A body politic – the right to make live and let die

Most political geographers would get the allusion of the title. The first part is to the 17^th century world of sovereignty, rights and social contract theory of Thomas Hobbes. For Hobbes peace would be secured when “a multitude of men, united as one person by a common power” choose to covenant their individual power to the ‘body politic’ by relinquishing some of their rights to a sovereign (the right to make war or take life for example) [see Hobbes 1640, Chp XIX, para 8].

The second part references Michel Foucault’s biopower where the claim to legitimacy by ‘the state’ is based on the guarding and fostering of productive life (see Foucault “Society Must Be Defended, Lectures 1975-76”, page 241) and the commensurate extension of state control over the biological. Foucault argued that in modernity man’s existence as biological (in contrast to legal or political) beings becomes the target of state strategies (biopower). He distinguished two forms of biopower: anatomo-politics and biopolitics – the former targeting the individual subject, the human body, the latter targeting man as a collectivity, the population as a body politic.

Concern with life and death of the individual and population comes to the fore in the questions around organ donation, revealing tensions between the body-politic and the politics of the body .

Defaults, organs and the state

Sadly it is statistically likely that three people in the UK died today awaiting a suitable donor.

As Rhys, Jessica and Mark noted in their article “Geographies of Soft Paternalism”, published earlier this year, “organ donation has become an intensive site for soft paternalist policy experimentation […] One classic tool of soft paternalism [that] has been controversially proposed as an ultimate solution to organ donation shortfalls: the re-setting of the organ donation default.” [draft for Geog Compass viewed here]

In the UK this default is based on the notion that the body is gifted, that is it is voluntarily made available for use after death through an act of conscious choice. So we have an opt-in system where people choose to enter their names on an Organ Donor Register. Doing so is simple, via phone, online or at various sites that we all visit such as the doctors surgery. Yet despite the ease and our consistent collective affirmation that organ donation is a good thing and we would like to be an organ donor in reality only about a quarter of us have done it. This coupled with increasing surgical advances, problems of organ compatibility, and the increase in demand (as life style related conditions like diabetes, liver and heart disease continue to rise) has seen year on year repeated headlines about soaring waiting list times.

Switching to a system based on ‘presumed consent’, (where the citizen is entered onto the register and has to opt-out of it) has been debated in the UK for years. It is common in much of Europe and seems to result in higher donor rates but local and cultural factors may be equally significant.

In nudge terminology this is changing the default option, a powerful tool for changing behaviour because the default position is what happens when you have a choice but choose to do nothing. The rationale for the presumed consent default is that numerous surveys show wide public support and a willingness to be entered on the register of organ donors but that that support is not reflected in the number who actually make the effort to place themselves on it. Why this is the case is varied, with the failure to follow through on stated preferences ranging from irrationality and insecurity – that doctors will not work as hard to save a patient, or an aversion to thinking about ones own death – to simple inertia – people are not motivated enough to enact their preferences by seeking out a means of entering their name on the donor register

But messing with the body, or more precisely the corpse, is a provocative act that turns the body into a site of contestation between state and citizen. In particular some argue that subtle changes in the default position like this reflects the over-reaching of the state and people’s loss of control over their own bodies following death. Indeed in the absence of actual consent the autonomy of the individual, the patient, is undermined. As such changing the default for organ donation raises fundamental questions about legitimate state action and personal freedom.

One of these was pointedly raised by the Archbishop of Wales in his Presidential Address to the Governing Body of the Church in Wales last month when he argued:

Archbishop Barry Morgan

“There is, in presumed consent, a subtle or perhaps not so subtle change of emphasis in the relationship between the individual and the State.  That is, that unless we have opted out, our organs belong to the State and the State has the right to do with them as it wills.”

His comments, which echo those of a number of other faith leaders, came following the announcement by Health Minister Lesley Griffiths last month that Wales would introduce what they call a “soft opt-out” system (a White Paper outlining the proposals is imminent). This presumes consent unless the deceased has stated a contrary view or the family object.

This stands in contrast to the Coalition Government policy which has opted for Richard Thaler’s archetypal nudge of using ‘prompted choice’ to encourage organ donation. When you register online for a new drivers licence, you are required to complete a question about organ donation. The freedom of choice remains absolute (you can answer : yes, no or “not yet”) except in so far as the citizen is required to express a choice about organ donation in order to continue with their online driving licence application

In other parts of the world experiments with incentivisation schemes are being tested. For example, Israel and Singapore are experimenting with a ‘priority allocation’ system where those already on the organ donors register are given priority on the waiting list should they need a transplant. In similar vein the Nuffield Council on Bioethics has recently suggested the state might pay the funeral expenses of the deceased who donate their organs (and rejected changing the default to an opt-out scheme).  Spain, which has the highest rate of organ donation in the world (nearly 3 times that of the UK), also has a soft opt-out system. But a key factor in its effectiveness seems to be an emphasis on “procurement” with specially trained hospital staff who will always approach relatives of the deceased to ask about donation.

The body-politic is a complex beast. Changing the default is not necessarily a panacea in itself, indeed it is far to simplistic to look at a nudge policy (like opt-in/out) in isolation and anticipate or attribute a population wide outcome to its implementation.

And this debate about the use of behavioural insights to influence what we do with our decaying empty vessels also reveals something about the governmental rationality of this ‘nudging’ by the state. It has consequences that extend beyond the seemingly party politically neutral target of the intervention. In this case the choice of ‘nudge’ may shift in un-noticed but fundamental ways the relationship between the state and citizen.

For the body-politic the covenanting of rights after death to the ‘head’ of that body – the government – may prove an exercise in biopower, of making live and letting die that provokes some serious soul searching by both state and citizen.

Whilst personally on balance I find pragmatically I agree with an opt-out system for Wales I can’t help but be a little wary of what it means for the body politic. Does an opt-out system extend the reach of the state too far into our private lives and deaths? Does it force on us the relinquishing of further rights to the state? Does it, in Foucault’s terms, reconstitute the citizens body as a subject of the state?

Marc

To Nudge, Shove or Prod – when is a bag tax not a bag tax?

From this Saturday (1^st October) all retailers in Wales will be required to charge 5 pence for every single use carrier bag it hands out [Note: the levy in Wales is not restricted to plastic bags]. Any business caught handing out bags without charging the levy face a £5,000 fine.

This will make Wales the first country in the UK to introduce such a charge. The Northern Ireland Executive is consulting on similar proposals now. Scotland and England may head in the same direction.  At a UK level plastic bag use fell quite substantially between 2006 and 2009 following a concerted effort by the Labour government, business and environmental campaigners to drive down the 11bn bags we used in 2006 to just under 6.5 bn in 2009. However that trend bottomed out and bag use rose again last year. As a result the Coalition Government is “looking carefully” at what happens in Wales with the introduction of a mandatory charge.

Although pejoratively referred to as the “Welsh bag tax” no money from the charge goes directly to the Welsh Government (VAT is collected for HM Treasury). Rather than a means of direct revenue generation instead the charge has been introduced with an explicitly behaviour change objective – to reduce the number of single use bags given out in Wales, (in 2009-10 this was estimated at 350 million bags from supermarkets alone). The Welsh Government anticipates the charge will see a 90% reduction in the number of bags distributed in Wales.

Not everyone, least of all the Carrier Bag Consortium or the pressure group the Tax Payers Alliance, is happy about this new “stealth tax”. Bag tax is also criticised as rather marginal in environmental terms. They form a relatively small component of the waste stream yet have been easy for politicians, environmentalists and even big business to characterise as a major menace that everyone can tackle providing a superficial quick win and self-congratulatory slaps on the backs all round.

By pushing onto the public yet another ‘easy step’ on the path to sustainability and encouraging the consumption of ‘eco-bling‘ (as George Monbiot describes it), the fetishisation of the plastic bag menace is charged with doing little to change underlying mindsets of consumption and disposability or more damaging behaviours. But one outcome will be an additional pot of cash for environmental projects in Wales.

Revenue raised is supposed to then go to “good causes”, causes of the retailers own choosing (estimated at £3 million in the first year). The extent to which this will happen is unclear as in another ‘nudge’ the Welsh Government will not prescribe where retailers spend the additional money. It has an expectation that the proceeds of the tax will “be passed on to charities or good causes in Wales, and in particular to environmental projects”. A little wooly and light touch perhaps but this carrot is backed up with the usual governmental stick of the promise of further regulations to determine where the money is spent if Welsh business does not play ball.

Of course none of this is particularly new. Many companies such as Marks & Spencer and Ikea voluntarily introduced charges on such bags a few years ago. Other countries have either imposed an outright ban or introduced a levy upon plastic bags (e.g. China, Italy, Rwanda, South Africa, Mexico City, Washington DC, Hong Kong, Ireland).

The citizens pledge - Uttarakhand is a state in northern India

And a number of British towns and cities have tried to emulate the success of Modbury in Devon (Britain’s first “plastic bag free town”) launching voluntarist campaigns trying to persuade local retailers and consumers to switch from plastic carrier bags. With support from all 33 borough councils in London Borishas unsuccessfully spent two years promoting the idea of making “London a plastic bag free city” in time for the Olympic Games.

(2008 Survey)

 

You would think this issue would have been dealt with years ago, given explicit cross party political and public support (although nudgers would note the discrepancy between what people say and do, but see the Daily Mail/ICM Poll, 2008). Yet the lack the legal powers to impose and enforce a ban/levy coupled with the inertia and entropy inherent in much grassroots campaigning has seen many local campaigns flounder. So Wales has become the first place in the UK where the bag menace can be tackled through a combination of the nudge and the shove to try and achieve a shift in the behaviour of a population. Quite where the nudge comes in is perhaps less clear than might appear.

If this is indeed a nudge then it is really more about the state mandating the placement of a question and a consequent choice in front of the consumer where previously one did not exist. So the introduction of a charge, however small, for something that was previously a ‘free gift with any purchase’ (the cost was already factored in to retailers overheads) reframes the relative value of the bag.

A softer nudge would be training the cashier to ask you an innocuous sounding question like “Good morning, do you have your bags with you?” Underpinned by a legislative shove the Welsh Government nudge seems more of a prod that aims to inculcate a new social norm (bag for life, avoid the strife). No one has to pay the charge, they could make do without a bag or bring their own. In other words they could change their behaviour and from the Irish example it seems likely the majority will do so.

Arrggh! It's the Slovenian plastic bag monster!

Ireland married its bag tax with a large scale education programme and receipts went directly into an Environmental Fund so the link between tax and spend was clear. It is a shame Wales has been unable to do likewise. Unfortunately the awareness raising campaign in Wales has been limited so far, one consequence of which may be to compound resistance and irritation over the Welsh levy which may diminish its effectiveness. Setting the charge at the relatively low level of 5 pence may counter this, though conversely it may also make it easier for the consumer citizen to carry on as before (Ireland is increasing its charge to 22 cents as bag usage has recently begun creeping up again).

But it is an interesting experiment all the same. Watch this space to see whether this combination of nudge and shove does indeed produce a profound change in environmental behaviour of the Welsh population the government hopes for, or whether further prodding may be required …

Marc