Cases of poor care have been documented across the world. Contrary to professional requirements, evidence indicates that these sometimes go unaddressed. For patients, the outcomes of this inaction are invariably negative. Previous work has either focused on why poor care occurs and what might be done to prevent it, or on the reasons why those who are witness to it find it difficult to raise their concerns. Here, we build on this work but specifically foreground the responsibilities of (...) registrants and students who witness poor care. Acknowledging the challenges associated with raising concerns, we make the case that failure to address poor care is a breach of moral expectation, professional requirement and, sometimes, legal frameworks. We argue that reporting will be more likely to take place if those who wish to enter the profession have a realistic view of the challenges they may encounter. When nurses are provided with robust and applied education on ethics, when “real‐world” cases and exemplars are used in practice and when steps are taken to develop and encourage individual moral courage, we may begin to see positive change. Ultimately however, significant change is only likely to take place where practice cultures invite and welcome feedback, promote critical reflection, and where strong, clear leadership support is shown by those in positions of influence across organisations. (shrink)

In many high-income countries, an initial response to the severe impact of Covid-19 on residential care was to shield residents from outside contacts. As the pandemic progressed, these measures have been increasingly questioned, given their detrimental impact on residents’ health and well-being and their dubious effectiveness. Many authorities have been hesitant in adapting visiting policies, often leaving nursing homes to act on their own safety and liability considerations. Against this backdrop, this article discusses the appropriateness of viewing the continuation (...) of the practice of shielding as a moral failure. This is affirmed and specified in four dimensions: preventability of foreseeable harm, moral agency, moral character, and moral practice (in MacIntyre’s sense). Moral character is discussed in the context of prudent versus proportionate choices. As to moral practice, it will be shown that the continued practice of shielding no longer met the requirements of an (inherently moral) practice, as external goods such as security thinking and structural deficiencies prevented the pursuit of internal goods focusing on residents’ interests and welfare, which in many places has led to a loss of trust in these facilities. This specification of moral failure also allows a novel perspective on moral distress, which can be understood as the expression of the psychological impact of moral failure on moral agents. Conclusions are formulated about how pandemic events can be understood as character challenges for healthcare professionals within residential care, aimed at preserving the internal goods of residential care even under difficult circumstances, which is understood as a manifestation of moral resilience. Finally, the importance of moral and civic education of healthcare students is emphasized to facilitate students' early identification as trusted members of a profession and a caring society, in order to reduce experiences of moral failure or improve the way to deal with it effectively. (shrink)

As the mother of a daughter who has and will always require care to meet her most basic needs, I have seen firsthand how critical it is to have adequate means by which to meet those needs—for her sake, mine, and my family’s. Her flourishing life has contributed to enhancing not only our own, but those of all who care for her and who enter our lives. I have wanted to see us do better by all the families (...) who struggle and have to scratch and claw their way to access services and resources their children need. I have tried in my past writings to articulate the need and the reason why we as a society, as a community, are neither just nor caring as long as we leave their needs unmet. At the same time, I have watched as .. (shrink)

Health‐care and public sector institutions are high‐risk settings for workplace bullying. Despite growing acknowledgement of the scale and consequence of this pervasive problem, there has been little critical examination of the institutional power dynamics that enable bullying. In the aftermath of large‐scale failures in care standards in public sector healthcare institutions, which were characterised by managerial bullying, attention to the nexus between bullying, power and institutional failures is warranted. In this study, employing Foucault's framework of power, (...) we illuminate bullying as a feature of structures of power and knowledge in public sector institutions. Our analysis draws upon the experiences of a large sample (n = 3345) of workers in Australian public sector agencies – the type with which most nurses in the public setting will be familiar. In foregrounding these power dynamics, we provide further insight into how cultures that are antithetical to institutional missions can arise and seek to broaden the debate on the dynamics of care failures within public sector institutions. Understanding the practices of power in public sector institutions, particularly in the context of ongoing reform, has important implications for nursing. (shrink)

The purpose of advance care planning is to allow an individual to maintain autonomy in end-of-life medical decision-making even when incapacitated by disease or terminal illness. The intersection of EOL medical technology, ethics of EOL care, and state and federal law has driven the development of the legal framework for advance directives. However, from an ethical perspective the current legal framework is inadequate to make ADs an effective EOL planning tool. One response to this flawed AD process has (...) been the development of Physician Orders for Life Sustaining Treatment. POLST has been described as a paradigm shift to address the inadequacies of ADs. However, POLST has failed to bridge the gap between patients and their autonomous, preferred EOL care decisions. Analysis of ADs and POLST reveals that future policy should focus on a communications-based approach to ACP that emphasizes ongoing interactions between healthcare providers and patients to optimize EOL medical care to the individual patient. (shrink)

Unfortunately, cases like Mr. Turner’s are common, and likely to become more so in the near future, as the number of people aged 65 and older is expected to increase to about 74 million by 2030, an...

The occurrence of poor patient care is emerging as one of the most significant, challenging, and critical issues confronting contemporary nursing and those responsible for the provision of health care more generally. Indeed, as a consequence of the increased recognition of the manner in which nurses can be implicated in the occurrence of poor patient care, there has been sustained critical debate that seeks to understand how such healthcare failings can occur and, in particular, why nurses seemingly (...) fail to intervene, raise concerns, and effectively respond to prevent the occurrence and continuation of such poor patient care. In seeking to contribute to this critical discussion, and in contrast to those “situational explanations” that maintain that the failure to raise concerns is a consequence of the contextual factors and challenging conditions to which nurses can be subject in the clinical setting, this paper will provide a resolutely philosophical analysis of that failure. In particular, it will draw upon the work of Jean‐Paul Sartre—the French philosopher generally regarded as one of the most influential thinkers of the twentieth century—in order to propose that his work can be productively recontextualized to provide a detailed, challenging, and provocative critical analysis of the occurrence and continuation of poor patient care and the role of individual nurse practitioners in such healthcare failings. (shrink)

Moral Failure: On the Impossible Demands of Morality asks what happens when the sense that "I must" collides with the realization that "I can't." Bringing together philosophical and empirical work in moral psychology, Lisa Tessman here examines moral requirements that are non-negotiable and that contravene the principle that "ought implies can.".

The exercise of identifying lessons in the aftermath of a major public health emergency is of immense importance for the improvement of global public health emergency preparedness and response. Despite the persistence of the Ebola Virus Disease outbreak in West Africa, it seems that the Ebola ‘lessons learned’ exercise is now in full swing. On our assessment, a significant shortcoming plagues recent articulations of lessons learned, particularly among those emerging from organizational reflections. In this article we argue that, despite not (...) being recognized as such, the vast majority of lessons proffered in this literature should be understood as ethical lessons stemming from moral failures, and that any improvements in future global public health emergency preparedness and response are in large part dependent on acknowledging this fact and adjusting priorities, policies and practices accordingly such that they align with values that better ensure these moral failures are not repeated and that new moral failures do not arise. We cannot continue to fiddle at the margins without critically reflecting on our repeated moral failings and committing ourselves to a set of values that engenders an approach to global public health emergencies that embodies a sense of solidarity and global justice. (shrink)

This article examines the consequences of the politicization of health care in the United Kingdom following the creation of the National Health Service (NHS) in 1948. The NHS is founded on the principle of universal access to health care free at the point of use but in reality charges exist for some services and other services are rationed. Not to charge and/or ration would create a common-pool resource with no means of conserving scarce resources. Taking rationing decisions in (...) the political realm means that the values and priorities of individual patients are marginalized and the preferences of powerful organized groups able to capture the political process dominate. The key lesson for international health care reform is that the politicization of health care via the NHS has not led to the realization of egalitarian ends but rather has empowered vested and organized interests at the expense of individual patients. (shrink)

This book is about the ways in which real-world democracies fall short of democratic ideals and why those shortfalls matter. The project is rooted in a vast body of empirical findings that political scientists have accumulated over the last seven decades. These are findings about political ignorance, voter behaviour, the policymaking process, polarization, and the popular control of representatives. These findings are often both surprising and troubling—they suggest our democracies fall far short of democratic ideals. The book is a detailed, (...) careful exploration of why such findings matter. In part, that involves giving an account of what makes democracy valuable in the first place: why does democracy matter? And in part it involves connecting the value of democracy to the rights and duties of ordinary citizens. The overarching argument is that our duties to obey the law, and the moral permissibility of enforcing those laws, depend on the realization of democratic ideals. So the shortfalls of our democracies undermine the moral authority and legitimacy of our states. (shrink)

In his 1993 health-care reform proposal, Bill Clinton offered health care as a civil right. If his proposal had been accepted, all Americans would have been guaranteed a basic package of health care. At the same time, they would have been forbidden to provide or purchase better basic health care, as a cost of participating in a national system to which they were compelled to contribute. A welfare entitlement would have been created and an egalitarian ethos (...) enforced. This essay will address why such egalitarian proposals are morally unjustifiable, both in terms of the establishment of a uniform health-care welfare right, and in terms of the egalitarian constraints these proposals impose against the use of private resources in the purchase of better-quality basic health care, not to mention luxury care. (shrink)

In his 1993 health-care reform proposal, Bill Clinton offered health care as a civil right. If his proposal had been accepted, all Americans would have been guaranteed a basic package of health care. At the same time, they would have been forbidden to provide or purchase better basic health care, as a cost of participating in a national system to which they were compelled to contribute. A welfare entitlement would have been created and an egalitarian ethos (...) enforced. This essay will address why such egalitarian proposals are morally unjustifiable, both in terms of the establishment of a uniform health-care welfare right, and in terms of the egalitarian constraints these proposals impose against the use of private resources in the purchase of better-quality basic health care, not to mention luxury care. (shrink)

The duty to protect patient welfare underpins undergraduate medical ethics and patient safety teaching. The current syllabus for patient safety emphasises the significance of organisational contribution to healthcare failures. However, the ongoing over-reliance on whistleblowing disproportionately emphasises individual contributions, alongside promoting a culture of blame and defensiveness among practitioners. Diane Vaughan’s ‘Normalisation of Deviance’ provides a counterpoise to such individualism, describing how signals of potential danger are collectively misinterpreted and incorporated into the accepted margins of safe operation. NoD is (...) an insidious process that often goes unnoticed, thus minimising the efficacy of whistleblowing as a defence against inevitable disaster. In this paper, we illustrate what can be learnt by greater attention to the collective, organisational contributions to healthcare failings by applying NoD to The Morecambe Bay Investigation. By focusing on a cluster of five ‘serious untoward incidents’ occurring in 2008, we describe a cycle of NoD affecting trust handling of events that allowed poor standards of care to persist for several years, before concluding with a poignant example of the limitations of whistleblowing, whereby the raising of concerns by a senior consultant failed to generate a response at trust board level. We suggest that greater space in medical education is needed to develop a thorough understanding of the cultural and organisational processes that underpin healthcare failures, and that medical education would benefit from integrating the teaching of medical ethics and patient safety to resolve the tension between systems approaches to safety and the individualism of whistleblowing. Data sharing not applicable as no datasets generated and/or analysed for this study. (shrink)

Peterson et al. (2023) outline a broad ethics agenda for imminent research on psychedelic agents for Alzheimer’s disease and related dementias (AD/ADRD) by acknowledging the therapeutic promise of...

Care exploitation pervades our lives. Consider the public school teachers who care about helping children achieve their goals by providing them with a proper education and are expected to do so by parents, administrators, or legislators—even with abysmal pay and little appreciation. Perhaps the most common case of care exploitation is the expectation of a mother to make great (and disproportionate) sacrifices in her life for the well-being of her child, which mothers often meet because they bear (...) a caring orientation toward their child. Despite their willingly assenting, there is something morally problematic about their treatment. I argue that an injustice has been perpetrated against them, drawing on interpersonal accounts of exploitation to highlight that the unique wrong of care exploitation is the failure to respect one’s dignity by taking advantage of their vulnerability of caring about. Following this, I articulate the necessary and jointly sufficient conditions of care exploitation and their relationships to one another. (shrink)

Many health care decisions depend not only upon medical facts, but also on value judgments—patient goals and preferences. Until recent decades, patients relied on doctors to tell them what to do. Then ethicists and others convinced clinicians to adopt a paradigm shift in medical practice, to recognize patient autonomy, by orienting decision making toward the unique goals of individual patients. Unfortunately, current medical practice often falls short of empowering patients. In this article, we reflect on whether the current state (...) of medical decision making effectively promotes patients' health care goals. We base our reflections, in part, on research in which we observed physicians making earnest efforts to partner with patients in making treatment decisions, but still struggling to empower patients—failing to communicate clearly to patients about decision-relevant information, overwhelming patients with irrelevant information, overlooking when patients' emotions made it hard to engage in choices, and making recommendations before discussing patients' goals. (shrink)

In July 2008, Pacific Rim Mining, a socially responsive Canadian gold mining Multinational Corporation (MNC) with $77 million invested in El Salvador, experienced a 30% decline in stock price when it suspended exploration drilling for gold there. In April 2009, the company filed a lawsuit against the government of El Salvador through Central American Free Trade Agreement to recover its investments plus damages. This corporate failure is explored based on: (1) four globalization economic development models, (2) the social, political, and (...) economic history of El Salvador, (3) the El Salvador gold mining industry, and (4) social movement reactions to international mining companies. MNCs must carefully engage "Social Justice" Nongovernment Organizations when pursuing economic development projects to ensure a nation's successful integration into the global economy. (shrink)

In the Netherlands fertility doctors increasingly formulate protocols, which oblige patients to quit their unhealthy lifestyle before they are admitted to IVF procedures. We argue that moral arguments could justify parenting protocols that concern all future parents. In the first part we argue that want-to-be parents have moral responsibilities towards their future children to prevent them from harm by diminishing or eliminating risk factors before as well as during the pregnancy. This is because of the future children's potential to become (...) of a certain type, more specifically: a person that will be the want-to-be parents' child. Want-to-be parents intend to become pregnant and therefore have an additional moral reason to diminish the risks. Also, people who become pregnant unintentionally have the responsibility to prevent their children from harm, unless they become pregnant due to contraception failure. All people not wanting to become pregnant should use contraception methods carefully.In the second part of this paper we translate the want-to-be parents' responsibilities into practice. We distinguish four determinants of risk factors: modifiability, chance, severity and effort. We examine some evidence-based risk factors based on these variables and deduce levels of responsibility.In conclusion, formulating informal requirements for want-to-be parents is morally required and therefore also for want-to-be parents in need of medical assistance. The protocols developed by fertility doctors in the Netherlands could be seen as the precursor for a general, informal Parenting Protocol that could be developed on the basis of an extended and thoroughly debated risk-responsibility analysis. (shrink)

Politics, Philosophy & Economics, Volume 21, Issue 2, Page 165-189, May 2022. It is generally acknowledged that a certain amount of state intervention in health and health care is needed to address the significant market failures in these sectors; however, it is also thought that the primary rationale for state involvement in health must lie elsewhere, for example in an egalitarian commitment to equalizing access to health care for all citizens. This paper argues that a complete theory (...) of justice in health can be derived from a commitment to correcting market failure, or in other words promoting Pareto-efficiency, in the domain of health. This approach can address familiar problems around access to care, as well as problems related to resource allocation and rationing, the control of health care costs, and the foundations of public health. Egalitarian theories of justice in health cannot make sense of the depth and pervasiveness of state involvement in health and health care; only a theory rooted in the need to correct market failure can. (shrink)

Discourses of interdisciplinary health‐care are becoming more centralised in the context of global healthcare practices, which are increasingly based on multisystem interventions. As with all dominant discourses that are narrated into being, many others have been silenced and decentralised in the process. While questions of the nature and constituents of interdisciplinary practices continue to be debated and rehearsed, this paper focuses on the discourse of interdisciplinary collaboration using psychiatry as an example, with the aim of highlighting competing and alternative (...) discourses. The fundamental premise of this paper is that collaborative relationships form the basis of interdisciplinary practices in psychiatry. Through a critical engagement and a deconstructive reading of the pretext, context and subtexts of interdisciplinarity, we interrogate the concept of interdisciplinary practice within psychiatry. We contend that an important part of understanding and further conceptualising the discourse is through fracturing it. This process is illustrated in the successive stages of our conceptual map of discourse development: establishing, maintaining and developing discourses. An understanding of interdisciplinary practice is not only critical for psychiatry, but also offers important insights into the performance of collaborative failures and indeed successes across nursing and allied health professions. (shrink)

Summary Care and cure have been described as different kinds of ethical approaches to clinical situations. Female concerns in nursing care have been contrasted with masculine, cure orientated physician's attitudes. Ethics in such different voices may have sociologic determinants, but they do not represent intrinsic distinctions. Medicine has shown a divergent development, on the one hand stressing cure in a deterministic and instrumental way, on the other hand being aware that disease is as much a pathographic as a (...) biographic, care‐requiring existential situation. Disease is a breakdown of the living organism, to be cured by therapeutic efforts, but it is also the distressing failure of the lived body, requiring concern and care. Based on Lévinas’ ethics of encounter, it is suggested that any interpersonal relatedness is based on concern for the other, being grounded on an essentially ethical interaction. The clinical encounter is a paradigm of such ethics‐based relationships, which necessarily builds on awareness of the other qua other, and is concerned with fulfilling the therapeutic mandate. Caring for the other means doing one's best to help her/him, so that care and cure are inextricably interwoven, although care is the more fundamental form of human relatedness. Thus, neither gender nor professional tasks can allow for a caring attitude to develop without curing concerns, just as trying to cure without caring is unthinkable. (shrink)

In the Netherlands fertility doctors increasingly formulate protocols, which oblige patients to quit their unhealthy lifestyle before they are admitted to IVF procedures. We argue that moral arguments could justify parenting protocols that concern all future parents. In the first part we argue that want‐to‐be parents have moral responsibilities towards their future children to prevent them from harm by diminishing or eliminating risk factors before as well as during the pregnancy. This is because of the future children's potential to become (...) of a certain type, more specifically: a person that will be the want‐to‐be parents' child. Want‐to‐be parents intend to become pregnant and therefore have an additional moral reason to diminish the risks. Also, people who become pregnant unintentionally have the responsibility to prevent their children from harm, unless they become pregnant due to contraception failure. All people not wanting to become pregnant should use contraception methods carefully.In the second part of this paper we translate the want‐to‐be parents' responsibilities into practice. We distinguish four determinants of risk factors: modifiability, chance, severity and effort. We examine some evidence‐based risk factors based on these variables and deduce levels of responsibility.In conclusion, formulating informal requirements for want‐to‐be parents is morally required and therefore also for want‐to‐be parents in need of medical assistance. The protocols developed by fertility doctors in the Netherlands could be seen as the precursor for a general, informal Parenting Protocol that could be developed on the basis of an extended and thoroughly debated risk‐responsibility analysis. (shrink)

In the Netherlands fertility doctors increasingly formulate protocols, which oblige patients to quit their unhealthy lifestyle before they are admitted to IVF procedures. We argue that moral arguments could justify parenting protocols that concern all future parents. In the first part we argue that want‐to‐be parents have moral responsibilities towards their future children to prevent them from harm by diminishing or eliminating risk factors before as well as during the pregnancy. This is because of the future children's potential to become (...) of a certain type, more specifically: a person that will be the want‐to‐be parents' child. Want‐to‐be parents intend to become pregnant and therefore have an additional moral reason to diminish the risks. Also, people who become pregnant unintentionally have the responsibility to prevent their children from harm, unless they become pregnant due to contraception failure. All people not wanting to become pregnant should use contraception methods carefully.In the second part of this paper we translate the want‐to‐be parents' responsibilities into practice. We distinguish four determinants of risk factors: modifiability, chance, severity and effort. We examine some evidence‐based risk factors based on these variables and deduce levels of responsibility.In conclusion, formulating informal requirements for want‐to‐be parents is morally required and therefore also for want‐to‐be parents in need of medical assistance. The protocols developed by fertility doctors in the Netherlands could be seen as the precursor for a general, informal Parenting Protocol that could be developed on the basis of an extended and thoroughly debated risk‐responsibility analysis. (shrink)

If we’re the kind of people who care both about not being racist, and also about basing our beliefs on the evidence that we have, then the world presents us with a challenge. The world is pretty racist. It shouldn’t be surprising then that sometimes it seems as if the evidence is stacked in favour of some racist belief. For example, it’s racist to assume that someone’s a staff member on the basis of his skin colour. But what if (...) it’s the case that, because of historical patterns of discrimination, the members of staff with whom you interact are predominantly of one race? When the late John Hope Franklin, professor of history at Duke University in North Carolina, hosted a dinner party at his private club in Washington, DC in 1995, he was mistaken as a member of staff. Did the woman who did so do something wrong? Yes. It was indeed racist of her, even though Franklin was, since 1962, that club’s first black member. (shrink)

An ethics concerned with health care developments and systems must be historically continuous, especially as it concerns the application to managed structures of key moral-epistemic concepts such as care, love and empathy. These concepts are traditionally most at home in the personal, individual domain. Human beings have non-instrumental worth just because they are human beings and not by virtue of their capacities. Managed health care systems tend to abstract from this worth in respect of both individuals' distinctness (...) and individual identity. The first, a common feature of quantitative approaches to health care assessment and delivery, is avoidable. The second, by contrast, is necessarily sacrificed in impersonally managed structures. Failure to distinguish the two encourages confusion and distress, and the demand for impossible medico-moral relationships. (shrink)

This paper investigates a moral conflict that care workers, defined as workers who care for dependent others, confront when they go on strike. Care workers who confront decisions about whether to go on strike are, in my analysis, caught between impossible options: Should they prioritize the needs of those who are currently dependent upon them, and forego striking, or prioritize their long-term ability to provide the best possible care, and partake in strikes? I argue that (...) class='Hi'>care workers who confront these decisions are often caught in a tragic moral conflict where “moral failure” is inevitable. However, I argue that we should place blame for said moral failures not upon striking care workers themselves but upon employers and others responsible for creating the decision contexts in which care workers must morally fail. I also argue that those responsible for creating the decision contexts in which care workers must morally fail are guilty of various moral and material harms to care workers. (shrink)

In United States ex rel. Quirk v. Madonna Towers, Inc., the U.S. Court of Appeals for the Eighth Circuit held that the failure of a skilled nursing facility's executives to seek a legal opinion regarding a billing practice they considered valid did not meet the definition of knowingly presenting a false claim for payment to the federal government under the False Claims Act. Alleging that the facility that provided care to his aunt fraudulently submitted claims to Medicare for services (...) provided free of charge, the appellant brought this case qui tam on behalf of the federal government under the FCA.The FCA was passed by the legislature in an effort to punish and deter fraud against the federal government. It provides financial incentives for private individuals to come forward with information about fraudulent activity. (shrink)

Literature on consumer ethics tends to focus on issues within the public sphere, such as the environment, and treats other drivers of consumption decisions, such as family, as non-moral concerns. Consequently, an attitude–behaviour gap is viewed as a straightforward failure by consumers to act ethically. We argue that this is based upon a view of consumer behaviour as linear and unproblematic, and an approach to moral reasoning, arising from a stereotypically masculine understanding of morality, which foregrounds abstract principles. By demonstrating (...) the importance of context to consumption decisions and articulating the impact of caring relationships, we highlight how such decisions are both complex and situated. This is particularly evident for decisions involving the needs of others, as occurs in family life. We argue that the incorporation of care ethics provides both theoretical insights and a more complete account of consumer ethics. This is explored empirically through an investigation of the ethical dilemmas arising from consumption decisions made by mothers of young children. Such decisions juxtapose an ethical consumption orientation with care for one’s child. Therefore, what has been previously considered a failure to act ethically may in fact be the outcome of complex decision making, which involves competing ethical considerations. We discuss the implications of our findings for theory and practice and how this approach to consumer ethics could be applied more widely. (shrink)

Historians often feel that standard philosophical doctrines about the nature and development of science are not adequate for representing the real history of science. However, when philosophers of science fail to make sense of certain historical events, it is also possible that there is something wrong with the standard historical descriptions of those events, precluding any sensible explanation. If so, philosophical failure can be useful as a guide for improving historiography, and this constitutes a significant mode of productive interaction between (...) the history and the philosophy of science. I illustrate this methodological claim through the case of the Chemical Revolution. I argue that no standard philosophical theory of scientific method can explain why European chemists made a sudden and nearly unanimous switch of allegiance from the phlogiston theory to Lavoisier's theory. A careful re-examination of the history reveals that the shift was neither so quick nor so unanimous as imagined even by many historians. In closing I offer brief reflections on how best to explain the general drift toward Lavoisier's theory that did take place. (shrink)

Epistemic injustice has rapidly become a powerful tool for analysis of otherwise hidden social harms. Yet empirical research into how resistance to knowing and understanding can be generated and replicated in social programmes is limited. We have identified a range of subtle and not-so-subtle inflections of epistemic injustice as they play out in an intervention for people with chronic depression in receipt of disability benefits. This article describes the different ‘species’ of epistemic injustice observed and reveals how these are unintentionally (...) produced at frontline, management, commissioning and policy levels. Most notably, there remains a privileging of clinical knowledge over other forms of knowledge, producing a ‘pathocentric epistemic complex’. This, combined with the failure of different agencies with competing ideologies to adequately understand each other, and a vicious policy context, added to the injustices already faced by people with mental health issues, generating multiple harms. This has important implications for a range of integrated care and welfare interventions – not least by drawing attention to their unintended potential for replicating epistemic injustice as an institutionalised complex. Careful evaluation and design of such programmes, applying the philosophical and epistemic resources illustrated here, can help mitigate this outcome. Further, by raising awareness of epistemic injustice among programme participants, we can generate epistemic structures that secure programme integrity locally, and promote better policy. (shrink)

I was a second-year neonatal-perinatal fellow in a meeting between other members of the neonatal intensive care team and parents who had just received devastating news about their planned-for and highly desired baby, born after what had been an uncomplicated pregnancy. At home, a little sister was waiting to meet her new brother. These conversations are never easy, but this one I found particularly disturbing. John had been born at term via emergency cesarean section after his mother, Muriel, had (...) come for a routine obstetrical visit and reported decreased fetal movement. The obstetrician had detected a very slow fetal heart rate and sent Muriel to the hospital for emergent delivery. John was born floppy, with no respiratory effort. He was resuscitated, but a heart rate was not detected until fifteen minutes after birth. Not until several months later did I discover what had troubled me so much in this family meeting. (shrink)

In the early 1980s, U.S. universities began regulating sexual relationships between professors and students. Such regulations are routinely justified by a rationale drawn from sexual-harassment law in the employment context: the power differential between professor and student precludes the possibility of genuine consent on the student’s part. This rationale is problematic, as feminists in the 1980s first observed, for its protectionist and infantilizing attitude toward (generally) women students. But it is also problematic in that it fails to register what is (...) truly ethically troubling about consensual professor-student sex. A professor’s having sex with his student constitutes a pedagogical failure: that is, a failure to satisfy the duties that arise from the practice of teaching. What is more, much consensual professor-student sex constitutes a patriarchal failure: such relationships often feed on, and reinforce, women’s second-class standing in higher education. As such, these relationships can thwart the legal right of women students, under Title IX, to exist in the university on equal terms with their male counterparts. Whether or not we should ultimately favor such an interpretation of Title IX—whether or not, that is, it would render campuses ultimately more equal for women and other marginalized people—it is clear that university professors need to attend more carefully to the sexual ethics of their own practice. (shrink)

True beliefs are better guides to the world than false ones. This is the common-sense assumption that undergirds theorizing in evolutionary epistemology. According to Alvin Plantinga, however, evolution by natural selection does not care about truth: it cares only about fitness. If our cognitive faculties are the products of blind evolution, we have no reason to trust them, anytime or anywhere. Evolutionary naturalism, consequently, is a self-defeating position. Following up on earlier objections, we uncover three additional flaws in Plantinga's (...) latest formulation of his argument: a failure to appreciate adaptive path dependency, an incoherent conception of content ascription, and a conflation of common-sense and scientific beliefs, which we diagnose as the ‘foundationalist fallacy’. More fundamentally, Plantinga's reductive formalism with respect to the issue of cognitive reliability is inadequate to deal with relevant empirical details. (shrink)

Publicity for (and laterly increased economic stringency which makes more likely), failures of care in the NHS engender concern for care quality while its assurance remains the subject of a fragmented and unhelpful literature. A selective attempt is made to examine some underlying principles by posing and answering three questions. What is the quality of care? What basic principles must be followed in defining `standards'? How then may quality be assured? Any definition of care must (...) be multi-faceted and in common use pervaded with the patients' pre-occupation with a search for cures. Nevertheless, it is argued that there are gains in restricting the technical use of the term `care' to those systematic processes of health services and their culture which impinge on the personal experience of patients and which fashion their response. In contemporary society care ought to be designed to restore and enhance the independence, dignity and choice of the patient. Although there is a contrary tendency to abandon problems of care to the professionals, standards for care should be judged ultimately not from the specialised professional but from the viewpoint of lay people whose behaviour in the outside world fashions those norms by which independence, dignity and choice are judged. A number of difficulties in identifying and securing improvements in care are discussed. In particular, it is argued that such is the interdependence of the style of management of an institution and the style of care it provides that enforcement of high quality care is likley to be a contradiction in terms. Only trained and sensitive staff can act intuitively and pre-emptively to prevent even incipient deterioration in care. They cannot carefully foster at all times the independence and dignity of their patients unless they are treated in a similar way as professional employees. As an initial step in improving the quality of care a simple start is urged upon implementing an inventory of checks. These are designed to establish the identification and operation of health care policies and practices which give appropriate recognition to the characteristics of care that patients and public expect, coming as they do from a lay rather than professional world. The article concludes with an appropriate inventory of questions to be put to professionals by those laymen who are increasingly imported into health care management through community representation (in CHCs) and staff participation (in joint consultation) and whose interest and concern should be harnessed appropriately. (shrink)

Background Recently, palliative care is increasingly important, with an emphasis on the process of dying with dignity. However, nurses who care for such patients experience the associated ethical dilemmas. Objective To explore the meaning of nurses’ experiences in dealing with ethical dilemmas in relation to palliative sedation. Research design A qualitative research design was employed with a thematic analysis approach. Participants and research context Using purposive sampling, 15 nurses, working at palliative care units for at least 1 (...) year, were recruited as participants. Data were collected using unstructured in-depth interviews, and data collection and analysis was performed simultaneously. Ethical considerations Ethical approval was obtained from the authors’ institutional review board. All participants provided informed consent. For the face-to-face interview, the South Korean standard COVID-19 quarantine guidelines, such as mandatory masking and social distancing, were followed. Results Dilemmas raised by patients, were related to concerns about appropriate drug dose; dilemmas raised by nurses, were related to passive care, sense of guilt for failure to predict death, and colleague’s disrespectful attitudes toward patients; dilemmas from patients’ families were related to demands for palliative sedation and reversal of those demands. Care actions to deal with ethical dilemmas comprised evidence-based care, person-centered thinking, reflecting on the death situation, compassion, providing explanation and help to family members. Conclusion Nurses’ ethical dilemmas were pre-dominantly influenced by themselves, rather than by the patients or their families, especially if they felt they could not do their best for patients. The core concept of care actions to deal with the ethical dilemmas, was person-centered care and compassion. Then, how patients and their family members perceive person-centered care and compassion, should be further explored to improve palliative sedation. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:The Journal of Aesthetic Education 38.1 (2004) 1-11 [Access article in PDF] The Artistic Failure of Crime and Punishment Crime and Punishment Hugh Mercer Curtler This essay begins by noting some fundamental differences between poets, in the broad sense of that term, and philosophers, or those who reflect discursively. It then moves to an examination of the epilogue to Crime and Punishment where Dostoevsky abandons poetry in order to (...) make a philosophical statement about human freedom. 1 Indeed, it can be said that much of Dostoevsky's mature writing was a battle between the man's urge to make pronouncements and the poet's need to control those urges. Fortunately, the poet nearly always won; at times he did not. This can be seen in the case of Crime and Punishment where Dostoevsky, the man, insisted on formulating an idea, specifically, the "idea of freedom." This statement marks the artistic failure of the novel, a concession on the part of the poet to the man. The tension in this novel, and indeed in many novels, is an important focalpoint in the teaching of great literature, because readers of fiction frequently forget that great novels are also great works of art. In this regard, despite the fact that he is an extremely careful reader of Dostoevsky's books, the psychologist/critic René Girard misses in his quest to find hidden messages — precisely what makes Dostoevsky a great artist who writes novels. 2 What this means to teachers of exceptional literature is that we must be attuned not only to what the author says, but also to the way in which he or she says it. In his writings about Dostoevsky, Girard is not terribly interested in what the poet has to say; he is interested in the way the man works out a particular psychological problem. Consequently, like many other critics, Girardglosses over the fundamental difference between the body of Crime and Punishment and its epilogue. Poetry and Philosophy Contrasted There is no truth in art, strictly speaking. If the term "true" has any application whatever to the world of art, it means "honest," or "true to life" [End Page 1] (which, as Kafka has shown, is not terribly important). Moreover, "true" may refer to the work's adherence to rules of craft, its internal harmony and coherence as a distinctive work of the human imagination. What one finds in poetry or linguistic art is a hodgepodge of images, thought fragments, figures, episodes, incidents, hints, and bits and pieces, and (if the poet is a good one) stunning insights. Poetry is, like all art, ineluctably ambiguous. It does not have a "message"; it has many messages. This is precisely why we need art and what makes art different from philosophy in its struggle to eliminate ambiguity. We will not find truth, in the form of knowledge or understanding, among the poet's wares, since knowledge, systematized and rendered coherent by means of the laws of thought, is the charge of the philosopher and his modern stepchildren.What this means is that those who approach novels intent upon finding a message run the risk of hammering poetry into a sheet by reducing it to philosophy. But novels, if they are any good, are not philosophical treatises, and this sort of reduction glosses over fundamental differences of scope and method.In an age that collapses distinctions lazily in order to reduce complex matters to simple terms, we must insist upon the fundamental differences between poets and philosophers. The domain of the philosopher is that of the concept or the principle, of ideas as objects of reflection. Philosophers deal in discursive thought as they seek logical coherence and conceptual clarity. The poet may employ ideas, but he uses them and embodies them imagistically: he does not try to develop them or verify them. 3 The philosopher's domain is unfriendly and unfamiliar to the poet. The law of contradiction reigns supreme there, and this law is anathema to the poet with his love of paradox.The poem presents images that must be apprehended in... (shrink)

In lieu of an abstract, here is a brief excerpt of the content:The Journal of Aesthetic Education 38.1 (2004) 1-11 [Access article in PDF] The Artistic Failure of Crime and Punishment Crime and Punishment Hugh Mercer Curtler This essay begins by noting some fundamental differences between poets, in the broad sense of that term, and philosophers, or those who reflect discursively. It then moves to an examination of the epilogue to Crime and Punishment where Dostoevsky abandons poetry in order to (...) make a philosophical statement about human freedom. 1 Indeed, it can be said that much of Dostoevsky's mature writing was a battle between the man's urge to make pronouncements and the poet's need to control those urges. Fortunately, the poet nearly always won; at times he did not. This can be seen in the case of Crime and Punishment where Dostoevsky, the man, insisted on formulating an idea, specifically, the "idea of freedom." This statement marks the artistic failure of the novel, a concession on the part of the poet to the man. The tension in this novel, and indeed in many novels, is an important focalpoint in the teaching of great literature, because readers of fiction frequently forget that great novels are also great works of art. In this regard, despite the fact that he is an extremely careful reader of Dostoevsky's books, the psychologist/critic René Girard misses in his quest to find hidden messages — precisely what makes Dostoevsky a great artist who writes novels. 2 What this means to teachers of exceptional literature is that we must be attuned not only to what the author says, but also to the way in which he or she says it. In his writings about Dostoevsky, Girard is not terribly interested in what the poet has to say; he is interested in the way the man works out a particular psychological problem. Consequently, like many other critics, Girardglosses over the fundamental difference between the body of Crime and Punishment and its epilogue. Poetry and Philosophy Contrasted There is no truth in art, strictly speaking. If the term "true" has any application whatever to the world of art, it means "honest," or "true to life" [End Page 1] (which, as Kafka has shown, is not terribly important). Moreover, "true" may refer to the work's adherence to rules of craft, its internal harmony and coherence as a distinctive work of the human imagination. What one finds in poetry or linguistic art is a hodgepodge of images, thought fragments, figures, episodes, incidents, hints, and bits and pieces, and (if the poet is a good one) stunning insights. Poetry is, like all art, ineluctably ambiguous. It does not have a "message"; it has many messages. This is precisely why we need art and what makes art different from philosophy in its struggle to eliminate ambiguity. We will not find truth, in the form of knowledge or understanding, among the poet's wares, since knowledge, systematized and rendered coherent by means of the laws of thought, is the charge of the philosopher and his modern stepchildren.What this means is that those who approach novels intent upon finding a message run the risk of hammering poetry into a sheet by reducing it to philosophy. But novels, if they are any good, are not philosophical treatises, and this sort of reduction glosses over fundamental differences of scope and method.In an age that collapses distinctions lazily in order to reduce complex matters to simple terms, we must insist upon the fundamental differences between poets and philosophers. The domain of the philosopher is that of the concept or the principle, of ideas as objects of reflection. Philosophers deal in discursive thought as they seek logical coherence and conceptual clarity. The poet may employ ideas, but he uses them and embodies them imagistically: he does not try to develop them or verify them. 3 The philosopher's domain is unfriendly and unfamiliar to the poet. The law of contradiction reigns supreme there, and this law is anathema to the poet with his love of paradox.The poem presents images that must be apprehended in... (shrink)

In lieu of an abstract, here is a brief excerpt of the content:The Journal of Aesthetic Education 38.1 (2004) 1-11 [Access article in PDF] The Artistic Failure of Crime and Punishment Crime and Punishment Hugh Mercer Curtler This essay begins by noting some fundamental differences between poets, in the broad sense of that term, and philosophers, or those who reflect discursively. It then moves to an examination of the epilogue to Crime and Punishment where Dostoevsky abandons poetry in order to (...) make a philosophical statement about human freedom. 1 Indeed, it can be said that much of Dostoevsky's mature writing was a battle between the man's urge to make pronouncements and the poet's need to control those urges. Fortunately, the poet nearly always won; at times he did not. This can be seen in the case of Crime and Punishment where Dostoevsky, the man, insisted on formulating an idea, specifically, the "idea of freedom." This statement marks the artistic failure of the novel, a concession on the part of the poet to the man. The tension in this novel, and indeed in many novels, is an important focalpoint in the teaching of great literature, because readers of fiction frequently forget that great novels are also great works of art. In this regard, despite the fact that he is an extremely careful reader of Dostoevsky's books, the psychologist/critic René Girard misses in his quest to find hidden messages — precisely what makes Dostoevsky a great artist who writes novels. 2 What this means to teachers of exceptional literature is that we must be attuned not only to what the author says, but also to the way in which he or she says it. In his writings about Dostoevsky, Girard is not terribly interested in what the poet has to say; he is interested in the way the man works out a particular psychological problem. Consequently, like many other critics, Girardglosses over the fundamental difference between the body of Crime and Punishment and its epilogue. Poetry and Philosophy Contrasted There is no truth in art, strictly speaking. If the term "true" has any application whatever to the world of art, it means "honest," or "true to life" [End Page 1] (which, as Kafka has shown, is not terribly important). Moreover, "true" may refer to the work's adherence to rules of craft, its internal harmony and coherence as a distinctive work of the human imagination. What one finds in poetry or linguistic art is a hodgepodge of images, thought fragments, figures, episodes, incidents, hints, and bits and pieces, and (if the poet is a good one) stunning insights. Poetry is, like all art, ineluctably ambiguous. It does not have a "message"; it has many messages. This is precisely why we need art and what makes art different from philosophy in its struggle to eliminate ambiguity. We will not find truth, in the form of knowledge or understanding, among the poet's wares, since knowledge, systematized and rendered coherent by means of the laws of thought, is the charge of the philosopher and his modern stepchildren.What this means is that those who approach novels intent upon finding a message run the risk of hammering poetry into a sheet by reducing it to philosophy. But novels, if they are any good, are not philosophical treatises, and this sort of reduction glosses over fundamental differences of scope and method.In an age that collapses distinctions lazily in order to reduce complex matters to simple terms, we must insist upon the fundamental differences between poets and philosophers. The domain of the philosopher is that of the concept or the principle, of ideas as objects of reflection. Philosophers deal in discursive thought as they seek logical coherence and conceptual clarity. The poet may employ ideas, but he uses them and embodies them imagistically: he does not try to develop them or verify them. 3 The philosopher's domain is unfriendly and unfamiliar to the poet. The law of contradiction reigns supreme there, and this law is anathema to the poet with his love of paradox.The poem presents images that must be apprehended in... (shrink)

The object of this essay is to explore the central role played by the ‘ethic of care’ in debates within and beyond feminist legal theory. The author claims that the ethic of care has attracted feminist legal scholars in particular, as a means of resolving the theoretical, political and strategic difficulties to which the perceived ‘crisis of subjectivity’ in feminist theory has given rise. She argues that feminist legal scholars are peculiarly placed in relation to this crisis because (...) of their reliance on the social ‘woman’ whose interests are the predominant concern of feminist legal engagement. With the problematisation of subjectivity, the object of feminist legal attention disappears and it is in attempts to deflect the negative political consequences of this that the ethic of care has been invoked, the author argues, unsuccessfully. The essay concludes with suggestions as to how the feminist project in law might proceed in the wake of the crisis of subjectivity and the failure of the ethic of care to resolve it. (shrink)

Whether practiced by ethics committees or clinical ethicists, medical ethics enjoys a solid foundation in acute care hospitals. However, medical ethics fails to have a strong presence in the primary care setting. Recently, some ethicists have argued that the reason for this disparity between ethics in the acute and primary care setting is that primary care ethics is distinct from acute care ethics: the failure to translate ethics to the primary care setting stems from (...) the incorrect belief that acute care ethics can be applied to the primary care setting. In this paper, I argue that primary care ethics and acute care ethics are species of the same ethical genus, and that the ethical differences are not ones of kind but of circumstance. I do this by appealing to the role obligations that underlie acute care and primary care clinicians’ medical ethical obligations and the shared institutions that ground those obligations. (shrink)

BlOMQVIST K, THEANDER E, MOWIDE I and LARSSON V. Nursing Inquiry 2010; 17: 317–323 What happens when you involve patients as experts? a participatory action research project at a renal failure unitAlthough there is a trend towards developing health care in a patient‐centred direction, changes are usually planned by the professionals without involving the patients. This paper presents an ongoing participatory action research project where patients with chronic renal failure, nurses at a specialist renal failure unit, a hospital manager (...) and a researcher worked together to develop patient‐centred care. The project combined the expertise of patients in their own experiences of living with a chronic condition with the professional expertise of nurses, the manager and the researcher. As the workload on the unit was uneven, the development work needed to be low in intensity but long‐term. Based on a number of dialogues in focus groups, four main development areas were identified; access to test results, prerequisites for postponing the progress of the illness, general awareness and understanding of living with chronic renal failure, and family‐focused care. A number of changes have been planned or implemented, such as developing a prototype for a web‐based feed‐back system, expanding patient education to newly diagnosed patients, steering the nurses' role towards a guiding and family‐focused function, and planning a digital story‐telling workshop. Involving committed people who have the mandate to change practices were prerequisites for success. (shrink)