Self-Interest and the Common Good
I have been working in Canada lately on healthcare reform and system integration. The part of Canada where I am working has regional health authorities; despite statutory authority, these must compete for loyalty with local hospitals and their boards. One regional health authority convened a large group of constituents to form working teams and collectively form a vision of the system of the future. As part of this effort, they held a meeting of local boards of healthcare agencies, including hospitals, community health centers, and other care providers. The meeting began with a description of the project, with exhortations to seize upon this rare opportunity to create a new design for the healthcare system. As well, the “governors” were asked to think beyond their local interests, to think in terms of the larger system.
After the opening presentation, the facilitators opened the meeting for comments. Three in particular stood out for me:
• Two Board members from the aboriginal community: “We have had a Board of Boards for the past two or three years. It is working for us. For instance, last year one of our Boards took a 10% cut in programs to maintain a different program that we agreed was in the best interest of the community.” (Comment A)
• A local hospital Board member: “I have to be candid- my primary interest is my local hospital and community. I know there is a system as well, but for me it is secondary.” (Comment B)
• From the Board Chair of a hospice: “I think we need to learn from those who are better than we are at working as a community (turning toward the first speakers); we need to work better together; and if we do, I am convinced we will save money.” (Comment C)
For me, these comments highlighted the perennial tension between self-interest and the common good. In this case, the tension is played out in terms of “system” interests versus “local” interests. The comment from the Aboriginals is striking because they have already been working together as a Board of Boards; they have already sacrificed local interests for the common good; and they proclaim that this is working for them. This is occurring at a time when others, like the third speaker, believe that local interests are paramount and that upholding them is the right thing to do.
How do we decide which approach works best? It depends on our goals. If we want to optimize the whole, and we believe that will serve the best interest of the parts, Comment A is the way to go. If we want to optimize parts, and we assume that will lead to optimization of the whole, comment B above makes sense. If we think that some combination of both makes sense, Comment C marks the way forward. However, this is only the beginning of the discussion. The first and second speakers agree that we need to include both parts (local Boards) and wholes (the “system”) in our analysis. If we have intermediaries whose job is to connect, align, and even integrate the two (such as a Board of Boards), the task of the intermediary is to determine when, and how, to honor the interests of each.
Are there rules of thumb? If we are to create a better healthcare system, what principles of governance should we follow? Various approaches to systems thinking and system dynamics contend that we need to “bring the whole system into the room” and create solutions that place system priorities first, local priorities second. The governors in the meeting we are discussing were advised to follow this path. The cultural and political tendency in Canada and the U.S., though, is to place more faith in the individual, local option as a path to breakthrough. The assumption is that invention does not happen collectively, and that major initiatives often start from the efforts of a few individuals. Even apart from the politics of representing one’s local constituency, there is a strongly held view that the best, smartest way to solve tough problems is to rely on talented individuals to come up with solutions.
Does the third speaker pose a synthesis? He implies that both local and system interests are valid and need to be reconciled. Further, he says that if we do include both in our solutions, “we will save money,” thus fulfilling pragmatic criteria for solutions. But the weight of the majority tradition, history, and culture in Canada tilts toward the views of the second speaker: when in doubt, trust individual, local solutions. This is why the Aboriginal response is striking: it comes from a different tradition and belief system, one that places the parts in service to the whole. When I asked my contact from the regional health authority how many governors would agree with the first statement, she said “Ten per cent.” We estimated that at least 60% would agree with the third statement.
If the systems theorists are right, this poses a significant challenge for us. Many of our most complex, difficult, and compelling problems appear to be systemic in nature- healthcare redesign, environmental improvement, and reform of our financial systems. In dealing with these problems, the systems view goes, we must follow the lead of our Aboriginal neighbors. However, our dominant culture (at least in Canada and the U.S.) suggests the opposite- when in doubt, support individual solutions and trust that the system will be improved as a consequence. How do we test these models? How do we recognize systemic problems as such, and use appropriate methods to solve them? How do we align the principles of emerging system sciences with our political, cultural and social systems? It may be that our fate rests in the balance.