Column

We can’t ignore basic instincts

Human beings are instinctively competitive. Competition fosters excellence. If they are to prosper societies should give free rein to this fundamental impulse.

Without doubt these beliefs are true. But it is equally certain that they are only a very small part of the picture. Human beings are driven by many kinds of motivation, and we have many instincts. Two, at least, are absolutely basic — our compulsion to compete and our need to collaborate. Advanced societies recognise that the human psyche is imperfect, and try to devise social institutions capable of accommodating these discordant instincts. Immature or senile societies try to eradicate one or the other completely.

The communists forbade private enterprise — but by trying to suppress an irresistible drive they succeeded only in creating an enormous black market. The proletariat traded at every possible opportunity — lettuces and ribbons in subways, badges of Lenin to Western tourists, vodka from unmarked boxes on street corners — if there was a profit to be made from it. The communists were entranced by one basic instinct — the urge to associate with others, the longing not to be different from the herd — but (officially at least) they were blind to the other. Capitalists commit a similar error. We openly relish the thrill of the deal, we cherish individual success, we turn our homes into castles. And increasingly, just as the communists did, we are designing organisations compatible with only one basic instinct.

Whenever one instinct is forced over the other, whenever innate dispositions are denied, people become disorientated and angry. And, unmistakably, this is happening in health care. It is true that there are some aspects of health work that can be carried on as if caring were a business (payments for simple services, competition between suppliers of pharmaceuticals, consumer choice) but ultimately health care is not inspired by the competitive instinct. At its purest it is done simply because health carers wish to offer better lives to those for whom they care.

Most people know intuitively that a hospital has a different function from a shop or a factory. Yet NHS trusts, which used to offer a public service explicitly, are now supposed to be guided by the competitive instinct. Thus disorientated they have claimed ‘commercial sensitivity’ over matters which are the concern of all citizens, they seek to compete with companies which offer only those services which turn a financial profit, and they have appointed executives who behave as if they are running private manufacturing industries. With alarming speed trusts, and their many unhappy workers, have become utterly bewildered.

Under the collaborative instinct a medical innovation made by a researcher working for a trust should be made available to everyone as soon as possible. But the competitive instinct insists that it must be kept secret, at least until it is patented, and that ways must be found to ensure that it first benefits the particular trust. This is a good business strategy, and in its place it is appropriate. But hospitals are the place for compassion and co-operation, not competition.

If we are to become a well-balanced society we must acknowledge that people are paradoxical beings. We must accept the fact that we have conflicting instincts, and try to sort out where these different instincts feel right and work for us. We are much more confused than we care to recognise, but we have the capacity for rational thought and we can, if we want to, again find ways to construct practical environments that are not confusing, and that give us the opportunity to enjoy the fruits of both our instincts.