My interest in David Graeber’s extraordinary book “Debt: The First 5, 000 Years” stems from my work on incentives in healthcare. I don’t have much to say about debt and political economy. On these matters I am an ordinary citizen-punter and the most sophistication I can muster is to parrot John Lanchester’s better lines. But I know a little bit about incentives, and here I want to say a few things about the connections.
The current debate about incentives in healthcare can be split in half. One half concerns the use of incentives to motivate professionals and institutions to provide better, or different, care and services to patients and clients, citizens and customers. This is a very important debate, with roots in Adam Smith’s suspicion of professions as conspiracies against the public, the public choice theorists’ suspicion of regulation by rule-making, and the management consultant’s belief that people’s behaviour at work is driven principally by the available rewards.
Interesting as this debate is, and however troubling it may be to those of us who think that work, especially professional work, is about craft, vocation, public service, and other non-monetary considerations, at the end of the day, work is work and it is paid, or it is not done. Work sits within the economy, and the use of incentives to shape and frame that work surprises no one very much and upsets no one very much. Upset is caused by inequality in remuneration, exploitation in the labour market, and so on. But this doesn’t unsettle the basic idea that work and incentives go together. Who gets the incentive, how much, contingent on what, etc. is all up for argument and negotation, obviously. So is the problem of what money payment is actually paying for: in The City, does the high pay remunerate not only extraordinary hours of work, but also being subject to bullying, sexist and sexual abuse? In the Forces and civil defence, does payment trade off against the level of risk to which one is exposed? However we handle these questions, there is no question of incentives being “out of place”.
The other side of the incentive debate focusses on payments to patients, citizens, clients and consumers. Here we have two parallel debates. One debate, in social policy, focusses on “conditional cash transfers”. The other debate, in health policy, focusses on “incentives for healthy behaviour”. An example of the former is the Mexican Progresa scheme which makes certain welfare payments conditional on children’s regular attendance at primary school. An example of the latter is “contingency management” in drug treatment, whereby a drug addicted client of a drug treatment service is paid small rewards in cash or in vouchers if they prove to be drug free at regular intervals over a course of treatment.
There are many things to say about these schemes. Most of the debate, at least in health policy, has focussed on the question of whether these schemes violate autonomy in some way (through coercion, bribery, treating the recipient as a mere “nudgee” etc.) Within social policy, the incentive debate connects old concerns about the division of the poor into the deserving and the undeserving, conservative criticisms about perverse incentives and rewarding irresponsibility, and newer concerns about “advanced liberalism” and “governmentality” through management of individual conduct.
One thread of these debates on personal incentives to patients and citizens which is sometimes flagged up but which has received little close attention is this: the (putative) wrongness of the use of money incentives in health policy (especially) has to do with introducing money into what should be a non-monetary relationship. Money is out of place. In social policy, this debate also gets some attention, but since social policy and the payment of benefits have gone together for so long, the concern there is more with the way incentives are contingent than on the form of the incentive as a money payment.
How can we state the “money out of place” argument clearly? There are various objections we can make: for instance, that incentives make people do the right thing for the wrong reason, or that they “drive out” non-monetary motivations, or that they reward weakness of will in a few while not benefiting responsible conduct in the many, and so on. But when we sort out these objections, reject those without empirical support, and focus on the arguments which are specific to the use of money as such, we come down to two basic claims. First, we should not use money in this context; and second, this is because this context involves a form of relationship to which money is or should be alien and which will be displaced or corrupted if money is introduced.
The value of David Graeber’s work in this debate is that he gives us two things. The first thing he gives us is an historical anthropology of money which denaturalises its role in human societies. One difficulty with establishing the “money out of place” arguments in the incentives debate is that this debate is dominated by economists and psychologists who simply cannot see or understand any form of behaviour other than response to reward and satisfaction of consumer preferences. There is a conceptual blindness which means that they cannot even “see” evidence which might unsettle the frameworks from within which they organise their experimental and theoretical work. So one thing David Graeber enables us to do is show the many myriad ways in which societies are and have been organised without money, or without money being central, or with money used for quite different purposes to those with which “we” are familiar. We don’t, after Graeber, have to take money for granted, either as a real medium of exchange (etc.) or as the fundamental unit of theory within the human and behavioural sciences. it may be that much of what economists and psychologists say of money incentives is true; but this then becomes a sociological observation rather than a discovery about Human Nature.
The other thing that David Graeber’s work can directly contribute to the debates about personal incentives is the close attention to the meaning of money in specific settings. He shows very convincingly that money is not one thing, and that while there may be dominant meanings of money in particular times and places, meanings so dominant that they become “obvious”, “natural” and hegemonic, these are nevertheless local, contextual and can only predominate through hard pratical and discursive work. Thus, in the incentive debates, we need to pay close attention to what meanings attach to money, payment, exchange and so on. It is not enough for public health policy makers and ethicists (like myself) to simply stipulate that an incentive is not a payment, reward, bribe, etc., and that the offer of an incentive is not coercive, a trade, or what have you. We have to pay close attention to what the donor and recipient think is going on when an offer of an incentive is made. When explaining incentives in health I often use the analogy of a way-marker during a long run. Thinking of running for an hour, or for7-8 miles is difficult and sometimes dispiriting; whereas thinking that in 10 minutes I will see a lovely view over the fields, or I will beat my personal best on this section, is a better motivator as it is near at hand, evidently appealing, and its achievement is palpable. So with an incentive scheme to aid me stopping smoking. Well and good; if that is the account a would-be quitter of smoking gives himself, so be it. The aims and narratives of donor and recipient are aligned. But there are other accounts, and those can shape the effect of the incentive scheme in particular cases and in general, and they can shape the acceptability (and consequently, the ethics) of the scheme.
SoDavid Graeber’s book prompts me to think we need a better anthropology of incentives. What it doesn’ tprompt me to think is that we can read this off from his book, and deductively infer what incentives really are (even if we qualify that with here and now). We can certainly look at the social policy context of what is often called “neoliberal governance”, with a better informed eye thanks to his book, and David Harvey’s work, to name another influential writer in this domain. But we need to be careful and specific about what is actually going on when a doctor offers a structured incentive to a patient in a therapeutic context. We don’t get just to assume or diagnose from the fact of money changing hands that the doctor-patient relationship is corrupted, the patient is being bribed or paid to stay healthy, or that she is being “interpellated” as a “responsibilised subject”. We can certainly worry about whether that is happening; and be concerned about transformations of the doctor-patient relationship, the patient role, the concept of illness behaviour, and so on. We don’t have to buy the economists’ and psychologists’ assumption that there is nothing out of the ordinary here. The best tribute we can pay to David Graeber’s work here is to slow down and listen.