INTRODUCTION

In this chapter we consider the broad context of the 21st century within which professionals think and act. We look specifically at trends and patterns that have significance for clinical reasoning and decision making. We illustrate the current clashes of values and therefore of discourse in use by government, by health care, in education, in health management, in the media and by the public.

LIQUID MODERNITY: THE NATURE OF 21ST CENTURY LIFE

It seems to be commonly accepted that the world of the early 21st century is characterized by fragmentation and uncertainty. The global village that we all now inhabit enables on a daily basis the rapid spread of intimate knowledge of both current and potential major disasters. This frequent reminder of our vulnerability is distinctly destabilizing and anxiety-generating. Increasingly blurred national boundaries, problems of world aid and the complexity of balancing economic demands with the decreased resources of the public purse all have implications for consumers and providers (Higgs et al 1999). The major implication of these factors is our inability to cope with anything but ‘now’ and anyone but ourselves. This increasingly drives professionals to seek answers to such questions as ‘Why?’, ‘Why not?’, ‘Why now?’, ‘Who is to blame?’, and is reason enough for professionals to be ready with explanations of their clinical reasoning and decision making and able to articulate their explanations in a language appropriate to the listener or situation.

The terrible imbalances between the needy and impoverished developing world and the wealthy and self-absorbed West are clear. (And the Third World is not entirely located geographically separately from the Western world, but rather is often inside it.) Bauman (2000, 2005) has caught the spirit of life in the West in the 21st century in his term ‘liquid modernity’. This mercurial ‘liquid modern age’ metaphor captures well the values and desires that are the current mark of the prosperous West. These values and desires involve considerable opposition to and rejection of the attitudes that predominated in the second half of the 20th century (such as the vision that puts others first, the sense of mystery of things beyond us, and recognition of the fallibility of human knowledge). They also challenge the ideals of service and moral responsibility that many professionals still have and, we would argue, should cling to, since exploring our clinical thinking is helped by having ideals to aspire to and a standard of expertise for which to strive.

Bauman’s ideas, though extreme, certainly highlight current trends. In the liquid modern world, shortcuts are sought in order to do away with avoidable and resented chores or pass them on to others (outsourcing, delegation, restricted job specifications). A focus on – indeed an obsession with – the enjoyment of present goals and desires obscures the importance of the short term and obliterates the significance of the long term. Even consumerist values have changed. Durable and long-lasting products and possessions which used to be seen as attractive are now rather seen as liabilities. Long-term employment is increasingly considered an entanglement or a pipe dream. Solidity (including the strength of human bonds) is resented as a threat. Commitment augurs ‘a future burdened with obligations’; and ‘the prospect of being saddled with one thing for the duration of life is downright repulsive and frightening’ (Bauman 2005, p. 40–41).

In this liquid modern age, things are expected to last for a fixed term only. Motives are characterized by impatience for the fulfilment of self-gratification rather than by the caution, patience and delay that attend both ‘waiting’ and the concern for others beyond ourselves. Today, these things somehow suggest inferiority. ‘Rise in social hierarchy (status) is measured by the rising ability to have what one wants (whatever one may want) now – without delay … time is a bore and a chore, a pain, a snub to human freedom and a challenge to human rights, neither of which must or needs to be suffered gladly’ (Bauman 2005, p. 38). Today’s consumerism is not about the accumulation of things but their one-off enjoyment. As Neuberger (2005, p. xviii) writes: ‘we have become demanders, not citizens; we look to ourselves rather than to society as a whole … the idea of an obligation to society, beyond the demands we ourselves wish to make, has become unfashionable.’

Where health care is still concerned with commitment – to patients, to best possible care, to persistence, to resilience, to carefulness and to obligations arising from and through multi-professional teamwork – the liquid modern age seeks instant gratification and constant movement (which goes beyond fluency and flexibility to volatility, fragmentation and short life span of knowledge, tasks, work groups, etc.). Indeed, it apparently values not only the meretricious but also the ability to skate swiftly on thin ice rather than conduct oneself with the steadfastness of careful attention to detail or consideration for others.

It also seeks to foster ‘loose knit organizations that could be put together, dismantled and reassembled as the shifting circumstances require – at short notice or without notice’ (Bauman 2005, p. 44). Consider, for example, the independent treatment centres in the UK and how these are diminishing the role of NHS (National Health Service) hospitals (see Ribero, in Sylvester 2005). Politics play a key role in such shifting healthcare structures, with grand new plans and promises being the hallmark of each new government. In many such moves there is considerable loss: of institutional wisdom that avoids repeated errors and ill-advised quick fixes; of human motivation based in shared ownership of decision making and goal pursuit; and a clear, at least mid-term, sense of direction.

Thus, in the liquid modern world, established knowledge and know-how have a short life, and tradition and experience are no longer valued. Indeed, in the UK, for example, successive governments have declared history as of no importance and have uncritically pursued ‘modernization’ as a mantra for compulsive and impulsive change. In this atmosphere, hardly any form keeps its shape long enough to warrant trust and to gel into long-term reliability. ‘In the volatile world of instant and erratic change the settled habits, solid cognitive frames and stable value preferences’ (Bauman 2005, p. 44) are cast as handicaps.

Yet the fundamental relationship that enables healthcare practitioners to manage patient care is trust. The ‘fiduciary relationship’ which establishes trust is fostered by the ability of practitioners to explain professional matters articulately and clearly to all parties and to take proper account of their own values as well as the needs and values of all those involved or influential in patient/client care (including those providing services to other clients beyond the direct clinical context, e.g. in schools, community settings and industry). It is particularly hard to maintain this standard, given the general failure of trust and aversion to risk that occurs, in a world where health professionals ‘do not trust the politicians not to blame them when things go wrong’ and where society believes that ‘politicians lie when they … [promise] various services for all of us’ (see Neuberger 2005, p. xix). But trust is essential, and professionals have to have the integrity to do all they can to earn it, even if they feel undervalued.

We believe that, ironically, the current drive for ‘modernization’ combined with a distorted bureaucratic form of ‘political correctness’ are bringing with them a world-wide drive for sameness or cloning which is using management control mechanisms to ensure that everyone is treated the same, behaves the same, adheres to the same ideas and which therefore has little room for creativity and individuality. There is something deeply undemocratic about bureaucrats imposing their values, their endless anxieties about ‘conflicts of interest’, their rule-book ways of working and their watchdog approach to accountability on professionals. As responsible members of a profession, their role is precisely to argue their moral position, utilize their abilities to wear an appropriate variety of hats on different occasions with proper transparency and integrity, and exercise their clinical thinking and professional judgement in the service of differing individuals while making wise decisions about the relationship between the privacy of individuals and the common good.

However, the new capitalism of the West is certainly set to impose this bureaucratic approach on ever wider realms, fuelling both avarice and a demand for a dubious ‘transparency’ that renders everything about us relevant to the world at large and which arises from a distorted view of equality and diversity. As Bauman writes, quoting Dany-Robert Dufour: ‘Capitalism dreams of not only pushing the territory in which every object is a commodity … to the limits of the globe, but also to expand it in depth to cover previously private affairs once left to the individual charge (subjectivity, sexuality)’ (Bauman 2005, p. 45). A recent ePress Kit, The Future of Health Care, by Deloitte & Touche USA (2006) stated ‘The outlook among U.S. hospital administrators is more positive about the financial future of their facilities. At the same time … [the report writers noted] that thin margins translate to a need for closer scrutiny of all hospital operations to boost revenues and reap cost savings through enhanced efficiencies.’

THE DOT.COM MENTALITY: MODERNIZATION A MAJOR THEME

The new ‘modernized’ world of work in the West is seated firmly within the liquid modern age and mirrors its values. It is, as Sennett points out, based on a very unrepresentative business model, that of internet startups and dot.com. entrepreneurs (see Garner 2006).

Sennett, who has studied society and culture for several decades in Britain and America, writes of the challenges facing us all today that ‘only a certain kind of human being can prosper in unstable, fragmentary conditions’ (Sennett 2005, p. 3). He argues persuasively that in Britain in the 21st century, the Labour government has been seduced by the superficial glamour of hot-desking and the short-term, no ties mentality of dot.com companies and is trying to impose it wholesale on the public sector. He adds: ‘There is something bizarre about taking the conditions of an IT [information technology] startup firm and thinking you can run a hospital or a university that way. He notes that when New Labour talks about reforming the public sector – and they are endlessly bringing in one new policy after another without allowing anything to bed in – they are not talking about making it do what it does better. As he points out, it takes time to learn how to make things work through trial and error, but if you change it constantly you never find out what works and what does not. It is like a form of ADHD (attention deficit hyperactivity disorder) (see Sennett 2005, Garner 2006).

O’Neill (2002) made the same point when she suggested that the particular system of accountability that has been foisted on us by what we would call the human resources industry ‘actually damages trust’. ‘Plants’, she wrote, ‘don’t flourish when we pull them up too often to check how their roots are growing: political, institutional and professional life too may not flourish if we constantly uproot it to demonstrate that everything is transparent and trustworthy’ (p. 19).

Both ‘liquid modernity’ and the ‘dot.com mentality’ emphasize short-term fixes in the abstract, rather than long-term relationships with people. Lack of stability is par for the course, and there is endless shifting around of both ideas and products to make them catch the eye and sell better. Further, as Sennett points out, the business world favours young people who have no commitment and no sense of commitment, and encourages a culture that does little to bind community together. Under the pressure of more vested and glamorous priorities, calm rational and humane thinking are sidelined. Society’s ‘managed’ acceptance of the diminishing importance of maintaining the continuity of care for a given patient is a major example of how the climate of the times seduces us to go along with ideas and values that we could not actually defend in cold blood.

Thus we see that the modernization of everything that moves has produced a system geared up to institutions shedding their responsibilities to employees and not making long-term commitments (such as pensions). It is all about how quick you can be rather than how seriously you take the problem. And as Sennett shows, in Britain (unlike Finland and Sweden) there is no political discussion of what is happening. However, we are optimistic that this is a ‘self-limiting disease’. With Sennett, as quoted in Garner, we believe that this new capitalism is ultimately doomed because more and more people will come to understand that it is not about reforming the system but deforming it. As Sennett says perspicaciously, ‘This [realization] will be the drama of the coming decades’ (Garner 2006, p. 12).

Coincidentally with all this, healthcare professionals will need to maintain their integrity and their moral commitment to their patients, and will thus take a lead in establishing and enacting important values in health care. To do so they will need to understand better both the importance of their clinical reasoning and its role in developing that essential core of professional practice, namely professional judgement, and they will need to engage actively in continuing education. But initially at least they are likely to find the climate of health care in the Western world less than comfortable and encouraging.

CHANGING PATTERNS OF HEALTH CARE AND GOVERNMENT HEALTH AGENDAS

The context of clinical decision making in the 21st century is strongly influenced by changing policies and patterns of health care. The Fourth European Consultation on Future Trends, held in London in 1999, considered the prospects for implementing the WHO HEALTH21 policy framework (Barnard 2003). Two key practical issues were identified. Firstly, there is a need to break down the barriers between the curative services of clinical medicine and the services provided by many other health workers under the heading of ‘public health’. Secondly, there is a recognition that while endeavouring to build policies, service development and professional practice on strong knowledge foundations, it is important to remember that policy and service provision environments are never static and the knowledge context of health care is highly dynamic. The consultation predicted a complex, volatile and stressful future for policy makers and implementers.

But while these ideas are unquestionably important, the language which presents them as ‘workforce’ issues and systems problems reveals priorities that are far from sympathetic to professionals’ humanistic values. For example, the UK Pathfinder report of the ‘Policy futures for UK health’ project has identified six issues to inform UK health policy to 2015 (Barnard 2003):

Healthcare systems in many countries face changing patterns of disease and disability, changing locations for health services provision, an increased focus on chronic diseases, and an increase in the need for complex disease management strategies. The pattern and location of healthcare provision is changing, with shorter hospital stays, an increase in outpatient/short-stay surgery, and an increasing percentage of healthcare expenditure (over 75% in Australia) on health care outside of hospitals (Horvath 2005). Horvath argues that medical education is not keeping up with these trends. In conjunction with these trends are demographic changes (e.g. ageing populations, an increase in multicultural populations) which bring concomitant challenges and demands to healthcare provision.

The healthcare needs of society are also changing. Patients’ expectations are shifting from wanting to be told what to do to wanting to be involved and informed about treatment options (Lupton 1997). Trede (2000) argues that more patients want to be taken seriously as people, rather than ‘conditions’, and this shift in patient role and expectations requires a parallel shift in clinicians’ roles. Given the rise in incidence of chronic illnesses, with no cure commonly available in the near future, the role of clinicians is being and needs to be transformed from that of technical expert and authoritarian advisor to that of collaborative partner (Trede & Higgs 2003). This may prompt a return to a ‘therapeutic relationship’ in which the true value of each patient is the central motivator for care (Fish & de Cossart 2007), and where ‘the power of medicine [and all health care] then becomes the power letting go control, [and] using knowledge of the limitations of medical work to encourage the patient to take part in the shared task of trying to understand and deal with the illness that affects his or her personal being’ (Campbell 1984, p. 28).