Policy & Politics in Nursing and Health Care.xhtml

::: {#pagebreak_45.pgnum type="pagebreak" title="45"} ::: {#CN} []{#CHP0006}[]{#ch41} 6 ::: []{#c0006} [A primer on political philosophy]{type="title"} {#a-primer-on-political-philosophy.chaptitle} ================================================ Beth L. Rodgers, Sally S. Cohen *"If I were to at...

::: {#pagebreak_45.pgnum type="pagebreak" title="45"} ::: {#CN} []{#CHP0006}[]{#ch41} 6 ::: []{#c0006} [A primer on political philosophy]{type="title"} {#a-primer-on-political-philosophy.chaptitle} ================================================ Beth L. Rodgers, Sally S. Cohen *"If I were to attempt to put my political philosophy tonight into a single phrase, it would be this: Trust the people."* ***Adlai Stevenson*** Terminology and ideas related to political thought are showing up in conversations in all sorts of venues. Consumers of popular media, scientists reading scholarly work, and people in the course of their everyday lives often comment on ideas and positions using a variety of labels and terminology to characterize their thoughts or to label the ideas of others. It is important to understand some of the major concepts and traditions from political philosophy. This is particularly important as it provides a way to get beyond what can seem confrontational, to dissect various positions in an effort both to understand and to evoke action. Nurses need to be mindful of the ideologic, philosophic, and political themes that structure contemporary health policy debates. Such knowledge can enhance the ability of nurses to develop strategies that consider political and ideologic perspectives, many of which are not always evident but nonetheless often drive political deliberations and outcomes. This foundational understanding of political philosophy then informs discussion regarding the role of the state, the evolution of major political ideologies, and an examination of how the crucial issues, such as race and gender, influence political thought and action. ::: {#s0025.section} ::: {.abstract type="preamble"} ::: Political philosophy {#st0020.h1hd} -------------------- Political philosophers examine, analyze, and search for answers to fundamental questions about the state and its moral and ethical responsibilities. They ask questions such as, "What constitutes the state?," "What rights and privileges should the state protect?," "What laws and regulations should be implemented?," and "To what extent should government control people's lives?" Political philosophy encompasses the goals, rules, or behaviors that citizens, states, and societies ought to pursue. It is closely related to legal and moral philosophy as all three involve discussion of values, the distinctions between right and wrong, and the "distribution of the burdens and benefits, with legal philosophy specifically addressing legal regulations on rights, responsibilities, and opportunities" ([Reiff, 2018](#bib0080){#cref9148}, p. 70). From another perspective, political philosophy addresses two issues. The first is about the distribution of material goods, rights, and liberties. The second issue pertains to the possession and determination of political power. It includes such questions as, "Why do others have rights over me?," "Why do I have to obey laws that other people developed and with which I disagree?," and "Why do the wealthy often have more power than the majority?" ([Wolff, 1996](#bib0100){#cref9149}). [Reiff (2018)](#bib0080){#cref9150} provides a contemporary perspective on the enduring question of the nature of political philosophy by pointing out that it "should be about how we can better understand the nature and potential of social cooperation and how we can use that understanding to improve the arrangements under which we live" (p. 69). Although political philosophy sometimes can seem detached from real life, it can help with understanding basic questions about human nature, the role of government, the place for regulation, the provision of services to meet basic needs, and other critical questions about the organization of human existence. The "doctrines" of political philosophy have strong historical roots; yet, they continue to be integral to "our most basic outlooks and attitudes that are still alive and very much with us" ([Smith, 2012](#bib0095){#cref9151}, p. 4). Although "there are no permanent answers" to the questions that political philosophers ask, their questions endure over centuries, with disagreement within and across eras regarding issues such as []{#pagebreak_46.pgnum type="pagebreak" title="46"}justice, rights, freedom, authority, and what constitutes a good citizen or a good person ([Smith, 2012](#bib0095){#cref9152}). Political philosophy is a normative discipline; it tries to establish how people ought to be, as expressed through regulations or laws. It involves making judgments about the world rather than simply describing or observing people and society. Political philosophers attempt to explain what is right, just, or morally correct. It is a constantly evolving discipline, prompting us to think about how concerns and questions can have different answers over time. The "proper subject of political philosophy is political action" ([Smith, 2012](#bib0095){#cref9153}, p. 5). This refers to political action aimed at changing or improving the status quo, or action aimed at preserving it, so that it does not become worse. For nurses, political philosophy offers ways of analyzing and working with situations that arise in practice, policy, organizational, and community settings. For example, it helps to determine how far government authorities may go in regulating nursing practice. It offers ways of understanding complex ethical situations---such as end-of-life care, the use of technology in clinical settings, and reproductive health---when there is no clear answer regarding what constitutes the rights of individuals, clinicians, government officials, or society at large. Political philosophy offers normative ways of addressing such situations by focusing on the relationships among individuals, government, and society. Finally, political philosophy enables nurses to think about their roles as members of society, organizations, and health care delivery settings in attempting to attain important health policy goals, such as reducing the number of people without health care coverage and eliminating disparities among ethnic groups. ::: ::: {.section} []{#s0030} The state {#st0025.h1hd} --------- The idea of the *state* is key to understanding political philosophy. In political philosophy (and political science), the state does not refer to one of the 50 states of the United States. Rather, it is a "particular kind of social group" ([Shively, 2014](#bib0090){#cref9154}, p. 18). The state arose from the notion that people cannot rule at their will. As Andrew [Levine (2002)](#bib0050){#cref9155} explained, "Few, if any, human groupings have persisted for very long without authority relations of some kind" (p. 6). The *modern state is* a highly organized, government entity that influences many aspects of everyday lives ([Shively, 2014](#bib0090){#cref9156}). It typically refers to the "governing apparatus that makes and enforces rules" ([Shively, 2014](#bib0090){#cref9157}, p. 64). Therefore, the terms *state* and *government* may be interchangeable. It is the role of the state (or government) in health policy issues---such as licensure of health professionals and institutions, financing care, ensuring adequate environmental quality, protecting against bioterrorist attacks, and subsidizing care---that is important for nurses in their professional practice and personal lives. Usually people think of national governments as the modern state*.* However, local and geographic state governments also assume important roles in protecting individuals, regulating trade, and ensuring individual rights and well-being. In distinguishing between a nation and a state, note that a state is a political entity "with sovereignty," meaning it has responsibility for the conduct of its own affairs. In contrast, a nation is "a large group of people who are bound together, and recognize a similarity among themselves, because of a common culture" ([Shively, 2014](#bib0090){#cref9158}, p. 57). A common theme of current conversation about policy and politics in the United States is how much authority and sovereignty belongs to the national government, and how much should be under the control of other geographically bounded entities. Despite these distinctions, the terms *state* and *nation* may overlap in common parlance because government leaders often appeal to the "emotional attachment of people in their nation" in building support for the legal entity of a *state* ([Shively, 2014](#bib0090){#cref9159}, p. 58). Few would dispute that the political culture of the United States is different from that of other countries. Historically, the social context of the United States has taken pride in the sense of individualism, a laissez-faire approach to government and economics, and a strong belief in the rights of individuals. Policy analysts often point to the unique political culture as an explanation for why U.S. social policy deviates from that of other countries. An example is the difficulty in establishing any type of national health insurance program. The Affordable Care Act (ACA) may have been considered progress in this regard, but it still relied on a combination of private and public initiatives, while most other developed countries have strong, state-sponsored health care insurance (Canada) or delivery systems (United Kingdom). ::: {.section} []{#s0035} ### Individuals and the state {#st0030.h2hd} The idea of the state exists to capture the notion that people need some form of organization and rules to prevent chaos and disorder. Free will is an important idea when talking about human behavior; however, most philosophers will argue that free will either must have, or inherently does have, limits particularly in reference to its interface with the free will of others who may be on a different path. The state is the mechanism for imposing some degree of order or control while recognizing the fact that the thing being ordered involves an array of individuals. Numerous philosophers have addressed this delicate relationship between individuals and the state, and a few of the more significant contributors to shaping our ideas of this relationship are described in the following sections. ::: {#pagebreak_47.pgnum type="pagebreak" title="47"} ::: **Thomas Hobbes (1588--1679).** Hobbes helped to shape ideas regarding the relationship between individuals and the state with his emphasis on a "social contract" which claims, "individuals in a hypothetical state of nature would choose to organize their political affairs" ([Levine, 2002](#bib0050){#cref9160}, p. 18). As [Shively (2014)](#bib0090){#cref9161} succinctly explained, "Of their free wills, by a cooperative decision, the people set up a power to dominate them for the common good" (p. 47). Hobbes's theory was important in establishing governance and authority, without which people would live in a natural condition of chaos. To avoid such situations, according to Hobbes, people living in communities voluntarily establish rules by which they abide. **John Locke (1632--1704).** Locke, a British political philosopher who greatly influenced liberal thinkers, including the writers of the U.S. Constitution, emphasized the importance of individual rights in relationship to the state. For Locke, individual rights were more important than state power, and states exist to protect the "inalienable" rights afforded mankind. One of the premises of Locke's theories is that people should be free from coercive state institutions. Moreover, the rights inherent in such freedom are different from the legal rights established by governmental authority under a Hobbesian contract. They are basic to the nature of humanity. **Jeremy Bentham (1748--1832).** Bentham, heralded as the father of classic utilitarianism, asserted that individuals and governments strive to attain pleasure over pain. When applying this principle to governments, the primary interest of a community is its pleasure, good, or happiness. The interests of the community must include the interests of the individual, thus this same principle applies to individual good or pleasure ([Bentham, 1789/1907](#bib0020){#cref9162}) and "requires us to maximize the greatest happiness of the greatest number in the community" ([Shapiro, 2003](#bib0085){#cref9163}, p. 19). Instead of relying on natural law, Bentham favored the establishment of legal systems "enforced by the sovereign" ([Shapiro, 2003](#bib0085){#cref9164}, p. 19). Bentham's utilitarianism has become foundational to many contemporary theories in economics, political science, bioethics, and other disciplines. The tension between individual rights and the role of the state is inherent in many health policy discussions. For example, consider substance use. Although individuals have the "right" to smoke tobacco and drink alcohol and one might argue that the state should protect individuals' rights to do so, such freedoms may interfere with others' rights to fresh air and freedom from harm (e.g., from second-hand smoke inhalation or from incidents related to alcohol use). The state has a legitimate role to intervene, but the challenge lies in finding the right balance between the rights of individuals on both sides of the issue and balancing them with the rights of the state. These debates also can raise questions about the nature of the individual, or personhood, which may be invoked in policy discussion related to contraception and embryonic stem cell research. ::: ::: {.section} []{#s0040} ### Political ideologies {#st0035.h2hd} Contemporary conversations involve a lot of terminology and labels about policy positions that can evoke emotional response in many cases, and often the terminology is not applied accurately. Discussion of political philosophy needs clear definitions for different ideologies and the terminology used to characterize diverse viewpoints. A political ideology is a "set of ideas about politics, all of which are related to one another and that modify and support each other" ([Shively, 2014](#bib0090){#cref9165}, p. 23). Political ideologies are characterized by distinctive views on the organization and functioning of the state. They help people to analyze and make decisions about complex, political issues and provide a way for policymakers to convince others that their position on an issue will advance the public good. Three major political ideologies, liberalism, socialism, and conservatism, originated with 18th- and 19th-century European philosophers and are the basis of political deliberations and policies throughout the world ([Shively, 2014](#bib0090){#cref9166}). The terms and definitions of *liberalism* and *conservatism* have evolved over time and are not necessarily consistent with the ideologies as they currently exist. In addition, ideology may vary across topics (such as social conservatism and fiscal conservatism), and other variations occur over time, leading to the use of "neo-" and "post-" to distinguish versions. Nevertheless, it is critical to appreciate the origins of these ideologies so that the nuances in their rhetoric and their role in health policy can be fully understood. Major points of each of these ideologies are provided in [Box 6.1](#b0010){#cref0010}. ::: {#b0010.boxg1} BOX 6.1 Comparison of Dominant Political Philosophies ::: {#t5010.pageavoid} +----------------------+----------------------+----------------------+ | Liberalism | Conservatism | Socialism | +======================+======================+======================+ | ::: {#l0010} | ::: {#l0015} | ::: {#l0020} | | | | | | []{#p0015}Individual | []{#p0040}Historical | []{#p0060}Government | | s | ly: | should protect | | should be able to | Those in power have | workers for negative | | develop fully as | responsibility to | situations and | | individuals | help those not in | conditions | | | power | | | | | []{#p0065}Equality | | []{#p0020}Emphasizes | | regardless of role | | individual rights | []{#p0045}Contempora | or status | | and freedom of | ry | | | thought and | form: Opposes rapid | []{#p0070}Economy | | expression (but not | and fundamental | supports the good of | | without limits) | change but advocates | all | | | for decreased | | | | federal involvement | []{#p0075}Concept | | []{#p0025}Individual | in all matters, | of a common good | | s | reduced tax burden, | | | have control over | traditional social | []{#p0080}Lack of | | own bodies and | values, and transfer | individual ownership | | minds, but not to | of authority to the | | | extent of harming | geographic states | []{#p0085}Lack of | | others | | privatization | | | | | | | []{#p0050}Preference | | | []{#p0030}Democracy | for tradition, | []{#p0090}Centralize | | as ideal form of | stability, and | d | | government, allowing | structure | government in | | everyone to | | control | | participate and | []{#p0055}Patterns | ::: | | express views freely | of power that are | | | | predictable | | | | ::: | | | []{#p0035}Government | | | | protections against | | | | abuse of power | | | | ::: | | | +----------------------+----------------------+----------------------+ ::: ::: ::: ::: {.section} []{#s0045} ### Liberalism {#st0040.h2hd} American political thought was greatly influenced by 18th-century European liberalism and the political thinking of Hobbes, Locke, and others. Liberalism relies on the notion that members of a society should be able to "develop their individual capacities to the fullest" ([Shively, 2014](#bib0090){#cref9167}, p. 29). People also must be responsible for their actions and must not be dependent on others. **John Stuart Mill (1806--1873).** Mill, a British political philosopher, published an influential essay "On Liberty" (1859) that is foundational to modern liberal thinking. Mill was committed to individual rights and freedom of thought and expression but not unconditionally. He based his work on Locke's philosophies, tempered by Bentham's utilitarian philosophy. Mill contended that individuals were sovereign over their own bodies and minds but could not exert such []{#pagebreak_48.pgnum type="pagebreak" title="48"}sovereignty if it harmed others. A leading, contemporary political philosopher and political scientist, Ian Shapiro, applied Mill's balancing of individual rights with his "harm principle" as follows: *"*. . . although sanitary regulations, workplace safety rules, and the prevention of fraud coerce people and interfere with their liberty, such policies are acceptable because the legitimacy of the ends they serve is 'undeniable'" ([Shapiro, 2003](#bib0085){#cref9168}, p. 60). ::: ::: {.section} []{#s0050} ### Conservatism {#st0045.h2hd} Although liberals call for changing the existing social and political order, conservatives counter with a preference for stability and structure. Conservatism often is traced to origins following the French Revolution, when it began to develop as a distinguishable ideology. British Parliamentarian Edmund Burke often is regarded as the originator of modern conservatism. In his seminal text, [*Reflections on the Revolution in France* (1790/1890)](#bib0025){#cref9169}, Burke argued for a return to prerevolution ideas and the stability that preceded the revolutionary period, referring to the revolution and instability as the loss of a compass (p. 87). Although several variations of conservative ideology have evolved throughout history, including the attribution of the term "conservative" to some communist groups in the 1980s, conservatism generally favors tradition and stability in the guidance of human existence. Guided by the notion that government had a responsibility to provide structured assistance to others, 19th-century European conservatives, especially in Great Britain and Germany, developed many programs that featured government support to the disadvantaged (e.g., unemployment assistance and income subsidies). They accepted welfare policies that were foundational to the revival of Europe after World War II. They have been major players in contemporary European politics, especially in Great Britain, offering a synergy with American conservatism. ::: ::: {.section} []{#s0055} ### Socialism {#st0050.h2hd} Socialism grew out of dissatisfaction with liberalism by many in the working class. Unable to prosper under liberalism, which relied on individual capacities, socialists looked to the state for policies to protect workers from sickness, unemployment, unsafe working conditions, and other situations. Karl Marx, the German philosopher (1818--1883), is widely considered the originator of socialism. For Marx, individuals could improve their situation only by identifying with their economic class. The 19th-century Industrial Revolution had created the working class, which, according to Marx, was oppressed by capitalists who used workers for their profits. According to Marx, only revolution could relieve workers of their oppression. Socialism arose to equalize access to resources through more centralized control. The collective nature of socialism is in contrast to the primacy of private property that characterizes capitalism. Additional tenets of socialism are provided in [Box 6.1](#b0010){#cref0015}. ::: {.section} []{#s0060} #### Communism and democratic socialism. {#st0055.h3hd} Socialism originated and proliferated in Europe toward the end of the 19th and into the early 20th centuries when it split into two ideologies, communism and democratic socialism. In 1917, communists, under the leadership of V. I. Lenin, took over the Russian Empire and formed a socialist state, the Union of Soviet Socialist Republics (USSR). Lenin and his communist followers believed in revolution as the only way to advance socialism and achieve total improvement in workers' conditions. In contrast, democratic socialists were more willing to work with government []{#pagebreak_49.pgnum type="pagebreak" title="49"}institutions, participate in democracies, and "settle for partial improvements for workers, rather than holding out for total change" ([Shively, 2014](#bib0090){#cref9170}, p. 38). Between 1989 and 1991, communist regimes in Eastern Germany, the USSR, and throughout Eastern Europe collapsed. In their quest for economic and political change, the new Eastern European governments have turned to democracy, democratic socialism, capitalism, and other economic and political models. Currently, only a handful of countries (e.g., Cuba, China, North Korea, Vietnam) are under communist rule. Socialists, especially democratic socialists, have prevailed in Scandinavia and Western Europe. They have been instrumental in advancing the modern welfare state in those countries and elsewhere around the world ([Shively, 2014](#bib0090){#cref9171}). Because of the widely varying forms of socialism, including promarket socialism, deep scrutiny is needed before applying this label to a specific political viewpoint. ::: ::: ::: {.section} []{#s0065} ### Contemporary conservatism and liberalism {#st0060.h2hd} Contemporary political conservatism grew in popularity in United States in the late 20th century. It is similar to classic conservatism but differs in that contemporary conservatives oppose a strong government role in assisting the disadvantaged, and oppose rapid, fundamental change. They call for devolution of responsibility for health and other social issues from the federal government to state authorities, a diminished presence of government in all aspects of policy, a reduced tax burden, and the importance of traditional social values. Many political observers point to the 1980 election of President Ronald Reagan as a turning point for the rise of contemporary American conservatism. In contrast, liberals today support an expanded government role to help people who need income support, health care coverage, child care assistance, vocational guidance, tuition, and other aspects of social policy. The Great Society programs of President John F. Kennedy and Lyndon B. Johnson in the 1960s and early 1970s boosted American liberal policies. Among the highlights of the Great Society initiatives were the enactment of Medicare, Medicaid, and Head Start. These federal government initiatives were founded on the importance of the state helping the disadvantaged through government-sponsored programs. They are in line with traditional liberal philosophies, described previously, which support the notion that individuals should be given equal opportunities to pursue their inalienable rights. Such rights include their health and welfare, broadly defined, even though the right to health care is not a legal one under the U.S. Constitution. Although much discussion tends to place liberal and conservative views as extremes, most people's views lie somewhere in between. Moreover, many organizations take policy positions on health care and other issues that are in concert with a certain ideologic perspective but may deviate from those positions on other matters. Considering the diversity of existing thought, decision making may benefit from collective discussion that supports optimal outcomes rather than a win or lose of one perspective over another. ::: ::: ::: {.section} []{#s0070} Gender and race in political philosophy {#st0065.h1hd} --------------------------------------- In the postmodern era of philosophy, scholars noted traditional philosophy failed to represent the voices of numerous groups. Two perspectives that were notably absent were those based on gender and race. More recently, the perspective of class has emerged to introduce new ideas, leading to the evolution of political ideologies of division along a variety of lines, both obvious and subtle. Gender emerges in political philosophy as a particular policy viewpoint, as well as an emphasis on the treatment of people of different genders. Feminist political philosophy emphasizes politics as a social contract, and rejection of the contract as being necessarily male-centered. [Pateman (2018)](#bib0070){#cref9172} noted that the social contract fails to recognize the unique needs of women and, instead, tends to subjugate them to the concerns of the males who formulated earlier ideas of political philosophy. Feminism, as a political philosophy, ranges from a call for consideration of women's perspectives to radical feminism and may be extended to rejection of the heterosexual norm ([MacKinnon, 2007](#bib0055){#cref9173}). Democratic feminism, a variant of democratic theory, argues for an egalitarian foundation in which there are "norms of equality and symmetry" and "open debate" is possible ([Benhabib, 1996](#bib0015){#cref9174}, p. 70). This theory in political philosophy is related to "deliberative democratic theory," which focuses on deliberation in the process of decision making. Democratic feminists would argue that deliberation must include diverse perspectives, including those of women, to be effective. One drawback to feminist political philosophy is that it can divide people based on gender. Someone's identity is not merely female or male but is connected with ethnicity, socioeconomic status, work role, family structure, sexual orientation, and other related factors. Consequently, a focus on gender as a key point in political philosophy fails to recognize the intricate interplay of the various facets that constitute identity and the phenomenon referred to as intersectionality ([Crenshaw, 1989](#bib0035){#cref9175}). Failure to recognize the intersection of these aspects contributes to fractured identities and polarization as various individuals are more easily reconceptualized as "other" ([Bradley, 2016](#bib0030){#cref9176}). Building on the initial release of Carol Pateman's *Sexual Contract*, [Mills (1997)](#bib0060){#cref9177} identified the "Racial Contract" as []{#pagebreak_50.pgnum type="pagebreak" title="50"}another example of how traditional approaches to political philosophy overlooked the realities of most of the world's population of people of color, which includes Black people, Native Americans, people of Asian origin, and millions of others who are non-White in ancestry. [Mills (1997)](#bib0060){#cref9178} explained that the "social contract tradition," which is essential for much of "Western political theory," was a contract that White men had written and intended only to apply to themselves (p. 3). ::: ::: {.section} []{#s0075} The welfare state {#st0070.h1hd} ----------------- The welfare state refers to the "share of the economy devoted to government social expenditures" ([Hacker, 2002](#bib0045){#cref9179}, pp. 12--13). According to the [Organization for Economic Co-operation and Development (OECD) (2018)](#bib0065){#cref9180} statistics, the United States ranks below the midpoint in social expenditures as a percentage of gross domestic product (GDP) compared with other developed countries. In health expenditures, it consistently ranks higher than all other countries used for comparison purposes. However, the portion funded by government is not proportionately increased in comparison ([OECD, 2018](#bib0065){#cref9181}). The cornerstone of the U.S. welfare system is the 1935 U.S. Social Security Act, which established the Social Security program, welfare, federal maternal and child health programs, and other important initiatives to ameliorate the devastation of the Great Depression. Occasionally, social security is erroneously referred to as an "entitlement," although it is not a welfare program. As approximately 24% of the federal budget, this would provide a faulty inflation of the amount of funding going toward "welfare" ([Pew Research Center, 2017](#bib0075){#cref9182}). ::: {.section} []{#s0080} ### Types of welfare states {#st0075.h2hd} The phrase "welfare state" often is used as if it were a description of a static entity; rather, there are multiple variations of welfare states across the United States and internationally. There are many different types of welfare states, based on the division of responsibilities for social services between public and private sectors and the role of a central government authority. The most well-known categorization is [Esping-Andersen's (1990)](#bib0040){#cref9183} description of three types of welfare state: social-democratic, corporatist, and liberal. Although this categorization encompasses all aspects of social policy, [Aspalter (2011)](#bib0010){#cref9184} further emphasizes the origin of support, as well as its duration across the life span. In social-democratic welfare states (e.g., Scandinavian countries), most social programs are publicly administered and relatively few privately sponsored social benefits are offered. These countries have "pursued a welfare state that would promote an equality of the highest standards" ([Esping-Andersen, 1990](#bib0040){#cref9185}, p. 27). Corporatist welfare states are typically the Western European nations (e.g., France, Italy, and Germany), where social rights and status differentials have endured and affected social policies. These countries grant social rights to many but primarily provide state interventions when family capacities fail. Liberal welfare states include the United States, Canada, and Australia, where privately sponsored benefits dominate. Among liberal welfare states, the United States is distinctive for its large percentage of social spending in the form of privately sponsored benefits. Welfare and other social benefits are highly stigmatized, and the state encourages market involvement as much as possible ([Esping-Andersen, 1990](#bib0040){#cref9186}). ::: ::: ::: {.section} []{#s0085} Political philosophy and implications for nurses {#st0080.h1hd} ------------------------------------------------ How might nurses apply these concepts of political philosophy to their involvement in health politics and policy? Nurses are participants in the larger society and need to be aware of the context, trends, and policies that affect their lives and the lives of others in their community. Nurses bring a unique perspective to policy discussions, with expertise and experience related to social issues, community well-being, and health care. Regardless of partisan preference, nurses can participate in the ideologic and political debates that shape health policy and the lives of others in their communities. Everyone has perspectives on the role of government and individual's rights, with regard to certain policies, and this includes a political ideology and policy positions. Understanding one's own perspective is essential to engaging in conversation with others who may hold similar or widely disparate views. That knowledge can be used as the basis for advocating for policies that have the potential to improve health and patient outcomes and in understanding the perspectives of others. When engaging in political deliberations, listen to the rhetoric that others use and identify the underlying political and philosophical threads. Use similar language based on sound knowledge when you meet with policymakers, or use written texts to advance your positions. [Box 6.2](#b0020){#cref0020} provides cases of how ideology influences policy choice. ::: {#b0020.boxg1} BOX 6.2 Ideology and Policy Options: Case Examples []{#s0010} Uninsured Americans ::: {#l0025} 1. [1. []{#p0100} Ideology that government role should be minimal leads to increased emphasis on individual accountability (conservatism). Policy options favor incentives for health savings accounts, tax credits, and other policies that support individual action.]{#o0010} 2. [2. []{#p0105} Ideology that the state has an obligation to ensure basic level of care and access leads to creation or support of government-run programs (socialism). Policy options favor expansion of government programs such as Medicare, Medicaid, and Children's Health Insurance Program (CHIP) for those lacking insurance.]{#o0015} []{#s0015} Motorcycle helmet use ::: {#l0030} 1. [1. []{#p0115} Ideology that promoting a peaceful and orderly society is important and control of personal action is warranted if necessary for the good of society (Hobbesian or Social Contract framework, idea of common good). Policy options favor laws and enforcement requiring helmets to decrease burden on society.]{#o0020} 2. [2. []{#p0120} Ideology that motorcyclists have the right to decide for themselves whether or not they wear helmets (liberal). Policy option favors no helmet law and promotion of individual choice.]{#o0025} ::: ::: ::: The relationship between nursing and the state has yet to be carefully explored. There are many aspects of nursing's political history that remain untapped and that warrant closer examination of how the profession has interacted with state structures in the policy process. Whether working with public officials, strategizing to create links between policy and practice, or studying the role of the state in policies pertaining to nursing, political philosophy is the foundation of thought and action. It can be a lively []{#pagebreak_51.pgnum type="pagebreak" title="51"}[]{#p51}aspect of nurses' strategic thinking in linking policy, politics, and practice. ::: ::: {.section} []{#s0090} Discussion questions {#st0085.h1hd} -------------------- ::: {#l0035} 1. [1. []{#p0340} When meeting a nursing delegation from 10 different countries, how might you use political philosophy to explain the U.S. health care system (access, quality, and financing), the role of the U.S. welfare state, and the position of national nursing organizations on related issues?]{#o0030} 2. [2. []{#p0345} Consider certain groups that have been excluded from mainstream political philosophy: what do you see nursing's individual and collective role in ensuring that they receive the same benefits and privileges as people from other groups?]{#o0035} ::: ::: References {#st00201.reftitle} ---------- []{#ref0010} Aspalter C. *The development of ideal-typical welfare regime theory* International Social Work 6, 2011;54: 735-750. []{#ref0015} Benhabib S. Democracy and difference: Contesting the boundaries of the political 1996; Princeton University Press Princeton, NJ. []{#ref0020} Bentham J. An introduction to the principles of morals and legislation 1907; Clarendon Press Oxford (Original work published 1789). []{#ref0025} Burke E. F.G. Selby Reflections on the revolution in France 1890; Macmillan London (Original work published 1790.). []{#ref0030} Bradley H. Fractured identities: Changing patterns of inequality 2016; Polity Malden, MA. []{#ref0035} Crenshaw K. Demarginalizing the intersection of race and sex: A Black feminist critique of antidiscrimination doctrine, feminist theory and antiracist politics University of Chicago Legal Forum 8, 1989;1: 139-168. Retrieved from. []{#ref0040} Esping-Andersen G. The three worlds of welfare capitalism 1990; Princeton University Press Princeton, NJ. []{#ref0045} Hacker J.S. The divided welfare state: The battle over public and private social benefits in the United States 2002; Cambridge University Press New York. []{#ref0050} Levine A. Engaging political philosophy from Hobbes to Rawls 2002; Blackwell Publishers Malden, MA. 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[]{#ref0070} Reiff M.R. *Twenty-one statements about political philosophy: An introduction and commentary on the state of the profession* Teaching Philosophy 1, 2018;41: 65-115. []{#ref0075} Shapiro I. The moral foundations of politics 2003; Yale University Press New Haven. []{#ref0080} Shively W.P. Power and choice: An introduction to political science. 14th ed. 2014; McGraw-Hill New York. []{#ref0085} Smith S.B. Political philosophy 2012; Yale University Press New Haven. []{#ref0090} Wolff J. An introduction to political philosophy 1996; Oxford University Press Oxford, UK. Online resources {#st00151.reftitle} ---------------- []{#or0010} []{#txr0010}Open courses on political philosophy, such as this one offered by Professor Stephen B. Smith at Yale University, including short lectures on YouTube. [*https://oyc.yale.edu/political-science/plsc-114*](https://oyc.yale.edu/political-science/plsc-114){#int0010} []{#or0015} []{#txr0015}Internet Encyclopedia of Philosophy. [*www.iep.utm.edu*](http://www.iep.utm.edu){#int0015} :::