Engagement and suffering in responsible caregiving: On overcoming maleficience in health care

The thesis of this article is that engagement and suffering are essential aspects of responsible caregiving. The sense of medical responsibility engendered by engaged caregiving is referred to herein as ‘clinical phronesis,’ i.e. practical wisdom in health care, or, simply, practical health care wisdom. The idea of clinical phronesis calls to mind a relational or communicative sense of medical responsibility which can best be understood as a kind of ‘virtue ethics,’ yet one that is informed by the exigencies of moral discourse and dialogue, as well as by the technical rigors of formal reasoning. The ideal of clinical phronesis is not (necessarily) contrary to the more common understandings of medical responsibility as either beneficence or patient autonomy — except, of course, when these notions are taken in their “disengaged” form (reflecting the malaise of “modern medicine”). Clinical phronesis, which gives rise to a deeper, broader, and richer, yet also to a more complex, sense than these other notions connote, holds the promise both of expanding, correcting, and perhaps completing what it currently means to be a fully responsible health care provider. In engaged caregiving, providers appropriately suffer with the patient, that is, they suffer the exigencies of the patient's affliction (though not his or her actual loss) by consenting to its inescapability. In disengaged caregiving — that ruse Katz has described as the ‘silent world of doctor and patient’ — provides may deny or refuse any ‘given’ connection with the patient, especially the inevitability of the patient's affliction and suffering (and, by parody of reasoning, the inevitability of their own. When, however, responsibility is construed qualitatively as an evaluative feature of medical rationality, rather than quantitatively as a form of ‘calculative reasoning’ only, responsibility can be viewed more broadly as not only a matter of science and will, but of language and communication as well — in particular, as the task of responsibly narrating and interpreting the patient's story of illness. In summary, the question is not whether phronesis can ‘save the life of medical ethics’ — only responsible humans can do that! Instead, the question should be whether phronesis, as an ethical requirement of health care delivery, can ‘prevent the death of medical ethics.’     

‘Do-It-Yourself’ Healthcare? Quality of Health and Healthcare Through Wearable Sensors

Wearable sensors are an integral part of the new telemedicine concept supporting the idea that Information Technologies will improve the quality and efficiency of healthcare. The use of sensors in diagnosis, treatment and monitoring of patients not only potentially changes medical practice but also one’s relationship with one’s body and mind, as well as the role and responsibilities of patients and healthcare professionals. In this paper, we focus on knowledge assessment of the online communities of Fitbit (a commercial wearable device) and the Quantified Self movement. Through their online forums, we investigate how users’ knowledge claims, shared experiences and imaginations about wearable sensors interrogate or confirm the narratives through which they are introduced to the publics. Citizen initiatives like the Quantified Self movement claim the right to ‘own’ the sensor generated data. But how these data can be used through traditional healthcare systems is an open question. More importantly, wearable sensors trigger a social function that is transformative of the current idea of care and healthcare, focused on sharing, socialising and collectively reflecting about individual problems. Whether this is aligned with current policy making about healthcare, whose central narrative is focused on efficiency and productivity, is to be seen.     

The Moral Laboratory: On Kant’s Notion of Pedagogy as a Science

Following Kant, it is clear that, but probably not completely how we are morally obligated. I will point out that there are three possible ways to struggle for an understanding of how we can be obligated as rational beings and also as ordinary human beings. There is (a) the argument from rational feeling (‘Achtung’), (b) the argument from language, and finally (c) the argument from systematization. Reading the later passages of the ‘Critique of pure Reason’ and following its instructions, we will understand why education has to be founded by the same kind of argumentation as the natural sciences. The systematical analysis of Kant’s analogy between the physical body and the moral obligation will explain the suspected gap between our just rational and our whole selves. The most important part of the demanded bridge will be Kant’s Moral Laboratory.     

Small acts,kind words and “not too much fuss”: Implicit activisms

In this paper, we suggest that social scientists' accounts of ‘activism’ have too often tended to foreground and romanticise the grandiose, the iconic, and the unquestionably meaning-ful, to the exclusion of different kinds of ‘activism’. Thus, while there is a rich social-scientific literature chronicling a social history of insurrectionary protests and key figures/thinkers, we suggest that there is more to ‘activism’ (and there are more kinds of ‘activism’) than this. In short, we argue that much can be learnt from what we term implicit activisms which – being small-scale, personal, quotidian and proceeding with little fanfare – have typically gone uncharted in social-scientific understanding of ‘activism’. This paper will reflect upon one example of this kind of ‘implicit’ activism, by re-presenting findings from interviews undertaken with 150 parents/carers, during an evaluation of a ‘Sure Start’ Centre in the East Midlands, UK. From these interviews emerged a sense of how the Centre (and the parents/carers, staff and material facilities therein) had come to matter profoundly to these parents/carers. We suggest that these interviews extend and unsettle many social-scientific accounts of ‘activism’ in three key senses. First: in evoking the specific kinds of everyday, personal, affective bonds which lead people to care. Second: in evoking the kinds of small acts, words and gestures which can instigate and reciprocate/reproduce such care. And third: in suggesting how such everyday, affective bonds and acts can ultimately constitute political activism and commitment, albeit of a kind which seeks to proceed with ‘not too much fuss’.     

The invisibility of richness: A critique of Vice’s ‘strange place’

Abstract

This article builds on Samantha Vice’s argument on the problem of whiteness in contemporary South Africa. I will explore the thesis of invisibility regarding whiteness and argue for its relevance to the rich per se. This thesis demonstrates how white privilege and affluence, despite being glaringly visible in a concrete sense, is rendered invisible together with the mostly black poverty by which it is contrasted. The invisibility of whiteness translates and flows into the so-called ‘invisibility of richness’, which involves anyone who is economically affluent in this country and has the same effect of rendering poverty invisible. The massive and ever-growing divide between rich and poor means that both have fundamentally incommensurate experiences of life in this country, which is why post-apartheid South Africa is such a strange place to live in for all of its inhabitants. In the latter part of the article, a suggestion will be made about what the appropriate response to the injustices of this strange place might look like for whites.     

Spiritual Versus Religious Identity: A Necessary Distinction in Understanding Clinicians’ Behavior and Attitudes Toward Clinical Practice and Medical Student Teaching in This Realm

Social sciences view spirituality and religion separately; medicine views them together. We identified distinctions regarding clinical practice and teaching among clinician educators based on their self-identified spirituality versus religiosity. We emailed a 24-item survey on spiritual/religious (S/R) issues to clinician educators (n = 1,067) at our institution. Three summary scales were created. Responses to statements, ‘I consider myself to be spiritual’ and ‘I consider myself to be religious’ generated four comparison groups: ‘spiritual only,’ ‘religious only,’ ‘both spiritual and religious’ and ‘neither.’ Analyses employed ANOVA and T tests. A total of 633 (59 %) surveys were completed. Four percentage self-identified as ‘religious only’; remaining respondents divided evenly, about 30 % into each of the other categories. Groups differed from one another on all summary scales (p < .0001). Using T tests, the ‘spiritual only’ group differed from the ‘religious only’ group regarding teaching. The ‘spiritual and religious’ group had the highest mean ratings for all summary scales. The ‘neither’ and ‘religious only’ group had the lowest mean ratings. Clinicians’ spiritual versus religious identity is associated with differences in behavior/attitudes regarding S/R toward clinical practice and medical student teaching. These findings elucidate opportunities for faculty development to explore effects of beliefs on behavior and attitudes within this realm.     

Weight for Stephen Finlay

According to Stephen Finlay, ‘A ought to X’ means that X-ing is more conducive to contextually salient ends than relevant alternatives. This in turn is analysed in terms of probability. I show why this theory of ‘ought’ is hard to square with a theory of a reason’s weight which could explain why ‘A ought to X’ logically entails that the balance of reasons favours that A X-es. I develop two theories of weight to illustrate my point. I first look at the prospects of a theory of weight based on expected utility theory. I then suggest a simpler theory. Although neither allows that ‘A ought to X’ logically entails that the balance of reasons favours that A X-es, this price may be accepted. For there remains a strong pragmatic relation between these claims.     

An outline explanation of how therapy heals

Therapists are unable to provide a comprehensive account of therapy as an intelligible activity. This is at least partly due to the unresolved problem of explaining how phenomenology is even possible. An alternative to providing a comprehensive account of therapy is to take the fact of phenomenology for granted and provide just an outline account of how therapy heals. One way this can be achieved is to set therapy in the context of medical anthropology which will facilitate a view of therapy as just another healing ritual. Insight into how healing rituals heal is provided in this paper by a long and in-depth look at the so-called ‘paradox’ of the placebo effect. This will reveal the so-called ‘placebo effect’ as a misunderstood, modern example of healing ritual self-healing. In fact, the single term ‘placebo effect’ will be abandoned and replaced by the two concepts of ‘SMCH’ (‘specifically modified consultation and health care’) and ‘RMH’ (‘response to modified health care’). These two concepts provide an outline explanation of how all healing rituals heal and so provide an outline explanation of how the healing ritual of therapy heals, also. At least one problem arises out of explaining therapy as healing ritual self-healing, namely that this conception conflicts with the idea in therapy circles that, in therapy, it is the relationship that counts. Nonetheless, it will be maintained that the purpose of therapy is healing, that the healing that is achieved is self-healing and that its fulfilment is not dependent upon one-to-one relationships. Finally, it will be argued that the further development of therapy requires a better understanding of what aids and obstructs psycho-emotional self-healing.     

Framing,Reciprocity and the Grounds of Egalitarian Justice

John Rawls famously claims that ‘justice is the first virtue of social institutions’. On one of its readings, this remark seems to suggest that social institutions are essential for obligations of justice to arise. The spirit of this interpretation has recently sparked a new debate about the grounds of justice. What are the conditions that generate principles of distributive justice? I am interested in a specific version of this question. What conditions generate egalitarian principles of distributive justice and give rise to equality as a demand of justice? My paper focuses on relationalist answers to this question. Advocates of relationalism assume that ‘principles of distributive justice have a relational basis’, in the sense that ‘practice mediated relations in which individuals stand condition the content, scope and justification of those principles’. To say that principles of justice are ‘based’ on and ‘conditioned’ by practice mediated relations is ambiguous. I will here be concerned with advocates of what I call the relationalist requirement, viz. positions which assume that ‘practice mediated relations’ constitute a necessary existence condition for principles of egalitarian distributive justice. Relationalists who endorse this view come in different varieties. My focus is on relationalists that view social and political institutions as the relevant ‘practice mediated relation’. The question at stake, then, is this: Are institutionally mediated relations a necessary condition for equality to arise as a demand of justice? Strong relationalists of the institutionalist cast, call them advocates of the institutionalist requirement, differ in important respects. They argue about what set of institutions is foundationally significant, and they disagree on why only that institutional relation gives rise to egalitarian obligations of justice. My paper engages two ways of arguing for the institutionalist requirement: Julius’s framing argument and Andrea Sangiovanni’s reciprocity argument. The issue at stake are the grounds of egalitarian justice and I will argue that the institutionalist requirement is mistaken. It is not the case that egalitarian obligations of distributive justice arise only between and solely in virtue of individuals sharing a common institution.     

The cultural hermeneutic of Russia’s historical experience: the case of Aleksandr Samojlovič Akhiezer

The article presents an overview of A. S. Akhiezer’s reconstruction of Russia’s socio-cultural history as a cultural hermeneutic. The underlying idea is that the way humans make sense of their existence is driven by an algorithm of meaning production informing the organization of their ‘world’, in particular the selection of the means involved in that production. Thus the central axis of Akhiezer’s hermeneutic, methodogically, is symbolization: ‘worlds’, that is, socio-cultural matrices, are made according to and reflect specific modes of symbolization. Akhiezer’s account of the Russian socio-cultural experience is centred on the particular algorithm that he names raskol (schism). His purpose was twofold: to examine the ‘logic’ of raskol, on the one hand, and to investigate, on the other hand, in the manner of a historian, its impact and consequences for Russian society at large, including its effects on institution-building. In this way, the study of raskol goes hand in hand with an investigation of and commentary concerning the uncertain state in Russia of what Akhiezer named the bol’?oe ob??estvo (roughly, the modern differentiated, dynamic institutional order). In effect, his theory is a social ontology with culture at the centre.     

Integrating and Enacting ‘Social and Ethical Issues’ in Nanotechnology Practices

The integration of nanotechnology’s ‘social and ethical issues’ (SEI) at the research and development stage is one of the defining features of nanotechnology governance in the United States. Mandated by law, integration extends the field of nanotechnology to include a role for the “social”, the “public” and the social sciences and humanities in research and development (R&D) practices and agendas. Drawing from interviews with scientists, engineers and policymakers who took part in an oral history of the “Future of Nanotechnology” symposium at the Cornell NanoScale Facility, this article examines how nanotechnology’s ‘social and ethical issues’ are brought to life by these practitioners. From our analysis, three modes of enactment emerge: enacting SEI as obligations and problems-to-be-solved, enacting SEI by ‘not doing it’ in the laboratory, and enacting SEI as part of scientific practice. Together they paint a complex picture where SEI are variously defined, made visible or invisible, included and excluded, with participants showing their skill at both boundary-work (Gieryn Am Sociol Rev 48:781–795, 1983, 1999) and at integration. We conclude by reflecting on what this may mean for the design and implementation of SEI integration policies, suggesting that we need to transform SEI from obligations into ‘matters of care’ (Puig de la Bellacasa Soc Stud Sci 41(1):85–106, 2011) that tend to existing relationalities between science and society and implicate practitioners themselves.     

Against the iDoctor: why artificial intelligence should not replace physician judgment

Experts in medical informatics have argued for the incorporation of ever more machine-learning algorithms into medical care. As artificial intelligence (AI) research advances, such technologies raise the possibility of an “iDoctor,” a machine theoretically capable of replacing the judgment of primary care physicians. In this article, I draw on Martin Heidegger’s critique of technology to show how an algorithmic approach to medicine distorts the physician–patient relationship. Among other problems, AI cannot adapt guidelines according to the individual patient’s needs. In response to the objection that AI could develop this capacity, I use Hubert Dreyfus’s analysis of AI to argue that attention to the needs of each patient requires the physician to attune his or her perception to the patient’s history and physical exam, an ability that seems uniquely human. Human physician judgment will remain better suited to the practice of primary care despite anticipated advances in AI technology.     

On presence in the psychoanalytic relation

This paper discusses presence in the psychoanalytic relation, the analysand’s and the analyst’s. Clinical situations with different qualities of presence will be considered focusing on what kind of interplay between analysand and analyst they may lead to. As examples, I have chosen three different clinical situations: In the first there is an interplay between the analysand’s free associations and the analyst’s ‘evenly suspended attention’. In connection with this I will discuss Bion’s concepts of ‘reverie’ and of ‘O’. In the second there is where the interaction is characterised by what Meltzer calls ‘geographical confusion’. In the third there is a ‘transference delusion’ in the psychoanalysis of breakdown as Winnicott describes it.     

Narrative and Rhetorical Approaches to Problems of Education. Jerome Bruner and Kenneth Burke Revisited

Over the last few decades there has been a strong narrative turn within the humanities and social sciences in general and educational studies in particular. Especially Jerome Bruner’s theory of narrative as a specific ‘mode of knowing’ was very important for this growing body of work. To understand how the narrative mode works Bruner proposes to study narratives ‘at their far reach’—as an art form—and on several occasions he refers to the dramatistic pentad as an important method for ‘unpacking’ narratives. The pentad proposed by Bruner to study narratives was developed by the American philosopher and rhetorician Kenneth Burke and is embedded in his general linguistic theory of dramatism. From an educational perspective Bruner’s reference to the work of Burke has not been elaborated upon thus far. In this paper we aim to take Bruner’s suggestion at hand and explore how his educational theory of narrative as a mode of knowing can indeed be enriched by Kenneth Burke’s theory and method of dramatism. We claim that specifically the rhetorical framework that is developed by dramatism offers an important perspective about perspectives for education in a context that is increasingly confronted with a plurality of interpretive frameworks.     

Multivalent Semantics for Vagueness and Presupposition

Both the phenomenon of presupposition and that of vagueness have motivated the use of one form or another of trivalent logic, in which a declarative sentence can not only receive the standard values true (1) and false (0), but also a third, non-standard truth-value which is usually understood as ‘undefined’ (#). The goal of this paper is to propose a multivalent framework which can deal simultaneously with presupposition and vagueness, and, more specifically, capture their projection properties as well as their different roles in language. Now, there is a prima facie simple way of doing this, which simply consists in assimilating the two phenomena, and using an appropriate type of trivalent logic. On this view, we just need a compositional system that deals with the ‘undefined’ truth-value, and does not care about whether the source of undefinedness is ‘presuppositional’ or related to vagueness. I will argue that such a simple solution cannot succeed, and point out a number of desiderata that any successful approach must meet. I will then present and discuss two seven-valued semantics, inspired, respectively, by the Strong Kleene semantics and by supervaluationism, which meet these desiderata.     

The world,the flesh and the argument from design

In the the passage just quoted from theDialogues concerning Natural Religion, David Hume developed a thought-experiment that contravened his better-known views about “chance” expressed in hisTreatise and firstEnquiry. For among other consequences of the ‘eternal-recurrence’ hypothesis Philo proposes in this passage, it may turn out that what the vulgar call cause is nothing but a secret and concealed chance. (In this sentence, I have simply reversed “cause” and “chance” in a well-known passage fromHume's Treatise, p. 130). In the first eight sections of this essay, I develop one topological and model-theoretic analogue of Hume's thought-experiment, in which ‘most’ (‘A-generic’) modelsM of a ‘scientific’ theoryU are both ‘eternally recurrent’ and topologically random (in a sense which will be made precise), even though they are ‘inductively’ defined, via a step-by-step (‘empirical’?) procedure that Hume might have been inclined to endorse. The last aspect of this model-theoretic thought-experiment also serves to distinguish it from simpler measure-theoretic prototypes that are known to follow from Kolmogorov's Zero-One Law (cf. the Introduction, 5.2, 6.1 and 6.7 below). In the last three sections, I will argue more informally

1. that the metamathematical thought-experiments just mentioned do have a genuine metaphysical relevance, and that this relevance is predominantly skeptical in its implications;
2. that such ‘nonstandard’ instances of semantic underdetermination and ‘pathology’ seem to be the metatheoretic rule rather than the exception; and therefore,
3. that metamathematical and metatheoretic ‘malign-genius’ arguments are quite coherent, contrary (e.g.) to assertions such as that of Putnam (1980), pp. 7–8.

In the essay's conclusion, finally, I assimilate (2) and (3) to the familiar datum that ‘simplicity’, rather than ‘pathology’, has more often than not turned out to be an anomalous ‘special case’ in the historical development of scientific and mathematical ontology.     

No I,No Problems: The Quintessence of Buddhist Psychology of Awakening

If psychology is viewed as the science of human mind, the Buddha could unarguably be termed as the finest depth psychologist humanity has seen. Not only did he penetrate deep into the hidden recesses of human mind and uncovered the machinations of the latent tendencies, he also found the way out of their stranglehold on mankind. As a compassionate teacher, he focused his entire teaching primarily on the later practical aspect. He often mentioned that he taught only two things: there is unhappiness (dukkha) and there is a way out of this unhappiness. The root cause of this unhappiness, he identified as the primeval ignorance avijja, which creates the notion of ‘I’ as an individual entity, the doer, the feeler and the thinker. This in turn gives rise to the concepts of ‘I and mine’, ‘thee and thine’ from which originate craving (raga) and aversion (dosa). The Buddha’s penetrative insight into the nature of human reality revealed that what we call ‘I’ or a ‘being’ is only a concatenation of the five impermanent aggregates, viz. the body, consciousness, intellect, feelings and volitional mental formations, which work interdependently, changing from moment to moment in accordance with the law of cause and effect. By a systematic cultivation of the mindfulness of these aggregates anyone can progressively uproot the ego and purify the mind by extinguishing this fire of defilements continuously burning within it. As the mind gets progressively purified, it awakens from the illusion of ‘personality’ and naturally abides in loving kindness (maîtri), compassion (karuna), altruistic joy (mudita) and equanimity (upekkha) to increasing degree. ‘No I, No problems’, as one contemporary Master puts it.     

A quality assurance programme for psychotherapy — The finnish experience

In many respects the status of psychotherapy in public health-care systems is similar to that of alternative medicine. The roots of training are outside universities. Legitimation and public funding have been non-existent or insufficient as compared with other fields of health care. Also a great deal of mysticism is attached to both. It is therefore relevant to study the role of psychotherapy from the frame of reference given by research into alternative health care.

Formal health care is characterised by (1) legalised status, (2) access to public funding and (3) integration in the formal medical curriculum. On the other hand there are several treatment philosophies which remain as outsiders from the point of view of formal health care. Informal health care approaches are characterised by (1) lack of legalised status, (2) no access to public funding and (3) no integration in the medical curriculum. Alternative medicine is a term usually attached to forms of informal health care like acupuncture, Spa-culture etc.

Psychotherapy in the public health sector lies somewhere between formal and informal health care. While it has no legalised status, anyone may call himself ‘psychotherapist’. Its definition remains obscure and its public accountability poor.

In this paper I have tried to show how one country — Finland — has tried to grapple with this problem as it attempted to set up psychotherapy services whose quality could be properly monitored — ‘Quality Assurance’ — allowing for public accountability. Now that psychotherapy is well established as a valuable treatment in the field of mental health it is possible to consider future expansion as a cost-effective way to improve the general mental health of the country.