Ethics of conviction and ethics of responsibility in healthcare systems

In this guest blog, health commentator Ian Powell explores the tension between ideology and accountability in New Zealand’s healthcare system — and why the failure to balance conviction with responsibility has repeatedly led to damaging structural upheaval.

Ethics of conviction vs ethics of responsibility

The distinction between the ethics of conviction, on the one hand, and the ethics of responsibility, on the other, is not just interesting in its own right but also highly pertinent to healthcare systems, particularly its decision-makers.

The former ethic requires people to uphold their principles while the latter requires people answer for the consequences of their actions when expressing these convictions.

On 19 December I published a post in my other blog Political Bytes on the relationship between these two ethical constructs. This was done with a particular emphasis on free speech in mind: Free speech and the ethics of conviction and responsibility.

Why Max Weber prioritised responsibility over conviction

I referred to Max Weber (1864-1920), a German intellectual who was one of the central figures involved in the development of sociology and the wider social sciences.

Of the two ethical constructs Weber had concluded that the ethics of responsibility was more important.

Some political leaders are described as ‘conviction politicians’. In my post I gave the example of former British Conservative Party prime minister Margaret Thatcher.

As I stated in my above-mentioned post:

Her strongly ideological conviction was to comprehensively extend the role of the ‘not-so-free market’ into economic and social life, including in the provision of public goods such as healthcare, education and transport.

In other words, neoliberalism. While the consequences of neo-liberalism were beneficial for the ‘few’, they were devastating for the ‘many’, including much increased impoverishment.

How neoliberal reforms reshaped New Zealand’s healthcare system

In Aotearoa New Zealand Roger Douglas and Ruth Richardson were the finance ministers of the Labour government of the 1980s and the National government of the early 1990s respectively who successfully introduced this same neoliberalism here.

These two ethical constructs of conviction and responsibility are also directly related to healthcare systems. New Zealand’s system is no exception.

From the inception of our universal healthcare system in 1938 until 1983 there was no substantive restructuring. The first restructuring involved the establishment of area health boards over a six year transition. This was a bipartisan change.

Then, in 1993, there was a major restructuring involving requiring the healthcare system to function as if it was a competitive business market.

In 2001 the system was again restructured with the abandonment of the market model replacing competition with the ethos of cooperation, and the establishment of district health boards.

In 2022 there was the quickest restructuring of them all – the replacement of the devolved system of DHB’s by a new vertically centralised system.

So of the nearly 90 years since the establishment of our universal healthcare system, the  first 45 years were restructuring-free.

In striking contrast, over the next nearly 45 years, there have been four restructurings; two of which (1993 and 2022) were major upheavals.

When ideology overrides responsibility in health policy

In my involvement in the healthcare system (since 1989) there have been, if my memory serves me correctly, 13 health ministers including the incumbent Simeon Brown.

Excluding the incumbent, only two found themselves putting the ethics of conviction ahead of the ethics of responsibility – one National and the other Labour. Both were responsible for the two above-mentioned restructuring upheavals.

Simon Upton and the market experiment in healthcare

The first health minister was the intelligent and personable Simon Upton. But these positive characteristics are unhelpful when they are trumped by ideological purity (aka rigidity).

Influenced by neoliberal thinking in the United Kingdom (and reinforced by Treasury and selected business consultants), Upton held the firm but misplaced view that what he called the funder (or purchaser)-provider split was the dominant tension in the healthcare system.

The way this needed to be addressed, so his argument went, was to structurally separate funding out on a regional basis in order to create a competitive internal market.

Public hospitals became state-owned companies governed by market forces under the Commerce Act. Cooperation was no longer to be a system driver. Instead they were to compete with each other and with the private sector for funding.

At the time then Chair of the New Zealand Medical Association Dr Alister Scott described the new system as being designed the sort of people who would try to make a profit out of a soup kitchen.

My less intellectual comment at the time was that it was like splitting a fish and chip shop into two; one selling fish and the other hot dogs and then requiring them to compete against other.

The upheaval that arose out of this theoretical construct was because it treated healthcare as a commodity rather than a universal public good and was in opposition to the cooperative ethics of health professionals at the clinical ‘coalface’.

Such was the disruptive unworkable impact on the healthcare system of this restructuring that it did not survive the change of government in late 1999. But the damage it did to the system was not easily repairable.

Andrew Little and the risks of over-centralisation

Andrew Little was appointed health minister after Labour’s electoral success in late 2020.

Unlike Simon Upton, he was not ideological. However, he was a linear thinker who struggled to see beyond structures and comprehend the importance of functions first.

His failure to fully understand healthcare system complexity meant that he could only see increased centralisation as the solution. He could not grasp the importance of having a high level of decision-making close to where most healthcare is provided.

Little’s contribution was to vertically centralise a healthcare system which by international standards was already centralised.

This narrow focus led him to ignore the widespread workforce crisis across all health professionals (a situation Simon Upton did not face) and then proceed to introduce his restructuring in the midst of the pandemic (unprecedented incompetence).

It also inevitably led to a top-down ‘command and control’ leadership culture isolated from where healthcare is overwhelmingly provided.

Little’s narrow vision meant that, like Simon Upton, he didn’t trust the healthcare system leadership and instead relied primarily on external business consultants for implementation; akin to asking panel-beaters to design a traffic round-about.

The result is the terrible mess that the healthcare system now finds itself in through no fault of its own.

Simeon Brown and the next test of responsibility

Simon Upton and Andrew Little were both removed from the health portfolio by their respective prime ministers because of the electoral damage their restructuring upheavals were causing.

Upton was removed within two years of his appointment and before the planned restructuring came into force. Little lasted little more than two years. It has to be said, however, that their respective ‘kitchen cabinets’ also share responsibility.

Both former health ministers are driven by the ethics of conviction. But both equally failed to meet the higher threshold of the ethics of responsibility.

Both failed to take responsibility for the actions leaving the healthcare system in a much worse position than they found it. Both lacked peripheral vision; one because of ideological rigidity and the other because of narrow linear thinking.

So what about current health minister Simeon Brown. It is too early to tell but it only took both Upton and Little a very short time to inflict their damage.

Unfortunately the outlook is not promising for Brown beginning with running public hospitals down in order to privatise less complex planned surgery and allowing the top-down ‘command and control’ culture of Health New Zealand to continue.

The ball is in your court, minister. By all means have conviction ethics but make sure you balance them with responsibility ethics as well.

This analysis is not simply historical reflection — it is a warning. Without a clear commitment to responsibility over ideology, New Zealand risks repeating the same structural mistakes that have already cost its healthcare system dearly.

Ian Powell was Executive Director of the Association of Salaried Medical Specialists, the professional union representing senior doctors and dentists in New Zealand, for over 30 years, until December 2019. He is now a healthcare systems, labour market, and political commentator living in the small river estuary community of Otaihanga (the place by the tide). First published at Political Bytes