Saturday, January 26, 2019

The economization of human relationships under capitalism: from abstract labor and exchange value to commodity fetishism and alienation

Amidst the satisfaction people feel with their material progress, there is a spirit of unhappiness and depression haunting advanced market democracies [i.e., affluent capitalist welfare state democracies] throughout the world, a spirit that mocks the idea that markets maximize well-being and the eighteenth-century promise of a right to the pursuit of happiness under benign governments of people’s own choosing. The haunting spirit is manifold: a postwar decline in the United States in people who report themselves happy, a rising tide in all advanced societies of clinical depression and dysphoria (especially among the young), increasing distrust of each other and of political and other institutions, declining belief that the lot of the average man is getting better, a tragic erosion of family solidarity and community integration together with an apparent decline in warm, intimate relations among friends. — Robert E. Lane, The Loss of Happiness in Market Democracies (2000) 

In arguments in support of capitalism, the following propositions are sometimes advanced or presupposed: (a) The best life for the individual is one of consumption, understood in a broad sense that includes aesthetic pleasures and entertainment as well as consumption of goods in the ordinary sense. (b) Consumption is to be valued because it promotes happiness or welfare, which is the ultimate good. (c) Since there are not enough opportunities of consumption to provide satiation for everybody, some principles of distributive justice must be chose to decide who gets what. (d) The total to be distributed has first to be produced. What is produced depends, among other things, on the motivation and information of producers. The theory of justice must take account of the fact that different principles of distribution have different effects on motivation and information. (e) Economic theory tells us that the motivational and informational consequences of private ownership of the means of production are superior to those of the various forms of collective ownerships. — Jon Elster, “Self-realisation in work and politics: the Marxist conception of the good life,” in Jon Elster and Karl Ove Moene, eds. Alternatives to Capitalism (1989)

We have been looking in the wrong place to found the good life (the normativity of value) and a truly civil society. It is not enough to expect to find a truly socialist civil society by looking simply at what agents actually desire and, adopting the sentimental response, hoping to employ the state to interfere and promote what is desired. That loses the normative edge that makes us socialists in the first place: the normative edge that gives us the notion that there is a way society ought to be, regardless of how people evaluate the way it actually is. … [W]e can only provide a distinctive notion of what socialism is by rejecting the prevailing assumptions of liberal theory. We need to examine the conditions necessary for the good life, for a truly civil society. — Michael Luntley, The Meaning of Socialism (1990) 

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“Jeffrey Pfeffer has an ambitious aspiration for his latest book. ‘I want this to be the Silent Spring of workplace health,’ says Pfeffer, a professor of organizational behavior at Stanford Graduate School of Business. ‘We are harming both company performance and individual well-being, and this needs to be the clarion call for us to stop. There is too much damage being done.’ Dying for a Paycheck … maps a range of ills in the modern workplace — from the disappearance of good health insurance to the psychological effects of long hours and work-family conflict — and how these are killing people.

Pfeffer recently sat for an interview with Insights. The following has been edited for length and clarity. 

I was struck by the story of Robert Chapman, CEO of Barry-Wehmiller, standing in front of 1,000 other CEOs and saying, ‘You are the cause of the health care crisis.’

It’s true. He takes three points and puts them together. The first point, which is consistent with data reported by the World Economic Forum and other sources, is that an enormous percentage of the health care cost burden in the developed world, and in particular in the U.S., comes from chronic disease — things like diabetes and cardiovascular and circulatory disease. You begin with that premise: A large fraction — some estimates are 75 percent — of the disease burden in the U.S. is from chronic diseases. 

Second, there is a tremendous amount of epidemiological literature that suggests that diabetes, cardiovascular disease and metabolic syndrome — and many health-relevant individual behaviors such as overeating and under-exercising and drug and alcohol abuse — come from stress.

And third, there is a large amount of data that suggests the biggest source of stress is the workplace. So that’s how Chapman can stand up and make the statement that CEOs are the cause of the health care crisis: You are the source of stress, stress causes chronic disease, and chronic disease is the biggest component of our ongoing and enormous health care costs. 

Has this connection always been there, or has there been an evolution in workplace culture that got us to this point?

I think the connection as just described has always been there, because the physiology and etiology of disease have not really changed. But I would say that with all the evidence I’ve encountered — and it’s not perfect evidence — I’ve seen nothing inconsistent with the statement that the workplace has generally gotten worse. Job engagement, according to Gallup, is low. Distrust in management, according to the Edelman trust index, is high. Job satisfaction, according to the Conference Board, is low and has been in continual decline. The gig economy is growing, economic insecurity is growing, and wage growth overall has stagnated. Fewer people are covered by employer-sponsored health insurance than in the past, according to Kaiser Foundation surveys. And a strikingly high percentage of people, even those covered by insurance, say they forgo treatment and medications because of cost issues. I look out at the workplace and I see stress, layoffs, longer hours, work-family conflict, enormous amounts of economic insecurity. I see a workplace that has become shockingly inhumane.” The full interview is here. 


For researchers who work in the field of public health and health justice, Pfeffer’s findings, however alarming, are not at all surprising. The same could be said of those psychoanalytic, humanist, and existential psychologists who have long been concerned about how the greater social world (i.e., beyond immediate family relations) clearly affects the mental health and well-being as well as the physical health of their analysands, patients, or clients, concerns that go back to the inter-War period in Europe when psychoanalysts (many of whom were also physicians) were often at the same time Marxists or simply fell out somewhere along the Left spectrum from Communism/communism to social democracy.

Such research clearly reveals, once again, the severe constraints of the conventional and thus still prevailing bio-medical model of disease causation, frequency and distribution that is dominant in epidemiology. As Sridhar Venkantapuram explains in Health Justice: An Argument from the Capabilities Approach (2011), both the bio-statistical theory of health and the biomedical model in epidemiology (aptly termed ‘health individualism’) should be demoted not only because jointly they “focus[] too narrowly on the causation and distribution of disease,” but more importantly because they are unable to “explain fully the causation and distribution of diseases most prevalent in developed [affluent] economies, namely chronic and degenerative conditions.” The dominant epidemiological model, in other words, is structurally incapable of analyzing “the possible causal impact of social conditions” [and, I would add, appreciating complex body/mind interactions or physical and mental dynamics]. What is urgently needed is an alternative epidemiological model capable of integrating “micro” and “macro” variables of behaviors and conditions, the natural and social sciences (including the humanist, existentialist, or psychoanalytic ‘science of subjectivity’), thereby linking, in short, individual level phenomena with population level phenomena (in many respects this blurs the distinctions between ‘private’ health care and provision and the field of ‘public health’). Venkatapuram himself argues for a “new multi-dimensional theory for epidemiology” that builds on earlier public health efforts and findings in this regard, efforts that presumed physical and mental health were intimately even if sometimes mysteriously related to each other. 

These earlier efforts, ironically enough, trace back to the origins of epidemiology in the United Kingdom, when this method of inquiry evidenced clear if not overarching “concern over social class inequalities in mortality and impairments” just after the Second World War. The appreciation because “recognition of differences in mortality and its rate of progress across socio-economic classes over time” was one reason for the creation of the National Health Service (NHS), “which provided free healthcare to all, [and] was meant to ensure that all parts of society would share in the health improvement.” Despite notable achievements on several fronts, the NHS alone of course was not capable of fully addressing “inequalities in health achievements across the socio-economic classes,” especially the “persistence of higher mortality rates and slower progress among the poorest classes.” The studies culminating in the release of the Black Report by the Working Group on Health Inequalities (WGHI) in 1980, concluded “significant public resources would need to be spent to improve the health of the poorest classes” if the government was to begin to sufficiently address obdurate social inequalities in health achievements, particularly longevity. As Venkatapuram notes, “the report has had a profound impact on the scope and nature of public debate on health, health research and poverty alleviation which continues to the present day in the United Kingdom and beyond.”

Findings “from a 1978 study looking at the health of 17,520 British civil servants known as the Whitehall Study,” complemented if not made more complex the precise causal variables implicated in health achievements: 

“What started out as a conventional study of the risk factors for cardiovascular and respiratory disease among a large, defined and accessible population of research subjects produced startling findings. The conventional thought at the time was that senior managers at the top of the organization were the most under stress and suffered more heart disease and mortality. Michael Marmot and colleagues reported results which showed the opposite. The individuals at the bottom of the organization had higher rates of mortality and disease. But what is most astounding is that the researchers found a clearly step-wise gradient in disease and mortality paralleling the rank of employment. Starting from the top grade, each rank of civil servants had worse health than the rank above. In comparison, the WGHI did not really focus on the gradient in mortality across the five socio-economic classes; it was focused largely on the mortality of the lower classes.”

The Whitehall Study manifestly prefigures Pfeffer’s findings, for it “showed that even when absolute material deprivation is not a factor, as all civil service employees across all grade level were above the threshold of poverty, there still was a social gradient in health right across all the employment grades. So, something else aside from material deprivation [and individual behavioral risk factors, such as smoking] was influencing health.” 

And here is where our conventional and often moralizing approach to physical and mental health at the level of individual behavioral risk factors falls short: “Subsequent studies which controlled for individual behaviours, such as smoking and diet, showed individual behaviours could not explain the distribution [pattern across all diseases]; the social gradient still persists.” Venkatapuram rightly concludes that

“… by establishing a link between social conditions and ill-health and mortality and the social gradient in health outcomes, the studies highlighted the limitations of the classical biomedical model in epidemiology. The classic biomedical model’s causal factor of biological endowment, individual behaviours, and exposure to harmful agents could not fully explain the ill-health of individuals, and the step-wise gradient. The Whitehall research has generated the hypothesis that a social cause can distribute the harmful exposure to different social groups differently, while also being the cause of disease in individuals. [….] The Whitehall research has also expanded the research into psycho-social processes such as those affected by workplace environment. Some of the Whitehall II studies suggest that the social gradient in mortality reflects an individual-level, psychosocial mechanism mediating between external social conditions and the production of disease within the individual. The ‘infection’ travels through psychobiological pathways. An individual’s ‘control,’ ‘agency,’ ‘dignity,’ and how fairly individuals are treated, as well as how interesting they find their work, has been suggested as aspects of the workplace which differ according to employment grade and may be correlated to the gradient in health outcomes. The expectation is that such workplace features can be extrapolated to other environments such as the home and community.” 

To complicate matters a bit, consider this snippet from Gopal Sreenivasan’s entry (sans citations) on “Justice, Inequality, and Health” for the Stanford Encyclopedia of Philosophy:

“The existence of a social gradient in health certainly suggests that something in addition to health care exercises a powerful influence on an individual’s health—something, moreover, that at least correlates with a social variable. However, it is not clear exactly what this something is. To begin with, similar domestic gradients in individual life expectancy can be found when the social variable is income; when it is education; and when it is social class. By itself, therefore, the surface fact of a social gradient in health is compatible with quite different accounts of the underlying causal influences on individual health. Each distinct social variable might function as a ‘marker’ for a different underlying causal factor, different social variables might function instead as alternative markers for the same underlying causal factor, or there may be some mixture of both. (It is also possible that some social variables — e.g., education — function as a relatively direct causal factor.)

Furthermore, it is not clear how much of the correlation between health and a given social variable is properly causal in the first place. In some cases, there is clearly some ‘reverse causation’ between health and a social variable, notably from poor health to lower income. In addition, there is plainly some causation among social variables, notably from education both to higher income and to higher occupational status. 

The choice of the social variable in terms of which to describe some social gradient in health can be made on a number of different grounds. One obvious ground would be to choose the variable(s) that came closest to conveying the operative causal mechanism(s). Another ground would be to choose the variable(s) that have independent moral significance, such as race and gender. These grounds need not exclude each other and there may be a case for choosing the same variable on both grounds. The second ground acquires a special relevance if health inequalities suffered by individuals who also suffer, for example, from racial discrimination are more unjust than health inequalities (of the same magnitude) suffered in the absence of racial discrimination. If one injustice can compound another, then the choice of social variable may affect the kind of inequality in health at issue, and not simply its magnitude.

When the social variable is income, there is an important further definitional dispute to consider. Income appears to have a significant effect on life expectancy, even controlling for education. However, there is an on-going debate about which definition of ‘income’ is adequate to capture the contribution individual income makes to individual life expectancy. According to the absolute income hypothesis, the contribution income makes to individual life expectancy is entirely a function of the individual’s non-comparative income. By contrast, the relative income hypothesis holds, roughly, that an individual’s life expectancy is also a function of the relative level of her income—that is, its level compared to others’ income in her society—and not simply of its non-comparative level. To make this second hypothesis precise requires one, among other things, to specify the reference group to which the individual’s income is compared and also the nature of the comparison.” 

Relevant Bibliographies:


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