Health and society – conceptual paradoxes and
challenges for a business plan, for a new political agenda
and for a strategy for action in the information age
Angela Lacerda Nobre
Escola Superior de Ciências Empresariais do Instituto Politécnico de Setúbal ESCE-IPS
Campus do IPS, Estefanilha, 2914-503 Setúbal, Portugal
Abstract. The present paper considers the activity of tele-care within the broad
framework of the information age, of how modern society is organised and of
the structuring role of the health sector. The importance of key concepts such as
social structures, human agency and the instance of being-in-the-world, are
highlighted and explored. The inputs of computer ethics, critical realism and
philosophy of action are used and presented. These conceptual arguments are
applied to the particular settings of tele-care business planning and of policy
making. This paper assumes the controversial role of questioning our own
assumptions as thoroughly as possible, and of working from that questioning
1 Introduction
The current paper has the main objective of exploring the links and relations between
theoretical, conceptual and philosophical inputs, and their outputs, applications, and
products at social and cultural level. In other words, this paper argues that current
practices and structures are fundamentally determined by a historical and situated
development of mentalities and conceptions. The better we are able to acknowledge
and to understand these links, the better able we become to have an effective role in
the current settings and within the present social structures of the information age.
Health service provision, in particular tele-care, may be substantially improved, and
developed conceptually and in practice, if we undertake the necessary mediations and
theory building steps.
Thus, section number two relates tele-care with the technological revolution and
stresses the underlying dynamism which it hides. Section three, refers to the areas of
health and education and their role in society. Section four, takes this structuring role
and relates it to the importance of social structures and of human agency. Section five,
refers to social complexity and to the historical philosophical development, stressing
the role of technological revolutions. Section six, focus on the computer revolution
and on the revolution of mentalities. Section seven, refers to ‘the world and our role in
it’ from the perspective of institutional and organisational settings. Section eight,
deals with the implications to a business plan of a tele-care activity of the present
Lacerda Nobre A. (2004).
Health and society conceptual paradoxes and challenges for a business plan, for a new political agenda and for a strategy for action in the information
In Proceedings of the 1st International Workshop on Tele-Care and Collaborative Virtual Communities in Elderly Care, pages 143-159
DOI: 10.5220/0002682601430159
arguments and also to their importance to the policy making areas. Finally, the present
paper offers three figures which schematise the arguments developed within its main
2 Tele-care and the technological revolution – the underlying
The idea, the possibility and the concept of tele-care can only exist because there has
been a technological development, namely the development of computer technology
and of the information and communication technology, which enabled this possibility
to occur. When considering tele-care activities we are performing a double analysis:
(i) on the potential and possibilities being opened by the new technology, and (ii) on
our current understanding of what health care means, incorporates and signifies.
However, both these questioning processes are inherently dependent on broader and
more general conceptual frameworks. These frameworks can be understood as a
general mentality or as the current cultural perspective of a specific time and place:
for instance, the early twenty first century Western world view on whatever we may
be considering. These broad lines of thought have a deep and profound impact in the
way we interpret our daily lives and directly affect our decision making processes. As
researchers we obviously cannot simply step out of our ingrained culture though, as
social scientists, we have the privilege as well as the burden of potentially being more
aware of the forces and influences which determine us as well as which directly affect
our actions.
Within the general range of human activities, the ones related to the broad areas of
health care and education present a degree of sophistication and of complexity that is
seldom recognised. In order to grasp this complexity, as well as in order to profit from
the potential that they have to offer, it is necessary to revise our deepest assumptions
and reasoning processes. Our culturally and socially determined perspectives include
both dead ends and conceptual knots, as well as potentially creative ideas and
innovative concepts. The task of the present paper is to consider the specific context
of tele-care activities, and to revise and, when possible, to reformulate common
conceptions in order to help to bring in new, innovative and breakthrough conceptual
perspectives able to inform and change current practices.
3 Health and health care, and education and learning, in the
information age
As society developed, one critical dimension has been the transference from the
private to the public domain of the activities related to health and education. Mass
care and education are a benefit of modern societies. On the other hand, this
transference has implied a certain dismissal from individuals and families in relation
to issues which were initially under their direct and personal sphere. According to the
perspective taken in this paper, this apparently minor issue constitutes one of the
deepest and most serious concern to be considered by modern societies. It is the main
objective of this paper to explain why. A second objective is the statement that a tele-
care initiative may consist on a pilot experience where an alternative conception of
health and education may be tested and experienced. A third potential aim is to use
both a new conceptual framework as well as the possibility of a concrete experience
to inform and transform current policy making.
With a limited paper length, it is not possible to develop extensively such
ambitious objectives so that the first and main aim, that of clarifying and stressing the
importance of common conceptions and general theoretical frameworks in
determining our actions and our perceptions of ourselves, of the world, and of our
place in the world, will take the lion’s share of the current paper. The importance that
health and education have in society is related to their potential to influence and
determine a society’s overall mentality. Of course that socialisation and culturisation
processes cannot be subscribed to specific and direct activities as they are embedded
at every level of social interaction through all stages of life. Nevertheless, it is critical
to recognise the potential that health and education have to impact on individual’s
conceptions and this happens as much in singular terms as well as at group and
community level. It is the strength of these ties and links which keeps a society
together. And it is these dynamisms which constitute a society as such.
Within the educational field, we are witnessing a change in practices and
perspectives. The traditional reliance on expository methods and on heavy time
schedules is giving rise, at school level, to time for both team work as well as
independent study. At university level the pressure is even greater to transfer more
time and responsibility to the student, through access to better resources, greater
freedom to pursue different methods, and more peer interaction even at international
level. The harmonisation being defined at European level, bringing together the
different educational policies of European Union member countries, includes and
stresses these changes. The student-teacher relationship as well as the patient-doctor
relationship are changing accordingly. From a traditional and conventional position
where both teacher and doctors were generally considered as the only legitimate and
credible sources and possessors of all relevant knowledge, who would expose and
deliver their insights to receptive and passive listeners, now we have a model where
both sides are more in balance, where both parts share different types of contents and
of skills and the idea is that they work together to achieve common goals. Active
students and patients help to bring better quality results.
This model and perspective is part of an overall movement which the present paper
aims at deciphering and clarifying. The basic argument is the following: the
knowledge economy of the information age represents a major change in relation to
previous reality. Though most changes still remain encapsulated at a potential level,
many have already been realised. The overall change process, due to its immense
complexity, cannot be fully predicted or planned as was often possible in previous
and more stable environments. Thus a sensible solution is to aim at improving the
flexibility and adaptability of every activity. For instance, within education, instead of
relying only on fixed and rigid acquisition of lists of contents, the shift has to be
towards focusing on the learning process itself and on improving its potential through
a learning-to-learn and learning-by-doing approach. Similarly, under this new
perspective, each doctor recognises the role of the patient as a key and unavoidable
partner, one who has the ultimate say in most health related matters.
In parallel with this positive shift we witness an inversion in terms of areas which
were not typical health problems and which now represent major health issues.
Pregnancy, though not an illness, represents an important health care area. In terms of
public health, the hospital provision of obstetric services is an important achievement.
However, when there is an unusual and unfounded rise in caesarean interventions we
may question what kind of role health care is representing in these cases. More
importantly, this question is raised when there are situations which belong to the
realm of daily life such as health related problems connected to professional stress.
Besides the huge importance of health-professional stress issues there are many others
to take into account. When faced with life changing situations such as the death of a
member of the family, unemployment or divorce, it is common to see a call for help
through health service providers.
The question that we raise is not a yes or no, black or white, right or wrong
discussion on the acceptability of these situations. The issue that we want to call
attention to is that health and educational instances have a critical role to play in
society and this role cannot be performed by a simple transference of responsibilities
from one sphere to the other, i.e. from the private, personal and family sphere to the
public, official and institutional sphere of service provision. There are many levels of
complexity and it is necessary to grasp them as thoroughly as possible. One central
problem is the reliance on a health system which is based not in preserving health but
is solving illnesses. Preserving health is not simply vaccinating or promoting
prevention campaigns. Health maintenance is much more than this and cannot be
exhaustively defined. Fundamentally, it has to do with the deep and ingrained values
that a society transmits and represents.
One possible answer to this puzzle is the avoidance of the exclusive reliance on a
medically based and illness centred approach, such as we currently have in most
Western world health systems, and to focus in two pairs of main ideas. The first pair
is related to (i) health and to (ii) health care, and the second pair is related to (iii)
education and (iv) learning. The points to acknowledge are the following: (i) first, that
health related issues are to be dealt with within a therapeutic relationship. This
relationship includes, but is not reduced and limited to, the circle of professional
health providers, rather it is extended and includes all relevant social relations. (ii)
Second, that a therapeutic relationship is one that helps each individual to deal in the
best possible way and according to each one’s potential with the specific situation and
reality that is being faced, i.e., to care is to help others learn to care for themselves.
TO LEARN = to participate in this collective experience which
is a transformation and a recreation developmental process.
A patient with a terminal disease or one with a minor injury may both benefit from
a relationship that helps them to deal with their unique reality by making the most of
their own resources, no matter how limited or how rich they are. To put in another
words, it is through a creative and constructive relationship that human beings may
develop their full potential. These relationships are socially and culturally embedded.
Accordingly, it pays off to invest as much as possible in devising ways that help us to
improve social interaction and to transform this interaction in generative and
distributed ways of potential building and reification, i.e. to invest in effective
therapeutic relationships. It is by achieving more, in terms of therapeutic
relationships, that more may be achieved, in terms of potential development. It is by
stretching and fulfilling current potential that future potential may be increased. It is
by exploring all possible current developmental opportunities that future development
may be achieved. It is by opening up to present reality that future opportunities may
be created. The second pair of issues centres on education and learning to stress that,
(iii) first, the previously mentioned social interaction and developmental process,
which is integral to the therapeutic relationship, is inherently, intrinsically and
constitutivelly a learning process. (iv) Second, that education, if it is to fulfil its
potential and its true domain it has to acknowledge the learning dimension of all
social interaction, and thus it has to promote social structures and practices which take
this strength into account. Possibly, what we are referring to, is a revolution in
mentalities. A revolution in mentalities may be achieved by a revolution in the way
health and education are seen, delivered and used. A revolution in health and
education is even more drastically revolutionary if we take into account the changes
implicit in the computer revolution of the information age. A tele-care project, a
simple and non ambitious health care provision project, inherently transports all this
complexity and also all this potential.
4 Health and education as structuring sectors of a society – world
views, social conceptions and human agency
Health care and education represent two of the most critical areas within a society.
Together with other broad impact areas they are structuring sectors of an economy,
defining, conditioning and determining the bedrock from where other economic
activities develop. The physical infrastructures, the public transport facilities, the
communication network, the law and justice system, the media, and the political
system are all examples of baseline structuring sectors. However, the specificity of
health and education far exceed the impact of others. It is not a question of
quantitative, direct, immediate or short term impact, the sort of influence which may
be reasonably measured, predicted and planned. The crux of the issue is that both
health and education, taken in their broadest sense, represent the first and determining
conditions for further development. All others, though they may share some degree of
impact at this level, generally interfere at a later level, more related to solving
problems and designing solutions. The creative, generative, innovative, long term
capacity to develop is strongly determined by the health and education areas of a
society. This could be taken as wishful thinking though the validity of this assertion
most probably depends on how we may define and interpret what we include in the
societal field of health and education.
Two issues may be of relevance here. The first one is what concept of the human
being we are using. And the second one is how we relate this concept with how the
world works or, better, with whatever perception we have of how the world works.
Both the arguments of the previous sections as well as of the next sections are
summarised in the graphical schemes presented in Figure One – ‘World view and
action’, Figure Two – ‘Social structures and social practices’, and Figure Three –
‘Human agency as the product of a social relationship and of a learning process – the
potential role of health care and education’.
In terms of general mentality and ingrained culture we, the Western society of the
early twenty first century, are still deeply influenced by the concept of human beings
as rational, autonomous and independent entities which was the product of the
philosophical theories of the Enlightenment period of the seventeen and eighteen
centuries. The rationalist theories such as those of I. Kant, as well as the utilitarian
conceptions, such as those from J. Bentham and J. S. Mill, are representative of such
conceptual approaches and philosophical theories. In face of this it is hardly
surprising that most management theories and models, and even business or computer
ethics, are conceptually based on these broad theories.
A critical concept to this analysis is the idea of human agency, understood as the
individual capacity to interfere with, and to change and influence the areas and
spheres to which each individual has access to. It is this capacity that may determine,
in cumulative terms, and in the long run, how societies change and develop. In order
to understand and to explore these influences we will use three broad level references.
Firstly we will use K. Gorniak-Kocikowska comments on the historical development
of Western philosophical thinking, applied particularly to the computer ethics field of
study [8]. Secondly, we will use Roy Bhaskar’s critical comments on the importance
of social structures and human agency [1]. And thirdly, we will refer to the works of
J. Gonçalves [7] within the field of action philosophy in order to bring in critical and
fundamental concepts.
5 Social complexity and historical philosophical development – the
role of technology revolutions
In order to understand current mentalities and commonly shared understandings it is
fundamental to step back and to distance ourselves from current thinking patterns
through the use of historical social and philosophical analysis. This is what Gorniak
proposes and she traces current thinking to centuries’ old influences.
Gorniak, referring to the field of computer ethics, states that «Since... prominent
scholars... use the ethics of Bentham and Kant as the point of reference for their
investigations, it is important to make clear that both these ethical systems arrived at
the end of a certain phase of profound and diverse changes initiated by the invention
of movable printing press.» [8](italics in the original text). The first printed book in
Europe was J. Gutenberg’s ‘Constance Mass Book’, in 1450, and forty years later
there was already the profession of book publishers [8][9]. At a foot note to this
comment Gorniak adds: «Of course the printing press was not the only cause of such
profound changes, but neither was the steam engine or the spinning machine. I do
recognise the tremendous complexity of the processes we are talking about.»
[8](italics not added). In the main text, continues: «The question is: were these ethical
systems merely solving the problem of the past or were they vehicles driving
humankind into the future?» [8]. Gorniak claims that the ethical systems of Kant and
Bentham were created during the time of the Industrial Revolution, but they were not
a reaction to, nor a result of, the Industrial Revolution of the eighteen and nineteen
centuries. Gorniak explains:
«There was no immediate reaction in the form of a new ethical theory to the
invention of the printing press. Rather, problems resulting from the
economic, social, and political changes that were caused by the circulation of
printed texts were at first approached with the ethical apparatus elaborated
during the high Middle Ages and at the time of the Reformation. Then, there
was a period of growing awareness that a new set of ethical rules was
necessary. The entire concept of human nature and society had to be revised.
Hobbes, Locke, Rousseau, and others did that work. Finally, new ethical
systems like those of Kant and Bentam were established. These ethics were
based on the concept of the human being as an independent individual,
capable of making rational judgements and decisions, freely entering the
‘social contract’. Such a concept of the human being was able to emerge in
great part because of the wide accessibility of the printed text.» [8].
Gorniak stresses that the ethics of Kant and Benthan were both manifestations of
and summaries of the European Enlightment: «They were created at a time when
Europeans were experimenting with the idea of society’s being a result of an
agreement (a ‘social contract’) between free and rational human individuals, rather
that the submission to divine power or to the power of Nature. Moreover, such a new,
contractual society could have been created in separation from traditional social
groups. The conquest of the world by Europeans... made it possible.» [8] (italics in the
According to Gorniak, despite Kant’s and Bentham’s claims of universalism, their
concepts of the human being refers to European man as defined by the Enlightenment,
as free and educated enough to make rational decisions. Gorniak specifies:
«’Rational’ means here the type of rationality that grew out of the Aristotelian and
scholastic logic and those mathematical theories of the time of printing press
revolution. This tradition was strengthened by ideas of Pascal, Leibniz, and others;
and it permitted one to dismiss from the ranks of partners in discourse all individuals
who did not follow the iron rules of that kind of rationality. The term ‘mankind’ did
not really apply to such individuals. Finally, this tradition turned into Bentham’s
computational ethics and Kant’s imperialism of duty as seen by calculating reason.»
[8]. Gorniak concludes that the nature of both ethical systems must be «very attractive
and tempting for computer wizards, especially for those who grew up within the
influence of the ‘Western’ set of values.» [8].
This argument develops in the context of the discussion of the impacts of the
current computer revolution and Gorniak stresses and resumes the main ideas stating
that: «It now seems very likely that a similar process of ethical theory development
will occur... The Computer Revolution is revolutionary; already computers have
changed the world in profound ways... My claim is that the number and difficulty of
the problems will grow. Already, there is a high tide of discussions about an ethical
crisis in the United States. It is starting to be noticeable that traditional solutions do
not work anymore... The more computers change the world as we know it, the more
irrelevant the existing ethical rules will be and the more evident will be the need for a
new ethic.» [8].
Gorniak’s impressive account highlights the crux of the problem. In order to grasp
why and how health and education are so critical to society we must first
acknowledge what kind of conceptual framework we currently have to situate and
ground our thoughts about the human being. According to Gorniak, most current
theories, at least in the field of computer ethics, are grounded in rationalist and
utilitarian ideas.
6 The computer revolution and the revolution of mentalities
A double issue is at stake in the argument that this paper develops: (i) that computers
are changing the face of the world and creating the knowledge economy of the
information age [10], and (ii) that there is a vast range of alternatives in terms of
philosophical theories about the concept of a human being. Each of these theories
corresponds to a general and society level mentality.
One philosophical conception is that humans are ‘deficient’ animals as they have
not been born with any particular skill or speciality. All other animal species have an
innate capacity to fly or to swim, or to perform whatever activity which guarantees its
survival in the environment where they are born. Humans, on the other hand, have a
tremendous capacity to learn and to adapt to very diverse conditions. This malleability
is exactly the characteristic that J. Moor [4][11] argued that made computer
technology genuinely revolutionary and different to all previous technologies. Moor’s
suggestions about the information age are rooted in a perceptive understanding of
how technological revolutions proceed.
«Computers are logically malleable in that they can be shaped and moulded
to do any activity that can be characterised in terms of inputs, outputs and
connecting logical operations... Because logic applies everywhere, the
potential applications of computer technology appear limitless. The computer
is the nearest thing we have to a universal tool. Indeed, the limits of
computers are largely the limits of our own creativity.» [11].
In terms of possible contributions to the concept of human beings, critical realism,
and the works of Roy Bhaskar’s, the father of this conceptual framework, are relevant
and they introduce a new tone. Archer and Bhaskar [1] state:
«... all agents have practical knowledge (not necessarily cognitively
available) and some degree of understanding of the real nature of social
structure which their activities sustain, [however] unintended consequences,
unacknowledged conditions, and tacit rules limit the individual’s
understanding of his or her social world.»
A further level of complexity may be introduced through the specific perspective
of philosophy of action, which will be further developed in the next section.
According to J. Gonçalves [7], there are two opposing interpretations of philosophy:
one more theoretical, contemplative and interior to the human process of thinking;
another one, which interprets philosophy as a doing, as a practice, and as an action.
As philosophy is highly complex both interpretations are possible. Philosophy of
action stresses the meaning creation process inherent to all human action.
There are also two distinct possible perspectives of analysis: «the subject-object
instance refers to the closed relationship, unidirectional, between the researcher, the
subject, and his object of research; the being-in-the-world instance, a concept of
contemporary philosophy, precedes and includes the former one, and is ontologically
rooted thus bringing forth the concept of the world and the unity of action.» [7](italics
in the original text). Ontology is the manifestation of being of all reality. According to
this author, the action involved in the development of human beings and the action
involved in the development of the world, is inherently the same. It is not possible for
human beings to manifest themselves unless in a constitutive relationship with the
world. The world is, then, «no longer the mere object of the consciousness of the
subject.» [7](italics in the original text).
Gonçalves stresses a particular point: «Philosophy must be critical but through the
demand of ontological development, through hierarchisation and selection. If we use
the notion of philosophy focused on human’s inner transformation or in a critical
attitude, then there is the risk that this approach will overlook the central role of
action in the world and its essential de-centring process.» [7]. This comment calls
attention to the dangers of pure and reductive cognitivist, mentalistic or voluntaristic
positions which are common within positivist perspectives of reality. If we conduct a
thorough analysis of current perspectives within the general field of management and
of organisational studies we will conclude that most would subscribe to this specific
position. This author stresses that pseudo-education or a reductive approach to
learning is the effort to transform human beings as if they were an isolated
psychological entity, with no constitutive relation with the world. It is thus necessary
to develop the world in order to educate and to transform human beings, as this is the
only way that humans can change. However, according to Gonçalves, instead of de-
centring, as much as possible, human beings in the world, humans are often reduced
to a diminutive and artificial psychological world, especially the one indicated by
7 The world and our role in it – the organisational and institutional
To clarify the argument which is being developed, we stated not only that health
and education were critical structuring areas of a society but also that they were
especially so, i.e. they have a specificity and a idiosyncrasy which enables them to
have an a priori effect, creating the basic conditions from where other areas
departure. We argued that in order to grasp the dynamism of these effects it was
necessary to take into account our common and current vision and conception of the
human being and of the world, that is, the common features of our general mentality.
Under this task, we revised several authors points of view, and stressed their implicit
message: our general mentality is still being basically influenced and determined by
the Enlightenment perspectives of rationalist and utilitarist conceptions, and by the
Cartesian mentalistic idea of rationality.
Critical realism and philosophy of action present alternative perspectives to the
conception of the human being, perspectives which call attention to the (i) importance
of the social relations and of the social structures, as well as to (ii) how humans are
defined within a thorough immersion in a specific ‘world’ and reality, the being-in-
the-world philosophical instance. In order to clarify this notion of the world, the way
that we interpret the social contexts to which we belong, we can use the specific
setting of an organisation or an institution.
According to Gonçalves’ work on the philosophy of action [7] rationality is not a
structure, a paradigm, nor a frame or a rigid law, permanently defined; it is the
meaningful reality which emerges from action, which is the process of constituting an
organised whole. Rationality cannot be reduced to mental schemes, as it is nurtured
from a global rationality which arises from the structure of action. Humanism should
not be reduced to the world of human beings but considered as the humanism of the
world, as the value of humans within the world process. Within an institutional
context, the perspective of the philosophy of action, according to Gonçalves [7],
considers the community as a key ontological manifestation of the world which has a
decisive role in the development of the instance of being-in-the-world. A community
may be understood from different perspectives, ranging from the psychological level
to the sociological one. The deep soil of an institution, however, is its ontological
grounding, in particular and especially that of its community. When the presence of
human beings is referred, it is not the individuals themselves, nor the sum of all
individuals, that are being referred to but rather the community itself whose statute
largely overpasses the simple sociological horizon. The maximum degree of
possibilities of being-in-the-world has in a community, thus interpreted, its
fundamental interpreter and protagonist.
At organisational level, the practices and processes are supported by social
relations which may be characterised as social structures. Archer and Bhaskar [1]
develop extensively the notion of social structures, posing the question as to how they
should be conceptualised. These authors argue that individuals and persons surely
exist, though social structures do not exist in the sense of either of these. Roy
Bhaskar, the father of critical realism theory, argues that without the concept of social
structure, or something like it, we cannot make sense of persons, since «all the
predicates which apply to individuals and mark them uniquely as persons are social.
We can predicate a shape, size and colour of a person just as we can of a stone or a
tree... but the moment we say that the person is a tribesman or a revolutionary, cashed
a check, or wrote a sonnet, we are presupposing a social order, a banking system and
a literary form.» [1]. Bhaskar insists that the problem is that we need the idea of a
social structure, but that a social structure does not exist in the same way as a
magnetic field. «... society is incarnate in the practices and products of its members. It
does not exist apart from the practices of the individuals; it is not witnessable; only its
activities and products are.» [1](italics in the original). Structures are both medium
and product, enabling and constraining.
Since social structures do not exist independently of activities, they are not simply
reproduced but are, as Bhaskar notes, reproduced and transformed. This author
explains that it is because society is incarnate in the practices of its members, that it is
easy to lapse into methodological individualism, in which society disappears and only
individuals exist. Of course, «society has not disappeared, since these individuals are
persons and their acts are situated, not simply in a ‘natural’ world but in a world
constituted by past and ongoing human activity, a humanised natural and social
world.» [1](italics in the original).
The argument of these authors follows that because social structures are incarnate
in the practices of persons, this means that they do not exist independently of the
conceptions of the persons whose activities constitute (reproduce, transform) them. It
is because persons have beliefs, interests, goals, and practical knowledge acquired in
their epigenesis as members of a society that they do what they do and thus sustain
(and transform) the structures. Bhaskar further elucidates this point: «... changes in
activity do change society. This suggests that social science is potentially liberating.
For Marx, social science was revolutionary... one must conclude that the modern
social sciences have been, unwittingly or not, defenders of the status quo. As Veblen
put it, rather than ‘disturb the habitual convictions and preconceptions’ on which
present institutions rest, social science has ‘enlarged on the commonplace’ and
offered ‘complaisant interpretations, apologies and projected remedies’ – none of
which have been dangerous to the status quo.» [1].
Most fundamentally, this was a result of the failure on the part of mainstream
social scientists to acknowledge that, while social reality is real enough, it is not like
‘unchanging nature’, but is just that which is sustained by human activities, activities
regarding which humans have the only say. If people are causal agents, they are
capable of re-fashioning society in the direction of ‘greater humanity, freedom and
justice’ [1]. To do this, of course, they must (i) see that they have this power; they
must (ii) acknowledge that present arrangements can be improved; and they must (iii)
have some clarity about how they can be improved. But even if they have some grasp
of the reality of society, the solitary individual cannot make change. For change to
come about, practices must be altered, which means that most of those engaged in
reproducing the practices must together alter their activity: «The aim of social science
is an understanding of society and social process, where ‘understanding’ does not
have any special sense – for example, involving empathy or some intuition of
subjectivity. To be sure, action is meaningful, and understanding society involves
understanding what acts mean to actors, but while this is part of the story, it is not the
whole of it... it also involves, as Marx saw, a knowledge of how definite practices are
structured, the relations between social practices and structured practices, and the
tendencies of such practices towards transformation or disintegration.» [1].
There is some parallelism with specific approaches set forward by organisational
literature. Peter Senge [13] states that: “Organisations change only when people
change” and “People change only when they change from within”. To learn, to
acquire, to create knowledge, is a social process thus not an individual and isolated
task. Personal learning as any personal phenomena is intrinsically and inherently
social in essence. The notion of knowledge as values and beliefs is also constitutively
socially structured. “Knowledge, unlike information, is about beliefs and
commitments” [12]. And also: “The power of Knowledge to organise, select, and
judge comes from values and beliefs as much as, and probably more than, from
information and logic.” [6]. Organisations cannot be regarded as objective and neutral
entities as it is critical to recognise the powerful impact of people’s beliefs and values
- people’s thoughts and actions are inescapably linked to their value system, they are
integral to knowledge, determining what the knower sees, absorbs, and concludes
from her observations. People with different values ‘see’ different things and organise
their knowledge according to their values. Argyris and Schon [2][3] are two of the
founders of the field of organisational learning, and their concept of double-loop
learning, which implies the constant questioning of our assumptions, stresses this
precise point of permanent reflection and self-criticism, i.e. of constantly trying to
disclose the lenses which we use to see, read and interpret the world.
Figure One – World view and action
Our vision,
conception, idea
of the WORLD,
Our vision,
conception, idea
about ourselves,
about our own
And our ROLE
and place in
that WORLD,
i.e. how the
SELF relate
It also includes,
implicitly, our
conception of
of the world
determines and
And it is
through our SOCIAL
with the WORLD
World Self Role of Self
Universe Human beings Role of human beings
determine and condition our
This implies that perceptions, actions and decisions
ALSO determine and condition our conceptions
Figure Two – Social structures and social practices
A dynamic social
is an
This experience can be best
understood through a
instead of a SUBJECT-OBJECT
... because it is
... thus it is a
An experience, a dynamic
social interaction, a being-in-
the-world phenomena, is a
... it is a
... through the
in which we take part
Dynamic social interaction Socially and Culturally embedded
Being-in-the-world phenomena Complex process
This means and this implies that this experience,
this dynamic process,
socially CONSTRUCTED and socially STRUCTED
That it is worth to become ATTENTIVE and to ACKNOWLEDGE the
crucial importance of the way we CONSTRUCT and STRUCTURE the
communities, groups, organisations, relationships and practices that
constitute ou
SOCIAL realit
And, in turn, what
does this
mean and
Figure Three – Human agency as the product of a social relationship and of a learning
process – the potential role of health care and of educational activities
... are incarnate in
and products of
their members
... are both
... and are
by those activities
and practices
by past and
ongoing human
... and it does not exist
independently of the
conceptions of the
persons whose
activities constitute
AGENCY is this
power and
capacity to
interfere back
... and changes in
activity DO CHANGE
Implications in terms of the relationships that are to be promoted,
facilitaded and fostered
the social relationships that we help to build, the more
POTENTIAL of our social communities and environments
In terms of an interpersonal relationship this means that:
The more a relationship helps to strengthen the AGENCY capacity of
each individual, the more transformative and developmental capacity
they will have
This capacity TO ACT and this AGENCY are the product of a
THERAPEUTICAL relationship and a LEARNING process
TO CARE = to help others learn to care for themselves
and, when possible, to care for others
TO LEARN = to participate in this collective experience which
is a transformation and a recreation developmental process
... possible implications
for Health and
8 Tele-care business-plan implications and policy making concerns
At the level of product/service definition the implications of these conceptual
perspectives can be substantiated and materialised through a specific business model.
Fundamentally, the integration of health care services provision with general and
broad range service provision, would be a way to illustrate this approach. The
justification for this is the following. As long as health care, in foundational terms,
may be paralleled with a therapeutic relationship as well as with a learning process,
and these, in turn, can be understood as a constructive social relation, then health
relations may be seen within a continuum of general social relationships. In business
terms this implies an integration of health care services with broad level services.
This option is consistent with current strategic theory which states that the more
complex the business environments and the market relations the more important it is
that there are broad level relationships between customers and the product or service
providers. Even when there are strong speciality areas where there has to be a focus in
specific core issues the diversification and integration within a broad range provision
scheme may be achieved through more or less structured and more or less formal
arrangements such as holdings, partnerships, associations, consortiums, protocols and
agreements. In terms of market segmentation and market positioning, there are
specific elements to take into account. Instead of segmenting in terms of service and
reductive views of a customer’s needs, it is more important to segment in terms of
point-of-sale or of groups of end clients. As an example, a tele-care service could be
integrated within a general service provision virtual platform that would integrate the
health services within a broad range of services. This way it could focus in a specific
client’s broad needs and offer diverse products that would share a common and
unique characteristic, that of closely and intimately understanding, and thus
responding adequately to, the specificity and idiosyncrasy of that client.
If we take, as an example, three types of clients such as an organisation, a private
home and a local community, we could devise a range of products that would respond
to the unique characteristics of these general-type clients and, simultaneously,
integrate health service provision among the list of offered services and products. This
certainly would be a more complex arrangement than a typical tele-care service
though it would have the critical advantage of using and applying a health as well as a
health care provision concept far more effective and thus potentially revolutionary in
terms of the effect that it may have in the daily lives of its clients.
For instance, this broad level service provision, within an organisation, could
integrate health related areas with general training, strategic thinking and
organisational learning and development consulting services. Within the setting of a
private home, it could integrate the health area with other activities such as
entertaining and educational, specialised and diverse advice, from financial to
psychological or career related, and also with more daily related services such as
shopping logistics, house cleaning or babysitting. In terms of a local community it
could promote health related services with citizen and e-government related issues.
These are just loose examples and they simply serve the purpose of illustrating
drastically innovative ways of promoting tele-care services.
In parallel to the exercise of focusing on the broad range needs of a particular
client-type it is essential to analyse the key characteristics of on-line service
provision. More important than actually providing the real services or products often
more crucial is to provide access to informed and critically assessed providers,
suppliers and strategic partners within this overall scheme. It would be more like an
intelligentsia activity, a network of trustworthy providers.
To stress the key point, this business strategy of providing tele-care, would offer,
sell, and also transport, become the vehicle of a specific idea and conception of what
health and health provision means and signifies. Both in market as well as in
marketing terms this represents a significant contribution both to the market in
general and also to the specific clients served by this approach. In business terms, it is
the possibility to generalise a client-type service provision that enables this idea to
become profitable both in financial terms and of the potential gain to the community
or society as a whole. In business terms, the closer example is the S.A.P. provision of
general type information systems, which are individually parameterised to respond to
specific situations. Nevertheless, S.A.P. is able to design, promote, sell and constantly
upgrade systems that deal with particular but generalisable client needs, such as
accounting, human resource management, finance, logistics or sales.
Health care provision is an activity of huge complexity and the present proposal
does not imply that we are taking a reductionist perspective. Quite the contrary,
instead of interpreting this complexity as a collection of almost infinite specialisations
and activities, it confronts this variety with what these activities mean from the
perspective of the patients themselves or of the potential patients and health service
users that we all are. From a daily life perspective, health and health care is related to
activities which we can improve and develop and also learn while we do it, as it is a
learning-by-doing process. These quality of life issues as well as the community
building mechanisms which enable their promotion are a central current concern of
policy makers. Both at local, regional, national and supra-national or international
level, these questions represent the core of the health related political discussion and
negotiation. If understood under this more general framework it is possible to grasp
and to acknowledge the importance of the issues raised by this paper. Because of
paper length limitations this can only be a general introduction to a potentially
revolutionary theory building and innovative practice within the health related and
computer supported service provision field.
9 Final words
The present paper’s contribution is to bring light into the complexity of health care
delivery services by questioning basic assumptions about health, in particular, but also
about the general way that societies organise and determine themselves. Broad level
issues are considered, ranging from the insights of the historical philosophical
development that conditions current perspectives of the computer ethics field, to the
contributions of critical realism and of philosophy of action. Throughout the paper the
double role of health and educational activities as crucial structuring sectors of society
is stressed and developed. The main argument is that health and education, at their
most general and essential level, are the potential bedrock for societal development.
Health care may thus be paralleled to the constructive social and therapeutic
relationship that helps each individual to reach their full potential. This social
experience is constitutivelly a learning activity and process. The double and parallel
role of health and education is further developed as a potential foundation for an
innovative and breakthrough health service delivery business. Tele-care is thus
explored as an activity which represents both the potential challenges and
opportunities of the information age as well as the philosophical assumptions that
shape current mentalities.
The present paper offers a road map that enables further development at conceptual
level as well as further application within both business strategic planning and at
policy making settings. And a final vote: that the uneasiness with which business and
managerial areas deal with philosophical and sociological analysis may be overcome
by effective and breakthrough mediations, as the exploring of the full potential of the
information age challenges crucially depends on researchers and practitioners role in
bridging these fields of knowledge. And this is what we call not only a technological
revolution but also a revolution of mentalities.
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