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Where has the sense of responsibility gone?

The Government’s obsession with choice in public services is misleading and damaging, says Hugh Rayment-Pickard


IN 1945, the Viennese psychologist Viktor Frankl wrote a short book: . . . trotzdem Ja zum Leben sagen (Saying Yes to Life in Spite of Everything), published later in English under the more formal title Man’s Search for Meaning. Earlier that year, Frankl had been liberated after three years in Auschwitz and Dachau, and the book chronicles the life of a concentration-camp inmate from a psychological point of view.

What astonished Frankl was the scope for moral choice, even in the hell of the camps. “We who lived in concentration camps can remember the men who walked through the huts comforting others, giving away their last piece of bread. They may have been few in number, but they offer sufficient proof that everything can be taken from a man but one thing: the last of the human free­doms — to choose one’s attitude in any given set of circumstances, to choose one’s own way.”

Over the past few years, a political consensus has been growing — left, right, and centre — around the belief that the expression of consumer “choice” is the key to creating effective public services. Parental choice and patient choice have become buzz words in the literature of all parties.

The official NHS website now carries the banner headline: “NHS Choices”. This is a significant use of language. Most people who are sick are not seeking to “make a choice”, but would like to be treated and get better. Similarly with schools: parents want a good education for their children. If the local school is a good one, few parents will complain if it is the only option.

It is easy to see how, from a purely pragmatic point of view, the introduction of consumer choice can encourage better public services, because we will tend to choose those services that are most effective. In this way, “choice” can drive im­provement in a vast and complex organisation such as the NHS.

Yet something more philo­sophically significant has been developing in our public thinking: the value of choosing in itself has been elevated to the status of a moral virtue. In NHS policy now, patient choice is not just a mechanism to jack up standards, but an absolute “right to choose”.

This new language of rights is being claimed by all parties. The Conservatives have assembled their education and health policies on a website called righttochoose.com. The Liberal Democrats are more cautious, arguing that our choices should be “informed”, but they also believe in “the greatest possible choice” for patients. It is agreed on both sides and in the middle that giving people maximal choices is a natural good.

Although “right to choose”, like motherhood, is apparently hard to disagree with, there are a number of good reasons why we should treat this new rhetoric of choice with suspicion.

We should question the elevated status that is being given to the act of choosing. The NHS speaks — slightly recklessly, I think — about something called “free choice”, which seems to mean: “Whatever your reason, it’s your right to choose.”

This implies that it is better for patients to choose treatment at an inferior hospital than it is for them to have a good hospital forced upon them. The abstract value of making a free choice, no matter what the choice, is higher than the practical value of receiving the best treatment.

This could lead the NHS to congratulate itself on delivering a poor service, on the grounds that it had been freely chosen by one of its “consumers”.

WE SHOULD also be wary of the cultural origins of the concepts of “right to choose” and “maximum choice”. Last year, the Department of Health started to speak about something called “Your Health, Your Way”.

This slogan can be traced back to a 1974 advertising campaign for Burger King, which said “Have it your way”, referring to our en­titlement to customise our burgers. The slogan was revived by Burger King in 2004, and has now seeped into the way the Government is speaking about the treatment of long-term health conditions.

When Frankl wrote about choosing, he regarded choice as an existential responsibility, not a consumer entitlement. Even when one’s options are hideously re­stricted, choice is not a right, but a duty. And our duty is, as best we can, whether at the point of death or in the supermarket, to choose what is right, and not just what we like.

In all the hype about choice, we have forgotten the distinction made by John Locke between “liberty” and “licence”. Licence is the exercise of choice without moral responsibility. Liberty is the exercise of freedom with justice and love. We need to inject this distinction into our political thinking about our alleged “right to choose”.

Talk about choice in education or health-care is not wrong per se, but it must be anchored in a profound concern to make the right choices, not just any choice. The act of choosing in itself has no particular value, unless it is directed by a desire to act correctly. Choice provides us with the potential for virtue, but choosing is not intrinsically vir­tuous. This has always been at the heart of the Christian idea of free­dom: we realise the ethical potential of freedom only by dedicating that freedom to God’s service.

It is wrong for Governments to offer the public a “right to choose” without also insisting on civil and personal responsibility — for ex­ample, the responsibility for keeping GPs’ appointments, for taking the best health advice, and for living a healthy lifestyle. The free­dom to choose is onerous, and good health — like any other kind of good­ness — requires a serious com­mit­ment to the path of virtue.

We may have the right to choose to smoke, but that does not make smoking right. “Your Health, Your Way” is an accept­able slogan only when it is ac­companied by the motto “Your Health, Your Responsibility”.

The Revd Dr Hugh Rayment-Pickard is Vicar of St Clement’s and St James’s, Notting Dale, in London.



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