par Vincke, Philippe
Référence European Journal of Operational Research, 10, 1
Publication Publié, 1982
Article révisé par les pairs
Résumé : Health care systems, amongst the most complicated systems that serve mankind, have been in turmoil for many years. They are characterized by widespread dissatisfaction, repeated reforms and a general perception of failure. Is it possible that this abominable situation derives from underlying causes, which are inherent to the most basic elements of these systems? Those elements compromise the use of words and definitions in the formulation of their principles and their way of action, in their logical structure as well as in the social order in which they exist. An in-depth investigation of these elements raises findings that may negate the basic feasibility of the success of such complex systems, as currently known in the western world. One of the main elements of the democratic regime is its system of decision/choice making, i.e. the majority vote. But, already in the nineteenth century, it was discovered that a majority was an intransitive ordering and did not produce a consistent definition of a preference. The Marquis of Condorcet in his famous 1785 "Essai sur l'application de l'analyse a la probabilite des decisions rendues a la plurite des voix", clearly demonstrated that majority decisions might lead to intransitivity and an indeterminancy in social choices. On the basis of his discoveries, it was later shown that legislative rules may lead to the choice of a proposal that is actually opposed by the majority, or to a deadlock and therefore, to socially undesirable implications. Subsequent to these theories of Condorcet, which became known as "The Paradox of Condorcet", many papers were published in the 19th and 20th centuries regarding the issue of problems dealing with individual preferences leading to social order--a complex procedure of, amongst others, aggregation in a defined axiomatic framework. During the twentieth century it became astoundingly manifest that certain issues, although correctly attacked logically, could not be resolved. Two such famous results are Kurt Godel's seminal paper in 1931: "Ueber formal unentscheidbare Saetze der Principia Mathematica and verwandter System I" and Arrow's Nobel Prize winning "Impossibility Theorem" (Social Choice and Individual Values, 1951). Godel showed, unequivocally, that there is an enormous gap between what is being perceived as truth and what in fact can be proven as such. Arrow showed that the translation of individual preferences into a social order is impossible--except in a dictatorship. The unsolved controversies concerning the desirable or ideal structure of health care systems are impinged upon by these findings generally, and, in the case of the impossibility theorem, also directly. There is the impossibility of aggregating preferences and, at a deeper level, the impossibility of defining certain fundamental values, coupled with the problematic use of certain words, the absence of the possibility of creating, on a logically defined base, a complex system, complete and comprehensive in its own right. This is added to the fact that according to the elaboration by Stephen Wolfram in "A New Kind of Science", it is not easy to reduce complicated systems to simple components and to predict the continuation of their development even from simple basic laws without complicated calculations. All of these factors impede the construction of satisfying health care systems and leave obvious problems which overshadow the structure and the operation of health care systems.