“… the ideas of economists and political philosophers, both when they are right and when they are wrong, are more powerful than is commonly understood. Indeed the world is ruled by little else. Practical men, who believe themselves to be quite exempt from any intellectual influence, are usually the slaves of some defunct economist. Madmen in authority, who hear voices in the air, are distilling their frenzy from some academic scribbler of a few years back. I am sure that the power of vested interests is vastly exaggerated compared with the gradual encroachment of ideas. Not, indeed, immediately, but after a certain interval; for in the field of economic and political philosophy there are not many who are influenced by new theories after they are twenty-five or thirty years of age, so that the ideas which civil servants and politicians and even agitators apply to current events are not likely to be the newest. But, soon or late, it is ideas, not vested interests, which are dangerous for good or evil.” John Maynard Keynes, The General Theory of Employment, Interest and Money (pp. 383–4))
This famous quote from Keynes used to baffle me a bit (or rather, the sentence “Practical men, who believe themselves to be quite exempt from any intellectual influence, are usually the slaves of some defunct economist” which is the bit I had come across)
Medicine and healthcare are the domain of pragmatism.This has always been the case, but is heightened in a wider intellectual world which often sees itself as “post ideological” (although political events on both sides of the Atlantic, not to mention everywhere else, tend to show that actual populations don’t necessarily believe that) Evidence-based medicine elevates “what works” far above what is physiologically plausible. Models of illness such as Bill Fulford’s “full field” model of mental illness increasingly integrate disparate theoretical approaches with a main emphasis on lived experience. These approaches have an awful lot to be said for them; and I personally have always seen myself as a pragmatic practitioner, not wedded to any particular dogma.
Keynes quote, especially considered in full, extends far beyond economics. Pragmatic practice is always located in some kind of intellectual framework. Medical models in psychiatry, for instance, may seem focused on pragmatic approaches but are rooted in a philosophical approach of great complexity. Mental health policy, it often seems, cam be driven by responses to anti-psychiatry writings from the late 1960s, the formative years of many of those now in positions of power and influence.
Ideas which seem simple and uncontroversial – such as the idea that health care should be less and less delivered by large institutions and more and more “in the community” – are themselves located amidst a massive array of beliefs and assumptions which are rarely unpacked.