I read with great interest the whole thing (I mean the longer deliverable here. I found the commentary to the contract’s articles very helpful for me to engage with the document). I have two comments.
Social contract for open care initiatives or social contract for OpenCare?
This is kind of internal to OpenCare as a project. The social contract is mentioned in our proposal and Grant Agreement as deliverable D4.5. It is described like this:
A draft explicit social contract for community-driven care services design, aimed at removing exploitation from the participatory design picture. This is done by styling the community as a collective author and researcher, rather than a “rightless volunteer”, like in most crowdsourcing exercises.
So, I was expecting a sort of TOS for contributing to OpenCare. Over 300 people contributed their experiences, ideas and wisdom to OpenCare. How do we credit them? How are we accountable to them? What promises can we reasonably make? Which rights do they have?
Instead, this seems to be a kind of constitution for someone wishing to provide community care services. Don’t get me wrong, it’s super-interesting, but it does leave me a bit confused. Was there some shift in focus I missed? Am I looking at something other than D4.5?
Is community care necessarily best-effort?
The second comment takes the social contract for what it is. It is this: it seems there is an untenable tension between the document’s ethical reach and the reality of community-provided care as we see it in OpenCare. For example, article 5 and its commentary state that access to care can not be restricted, as it is a human right. Article 6 and commentary invoke independent oversight. Article 3 commits to funding transparency, and it does so in a language that strikes me:
[…] we commit to procuring and managing resources adhering to the ethical standards we apply in all our activities, and in measure to sustain the continuity of our action, designing adequate fallback strategies should causes of force majeure cut us short of planned funding.
All of this sounds distinctly unlike the open care initiatives I have in mind from participating in the OpenCare conversation. What sort of transparency can the Cytostatic network, which is essentially underground, commit to? What happens when the Helliniko Community Clinic doctors and volunteers are exhausted and burned out, and still people in need of care come? What standards can they secure? And if Buoy or Woodbine fail to deploy risk mitigation strategies (for example taking on insurance), does this mean they are failing?
I am not convinced of all this. As far as I can see, community care initiatives are, technically, “best effort” services. “We will do our best, but cannot commit to a minimum standard. Moreover, it is not fair that you expect one from us, we are doing our best here.”
These initiatives seem to emerge to meet immediate and urgent needs, and everybody seems clear that best effort is better than what’s available right now. They remind me of Amartya Sen’s discourse on justice: there is a large difference, he claims, between advancing the cause of justice (for example, by stopping people from deporting innocent children of illegal immigrants) and designing a system of perfect justice. Community care initiatives are Sen-ian that way: they improve the care panorama, but cannot possibly take on the delivery of a flawless system of care – and they don’t seem to think that is their job anyway. See, for example, the insistence of the Helliniko crowd that “they do not want to replace a national health service, they want to push it to be more inclusive, humane and efficient”. A good, complete care system is desirable, but it’s someone else’s job to deliver it.
Coda on this: transparency, accountability and risk mitigation are all great things, but they are also overhead. In Europe’s welfare states, national health services are required to have all this. But then they struggle to maintain financial viability, universality of coverage, or both. And this resonates also in the jurisprudence around human rights: social rights are “left hanging”. We have a right to care as humans, but nobody has an obligation to provide care to humans as such, bar exceptions. If a person has cancer and no health insurance and no assets in the wrong country, that person will die. Nobody will necessarily go to jail for dereliction of duty.
So, maybe, community care can only be best effort. It is what makes it efficient and fast. Asking these initiatives to behave as if they were regular hospitals means, effectively, saying they should not exist. Am I wrong?