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)

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)

'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)

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)

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)

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)

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)

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)

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)

Interest in ethical leadership from academics and practitioners has grown enormously in recent years. This article addresses this literature through a framework that identifies three interlocking questions. First, who are ethical leaders and what are their characteristics? Second, how do ethical leaders do what they do? Third, why do leaders do as they do and what are the outcomes of ethical leadership? Different dimensions to ethical leadership are examined and presented as three interlocking circles; Virtues, Purposes and Practices. This framework (...) presents an integrated approach to ethical leadership and argues that future research take this holistic framework and apply it to different sectors or contexts. (shrink)

The authors develop an axiomatic theory of nonexistent objects and and give a formal semantics for the language of the theory.

A centipede can walk until it thinks about howit does so. Thereafter it stumbles, over thesheer impossibility of the information andcoordination required. Life in the economy islittle different. Those engaged in productionand exchange discover, pragmatically, ways tomake them work. Those observing the processsee, realistically, the immense improbabilitythat it should do so. That most economies workin practice, but must pass such toughteleological tests to succeed in theory,highlights a difference between players' andspectators' outlook which may help to explainwhy the game has repeatedly (...) been thrown wideopen just when conclusive results seemed withinreach.Section 1 of this paper identifies the fourforms of realism which economists have tendedto adopt. Section 2 considers the pragmatism ofeconomic agents, when observed in action bypsychologists and management scholars notoverly steeped in economic theory. Theconcluding section reviews the ways in whicheconomists have tried to blur the distinction,by reclassifying agents as realistic or theirown views as pragmatic, and suggests that amore pragmatic economics might bridge thedivide. (shrink)

The desire to minimize the number of individual new entities postulated is often referred to as quantitative parsimony. Its influence on the default hypotheses formulated by scientists seems undeniable. I argue that there is a wide class of cases for which the preference for quantitatively parsimonious hypotheses is demonstrably rational. The justification, in a nutshell, is that such hypotheses have greater explanatory power than less parsimonious alternatives. My analysis is restricted to a class of cases I shall refer to as (...) additive. Such cases involve the postulation of a collection of qualitatively identical individual objects which collectively explain some particular observed phenomenon. Especially clear examples of this sort occur in particle physics. 1 Introduction 2 Particle physics: a case study 3 Three kinds of simplicity 4 Explanatory power 5 Explanation and non-observation 6 Parsimony and scientific methodology 7 Conclusions. (shrink)

Introduction: Natural necessity, being, and becoming -- Accentuate the negative -- Diffracting dialectic -- Opening totality -- Constellating ethics -- Metacritique I : philosophy's primordial failing -- Metacritique II : dialectic and difference -- Conclusion: Natural necessity and the grounds of justice : natural necessity as material meshwork.

Despite immediate appearances, this book is not primarily a hermeneutical exercise in which the superiority of one interpretation of canonical texts is championed against others. Its origin lies elsewhere, near the overlap of history, psychoanalysis, aesthetics, and social theory of the usual kind. Weber, Pareto, Freud, W. I. Thomas, Max Scheler, Karl Mannheim, and many others of similar stature long ago wondered and wrote much about the interplay between societal rationalization and individual rationality, between collective furor and private psychopathology—in short, (...) about the strange and worrisome union of “character and social structure” (to recall Gerth and Mills). Pondering the history of social thought in this century can lead to the unpleasant realization that such large-scale questions slipped away, especially from sociologists, sometime before World War II. Or, if not entirely lost, they were so transformed in range and rhetoric that a gap opened between contemporary theorizing and its European background. Perhaps this partly explains Weber’s continuing appeal. By dealing with him, one might again broach topics long at odds with “social science” of the last forty years.—From the Preface. (shrink)

Alan Gross applies the principles of rhetoric to the interpretation of classical and contemporary scientific texts to show how they persuade both author and audience. This invigorating consideration of the ways in which scientists--from Copernicus to Darwin to Newton to James Watson--establish authority and convince one another and us of the truth they describe may very well lead to a remodeling of our understanding of science and its place in society.

In this paper, I demonstrate how the Passover Haggadah exploits certain features of conversational interaction in both the production formats of its texts and in its performance formats (or ways it indicates it should be performed) during the Passover Seder. Some conversational methods used include the use of dispreferred second pair parts which creates an impression that at least part of the Haggadah's text resembles a kind of conversational argument. Furthermore, as a recitable text, the Haggadah exploits the use of (...) and changes in footings in a manner reminiscent of how reported speech is used in ordinary conversation to introduce participant roles and virtual participants with their own commitments, orientations and positions which may not represent those of the animators of the recited text. While the Haggadah is not an actual argument in conventional terms, it is a script of ritual texts organized according to a logic similar to the one by which certain kinds of conversational arguments are organized. Participants are able to animate participatory roles and assess the positions, orientations and commitments such roles represent in a manner that rehearses how such positions, orientations and commitments might be accomplished in actual argumentation. (shrink)

We introduce a notion of complexity for interpretations, which is used to prove some new results about interpretations of sequential theories. In particular, we give a new, elementary proof of Pudlák's theorem that sequential theories are connected. We also demonstrate a counterexample to the infinitary distributive law $a \vee \bigwedge_{i \in I} b_i = \bigwedge_{i \in I} (a \vee b_i)$ in the lattice of chapters, in which the chapters a and b i are compact. (Counterexamples in which a is not (...) compact have been found previously.). (shrink)

In Value and Context Alan Thomas articulates and defends the view that human beings do possess moral and political knowledge but it is historically and culturally contextual knowledge in ways that, say, mathematical or chemical knowledge is not. In his exposition of "cognitive contextualism" in ethics and politics he makes wide-ranging use of contemporary work in epistemology, moral philosophy, and political theory.

Consider this propositional function which includes the dyadic predicate “loves”: “X does not love Y unless Y loves X” (or “if Y does not love X”). This function may be treated in four ways. (1) If universally quantified, it states a (purported) conceptual truth about “love” or the nature or essence of love. Love is necessarily reciprocal. (2) If universally quantified, it may alternatively be a nomological generalization stating an empirical or factual truth about human nature, i.e., about a pattern (...) of reciprocity that occurs among people who are independently identified as lovers. (3) If instantiated with constants, it is an empirical proposition about the attitudes or behaviors of particular individuals (a, b, c). Finally, (4) the function may be treated axiologically; it expresses a normative judgment about what love ought to be or what lovers ought to feel or do. Other propositional functions may be constructed for the constancy, exclusivity, and benevolence of love. This essay investigates the implications of these understandings of the function and how they are logically related to each other. (shrink)

The goal of this paper is to encourage a reconfiguration of the discussion about typology in biology away from the metaphysics of essentialism and toward the epistemology of classifying natural phenomena for the purposes of empirical inquiry. First, I briefly review arguments concerning ‘typological thinking’, essentialism, species, and natural kinds, highlighting their predominantly metaphysical nature. Second, I use a distinction between the aims, strategies, and tactics of science to suggest how a shift from metaphysics to epistemology might be accomplished. Typological (...) thinking can be understood as a scientific tactic that involves representing natural phenomena using idealizations and approximations, which facilitates explanation, investigation, and theorizing via abstraction and generalization. Third, a variety of typologies from different areas of biology are introduced to emphasize the diversity of this representational reasoning. One particular example is used to examine how there can be epistemological conflict between typology and evolutionary analysis. This demonstrates that alternative strategies of typological thinking arise due to the divergent explanatory goals of researchers working in different disciplines with disparate methodologies. I conclude with several research questions that emerge from an epistemological reconfiguration of typology. (shrink)

"Liberalism" is widely used to describe a variety of social and political ideas, but has been an especially difficult concept for historians and political scientists to define. Burckhardt, Mill, and Tocqueville define one type of liberal thought. They share an aristocratic liberalism marked by distaste for the masses and the middle class, opposition to the commercial spirit, fear and contempt of mediocrity, and suspicion of the centralized state. Their fears are combined with an elevated ideal of human personality, an ideal (...) which affirms modernity. All see their ideals threatened in the immediate future, and all hope to save European civilization from barbarism and militarism through some form of education, although all grow more pessimistic towards the end of their lives. Aristocratic Liberalism ignores the national boundaries that so often confine the history of political thought, and uses the perspective thus gained to establish a pan-European type of political thought. Going beyond Burckhardt, Mill, and Tocqueville, Aristocratic Liberalism argues for new ways of looking at nineteenth-century liberalism. It corrects many prevalent misconceptions about liberalism, and suggests new paths for arriving at a better understanding of the leading form of nineteenth-century political thought. The new Afterword by the author presents a novel description of liberal political language as the "discourse of capacity," and suggests that this kind of language is the common denominator of all forms of European liberalism in the nineteenth century. Aristocratic Liberalism will be valuable to students of history, political science, sociology, and political philosophy. (shrink)

This paper is partly a tribute to Richard Jeffrey, partly a reflection on some of his writings, The Logic of Decision in particular. I begin with a brief biography and some fond reminiscences of Dick. I turn to some of the key tenets of his version of Bayesianism. All of these tenets are deployed in my discussion of his response to the St. Petersburg paradox, a notorious problem for decision theory that involves a game of infinite expectation. Prompted by that (...) paradox, I conclude with some suggestions of avenues for future research. (shrink)

Many health care systems include programs that allow patients in exceptional circumstances to access medical interventions of as yet unproven benefit. In this article we consider the ethical justifications for—and demands on—these special access programs (SAPs). SAPs have a compassionate basis: They give patients with limited options the opportunity to try interventions that are not yet approved by standard regulatory processes. But while they signal that health care systems can and will respond to individual suffering, SAPs have several disadvantages, including (...) the potential to undermine regulatory and knowledge-generation structures that constitute significant public goods. The “balance” between these considerations depends in part on how broadly SAPs are used, but also on whether SAPs can be made to contribute to the generation of knowledge about the effects of health interventions. We argue that patients should usually be required to contribute outcome data while using SAPs. (shrink)

An organizing framework is set out for the diverse literature on business ethics in relation to strategic management. It consists of sets of bi-polar components, spanning themes and topical themes, with a derived typology of contributions. Then, in the spirit of classical pragmatism, the organizing framework is re-cast as an integrative conceptual model of the strategy–ethics relationship. The approach recognizes that both pragmatism and dialectics can underpin progress towards integration, encompassing both normative and empirical aspects.

Thomas Nagel's criterion for an acceptable theory of conscious awareness, that it address the question of “what it is like” to be a conscious subject has been misunderstood in the light of an implicit act/object model of conscious awareness. Kant's account of conscious experience is an adverbial theory precisely in the sense that it avoids such an act/object interpretation. An “objectualist” and an “actualist” construal of views of conscious awareness are contrasted. The idea of an adverbial theory of conscious experience (...) is further developed by examining recent re-interpretations of Brentano as an adverbial theorist (Thomasson) or as an identity theorist (Hossack). Identity theory is independently criticized as a free standing account of consciousness. Kant's adverbial view is further developed and extended to an account of self-ascription and self-knowledge. (shrink)