Sunday, August 22, 2010

Secrecy and privacy

"Sir Humphrey Appleby" reviews Yes, Prime Minister: The Diaries of the Rt. Hon. James Hacker MP. Although embedded in several layers of fiction (the actual author is of course Yes, Minister and Yes, Prime Minister creator and writer Jonathan Lynn) there's some real truth* in this article.

*How to interpret fiction in a social and political context is not at all trivial, but we can at least say that an author of a fictional work usually believes that the underlying themes of the work correspond in some sense to reality, and a work that achieves substantial popularity must somehow appeal to the audience's own beliefs about reality. We can feel even more confident about works such as Yes, Minister and Yes, Prime Minister, which are only one step removed from pure roman à clef.

"Sir Humphrey" observes that "the movement to 'open up' government," by making public the deliberations of politicians, "if successful, always achieves a gratifying increase in level of secrecy. The reason is obvious."
Once a meeting - Parliament, local council, Cabinet - is opened up to the public, it is used by those attending as a propaganda platform and not as a genuine debating forum. The true discussions take place privately in smaller informal groups. In government these smaller groups often contain one or more senior civil servants, so that some element of intelligence and practicability can be built into proposals before they become public and have to be defended with arguments which represent a victory of personal pride over commonsense. So the move to greater openness in public affairs has greatly strengthened the level of secrecy and therefore the quality of decision-making in the higher echelons of government.
We can see an analogous situation with regard to physicians.

We normally expect physicians to have a strong ethical duty to full disclosure to their patients. Their analyses of decisions made on specific cases and the outcome of those decisions, however, are usually made confidentially. Medicine is an enormously complicated field, and physicians have to make life-and-death decisions with limited information and under enormous time pressure. It's inevitable that they will make decisions they would have made differently knowing the outcome and with the leisure of unlimited deliberation. The profession considers it more important for individual physicians to learn from their mistakes and for the profession as a whole to use adverse outcomes to improve their practices and procedures than it is to assign and punish blame.

It would be nice in the abstract if the general public could "listen in" on these conversations with the same goals and interests in mind, and the same detachment from finding fault, but people aren't really built that way. And given an environment of competing interests, it seems inevitable that there will be some interests hostile to understanding and improving scientific medicine; it seems unwise to blithely hand ammunition to such hostile interests.

Of course, this tradition of confidentiality has its drawbacks. Keeping discussions of inevitable and entirely forgivable human error private seems to create a tendency in physicians to cover up outright and egregious incompetence. It's a trade-off: closure and honesty vs. protection of incompetence, openness and propaganda and disingenuity and exposure of incompetence. There are more incompetent physicians than I would like, but most physicians really are highly competent, and most medical practices and procedures really are effective and efficient.

I think the same has to be true of even a democratic political process. Leaving aside the judiciary, pure direct democracy, where every political decision is made by a vote of all the people, seems inefficient in a society of even a few million, much less the hundreds of millions of people in the United States. Some form of representation — with all the social institutions and constructions to manage that representation — seems enormously beneficial. The question then becomes what sort of social institutions do we need to ensure that democratic representatives are truly the servants of people and not their masters? How do we ensure that our representatives really act like experts, and not authorities?

Taking our cue from the medical profession, it seems crucial to separate issues of material fact from professional opinion and deliberation. It is grossly unethical for a physician to withhold any issue of material fact from her patient. If some test or symptom contradicts an earlier diagnosis or treatment, that fact must be disclosed and the diagnosis or treatment altered, regardless of any embarrassment to the physician. Not only must such facts not be withheld, they must be actively brought to the attention of the patient and their objective meaning and implication carefully and accurately described. On the other hand, it seems legitimate to keep deliberations, especially after the fact analyses of individual cases, entirely private, to encourage honesty.

It might be difficult, but it is not impossible to allow political representatives to deliberate honestly (or at least sincerely) in private while ensuring they always strongly publicly disclose issues of material fact. If we can do it reasonably well for physicians, we can do it for politicians.

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