O. Properties of Americans.

James Livingston and Martin Sklar join the author in a round of history — basic details of late nineteenth century corporate capitalism related — the legal status of property as rights and the creation of a regulatory state are identified as Important Related Subjects — Morton Horwitz joins the party — Significant Articles in the history of property law cited — institutional economics tapped — Charles Sabel joins the party and Stays Late.

1. Americans questioning the source of value was a familiar sight at the turn of the twentieth century. James Livingston [Livingston94] explains progressive era debates that pitted 'producing classes' against bankers, merchants and lawyers around this question of productive and unproductive labor. The producer classes' claims to have produced consumer goods— real tangible entities, the table-pounding basis of property— were pitted against the "artifical persons" (corporations in the wake of the Santa Clara court case) and procapitalist professionals who could equally claim rights in a kind of intagible property increasingly identified with 'market value.' Pro-capitalist observers, Livingston continues, countered the arguments of the producer classes with the claims that they added "mental labor" giving to use values a needed exchange value that allowed them to circulate in the first place (Livingston, 43ff). Livingston makes this quasi-class separation do the double duty of political economic and cultural differentiation via reflection on the meaning of money (49). Artists and writers initiated a modernism of self and society in which "high culture" became the justification of capitalism, grounding the necessity of "mental labor", while marginalist economics shifted the locus of value from human labor in the production of things to human desire for the utility of things. These justifications for the changes were not the changes themselves, however, and it is in the realms of political power, legal regimes and market definitions that the conventional material changes could become nature. Martin Sklar refers to this period from 1890-1916 as "the corporate reconstruction of american capitalism" [Sklar88].

2. "The corporate reconstruction of american capitalism" avoids the cliche of revolution that Livingston applies to the same period (albeit Livingston titles it a revolution of 'culture'— by which he means, specifically, the creation of new modes of subjectivity and the emergence of what became high moderism), partially to signal a difference from violent and complete reversal, and partially to emphasize that given the magnitude of the change, that it happened as peacefully as it did should be surprising. Of course, the change did not happen without devastation, and many historians and observers experience this change as the last gasp of an unprotected American working class, or the first in a long twentieth century of defeats by corporate capitalism. But "corporate reconstruction" also emphasizes the deliberate rebuilding, in particular the importance of effective language— programmed language— the legal code, the administrative state, and the system of legitimacy that allowed these words their performative force, as the essential aspect of this reconstruction, without which force, all the mental labor in the world couldn't have moved a molehill. This transformation occurs in law, a transformation in the institutional relations of exchange, not the material relations of production, or of the application of science to production.

3. Sklar's transition tells of a country going from "proprietary competitive capitalism" to "corporate administrative" capitalism. In a Marxist key this transition would be downplayed in favor of a focus on the first and second industrial revolutions that straddle it— referencing science and technology rather than law. Livingston's 'revolution' focuses on saving and spending, surplus and self in an attempt to retell how pragmatist philosophers and naturalist novelists reconstructed subjectivity in the wake of a legal, economic and political reconstruction of capitalism; and in Karl Polanyi's retelling, this whole period is a worldwide experiment he calls "the great transformation," resting on the international balance of power, the gold standard, the self-regulating market and the liberal state, and after which "society took measures to protect itself"— leading to an international twentieth century devoted to various modes of redistribution and regulation [Polanyi44]. Toggling these tellings, I want to create a set-up for the possibility of Amicas— as it exists in the scale and convention of the present, locked into questions of value about things and contracts— about open sources, free software, and revolutions galore. I also want this set-up to serve as background to the contemporary state of healthcare, and the idiosyncracies of Amicas' ideas about both the internet and healthcare; about the reconstructions of law and contract that relate the openeness and freedom of FSF and the fear and loathing of Microsoft; and about the conventions we call law and code, those conventions that Lessig worries are merging (or have always been merged), and the scale that this emerging merger covers. Why is this early period is important to this understanding? Perhaps only because it is the given that structures the present. Perhaps because the question of convention and scale is posed there without the benefit of software and networking, as a kind of laboratory of the future. In either case, there are three specific reasons that this institutional second nature is still yet important as background and comparison:

4. First, the transformation in the legal and corporate conception of property and property rights. In particular the legal legitimation of property as a right, or bundle of rights to something. Related to this conception and its effect on political economy is contract law and its conception of rights and the relationship of volition to voice, and problematically, to writing. These transformation continue to this day, broaching a problem of the tangible and the intangible that still orders political debate about the justness of production and consumption.

5. Second, the creation of an administrative-regulatory state designed to mimic the organizational structure of the businesses it sought to regulate, and the delegation by the U.S. government of governance to these quasi-private agencies; since at least the sixties this configuration of agencies and experts has been under perpetual attack, from left and right, and in the last twenty years has seen agressive dismantling, without a consonant return of power to a federal system of government. The administrative and regulatory state is being replaced today by the internet, and it is this process that I try to examine with respect to healthcare, which is a peculiar example, but one well suited to uncovering the ececticism of proposed and actual changes in this configuration of science, technology, law, and governance.

6. Third is the fact that both of these changes implement a representational shift to a fluidly programmable mode of governenace, i.e. an organizational structure that maximizes communications of relevant information— a dynamic organizational structure, one amenable to rapid change. Such a system recognizes "information" as the necessary factor in any decision, and depends on the existence of measurability (which in turn presupposes standardization) for its flexibility and its power to be programmed. Only in this manner does governance install itself as a kind of microstate, a processor that guarantees a rule by law that references only a system of visible, adjustible, logical arguments— not the arbitrary, opaque judgments of individuals, and allows a form of justice whose only keyword is openness, and in its measurability, a question of open standards.

Property and regulation

7. Property is the centerpiece of the reconstruction of capitalism. In the history of the concept, its relation to rights is secure. From Locke forward, owning is an assertion of right— natural or otherwise. Owning has a peculiar history that the vernacular does not capture. Property is valuable things— but things are owned and thereby attain value? Like the enigma of money, which once was made of gold, then represented gold, now represents nothing more— or less— than itself[1], things need some-thing else (but what, a property?) to make them thinglike and appropriable, and the origin of value is once again shrouded in mystery. According to most commentators from Locke on, ownership consists in right, and right is sometimes by "nature" sometimes "culture"— but in any case guaranteed only by the claiming. Such a claim could be shared, in the form of contract, subjected to strategy and therefore to the artifical arena of the market ecconomy; or it could simply be the mute claiming of a declaration of rights, in which rights are identified as the basis of humanity, guaranteed only by self-evidence.[2]

8. The impossible guarantee of rights, however, has never stopped them from being claimed. When the question is less philosophical than historical, a series of institutions make these claims and back them up, by force, performance and reputation.

9. During the nineteenth century, the American legal system came to identify property less as a tangible thing owned by virtue of priority or might than a certain expectation of gain held by an individual. Property was not just a tangible thing with a customary value, but should be subject to the maximization of its efficienct use (Horwitz77, p 31ff) [3]. This identification, as Horwitz points out through various examples, shows the "American willingness to sacrifice the sanctity of private property in the interest of promoting economic development (Horwitz77, 47). As early as the Mill Acts of the early eighteenth century, according to Horwitz, property came to be seen less as something valuable in itself, and more as "an instrumental value in the service of the paramount goal of promoting economic growth." This particular tendency of the American legal orthodoxy led to a kind of subsidized economic growth, an alternative to taxation that deliberately avoided the possibility of political upheaval, and resulted in a court doctrine that saw property as a reciprocal set of rights and duties aimed at "balancing the utility of economically productive activity." This conception of rights in property still referred to eminently tangible things, however, in particular land and equipment, but it was the system of rights held over the possible uses and protections of this property that was at issue.

10. During the same time period, contract law rejected a theory of fair exchange that subordinated contract to property law, in favor of a theory of contract which Horwitz also identifies with the recognition of an expectation of value, rather than an established or inherent value (173). In the "will theory of contract" expected value, as in a futures market, became enforceable. This particular development had as much to do with the development of a laissez-faire ideology and a 'self-regulating' market as it did with any deliberate legal reasoning on the part of lawyers and judges. As with the legal support of expected return from property, expected return from futures was a way of protecting against changes in supply and price in a market. In the wake of a marginalist revolution that enforced the laws of supply and demand and marginal utility, attempting to assign customary values to goods, or to determine the just price of an item, thus became less and less just. The corresponding theory of property, in which tangible things are owned when individuals mix their labor or their will with them also gave way to a theory in which property became the rights to an expectation of value [4].

11. Imbricated into the relations of economic development and commercial practice, property and contract law were much less a realm of justice than a realm of legitimation for certain sectors of society and certain modes of economic organization (even if, given the benefit of the doubt, those sectors always promoted some version of a liberalism that was meant to be good for everyone). Horwitz is straight-forward about this transformation: "that it actively promoted a redestribution of wealth against the weakest groups in society" (254) and more importantly, that it engaged in a self-construction in which formalism, scientific ideology and codification were the highest virtues. This system, which sought separation of law from politics in the prestige of science, aimed at completeness. In the Progessive era, like all sorts of American instituons (e.g. medicine, management, and social science), Law fell in love again with Science, in particular, mathematical formalism, and it eventually fell to progressive politicians and lawyers to face the difficult truth that the abstractness of a system did not guarantee its justness.

12. Several operations of this formal system occured in the late nineteenth century that smoothed the creation of a corporate capitalism that might not have been possible without it. Paramount, of course, was the Santa Clara decision that made corporations persons, not so much to reify some metaphysical inhumanity into a rightful executor of pure profit, but because corporations are made up of people, in particular, property-owning people, organized together for the legitimate purpose of economic development. And if property could be construed as the reasonable expectation of economic efficiency from a particular thing, then that right must be guaranteed as much for corporations as for any "natural kind" that might be posited from which to distinguish it. The "artificial", "metaphysical" person unleashed theories upon theories, writing of the period is dominated by the "trust question," sometimes just shortened to the problem of the "corporation" [5]. If Livingston's cultural revolution is a revolution of subjectivities, of new selves, selfhoods, self-understandings, autobiographies then it is this bodiless person and its rights that inhabits the imagination of Dewey, James, and Dreiser, and Adams. These debates were not restricted to America, either, and one could trace the outlines of corporate personality in the modernist French and German sociological works of Durkheim, Weber, and Simmel— methodological individualism and conscience collective spin questions of the relationship of individual to collective organizations in the shadow of the legal construction of collective entities. Durkheimian corporatism itself far outlasts this period as one model for the organic solidarity that emerges from the division of labor[6].

13. Property also changed again, in concrete legal terms, during the turn of the century. In this case the question of eminent domain again became central, collapsing a relationship between the rights of individuals and the role of government in a scientistic legal definition of property as a "bundle of rights": "We must look beyond the thing itself, beyond the mere corporeal object, for the true idea of property...The dullest individual among the people knows and understands that his property in anything is a bundle of rights." (John Lewis, from Treatise on the law of eminent domain in the US, quoted in [Horwitz92], 147). In eminent domain, the question of what constituted a "taking" could be recast as a question of the violation of an individual's rights, not just to something inherited or purchased, but to something expected. Expectation might at first sight be an irrationally subjective measure of property, but the expectation substituted for physicalist notions of property rested on one of the most tangible non-physical things in existence: market value. Without "market value," any number of things in circulation, including the most edible of things, would cease to obey the already proven laws of supply and demand, not to mention the fiction of price as a crypto-democratic measure of quality. Courts during this period, in the pockets of huge corporations, ruled over and over against just about any action taken by the government against private indivduals that might affect market value, expanding the possible definition of a taking to the point where "American courts came as close as they ever had to saying that one had a property right to an unchanging world." [7].

14. The combined redefinition of persons and things that made up the corporate reconstruction created the resolutely modernist possibility of the separation of ownership from management [8], and more specifically enabled, as Sklar puts it: "the liquidification of property, the transferability or negotiabilty of titles-to-ownership, and hence to titles to earnings or gains, through the conversion of capital from fixed tangibles into fluid intangibles...it...imposed capital immobilty on the firm...bestowed capital mobility on the capitalist" (50).

15. While the legal and corporate redefinition of property proceeded without much public discussion, the "trust question", overproduction, and unemployment gave a visible public life to an otherwise arcane Sherman Anti-trust Act. While the particular issues around the Anti-trust legistlation, and the series of court cases from 1890 to 1912 that relied on it are complex, experiment arranged law and politics to settle a nationwide concern over contract, common law, 'bigness' and monopoloy. For the purpose of understanding changes in the infrastructure of the market, it should be sufficient to recount that the result that the Sherman Act and the court cases surrounding it adapted federal law to corporate capitalism, creating not only a century of new, large corporate possibilities, but encouraged a shift, perhaps even a delegation, of power from the government to the private citizens in control of corporations. The pragmatic response to this from legal scholars, institutional economists, reformers and philosophers was the creation of a set of regulatory agencies that could be organized in the same manner as these corporations and would bring expertise and science to bear directly on the legislation that controlled these interests. Two things are important to note from this history. First is the dissolution of the legal line between public and private that was identified by the American legal realists and has lasting implications for how governance and private commerce are construed today. Second is the legacy of the administrative state as the unelected government of the public sphere— infrastructure raised to the level of superstructure— that informs a current reading by Charles Sabel of the relationship between the organization of capitalism and the paralysis of constitutional government.

16. With respect to the legal structure of property, the relationship between public and private institutions, the most famous critiques were provided by Morris Cohen ("Property and Sovereignty" [Cohen27]) and Robert Hale ("Coercion and Distribution in a supposedly non-coercive state"[Hale23], "Rate-making and the revision of the property concept" [Hale22]). In the particular problem of public utility rate regulation, Robert L. Hale provided a strong statement [9] to the effect that rate regulation constituted coercion by the government of some individuals to yield income to property owners, thus fundamentally blurring the line between public and private concerns— and displaying the very tangible possibility of a delegation of governmental power to private organizations. Hale identifies the very basis of property as the ability of a soverign power to coerce one citizen to yield value to another— and the extension of regulation beyond constitutional guarantees elaborates and complicates this fact. Hale calls for no less than a complete revision of the legal concept of property ("Rate Making" 216).

17. Little discussion ensued, however, because by 1964 Charles Reich was able to manifest a similar degree of alarm in an influential article ("The New Property"[Reich64]) that typologizes government largess in order to articulate how property rights have become property statuses— not quite class, and yet comparable in Reich's telling to feudalism. In Reich's story, property has indeed been radically transformed, not as a result of some rational judicial review of law, or any national public discussion, but as a result of the experimental expansion of government largess and regulation to every conceivable industry, group and individual. Reich initiates a contemporary concern with the location of privacy by identifying it as the zone of the proper, and relating that private personality to the public status the state replaces it with, insisting that "there must be a zone of privacy for each individual beyond which neither government nor private power can push— a hiding place from the all-pervasive system of regulation and control....it must be recognized that we are becoming a society based upon relationship and status--status deriving primarily from source of livelihood. Status is so closely linked to personality that destruction of one may well destroy the other. Status must therefore be surrounded with the kind of safeguards once reserved for personality" (New Property, 784). This vanishingly small zone of interiority is the last bastion of the proper, and it operates all other forms of rights and property. If we draw this legacy to the edge of the internet, then the the problematic intangibility of property on the internet appears less as a function of the technology, and more as a function of the history of legal and institutional organization precipitated by a fundamentally technocratic relationship to governance, making the internet an ideal medium for its expression.

18. Alongside these legal assessments, a subterranean institutional economics has spanned the twentieth century, and in a pragmatic key, deferring neo-classical syntheses and mathematical virtuoisty, insisted on an empiricism of institutions and actually existing forms of organization. John R. Commons attempted formulations in "The Legal foundations of Capitalism" [Commons57] swerves economic theory ever closer to the anthropological formulations of Mauss, Malinowski, Firth, and Polanyi by insisting on the second nature of human institutions that supplements (perhaps precedes) economics' sole human behavior of self-interest. Commons focuses his assessments on the 'transaction,' over against the 'commodity' or the 'feeling' (initiating a tripartite social theory that would perhaps be recognizable to Lacan, mapping anticipation, commodity and price onto psychological value, real value, and nominal value respectiviely) and substitutes the "going concern" for the abstraction of the market. In the transaction (which is also the basis of Mauss' theory of the gift (focused as it is on the term of exchange rather than the thing possessed), and without such formulations, the present "going concerns" of the internet as primarliy focused on the transaction, rather than the product or the service. From Ely to Veblen to Commons, past Hayek, Williamson and into a present array of economic sociologists, economic anthropologists and new institutional economists (Sabel, the French neo-institutionalists Thevenot, Orlean, et. al. "The Economics of Convention" [10]) there is a focus on the institutional arrangements, the empirical facts of transaction and exchange.

19. The legacy of regulation and administration thus appears as essential background to the present because it is the locus of game rules for any "new economy." In its beginnings regluation set judicial procedural rule against pragmatism, legal formalism against scientific assessments as legislative evidence. The ICC, the FTC and SEC experimented early with rule of private citizens by private citizens charged with bringing expertise to bear on the regulatees. Between scientific management {Tayolr etc.) and Technocracy Inc. (Howard Scott) lay an essentially pragmatic attempt to mimic business organization in goverment agencies over against what was assessed in the legal sphere as a rigid and formalistic approach to judicial review {recounted in Horwitz) [11]that was nothing less than a disingenuous disavowal of the imbrication of law and politics. The application of expertise about a given market, industry, or technology was wielded for the creation of a common law that would govern these industries, both to prevent the excesses of the judicial branch and its threat to property as expected value, and to make of common law (the crux upon which the Sherman Act would decide the justness of freedom of contract and rights of association) a more scientific and procedurally just system. Despite attempts by judges to restrict the delegation of power to administrative agencies, they proliferated with abandon, reaching a certain apotheosis in the New Deal. Combined with the turn to professionalism in the same period, the administrative-regulatory state took on a life of its own. By 1970, Alfred E. Kahn, dean of regulation economics, could describe the gradual movement from judicial control over specific industries (insurance, public utilities, banks) in Hale's day to the openning of regulation to any reasonable, non-discriminatroy and non-arbitrary legislative control and suggest that "the list [of regulated industries] could be extended indefinitely; the excercise would shed interesting light on the truly mixed character of the american economy" and as a result: "as far as the United States Constitution is concerned, there is no longer any distinction between the public utilities and other industries."(8)[12]

20. From the present perspective, it is the parallel with national and international standards making organizations as they come to be recognized as centers of de facto legislation that is striking. This kind of experience-based regulation, in which private citizens are employed to govern their peers by virtue of some combination of expertise and public concern for safety, efficiency, or workability, that at bottom, binds standardization to regulation, and hence to governance, making explicit the intuition people feel that seemingly low-level standards decisions of large corporations are in fact essentially political, more specifically, essentially governmental decisions.

21. The double delegation of power, in the form of granting property rights in expected value, especially in realms like public utilities or telecommunications, and the creating of a quasi-independent judicial branch forms the basis of the infrastructure of legitimacy within which the technical development of telecommuncations and software can be traced, and should serve as set-up to an attempt to connect standards to regulation, and therby to law, and then to explain how this seemingly abstract set of issues actually forms the material infrastructure of the current political architecture of the American world, not to mention the possibility for a significant change in the relation of democratic institutions to the individuals governed by them.

Fluid programmable governance

22. Fast forward to the present, and to the question of what the internet, Amicas and healthcare learn from this American experience of experimental pragmatic legislation and intangibile American properties. Charles Sabel offers counsel in "Design, Deliberation and Democracy: On the new Pragmatism of Firms and Public Institutions"[13]. Casting aside simplistic heralds of the triumph pf capitalism over socialism, bracketing economics' timeless principles, Sabel offers to evaluate the organizational forms of the present, and propose tentative suggestions for the legistlative paralysis (playing in the background is Lessig's concern that we don't know how to govern ourselves) that currently affects the country. Sabel identifies the theoretical origin point of the present in Durkheim and Hayek, for their shared, argued, belief that "the division of labor proceeds by a kind of spontaneous self-organization, without the need for central direction," (§1 ¶4) a theoretical legacy that might appeal (pace Lessig) to those whose "single unifying belief is that we don't want the government running things." Sabel sets up the "defining distinction" of both of these modern views of self-organization as that between "tacit knowledge" and "guiding rule" in order to collapse it beneath the innovation of new organizational forms.

It is precisely this distinction between tacit action and formal, ultimately political rule, I will argue, that is overturned by the central innovation of the new organizations: the invention of institutions that allow each part of a collaborative whole to reflect deliberately, and in a way accessible to the others, on the aptness of its ends and the organizational means used to prosecute them, even as those common ends are themselves continuously redefined by the cumulative, mutual adjustments of partial purposes, activities, and organizational connections (Section 1, ¶7).

23. Although he does not explicitly include them, I think it is safe to include the start-up company in this list of new organizational forms (Sabel's "basic unit" is the team or workgroup, which is formally though not legally independent from larger corporate organizations), since it meets the criteria essential to Sabel's description, namely its relationship to fixed, or sunk costs, i.e. infrastructure. Fixed costs are no longer distributed across an entire organization awaiting use regardless of the activity of any subgroup, but rather mobilized only when there are goals to be met. With this flexibility, obviously, comes economic insecurity, which has been well studied and oft decried [14]. This is not the only reason for yoking my argument to Sabel's. He continues:

These institutions, we will see, allow articulation of a single language of practical reason in which questions regarding the performance and the coordination of particular tasks can be addressed by disciplines with similar syntax. These innovations transform general ideas about the social exploration of ambiguity originally formulated by the pragmatists by extending them to economic and, potentially, political life. They reintegrate conception and execution by transforming corporate bureaucracies founded on their distinction; they evoke as well the prospect of joining democracy and workaday activity to combine the freedom of the ancient citizen to participate directly in lawmaking, but in a state that disdained concerns of daily life, and freedom of the modern citizen to express views on every manner of activity, but in a form, that of the public opinion apt to influence the law only at a remove. (Section 1, ¶7, emphasis mine).

24. Sabel's ambitious claims are founded on a precise reference to language— in particular, language as conceived by pragmatism [15]. The "single language of practical reason" and the "similar syntax" are partially articulated references to that which allows an industry to be an industry, that which allows the arduous labor of coordination to disappear from view, replaced by a temporarily unambiguous language that allows work to be done. This syntax, I insist, is standardization. It maps evenly onto my canned histories of standardization— from the autonoumous proprietary language of corporations to the bureaucratic inter-organizational methods of ISO/ITU-style standards to the open-ended pragmatism of the IETF and the W3C. I also insist that it is not an accident, or a metaphorcial choice that this coordination is a syntax— is, in fact language— in its form as something equally substance and subject. Language as communication, as information, as software, and as poetry, are a continuous funtion. Deriving one from the other can be arbitrarily complex, and ambiguity (e.g. my use of the term 'continuous function') signals unstandardized speech— a realm in which there is not explicit agreement preceding use (do I intend to formalize a theory of language according to calculus, or do I intend a metaphorical image of the continuous function to stand in as explanation? Can I mean both? Am I using the term wrong?). Furthermore, the connection Sabel draws to lawmaking and the ancient and modern freedoms provides broad outlines for an understanding of how the internet will relate to the structure of international governance, to the critiques of the public/private distinction listed above, and to the contemporary American inversion of this ancient opposition between necessary labor and the good life.

25. Hitching my wagon to Sabel's requires a circuitous and probably inefficient procedure, which is first to elaborate how the internet, via the example of Amicas, represents this capacity to avoid some of the fixed costs associated with production (even though Amicas is engaged in a service to a quasi-public institution with its own outrageously baroque infrastructure and fixed costs— one in the midst of disentagling itself from governmental support and welfare rights to emerge as a private industry in its own right, though subject to considerably more regulatory constraints than most). If the internet can itself be understood as this infrastructure for the sharing and co-monitoring of institutions— the syntax— then it is possible to look again at the concerns of Lessig, vis-à-vis governance, and ask anew what the role of government in a post-technocratic era will look like. And finally, if this is not complicated enough, it will also be necessary to re-examine the relationship between intellectual property and contract law that laces the path with a problematic notion of regulation to see that we are in the midst of another corporate reconstruction of America, one which separates the financial and management power of the corporation from the actual productive activity to such an extent that it should no longer be obvious that the locus of governance is the government.

26. "Learning by Monitoring" is Sabel's label for the procedure by which these new forms work. "Iterated goal setting" allows a company the possbility of perpetually updating its goals by reference to the progress of competitors, changes in technology, shifts in markets, comparison with "best practices."

27. For the purposes of comparison, it is probably least mystifying to imagine Amicas as a department within Partners Healthcare. This is dangerous, however, in that the specific history of Amicas and Adrian's experience in this realm, taught them to be very careful about the legal relation to MGH. The formal relation, however might be considered as similar to other research groups in the hospital. There is a further danger in this comparison, in that the fixed costs of Partners are huge, and Partners has been making little adjustment to that based on the kinds of reforms that Sabel investigates (however, this is exceptionalism on the part of a highly traditionalistic and willfully peculiar institution— most healthcare institutions are feeling the pressures of 're-engineering', or streamlining, and there is much talk of "cost centers" and "revenue centers" which is usually identified with the accounting and management practices of HMOs). Amicas spent its first few development cycles as a parasite on this large "integrated" corporation— given office space, using them as a large testing environment, relying on the overhead of the hospital. Their actions, however, bear comparison to the workgroup that has the freedom within a large corporation to bypass internal hierarchical decisions about costs, expenditures, suppliers or customers. There is a final danger because it has in each case been unclear whether Amicas should cooperate or compete with other groups within Partners (it might be worth comparing the relatively constrained actions of Partners Telemedicine, with respect to the information services department, and other groups competing for research funds, except that there is nothing to say about it— PTC spent all of their energy fighting this internal bureacracy, competing with others rather than comparing itself to them, or monitoring them. Indeed, the Partners Telemedicine Center experienced Amicas—and treated them— almost uniformly as hostile competitors). Despite this, the goal of "improving healthcare" was often invoked as a cooperative endeavor, even if the hypocracies, confusions, or legitimate concerns of academics or hospital administrators interfered.

28. So despite these dangers, I continue the comparison. Sabel's examples are automobile firms, whose design and production processes are increasingly organized by constant lateral monitoring of other groups within the same institution (which is now fundamentally based on an integrity of finance and brand— not manufacturing) and design groups, suppliers or contracters in other firms. "Learning by Monitoring" moves capitalism from a stage of administration by hierarchical integration to a kind of fluid programmable capitalism. It is a stage within which the practical reason trumps theoretical, where the gulf between conception and execution is filled with the debris of regulative ideals, fundamental rules, and legitimate authority. In its place rests rapid prototyping, constant quality improvement, and a bookshelf full of handbooks that train people to be vigilant to the point of radical insecurity. While these changes may not have come to all of healthcare, the rhetoric has clearly arrived.

Last Modified 11-Sep-99 9:01 PM ckelty@mit.edu

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