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First published online June 15, 2010

Why do public policies fail so often? Exploring health policy-making as an imaginary and symbolic construction

Marianna FotakiView all authors and affiliations
Volume 17, Issue 6
https://doi.org/10.1177/1350508410366321

Abstract

Although it is widely accepted that public policies are difficult to implement, most analyses of policy failures are conceived of as predominantly rational processes. This article questions that assumption by introducing ideas of a desiring subject and socio-symbolic order drawn from Lacanian psychoanalytic theory to suggest that public policies are also a product of social fantasy, and to draw attention to the implications of this unrecognized function of policy-making. It also employs the idea of defensive splitting borrowed from Kleinian object relations theory to explain the difficulty of translating policy into public organizations, which have to perform often conflicting societal tasks. The example of patient choice in the UK National Health Service (the NHS) is used to illustrate theoretical arguments and to propose an alternative understanding of public policy-making by way of bridging fantasy with reality.

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1.
This article was conceived after many productive discussions with colleagues and friends. The comments of Dr Paula Hyde, Professor Nancy Harding and Professor Yiannis Gabriel were particularly enlightening and have improved the article greatly. I would also like to thank three anonymous referees for their incisive comments, ideas and invaluable suggestions and Professor Martin Parker for judicious guidance in preparing this article. I would also like to thank my son Ion Sioras for the final proof reading of the whole article. All the remaining errors and infelicities are mine alone.
2.
1 The concept of the ‘other’ with small letters denoting the ‘other person’ has to be differentiated from the ‘Other’ with capital letters, which signifies the socio-symbolic meaning that is given to it after the subject enters language and its life in society.
3.
2 Objet petit à—(little object to) denotes the unattainable object cause of desire (italics mine), which we seek in the other according to Lacanian psychoanalysis. The subject can have many ‘stand-ins’ for the objet petit à, which can be referred to as ‘temporary objects of desire’ but ‘the object cause of desire’ will remain always elusive. Although not synonymous with the fantasy object per se, this could also be thought of as the fantasized part object of Melanie Klein’s object relations theory.
4.
3 There are other differences concerning the role of Kleinian part objects as defendants against anxiety that Lacan opposes by developing his ideas on phobic objects which are transmuted into fetishes. In ‘The Signification of the Phallus’ for example Lacan (1958/2006:577) argues: ‘it would be pointless to ask these authors to formulate this difference from the perspective currently in favor going by name “object relations”. For on this subject they have no other reference than the approximate notion of part-object, which has never been subjected to criticism since Karl Abraham introduced it. This is unfortunate given the comfort it offers analysts today’. However, my intention is not to adjudicate between those two positions about the origins of anxiety in the subject (for Lacan anxiety is structured in lack unlike for Klein who sees it as a result of the fear against accepting the negativity within the self). In contrast, I bring them together to illuminate various manifestations of anxiety in the social arena.
5.
4 I am indebted to one of the reviewers for drawing my attention to the difference between the ‘fragmentation’ and the ‘split’ as two related and yet distinct concepts behind the idea of Lacanian subjectivity. Whereas the former refers to the process of fragmentation experienced by the subject during the mirror stage, the latter is about the fundamental alienation from the ‘self’ the subject has to contend with throughout its existence, which is crucial to the construction of its unconscious. Henceforth, I will not use these two concepts interchangeably.
6.
5 I am again grateful to the same reviewer for pointing out the possibility of interpreting ‘the mirroring experience’ in a more metaphorical sense. As the argument goes, the child subject may see ‘their reflection’ (as an existence) through the language of the other (m-other), which may or may also not coincide with the actual mirror recognition. While this is certainly a possibility, my understanding is of two distinct phases: one is when the literal reflection stage (of the imaginary identification created by the illusory image of the self) occurs. This precedes the second phase of alienation that comes with the linguistic signification
7.
6 De Board (1978) has put forward a proposition that the fundaments of society could be interpreted as enacting defensive dysfunctional mechanisms, termed as basic assumptions by Bion (1961). For example, the army was concerned with enacting the fight or flight mechanism on behalf of the society, the Church was primarily concerned with dependency, externalized in the concepts of deliverance and salvation and the aristocracy with the conception and birth of a genetically pure leader. Obholzer (1994) extended this thinking to various public agencies enacting social fantasies (e.g. the education system was tasked with ensuring survival through equipping new generations with adequate skills, prisons with containing delinquency and health systems with keeping death and dying at bay).
8.
7 My gratitude goes to the reviewer who provided me with the useful quotation by Lacan Seminar X (quoted in Fink, 1995: 83) on anxiety: ‘What is most anxiety producing for the child is when the relationship through which he comes to be—on the basis of lack which makes him desire—is most perturbed: where there is no possibility of lack, when his mother is constantly on his back’.
9.
8 For a more detailed exposition of this line of argument see Le Grand’s (2003) oversimplified but influential account of motivation and human agency. Users are seen as ‘pawns’ in the pre-market welfare state but they are now promoted to ‘queens’ (of the chessboard) via choice; meanwhile David Hume’s ideas are transposed to doctors and other professionals delivering public services, including civil servants, whose behaviours are equated with those of ‘knaves’ rather than ‘knights’.

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Volume 17, Issue 6
Pages: 703 - 720
Article first published online: June 15, 2010
Issue published: November 2010

Keywords

  1. fantasy
  2. health policy
  3. patient choice
  4. social defences
  5. socio-symbolic order
  6. the NHS

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Marianna Fotaki
Organization Studies Group, Manchester Business School, [email protected]
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