Friday, January 19, 2018

Surfaces of Inscription

Surfaces of inscription may include such things as sheets of paper, computer screens, digital writing pads, scrolls, tapestries, bank notes, invoices, receipts, postage stamps, licenses, certificates, diplomas, sheets of cardboard, and sheets of canvas.
      Surfaces of inscription may also include such things as windowpanes, glass bottles or jars, coffee mugs, watch or clock faces, cement or asphalt surfaces (such as streets and sidewalks), street signs, blackboards, posters, and billboards. 
      They may also include wooden surfaces (such as furniture, walls, doors, and floors), medicinal tablets or capsules, surfaces of the human body, and articles of clothing.
      They may also include blocks of stone (such as pillars, columns, gravestones, statues, and monuments), stone walls (such as cave walls), blocks of soap, wax, clay, or brick, and coins, medals, insignias, badges, tools, and weapons.
      Surfaces of (metaphorical) inscription may include such things as thoughts, impressions, memories, emotions, feelings, attitudes, and (moral, aesthetic, and cultural) sensibilities.
      Inscriptions may vary in their legibility and durability. Some may be relatively permanent, others merely temporary.
      Instruments of inscription may include pencils, pens, needles, styluses, crayons, paint or ink brushes, spray guns, pieces of chalk, drills, computers, video or movie projectors, and printing presses.
      To inscribe may be to write, print, draw, paint, carve, engrave, stamp, paste, or burn words, letters, symbols, or images onto something. It may also be to write a signature, personal message, or dedication (e.g. inside the covers of a book, on a photograph, or on a work of art).
      The body surface may be a site, locus, or medium of self-inscription, self-identification, self-representation, and self-expression. An interesting exception to this rule, however, may be when people inscribe other people’s names (such as the names of friends or family members) on their own bodies.
      We may inscribe or map our social identities onto our own bodies (e.g. through the use of makeup, lipstick, nail polish, jewelry, tattoos, and body piercings). Cosmetic surgery may be another means of inscribing or altering the surface and contour of the body. Bodily inscriptions may be markers of not only social identity, but also social and cultural difference.
      Growth or shaving of facial or body hair, and the wearing of wigs, toupees, and particular hairstyles may also be ways of inscribing particular aesthetic, religious, political, social, and cultural values and attitudes onto the surface of the body.
      Modes of inscription may be governed by textual (aesthetic, interpretive, stylistic, and rhetorical), social, and cultural codes. The wearing of a bodily inscription may be a kind of performance that may be governed by social performance codes (as when bodily inscriptions have to be disguised or concealed in certain social settings).
      Michel Foucault (1977) describes the human body as a surface of inscription of events that are traced by language and dissolved by ideas.1 History inscribes or imprints itself on the human body. The body is the site of a dissociated self, insofar as genealogy (as an analysis of ancestral descent) requires us to maintain past events in their proper dispersion. Genealogy requires us to identify the accidents that gave birth to what exists and has value for us, and to discover that at the root of what we know and what we are there is not truth or being, but the exteriority of accidents.2,3
      Jacques Derrida (1974) says that writing signifies inscription, insofar as it is taken to mean something durable and something occurring spatially. The world may be seen as a space of inscription.4
      Gilles Deleuze (1986) says that the human face may be a surface of inscription, insofar as thoughts, feelings, and emotions may be inscribed on it.5
      Ernesto Laclau (1990) argues that structural dislocations in society provide spaces of representation for individuals, and that those spaces of representation may function as alternatives to the socially dominant forms of structural discourse. The suturing of structural dislocations may in turn create new spaces of representation. These new spaces function as surfaces on which structural dislocations and social demands are inscribed. Structural dislocation is therefore a source of freedom for the individual subject. The individual subject’s acts of self-identification and self-determination are made possible by structural indeterminacy and undecidability. The relation between the surfaces of inscription constituted by spaces of representation and whatever is inscribed on them is therefore essentially unstable. The incomplete and unfinished nature of surfaces of inscription is the condition of possibility for the constitution of social “imaginaries” (which in turn are horizons of possibility for the emergence of the world of objects).6
      Elizabeth Grosz (1993) distinguishes between two kinds of approach to theorizing the human body: (1) the inscriptive, and (2) the lived body. The inscriptive approach conceives the body as a surface on which social law, morality, and values are inscribed, while the lived body approach is concerned with the lived experience of the body, and with the body’s internal or psychic inscription.7 Grosz explains that “the body can be regarded as a kind of hinge or threshold: it is placed between a psychic or lived interiority and a more sociopolitical exteriority that produces interiority through the inscription of the body’s outer surface.”8
      Grosz (1994) also explains that “the body’s psychical interior is established as such through the social inscription of bodily processes, that is, the ways in which the 'mind' or psyche is constituted so that it accords with the social meanings attributed to the body in its concrete historical, social, and cultural particularity.”9 This does not mean that the self or ego is “an effect of which the body or the body’s surface is the cause…The ego is derived from two kinds of 'surface.' On the one hand, the ego is on the 'inner' surface of the psychical agencies; on the other hand, it is a projection or representation of the body’s 'outer surface.'"10
      Margo DeMello (2000), in discussing the social significance of tattoos, notes that the human body may be both inscribed and reinscribed by culture and society. Tattoos may be a means for individuals to write themselves into a particular kind of social context, and also to be “read” within that context. People may construct “tattoo narratives” about their own tattoos in order to provide others with an appropriate social context within which to determine their meaning.11 Tattoos (and surgical scars, and other kinds of bodily inscriptions) may “tell a story” about their wearers, and their wearers may in turn “tell a story” about them.


1Michel Foucault, “Nietzsche, Genealogy, History,” in Language, Counter-Memory, Practice: Selected Essays and Interviews, edited by Donald F. Bouchard, translated by Donald F. Bouchard and Sherry Simon (Ithaca: Cornell University Press, 1977), p. 148.
2Ibid., p. 146.
3Foucault, “Nietzsche, La Généalogie, L’Histoire,” in Hommage À Jean Hyppolite, edited by Suzanne Bachelard, et al. (Paris: Presses Universitaires de France, 1971), p. 152.
4Jacques Derrida, Of Grammatology, translated by Gayatri Chakravorty Spivak (Baltimore: The Johns Hopkins University Press, 1974), p. 44.
5Adrian Jonston and Catherine Malabou, discussing Deleuze’s Cinema 1 (1986), in “The Face and the Close-Up: Deleuze’s Spinozist Approach to Descartes,” in Self and Emotional Life: Philosophy, Psychoanalysis, and Neuroscience (New York: Columbia University Press, 2013), p. 46.
6Ernesto Laclau, New Reflections on The Revolution of Our Time (London: Verso, 1990), p. 63.
7Elizabeth Grosz, “Bodies and Knowledges: Feminism and the Crisis of Reason,” in Feminist Epistemologies, edited by Linda Alcoff and Elizabeth Potter (New York: Routledge, 1993), p. 196.
8Ibid., p. 196.
9Elizabeth Grosz, Volatile Bodies: Toward a Corporeal Feminism (Bloomington: Indiana University Press, 1994) p. 27.
10Ibid., p. 37.
11Margo DeMello, Bodies of Inscription: A cultural history of the modern tattoo community (Durham: Duke University Press, 2000), p. 12.

Thursday, January 4, 2018

Luis Villoro's Power and Value: Fundamentals of a Political Ethic

In El poder y el valor: Fundamentos de una ética política (1997, not yet published in English), Luis Villoro is concerned with the relation between political power and moral values. He explores the question of whether there is any necessary opposition between the will to power and the realization of the good. He also explores the question of how political power may be combined with moral values in order to promote the interests of the whole of society.
      The first part of the book outlines a general theory of value. The three following parts describe three different ways of defining the relation between political power and moral values. The first way is to delineate the characteristics of political action, in which the relation between power and value converges with two distinct forms of rationality: instrumental and evaluative. The second way is to describe political change from the standpoint of the relation between social morality and the ethical proposals of politics. The third way is to describe the aims of the two previous approaches, namely, to describe the particular values and kinds of political association they aim to realize.1
      Villoro says that, as a first approximation, we may understand “value” as the characteristics of an object or situation that cause us to have a favorable attitude toward it.2 A favorable attitude toward an object may have a reverse aspect: a perception that the object is lacking something valuable.3 "Value" is then whatever alleviates a deprivation, placates the tension of desire, fulfills a longing, or returns plenitude to a lacking world. The realization of value in a particular good suspends (at least partially and temporarily) the perception that it may also be lacking something valuable.
      Value may be intrinsic or extrinsic, but some objects may be both intrinsically and extrinsically valuable, i.e. they may be both valuable in themselves and valuable insofar as they enable us to obtain other objects, states, etc. that are valuable.
      Villoro explains that there are at least four kinds of valid reasons to doubt the reality of an experience of value: (1) sufficient reasons to believe that it has been produced by a distortion or disruption of reliable faculties of perception, (2) sufficient reasons to believe that it has been produced by subjective alterations of actual reality, (3) sufficient reasons to believe that it is motivated by beliefs that are insufficiently justified, and (4) prior beliefs that are objectively justified and that contradict it.
      The boundary between reasonable belief and knowledge cannot be precisely determined, says Villoro. Objective knowledge may be no more than the limit to which beliefs based on more or less sufficient reasons extend.4 Thus, beliefs about value, even when based on sufficient reasons, may not provide us with complete certainty.
      To depart from the first approximation to the meaning of value (“value” as a term for a positive attitude toward something), we need to distinguish between those judgments that declare that an object is considered to be valuable by a particular subject and those that assert that the object is valuable independently of the attitude of a particular subject. A particular subject may affirm without contradicting herself that “I know x is valuable, but I don’t feel any esteem or admiration for it,” or “I should admire or appreciate x, but it’s too bad that I’m incapable of doing so!”5 We must therefore distinguish between subjective and objective value.
      If an object’s value is purely instrumental, then its desirability is conditioned by the choice of the end that it serves. Thus, if x leads to y, and S desires y, then S should choose x (if the word “should” is taken to have a purely instrumental meaning). But if this instrumental rule is valid for every subject under determinate conditions, then every subject becomes a member of a collectivity for whom x is now an objective value, and the instrumental rule is converted into an unconditional norm, insofar as it provides a universal guide for action. The conjunction of such norms constitutes an ethic. Ethical norms may therefore be seen as precepts for the realization of objective values.6
      The term “value” may thus be used in at least two senses. As a first approximation, we may say that a value is the intentional object of a positive attitude, i.e. that which is desired or admired by a particular subject. As a second approximation, we may say that it is that which is desirable or admirable for any subject under determinate conditions. The attribution of subjective value to an object indicates that the object is desired or admired by a particular subject, while the attribution of objective value to it indicates that it is desirable or admirable independently of being seen as such by any particular subject.7
      Values may sometimes conflict with, or be opposed to, one another. The realization of one value may sometimes come at the cost of the realization of other values. A hierarchy of values may therefore have to be established in order for us to determine those that are most important for us to realize.8
      A political ethic deals most importantly with values that satisfy the general interest of society as a whole by encouraging social cooperation and promoting the common good. The major tasks of a political ethic are therefore (1) to determine the common values that are worthy of being esteemed by any individual, (2) to show that those values have been chosen for objective reasons, and (3) to indicate the regulative principles of political action so that those principles may be realized.9
      According to Villoro, there is in fact an implicit ethic in any political discourse. In any political text (speech, document, proclamation, manifesto, or party program), we may encounter two types of language, which may often be intermingled and confused with each other. The first is justificatory, the second explicative. Justificatory discourse engages practical reason, and it may be expressed in an ethics of political action. Explicative discourse puts into effect both theoretical reasoning about facts and instrumental reasoning about the relation between means and ends.10
      Ethical movements in the field of politics have always wanted to limit the power of the state, says Villoro. Because of the inevitably corrupting nature of power, imposed power may always exceed the end that justifies it. But the attempt to end oppression may also require power. How then can the circle of power and domination be broken?
       “Counterpower” (contrapoder) may be an effective means of halting the excesses and abuses of power, says Villoro. Counterpower replaces intolerance with tolerance, conflict with cooperation, and confrontation with negotiation and dialogue. Its ultimate goal is the abolition of imposed power. While this goal may never be fully achieved, counterpower may still effectively restrain and control political power.11 It is not an imposition of power, nor is it a will to power. It is rather a resistance to imposed power, and to the will to power.
      According to the function they serve, political ideologies may be divided into those that reinforce an existing system of power and those that subvert or disrupt it. The first may be described as reiterative, the second as subversive or disruptive. What makes an ideology reiterative or disruptive may depend on the function it performs in a particular society, rather than on the particular content of its doctrines. For example, a nationalist ideology may be reiterative of a totalitarian system of power, but subversive of a colonialist system of power. A socialist ideology may be reiterative of a socialist system of power, but subversive of a capitalist system of power.12
      Some ideologies may be more pragmatic than theoretical, while others may be more theoretical than pragmatic. Between those that are predominantly theoretical and those that are predominantly pragmatic, there may be intermediate cases.
      According to the function they perform, “pragmatic” ideologies may be reiterative or disruptive of a system of domination. The same may be said of “theoretical” or “doctrinal” ideologies.13
      Villoro distinguishes between ideology and ethics by saying that ideologies present as objective those values that respond to the needs of a particular group, while ethics presents as objective those values that may be considered valid for any individual or group. Ideologies may be motivated by the striving for power, while ethics may be motivated by the striving for value.14 Nevertheless, the distinction between ideology and ethics may not always be clear. There may be ideologies that contain moral doctrines, and there may be systems of power that attempt to legitimize themselves by means of a discourse that contains moral principles.15
      Ideologies may therefore attempt to reconcile two discourses: ethical discourse and discourse aimed at the achievement of political power. But ethical discourse may be shown to be in contradiction to the pursuit of power that the ideologue attempts to justify. The ideologue has to reinterpret the two discourses in a manner that conceals their contradiction. The maintenance of power may be based on this act of deception.16
      Villoro also distinguishes between an association (asociacíon) and a community (comunidad). In an association, the more we try to detach ourselves from our own interests, the more we are faced with the conflict between those interests and the interests of other subjects in the association. In a community, on the other hand, such conflict is eliminated, because the interests of every subject include the interests of the whole community.
      According to Villoro, utopianism may express both an attitude of departure from the real world and an affirmation of an ideal world. The opposition between the projected ideal world and the actual world corresponds to the distinction between ideal values and actual facts that are deprived of value.17 Utopianism proposes an imaginary or ideal reality where an objective order is fulfilled, valid for every community, and at its limit, valid for every individual.
      Utopianism may therefore be characterized as a kind of disruptive mode of thought that establishes a maximal tension between a projected ideal world and the actual world, between ultimate and proximate ends, between what ought to be and what is.18
      Villoro says that the most common criticism of utopianism is that it lacks efficacy. It desires an ideal end without putting into practice the means to realize that end.19 The ideal society has a normative character; it directs political action, but is never fully realized.
      He also explains that moral action in politics presupposes two kinds of knowledge: (1) knowledge of both the values that constitute the common good and the political means necessary for the realization of those values (this kind of knowledge corresponds to principles of rationality of means and ends) and (2) knowledge of the actual facts that will lead to the realization of those values in society (this kind of knowledge corresponds to both theoretical rationality concerning existing social forces and instrumental rationality concerning the effective means of achieving desired ends).20
      A political ethic, according to Villoro, cannot be limited to promulgating general norms or establishing abstract principles; it must be a concrete ethic, subject to three kinds of rationality: (1) valuative rationality concerning the ends and values that fulfill the general interest, (2) theoretical and instrumental rationality concerning the actual circumstances and consequences of actions, and (3) rationality of judgment that weighs, in every case, the relations between the given data and the two previous kinds of rationality.21


1Luis Villoro, El poder y el valor: Fundamentos de una ética política (Ciudad de México: Fondo de Cultura Económica, 1997), p. 8.
2Ibid., p. 13.
3Ibid., p. 15.
4Ibid., p. 27.
5Ibid., p. 41.
6Ibid., p. 45.
7Ibid., p. 45.
8Ibid., pp. 46-47.
9Ibid., p. 74.
10Ibid., pp. 74-75.
11Ibid., p. 88.
12Ibid., p. 188.
13Ibid., p. 191.
14Ibid., p. 192.
15Ibid., pp. 192-193.
16Ibid., pp. 193-194.
17Ibid., p. 210.
18Ibid., p. 211.
19Ibid., p. 213.
20Ibid., p. 123.
21Ibid., pp. 124-125.

Saturday, November 11, 2017

Fernando Broncano's The Melancholia of the Cyborg

Fernando Broncano Rodríguez (b. 1954) is a Spanish philosopher who was born in Linares de Riofrío, Salamanca, Spain. He received his doctoral degree from the Universidad de Salamanca in 1981, and did postdoctoral studies at Brown University. He was titular professor of logic and the philosophy of science at the Universidad de Salamanca from 1977 until 2000, and has been full professor (catedrático) of the philosophy of science at the Universidad Carlos III de Madrid since 2001. His research interests include epistemology, philosophy of mind, philosophy of science, and philosophy of technology. His writings include Nuevas meditaciones sobre la técnica (1995), Mundos Artificiales: Filosofía del cambio technológico (2000), Saber en condiciones: Epistemología para escépticos y materialistas (2003), Jardines de la memoria y el olvido (2004), Entre ingenieros y ciudadanos: Filosofía de la técnica para días de democracia (2006), La melancholía del ciborg (2009), La estrategía del simbionte: Cultura material para nuevas humanidades (2012), and Sujetos en la niebla: Narrativas sobre la identidad (2013). He has a blog entitled El laberinto de la identidad at
      La melancholia del ciborg (The Melancholia of the Cyborg) is divided into seven chapters and an epilogue: "1. Cyborgs among other frontier beings,” "2. Material cultures and artefacts,” "3. Imaginary artefacts,” "4. The invention of the subjunctive,” "5. Not being able (to come) to be: Agency in times and places of obscurity,” "6. More faces of power,” "7. Pathologies of the imagination and of power,” and "Epilogue. Spaces of possibility.” As of 2017, it has not yet been published in English.
      Broncano explains at the outset that his examination of the kind of hybrid being that belongs to cyborgs is inspired by the writings of such philosophers as Donna Haraway (Simians, Cyborgs, and Women: The Reinvention of Nature, 1991), María Lugones (Pilgrimages/Peregrinajes: Theorizing Coalition Against Multiple Oppressions, 2003), Rosi Braidotti (Nomadic Subjects, 1994), and Andy Clark (Natural-Born Cyborgs: Minds, Technologies, and the Future of Human Intelligence, 2003).  He says that we are all, in some sense, like Galatea, the statue brought to life by its sculptor, Pygmalion, in ancient Greek mythology. We are all hybrids of the organic and the artisanal (or artefactual). Our experience of the world occurs on the frontier between representation and reality.
       We are also cyborgs insofar as we depend on artificial parts or mechanical devices for our being or functioning. The artificial devices on which we depend in order to carry out our daily activities function as prostheses for us; they occupy an increasing proportion of our attention and become indispensable to us, insofar as they not only remedy impaired organic functions (as with the use of eyeglasses, hearing aids, orthopedic prostheses, and pacemakers), but also create new possibilities of being.
      The whole array of social and cultural tools or instruments we employ, including oral and written languages, social institutions, codes and norms, religions and rituals, music and art, function as social and cultural prostheses for us, and thus transform our social and cultural possibilities.
      But cyborgs also suffer a melancholia that is the fruit of an uprooting, because the use of artificial parts or devices constitutes a kind of exile from the natural world. Cyborgs live on the frontier between the natural and artificial worlds, and thus they experience a sense of nostalgia for the natural world from which they've been exiled. Melancholia is therefore a characteristic state of cultural modernity.1
       Broncano explains that the categorization of phenomena as natural or artificial may have important moral, social, and political consequences, as, for example, when the origins of global warming are attributed to natural causes or to human activity, and when such social categories as gender, race, and ethnicity are attributed to natural or to socially constructed factors. The concept of a “natural” origin of a particular moral or religious mission may be a source of radical fundamentalism. On the other hand, the theory that all human categories are socially constructed may lead to radical skepticism or relativism.2
      One objection to the concept that we are all cyborgs is that cyborgs may be viewed as mere products of capitalism, as things that are designed or destined to become obsolete, like computers or electronic mobile devices. But Broncano argues that cyborgs are actually condemned not to obsolescence, but to loss of access to various cultural spaces, depending on how long their prostheses continue to allow them access to those cultural spaces.3
      Cyborgs belong to a class of beings that attempt to reconcile the antagonism between the natural and the artificial. In the 1980’s, they became part of the popular iconography of Hollywood, extraordinary beings composed of natural and artificial parts, in such films as Blade Runner (1982), The Terminator (1984) and RoboCop (1987).
      Donna Haraway, in her essay “A Cyborg Manifesto: Science, Technology, and Socialist-Feminism in the Late Twentieth Century” (1991) describes cyborgs as cybernetic organisms, hybrids of organic and inorganic parts. They are beings in whom nature and culture have been reworked, so that nature is no longer the resource for appropriation or incorporation by culture.4 They are also beings in whom not only the boundary between human and animal, but also the boundary between organism and machine has been breached.5
      Broncano says that Haraway describes cyborgs as symbols of the multifold and diverse identities of women, and as having many different social roles. He also says that Haraway seeks to reclaim for women what had previously been stigmatized: the natural in the feminine, the corporeal, the emotional, the maternal, closeness to the world, and the care of things.6
      Broncano concludes that melancholia is not a state of disenchantment, but a state of knowledge or wisdom. Modern melancholia is the melancholia of unrealized possibilities. It is therefore not a kind of infirmity or malady, but the very nature of frontier beings.7


1Fernando Broncano, La melancholia del ciborg (Barcelona: Herder Editorial, 2009), pp. 24-25.
2Ibid., p. 29.
3Ibid., p. 42.
4Donna Haraway, “A Cyborg Manifesto: Science, Technology, and Socialist-Feminism in the Late Twentieth Century,” in Simians, Cyborgs, and Women: The Reinvention of Nature (New York: Routledge, 1991), p. 151.
5Ibid., p. 151.
6Broncano, La melancholia del ciborg, p. 43.
7Ibid., 277

Saturday, July 15, 2017

Arnold Relman's Proposals for U.S. Health Care System Reform

Arnold Seymour Relman (1923-2014) was an American physician, medical researcher (in acid-base and electrolyte balance, nephrology, and renal physiology), medical school professor, editor, writer, and health care system reformer. He was born in Queens, N.Y., the younger of two children. His sister, Muriel (Relman Straetz), graduated from Smith College, the University of Rochester School of Medicine, and the Columbia Psychoanalytic Institute, and became a psychiatrist. His father, Simon Relman, was a businessman, and was also an avid reader who inspired his son to study philosophy.1  Arnold's mother, Muriel (Mallach) Relman, was a cellist who nicknamed him “Buddy,” and he thus became known to his friends and family as “Bud.”2 He attended Cornell University (graduating at the age of 19 in 1943 with a degree in philosophy), and graduated with a medical degree from the Columbia University College of Physicians and Surgeons at the age of 22 in 1946. He became assistant professor of medicine at Boston University School of Medicine (from 1951-1961), and then professor of medicine at Boston University (from 1961-1968,) and professor of medicine at the University of Pennsylvania (from 1968-1977), before becoming professor of medicine at Harvard Medical School and senior physician at the Brigham and Women’s Hospital in Boston (from 1977-1993). He served as editor of The Journal of Clinical Investigation from 1962-1967, and as editor of The New England Journal of Medicine from 1977-1991. In 1991 he became editor-in-chief emeritus of The New England Journal of Medicine (NEJM), and professor of medicine and social medicine at the Harvard Medical School. In 1993, he became professor emeritus of medicine and social medicine at the Harvard Medical School.  
      In 1953, he married his first wife, Harriet Morse Vitkin, with whom he had three children. Their marriage ended in divorce 40 years later.3 In 2009, he married his second wife, Dr. Marcia Angell, his colleague at the NEJM, who, after joining the editorial staff in 1979, became executive editor in 1988, and then interim editor-in-chief from 1999-2000. (She was the first woman to serve as editor-in-chief of the NEJM.)
      He was the recipient of many honorary degrees, including degrees from the Medical College of Wisconsin, Union University, the Medical College of Ohio, the City University of New York, Brown University, the State University of New York, and Temple University.
      He published numerous scientific articles, textbook chapters, journal editorials, and magazine articles, and he co-edited, with Franz J. Ingelfinger and Maxwell Finland, in 1966 and 1974, Volumes I and II of Controversy in Internal Medicine, which discussed the controversies surrounding the diagnosis and treatment of a variety of medical disorders.  His book, A Second Opinion: A Plan for Universal Coverage Serving Patients Over Profit, was published in 2007. He died in Cambridge, Mass., from complications of malignant melanoma, on his 91st birthday, June 17, 2014.
      Dr. Jerome Kassirer, a nephrologist, bioethicist, editor, and writer who succeeded him as editor-in-chief of the NEJM, described him as “one of the foremost public policy thinkers in American medicine.”4   
      Dr. Marcia Angell, a medical pathologist, bioethicist, editor, writer, and health care policy analyst, described him as “a towering figure in American medicine.”5 In an article entitled “On Arnold Relman (1923- 2014),” (published in The New York Review of Books, Aug. 14, 2014), she explained that “under his leadership, the NEJM’s standing as the world’s most prestigious medical journal grew, and it became a source not just of new research results, but of thoughtful analyses of important ethical and policy issues in medicine.”6 She also explained that his dominant concern was that the American health care system was increasingly becoming a profit-driven industry, driven by market forces rather than patient needs, and that his proposals for health care reform were therefore twofold: (1) a single-payer public insurance system, with no investor-owned private insurance companies, and (2) a non-profit health care delivery system, consisting of multispeciality physician groups paid by salary within a set budget.7
      In a ground-breaking article entitled “The New Medical-Industrial Complex” (in the NEJM, Oct. 23, 1980), Relman warned of the rise of the “medical industrial complex,” a network of private corporations analogous to the “military-industrial complex.” The medical-industrial complex includes private hospitals, nursing homes, diagnostic laboratories, home-care services, dialysis units, emergency and urgent care services, ambulatory surgery centers, and other private for-profit corporations engaged in the business of health care. Other private for-profit health care corporations include pharmaceutical companies, medical equipment companies, and medical supply companies (although Relman in 1980 did not yet regard them as constituting a potential threat to the future of the American health care system). Relman says that although the arguments for allowing the free market to operate in order to improve the efficiency and quality of health care include the argument that private for-profit corporations may have a greater incentive to control costs than public or governmental nonprofit institutions, there is actually no evidence that the medical-industrial complex is capable of lowering the cost and improving the efficiency of health care.
      According to Relman, health care is different from other commodities that are bought and sold in the marketplace.8 One reason is that many people consider health care to be a public rather than private good. “Pubic funds pay for most of the research needed to develop new [medical] treatments and new medical-care technology. [Public funds] also reimburse the charges for health-care services.”9
      Another reason that health care is different from other commodities is that when people are sick, they may not be in a position to be selective consumers with regard to the cost of the services they receive. Getting the best care available may be of much greater priority to them than getting the least expensive care. Thus, the usual laws of supply and demand do not operate with regard to the cost of health care services.10
      Another reason that health care is different from other commodities is that physicians are expected to put the interests of their patients before their own financial self-interests. Physicians and other care providers are expected to make decisions on the basis of what is medically best for patients, rather than on the basis of what is most economically profitable for themselves.
      A danger of the increasing commercialization of health care is that physicians who make decisions regarding proper utilization of heath care services may have an economic incentive to provide more services in order to receive greater reimbursement from insurance companies and third-party payers. Another danger of commercialization is that the practice of “cherry picking” patients in order to provide the most profitable services to the best-paying patients and avoid providing services to the least profitable patients (such as uninsured patients, poor patients, and patients with complex and chronic illnesses) becomes more pronounced.11 Another danger of commercialization is that the profit-making sector tends to emphasize expensive procedures and technology over personally-centered care.12
      Relman therefore advocates greater public accountability and increased regulation of the private health care industry.13 He also recommends that physicians separate themselves from any involvement in the medical-industrial complex (including financial interests in private hospitals and nursing homes, diagnostic laboratories, radiology centers, dialysis units, ambulatory surgery centers, and other for-profit health care services).
      In an article entitled “What Market Values Are Doing to Medicine,” (published in The Atlantic Monthly, March 1992), Relman notes that some defenders of fee-for-service medicine regard health care as a commodity to be bought and sold like other commodities, such as food, clothing, and housing. But he argues that doctors who are paid on a fee-for-service basis are expected to act in their patients’ best interests, and not simply in their own financial self-interest. Medical care is not a mere commodity; it is a social good.14 If physicians have economic incentives to provide more costly services and to make greater use of more costly technology, then market forces may encourage the expansion of less cost-effective care options and the overutilization of services.15 Private hospitals may also be influenced by market forces to avoid or limit service to the poor and uninsured. “Paying patients will get more care than they need, and poor patients will get less,” says Relman.16 He concludes that “greater reliance on group practice and more emphasis on medical insurance that prepays providers at a fixed annual rate” are the two best methods of solving the economic problems of health care, because they “put physicians in the most favorable position to act as prudent advocates for their patients, rather than as entrepreneurial vendors of services.”17
      In an article entitled “Restructuring the U.S. Health Care System,” (in Issues in Science and Technology, Summer 2003), Relman explains that in the 1990’s, the health insurance industry was able to generate tremendous profits by utilizing such strategies as denials of payment for hospitalizations and services deemed not medically necessary by the insurer.18 Publicly funded expenditures were also limited by the government’s method of reimbursing hospitals according to a fixed-fee schedule determined by patients’ diagnosis related groups (DRGs):

“Rather than paying fees for each hospital day and for individual procedures, the government would pay a set amount for treating a patient with a given diagnosis. Hospitals were thus given powerful incentives to shorten stays and to cut corners in the use of resources for inpatient care. At the same time, they encouraged physicians to conduct diagnostic and therapeutic procedures in ambulatory facilities that were exempt from DRG-based restrictions on reimbursement.”19

      Relman notes that the failure of such measures to control health care costs and to guarantee affordable care for everyone has led some policy analysts to propose a universal not-for-profit single-payer system of health insurance, funded either entirely through taxes or through a combination of taxes, employer contributions, and individual contributions. Such an insurance system would eliminate or reduce the number of private insurers who now receive a steadily increasing proportion of health care payments.
      In a long article entitled “The Health of Nations” (in The New Republic, March 7, 2005), Relman explains that managed care insurance plans have also attempted to control costs by requiring patients to select primary care physicians from among a panel of doctors approved by their particular insurance plan. Patients must obtain referrals to specialists from their primary care physicians in order for their care to be approved by the plan. Denials of payment may be made for services provided by specialists who are not under contract with the plan. The government has also contracted with managed care organizations (MCOs) and health maintenance organizations (HMOs) to control costs for its Medicaid and Medicare beneficiaries. Cost-controlling efforts by private and public insurers have included “case management” and "disease management" approaches, whereby patients are given advice and counseling by nurses in order to facilitate their compliance with treatment and help them avoid unnecessary emergency department and inpatient hospital care.20
      However, we now have an increasingly fragmented health care system that makes greater use of specialized outpatient services, with an increasing proportion of payments going to specialists for outpatient technological services, and a decreasing proportion of payments going to primary care physicians who provide continuity and integration of care.21 In 2005, total U.S. health care spending was approximately $2 trillion, representing 16 percent of national GDP. (According to the Centers for Medicare and Medicaid Services, total U.S. health care spending in 2016 was approximately $3.4 trillion, an average of $10,000 per person, and was projected to increase annually by 5.8 percent, rising from 17.8 percent of GDP in 2015 to 19.9 percent by 2025.22) According to Relman, this rate of inflation will eventually become unsustainable, and neither the government nor private employers will be able to keep up with rising health care costs.
      Relman concludes that

“First, since we cannot rely on the free play of markets to control costs or guarantee universal coverage, we should establish a tax-supported national budget for the delivery of a defined and comprehensive set of essential services to all citizens at a price we can afford. Employers should pay an appropriate part of the tax for their employees. These services should include both acute and long-term care, and they should be exclusively reimbursed through a single-payer national insurance plan, with other elective and non-essential services paid out of pocket or through privately purchased insurance. No services covered by the national plan should also be covered by private insurance plans, but the latter could insure services, such as "aesthetic" plastic surgery and private hospital rooms, that would not be covered by the national plan. There should be no billing by providers and no piecework payment in the single-payer plan, thus eliminating the huge business costs and the colossal hassle of the present billing and payment systems in multiple public and private insurance plans.

"Second, not-for-profit, prepaid multi-specialty groups of physicians should provide all necessary medical care on the approved list of insured services. The physicians in the groups should be paid salaries from a pool of money that would be a defined percentage of the total patient income received by the group from the central payer. The groups should be privately managed but publicly accountable for the quality of their services, and they should be expected to use standardized information technology that could be integrated into a national data system. They should be indemnified against losses due to adverse selection or other costs beyond their control, assisted with start-up and technology expenses, and exempted from antitrust restrictions. They should compete for patients on the basis of the quality of their services. All groups should be open to all citizens, although the number of members for a given-sized group should be regulated to ensure an appropriate ratio of doctors to patients.

"Third, patients should be free to choose their own physician group and to switch membership at specified intervals, but everyone must be included in the national plan and belong to a group--including politicians. (Lawmakers are unlikely to neglect the needs of a health care system that provides care for themselves and their families.) Physicians should be free to join any group that wanted them and to change their affiliation, but they should not provide services outside the national system that are covered by the latter.

"Fourth, all health care facilities (whether privately or publicly owned) that provide services covered by the central insurance plan should be not-for-profit, and should compete on the basis of national quality standards for patients referred by the physicians in the medical practice groups. Facilities should be paid, and monitored for their performance, by the central plan. They should have no financial alliances with the physicians or the management of the medical groups. Teaching facilities should be separately funded by the national plan and be paid for their extra
costs, including education. Budgets in all facilities should include salaries for full- and part-time clinicians providing essential services.

"Fifth, the health care system should be overseen by a National Health Care Agency, which should be a public-private hybrid resembling the Federal Reserve System. It should be independently responsible for managing its budget and establishing administrative policy, but should report to a congressional oversight committee and to the public. It is essential that the plan be sufficiently independent of congressional and administration management to be protected from political manipulation and annual budgetary struggles.”23
      Relman also explains that most proposals for a single-payer insurance system lack any plan for changing the health care delivery system, and thus do not solve the problem of rising health care costs.
      In an article entitled “Medical Professionalism in a Commercialized Health Care Market” (in the Journal of the American Medical Association, Dec. 12, 2007), he warns of the danger posed to medical professionalism by the growing commercialization of the health care system. He says that although some physicians may regard their medical practice as in some respects a business,

“the essence of medicine is so different from that of ordinary business that… [the two] are inherently at odds. Business concepts of good management may be useful in medical practice, but only to a degree. The fundamental ethos of medical practice contrasts sharply with that of ordinary commerce, and market principles do not apply to the relationship between physician and patient.”24

The ethical responsibilities of physicians require them to put the needs of their patients ahead of their own personal financial interests, and to avoid economic conflicts of interest that would undermine public trust in the medical profession.
      In an article entitled “The Health Reform We Need & Are Not Getting” (in The New York Review of Books, July 2, 2009), Relman acknowledges that health care system reform faces opposition from those with ideological objections to “big government,” who balk at proposals that would fundamentally transform the for-profit health care industry into a single-payer non-profit insurance and delivery system. One reason for higher health care costs in the U.S. than in other developed countries is that the U.S. has a higher proportion of medical specialists who rely more for their livelihood on performing expensive technical procedures than do primary care physicians.25 Another reason is that “there are greater financial incentives in the U.S. to use technology, since health care insurers pay doctors and clinical facilities most of what they charge for such services.”26 Another reason is that the great majority of private health insurers today are investor-owned businesses that have increased the commercialization of the health care industry through such practices as marketing and advertising. Investor ownership of insurance plans has resulted in increased health care costs. “Profits and management expenses take at least 10 to 20 percent of the premiums charged by investor-owned plans, including the costs of selecting those they will insure, whereas the overhead costs of Medicare—a government-run insurance plan covering everyone sixty-five and older—are about 3 percent. When private insurance companies provide coverage for Medicare patients (as in the Medicare Advantage plans), they cost the US government about 13 percent more than standard Medicare coverage.”27
      Relman explains that the health proposals made by President Obama in his budget message of February 2009 emphasized the need to reduce the costs and increase the affordability of health care. According to Obama’s fiscal 2010 budget, health insurance coverage should be made available to all. People should have a choice of health plans and physicians. To reduce health care costs, high administrative expenses should be eliminated, along with unnecessary tests, unnecessary services, and other inefficiencies. People should not be locked into their jobs just to secure health coverage, and no one should be denied coverage because of pre-existing medical conditions. Greater use should be made of electronic medical records in order to prevent medical errors and improve health care quality. Greater use should be made of data comparing the effectiveness of specific medical treatments. Greater investment should be made in preventive measures and wellness intervention.28
     Relman says that while these proposals were laudable, there is little evidence that they would actually have produced any substantial savings in health care expenditures. They did not address the main causes of rising health care costs, and they did not “recognize as a major problem the fragmented, entrepreneurial organization of a medical care system that is dominated by specialists and deficient in primary care doctors.”29
      The solution, says Relman, would be

“a single public payer that guaranteed comprehensive health care for all, funded by a progressive tax whose proceeds would be dedicated to medical care. This insurance and funding plan would be combined with a delivery system, overseen by a public agency but managed entirely on a not-for-profit basis by privately organized doctors and hospitals. The delivery of care and the use of health resources would be the responsibility of organized multispecialty groups of salaried physicians and other health professionals, which would include adequate numbers of primary care doctors.”30

He admits, however, that

“Neither my proposal, nor… any other plan that starts with the elimination of private employment-based insurance and depends largely on public funding stands much of a chance of being enacted now. It would be too great a change, and it would threaten insurance companies and other powerful vested interests that influence Congress. The same is true of any major reorganization of medical care that phases out fee-for-service practice in favor of nonprofit multispecialty groups of salaried physicians and dampens the commercial fire that has converted US medical care into an ever-expanding profit-seeking industry.”31

Not until health care expenditures become absolutely intolerable will major health care reform become politically possible.32
      In an article entitled “Health Care: The Disquieting Truth” (published in The New York Review of Books, Sept. 30, 2010), Relman argues that after the passage of the Affordable Care Act (ACA) in March 2010, there was little reason to think that it would actually control health care costs, because it failed to change the dependence of the U.S. health care system on private, for-profit insurance plans.

"By mandating and subsidizing the purchase of private insurance for almost all those not eligible for such government programs as Medicare or Medicaid, the legislation...created a virtual monopoly for the private insurance industry. True, the law...[restricted] some of the industry's worst practices, such as denial of coverage because of preexisting conditions...[and] rescinding coverage because of expensive illness. However, it [imposed] no effective controls on the price [that] private insurers can charge for premiums.”33

Relman also explains that 

“Before paying doctors and other providers of care, investor-owned health insurance companies now spend as much as 15 to 30 percent of their premiums to cover their many overhead costs, which include extravagant salaries and bonuses for top management, dividends for shareholders, and retained corporate profit…Because of its overhead, as well as the expense of billing and collecting it imposes on doctors and hospitals, the investor-owned for-profit insurance industry probably adds at least $150-200 billion to the annual cost of providing health coverage to the American population, as compared with government-run programs such as Medicare.”34

Thus, the worst defect in the ACA was that it did not fundamentally change how medical care is organized, paid for, and delivered. Its major effect was simply to expand insurance coverage in a basically unchanged health care insurance and delivery system.35
      In an article entitled “How Doctors Could Rescue Health Care” (in The New York Review of Books, Oct. 27, 2011), Relman says that one reason for Republican opposition in Congress to the Affordable Care Act (ACA) was that the “individual mandate” required that “all citizens not covered by public or private insurance plans be required to purchase private insurance or incur a tax penalty.”36 However, the ACA did not replace—but in fact expanded—the investor-owned private health insurance industry, and it did not change the method of payment for most medical care, which is based on a fee-for-service system.37 It also did nothing to reduce the fragmentation of medical care, which favors the use of specialty rather than primary care services.
      Relman notes that Republican alternatives to the ACA have included Representative Paul Ryan’s plan to privatize Medicare and change federal support of Medicaid by substituting fixed grants for the federal government’s current commitment to pay states a specified percentage of program expenditures. Under Ryan’s proposal,

‘the Medicare system covering most of the medical costs of elderly citizens would be gradually replaced by a federal voucher system. Starting in 2022, each new Medicare beneficiary would choose a private insurance plan and the government would give participants in the plan a voucher to help pay for coverage…However, actuarial experts predict a doubling of total Medicare costs within a decade; so Ryan’s proposed vouchers would fall far behind actual costs, and beneficiaries would have an increasing financial burden.38

Relman also notes that

“As for Ryan’s proposal to reduce Medicaid expenditures by making fixed grants to states, the states would have considerable discretion in spending these grants, and their deficits would almost certainly force them to curtail Medicaid services in order to meet other budgetary needs. The grant idea, although favored by some state governors, has provoked wide opposition because it threatens the medical services needed by low-income citizens, and because Medicaid money now also supports nursing home care for the elderly.”39
  Relman therefore argues that one way of controlling health care costs may be through the creation of not-for-profit multispecialty physician groups, in which physicians are paid annual salaries rather than on a fee-for-service basis, so that they don’t have a financial incentive to perform expensive procedures and provide unnecessary services. Group practices would be reimbursed for comprehensive care of patients on a per capita basis. Payment would be through a single public payer system supported by a universal, progressive, designated health care tax. In order to receive payment, “group practices would have to reimburse their physicians largely by salary. Regulations would require open enrollment of patients; [in order] to limit the risk of fixed payment for comprehensive care, groups would need public reinsurance or other financial guarantee to protect against the possibility that some patients might need expensive services.”40
      In an article entitled “Obamacare: How It Should Be Fixed” (in The New York Review of Books, Aug. 15, 2013), Relman says that

“more than a few liberals think the ACA was fatally compromised by deals…[that President Obama] made with the private insurance, hospital, and pharmaceutical industries to get their support, particularly the sacrifice of a “public option”—insurance the government would sell if private companies refused or their plans were seen as excessively expensive. They believe it will ultimately fail because it did not basically change our dysfunctional system. It expands and improves private insurance coverage, but provides no effective controls of rising costs and no significant change in the way medical care is delivered. Many of the critics think we need major reform that replaces private insurance and employment-based coverage with a publicly funded single-payer system.
      "Before the ACA was enacted, the president’s health care proposals were bitterly opposed by Republicans who said they violated two conservative principles: first, the familiar Reagan view that government involvement usually is the problem, not the solution; and second, an implied but rarely spoken belief that medical care is basically a special kind of business, and should conform to business practices. Republicans believe that the ACA flouts these principles by depending heavily on government regulation and interfering with free-market forces.
      "Republican opposition hardened even more after the legislation became law, culminating in a constitutional challenge before the Supreme Court. On June 28, 2012, the Court sustained by a 5–4 vote the contested major provision in the ACA that mandated insurance coverage. But by a 7–2 vote, the Court struck down the provision in the law that gave Congress the power to withhold federal Medicaid support from states refusing to expand their Medicaid program, which provides medical care for poor people. This decision made it financially feasible for states to opt out of the ACA’s provision requiring that the coverage of low-income patients be expanded. As of this writing, seven of them have done so. The Urban Institute estimates that this will deny insurance to nearly six million very poor people.”41

     According to the Kaiser Family Foundation, the Affordable Care Act (ACA), which expanded Medicaid coverage for many low-income Americans and also subsidized the purchase of insurance by many people through the establishment of new health insurance exchanges, decreased the number of uninsured people by nearly 13 million between 2013 and 2015. But by the end of 2015, nearly 29 million Americans under the age of 65 were still uninsured.42 According to the U.S. Census Bureau, the rate of uninsured adults below age 65 was about 13 percent (41 million people) in 2013, but decreased to about 9 percent (29 million people) in 2015.43 However, many people who live in states that have decided not to expand Medicaid or who are ineligible for insurance subsidies are still unable to afford health insurance.
      Relman argues that “replacement of all public and private insurance and elimination of itemized bills with a public tax-funded system that simply paid medical groups per capita for comprehensive care would avoid much of the expense and many of the other problems with the current system.”48
      In his last article, entitled “A Challenge to American Doctors” (in The New York Review of Books, August 14, 2014), published nearly two months after his death, Relman argues that “without leadership by physicians, it is unlikely that we will see any major change in the system for payment and organization of medical care within the next decade or two…and without such change…financial responsibility for health care coverage will increasingly fall on individuals, because neither government nor business employers will be able to afford the rising costs.”47
      Now, more than ever, as the U.S. Senate and House of Representatives resume their efforts to draft new health care legislation, Relman’s evaluation of the problems of the U.S. health care system and his proposals for health care reform need to be thoughtfully considered.


1Douglas Martin, “Dr. Arnold Relman, 91, Journal Editor and Health System Critic, Dies,” The New York Times, June 21, 2014, online at
3Bryan Marquard, “Dr. Arnold Relman, 91; ex-N.E. Journal of Medicine editor,” The Boston Globe, June 17, 2014, online at
4Jerome Kassirer, “A Tribute to Arnold S. Relman (1923-2014),” The Journal of Clinical Investigation (Oct. 1, 2014), 124 (10), 4152-4153, online at
5Marcia Angell, “On Arnold Relman (1923-2014),” The New York Review of Books, August 14, 2014, Vol. 61, No. 13, online at
8Arnold Relman, “The New Medical-Industrial Complex,” The New England Journal of Medicine, Vol. 303, No. 17, p. 966.
9Ibid., p. 966.
10Ibid., p. 966.
11Ibid., p. 968.
12Ibid., p. 969.
13Ibid., p. 969.
14Arnold Relman, “What Market Values Are Doing to Medicine,” The Atlantic Monthly, March 1992, 269(3), pp. 98-106, online at
18Arnold Relman, “Restructuring the U.S. Health Care System,” in Issues in Science and Technology, Volume XIX, Issue 4, Summer 2003, online at
20Arnold Relman, “The Health of Nations,” The New Republic, March 7, 2005, online at
22Centers for Medicaid & Medicare Services, “2016-2025 Projections of National Health Expenditures Data Released,” Feb. 15, 2017, online at
23Relman, “The Health of Nations, The New Republic, March 7, 2005, online at
24Relman, “Medical Professionalism in a Commercialized Health Care Market, Journal of the American Medical Association, Vol. 298, No. 22, Dec. 12, 2007, p. 2669.
25Relman, “The Health Reform We Need & Are Not Getting,” The New York Review of Books, Vol. 56, No. 11, July 2, 2009, online at
28Office of Management and Budget, “President Obama’s Fiscal 2010 Budget,” online at
33Relman, “Health Care: The Disquieting Truth,” The New York Review of Books, Vol. 57, No. 14, Sept. 30, 2010, online at
36Relman, “How Doctors Could Rescue Health Care,” The New York Review of Books, Vol. 58, No. 16, Oct. 27, 2011, online at
41Relman, "Obamacare: How It Should be Fixed" (in The New York Review of Books, Vol. 60, No. 13, Aug. 15, 2013, online at
42The Henry J. Kaiser Family Foundation, “Key Facts about the Uninsured Population,” Sep. 29, 2016, online at
43Sara R. Collins, Munira Z. Gunja, and Sophie Beutel, “New U.S. Census Data Show the Number of Uninsured Americans Dropped by 4 Million, with Young Adults Making Big Gains,” To The Point: Quick Takes on Health Care Policy and Practice (Sept. 13, 2016), online at
46Relman, “Obamacare: How It Should be Fixed,” online at
Relman, “A Challenge to American Doctors,” in The New York Review of Books, Vol. 16, No. 13, August 12, 2914, online at