Review

Culture

Economics

Politics

5 July 2024

10 min read

The book Keir Starmer says you must read

Will Hutton’s This Time No Mistakes surveys the thinking that could solve Britain’s ills.

John Milbank

John Milbank is a theologian, philosopher and poet. A co-founder of the Radical Orthodoxy movement, he is an Emeritus Professor of the University of Nottingham.

Kier Starmer sits on a sofa, leaning forward and holding papers he is reading. Rachel Reaves sits and looks on.

Starmer and Reeves.

Labour Party

In the aftermath of a historic election, one could do worse than read Will Hutton’s second big ‘state of the nation book’, recently published. This Time No Mistakes is worth reading just for the succinctness and clarity of its politic-economic history of the United Kingdom since the industrial revolution, which it provides in its central chapters. Indeed, Keir Starmer says it is a ‘brilliant book... read it if you haven't already ’ It may well take a sophisticated journalist to be able to do this so well: too often, even the best of academics cannot see the public wood for their private-obsessional trees.

But it is doubly and mainly worth reading for Hutton’s prognosis of our ills and his recommendations for solving them. The new Labour government could do far worse than try to carry through Hutton’s proposals, which almost anyone of common sense and goodwill (including all Tories) ought readily to endorse. Indeed, if the next government managed to initiate even a half of what he suggests, this country could be placed back upon the right tracks.

As to the history, which is crucial to the ultimate diagnosis: Hutton contends quite simply that Britain has been self-deceived by the peculiar nature of its industrial revolution, which was the first in history. It was largely a matter of private enterprise, partly enabled and later cushioned by empire, whose possession encouraged us to support an unqualified doctrine of free trade.

However, all other nations, including the United States, both when they sought to catch up with the steam and rail revolution, and when they later co-pioneered the ones based on gas and electricity, and ultimately on nuclear and digital, from the outset depended much more upon state intervention to promote needed expertise, education and investment. The United Kingdom, by contrast, remained captivated by the mythical glory of its initial take-off.

As a result, not just Conservative governments, but also Labour ones, right up to the New Labour one, and including the catastrophically misguided work of Margaret Thatcher (Hutton is admirably unqualified here) remained far too captivated by the norms of economic laissez-faire, ‘balancing the books’, a primacy of finance over production and obsessive Treasury concern with money, rather than productive wealth.

The exceptions to this were the pre-World War one Liberal government and the post World War Two Labour one. Yet all the strong ideas implemented by the latter came from ‘New Liberal’ thinkers and not Labour ones: notably from Keynes and Beveridge. Labour on its own, by comparison, has tragically and disastrously oscillated between a desire to replace capitalism with some sort of command economy on the one hand, and simply leaving capitalism as it is, with a bit of welfare tinkering, on the other. More recently this has been seen in the contrast between Corbyn and Blair.

It is at this juncture that Hutton proceeds to complement his political-economic diagnosis with a more purely political one. The split on the ‘progressive left’ is a catastrophe that has kept the Tories unfairly in power for much of a century. This split is both caused by and has prevented any reform of the first past the post voting system, which urgently needs to go.

For this reason then, political economy and constitutional reform go together.

As to the latter, we need proportional representation which would allow more reasoned debate instead of the inter-party squabble, alongside legally guaranteed local government and a different kind of informed, rather than overweening executive.

As to the former, we need flexible planning, public-private partnership in investment, a national wealth fund, sectional trade union bargaining, the breaking up of cartels and monopolies and required social purpose and stakeholding, for every business and financial enterprise.

One is tempted just to say hurray! But there are some historical and theoretical questions to be posed that may have hidden practical consequences.

Better than trying to ‘balance’ the private and the collective, as if the self and society were in rivalry, is to take the more Continental (and early Blairite!) course of stressing that we are always ‘persons in relation’.

Hutton now backs Tawney besides Keynes. But do they say the same thing? For the latter, capitalism is a wild, amoral and dynamic beast that can nonetheless be politically tamed. In certain phases of the capitalist cycle only (as Hutton rightly sees) this will be about boosting demand, but in others it can mean lessening it and temporarily hurting workers.

But Tawney, and Hutton clearly agrees with him, wanted a market economy permitting only useful and not merely acquisitive wealth. Given this ethical purpose it was for him possible for the market, aa a socialist market, to reach equilibrium, beyond extrinsic and always precarious state ‘management’.

Just how precarious was seen in the 1970s. For Hutton, the lapse of Keynesianism in this decade was simply a matter of the triumph of the wrong ideas. To a large degree this is surely right, and yet it is not the whole story. Were it the latter, then neoliberalism might not have spread beyond Anglo-Saxon lands to Europe and South America.

The other aspect is surely the reality that capitalism of its nature, as driven by the amoral search for profit, resists any prospect of a stable, social market. Achieving that and extending the corporatist order of negotiation between state, business and unions would have been the alternative way, instead of Hayekianism, to deal with ‘stagflation’. Rather than a competition between capital, labour and consumer for money that wasn’t there at the time, a fair division of spoils could have been consistently instituted by legally and culturally re-framing the firm and the market, something that would have immediately favoured a renewed degree of growth.

Really, almost everything that Hutton writes indicates agreement with this sort of thing, including the recognition that of itself, capitalism is not actually dynamic (that comes from technology and culture) but tends to build up sterile finance in the interests of the few, rather than productive growth in the interests of the many. But in that case ‘ethical socialism’ is not just a set of ideals, as he tends to imply, but a mode of achievable practice.

Similarly, a general mutualist national insurance approach to welfare, which he rightly favours, was not just a New Liberal advocacy as he claims, but deeply rooted in co-operative socialism and in Christian (especially Anglican) social thinking whose influence -- except silently in the case of Tawney -- goes unmentioned. Yet the very phrase ‘welfare state’ is Archbishop William Temple’s and Tawney’s social analysis, intended for the general public, concluded with an unabashed High Church ecclesiology!

It is relevant here that Hutton speaks of the need to combine the ‘I’ with the ‘We’ and yet he clearly does not endorse just any old exercise of ‘individual agency’, even if he sometimes appears to do so, when defining the operation of the price mechanism as necessarily ‘wild’, after Adam Smith’s exclusion of commercial transactions from the immediate operation of social sympathy. Better than trying to ‘balance’ the private and the collective, as if the self and society were in rivalry, is to take the more Continental (and early Blairite!) course of stressing that we are always ‘persons in relation’ – at once within and outside each other, in a constant creative weave.

Nothing could be further from Keynes’ despising of the proletariat and favouring of learned leisure, that John Ruskin’s revolutionary mystique of the artisanal.

There are two deeper questions about Hutton’s approach. First, his excessive ‘idealism’, as with his analysis of the Seventies switch, may still underrate the difficulty of overcoming the power of entrenched interests – the need indeed not so much for class, as for popular warfare against plutocracy.

Secondly, he tends to underplay a theoretical tension between secular and materialist thinkers, including New Liberals, on the one hand, and religious and Idealist thinkers like the first ‘New Liberal’, T.H Green on the other.

The latter was much more like Alasdair Macintyre or Michael Sandel than like John Rawls, as Hutton claims: for by human ‘self-realisation’ he meant the ‘positive liberty’ of pursuing the objectively true ends of human flourishing: religious contemplation, artistic creation of genuine beauty, active citizen participation.

By contrast, the secular New Liberals, including Keynes, tended to reduce the ethical good to the negative liberty of rights, private friendship and utility – often leading them to favour eugenics and to indulge in racism. Nothing could be further from Keynes’ despising of the proletariat and favouring of learned leisure, that John Ruskin’s revolutionary mystique of the artisanal.

Hutton tends to express surprise that a Tory like Ruskin, or a reactionary like Carlyle, should have favoured the cause of the worker – and indeed in Ruskin’s case also espoused ‘communism’, as Hutton elides from the picture. But this is to fail to see how Tory Radicalism and even paternalism is actually a third strand in the kind of transformative thinking that we continue to need, was always a crucial influence on Labour and was a crucial element of the postwar settlement.

If these thinkers indeed favoured ‘hierarchy’, then that was in part because they wanted more interpersonal and mediated chains of command, rather than brutally centralised and mechanical ones. Surely Hutton wants that also, as his excellent reservations about the use of Artificial Intelligence would indicate?

There is a recognition that economic individualism usually ‘on the right’ is actually matched and encouraged by a cultural individualism usually ‘on the left’.

This is perhaps the limit of talking in terms of ‘progressive’ versus ‘conservative’. Hutton harks back to the norms of the Enlightenment. Yet, as Richard Whatmore has shown, all the great British enlightenment thinkers came to think that pure enlightenment was failing.

They saw its anti-religious fanaticism stance as challenged by the rise of new secular, nationalist and direct democratic fanaticisms, as supremely with the French Revolution. By ‘populism’, as we might now say!

But they also already recognised that the breakdown of a rational peace had been encouraged by excessive consumer greed and by the over-implication of commerce in state borrowing (whose pre-enabling of industry in Britain, Hutton does not mention) and so also in war and empire.

It was exactly in this context that the enlightenment thinker Edmund Burke began to consider the virtues of the longer-term embedding of enlightenment in Christianity and the importance of the medieval ‘gothic’ legacy of a corporate order binding social body to social body, rather than individual to individual via contract, mediated by the market and backed up by the state.

In Burke’s wake, for example with the radical William Cobbett, much of the Nineteenth Century critique of economism, to which Hutton is the heir, was of a ‘Romantic’ and often ‘neo-medieval’ rather than purely enlightenment cast. (Hutton at times wrongly reads medieval ‘feudalism’ as ‘absolutist’ – a specifically early modern phenomenon.) This matters, because this tradition contains a stronger recognition that the centralising state (which the Enlightenment favoured as a substitute for the Church) can be just as alienating and anti-social as the uprooting market – even if, as Karl Polanyi later saw, one needs the power of the state today in order to restore the primacy of the social and of inter-human fellowship.

Within the same current, there is a recognition that economic individualism usually ‘on the right’ is actually matched and encouraged by a cultural individualism usually ‘on the left’. And here Hutton is perhaps inconsistent – he definitely sees this, mentioning the dubious overriding of the universal by identitarian concerns, and yet also recognises it somewhat uneasily, as it challenges certain ‘progressivist’ assumptions.

As a result, he rather disallows the validity of some populist concerns – ironically rather like the incomprehension of the older enlightenment in the face of the new revolutionary era. For example, concerns with the normative primacy of the heterosexual family and the enabling of family and children, with regional and national identity, with the academic ‘woke’ trashing of the entire Western legacy, with the exploitation and cultural disruption of excessive immigration, with ecological policies that simply override current human needs while doing little to assist the future of nature.

The danger of these partial blind spots could be a continued failure of the roughly ‘communitarian’ Left, or the sensible Right, to win over the mass of the people to their cause. For they must be won over if not just the United Kingdom, but humanity as a whole, is to have a decent future.

Towards building that future, no one has contributed more, or more valiantly, than Will Hutton.

Article

Assisted dying

Care

Culture

Death & life

13 November 2024

8 min read

The deceptive appeal of assisted dying changes medical practice

In Canada the moral ethos of medicine has shifted dramatically.

Ewan Goligher

Ewan is a physician practising in Toronto, Canada.

a doctor consults a tablet against the backdrop of a Canadian flag.

Once again, the UK parliament is set to debate the question of legalizing euthanasia (a traditional term for physician-assisted death). Political conditions appear to be conducive to the legalization of this technological approach to managing death. The case for assisted death appears deceptively simple—it’s about compassion, respect, empowerment, freedom from suffering. Who can oppose such positive goals? Yet, writing from Canada, I can only warn of the ways in which the embrace of physician-assisted death will fundamentally change the practice of medicine. Reflecting on the last 10 years of our experience, two themes stick out to me—pressure, and self-deception.

I still remember quite distinctly the day that it dawned on me that the moral ethos of medicine in Canada was shifting dramatically. Traditionally, respect for the sacredness of the patient’s life and a corresponding absolute prohibition on deliberately causing the death of a patient were widely seen as essential hallmarks of a virtuous physician. Suddenly, in a 180 degree ethical turn, a willingness to intentionally cause the death of a patient was now seen as the hallmark of patient-centered doctor. A willingness to cause the patient’s death was a sign of compassion and even purported self-sacrifice in that one would put the patient’s desires and values ahead of their own. Those of us who continued to insist on the wrongness of deliberately causing death would now be seen as moral outliers, barriers to the well-being and dignity of our patients. We were tolerated to some extent, and mainly out of a sense of collegiality. But we were also a source of slight embarrassment. Nobody really wanted to debate the question with us; the question was settled without debate.

Yet there was no denying the way that pressure was brought to bear, in ways subtle and overt, to participate in the new assisted death regime. We humans are unavoidably moral creatures, and when we come to believe that something is good, we see ourselves and others as having an obligation to support it. We have a hard time accepting those who refuse to join us. Such was the case with assisted death. With the loudest and most strident voices in the Canadian medical profession embracing assisted death as a high and unquestioned moral good, refusal to participate in assisted death could not be fully tolerated.

We deceive ourselves if we think that doctors have fully accepted that euthanasia is ethical when only very few are actually willing to administer it.

Regulators in Ontario and Nova Scotia (two Canadian provinces) stipulated that physicians who were unwilling to perform the death procedure must make an effective referral to a willing “provider”. Although the Supreme Court decision made it clear in their decision to strike down the criminal prohibition against physician-assisted death that no particular physician was under any obligation to provide the procedure, the regulators chose to enforce participation by way of this effective referral requirement. After all, this was the only way to normalize this new practice. Doctors don't ordinarily refuse to refer their patients for medically necessary procedures; if assisted death was understood to be a medically necessary good, then an unwillingness to make such referral could not be tolerated.

And this form of pressure brings us to the pattern of deception. First, it is deceptive to suggest that an effective referral to a willing provider confers no moral culpability on the referring physician for the death of the patient. Those of us who objected to referring the patient were told that like Pilate, we could wash our hands of the patient’s death by passing them along to someone else who had the courage to do the deed. Yet the same regulators clearly prohibited referral for female genital mutilation. They therefore seemed to understand the moral responsibility attached to an effective referral. Such glaring inconsistencies about the moral significance of a referral suggests that when they claimed that a referral avoided culpability for death by euthanasia, they were deceiving themselves and us.

The very need for a referral system signifies another self-deception. Doctors normally make referrals only when an assessment or procedure lies outside their technical expertise. In the case of assisted death, every physician has the requisite technical expertise to cause death. There is nothing at all complicated or difficult or specialized about assessing euthanasia eligibility criteria or the sequential administration of toxic doses of midazolam, propofol, rocuronium, and lidocaine. The fact that the vast majority of physicians are unwilling to perform this procedure entails that moral objection to participation in assisted death remains widespread in the medical profession. The referral mechanism is for physicians who are “uncomfortable” in performing the procedure; they can send the patient to someone else more comfortable. But to be comfortable in this case is to be “morally comfortable”, not “technically comfortable”. We deceive ourselves if we think that doctors have fully accepted that euthanasia is ethical when only very few are actually willing to administer it.

We deceived ourselves into thinking that assisted death is a medical therapy for a medical problem, when in fact it is an existential therapy for a spiritual problem.

There is also self-deception with respect to the cause of death. In Canada, when a patient dies by doctor-assisted death, the person completing the death certificate is required to record the cause of death as the reason that the patient requested euthanasia, not the act of euthanasia per se. This must lead to all sorts of moments of absurdity for physicians completing death certificates—do patients really die from advanced osteoarthritis? (one of the many reasons patients have sought and obtained euthanasia). I suspect that this practice is intended to shield those who perform euthanasia from any long-term legal liability should the law be reversed. But if medicine, medical progress, and medical safety are predicated on an honest acknowledgment about causes of death, then this form of self-deception should not be countenanced. We need to be honest with ourselves about why our patients die.

There has also been self-deception about whether physician-assisted death is a form of suicide. Some proponents of assisted death contend that assisted death is not an act of deliberate self-killing, but rather merely a choice over the manner and timing of one's death. It's not clear why one would try to distort language this way and deny that “physician-assisted suicide” is suicide, except perhaps to assuage conscience and minimize stigma. Perhaps we all know that suicide is never really a form of self-respect. To sustain our moral and social affirmation of physician-assisted death, we have to deny what this practice actually represents.

There has been self-deception about the possibility of putting limits around the practice of assisted death. Early on, advocates insisted that euthanasia would be available only to those for whom death was reasonably foreseeable (to use the Canadian legal parlance). But once death comes to be viewed as a therapeutic option, the therapeutic possibilities become nearly limitless. Death was soon viewed as a therapy for severe disability or for health-related consequences of poverty and loneliness (though often poverty and loneliness are the consequence of the health issues). Soon we were talking about death as a therapy for mental illness. If beauty is in the eye of the beholder, then so is grievous and irremediable suffering. Death inevitably becomes therapeutic option for any form of suffering. Efforts to limit the practice to certain populations (e.g. those with disabilities) are inevitably seen as paternalistic and discriminatory.

There has been self-deception about the reasons justifying legalization of assisted death. Before legalization, advocates decry the uncontrolled physical suffering associated with the dying process and claim that prohibiting assisted death dehumanizes patients and leaves them in agony. Once legalized, it rapidly becomes clear that this therapy is not for physical suffering but rather for existential suffering: the loss of autonomy, the sense of being a burden, the despair of seeing any point in going on with life. The desire for death reflects a crisis of meaning. We deceived ourselves into thinking that assisted death is a medical therapy for a medical problem, when in fact it is an existential therapy for a spiritual problem.

We have also deceived ourselves by claiming to know whether some patients are better off dead, when in fact we have no idea what it's like to be dead. The utilitarian calculus underpinning the logic of assisted death relies on the presumption that we know what it is like before we die in comparison to what it is like after we die. In general, the unstated assumption is that there is nothing after death. This is perhaps why the practice is generally promoted by atheists and opposed by theists. But in my experience, it is very rare for people to address this question explicitly. They prefer to let the question of existence beyond death lie dormant, untouched. To think that physicians qua physicians have any expertise on or authority on the question of what it’s like to be dead, or that such medicine can at all comport with a scientific evidence-based approach to medical decision-making, is a profound self-deception.

Finally, we deceive ourselves when we pretend that ending people’s lives at their voluntary request is all about respecting personal autonomy. People seek death when they can see no other way forward with life—they are subject to the constraints of their circumstances, finances, support networks, and even internal spiritual resources. We are not nearly so autonomous as we wish to think. And in the end, the patient does not choose whether to die; the doctor chooses whether the patient should die. The patient requests, the doctor decides. Recent new stories have made clear the challenges for practitioners of euthanasia to pick and choose who should die among their patients. In Canada, you can have death, but only if your doctor agrees that your life is not worth living. However much these doctors might purport to act from compassion, one cannot help see a connection to Nazi physicians labelling the unwanted as “Lebensunwortes leben”—life unworthy of life. In adopting assisted death, we cannot avoid dehumanizing ourselves. Death with dignity is a deception.

These many acts of self-deception in relation to physician-assisted death should not surprise us, for the practice is intrinsically self-deceptive. It claims to be motivated by the value of the patient; it claims to promote the dignity of the patient; it claims to respect the autonomy of the patient. In fact, it directly contravenes all three of those goods.

It degrades the value of the patient by accepting that it doesn't matter whether or not the patient exists.

It denies the dignity of the patient by treating the patient as a mere means to an end—the sufferer is ended in order to end the suffering.

It destroys the autonomy of the patient because it takes away autonomy. The patient might autonomously express a desire for death, but the act of rendering someone dead does not enhance their autonomy; it obliterates it.

Yet the need for self-deception represents the fatal weakness of this practice. In time, truth will win over falsehood, light over darkness, wisdom over folly. So let us ever cling to the truth, and faithfully continue to speak the truth in love to the dying and the living. Truth overcomes pressure. The truth will set us free.