The COVID-19 pandemic has upended in-person public education across the United States, a critical infrastructure of care that parents—especially mothers—depend on to work. To understand the nature and magnitude of school closures across states, we collected detailed primary data—the Elementary School Operating Status database —to measure the percentage of school districts offering in-person, remote, and hybrid instruction models for elementary schools by state in September 2020. We link these data to the Current Population Survey to evaluate the association between (...) school reopening and parents’ labor force participation rates, comparing 2020 labor force participation rates to those observed prepandemic in 2019. We find that, across states, the maternal labor force participation rate fell to a greater extent than that of fathers. In 2019, mothers’ rate of labor force participation was about 18 percentage points lower than fathers’. By 2020, this gap grew by 5 percentage points in states where schools offered primarily remote instruction. We show that schools are a vital source of care for young children, and that without in-person instruction, mothers have been sidelined from the labor force. The longer these conditions remain in place, the more difficult it may be for mothers to fully recover from prolonged spells of nonemployment, resulting in reduced occupational opportunities and lifetime earnings. (shrink)

The outbreak of SARS-CoV-2 has exposed a shared condition of vulnerability on a global scale. How can we use vulnerability as an effective paradigm in order to foster collective political initiatives? This essay claims that the idea of care is key to understand the vulnerability framework as being both an epistemic and a political resource to address ethical issues. The first half of the essay recollects several arguments in Adriana Cavarero’s and Judith Butler’s most recent works, insofar as both (...) theorists have insisted on the notion of vulnerability in order to interpret contemporary political mobilizations. The second part of the essay retraces a constellation of practices of care in the works of several Black and decolonial feminist thinkers situated in different socio-political contexts. Whereas for Christina Sharpe and Saidiya Hartman the focus is on the matter of Blackness and Black lives in their constitutive vulnerability, both Cristina Rivera Garza’s and Sayak Valencia’s works remarkably insist on the specific socio-political context of today’s Mexico. These authors urge the readers to adopt a critical posture when encountering official narratives, also because in their texts they exhibit their own vulnerability. For them, writing, their writing is an ethical demand to imagine alternatives and to foster new entanglements between bodies persisting on the margins, at the limits of the norms that regulate legibility. (shrink)

Next SectionIntensification of poverty and degradation of health infrastructure over recent decades in countries most affected by HIV/AIDS present formidable challenges to clinical research. This paper addresses the overall standard of health care (SOC) that should be provided to research participants in developing countries, rather than the narrow definition of SOC that has characterised the international debate on standards of health care. It argues that contributing to sustainable improvements in health by progressively ratcheting the standard of care (...) upwards for research participants and their communities is an ethical obligation of those in resource-rich countries who sponsor and implement research in poorer ones. (shrink)

Together with large biobanks of human samples, medical registries with aggregated data from many clinical centers are vital parts of an infrastructure for maintaining high standards of quality with regard to medical diagnosis and treatment. The rapid development in personalized medicine and pharmaco-genomics only underscores the future need for these infrastructures. However, registries and biobanks have been criticized as constituting great risks to individual privacy. In this article, I suggest that quality with regard to diagnosis and treatment is an (...) inherent, morally normative requirement of health care, and argue that quality concerns in this sense may be balanced with privacy concerns. (shrink)

Imagine you suddenly find yourself in the control room of a vast technological apparatus, sometime in the future, where you are told that science has satisfied all the needs of all living humans. Furthermore, you learn, the next generation of the species will not be produced in the usual way, but instead by this machine, provided only that somebody push a little red button. The catch: you have to give a reason for pushing it. You hesitate: what do you say? (...) Our own world is more like this scenario than we at first may be inclined to admit, not least in the fact that, mutatis mutandis, we seem to be struggling to come up with a good answer. The problem, says Rémi Brague, is fundamentally a metaphysical one. Now, mention of 'metaphysics' in decent society these days is likely to elicit a smile or an unimpressed shrug. If there is a shelf with that label on it in your typical bookstore you are as likely to find guides to crystals, chakras, or hemp care there as you are treatises by Aristotle, Aquinas, or Kant. And, in spite of the ongoing revival of academic interest in metaphysics, it remains a rather specialist domain, a marginal sub-discipline in departments of philosophy, be they analytical or continental in cast. But if you should take it too seriously, you'll lose your bearings in the real world, and you'll go adrift in some ethereal sea of dreams. It is, in a word, irrelevant--right? (shrink)

In The Republic of the Living, Miguel Vatter argues that, at the end of the 1970s, Michel Foucault did not convert to but criticized neoliberalism from a republican point of view. Neoliberal governmentality allegedly represses the capacity of human collectives to democratically govern themselves. The potential for republican self- government would then constitute the basis for an affirmative variant of biopolitics. I argue that this creative reformulation of Foucault’s oeuvre does not work as an interpretation of Foucault nor as a (...) valid critique of neoliberalism. Using the influ- ence of Georges Canguilhem on Foucault, I propose to locate the potential for affirmative biopolitics not in the collective capacity for self-government, but in the fragility of living beings in their interaction with their milieu. Because life is con- stitutively dependent on infrastructural conditions to flourish, we need a biopolitics that establishes institutions which support the sustenance of life. (shrink)

This article attends to the intimate contradictions that differentially shape and limit caring capacities and relations in a violent world, and the embodied ethical and political transformations at the heart of learning to care otherwise. From manifestos calling for ‘universal care’ in defiance of the state-sanctioned horrors of the pandemic era, to the abolitionist politics of care developed by BLM organizers through movement building and healing, and the proliferation of mutual-aid infrastructures to meet needs and distribute (...) resources in the face of overwhelming crisis and neglect—these examples and so many others illustrate with undeniable clarity that radical care is finally on the agenda. In what follows, I hope to contribute to this urgent conversation by pointing to how care is shaped in fundamentally contradictory ways under conditions of entrenched structural violence, and the limitations of normative frameworks when confronting this reality. To unambiguously valorize care in ethical and political life is to risk occluding the constitutive violence of existing social structures and norms, its impact on the intimacies of caring relations, and ultimately the ways that communities mobilize alternate economies and practices of care towards healing and social change. While it is crucial to value care and work for a more caring society, I claim that efforts to transform patterns of relational harm and develop new sensibilities should also be highlighted as integral components of radical caring praxis. (shrink)

While caregiving in northern, rural and remote communities takes place in the context of conditions unique to smaller communities, caregivers live with social policies that are shaped by urban norms rather than rural realities. In times of economic decline and government cuts rural issues of limited services and infrastructure as well as dependency on a single industry can lead to unemployment, community and family instability, and a decline in health and well-being. During these times caregivers face increased pressure to voluntarily (...) fill the gaps left by service cuts. Research with women caregivers in four communities in northern British Columbia (BC), Canada explores the experiences of caring and the social, geographic, economic and political contexts within which the caregiving occurs. The discourse of economic efficiencies that speaks solely to the monetary value of care is contrasted with the human condition of connectedness and relationships. These two contradictory perspectives are uncovered during interviews with women caregivers and analyzed in the framework of Olena Hankivsky's discussion of an ethic of care. (shrink)

Most components of urban infrastructure remain hidden. Due to this condition, we do not think about them in a way that pays attention to the full scope of moral possibilities. For instance, when such topics are forced from the periphery of our thinking to the forefront of our minds, it is usually in terms of figuring out who to blame when they fail to function properly. In turn, one could argue that we only care to talk about an action’s (...) moral status that pertains to infrastructure when it becomes a hazard. While this point deserves examination, the more significant issue is that we lack the moral language required to have conversations about moral praise regarding public works. The purpose of this paper, then, is to flesh out how to discuss morality and infrastructure regarding moral praise. (shrink)

In clinical research there is a tension between the role of a doctor, who must serve the best interests of the patient, and the role of the researcher, who must produce knowledge that may not have any immediate benefits for the research participant. This tension is exacerbated in HIV research in low and middle income countries, which frequently uncovers comorbidities other than the condition under study. Some bioethicists argue that as the goals of medicine and those of research are distinct, (...) it is a mistake for researchers to assume therapeutic responsibilities while engaging in research. Others propose that there is a duty of care, but disagree as to how this is limited and specified. In this qualitative study, principal investigators from HIV prevention trials discuss their experience of providing medical benefits to participants within the context of conducting research into HIV biomedical prevention technologies. They describe the limitations imposed at times by funders and at times by infrastructure constraints, and canvass the importance of ancillary care provision and capacity building in trial communities. The views of the principal investigators are compatible with the perspective that there is a duty of care, limited by the nature of the research, the depth of the relationship between research and participant, and the capacity of the research site. The therapeutic orientation in HIV prevention trial appears to be indivisible from competent research practise by making concrete and appropriate benefits available to trial participants and their communities that support rather than compete with local infrastructure. (shrink)

This paper explores ethical concerns arising in healthcare integration. We argue that integration is necessary imperative for meeting contemporary and future healthcare challenges, a far stronger evidence base for the conditions of its effectiveness is required. In particular, given the increasing emphasis at the policy level for the entire healthcare infrastructure to become better integrated, our analysis of the ethical challenges that follow from the logic of integration itself is timely and important and has hitherto received insufficient attention. We evaluated (...) an educational intervention which aims to improve child health outcomes by making transitions between primary to secondary care more efficient, ensuring children and parents are better supported throughout. The programme provided skills for trainee paediatricians and general practitioners in co-designing integrated clinical services. The key ethical challenges of integrated care that arose from a clinical perspective are: professional identity and autonomy in an integrated working environment; the concomitant extent of professional responsibility in such an environment; and the urgent need for more evidence to be produced on which strategies for integrating at scale can be based. From our analysis we suggest a tentative way forward, viewed from a normative position broadly situated at the intersection of deontology and care ethics. We adopt this position because the primary clinical ethical issues in the context of integrated care concern: how to ensure that all duties of care to individual patients are met in a newly orientated working environment where clinical responsibility may be ambiguous; and the need to orientate care around the patient by foregrounding their autonomous preferences and ensuring good patient clinician relationships in clinical decision-making. (shrink)

A critique and provincialization of Western social science and Global Northern academia by the author of The Digital Coloniality of Power, exposing shared colonial and extractive rationalities and histories of research, higher education, digitalization and bioeconomy while proposing in the idea of BluesCollarship a sketch for an alternative culture of worlding and commoning knowledge work and for making care matter in research and higher education. In a discourse analysis and provincialization of research and higher education, a tradition of elitarian (...) White Collaredness in academia and in the social sciences in general is criticized and an alternative attitude towards the production, transfer and use of knowledge - BluesCollarship - is proposed. The latter is rooted in a different idea of what 'infrastructure' is and in practices of decoloniality. Noting the current political climate of propaganda and populism, the persistence of social inequalities as well as of racism and misogynism, it is proposed that how people give warrant for knowledge claims should be reviewed under different terms. A coherent theme is that there is a genealogical root for current neo-extractive and neo-colonial rationalities in the Athenian idea of oikos conflating family, household, and property. In taking a distinctly writerly approach - rather than giving ready-made answers - the book aims at permanently provoking readers at every turn to think further, as well as before-and-beyond what is written, but to do so in thinking together with Others. Thereby the book addresses scholars and students from across the social sciences who seek challenges to established ways of thinking in academia without simply replacing one canon for merely another. This book is for those who think of themselves as knowledge and cultural laborers in this age of precarization who seek to replace the university and cognitive capitalism with a pluriversity and an infrastructure build on knowledge and culture as fundamental value. (shrink)

Mounting evidence suggests that participation in clinical trials confers neither advantage nor disadvantage on those enrolled. Narrow focus on the question of a “trial effect,” however, distracts from a broader mechanism by which patients may benefit from ongoing clinical research. We hypothesize that the existence of clinical trials infrastructure—the organizational culture, systems, and expertise that develop as a product of sustained participation in cooperative clinical trials research—may function as a quality improvement lever, improving the quality of care and outcomes (...) of all patients within an institution or region independent of their individual participation in trials. We further contend that this “infrastructure effect” can yield particular benefits for patients in low- and middle-income countries. The hypothesis of an infrastructure effect as a quality improvement intervention, if correct, justifies enhanced research capacity in LMIC as a pillar of health system development. (shrink)

Power, dominance, and hierarchy are prevalent analytical terms in social studies of health care. Power is often seen as residing in medical structures, institutions, discourses, or ideologies. While studies of medical power often draw on Michel Foucault, this understanding is quite different from his proposal to study in detail the “strategies, the networks, the mechanisms, all those techniques by which a decision is accepted” [Foucault, M. (1988). In Politics, philosophy, culture: Interviews and other writings 1977–84 (pp. 96–109). New York: (...) Routledge]. This suggestion turns power into a topic worth investigating in its own right rather than a basic analytical resource. It also suggests that technologies form an integral part of the networks and mechanisms, which produce and redistribute power in medical practice. The paper first engages critically with a number of recent discussions of technology and power in health care analysis. It then formulates an alternative conception of this relationship by drawing on Foucault and historian of science and technology Geoffrey C. Bowker’s notions of infrastructural inversion and information mythology. Illustration is provided through a case study of a wireless nursing call system in a Canadian hospital. (shrink)

Prior research has shown that human trafficking has multiple facets and is deeply enmeshed in societies around the world. Two central challenges for anti-trafficking organizations pertain to confronting systemic injustices and establishing caring organizations for survivors to start the process of healing and restoration. Analyzing the work of an anti-trafficking organization, International Sanctuary in Mumbai, we seek to elucidate how a space for caring for trafficking survivors is constructed in a largely non-egalitarian and unjust context. We contribute to discussions on (...) how caring infrastructures are possibly developed so that they do not write off existing gendered and in-egalitarian social structures and how they shape individual biographies. We also highlight how the specific, situated context—defined by those very structures—shapes and influences the transformative potential of care interventions. (shrink)

In the discussion of the Anthropocene, infrastructures play an eminent role as expression of man’s deep interference with nature. They mediate the planet by fundamentally shaping the relation between man and environments with long-lasting effects. While infrastructures are understood as stable formations, they need constant care to function properly. Against this background, the paper analyses abandoned infrastructures with respect to their precarious state between nature and culture, between life and death, fragility and stability. In der Diskussion (...) des Anthropozäns spielen Infrastrukturen eine herausragende Rolle als Ausdruck des tiefen Eingriff s des Menschen in die Natur. Sie vermitteln den Planeten, indem sie die Beziehung zwischen Mensch und Umwelt mit langfristiger Wirkung grundlegend gestalten. Während Infrastrukturen als stabile Formationen verstanden werden, brauchen sie ständige Pflege, um richtig zu funktionieren. Vor diesem Hintergrund analysiert der Beitrag verlassene Infrastrukturen in Bezug auf ihren prekären Zustand zwischen Natur und Kultur, zwischen Leben und Tod, Fragilität und Stabilität. (shrink)

In the discussion of the Anthropocene, infrastructures play an eminent role as expression of man’s deep interference with nature. They mediate the planet by fundamentally shaping the relation between man and environments with long-lasting effects. While infrastructures are understood as stable formations, they need constant care to function properly. Against this background, the paper analyses abandoned infrastructures with respect to their precarious state between nature and culture, between life and death, fragility and stability. In der Diskussion (...) des Anthropozäns spielen Infrastrukturen eine herausragende Rolle als Ausdruck des tiefen Eingriff s des Menschen in die Natur. Sie vermitteln den Planeten, indem sie die Beziehung zwischen Mensch und Umwelt mit langfristiger Wirkung grundlegend gestalten. Während Infrastrukturen als stabile Formationen verstanden werden, brauchen sie ständige Pflege, um richtig zu funktionieren. Vor diesem Hintergrund analysiert der Beitrag verlassene Infrastrukturen in Bezug auf ihren prekären Zustand zwischen Natur und Kultur, zwischen Leben und Tod, Fragilität und Stabilität. (shrink)

This paper represents one of the first critical social science interrogations of an agrifood just-in-case transition. The just-in-case transition speaks to a philosophy that values building buffers and flexibility into longer value chains to make them more resilient to shocks, which stands in contrast to the just-in-time philosophy with its emphasis on long, specialized, and often inflexible networks. Influenced by COVID-related disruptions and climate change induced uncertainties, the just-in-case transition examined here centers on the heightened interest in vertical farm-anchored supply (...) chains. Interviewing actors responsible for promoting vertical farm-anchored local supply chains in the US and Canada, I attempt to sketch out how these spaces, infrastructures, and practices care. Put differently, as understood through a feminist ethics of care, _whom_ and _what_ are cared for and _how_ is care practiced in these just-in-case transitions and _why_? Enumerative politics was observed in the data—the idea that we can make care count. Practices and discourses linked to infrastructural/supply chain transitions are highlighted that result in care being narrowly conceived as a technical or transactional matter. The paper concludes reflecting on what it means to afford just-in-case agrifood transitions animated by matters of care that hold greater emancipatory potentials. (shrink)

Intense interspecies engagements are central to the work of ecologists, as they seek to understand our rapidly changing world. To explore researcher-bird engagements in ecological fieldwork, we use a lens of care. Taking as a starting point the widely shared photos of bird-in-the-hand that portray situations where individual birds become sources of data about populations, we show the significance of complex care work in ethically and epistemically loaded moments. Crucial knowledge about survival, biodiversity loss and animal welfare emerges (...) at the intersection of multispecies care for individuals, for populations and for knowledge infrastructures. We put forth the concept of intermittent care to explain the changing concerns for individual birds here-and-now or for populations of the future. Attention to care therefore helps unravel how ecological knowing depends on entanglements between humans, nature, and technologies that take shape through a constant negotiation of different strands and matters of multispecies care. (shrink)

The health care industry has moved at a rapid pace away from paper records to an electronic platform across almost all sectors — much of it at the encouragement and insistence of the federal government. Such rapid expansion has increased exponentially the risk to individuals in the privacy of their data and, increasingly, to their physical well-being when medical records are inaccessible through ransomware attacks. Recognizing the unique and critical nature of medical records, the United States Congress established the (...) Health Care Industry Cybersecurity Task Force under the Cybersecurity Information Sharing Act of 2015 for the purpose of reviewing cybersecurity risks within the health care industry and identifying who will lead and coordinate efforts to address such risks among the various agencies. The Task Force has since issued a report setting forth six high-level imperatives that the health care industry needs to achieve in order to combat cybersecurity, and, notably, many of the vulnerabilities plaguing the industry identified in the Report as requiring correction are not necessarily related to specific flaws in the current cybersecurity framework, but rather susceptibilities presented by the infrastructure and associated regulatory regime that has evolved over the last few decades over the health care industry generally. That is, the current health care infrastructure by its nature exacerbates cybersecurity risk. Between a lack of information sharing of industry threats, risks, and mitigations, disparate leadership and governance goals for cybersecurity, the confluence and contradiction of existing federal and state laws, fragmentation in the fee-for-service delivery system, lack of care coordination, and disparate resources across and among sectors, the industry suffers from heightened cyber risk. Solutions that are reactive to problems within the current infrastructure will likely have little long term impact toward reducing cybersecurity vulnerabilities because they do not address the underlying system challenges. All of these confluences causes one to wonder whether if in fact the current health care delivery infrastructure is a contributing factor to the incidents of cybersecurity attacks and the exorbitant costs associated with resolving data breaches, should Congress look not just to curb breach incidents, but to address root cause systematic challenges in the health industry infrastructure that create increased exposure of cybersecurity threats? This article argues that cybersecurity risks will continue to be heightened and more costly to the health care industry as compared to other industries unless and until some general system redesign is achieved that allows for greater sharing of resources among industry participants to ensure the same protections are implemented at all levels of the industry, which can be strengthened through greater interoperability of systems across the health care industry; and increased focus and attention on the importance of cybersecurity issues as a priority among system reforms. (shrink)

Critical infrastructure services determine where people can survive and what they can do with their survival. This fact conditions political possibilities at a fundamental level but remains underexplored in the literature. Those who wish to extend the boundaries of political action, or to win protections and the possibility of a new political community for themselves and others, should focus a substantial part of their energies and attention on developing alternative infrastructure systems for supporting human life. Without such systems, political action (...) – no matter how revolutionary or ingenious – will ultimately find itself constrained by its position within the zones of survivability established by existing forms of infrastructure and by the hierarchies and configurations of power linked with those forms of infrastructure. As a result, those who wish to change current political and economic conditions should think of the capacity to take care of everyone as a condition for such change rather than its result. (shrink)

Midwives and nurses play a critical role in safeguarding the lives of women in resource-constrained African countries. Working within the context of scarce resources may undermine their moral agency and hinder their ability to care. The purpose of this paper is to understand the influence of resource scarcity on midwifery and nursing care and practice. A critical ethnography was conducted in the obstetric department of three tertiary-level facilities in Ghana. Purposive sampling was used to recruit 30 midwives and (...) nurses and semistructured interviews, field notes and documentary materials were used to generate in-depth understanding. Ethical approval was granted from Canada and Ghana and written, and ongoing informed consent was obtained from the participants. Five conceptual themes depicting the impact of scarce resources on midwifery and nursing care were discovered: compromised care, constrained care, dehumanized care, missed care and disengaged care. Improving the maternal health of women and averting avoidable maternal morbidity and mortality require governments and institutions to invest in health infrastructure that will support the delivery of ethical and safe midwifery care for women in their most vulnerable period. (shrink)

The global distribution of laboratory mouse strains is valued for ensuring the continuity, validity and accessibility of model organisms. Mouse strains are therefore assumed mobile and able to travel. We draw on the concept of ‘animal mobilities’ to explain how attending to laboratory mice as living animal, commodity and scientific tool is shaping how they are transported through contemporary scientific infrastructures and communities. Our paper is framed around exploring how animal strains travel, rather than animals, as we show that (...) it is only through understanding strain mobility that we can explain how and why live animal movement can be replaced by germinal products. The research is based on qualitative fieldwork in 2018 and 2019 that included 2 weeks ethnography and interviews with key informants involved in the movement of laboratory animals. The empirical analysis discusses practices that relate to managing biosecurity and animal welfare concerns when moving laboratory animal strains. In closing we reflect more broadly on the contemporary ‘ethico-onto-epistemological’ entanglement that shapes who or what travels to support laboratory science data-making practices, and the intensity of care ‘tinkering’ practices that facilitate the movement. We explain how a laboratory animal strain exceeds its value solely as a mobile and thus exchangeable commodity, illustrated in how values that relate to animal sentience and infection-risk supports its material transformation. Consequently, it is becoming increasingly common for non-sentient germinal products – embryos and gametes - to replace live sentient animals when being moved. (shrink)

In times like these, a new ethico-political ideal is required to contest the adequacy of dominant understandings of social interaction as matters of choice and rational decision-making and in contesting these understandings encourage us to imagine social alternatives. We wish to make a contribution to this project of expanding the universe of political discourse as a means to invigorating ethico-political debate. A range of existing vocabularies — the languages of trust (and relatedly respect), care and associated concepts, including corporeal (...) generosity — are currently put forward as the means to contest the dominance of neo-liberal premises about `atomistic individualism'. While many of these accounts focus on nation-states, others attend to an emerging global community. Nevertheless, we have some reservations about these languages and their premises. In our view they tend frequently to locate the `problem' in the character of citizens. We also make the case that such languages and their associated political agendas reinstate aspects of social hierarchy that mimic neo-liberal conceptions of autonomous individualism. Central to our critique is the claim that the problematic aspects of these existing languages of (inter)connection are due to an attenuated understanding of embodiment and an inadequate dialogue between the socio-political and embodiment. It is this inadequate dialogue we wish to redress. In this paper we offer a new ethical ideal called `social flesh' to ground an alternative politics for reconfiguring exploitative social relations. As an ethico-political starting point, `social flesh' highlights human embodied interdependence and in the process configures a new, more transformative political vision. It draws attention to shared embodied reliance, mutual reliance, of people across the globe on social space, infrastructure and resources. Insistence upon this shared reliance underpins a profoundly levelling perspective, a radical politics. (shrink)

Within contemporary health care, many of the decisions affecting the health and well-being of patients are not being made by the clinicians or health professionals, but by those involved in health care management. Existing literature on organizational ethics provides insight into the various structures, processes and strategies - such as mission statement, ethics committees, ethical rounds … - that exist to create an organizational climate, which fosters ethical practices and decision-making It does not, however, show how health (...) class='Hi'>care managers experience their job as being intrinsically ethical in itself. In the present article, we investigate the way in which ethical values are present in the lived experiences and daily practice of health care management. What does it imply to take up a managing position within a health care institution and to try to do this in an ethically inspired way? We carried out a qualitative study (Grounded Theory Approach) to explore the essence of values-based leadership in health care. We interviewed 15 people with extensive experience in health care management in the fields of elderly care, hospital care and mental health care in the various regions of Flanders, Belgium. Six predominant themes, presented as metaphors, illustrate the essence of values-based leadership in health care management. These are: (1) values-based health care management as managing a large garden, (2) as learning and using a foreign language, (3) going on a trekking with an ethical compass, (4) embodying integrity and authenticity in a credible encounter with everyone, (5) being a present and trustworthy leader during sun and storm, and (6) contributing to human flourishing by giving people wings to fly. Notwithstanding the importance of organizing a good ethics infrastructure, values-based leadership in health care entails much more than that. It is about the co-creation of an integrated and comprehensive ethical climate of which community-model thinking and authentic leadership are essential components. As a never-ending process, the six metaphors can help leaders to take substantive proactive steps to shape a fruitful ethical climate within their organization. (shrink)

In this third paper in a series of four, we explore some ways of doing education differently. An education that moves beyond the persistent failures and irredeemable injustices of modern mass schooling episteme. The episteme for education we adumbrate – an episteme of life continuance – begins with a recognition of interdependency and the value of diversity, diverse knowledges and relations of tolerance. We propose an escape from the extinction ethics which modern schools perpetuate and a new grammar of living (...) in which education and politics are processes of re-learning, co-learning, decision taking, limit testing, and conflict resolution in relation to an uncertain future. To achieve this, we outline a set of open and ‘unplanned’ commoning activities that would take place within local social infrastructures focused on re-politising learning itself and practicing the care of oneself, others, community and the environment. The proposal for a different education as common(ing) activities undertaken within social infrastructures, is about reimagining political and environmental relations, and co-creating a sense of collective ownership of and responsibility for the environment. A form of community that it is practical, rather than utopian, and that would be both the means and ends for such an education. (shrink)

This paper is going to explore the adverse effects of exposure to combat death on medics’ holistic well-being, which, if ignored could decrease individual readiness and negatively impact the mission. We rely on the experience of United States Air Force Special Operation Surgical Teams (AF SOST) whose exposure to mass casualty scenarios in austere environments could serve as approximations of conditions of future battlefields. Over the past two decades, the ability to deliver advanced medical care on and off the (...) battlefield along with a rapid casualty evacuation platform has allowed for unprecedented survival rates exceeding 90%. While laudable, these medical achievements have also set up a casualty management paradigm in which medical decision-making singularly focuses on life-saving care. Confronting peer-peer adversaries in large scale combat operations (LSCO) on a multi-domain battlefield will make casualty management frighteningly more complex by introducing major infrastructural, personnel, and resource constraints. When considering the high number of casualties expected in LSCO alongside enormous limitations in medical resource and resupply capability, the current casualty management paradigm will not be sustainable. The resource constrained environment in LSCO will shift medical decision-making away from a singular focus on life-saving care to triage, which hinges on the ability to determine futile medical interventions—a skill that has been lost in the past two generation of combat medics. As such, a broad ethical challenge that arises in preparation for LSCO is the need to set new expectations concerning dying and death. However, medical decision-making focused on death and dying has not been explicitly addressed in military medical training, research, or policy. Relying on a body of literature known as terror management theory (TMT) and ethnographic data from our study with AF SOST medics, we are going to argue that it is important to expose medics to death in mass casualty and triage training. (shrink)

This article engages with debates about the status and geographies of colonial science by arguing for the significance of meteorological knowledge making in late nineteenth- and early twentieth-century Mauritius. The article focuses on how tropical storms were imagined, theorized and anticipated by an isolated – but by no means peripheral – cast of meteorologists who positioned Mauritius as an important centre of calculation in an expanding infrastructure of maritime meteorology. Charles Meldrum in particular earned renown in the mid-nineteenth century for (...) theoretical insights into cyclone behaviour and for achieving an unprecedented spatial reach in synoptic meteorology. But as the influx of weather data dried up towards the end of the century, attention turned to developing practices of ‘single-station forecasting’, by which cyclones might be foreseen and predicted not through extended observational networks, but by careful study of the behaviour of one set of instruments in one place. These practices created new moral economies of risk and responsibility, as well as a ‘poetry’, as one meteorologist described it, in the instrumental, sensory and imaginative engagement with a violent atmospheric environment. Colonial Indian Ocean ‘cyclonology’ offers an opportunity to reflect on how the physical, economic and cultural geographies of an island colony combined to produce spaces of weather observation defined by both connection and disconnection, the latter to be overcome not only by infrastructure, but also by the imagination. (shrink)

The passage of the Patient Protection and Affordable Care Act in March 2010 represents a significant turning point in the evolution of health care law and policy in the United States. By establishing a legal infrastructure that seeks to achieve universal health insurance coverage in the United States, the ACA targets some of the major impediments to accessing needed health care for millions of Americans and by extension attempts to strengthen the health system to support key determinants (...) of health. Yet, like many newly passed legislative provisions, the ultimate effects and significance of the ACA remain uncertain. Those charged with implementing the ACA face formidable obstacles — indeed, some of the same obstacles that have been erected to impede other major pieces of social legislation in the past — including entrenched political opposition, constitutional challenges, and what will likely be a prolonged struggle over the content and direction of how the law is implemented. As these debates continue, it is nevertheless important to begin to assess the impact that the ACA has already had on health law in the United States and to consider the likely effects that the law will have on public health going forward. (shrink)

The widespread adoption of health information technology has been recognized as both a necessary element of health reform and a required building block of a modern, high performing health care system.

This paper depicts a case study of an organizational strategy for the promotion of ethical practice when introducing a new, high-risk, ethically-charged medical practice like Medical Assistance in Dying (MAiD). We describe the development of an interprofessional program that enables the delivery of high-quality, whole-person MAiD care that is values-based and sustainable. A “care ecology” strategy recognizes the interconnected web of relationships and structures necessary to support a quality experience of MAiD for patients, families, and clinicians. This program (...) exemplifies a care ecology approach that addresses common barriers to entry to MAiD practice, and also meets the needs of a variety of stakeholders through the creation of patient and family resources, team supports, standards of practice, professional development opportunities, organizational infrastructure, and community partnerships. We also describe how a thriving care ecology evolves to remain resilient, and to enable integration as the needs of the organization, team and program change over time. The design and development of this program may be adapted to other jurisdictions and organizations where MAiD is introduced, or where new patient populations become eligible for MAiD. This care ecology model may also be applicable to the creation of sustainable programs that provide other morally controversial or novel clinical services. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Bringing Cancer Care to Those who Don't Have ItLawrence N. ShulmanI have been treating cancer patients in the Harvard Medical School hospitals since 1977, and in those 35 years we have made tremendous progress. Though work still needs to be done, and far too many patients still die of cancer, many are cured. In particular, children and young adults have a high rate of cure from such diseases (...) as Hodgkin's lymphoma, non-Hodgkin's lymphoma, acute lymphoblastic leukemia, and childhood sarcoma. Patients with breast cancer in the US have a greater than 80% chance for long-term survival. The death rate from cervical cancer in the US is very low. These results have been achieved by making diagnoses earlier, in many cases surgical excision, and often systemic therapies such as chemotherapy, hormonal therapy, radiation therapy, and more recently by using so-called "targeted" therapies—those directed at particular molecular characteristics of the cancer cells.Princess Dina Mired has said that the opportunity to survive cancer should not be an accident of geography. In cases where we already have effective and inexpensive tools to cure cancer, these treatments should be considered a basic human right, a life-saving medical service.I met Patty, a young woman living in the U.S. during November of her senior year in high school, after she discovered a small lump above her left collar bone. Though she felt entirely well, she called her primary care doctor who saw her the next day, felt the enlarged lymph node, and referred her to a surgeon, who did a biopsy later that week. Her primary care doctor also called me, and we scheduled a visit when the pathology results were available. The following week the pathologist notified Patty's pediatrician that the biopsy showed Hodgkin's lymphoma. When I met Patty, she was a bright and focused young woman, waiting to hear about her college applications and enjoying her senior year. Her cancer diagnosis was completely out of context with her life as she planned it, but with the support of her family and boyfriend, she seemed prepared to take things one step at a time. A PET CT scan demonstrated a modest mass in the mediastinum (chest), but no other disease. She was in an early stage of the disease with an excellent prognosis. We recommended and administered six months of chemotherapy with doxorubicin, bleomycin, vinblastine, and dacarbazine—four chemotherapy agents that are off-patent, and relatively inexpensive. She lost her hair, not a trivial issue for her, but otherwise felt reasonably well during the treatment. She was determined to graduate with her classmates, and was able continue to attend school and keep up with her work. In June, seven months into her cancer diagnosis and treatment, she graduated with honors, and was on track to enroll in college in September.Like other 18-year-old women with Hodgkin's lymphoma, Patty had an over 80% chance for cure with the potential for a long and productive life ahead of her because we could perform a biopsy, make a diagnosis, and safely and effectively treat her with four inexpensive, off-patent, chemotherapy drugs. She had nearly the same likelihood of living a long and fruitful life as her classmates, and had the same chances for childbearing. In my line of work, with the knowledge we now possess, to allow someone like Patty to die without a chance of curative care is simply unacceptable. Treatment of curable cancers should be considered on par with the right to clean water, adequate nutrition, treatment for infectious disease, and access to maternal and child healthcare services.But in many places in the world, people with cancers we could easily eradicate in Boston have no access to cancer services, and do die unnecessarily. The local healthcare infrastructure has no [End Page E10] capacity to evaluate a patient, perform or process a biopsy, make a diagnosis, or treat the patient with potentially curative surgery, chemotherapy and radiation. I have rounded on the wards of hospitals in developing countries, stopping to talk with numerous patients like Patty: young women, some of whom might have had Hodgkin's lymphoma, but no... (shrink)

Responses to the COVID-19 pandemic globally disrupted lives and contributed to the exacerbation of pre-existing inequalities. Women in research were also affected. The prominent role that women played in professional and personal care duties had a detrimental effect on their research outputs, potentially hindering their career progression. Moreover, the challenges faced by women academics during the pandemic, including job loss, increased mental health issues, and the intersection of gender with other socio-demographic traits exacerbated existing gender disparities within academia. By (...) systematically scoping the qualitative literature on the experiences of women researchers during the pandemic, this study sought to explore how women experienced and reacted to the challenges generated by the COVID-19 pandemic. A qualitative meta synthesis of the included studies revealed three themes: gendered professional expectations, colliding identities and coping strategies. These themes show how gendered roles such as teaching and professional care work, associated with the hierarchical and gendered division of tasks both at home and in the workplace, made women feel unsupported and alienated as relevant agents in the academic context. The study reveals the importance of pastoral care, teaching and service work as the essential backbone of the academic infrastructure, especially in times of crises. It also exposes how productivity-focused researcher assessment criteria, rewarding mainly individual results and unrewarding of care and service work, can be viewed as perpetuating structural inequalities based on gender, parenting situations, contractual situations and background. In conclusion, this study exposes the need to proactively address the gendered practices and implicit biases which reproduce inequalities within academia and highlights how paying attention to the experiences and needs of women researchers is essential for improving the resilience and crises preparedness of academic the system. (shrink)

Information technology is considered a potentially transformative element in the field of health care by payers, providers, vendors, and consumers alike. Because of this transformative potential, health information technology adoption is viewed by many as a key component of health system reform. HIT is in its earliest stages, with diffusion of the technology still relatively limited; at the same time, there is growing awareness of its potential to affect the operation of the entire health care system as a (...) result of the vast amount of information that will become available to both health professionals and patients. (shrink)

Background eHealth was widely used during the COVID-19 pandemic. Much attention was given to the technical aspects of eHealth, such as infrastructure and cost, while the soft skill of compassion remained underexplored. The wide belief in compassionate care is more compatible with in-person interactions but difficult to deliver via e-platforms where personal and environmental clues were lacking urges studying this topic. Purpose to explore the experience of delivering compassionate care via an eHealth platform among healthcare professionals working to (...) contain the COVID-19 pandemic. Methods A qualitative study design with an interpretative phenomenological analysis approach was used. Twenty healthcare professionals (fifteen nurses and five physicians) who provided care using technology platforms, such as telephone hotlines, mobile apps, and social media, were interviewed individually. Ethical considerations Permission to conduct the study was obtained from the Institutional Review Board. Results Participants stated that “eHealth enabled compassionate care during the pandemic” by ensuring patient care availability and accessibility. They shared experiences of “communicating compassionate care via eHealth” with suggestions of addressing patients’ needs with empathy, adopting a structured protocol to guide eHealth communication, and using more advanced visual-media methods to promote human-to-human interaction. They recommended “setting realistic mutual expectations” considering the limitations of eHealth in handling complex health situations and staffing shortages. Participants considered “low eHealth literacy hinders compassion.” Additionally, they recommended the need for “institutional/system-level support to foster compassionate care.” Conclusion Participants recognized the importance of integrating compassion into eHealth services. Promotion of compassionate care requires standardization of eHealth services with institutional and system-level support. This also includes preparing adequate staffing who can communicate compassionate care via eHealth, set realistic expectation, and adjust communication to eHealth literacy level while meeting the needs of their patients. (shrink)

This paper describes the approach of empirical ethics, a form of ethics that integrates non-positivist ethnographic empirical research and philosophy. Empirical ethics as it is discussed here builds on the ‘empirical turn’ in epistemology. It radicalizes the relational approach that care ethics introduced to think about care between people by drawing in relations between people and technologies as things people relate to. Empirical ethics studies care practices by analysing their intra-normativity, or the ways of living together the (...) actors within these practices strive for or bring about as good practices. Different from care ethics, what care is and if it is good is not defined beforehand. A care practice may be contested by comparing it to alternative practices with different notions of good care. By contrasting practices as different ways of living together that are normatively oriented, suggestions for the best possible care may be argued for. Whether these suggestions will actually be put to practice is, however, again a relational question; new actors need to re-localize suggestions, to make them work in new practices and fit them in with local intra-normativities with their particular routines, material infrastructures, know-how and strivings. (shrink)

Human rights protect the conditions of a minimally decent life of which mental health is an indispensable element. Adequate care for mental health is thus recognized as part of the human right to health. However, for populations living far from urban centers, adequate in-person (mental) health care is often extremely costly and thus not provided. Digital mental health care options have become an effective alternative to in-person treatment. Benefitting from these new digital opportunities, though, requires sufficient access (...) to the internet. Because everyone has a human right to adequate health care, and digital mental health care is now an effective option for progressively realizing this human right for people who live in remote regions, these people also have to be understood to have a right to access to the internet. This right to internet access creates duties for public authorities and the international community to create the required digital infrastructure and (where needed) to cover the costs of internet access where this is the only feasible way of delivering, or progressively realizing, the mental health care that is indispensable for having the opportunity to lead minimally decent lives. (shrink)

Biobanking, the large-scale, systematic collection of data and tissue for open-ended research purposes, is on the rise, particularly in clinical research. The infrastructures for the systematic procurement, management and eventual use of human tissue and data are positioned between healthcare and research. However, the positioning of biobanking infrastructures and transfer of tissue and data between research and care is not an innocuous go-between. Instead, it involves changes in both domains and raises issues about how distinctions between research (...) and care are drawn and policed. Based on an analysis of the emergence and development of clinical biobanking in the Netherlands, this article explores how processes of bio-objectification associated with biobanking arise, redefining the ways in which distinctions between research and clinical care are governed. (shrink)

In this paper, we tell the story of efforts currently underway, on diverse fronts, to build digital knowledge repositories to support research in the life sciences. If successful, knowledge bases will be part of a new knowledge infrastructure—capable of facilitating ever-more comprehensive, computational models of biological systems. Such an infrastructure would, however, represent a sea-change in the technological management and manipulation of complex data, inducing a generational shift in how questions are asked and answered and results published and circulated. Integrating (...) such knowledge bases into the daily workflow of the lab thus destabilizes a number of well-established habits which biologists rely on to ensure the quality of the knowledge they produce, evaluate, communicate and exploit. As the story we tell here shows, such destabilization introduces a situation of unfamiliarity, one that carries with it epistemic risks. It should elicit—to use Niklas Luhmann’s terms—the question of trust: a shared recognition that the reliability of research practices is being risked, but that such a risk is worth taking in view of what may be gained. And yet, the problem of trust is being unexpectedly silenced. How that silencing has come about, why it matters, and what might yet be done forms the heart of this paper. (shrink)

The promises of precision medicine are often heralded in the medical and lay literature, but routine integration of genomics in clinical practice is still limited. While the “last mile” infrastructure to bring genomics to the bedside has been demonstrated in some healthcare settings, a number of challenges remain — both in the receptivity of today's health system and in its technical and educational readiness to respond to this evolution in care. To improve the impact of genomics on health and (...) disease management, we will need to integrate both new knowledge and new care processes into existing workflows. This change will be onerous and time-consuming, but hopefully valuable to the provision of high quality, economically feasible care worldwide. (shrink)

In 2005, The International Federation of Organic Agricultural Movements (IFOAM) developed four new ethical principles of organic agriculture to guide its future development: the principles of health, ecology, care, and fairness. The key distinctive concept of animal welfare in organic agriculture combines naturalness and human care, and can be linked meaningfully with these principles. In practice, a number of challenges are connected with making organic livestock systems work. These challenges are particularly dominant in immature agro-ecological systems, for example (...) those that are characterized by industrialization and monoculture. Some of the current challenges are partly created by shortages of land and manure, which encourage zero-grazing and other confined systems. Other challenges are created in part by the conditions for farming and the way in which global food distribution systems are organized, e.g., how live animals are transported, how feed is traded and transported all over the globe, and the development of infrastructure and large herds. We find that the overall organic principles should be included when formulating guidelines for practical organic animal farming. This article explores how the special organic conceptions of animal welfare are related to the overall principles of organic agriculture. The aim is to identify potential routes for future development of organic livestock systems in different contexts and with reference to the specific understanding of animal welfare in organic agriculture. We include two contrasting cases represented by organic livestock systems in northwestern Europe and farming systems in tropical low-income countries; we use these cases to explore the widely different challenges of organic livestock systems in different parts of the world. (shrink)

Futile treatment. Do not resuscitate. These terms and the thoughts they evoke may be unfamiliar to families with ill children. Similarly, laws, such as the Americans with Disabilities Act or the Emergency Medical Treatment and Active Labor Act, are probably unfamiliar. Yet these terms and laws, and, more important, their implications, are part of a new world of health care into which more families are thrust—the world of wrenching and complicated decisions.Although the number of these situations is increasing and (...) even predictable, the infrastructure of support services for families dealing with these medical decisions for seriously ill children has not been adequately addressed or developed. Parents know that some children are born with or develop serious illnesses and die. Amid absorbing large amounts of new information and interpreting the parameters and implications of what they are learning about their child's condition, families are forced by circumstances to assess—and to act on—their most critical, and perhaps previously unexamined, values. (shrink)

Futile treatment. Do not resuscitate. These terms and the thoughts they evoke may be unfamiliar to families with ill children. Similarly, laws, such as the Americans with Disabilities Act or the Emergency Medical Treatment and Active Labor Act, are probably unfamiliar. Yet these terms and laws, and, more important, their implications, are part of a new world of health care into which more families are thrust—the world of wrenching and complicated decisions.Although the number of these situations is increasing and (...) even predictable, the infrastructure of support services for families dealing with these medical decisions for seriously ill children has not been adequately addressed or developed. Parents know that some children are born with or develop serious illnesses and die. Amid absorbing large amounts of new information and interpreting the parameters and implications of what they are learning about their child's condition, families are forced by circumstances to assess—and to act on—their most critical, and perhaps previously unexamined, values. (shrink)

This article reports on ethnographic research into the practical and ethical consequences of the implementation and use of telecare devices for older people living at home in Spain and the United Kingdom. Telecare services are said to allow the maintenance of their users’ autonomy through connectedness, relieving the isolation from which many older people suffer amid rising demands for care. However, engaging with Science and Technology Studies literature on “user configuration” and implementation processes, we argue here that neither services (...) nor users preexist the installation of the service: they are better described as produced along with it. Moving beyond design and appropriation practices, our contribution stresses the importance of installations as specific moments where such emplacements take place. Using Etienne Souriau’s concept of instauration, we describe the ways in which, through installation work, telecare services “bring into existence” their very infrastructure of usership. Hence, both services and telecare users are effects of fulfilling the “felicity conditions” of an achieved installation. (shrink)

: Widespread collection and use of identifiable information can promote social goods while, at the same time, infringing on personal privacy. Information systems are developing within the context of a fundamental transformation in the organization, delivery, and financing of health care. Changes in the health care system include rapid development of employer-sponsored health coverage, managed care organizations, and integrated delivery systems. These complex, multifaceted arrangements for delivering and paying for health care require ever-more-sophisticated information systems that (...) facilitate extensive sharing of personal data. Systemic flows of sensitive health information occur both vertically and horizontally among employers, hospitals, insurers, laboratories, and suppliers. Beyond this complex web of vertical and horizontal sharing are the multiple demands for information management, quality assurance, research, governmental regulation, and public health. Theoretical problems exist with the law and ethics of informational privacy. The traditional method of exercising control over personal health information is through informed consent. Informed consent, however, within a modern health information infrastructure becomes highly complex. In this kind of environment, the doctrine of informed consent is flawed and does not provide sufficient control over personal information to assure adequate protection of privacy. (shrink)

Following an initial study of the needs of healthcare providers (HCP) regarding the introduction of Medical Assistance in Dying (MAiD), and the subsequent development of an assisted dying program, this study sought to determine the efficacy and impact of MAiD services following the first two years of implementation. The first of three aims of this research was to understand if the needs, concerns and hopes of stakeholders related to patient requests for MAiD were addressed appropriately. Assessing how HCPs and families (...) perceived the quality of MAiD services, and determining if the program successfully accommodated the diverse needs and perspectives of HCPs, rounded out this quality evaluation. This research implemented a mixed-methods design incorporative of an online survey with Likert scale and open-ended questions, as well as focus groups and interviews with staff and physicians, and interviews with MAiD-involved family members. There were 356 online surveys, as well as 39 participants in six focus groups with HCP, as well as fourteen interviews with MAiD-involved family members. Participants indicated that high-quality MAiD care could only be provided with enabling resources such as policies and guidelines to ensure safe, evidence-based, standardized care, as well as a specialized, trained MAiD team. Both focus group and survey data from HCPs suggest the infrastructure developed by the hospital was effective in delivering high-quality MAiD care that supports the diverse needs of various stakeholders. This study may serve as a model for evaluating the impact and quality of services when novel and ethically-contentious clinical practices are introduced to healthcare organizations. (shrink)

To provide basic health care services in rural areas is one of the major challenges for developing countries like Bangladesh because of lack of infrastructures and unavailability of qualified medical doctors in the villages. Telemedicine viewed as a new way of offering health care services that has the potential to overcome this problem. Author is a member of extended group at Dhaka University (DU) which has been developing telemedicine equipment and data acquisition software to promote telemedicine practice (...) in Bangladesh. PC based ECG equipment, Digital stethoscope, Digital microscope, Digital X-ray view box and some other essential medical equipment was developed for telemedicine services. The data acquisition software establishes an easy and appropriate patients to doctor interaction through a trained operator in a remote center that involve management and arrangement of consultation of a chosen and agreeing doctor by a patient. Upon establishing audio-visual connection between patient and doctor relevant physiological data from different diagnostic instruments will be uploaded securely in a dedicated web server which can be viewed real time using unique patient/doctor ID and password. Recently the Telemedicine group of DU and a local NGO named SAMAMA with support from Service innovation fund (SIF) of Prime Minister Office (PMO) of Bangladesh took the initiative to establish eight rural telemedicine centers and one expert center for the field trial of telemedicine in Bangladesh. The aim of this paper is to examine the ethical challenges of such health care system and our effort to overcome those problem before starting the field trial. (shrink)

Background Over the last decade, the return of results (ROR) in precision medicine research (PMR) has become increasingly routine. Calls for individual rights to research results have extended the “duty to report” from clinically useful genetic information to traits and ancestry results. ROR has thus been reframed as inherently beneficial to research participants, without a needed focus on who benefits and how. This paper addresses this gap, particularly in the context of PMR aimed at increasing participant diversity, by providing investigator (...) and researcher perspectives on and questions about the assumed value of ROR in PMR.Methods Semi-structured interviews with a purposive sample of investigators and researchers across federally funded PMR studies in three national consortia, as well as observations of study activities, focused on how PM researchers conceptualize diversity and implement inclusive practices across research stages, including navigating ROR.Results Interviewees (1) validated the value of ROR as a benefit of PMR, while others (2) questioned the benefit of clinically actionable results to individuals in the absence of sufficient resources for translating findings into health care for diverse and disadvantaged populations; (3) expressed uncertainties in applying the presumed value of ROR as a benefit for non-clinical results; and (4) and debated when the promise of the value of ROR may undermine trust in PMR, and divert efforts to return value beyond ROR.Conclusions Conceptualizations of diversity and inclusion among PM researchers and investigators raise unique ethical questions where unexamined assumptions of the value of ROR inform study recruitment efforts to enroll minoritized and under-represented populations. A lack of consideration for resources and infrastructure necessary to translate ROR into actionable information may hinder trustworthy community-research relationships. Thus, we argue for a more intentional interrogation of ROR practices as an offer of benefit and for whom. (shrink)