Against Hierarchy: Organizing Horizontally in Healthcare

Authority and hierarchy saturate social life, cutting across class, profession, gender, race, and every other line of difference. They structure what we imagine is possible, how we act, and the terms on which we do so; healthcare is no exception. From the clinical encounter to the organization of workplaces, authority is exercised, negotiated, and resisted. It shapes what is said and done in healthcare settings, who speaks, and who decides. Authority can be grounded in knowledge and experience, but it can also be conferred by gender, profession, or position. These arrangements are so entrenched that they often feel natural, almost inevitable, even when we resent them or would like to see otherwise. This article challenges that inevitability. I begin by mapping how hierarchy operates in everyday practice and asking which forms of authority, if any, should be accepted. To do so, I turn to anarchist scholarship, where authority and hierarchy have been subjected to sustained critique. I then consider the literature that documents the harms of hierarchical organization, within workplaces, but also for health more broadly. Across these domains, a consistent pattern emerges, notably that we do better when we have greater control over our lives, when we have a meaningful say in what happens around us, and when hierarchies are flattened. Finally, I show that alternatives are possible, drawing on examples of healthcare settings organized horizontally, I show that hierarchy is not inevitable nor is it desirable.