This paper critically examines the extent to which health promoting wearable technologies can provide people with greater autonomy over their health. These devices are frequently presented as a means of expanding the possibilities people have for making healthier decisions and living healthier lives. We accept that by collecting, monitoring, analysing and displaying biomedical data, and by helping to underpin motivation, wearable technologies can support autonomy over health. However, we argue that their contribution in this regard is limited and that—even with (...) respect to their ‘autonomy enhancing’ potential—these devices may deliver costs as well as benefits. We proceed by rehearsing the distinction that can be drawn between procedural autonomy and substantive-relational autonomy. While the information provided by wearable technologies may support deliberation and decision-making, in isolation these technologies do little to provide substantive opportunities to act and achieve better health. As a consequence, wearable technologies risk generating burdens of anxiety and stigma for their users and reproducing existing health inequalities. We then reexamine the extent to which wearable technologies actually support autonomous deliberation. We argue that wearable technologies that subject their users to biomedical and consumerist epistemologies, norms and values also risk undermining processes of genuinely autonomous deliberation. (shrink)

In this paper, we argue that there are important ethical questions about healthcare improvement which are underexplored. We start by drawing on two existing literatures: first, the prevailing, primarily governance-oriented, application of ethics to healthcare ‘quality improvement’ (QI), and second, the application of QI to healthcare ethics. We show that these are insufficient for ethical analysis of healthcare improvement. In pursuit of a broader agenda for an ethics of healthcare improvement, we note that QI and ethics can, in some respects, (...) be treated as closely related concerns and not simply as externally related agendas. To support our argument, we explore the gap between ‘quality’ and ‘ethics’ discourses and ask about the possible differences between ‘good quality healthcare’ and ‘good healthcare’. We suggest that the word ‘quality’ both adds to and subtracts from the idea of ‘good healthcare’, and in particular that the technicist inflection of quality discourses needs to be set in the context of broader conceptualisations of healthcare improvement. We introduce the distinction between quality as a measurable property and quality as an evaluative judgement, suggesting that a core, but neglected, question for an ethics of healthcare improvement is striking the balance between these two conceptions of quality. (shrink)

There are various reasons why efforts to promote “support for self-management” have rarely delivered the kinds of sustainable improvements in healthcare experiences, health and wellbeing that policy leaders internationally have hoped for. This paper explains how the basis of failure is in some respects built into the ideas that underpin many of these efforts. When support for self-management is narrowly oriented towards educating and motivating patients to adopt the behaviours recommended for disease control, it implicitly reflects and perpetuates limited and (...) somewhat instrumental views of patients. It tends to: restrict the pursuit of respectful and enabling ‘partnership working’; run the risk of undermining patients’ self-evaluative attitudes ; limit recognition of the supportive value of clinician-patient relationships; and obscure the practical and ethical tensions that clinicians face in the delivery of support for self-management. We suggest that a focus on enabling people to live well with their long-term conditions is a promising starting point for a more adequate conception of support for self-management. We then outline the theoretical advantages that a capabilities approach to thinking about living well can bring to the development of an account of support for self-management, explaining, for example, how it can accommodate the range of what matters to people for living well, help keep the importance of disease control in perspective, recognize social influences on people’s values, behaviours and wellbeing, and illuminate more of the rich potential and practical and ethical challenges of supporting self-management in practice. (shrink)

Patient safety is a central aspect of healthcare quality, focusing on preventable, iatrogenic harm. Harm, in this context, is typically assumed to mean physical injury to patients, often caused by technical error. However, some contributions to the patient safety literature have argued that disrespectful behavior towards patients can cause harm, even when it does not lead to physical injury. This paper investigates the nature of such dignitary harms and explores whether they should be included within the scope of patient safety (...) as a field of practice. We argue that dignitary harms in health care are—at least sometimes—preventable, iatrogenic harms. While we caution against including dignitary harms within the scope of patient safety just because they are relevantly similar to other iatrogenic harms, we suggest that thinking about dignitary harms can help to elucidate the value of patient safety, and to illuminate the evolving relationship between safety and quality. (shrink)

What is health policy for? In Health and the Good Society, Alan Cribb addresses this question in a way that cuts across disciplinary boundaries. His core argument is that biomedical ethics should draw upon public health values and ethics; specifically, he argues that everybody has some share of responsibility for health, including a responsibility for promoting greater health equality. In the process, Cribb argues for a major rethink of the whole project of health education.

In this paper I consider the routine moral burden of occupying a professional role and having to negotiate tensions between the normative expectations attached to that role and one's own personal moral compass. Using an example to introduce this central issue I then seek to explore it through a discussion of the tensions between, and spaces between, ‘identifying’ with one's role and ‘separating’ oneself from one's role. I suggest that ethical integrity at work is revealed through the successful negotiation of (...) these tensions, but that such negotiation depends upon the power and other resources available to individual professionals. Finally I argue that this discussion of ‘the ethics of role occupation’ has important implication for ‘the ethics of role construction’ and adds weight to concerns about the potential moral costs of managerialism. (shrink)

In this editorial essay I explore the possibilities of ‘improvement scholarship’ in order to set the scene for the theme of, and the other papers in, this issue. I contrast a narrow conception of quality improvement research with a much broader and more inclusive conception, arguing that we should greatly extend the existing dialogue between ‘problem-solving’ and ‘critical’ currents in improvement research. I have in mind the potential for building a much larger conversation between those people in ‘improvement science’ who (...) are expressly concerned with tackling the problems facing healthcare and the wider group of colleagues who are engaged in health-related scholarship but who do not see themselves as particularly interested in quality improvement, indeed who may be critical of the language or concerns of QI. As one contribution to that conversation I suggest that that the increasing emphasis on theory and rigour in improvement research should include more focus on normative theory and rigour. The remaining papers in the issue are introduced including the various ways in which they handle the ‘implicit normativity’ of QI research and practice, and the linked theme of combining relatively ‘tidy’ and potentially ‘unruly’ forms of knowledge. (shrink)

Disrespect in health care often persists despite firm commitments to respectful service provision. This conceptual paper highlights how the ways in which respect and disrespect are characterised can have practical implications for how well disrespect can be tackled. We stress the need to focus explicitly on disrespect (not only respect) and propose that disrespect can usefully be understood as a failure to relate to people as equals. This characterisation is consonant with some accounts of respect but sometimes obscured by a (...) focus on respecting people’s autonomy and dignity. Emphasising equality is consistent with connections patients draw between being (dis)respected and (in)equality. It readily accommodates microaggressions as forms of disrespect, helping to understand how and why experiences of disrespect may be unintentional and to explain why even small instances of disrespect are wrong. Our view of disrespect with an emphasis on equality strengthens the demand that health systems take disrespect seriously as a problem of social injustice and tackle it at institutional, not just individual levels. It suggests several strategies for practical action. Emphasising relational equality is not an easy or short-term fix for disrespect, but it signals a direction of travel towards an important improvement ambition. (shrink)

'Quality' is a widely invoked concept in healthcare, and 'quality improvement' is now a central part of healthcare service delivery. However, these concepts and their associated practices represent relatively uncharted territory for applied philosophy and bioethics. In this paper, we explore some of the conceptual complexity of quality in healthcare and argue that quality is best understood to be conceptually plural. Quality is widely agreed to be multidimensional and as such constitutively plural. However, we argue that quality is plural in (...) two further senses. First, quality is competitively plural : that is, different high-level conceptions of quality can be appropriately invoked in different contexts and serve... (shrink)

Bioethics is a diverse field that accommodates a broad range of perspectives and disciplines. The recent explosion of literature on methods in interdisciplinary and empirical ethics might appear, however, to overshadow the fact that ‘bioethics’ has long been an interdisciplinary field. The Interdisciplinary and Empirical Ethics Network (IEEN) was established, with funding from the Wellcome Trust, to facilitate critical and constructive discussion around the nature of this disciplinary diversity and shift focus away from the ‘empirical turn’, towards the ongoing development (...) of bioethics as an evolving field of interdisciplinary study. In April 2012 the IEEN organized a workshop at the Centre for Public Policy Research, King's College London, dedicated to discussing the relationship between aims and methods in interdisciplinary and empirical bioethics. This paper reports on that first meeting. (shrink)

In this paper we argue that austerity creates working conditions that can undermine professionalism in healthcare. We characterise austerity in terms of overlapping economic, social and ethical dimensions and explain how these can pose significant challenges for healthcare professionals. Amongst other things, austerity is detrimental to healthcare practice because it creates shortages of material and staff resources, negatively affects relationships and institutional cultures, and creates increased burdens and pressures for staff, not least as a result of deteriorating public health conditions. (...) After discussing the multiple dimensions of austerity, we consider the challenges it creates for professional ethics in healthcare. We highlight three mechanisms—intensification of work, practitioner isolation, and organisational alienation—which pose acute problems for healthcare professionals working under conditions of austerity. These mechanisms can turn ‘routine moral stress’ into moral distress and, at the same time, make poor care much more likely. While professionalism clearly depends on individual capabilities and behaviours, it also depends upon a complex sets of social conditions being established and maintained. The problems caused by austerity reveal a need to broaden the scope of professional ethics so that it includes the responsibilities of ‘role constructors’ and not just ‘role occupiers’. Austerity therefore presents opportunities for health professionals and associated ‘role constructors’ to contribute to a reimagining of future models of healthcare professionalism. (shrink)

This commentary welcomes the work of Ives et al. on Standards of practice in Empirical Bioethics, and especially the dialogical spirit in which the standards have been constructed and offered. It also raises some questions about the consistent interpretation and use of such standards.

In this paper, we consider the role of conversations in contributing to healthcare quality improvement. More specifically, we suggest that conversations can be important in responding to what we call ’normative complexity’. As well as reflecting on the value of conversations, the aim is to introduce the dimension of normative complexity as something that requires theoretical and practical attention alongside the more recognised challenges of complex systems, which we label, for short, as ’explanatory complexity’. In brief, normative complexity relates to (...) the inherent difficulty of deciding what kinds of changes are ’improvements’ or, more broadly, what is valuable in healthcare. We suggest that explanatory and normative complexity intersect and that anyone interested in healthcare improvement needs to be sensitive to both. After briefly introducing the idea of normative complexity, we consider some contrasting examples of conversations, reflecting on how they do and might contribute to healthcare quality. We discuss both conversations that are deliberately organised and facilitated (’orchestrated conversations’) and more informally occurring and routine conversations. In the first half of the paper, we draw on some examples of orchestrated and routine conversations to open up these issues. In the second half of the paper, we bring some more theoretical lenses to bear on both conversations and normative complexity, summarise what we take to be the value of conversations and draw together some of the implications of our discussion. In summary, we argue that conversations can play a crucial role in negotiating the normative complexity of healthcare quality improvement because of their capacity to hold together a plurality of perspectives, to contribute and respond to emergence and to help underpin institutional conditions for empathy and imagination. (shrink)

We argue that the privatisation of education needs to be understood through an ethical lens, and suggest a broad framework through which privatisation policies and practices might be ethically audited. These policies and practices -- it is suggested -- are creating new ethical spaces and new clusters of goals, obligations and dispositions. Whatever the merits of our particular reading of these changes, we would call for an urgent public debate on these questions -- one that looks beyond broad ideological questions (...) to consider the effects of privatisation on the nature of the services provided. (shrink)

In this paper we want to briefly illustrate the ways in which technical, ethical and political judgements of various kinds are interwoven in the processes of healthcare decision-making in the UK. Drawing upon the research for the “Choices in Health Care” project we will borrow the notion of the hidden curriculum from education to illuminate the nature of resource allocation decision processes. In particular we will indicate some of the fundamental but largely hidden political factors in play in these processes (...) and the importance of the inchoate and implicit notion of “NHS values” in shaping UK resource allocation policies. We suggest that these more diffuse, holistic and system level value judgements are both central to understanding priority setting and at the same time difficult to reduce or abstract out into lists of single values/principles. (shrink)

In his 1987 paper “Truth or Consequences,” Dan Brock describes a deep conflict between the goals and virtues of philosophical scholarship and public policymaking: whereas the former is concerned with the search for truth, the latter must primarily be concerned with promoting good consequences. When philosophers are engaged in policymaking, he argues, they must shift their primary goal from truth to consequences—but this has both moral and methodological costs. Brock’s argument exemplifies a pessimistic, but not uncommon, view of the possible (...) shape and nature of applied philosophy. The present paper paints a richer and more optimistic picture. It argues that the difference between theoretical philosophy and applied philosophy is not best understood as a choice between truth and consequences. On the contrary, applied philosophers engage in forms of truth‐seeking that are properly concerned with consequences—including the consequences of philosophical practice itself. (shrink)

In this paper we contribute to “sociology in bioethics” and help clarify the range of ways sociological work can contribute to ethics scholarship. We do this using a case study of an innovative neurotechnology, functional magnetic resonance imaging, and its use to attempt to diagnose and communicate with severely brain-injured patients. We compare empirical data from interviews with relatives of patients who have a severe brain injury with perspectives from mainstream bioethics scholars. We use the notion of an “ethical landscape” (...) as an analogy for the different ethical positions subjects can take—whereby a person’s position relative to the landscape makes a difference to the way they experience and interact with it. We show that, in comparison to studying abstract ethics “from above” the ethical landscape, which involves universal generalizations and global judgements, studying ethics empirically “from the ground,” within the ethical landscape foregrounds a more plural and differentiated picture. We argue it is important not to treat empirical ethics as secondary to abstract ethics, to treat on-the-ground perspectives as useful only insofar as they can inform ethics from above. Rather, empirical perspectives can illuminate the plural vantage points in ethical judgments, highlight the “lived” nature of ethical reasoning, and point to all ethical vantage points as being significant. This is of epistemic importance to normative ethics, since researchers who pay attention to the various positions in and trajectories through the ethical landscape are unlikely to think about ethics in terms of abstract agency—as can happen with top-down ethics—or to elide agency with the agency of policymakers. Moreover, empirical perspectives may have transformative implications for people on the ground, especially where focus on the potential harms and benefits they face brings their experiences and interests to the forefront of ethical and policy discussion. (shrink)

This paper presents findings from an empirical study that explored the meaning of ethics in the everyday work of neuroscientists. Observation and interviews were carried out in one neuroscience research group that was involved in bench-to-bedside translational research. We focus here specifically on the scientists’ perceptions of bioethics. Interviewees were often unfamiliar with bioethics as a discipline, particularly the more junior members of the group. Those who were aware of its existence largely viewed it as something distant from them, and (...) as either too abstract, not relevant or an alien imposition on their work. Some interviewees themselves pointed to the need for better ‘bridge building’ between ethical principles and real-world examples drawn from scientific practice, and we argue that this space is where a more empirically grounded ethics may be useful in terms of actually engaging scientists at both the bench and the bedside. (shrink)

Nursing Law and Ethics explores a variety of key legal and ethical issues in nursing practice using a thought-provoking and holistic approach. It addresses both what the law requires and what is right, and explores whether these two are always the same. The book provides an overview of the legal, ethical and professional dimensions of nursing, followed by exploration of key issues in greater depth. This edition features updated legislation and new material on patient safety. Key topics are accompanied by (...) both a legal and an ethical perspective, covering both law and ethics Case examples throughout place concepts in a real-life context Written by experts in the field and includes contributions from leading nurses, lawyers and ethicists Accessible, relevant, and comprehensive, this title is ideal for pre- and post-registration nurses. (shrink)

Person-centred care is a cornerstone of contemporary health policy, research and practice. However, many researchers and practitioners worry that it lacks a 'clear definition and method of measurement,' and that this creates problems for the implementation of person-centred care and limits understanding of its benefits. In this paper we urge caution about this concern and resist calls for a clear, settled definition and measurement approach. We develop a philosophical and conceptual analysis which is grounded in the body of literature concerning (...) the theory and practice of person-centred care. We consider a range of influential definitional frameworks of person-centred care, highlighting their differences and showing that they do not correspond to a clearly circumscribed and consistent underlying concept. We argue that a degree of indeterminacy and vagueness should not be seen as a problem with the concept of person-centred care; these are features of a rich and contested concept which exists prior to and outside of practical and technical operational definitions and applications. We defend the value of operating with multiple accounts of person-centred care, arguing that what counts as being person-centred can vary across different care contexts, in relation to different patient groups, and as a reflection of different, defensible ethical perspectives. Although the idea of a single, agreed definition is attractive and may seem to be a practical or even necessary step towards meaningful and coordinated action, we argue that this is only the case in a qualified sense. Comprehensive attempts to narrow down the concept in this way should be resisted, as they risk undermining what it is that makes person-centredness a valuable concept in healthcare. (shrink)

This paper analyses the ethics of routine measurement for healthcare improvement. Routine measurement is an increasingly central part of healthcare system design and is taken to be necessary for successful healthcare improvement efforts. It is widely recognised that the effectiveness of routine measurement in bringing about improvement is limited—it often produces only modest effects or fails to generate anticipated improvements at all. We seek to show that these concerns do not exhaust the ethics of routine measurement. Even if routine measurement (...) does lead to healthcare improvements, it has associated ethical costs which are not necessarily justified by its benefits. We argue that the practice of routine measurement changes the function of the healthcare system, resulting in an unintended and ethically significant transformation of the sector. It is difficult to determine whether such changes are justified or offset by the benefits of routine measurement because there may be no shared understanding of what is ‘good’ in healthcare by which to compare the benefits of routine measurement with the goods that are precluded by it. We counsel that the practice of routine measurement should proceed with caution and should be recognised to be an ethically significant choice, rather than an inevitability. (shrink)

What is good prescribing? In this paper we will look at the kinds of criteria which are relevant to evaluating prescribing. In particular we wish to challenge, or at least re-frame, the picture of prescribing as an essentially technical process. In so doing we hope to indicate something more general about the power, and limitations, of technical rationality in health care, and to contribute something to work in health care technology assessment. Finally we hope this discussion will act as a (...) stimulus towards a much needed revision of the way ‘good’ prescribing is defined by current policies, guidelines and protocols. (shrink)

Nordenfelt has presented a very useful philosophical analysis of the nature and ethics of health promotion. The first section of this paper is a response to the starting point of that analysis—the equation of health promotion with health promotion action. It is argued that this starting point leads to a serious ambiguity, and that this ambiguity is characteristic of other writing about health promotion, including that of the WHO. The second section of this paper explores the implications of this ambiguity, (...) as it appears in the wider health promotion literature, for drawing the borders of health promotion. (shrink)

Available from UMI in association with The British Library. Requires signed TDF. ;This thesis considers the place of values in comparative political inquiry. After a review of the debate in the philosophy of social science between the positivist and hermeneutic approaches , the argument is divided into two parts. The first part looks at the origins, and consequences, of the attempt to establish a positivistic value-free comparative political science. The second part considers the basis, and the potential nature, of a (...) self-consciously normative discipline of comparative politics. ;The idea of value-freedom is criticised; it is argued: that the failure to take into account the values of the comparative theorist results in the imposition of a non-neutral framework on the phenomena under investigation; and that the failure to take into account the values of the agents under investigation makes it impossible to properly describe or explain political phenomena. ;Examples are used to illustrate these points but also to show how, and why, the rhetoric of neutrality is sustained in practice. It is suggested that mainstream comparative political science conflates a positivist epistemology and a quantitative research methodology. This mixture results in a variety of confusions but is seen to protect comparative politics from "the problem of relativism", which is treated as the principal weakness of the hermeneutic approach. ;Two possible foundations for a normative comparative politics are considered. Firstly, the idea that it is possible to found comparative politics on a non-relative moral theory is reviewed and rejected. It is argued that the best candidates for such a theory, utilitarianism and "thin" theories of the good, cannot be established a priori. Secondly, the assumption that the existence of a plurality of cultures, moral beliefs, and theoretical perspectives leads to relativism is rejected. Instead it is argued that the existence of diversity and disagreement itself provides the basis for a coherent and self-critical discipline, and enhances the scope of comparative politics. (shrink)

This text attempts to show why the academic split between ethics and social sciences has been disastrous and argues that advances in vigour and sensitivity are made possible by closing this artificial divide.

Bioethics is an interdisciplinary field that accommodates a broad range of perspectives and disciplines. This inherent diversity sets a number of challenges for both teachers and students of bioethics, notably in respect to the appropriate aims and methods of bioethics education, standards and criteria for evaluating performance and disciplinary identity. The Interdisciplinary and Empirical Ethics Network (IEEN) was established, with funding from the Wellcome Trust, to facilitate critical and constructive discussion about the ongoing development of bioethics as an evolving field (...) of interdisciplinary study. In November 2012 the IEEN organised a workshop at the University of Birmingham to discuss the issues relating to teaching and learning in interdisciplinary and empirical bioethics. This paper reports on that meeting. (shrink)

The Interdisciplinary and Empirical Ethics Network was established in 2012 with funding from the Wellcome Trust in order to facilitate critical and constructive discussion around the nature of the disciplinary diversity within bioethics and to consider the ongoing development of bioethics as an evolving field of interdisciplinary study. In April 2013, the Interdisciplinary and Empirical Ethics Network organized a workshop at the Centre for Public Policy Research, King’s College London, which discussed the nature and possibility of professionalism within interdisciplinary and (...) empirical bioethics. This paper provides a report of that workshop. (shrink)

Background: Poverty and social deprivation have adverse effects on health outcomes and place a significant burden on healthcare systems. There are some actions that can be taken to tackle them from within healthcare institutions, but clinicians who seek to make frontline services more responsive to the social determinants of health and the social context of people’s lives can face a range of ethical challenges. We summarise and consider a case in which clinicians introduced a poverty screening initiative into paediatric practice (...) using the discourse and methodology of healthcare quality improvement. -/- Discussion: Whilst suggesting that interventions like the PSI are a potentially valuable extension of clinical roles, which take advantage of the unique affordances of clinical settings, we argue that there is a tendency for such settings to continuously reproduce a narrower set of norms. We illustrate how the framing of an initiative as QI can help legitimate and secure funding for practical efforts to help address social ends from within clinical service, but also how it can constrain and disguise the value of this work. A combination of methodological emphases within QI and managerialism within healthcare institutions leads to the prioritisation, often implicitly, of a limited set of aims and governing values for healthcare. This can act as an obstacle to a genuine broadening of the clinical agenda, reinforcing norms of clinical practice that effectively push poverty ‘off limits.’ We set out the ethical dilemmas facing clinicians who seek to navigate this landscape in order to address poverty and the social determinants of health. -/- Conclusions: We suggest that reclaiming QI as a more deliberative tool that is sensitive to these ethical dilemmas can enable managers, clinicians and patients to pursue health-related values and ends, broadly conceived, as part of an expansive range of social and personal goods. (shrink)

This paper aims to make an empirically informed analytical contribution to the development of a more socially embedded bioethics. Drawing upon 10 interviews with cutting edge stem cell researchers (5 scientists and 5 clinicians) it explores and illustrates the ways in which the role positions of translational researchers are shaped by the ‘normative structures’ of science and medicine respectively and in combination. The empirical data is used to illuminate three overlapping themes of ethical relevance: what matters in stem cell research, (...) experimental treatment, and responsible claim making (as contrasted with ‘hype’. Finally, we suggest that this kind of ‘descriptive’ ethical analysis has potential relevance for understanding other substantive areas of stem cell ethics in practice, and we briefly consider the questions our analysis raises about role positions and ethical agency, and the implications for bioethics as a field of scholarship. (shrink)

In this paper I investigate the theory-practice relationship in ethics by using the lens of theorist-practitioner relationships. In particular I discuss the contrasts between theorist-practitioner relationship inside and outside the classroom, the ‘extra-mural’ expertise of theorists, and the ethical issues which arise when theorists act as co-practitioners. I argue that understanding these social and ethical issues is essential to understanding the relationship between theory and practice in ethics, and shows the need for more emphasis on practice-oriented forms of ethical theorising.

This paper considers proposals for developing ‘co-productive’ medical partnerships, within the UK National Health Service (NHS), concentrating in particular on the potential problem involved in combining professional and lay conceptions of health. Much of the literature that advocates the introduction of co-productive healthcare partnerships assumes that medical professionals and patients share, or can easily come to share, a common set of beliefs about what is valuable with regard to health interventions and outcomes. However, a substantial literature documents the contestability of (...) the concept of health, particular across professional and lay divides. We suggest that this potential disagreement ought to be taken seriously, and suggest that the prospect of a co-productive NHS in which patients and professionals act in partnership is threatened by the existence of unresolved epistemic differences. We suggest that part of the solution may lie in re-framing this potential disagreement in the terms provided by Engel’s bio-psycho-social account of health, and demonstrate how support for this account can be grounded upon a critical realist foundation. What we call a ‘stratified conception of health’ reveals the potential complementarity between health beliefs which may have at first seemed to be essentially contradictory. We consider some of the practical implications this idea has for conceiving and creating co-productive medical partnerships. (shrink)