Healthcare, Modus Vivendi and the Art of Coexistence
One of my favourite games to play is discovering a connection between two things that seem completely unrelated. It is a bit like realising your tennis friend somehow knows your work friend and you are left wondering how on earth those worlds overlap. Early Facebook thrived on this. You would see 'friends in common' and stare at the screen thinking, how is this even possible?
That happened to me this week while reading about systems thinking in healthcare. It isn't an area I've spent much time reading about, so I was slightly thrown by how familiar some of it felt. I kept thinking, why does this sound like something I've already absorbed somewhere else? It took me a while to place it, but eventually I thought, hang on a minute, this sounds remarkably like the British philosopher John Gray. As you do. You know, the one who wrote about feline philosophy and human limits and the messiness of progress. Not, to be clear, the 'men are from Mars, women are from Venus' John Gray. Different man entirely. None of this feels particularly relevant yet, but it becomes more obvious when you start pulling at some of the other threads in his work.
One of Gray's most common stories is about his hometown of South Shields. He describes growing up on a multigenerational street where doors were rarely locked, crime was low, and life, although far from perfect, had cohesion. It was patriarchal. If you had ambition you often had to leave. Life was not glamorous. But there was belonging.
Eventually the street was demolished and replaced with modern housing. Central heating. Better architecture. Improved structural design. Families were relocated to new estates and reorganised like marbles shaken in a jar. On paper, living conditions improved. Yet socially and culturally something fractured.
The assumption had been simple. Improve the structure and people's lives will improve. Gray came to distrust that kind of social engineering. Human systems are not machines that can be redesigned from above and expected to behave predictably. They are more like spider webs, he says. You pull one strand with good intentions and tension appears somewhere else.
Reading Mintzberg's critique of managerial myths in healthcare, I could not help noticing the overlap. One myth is that healthcare can be fixed through clever structural reform. Identify the flaw, redesign the system, implement the solution. But who decides which flaw matters most? What if improving one part makes another worse? What if what looks like a problem from above feels like stability to the people living within it?
Systems thinking shifts the question from how do we fix this to why does the system produce the outcomes it does. That feels much closer to Gray's instinct that human arrangements are rarely problems waiting to be solved cleanly. They are ongoing balances. Ones that once changed may never return to their original states.
I have felt this tension increasingly in my own clinical work.
Ten years ago I had enormous success using low carbohydrate and ketogenic diets for a range of health issues. I saw improvements often enough that it became my default lens. When you repeatedly see something work, it is easy to start believing it is the answer.
Then one of my patients calmly explained that her vegan diet was not primarily about health. It was about animal welfare. She understood it might leave her vulnerable to certain deficiencies. She was willing to accept that. I tried to negotiate. What about higher welfare farms? Occasional dairy? A compromise somewhere?
She said, you are not listening. I wasn't.
She was not judging me. She was not telling me what to do. I have met vegans who do that. She was simply being clear about what mattered to her. It was me who was imposing my worldview on her.
A similar lesson came from my father. After years of gentle persuasion, he cut bread, increased protein and managed to start running again. I was delighted. It felt like impact, and impact with family carries extra weight.
A few months later he drifted back. My initial reaction was frustration, but when I asked him why, the answer was simple. Friday night pizza with his wife had always been their favourite ritual. The new diet disrupted that. They did not enjoy the alternatives. He also admitted he did not particularly enjoy eating more meat. His knees were better, but he found himself with a little less joy in his life. Yes, he could run again. But at what cost?
These things are far more complicated than a single clinical metric suggests. Health exists inside culture, economics, ethics and family life. You pull one strand and others tighten.
This does not mean you should run every piece of medical advice through a Black Mirror scenario of unintended consequences. But if you are fortunate enough to have time with a patient and understand what actually matters to them, that space becomes valuable. It allows you to pause before defaulting to the most efficient answer and consider whether it is the right one for this person. Efficiency will always matter in healthcare, and sometimes it has to. But perhaps our systems should have enough slack in them to allow for judgement and context rather than assuming every problem has a predictable fix.
Another key theme from Gray's work is that of progress. Outside of science, progress is often treated as inevitable, almost a given, yet he is sceptical of that assumption. He warns against assuming that scientific and technological progress guarantees moral or cultural progress. Healthcare sits right in that tension. We can have better scans, more advanced machines, AI and more targeted drugs, yet the experience of being a patient can feel colder or more fragmented. Progress in one domain does not automatically improve the human one.
In acute care, the aim is often straightforward. Someone is bleeding, septic or in cardiac arrest. The priority is stabilisation. You act. You intervene. You fix. There is very little room for reflection in that moment, nor should there be.
Primary care and especially aged care are different. Aged care is not simply about fixing a problem. It is about living. It is about dignity, autonomy, safety, connection, comfort and cost. Independence may matter more than risk reduction. Quality of life may matter more than longevity. These are not technical questions with clean answers. They are negotiations.
If healthcare is treated purely as a moral crusade or a managerial engineering project, it can become unstable — constantly reforming and correcting in pursuit of a cleaner model. Well-intentioned attempts at equity can sometimes drift into interference rather than support. Some groups genuinely want assistance. Others simply want to be left alone. Systems can unintentionally reward those who learn how to navigate them strategically while missing those who are less fluent.
Programs like the NDIS spring to mind here. Born from a genuine commitment to fairness and helping those in need, it created structures that work beautifully for people who understand how to use them. And some not so ethical fund managers who know the game better than anyone else. We'll return to the NDIS in a future blog.
This is where Gray's idea of modus vivendi becomes useful. An arrangement that allows conflicting priorities to coexist without pretending they will ever fully align.
Maybe the deeper problem is that we have lost the ability to sit with two things being true at once. Somewhere along the way, disagreement became a problem to be solved rather than a condition to be managed. Every contested space now seems to need a winner.
The GLP-1 debate, which I wrote about recently, is a reasonable example. These medications are genuinely improving lives and could ease real pressure on health systems. They are also arriving into a culture still negotiating its relationship with body image, and some of the progress made in eating disorder treatment may not survive that collision intact. Both of these things can be true. Neither cancels the other out.
We waste a lot of energy trying to decide which virtue wins. Most of the time the solution doesn't depend on resolving that at all.
The same logic applies to the clinical examples earlier in this piece. My father's knees improved. His Fridays got worse. There was no clean answer. There rarely is.
Healthcare often feels frustrating because many of its most important questions are not technical ones. Independence and safety. Longevity and quality of life. Access and sustainability. We often behave as though enough evidence will eventually settle these debates when, more often, it simply helps us understand the trade-offs more clearly.
Those who see John Gray as a pessimist would probably say he predicted all of this. Human beings repeatedly convincing themselves that the next reform, the next system or the next ideology will finally remove the compromises that have always existed.
But you do not have to read Gray as a fatalist. One of the more useful ideas in his work is that people do not need to agree on the same vision of the good life for things to function. They just need arrangements that allow different visions to coexist without constantly trying to defeat each other.
That strikes me as relevant to healthcare. The challenge is rarely deciding which value wins. More often it is recognising that several values matter at once, and that improving one may require giving ground somewhere else. We would probably get further accepting that than insisting our way of seeing things is the only one.
This piece draws on systems thinking frameworks I have been exploring through my graduate studies in health management and leadership.