Coping With the Cost of Health Care:
What Is The Public Voice?
Citizens are defined by their relationships with other citizens rather than with the state.Relationships are not the same as those of family and friends, yet they are unlike those in institutional politics, which may be based on patronage or party loyalty. Organic relationships are pragmatic or work related. They form when people coalesce in order to rescue and restore during a disaster, when they build houses for the homeless, or when they assist the police in watching for drug dealers in their neighborhoods. The names people give to problems reflect the things they hold dear and their basic concerns—their highest hopes and deepest fears as human beings. Safety from danger. Being treated fairly. The freedom to act as they see best. These names are different from those that people use when they are acting as professionals and politicians. For example, citizens want to feel that they are safe in their homes, and this feeling of security is less quantifiable but more compelling than the statistics professionals use to describe crime. The knowledge needed to decide what to do about these problems is created in the cauldron of collective decision making. It is formed by the interaction of people with other people, by the comparison of experience with experience. This knowledge is different from the way scholarly knowledge is created, which is through rigorously disciplined science. Decisions are based on the recognition that concerns are interrelated as well as competing, which is not the assumption in majority voting. Organic decision making is deliberative. Deliberation involves carefully weighing possible actions against what people consider most valuable, which has to be determined in a specific context. Institutional decision making can also be deliberative, although it is more often based on negotiation and bargaining. The resources needed to implement decisions in the wetlands come from citizens’ innate abilities, abilities that are magnified when people join in collective efforts. Citizens’ resources are often intangible, such as commitment and political will. These are different from the resources of institutions, which tend to be material and technical. People act in a variety of ways; their actions are loosely coordinated by a shared sense of direction. Actions taken by institutions are usually uniform and directed by a single plan or central agency. The commitment of resources to action is enforced by covenants or the promises people make to one another. Institutional commitments are enforced by legal contracts. Power comes from the ability of citizens to make things through their collective efforts and from the relationships forged in these efforts, rather than from institutional authority. Change comes about through collective learning and the innovation it generates, rather than from modifications of law and policy.