The expressions ‘high quality care’ and ‘low quality care’ are cognitive and linguistic artefacts that help to structure people’s lives and thinking; for example, moves are now afoot internationally to pay bonuses to health professionals for delivering high quality care. United States programmes, most conspicuously, are assuming that high quality care can be validly distinguished from low quality care, and incentivised through bonuses. This distinction is always at least implicit, for high quality care has no meaning without low quality care. (...) Through a ‘deconstructionist reading,’ this article discusses limitations of categorising the quality of care as either high or low. The limitations of this ‘binary opposition’ can include a lack of defining attributes; vagueness and fuzziness at the ‘boundaries’ between high quality care and low quality care; concealment of quality as a continuum; and use of the binary opposition to effect social order and control. Health policy implications of our analysis are discussed. Drawing upon the general medical services contract in the United Kingdom, we suggest an approach to overcoming the oversimplification and imprecision that categorisation tends to produce. (shrink)

Body image research focuses almost exclusively on women or overweight and obesity or both. Yet, body image concerns among thin men are common and can result, at least in part, from mixed messages in society around how men qua men should dress and behave in order to look good and feel good. Stand-alone interventions to meet these different messages tend to provide men with little therapeutic relief. This conceptual paper draws on literature from the medical humanities; gender and body image (...) studies; the social psychology of clothing; and the author’s own lived experience to address this contemporary problem. The paper embraces visual culture as a resource that can frame discussion of how two sets of ‘performativity’ might reduce male anxiety about thinness. First, thin men could choose repeatedly to wear masculine-looking clothing, which could create their masculinity as a personal aesthetic that strengthens the confidence to harness masculine traits in healthy ways. Secondly, health and allied health service providers could promote and reinforce such dress behavior by offering advice that integrates aesthetic and functional aspects of clothing. Empirical studies are needed to test this dual model of performativity. (shrink)

Power is an inescapable aspect of all socialrelationships, and inherently is neither goodnor evil. Doctors need power to fulfil theirprofessional obligations to multipleconstituencies including patients, thecommunity and themselves. Patients need powerto formulate their values, articulate andachieve health needs, and fulfil theirresponsibilities. However, both parties canuse or misuse power. The ethical effectivenessof a health system is maximised by empoweringdoctors and patients to develop `adult-adult'rather than `adult-child' relationships thatrespect and enable autonomy, accountability,fidelity and humanity. Even in adult-adultrelationships, conflicts and complexitiesarise. Lack of (...) concordance between doctors andpatients can encourage paternalism but may bebest resolved through negotiated care. Afurther area of conflict involves the `doubleagency' of doctors for both patients and thecommunity. Empowerment of all players is notalways possible but is most likely where eachparty considers and acknowledges power issues. (shrink)

New Zealand and United Kingdom governments have set new directives for increased consultation with the public about health care. Set against a legacy of modest success with past engagement with public consultations, this paper considers potentially adverse ethical implications of the new directives. Drawing on experiences from New Zealand and the United Kingdom, and on an Orthodox Jewish perspective, the paper seeks to answer two questions: What conditions can compromise the ethics of public consultation? How can the public respond ethically (...) to consultation? In answering these questions, the paper considers how Orthodox Judaism, as a specific positive morality, can aid the development of public policy. It is suggested that an Orthodox Jewish perspective does not require limiting the content of public consultations and helps to define a common procedural morality binding Jews and non-Jews. This procedural morality requires avoiding two conditions that, as shown from Jewish texts, make public consultation unethical. These are overpreparation and underpreparation. Members of the public who deem a consultation unethical should give feedback not on the proposal but on the conditions they perceive to prevent the consulting party from considering their viewpoints on the proposal. (shrink)

Person-centered care offers a promising way to manage clinicians’ conscientious objection to providing services they consider morally wrong. Health care centered on persons, rather than patients, recognizes clinicians and patients on the same stratum. The moral interests of clinicians, as persons, thus warrant as much consideration as those of other persons, including patients. Interconnected moral interests of clinicians, patients, and society construct the clinician as a socially embedded and integrated self, transcending the simplistic duality of private conscience versus public role (...) expectations. In this milieu of blurred boundaries, person-centered care offers a constructive way to accommodate conscientious objection by clinicians. The constitutionally social nature of clinicians commits and enables them, through care mechanisms such as self-care, to optimize the quality of health care and protect the welfare of patients. To advance these conditions, it is recommended that the medical profession develop a person-centered culture of care, along with clinician virtues and skills for person-centered communication. (shrink)

There is now broad agreement that ideas like person-centred care, patient expertise and shared decision-making are no longer peripheral to health discourse, fine ideals or merely desirable additions to sound, scientific clinical practice. Rather, their incorporation into our thinking and planning of health and social care is essential if we are to respond adequately to the problems that confront us: they need to be seen not as “ethical add-ons” but core components of any genuinely integrated, realistic and conceptually sound account (...) of healthcare practice. This, the tenth philosophy thematic edition of the journal, presents papers conducting urgent research into the social context of scientific knowledge and the significance of viewing clinical knowledge not as something that “sits within the minds” of researchers and practitioners, but as a relational concept, the product of social interactions. It includes papers on the nature of reasoning and evidence, the on-going problems of how to 'integrate' different forms of scientific knowledge with broader, humanistic understandings of reasoning and judgement, patient and community perspectives. Discussions of the epistemological contribution of patient perspectives to the nature of care, and the crucial and still under-developed role of phenomenology in medical epistemology, are followed by a broad range of papers focusing on shared decision-making, analysing its proper meaning, its role in policy, methods for realising it and its limitations in real-world contexts. (shrink)

Modern technologies sanction a new plasticity of physical form. However, the increasing global popularity of aesthetic procedures produces normative beauty ideals in terms of perfection and symmetry. These conditions limit the semblance of freedom by people to control their own bodies. Cultural emancipation may come from principles in Eastern philosophy. These reveal beauty in authenticity, including imperfection. Wabi-sabi acclaims beauty in common irregularity, while kintsugi celebrates beauty in visible signs of repair, like scars. These principles resist pressure to medicalize dissatisfaction (...) with healthy bodies and invite multi-sited interventions to educate taste and aesthetic choices. (shrink)

When the editorial to the first philosophy thematic edition of this journal was published in 2010, critical questioning of underlying assumptions, regarding such crucial issues as clinical decision making, practical reasoning, and the nature of evidence in health care, was still derided by some prominent contributors to the literature on medical practice. Things have changed dramatically. Far from being derided or dismissed as a distraction from practical concerns, the discussion of such fundamental questions, and their implications for matters of practical (...) import, is currently the preoccupation of some of the most influential and insightful contributors to the on‐going evidence‐based medicine debate. Discussions focus on practical wisdom, evidence, and value and the relationship between rationality and context. In the debate about clinical practice, we are going to have to be more explicit and rigorous in future in developing and defending our views about what is valuable in human life. (shrink)

Cooperation and conversation in the public sphere may overcome historical and other barriers to rational argumentation. As an alternative to evidence-based medicine (EBM) and patient-centered care (PCC), the recent development of a modern version of person-centered medicine (PCM) signals an opportunity for a conversational pluralogue to replace parallel monologues between EBM and its critics, and the calls to EBM to debate its critics. This article draws upon elements of Habermas’s theory of communicative action in order to suggest the kind of (...) pluralogue that is required for stakeholders in modern medicine to benefit more from publicly conversing with each other than speaking alone or using debate to argue against each other. This reasoned perspective has lessons for all discourse when deep value-based and epistemological differences cannot be easily adjudicated. (shrink)

This paper questions the conventional wisdom that physicians must suppress anger in response to patient misbehaviour. It distinguishes the emotion of anger from its expression, which leans toward concerned frustration and disappointment for the sake of professionalism in patient care. Drawing on the framework of person-centred health care as a virtue ethic, the paper first suggests four reasons why and when physician anger toward patient behaviour may occasionally be appropriate: the inevitability of sometimes feeling angry, anger as a cognitive and (...) behavioural resource, physician well-being, and potential patient benefit. The paper then proposes five conditions under which physician anger displays may be prudent as a measured response that balances emotional expression with professional conduct: ethical intention, rational justification, proportionality, problem-focused constructive expression, and precision. Potential benefits of this conceptualization of prudent anger include improved physician wellbeing, enhanced communication, and patient education to address perceived patient misbehaviour. The paper advocates for a cultural shift in health care environments to help allow for more authentic expression of physician frustration, aiming to harness prudent anger as a catalyst for positive change in patient-physician relationships and systemic improvements in health care delivery. (shrink)

Something important is happening in applied, interdisciplinary research, particularly in the field of applied health research. The vast array of papers in this edition are evidence of a broad change in thinking across an impressive range of practice and academic areas. The problems of complexity, the rise of chronic conditions, over-diagnosis, co- and multimorbidity are serious and challenging, but we are rising to that challenge. Key conceptions regarding science, evidence, disease, clinical judgement, health and social care, are being revised and (...) their relationships reconsidered: boundaries are indeed being redrawn; reasoning is being made 'fit for practice'. Ideas like 'person-centred care' are no longer phrases with potential to be helpful in some yet-to-be-clarified way: theorists and practitioners are working in collaboration to give them substantive import and application. (shrink)

Last year saw the 20th anniversary edition of JECP, and in the introduction to the philosophy section of that landmark edition, we posed the question: apart from ethics, what is the role of philosophy ‘at the bedside’? The purpose of this question was not to downplay the significance of ethics to clinical practice. Rather, we raised it as part of a broader argument to the effect that ethical questions – about what we should do in any given situation – are (...) embedded within whole understandings of the situation, inseparable from our beliefs about what is the case, what it is that we feel we can claim to know, as well as the meaning we ascribe to different aspects of the situation or to our perception of it. Philosophy concerns fundamental questions: it is a discipline requiring us to examine the underlying assumptions we bring with us to our thinking about practical problems. Traditional academic philosophers divide their discipline into distinct areas that typically include logic: questions about meaning, truth and validity; ontology: questions about the nature of reality, what exists; epistemology: concerning knowledge; and ethics: how we should live and practice, the nature of value. Any credible attempt to analyse clinical reasoning will require us to think carefully about these types of question and the relationships between them, as they influence our thinking about specific situations and problems. So, the answers to the question we posed, about the role of philosophy at the bedside, are numerous and diverse, and that diversity is illustrated in the contributions to this thematic edition. (shrink)

The unique discourse of Confucian ritual practice encompasses a powerful and sophisticated way of talking about individual fulfillment within the context of more substantive or universal conceptions of the good life. To make this case, I will consider both the text of the "Analects" and the influential readings of the "Analects" offered by Fingarette in "Confucius: The Secular as Sacred" and by Hall and Ames in "Thinking through Confucius". Though the two interpretive works are helpful in articulating the classical Confucian (...) contribution to the problem of balancing conformity and individuality, I will argue that an alternative reading is required to appreciate fully how values thought to embody and express the fullest humanity might be inculcated in ethical agents without undoing their individuality. Such an alternative is developed here. (shrink)

In Silence et langage Stephen A. Noble offers a new interpretation of the development of Merleau-Ponty’s phenomenology which analyses the central position of language within a philosophy of perception predicated upon the interdependence of seeing and speaking.

Traces the rise and fall of successive international systems from medieval times to the present, showing how international order is created, how it is maintained, and why it breaks down.

In animal cells, the Golgi complex undergoes reversible disassembly during mitosis. The disassembly/reassembly process has been intensively studied in order to understand the mechanisms that govern organelle assembly and inheritance during cell division. A long‐standing controversy in the field has been whether formation of Golgi structure is template‐mediated or self‐organizes from components of the endoplasmic reticulum. A recent study1 however, has demonstrated that a subset of proteins that form a putative Golgi matrix can be inherited during cell division in the (...) absence of membrane input from the endoplasmic reticulum. The outcome of this study suggests that a templating mechanism for the formation of Golgi structure may exist. This study has important implications for understanding mechanisms that govern Golgi biogenesis. BioEssays 24:584–587, 2002. © 2002 Wiley Periodicals, Inc. (shrink)

Clearchus of Soloi, a junior colleague of Aristotle's, devoted a work in at least two books to the topic of eros. Like most of what survives from his once substantial corpus, the remains of this work display wide learning, especially in history and literature, and a moralizing orientation. The work did not circulate widely; all that survives is a handful of passages in Athenaeus (frs. 21-35 Wehrli), most very brief. That is far too little to permit any reconstruction of its (...) overall structure or scope. But some of its interests and themes can be recovered. Clearchus discussed love, especially between the sexes, with more sympathy and subtlety than previous scholarship has recognized. His work on eros also appears to have been largely in tune with trends in early Hellenistic poetry. (shrink)

What could someone represent that would enable her to track, at least within limits, others' perceptions, knowledge states and beliefs including false beliefs? An obvious possibility is that she might represent these very attitudes as such. It is sometimes tacitly or explicitly assumed that this is the only possible answer. However, we argue that several recent discoveries in developmental, cognitive, and comparative psychology indicate the need for other, less obvious possibilities. Our aim is to meet this need by describing the (...) construction of a minimal theory of mind. Minimal theory of mind is rich enough to explain systematic success on tasks held to be acid tests for theory of mind cognition including many false belief tasks. Yet minimal theory of mind does not require representing propositional attitudes, or any other kind of representation, as such. Minimal theory of mind may be what enables those with limited cognitive resources or little conceptual sophistication, such as infants, chimpanzees, scrub-jays and human adults under load, to track others' perceptions, knowledge states and beliefs. (shrink)

The argument laid out in this book discusses and interprets the work of Hobbes in relation to religion. It compares a traditional interpretation of Hobbes where Hobbes’ use of conventional terminology when talking about natural law is seen as ironic or merely convenient despite an atheist viewpoint, with the view that Hobbes’ morality is truly traditional and Christian. The book considers other thinkers of the age in tandem with Hobbes and discusses in detail his theology inspired by corporeal mechanics. The (...) position is that there are significant senses in which Hobbes can be said to be a traditional natural law theorist. (shrink)

Over the course of the past 15 years, there has been a vast sea change in American psychoanalysis. It takes the form of a broad movement away from classical psychoanalytic theorizing grounded in Freud's drive theory toward models of mind and development grounded in object relations concepts. In clinical practice, there has been a corresponding movement away from the classical principles of neutrality, abstinence and anonymity toward an interactive vision of the analytic situation that places the analytic relationship, with its (...) powerful, reciprocal affective currents, in the foreground. These developments have been evident in virtually all schools of psychoanalysis in America, from the most traditional to the most radical. Collected together for the first time, this three volume set brings together this ongoing project for a new audience. _Relational Psychoanalysis: The Emergence of a Tradition_ - Each paper in Volume 1 is accompanied by an introduction, in which the editors place it in its historical context, and a new afterward, in which the author suggests subsequent developments in his or her thinking. This book is an invaluable resource for any clinical practitioner, teacher or student of psychoanalysis interested in exploring the exciting developments of recent years. _Relational Psychoanalysis: Innovation and Expansion_ - Volume 2 brings together key papers of the recent past that exemplify the continuing growth and refinement of the relational sensibility. In selecting these papers, editors Lewis Aron and Adrienne Harris have stressed the shared relational dimension of different psychoanalytic traditions, and they have used such commonalities to structure the best recent contributions to the literature. The topics covered in Volume 2 reflect both the evolution of psychoanalysis and the unique pathways that leading relational writers have been pursuing and in some cases establishing. _Relational Psychoanalysis: New Voices_ - Volume 3 is a forum for new relational voices and new idioms of relational discourse. Established writers, Muriel Dimen, Sue Grand, and Ruth Stein among them, utilize aspects of their own subjectivity to illuminate heretofore neglected dimensions of cultural experience, of trauma, and of clinical stalemate. A host of new voices applies relational thinking to aspects of race, class, and politics as they emerge in the clinical situation. (shrink)

Pompey does not accept defeat at Pharsalus. Rather, in an effort to gain support from powers beyond Rome, he makes for Egypt and, unbeknownst to him, his decapitation. As narrated in Lucan'sBellum ciuile, after deliberating in Cilicia with his senatorial advisers (8.259–455), Pompey stops at the island of Cyprus (8.456–9):tum Cilicum liquere solum Cyproque citatasimmisere rates, nullas cui praetulit arasundae diua memor Paphiae, si numina nascicredimus aut quemquam fas est coepisse deorum.Then they left the Cilician soil and steered their vessels (...) in haste for Cyprus—Cyprus which the goddess, mindful of Paphian waves, prefers to any of her shrines (if we believe that deities have birth, or if it is lawful to hold that any of the gods had a beginning).In Lucan, Pompey's trip to Cyprus is brief and includes a somewhat curious reference to Venus (diua), her origins (undae … Paphiae) and the birth of the gods. Other authors also record Pompey's visit to Cyprus, although the details vary. Some, including Julius Caesar, set his deliberations not in Cilicia but on Cyprus itself (Caes.BCiu.3.102.3.1–8.1; cf. Plut.Vit. Pomp. 77.1.1–2.1). Others, it seems, provide few if any details of Pompey at the island, for example the scanty evidence from Livy,Per. 112.1–10. (shrink)

This title includes the following features: Presents a comprehensivediscussion of the central issues of psychiatric ethics, defining and exploringeach of these issues; Contains essential readings for each of these central issues, providing in onevolume readings that would otherwise be difficult to obtain; Includes introductory essays that provide a comprehensive overview of eachissue, efficiently and effectively organizing the reader's approach to theselected readings; Draws on the success of the well-known and respected 'PsychiatricEthics'.

The primary goal of the peer review of research grant proposals is to evaluate their quality for the funding agency. An important secondary goal is to provide constructive feedback to applicants for their resubmissions. However, little is known about whether review feedback achieves this goal. In this paper, we present a multi-methods analysis of responses from grant applicants regarding their perceptions of the effectiveness and appropriateness of peer review feedback they received from grant submissions. Overall, 56–60% of applicants determined the (...) feedback to be appropriate, although their judgments were more favorable if their recent application was funded. Importantly, independent of funding success, women found the feedback better written than men, and more white applicants found the feedback to be fair than non-white applicants. Also, perceptions of a variety of biases were specifically reported in respondents’ feedback. Less than 40% of applicants found the feedback to be very useful in informing their research and improving grantsmanship and future submissions. Further, negative perceptions of the appropriateness of review feedback were positively correlated with more negative perceptions of feedback usefulness. Importantly, respondents suggested that highly competitive funding pay-lines and poor inter-panel reliability limited the usefulness of review feedback. Overall, these results suggest that more effort is needed to ensure that appropriate and useful feedback is provided to all applicants, bolstering the equity of the review process and likely improving the quality of resubmitted proposals. (shrink)

Drawing on Protestant scholasticism, Puritan "precisionism," and virtue ethics, "Virtue Reformed" offers a comprehensive rereading of the ethical position of ...