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)

DNA joining enzymes play an essential role in the maintenance of genomic integrity and stability. Three mammalian genes encoding DNA ligases, LIG1, LIG3 and LIG4, have been identified. Since DNA ligase II appears to be derived from DNA ligase III by a proteolytic mechanism, the three LIG genes can account for the four biochemically distinct DNA ligase activities, DNA ligases I, II, III and IV, that have been purified from mammalian cell extracts. It is probable that the specific cellular roles (...) of these enzymes are determined by the proteins with which they interact. The specific involvement of DNA ligase I in DNA replication is mediated by the non‐catalytic amino‐terminal domain of this enzyme. Furthermore, DNA ligase I participates in DNA base excision repair as a component of a multiprotein complex. Two forms of DNA ligase III are produced by an alternative splicing mechanism. The ubiqitously expressed DNA ligase III‐α forms a complex with the DNA single‐strand break repair protein XRCC1. In contrast, DNA ligase III‐β, which does not interact with XRCC1, is only expressed in male meiotic germ cells, suggesting a role for this isoform in meiotic recombination. At present, there is very little information about the cellular functions of DNA ligase IV. (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)

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)

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)

Legally blind participants were able to identify a visual stimulus attribute in the absence of consciously identifying its presence. Specifically, participants—with their corrective lenses removed—correctly guessed the hour-hand position above chance on a clockface shown on a computer screen. This occurred both when presented in a 1-clockface display , as well as when shown a display containing 4 clockfaces , in which only 1 face contained a hand. Even more striking, hand identification accuracy in the 4-clockface condition was comparable whether (...) the clockface containing the hand was or was not correctly identified. That legally blind individuals are capable of identifying stimulus attributes without conscious awareness provides an additional vehicle for exploring implicit perception. Consistent with previous research, the visualsystem can apparently cope with degraded visual input through information available through a secondary pathway via the superior colliculi. (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)

Various theories of moral cognition posit that moral intuitions can be understood as the output of a computational process performed over structured mental representations of human action. We propose that action plan diagrams—“act trees”—can be a useful tool for theorists to succinctly and clearly present their hypotheses about the information contained in these representations. We then develop a methodology for using a series of linguistic probes to test the theories embodied in the act trees. In Study 1, we validate the (...) method by testing a specific hypothesis (diagrammed by act trees) about how subjects are representing two classic moral dilemmas and finding that the data support the hypothesis. In Studies 2–4, we explore possible explanations for discrete and surprising findings that our hypothesis did not predict. In Study 5, we apply the method to a less well‐studied case and show how new experiments generated by our method can be used to settle debates about how actions are mentally represented. In Study 6, we argue that our method captures the mental representation of human action better than an alternative approach. A brief conclusion suggests that act trees can be profitably used in various fields interested in complex representations of human action, including law, philosophy, psychology, linguistics, neuroscience, computer science, robotics, and artificial intelligence. (shrink)

Almost since their publication, the writings of Michel de Montaigne have provided rich fodder for the work of scholars in myriad disciplines. Philosophers have considered Montaigne's views on skepticism; historians have examined his views on the Indians; deconstructionists and literary scholars have examined Montaigne's view of the self; and, political scientists have touched on his arguments for toleration. However, because each of these projects has been done largely in isolation, most scholars have failed to see the relationships between the various (...) aspects of Montaigne's thought. Alan Levine, in Sensual Philosophy, unites Montaigne's thought for the first time, ably and convincingly demonstrating the significant role Montaigne played in establishing the liberal ethos in the West. In exploring Montaigne's grounding for liberalism, Levine considers Montaigne's conceptualization of skepticism and its relationship to toleration. He argues that Montaigne's theories of self ground his idea of toleration without leaving it open to the corrosive charges of relativism and nihilism. Levine also articulates the importance of Montaigne's thought for contemporary conceptions of personal freedom, individuality, subjectivity, and self-creation by bringing him into dialogue with modern and postmodern political theorists such as Heidegger, Nietzsche, and Richard Rorty. This lively book persuades those who might be tempted by postmodernism that they should turn to Montaigne instead. (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)

He argues that an adequate idea of human rights must take such a diversity seriously, and unlike the UN Declaration, it must not presuppose Western institutions and values.

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 work, Alan Milne builds on the argument of his earlier book Ethical Frontiers of the State that limits on governmental action are to be understood in terms of humanistic social ethics. Here Milne considers the role of the market in politics, and in particular the relation of the market to the obligations of government to advance human wellbeing. Issues covered include contingency in politics, the command economy, capitalism, the welfare state, inequality, and representative democracy.

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)

The moral justification for government is, that it is needed to promote the community's interest. What is that interest an interest in? Upon what basis can disagreements about the community's interest and individual interests be reconciled? Can democracy enable dissatisfaction with their reconciliation to be lived with? Perhaps, if people are prepared to meet the requirements of democratic citizenship. What are these requirements, and what is their justification? These are the questions with which this book is concerned.

American undergraduates rated masculinity, femininity, and likability of two men from a videotaped interaction. Participants were informed that both men were cat persons, dog persons, heterosexual, adopted, or gay, or were unlabeled. Participants rated the men less masculine when cat persons than when dog persons or unlabeled, and less masculine and more feminine when gay than when anything else or unlabeled. The more masculine man received lower feminine ratings when a dog person than when a heterosexual, and higher masculine ratings (...) when a dog person than when unlabeled. Labels did not affect likability. Overall, the gay label consistently promoted cross-gender attributions, the dog person label encouraged somewhat heightened gender-appropriate attributions, and the cat person label allowed for normative attributions. (shrink)

People may exhibit two kinds of modifications when demonstrating action for others: modifications to facilitate bottom‐up, or sensory‐based processing; and modifications to facilitate top‐down, or knowledge‐based processing. The current study examined actors' production of such modifications in action demonstrations for audiences that differed in their capacity for intentional reasoning. Actors' demonstrations of complex actions for a non‐anthropomorphic computer system and for people (adult and toddler) were compared. Evidence was found for greater highlighting of top‐down modifications in the demonstrations for the (...) human audiences versus the computer audience. Conversely, participants highlighted simple perceptual modifications for the computer audience, producing more punctuated and wider ranging motions. This study suggests that people consider differences in their audiences when demonstrating action. (shrink)

Biomedical and behavioral research may affect strongly held social values and thereby create significant controversy over whether such research should be permitted in the first place. Institutional review boards responsible for protecting the rights and welfare of participants in research are sometimes faced with review of protocols that have significant implications for social policy and the potential for negative social consequences. Although IRB members often raise concerns about potential long-term social implications in protocol review, federal regulations strongly discourage IRBs from (...) considering them in their decisions. Yet IRBs often do consider the social implications of research protocols and sometimes create significant delays in initiating or even prevent such research. The social implications of research are important topics for public scrutiny and professional discussion. This article examines the reasons that the federal regulations preclude IRBs from assessing the social risks of research, and examines alternative approaches that have been used with varying success by national advisory groups to provide such guidance. The article concludes with recommendations for characteristics of a national advisory group that could successfully fulfill this need, including sustainability, independence, diverse and relevant expertise, and public transparency. (shrink)

Multilevel research strategies characterize contemporary molecular inquiry into biological systems. We outline conceptual, methodological, and explanatory dimensions of these multilevel strategies in microbial ecology, systems biology, protein research, and developmental biology. This review of emerging lines of inquiry in these fields suggests that multilevel research in molecular life sciences has significant implications for philosophical understandings of explanation, modeling, and representation.

Advancements in novel neurotechnologies, such as brain computer interfaces and neuromodulatory devices such as deep brain stimulators, will have profound implications for society and human rights. While these technologies are improving the diagnosis and treatment of mental and neurological diseases, they can also alter individual agency and estrange those using neurotechnologies from their sense of self, challenging basic notions of what it means to be human. As an international coalition of interdisciplinary scholars and practitioners, we examine these challenges and make (...) recommendations to mitigate negative consequences that could arise from the unregulated development or application of novel neurotechnologies. We explore potential ethical challenges in four key areas: identity and agency, privacy, bias, and enhancement. To address them, we propose democratic and inclusive summits to establish globally-coordinated ethical and societal guidelines for neurotechnology development and application, new measures, including “Neurorights,” for data privacy, security, and consent to empower neurotechnology users’ control over their data, new methods of identifying and preventing bias, and the adoption of public guidelines for safe and equitable distribution of neurotechnological devices. (shrink)

Titles and abstracts for the Pitt-London Workshop in the Philosophy of Biology and Neuroscience: September 2001.

We develop a general method for applying functional models to natural systems and cite recent progress in protein modeling that demonstrates the power of this approach. Functional modeling constrains the range of acceptable structural models of a system, reduces the difficulty of finding them, and improves their fidelity. However, functional models are distinctly different from the structural models that are more commonly applied in science. In particular, structural and functional models ask different questions and provide different kinds of answers. As (...) we clarify these differences and articulate how to use these models jointly, we extend our ability to do science and gain insight into the proper use of the terms organization , order , and emergence when describing systems in nature. (shrink)

This book taps the best American thinkers to answer the essential American question: How do we sustain our experiment in government of, by, and for the people? Authored by an extraordinary and politically diverse roster of public officials, scholars, and educators, these chapters describe our nation's civic education problem, assess its causes, offer an agenda for reform, and explain the high stakes at risk if we fail.

The contributors to The Moral of the Story, all preeminent political theorists, are unified by their concern with the instructive power of great literature. This thought-provoking combination of essays explores the polyvalent moral and political impact of classic world literatures on public ethics through the study of some of its major figures-including Shakespeare, Dante, Cervantes, Jane Austen, Henry James, Joseph Conrad, Robert Penn Warren, and Dostoevsky. Positing the uniqueness of literature's ability to promote dialogue on salient moral and intellectual virtues, (...) editor Henry T. Edmonson III has culled together a wide-ranging exploration of such fundamental concerns as the abuse of authority, the nature of good leadership, the significance of "middle class virtues" and the needs of adolescents. This collection reinvigorates the study of classic literature as an endeavor that is not only personally intellectually satisfying, but also an inimitable and unique way to enrich public discourse. (shrink)

The arts of rule cover the exercise of power by princes and popular sovereigns, but they range beyond the domain of government itself, extending to civil associations, political parties, and religious institutions. Making full use of political philosophy from a range of backgrounds, this festschrift for Harvey Mansfield recognizes that although the arts of rule are comprehensive, the best government is a limited one.

lthough it was in the early eighties when I began to feel a growing disaff'ection with the radicalized academic left, a decisive nausea-inducing body blow was administered by the PMLA of January 1989. In that infamous issue appeared a letter signed by twenty-four feminist academics attacking the eminent Shakespeare scholar Richard Levin, for "Feminist Thematics and Shakespearean Tragedy," which had appeared in PMLA the year before. Levin's essay, the work of a well-tempered, open-minded, and liberal supporter of many radical reforms (...) in the academy, was a penetrating critique of the feminist identity politics that were trying to wrest Shakespeare into the persona of a feminist scourge of sexism and patriarchy. Levin's temerity in taking on the distortions of identity politics was threatening enough, but his Enlightenment style and Swiftian wit, which he brilliantly deployed to dismantle the tendentious and self-serving hermeneutics of the "dictatorship of virtue" (a phrase I borrow here from Richard Bernstein) that constitutes avant-garde millenarianism in the U.S. academy, served further to inflame the hypersensitive skins of his holier-than-thou critics, who brook no criticism.. (shrink)