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Motivation, Agency, and Public Policy: Of Knights and Knaves, Pawns and Queens

By Julian Le Grand | Go to book overview

5 Agency and Public Services

Your patient has no more right to all the truth you know than he has to all the medicine in your saddle bags. He should only get as much as is good for him.

(Oliver Wendell Holmes, talking to American medical students; quoted in Angela Coulter, The Autonomous Patient)

It is for the patient, not the doctor, to determine what is in the patient's own best interests. You may wish to recommend a treatment or a course of action, but you must not put pressure on patients to accept your advice.

(General Medical Council in 2002)

So far in this book we have been concerned primarily with motivation, and specifically with the motivation of professionals and other providers in the public sector. It is time now to turn to questions related to agency: individuals' capacity for action and choice. These questions are largely normative in nature: that is, they are not concerned so much with what is but with what should be. In the context of the public sector and indeed of wider social welfare, how much power should individual citizens have? Should users of publicly funded services have control over how much and in what way they make use of those services? Or should their use be largely determined by professionals or others involved in service provision, as often happens in areas such as health care and education? This chapter considers some of the more theoretical and philosophical issues concerned in trying to answer these questions.

The arguments differ from area to area, and any answers they generate will depend heavily on the contexts in which they are deployed. Hence I shall concentrate on the issues involved in the aspects of public policy that are the principal concerns of this book: publicly funded health care and education and (in the next chapter) personal savings and state provision for pensions and long-term care. In Part III , I discuss some of the practical issues involved in specific policies designed to empower individuals in the areas concerned: health and education quasi-markets, demogrants, partnership savings schemes, and hypothecated taxes.

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