philosopher Onora O'Neill argued in her 2002 Reith Lectures, we must be able to trust them.
The young doctor I interviewed had long considered leaving her job – so when the opportunity to get a research-based position came up, she jumped ship. 'The system was forcing me to act against my own best judgment, again and again,' she said. 'It was the opposite of what I thought being a doctor was all about.' Now is the time to help reimagine a system in which she can recover that sense of purpose, to everyone's benefit.
Lisa Herzog
This article was originally published at Aeon and has been republished under Creative Commons. Read the original article.
In 2018 cOAlition S launched an ambitious program: to make all of the world's state-backed scientific papers open-access. Their agenda, Plan S—the S stands for "shock"—is backed by over a dozen European research agencies and funders.
While the group has fallen short of achieving their stated agenda by 2021, they're certainly making strides. Just this week, 160 Elsevier journals, including renowned publications by Cell Press, are registered as "Plan S aligned Transformative Journals." This could be a good move by Elsevier, which has been severely criticized in the past for price gouging practices—although critics cite increased researcher fees as a cause for alarm.
Unlike the 10-year-old Sci-Hub, which houses over 85 million research papers and regularly changes URLs to avoid the legal ramifications of providing access to paywalled studies, cOAlition S is changing the journal system from within. Their 10 principles call for greater autonomy for researchers conducting scientific studies and having publication fees covered by universities, not researchers. The latter could prove pivotal, as publication budgets are often no match for journal fees.
In just three years, cOAlition S has gained the support of the World Health Organization, the European Commission, and research institutions and agencies in China, Sweden, France, Jordan, and the United States, including the Gates Foundation and Howard Hughes Medical Institute. While many journals initially opposed this agenda, a few have come around. Bureaucratic red tape and inflated prices have hamstrung science for decades. Plan S is not a perfect solution, but it's the closest we've seen.
Science's associate news editor Jeffrey Brainard breaks down how open access works for authors. Publishing studies is an essential part of a researcher's career, bringing with it the potential for career advancement, tenure, peer respect, and, occasionally, popular renown. But it comes at a cost.
Golden open access is one model used by journals such as The Lancet Golden Health, which charges researchers up to $5,000 to make their studies open access. Nature publications now clock in at up to $11,600 and Cell charges $9,900, though the median fee for journals is $2,600.
Pay-to-play doesn't only exist in music. The more respect a journal carries, the higher the fee.
When Springer Nature, publisher of the reputable Nature journals, announced it was adopting a Plan S option last month, the editorial team announced the $11,600 fee was mandatory for anyone requesting their articles be made open-access, regardless of their financial status. These journals are notoriously expensive: submitting an article for consideration costs roughly $2,700 with no guarantee of publication. One journal, Nature Physics, rejects 90 percent of submissions.
cOAlition S executive director Johan Rooryck expressed happiness that Springer Nature is now offering an open-access model but stated "that doesn't mean we have signed a blank check and are willing to pay any price for the articles appearing in those journals."
Springer Nature has also adopted a model more in alignment with Spotify: universities and research institutions pay a single fee to publish their authors. Some publishers offer a hybrid approach: some articles are free while others live behind a paywall. There are also embargo models, where authors can offer their papers to the public free of charge after a six-month or year-long waiting period.
Chart: Science
The cost to publish remains prohibitive for some researchers, with certain journal prices for one article exceeding annual budgets. This has forced many researchers to confront an existential question: publish behind a paywall and wither in obscurity, or pay up and hope enough people read (and cite) your work.
While inflated journal prices have plagued the scientific community, Brainard notes that a purely open-access model could place even more of a burden on researchers.
"A complete shift to open access could lead publishers to boost publishing fees even further, to try to make up for lost subscription revenues[...] Although just over 30% of all papers published in 2019 were paid open access, subscriptions still accounted for more than 90% of publishers' revenues that year."
cOAlition S is advocating for increased transparency to push back on price gouging. Just as researchers must disclose funding and conflicts of interest, "Plan S requires publishers to disclose to funders the basis for their prices, including the cost of services such as proofreading, copy editing, and organizing peer review."
Although Brainard briefly mentions an increase in the number of non-researchers and institutions—laypeople—reading open-access journals, this topic is relevant to this conversation. America is suffering from a longstanding dearth of public science information, evidenced in the anti-vax fervor that's growing in volume (if not in numbers) since the introduction of the COVID-19 vaccines.
Access to scientific studies won't solve all of our woes. But lack of transparency is a major reason why so many citizens have grown suspicious of pharmaceutical companies and public health agencies. An ability to read studies without having to pay exorbitant prices (to the layperson) would be an important step in public health and science education.
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Stay in touch with Derek on Twitter and Facebook. His most recent book is "Hero's Dose: The Case For Psychedelics in Ritual and Therapy."
This critique rejects Homo economicus as the organising heuristic of human affairs. Human beings, it says, need more than material things to prosper. Calculating power is only a small part of what makes us who we are. Moral and spiritual relationships are first-order concerns. Material fixes such as a universal basic income will make no difference to societies in which the basic relationships are felt to be unjust.
Then there is the material critique of capitalism. The economists who lead discussions of inequality now are its leading exponents. Homo economicus is the right starting point for social thought. We are poor calculators and single-minded, failing to see our advantage in the rational distribution of prosperity across societies. Hence inequality, the wages of ungoverned growth. But we are calculators all the same, and what we need above all is material plenty, thus the focus on the redress of material inequality. From good material outcomes, the rest follows.
The first kind of argument for capitalism's reform seems recessive now. The material critique predominates. Ideas emerge in numbers and figures. Talk of non-material values in political economy is muted. The Christians and Marxists who once made the moral critique of capitalism their own are marginal. Utilitarianism grows ubiquitous and compulsory.
But then there is Amartya Sen.
Every major work on material inequality in the 21st century owes a debt to Sen. But his own writings treat material inequality as though the moral frameworks and social relationships that mediate economic exchanges matter. Famine is the nadir of material deprivation. But it seldom occurs – Sen argues – for lack of food. To understand why a people goes hungry, look not for catastrophic crop failure; look rather for malfunctions of the moral economy that moderates competing demands upon a scarce commodity. Material inequality of the most egregious kind is the problem here. But piecemeal modifications to the machinery of production and distribution will not solve it. The relationships between different members of the economy must be put right. Only then will there be enough to go around.
In Sen's work, the two critiques of capitalism cooperate. We move from moral concerns to material outcomes and back again with no sense of a threshold separating the two. Sen disentangles moral and material issues without favouring one or the other, keeping both in focus. The separation between the two critiques of capitalism is real, but transcending the divide is possible, and not only at some esoteric remove. Sen's is a singular mind, but his work has a widespread following, not least in provinces of modern life where the predominance of utilitarian thinking is most pronounced. In economics curricula and in the schools of public policy, in internationalist secretariats and in humanitarian NGOs, there too Sen has created a niche for thinking that crosses boundaries otherwise rigidly observed.
This was no feat of lonely genius or freakish charisma. It was an effort of ordinary human innovation, putting old ideas together in new combinations to tackle emerging problems. Formal training in economics, mathematics and moral philosophy supplied the tools Sen has used to construct his critical system. But the influence of Rabindranath Tagore sensitised Sen to the subtle interrelation between our moral lives and our material needs. And a profound historical sensibility has enabled him to see the sharp separation of the two domains as transient.
Tagore's school at Santiniketan in West Bengal was Sen's birthplace. Tagore's pedagogy emphasised articulate relations between a person's material and spiritual existences. Both were essential – biological necessity, self-creating freedom – but modern societies tended to confuse the proper relation between them. In Santiniketan, pupils played at unstructured exploration of the natural world between brief forays into the arts, learning to understand their sensory and spiritual selves as at once distinct and unified.
Sen left Santiniketan in the late 1940s as a young adult to study economics in Calcutta and Cambridge. The major contemporary controversy in economics was the theory of welfare, and debate was affected by Cold War contention between market- and state-based models of economic order. Sen's sympathies were social democratic but anti-authoritarian. Welfare economists of the 1930s and 1940s sought to split the difference, insisting that states could legitimate programmes of redistribution by appeal to rigid utilitarian principles: a pound in a poor man's pocket adds more to overall utility than the same pound in the rich man's pile. Here was the material critique of capitalism in its infancy, and here is Sen's response: maximising utility is not everyone's abiding concern – saying so and then making policy accordingly is a form of tyranny – and in any case using government to move money around in pursuit of some notional optimum is a flawed means to that end.
Economic rationality harbours a hidden politics whose implementation damaged the moral economies that groups of people built up to govern their own lives, frustrating the achievement of its stated aims. In commercial societies, individuals pursue economic ends within agreed social and moral frameworks. The social and moral frameworks are neither superfluous nor inhibiting. They are the coefficients of durable growth.
Moral economies are not neutral, given, unvarying or universal. They are contested and evolving. Each person is more than a cold calculator of rational utility. Societies aren't just engines of prosperity. The challenge is to make non-economic norms affecting market conduct legible, to bring the moral economies amid which market economies and administrative states function into focus. Thinking that bifurcates moral on the one hand and material on the other is inhibiting. But such thinking is not natural and inevitable, it is mutable and contingent – learned and apt to be unlearned.
Sen was not alone in seeing this. The American economist Kenneth Arrow was his most important interlocutor, connecting Sen in turn with the tradition of moral critique associated with R H Tawney and Karl Polanyi. Each was determined to re-integrate economics into frameworks of moral relationship and social choice. But Sen saw more clearly than any of them how this could be achieved. He realised that at earlier moments in modern political economy this separation of our moral lives from our material concerns had been inconceivable. Utilitarianism had blown in like a weather front around 1800, trailing extremes of moral fervour and calculating zeal in its wake. Sen sensed this climate of opinion changing, and set about cultivating ameliorative ideas and approaches eradicated by its onset once again.
There have been two critiques of capitalism, but there should be only one. Amartya Sen is the new century's first great critic of capitalism because he has made that clear.
Tim Rogan
This article was originally published at Aeon and has been republished under Creative Commons. Read the original article.
