Making Ends Meet: A Conceptual and Ethical Analysis of Efficiency.

Efficiency is often overlooked as an ethical value and seen as ethically relevant chiefly when it conflicts with other values, such as equality. This article argues that efficiency is a rich and philosophically interesting concept deserving of independent normative examination. Drawing on a detailed healthcare case study, we argue that making assessments of efficiency involves value-laden, deliberative judgments about how to characterize the functioning of human systems.

Truth and consequences.

In his 1987 paper "Truth or Consequences," Dan Brock describes a deep conflict between the goals and virtues of philosophical scholarship and public policymaking: whereas the former is concerned with the search for truth, the latter must primarily be concerned with promoting good consequences. When philosophers are engaged in policymaking, he argues, they must shift their primary goal from truth to consequences-but this has both moral and methodological costs. Brock's argument exemplifies a pessimistic, but not uncommon, view of the possible shape and nature of applied philosophy.

A wide vocabulary for person-centred care.

Many different words and phrases are used to describe healthcare that treats patients as people. Do terms such as 'person centred', 'patient centred', 'people centred' and 'personalised' mean broadly the same thing or do they refer to distinct concepts? Should we prefer one over the others? In this essay, we set out the value and limitations of some of the different terms used to describe what we broadly refer to as 'person-centred care'. We offer a critical conceptual analysis of the most commonly used words and phrases in this domain, exploring how they differ from, and relate to, one another.

Tackling disrespect in health care: The relevance of socio-relational equality.

Disrespect in health care often persists despite firm commitments to respectful service provision. This conceptual paper highlights how the ways in which respect and disrespect are characterised can have practical implications for how well disrespect can be tackled. We stress the need to focus explicitly on disrespect (not only respect) and propose that disrespect can usefully be understood as a failure to relate to people as equals.

An ethical analysis of policy dialogues.

Background: A policy dialogue is a tool which promotes evidence-informed policy-making. It involves deliberation about a high-priority issue, informed by a synthesis of the best-available evidence, where potential policy interventions are discussed by stakeholders. We offer an ethical analysis of policy dialogues - an argument about how policy dialogues ought to be conceived and executed - to guide those organizing and participating in policy dialogues.

Varieties of improvement expertise: Knowledge and contestation in health-care improvement.

The 'improvement' of health care is now established and growing as a field of research and practice. This article, based on qualitative data from interviews with 21 senior leaders in this field, analyses the growth of improvement expertise as not simply an expansion but also a multiplication of 'ways of knowing'. It illustrates how health-care improvement is an area where contests about relevant kinds of knowledge, approaches and purposes proliferate and intersect.

Patient Safety and the Question of Dignitary Harms.

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.

Unifying and universalizing Personalised Care? An analysis of a national curriculum with implications for policy and education relating to person-centred care.

Objective: To examine the Curriculum of England's Personalised Care Institute as a national initiative to promote person-centred practice.

Method: Analysis of Curriculum content and discourse RESULTS: The Curriculum describes an educational framework which aspires to unify approaches and universalize provision of Personalised Care. It presents 8 "models and approaches" and 6 "components" within the "whole" of Personalised Care.

Vagueness and variety in person-centred care.

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.

Pushing poverty off limits: quality improvement and the architecture of healthcare values.

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 (PSI) into paediatric practice using the discourse and methodology of healthcare quality improvement (QI).

Embedding biodiversity research into climate adaptation policy and practice.

Addressing climate change risks requires collaboration and engagement across all sectors of society. In particular, effective partnerships are needed between research scientists producing new knowledge, policy-makers and practitioners who apply conservation actions on the ground. We describe the implementation of a model for increasing the application and useability of biodiversity research in climate adaptation policy and practice.

Talking it better: conversations and normative complexity in healthcare improvement.

In this paper, we consider the role of conversations in contributing to healthcare quality improvement. More specifically, we suggest that conversations can be important in responding to what we call 'normative complexity'. As well as reflecting on the value of conversations, the aim is to introduce the dimension of normative complexity as something that requires theoretical and practical attention alongside the more recognised challenges of complex systems, which we label, for short, as 'explanatory complexity'.

Made to Measure: The Ethics of Routine Measurement for Healthcare Improvement.

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.

Well-Being and Pluralism.

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.

Defining What is Good: Pluralism and Healthcare Quality.

'Quality' is a widely invoked concept in healthcare, which broadly captures how good or bad a healthcare service is. While quality has long been thought to be multidimensional, and thus constitutively plural, we suggest that quality is also plural in a further sense, namely that different conceptions of quality are appropriately invoked in different contexts, for different purposes. Conceptual diversity in the definition and specification of quality in healthcare is, we argue, not only inevitable but also valuable.

Affordability and Non-Perfectionism in Moral Action.

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 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.

What does 'quality' add? Towards an ethics of healthcare improvement.

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.

Cost-Effectiveness Analysis of Natriuretic Peptide Testing and Specialist Management in Patients with Suspected Acute Heart Failure.

Objectives: To determine the cost-effectiveness of natriuretic peptide (NP) testing and specialist outreach in patients with acute heart failure (AHF) residing off the cardiology ward.

Methods: We used a Markov model to estimate costs and quality-adjusted life-years (QALYs) for patients presenting to hospital with suspected AHF. We examined diagnostic workup with and without the NP test in suspected new cases, and we examined the impact of specialist heart failure outreach in all suspected cases.