Commercialism , Holism , and Individual Responsibility Comment on “ Buying Health : The Costs of Commercialism and an Alternative Philosophy ”

Churchill and Churchill’s editorial discusses negative (health) effects of commercialism in the provision of health care and nutrition. Three parts of their argument are commented: the claim that the fundamental problem of markets is the decomposition of the whole into parts (“reductionism”); the call for individual responsibility; and the notion of holism. On the three aspects the commentary concludes thus: Because provision of health and food must be controlled and managed in some form, an alternative to some kind of decomposition is hard to see. The call for individual responsibility is controversial due to its lack of attention to socioeconomic inequalities. The concept of “holism” is problematic due to its epistemological and normative status.

Food and nutrition are considered increasingly important from a public health perspective.The so-called obesity epidemic is at the top of the agenda for health authorities throughout the world.Two issues are seen as particularly topical in the discussions, namely how the food industry contributes to obesity, and the changes in physical activity (or, rather, the lack of such).Regulating and controlling the food market is seen by many as one of the most important instruments in promoting health.
Regulating and controlling a market is, however, different from abandoning the market altogether.C&C's concern about a market mechanism that encourages forces that are detrimental to healthy nutrition is certainly interesting, although their alternative is not clearly spelled out.They rightly state that food has been provided in market like systems for a very long time.What has been changed?It seems that they consider a transition from a food market to a market for 'nutrition' to be an important part of the problem.This is perhaps an example of the decomposition of the whole into parts, which is in line with their argument that lack of holism is destructive to our health.
It is not clear to this reader, at least, that this is the most problematic feature of the market (whether we call it the food market or the nutrition market).There are empirical as well as theoretical reasons to be more concerned with the lack of control over untamed market forces.One of the features of profit motivated actors is the wish to stimulate increasing demand for their products.If, for example, sugar is added in most foods, we will be increasingly addicted.This biological inclination is probably well known among food producers.
The destructive effects of the market mechanism are not only seen in the market for food (nutrition) but also in the healthcare are and the medical industry.There is broad agreement in the literature with C&C's view that untamed markets are destructive.Even Adam Smith argued along such lines; a well-functioning market mechanism depends on the state to secure real competition between providers, i.e. capitalists (2).Uncontrolled capitalists will try to exploit the system in their search for profit, thus destroying what in principle could work well in the market.A bad functioning market is not only destructive to our health, but destructive to a number of social concerns.A reasonable interpretation of C&C's arguments is that the International Journal of problem with markets is the necessity to split up the "product" (e.g.health) into smaller units in order to make the product "marketable"-and this is a process that involves a danger to our health.I think there are three problems with this analysis.First, the diagnosis is rather general, in a way that crucial differences between different parts of health care are hidden.A separation of health care into smaller units may work perfectly fine for some types of health care, while it is more problematic for other types.A market organization for the supply of say, x-ray imaging, may function very well, while medical care for complex diseases like comorbid psychiatric diseases is much more prone to the weakness of a market.

Health Policy and Management
Secondly, it is hard to see an alternative to a market like provision.I use the term "market like" on purpose, since there is a reason to claim that any health care system share the necessity to divide health services into smaller units-in order to be able to manage the system.Centrally planned and governmentally funded health care systems, like the Scandinavian welfare states, are similar to a private system like US health care in this respect.A number of the problems attached to the provision of health care are in fact shared by systems based on private markets on the one hand and state owned monopolies on the other.In this perspective, factors like strategic play, asymmetric distribution of information and power are common challenges in both systems.Further, such factors and mechanisms are probably much more important than the separation of services into smaller units when it comes to controlling and managing the system-thus securing that the provision works to improve, not to destroy, the health of its patients.
In their conclusion, C&C argue that the alternative to commercialism (and the market) is a call for individual responsibility.They base their argument on the view that other factors than medical services and nutrition are much more important to our health.This is a perspective shared by most health researchers as well as health policy researchers.The insistence on the responsibility of the individual is however more controversial.The possibility to take responsibility for one's own health varies a lot between different individuals and groups.A significant part of such difference is due to socioeconomic status.It is well documented that health follows a social gradient (3,4).The gross difference between people's capabilities is not reflected in C&Cs' call for individual responsibility."The responsibility for knowing what nourishes us is ultimately ours", they state, "Then we can demand from our governmental leaders attention to social inputs that enable individuals to flourish".The combination of requesting individual responsibility and ignoring the social inequalities (which leads to large differences in health and health related behavior) is ethically and politically problematic.Combined with the lack of an analysis of how health care alternatively should be organized, the perspective is, at its best, naive.
Let me finally say a word about the concept 'holism' .Although there is broad agreement on the general idea that the whole is something different from the sum of the parts-also when it comes to our health-I am reluctant to the concept for epistemological and normative reasons.A holistic perspective promises much; perhaps more than it can keep.Epistemologically, it is problematic that the mere statement of an intention (to be holistic) is nothing more than a statement.It does not ensure that in fact the whole is taken into consideration.One would like to see how "the whole" is taken into consideration in practice.
Further, "holism" introduces a cognitive bias.It sounds much wiser to take 'everything' into account than just some parts of the whole.This introduces not only an epistemological bias, but also a normative bias.The holistic perspective becomes superior by definition.This is an approach that can lead to uncritical acceptance of certain ideas-not for their analytical superiority -only for their claim to be morally superior.