It is a commonly expressed sentiment that the science and philosophy of well-being would do well to learn from each other. Typically such calls identify mistakes and bad practices on both sides that would be remedied if scientists picked the right bit of philosophy and philosophers picked the right bit of science. We argue that the differences between philosophers and scientists thinking about well-being are more difficult to reconcile than such calls suggest, and that pluralism is central to this task. (...) Pluralism is a stance that explicitly drives towards accommodating and nurturing the richness and diversity of well-being, both as a concept and as an object of inquiry. We show that well-being science manifests a contingent pluralism at the level of methodology, whereas philosophy of well-being has largely rejected pluralism at the conceptual level. Recently, things have begun to change. Within philosophy, conceptual monism is under attack. But so is methodological pluralism within science. We welcome the first development, and bemoan the second. We argue that a joined-up philosophy and science of well-being should recognise the virtues of both conceptual and methodological pluralism. Philosophers should embrace the methodological justification of pluralism that can be found in the well-being sciences, and scientists should embrace the conceptual reasons to be pluralist that can be found in philosophical debate. (shrink)

People who have not experienced diseases and health conditions tend to judge them to be worse than they are reported to be by people who have experienced them. This phenomenon, known as the disability paradox, presents a challenge for health policy, and in particular, healthcare resource distribution. This divergence between patient and public preferences is most plausibly explained as a result of hedonic adaptation, a widespread phenomenon in which people tend to adapt fairly quickly to the state they are in, (...) good or bad, and adjust their baseline utility accordingly.If patient utilities can be shown to be inappropriate for use in public policy decision making, the disability paradox fades away. This paper offers a critique of one such attempt: the idea that adaptation leads to adaptive preferences. I argue that none of the main accounts of adaptive preferences in fact characterise adapted patient preferences as irrational. Adapted preferences should not, therefore, be treated as synonymous with adaptive preferences. I suggest that much patient adaptation should be understood as a form of the ubiquitous human ability to respond to environmental change. Consequently, we ought not to discount patient preferences. (shrink)

In this paper, we argue that there are important ethical questions about healthcare improvement which are underexplored. We start by drawing on two existing literatures: first, the prevailing, primarily governance-oriented, application of ethics to healthcare ‘quality improvement’ (QI), and second, the application of QI to healthcare ethics. We show that these are insufficient for ethical analysis of healthcare improvement. In pursuit of a broader agenda for an ethics of healthcare improvement, we note that QI and ethics can, in some respects, (...) be treated as closely related concerns and not simply as externally related agendas. To support our argument, we explore the gap between ‘quality’ and ‘ethics’ discourses and ask about the possible differences between ‘good quality healthcare’ and ‘good healthcare’. We suggest that the word ‘quality’ both adds to and subtracts from the idea of ‘good healthcare’, and in particular that the technicist inflection of quality discourses needs to be set in the context of broader conceptualisations of healthcare improvement. We introduce the distinction between quality as a measurable property and quality as an evaluative judgement, suggesting that a core, but neglected, question for an ethics of healthcare improvement is striking the balance between these two conceptions of quality. (shrink)

Patient safety is a central aspect of healthcare quality, focusing on preventable, iatrogenic harm. Harm, in this context, is typically assumed to mean physical injury to patients, often caused by technical error. However, some contributions to the patient safety literature have argued that disrespectful behavior towards patients can cause harm, even when it does not lead to physical injury. This paper investigates the nature of such dignitary harms and explores whether they should be included within the scope of patient safety (...) as a field of practice. We argue that dignitary harms in health care are—at least sometimes—preventable, iatrogenic harms. While we caution against including dignitary harms within the scope of patient safety just because they are relevantly similar to other iatrogenic harms, we suggest that thinking about dignitary harms can help to elucidate the value of patient safety, and to illuminate the evolving relationship between safety and quality. (shrink)

'Quality' is a widely invoked concept in healthcare, and 'quality improvement' is now a central part of healthcare service delivery. However, these concepts and their associated practices represent relatively uncharted territory for applied philosophy and bioethics. In this paper, we explore some of the conceptual complexity of quality in healthcare and argue that quality is best understood to be conceptually plural. Quality is widely agreed to be multidimensional and as such constitutively plural. However, we argue that quality is plural in (...) two further senses. First, quality is competitively plural : that is, different high-level conceptions of quality can be appropriately invoked in different contexts and serve... (shrink)

Person-centred care is a cornerstone of contemporary health policy, research and practice. However, many researchers and practitioners worry that it lacks a 'clear definition and method of measurement,' and that this creates problems for the implementation of person-centred care and limits understanding of its benefits. In this paper we urge caution about this concern and resist calls for a clear, settled definition and measurement approach. We develop a philosophical and conceptual analysis which is grounded in the body of literature concerning (...) the theory and practice of person-centred care. We consider a range of influential definitional frameworks of person-centred care, highlighting their differences and showing that they do not correspond to a clearly circumscribed and consistent underlying concept. We argue that a degree of indeterminacy and vagueness should not be seen as a problem with the concept of person-centred care; these are features of a rich and contested concept which exists prior to and outside of practical and technical operational definitions and applications. We defend the value of operating with multiple accounts of person-centred care, arguing that what counts as being person-centred can vary across different care contexts, in relation to different patient groups, and as a reflection of different, defensible ethical perspectives. Although the idea of a single, agreed definition is attractive and may seem to be a practical or even necessary step towards meaningful and coordinated action, we argue that this is only the case in a qualified sense. Comprehensive attempts to narrow down the concept in this way should be resisted, as they risk undermining what it is that makes person-centredness a valuable concept in healthcare. (shrink)

This paper analyses the ethics of routine measurement for healthcare improvement. Routine measurement is an increasingly central part of healthcare system design and is taken to be necessary for successful healthcare improvement efforts. It is widely recognised that the effectiveness of routine measurement in bringing about improvement is limited—it often produces only modest effects or fails to generate anticipated improvements at all. We seek to show that these concerns do not exhaust the ethics of routine measurement. Even if routine measurement (...) does lead to healthcare improvements, it has associated ethical costs which are not necessarily justified by its benefits. We argue that the practice of routine measurement changes the function of the healthcare system, resulting in an unintended and ethically significant transformation of the sector. It is difficult to determine whether such changes are justified or offset by the benefits of routine measurement because there may be no shared understanding of what is ‘good’ in healthcare by which to compare the benefits of routine measurement with the goods that are precluded by it. We counsel that the practice of routine measurement should proceed with caution and should be recognised to be an ethically significant choice, rather than an inevitability. (shrink)

One rationale policy-makers sometimes give for declining to fund a service or intervention is on the grounds that it would be ‘unaffordable’, which is to say, that the total cost of providing the service or intervention for all eligible recipients would exceed the budget limit. But does the mere fact that a service or intervention is unaffordable present a reason not to fund it? Thus far, the philosophical literature has remained largely silent on this issue. However, in this article, we (...) consider this kind of thinking in depth. Albeit with certain important caveats, we argue that the use of affordability criteria in matters of public financing commits what Parfit might have called a ‘mistake in moral mathematics’. First, it fails to abide by what we term a principle of ‘non-perfectionism’ in moral action: the mere fact that it is practically impossible for you to do all the good that you have reason to do does not present a reason not to do whatever good you can do. And second, when used as a means of arbitrating between which services to fund, affordability criteria can lead to a kind of ‘numerical discrimination’. Various attendant issues around fairness and lotteries are also discussed. (shrink)

Well-Being as Value Fulfillment: How We Can Help Each Other to Live Well By TiberiusValerieOxford University Press, 2018. xii + 214 pp.

Background: Poverty and social deprivation have adverse effects on health outcomes and place a significant burden on healthcare systems. There are some actions that can be taken to tackle them from within healthcare institutions, but clinicians who seek to make frontline services more responsive to the social determinants of health and the social context of people’s lives can face a range of ethical challenges. We summarise and consider a case in which clinicians introduced a poverty screening initiative into paediatric practice (...) using the discourse and methodology of healthcare quality improvement. -/- Discussion: Whilst suggesting that interventions like the PSI are a potentially valuable extension of clinical roles, which take advantage of the unique affordances of clinical settings, we argue that there is a tendency for such settings to continuously reproduce a narrower set of norms. We illustrate how the framing of an initiative as QI can help legitimate and secure funding for practical efforts to help address social ends from within clinical service, but also how it can constrain and disguise the value of this work. A combination of methodological emphases within QI and managerialism within healthcare institutions leads to the prioritisation, often implicitly, of a limited set of aims and governing values for healthcare. This can act as an obstacle to a genuine broadening of the clinical agenda, reinforcing norms of clinical practice that effectively push poverty ‘off limits.’ We set out the ethical dilemmas facing clinicians who seek to navigate this landscape in order to address poverty and the social determinants of health. -/- Conclusions: We suggest that reclaiming QI as a more deliberative tool that is sensitive to these ethical dilemmas can enable managers, clinicians and patients to pursue health-related values and ends, broadly conceived, as part of an expansive range of social and personal goods. (shrink)

Carina Fourie and Annette Rid’s edited volume What Is Enough? Sufficiency, Justice, and Health comprises fifteen original contributions which explore the possibility of a sufficientarian approach to healthcare priority setting and resource allocation. Sufficientarianism is a well-established theory of distributive justice, which tells us that justice requires that each person has “enough,” and assigns particular importance to a threshold level of goods under which no person must fall. Sufficiency is under-explored as a distributive principle in the healthcare context, and this (...) book makes a strong case for its inclusion among more familiar principles of justice such as utility, priority to the worst off, and equality. (shrink)