Chapter 4 Compassion in primary and community healthcare

Compassion is an attribute of a person’s affective understanding, which aims to enable, so far as possible, shared experiences of the world’s ills and some alleviation of those ills’ effects. Such an attribute is thus of great value within healthcare institutions such as general practices and other primary and community healthcare settings. It may characterise the people who participate in those institutions; or, it may not so characterise them. The appearance of compassion, under certain conditions and even in fragile and incomplete forms, is a kind of human excellence, a way of being for the good in community.* Compassion is not, therefore, a commodity, to be bought, sold and traded. Although time can be costed, there is no line for compassion in any budget. Were compassion to be thought a commodity, one could imagine trading it off against some more measurable factor (efficiency, cost-effectiveness, etc.). However, our human capacity for compassion, though fragile, tends to resist such marginalisation and reductionism

Political affections: a theological enquiry

The thesis is a theological enquiry into the nature of human affections (or ‘emotions’), their role in morality and their significance for political relations. The argument builds critically on the work of cognitivist theorists of emotion, such as Martha Nussbaum, who oppose both rationalist disavowals of the reasonableness of emotion and empiricist fascination with physical sensation. Nussbaum holds that emotions’ intentional (object-directed), evaluative quality indicates a cognitive aptitude. Using the language of ‘affection’, the argument shows how this aptitude shapes individuals’ and communities’ interrelation with their diverse systems of valuation, the created, vindicated moral order and creation’s God. Drawing on phenomenological and spiritual approaches, the endurance of affection is accounted for through the connection of memory and affection while virtue is assigned a secondary place as a fragmentary and less reliable contributor to such endurance. Affections emerge as the beginnings of attracted understanding concerning the world as it appears, the world as it is and the world as it will be, recognitions of value which are open to intersubjective discussion and initiate moral reflection and deliberation. Jonathan Edwards’ account of affections is found epistemologically and ethically implausible but his doctrine of excellency is adopted to interpret the nature of affections’ endurance and eschatological participation in the moral order. With particular attention to joy, shame, anger and awe, the intersubjective, affective dimension of political life is then explored through consideration of certain institutions, practices and traditions of modern political societies, ancient Israel and the early church as represented in Luke and Acts. Affective wisdom within institutions of political representation and law are considered in light of secular and Christian political eschatologies. Findings from this discussion then guide a conversation between European ‘constitutional patriotism’ and British conservatism which explores the connection between affections and locality. An account of national identity is given which takes localised affective understanding seriously yet relativises it in light of the transnational affective understandings which stem both from the international political system and from Christian faith. Finally, the role of churches’ affections within modern political society are discussed. Resources from the Lutheran tradition are utilised to examine the political significance of churches’ joyful praise of the crucified, risen Jesus Christ

Encoding truths?

This chapter critically examines an instrument at the meso-level of healthcare which was used to operationalise marketisation: Diagnosis-Related Groups (DRGs). It will contest four constitutive claims that have accompanied the introduction of DRGs: First, the claim that marketisation or quasi-marketisation is theologically and ethically neutral; second, the assumption that marketisation is a natural, impersonal and global evolution. Third, the claim that DRGs represent care transparently and therefore better, suggested by phrases such as ‘money follows the patient’. Finally, the claim that DRGs do not touch the substance of medical work will be examined. The four theologically informed counterpoints to the DRG system are theological significance, historical interpretation and consequently systemic responsibility, the representation of care and the transformative nature of vocation. These destabilise the marketisation discourse, which has attempted a transvaluation of values, fundamentally relocating and redefining healthcare whilst concealing this very move

Research needs for optimising wastewater-based epidemiology monitoring for public health protection

This is the final version. Available on open access from IWA Publishing via the DOI in this recordData availability statement: All relevant data are included in the paper or its Supplementary Information.Wastewater-based epidemiology (WBE) is an unobtrusive method used to observe patterns in illicit drug use, poliovirus, and severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2). The pandemic and need for surveillance measures have led to the rapid acceleration of WBE research and development globally. With the infrastructure available to monitor SARS-CoV-2 from wastewater in 58 countries globally, there is potential to expand targets and applications for public health protection, such as other viral pathogens, antimicrobial resistance (AMR), pharmaceutical consumption, or exposure to chemical pollutants. Some applications have been explored in academic research but are not used to inform public health decision-making. We reflect on the current knowledge of WBE for these applications and identify barriers and opportunities for expanding beyond SARS-CoV-2. This paper critically reviews the applications of WBE for public health and identifies the important research gaps for WBE to be a useful tool in public health. It considers possible uses for pathogenic viruses, AMR, and chemicals. It summarises the current evidence on the following: (1) the presence of markers in stool and urine; (2) environmental factors influencing persistence of markers in wastewater; (3) methods for sample collection and storage; (4) prospective methods for detection and quantification; (5) reducing uncertainties; and (6) further considerations for public health use.Natural Environment Research Council (NERC)Engineering and Physical Sciences Research Council (EPSRC

Oncogenic BRAF, unrestrained by TGFβ-receptor signalling, drives right-sided colonic tumorigenesis

Right-sided (proximal) colorectal cancer (CRC) has a poor prognosis and a distinct mutational profile, characterized by oncogenic BRAF mutations and aberrations in mismatch repair and TGFβ signalling. Here, we describe a mouse model of right-sided colon cancer driven by oncogenic BRAF and loss of epithelial TGFβ-receptor signalling. The proximal colonic tumours that develop in this model exhibit a foetal-like progenitor phenotype (Ly6a/Sca1+) and, importantly, lack expression of Lgr5 and its associated intestinal stem cell signature. These features are recapitulated in human BRAF-mutant, right-sided CRCs and represent fundamental differences between left- and right-sided disease. Microbial-driven inflammation supports the initiation and progression of these tumours with foetal-like characteristics, consistent with their predilection for the microbe-rich right colon and their antibiotic sensitivity. While MAPK-pathway activating mutations drive this foetal-like signature via ERK-dependent activation of the transcriptional coactivator YAP, the same foetal-like transcriptional programs are also initiated by inflammation in a MAPK-independent manner. Importantly, in both contexts, epithelial TGFβ-receptor signalling is instrumental in suppressing the tumorigenic potential of these foetal-like progenitor cells

Loyalty, conscience and tense communion : Jonathan Edwards meets Martha Nussbaum

This article responds to Jeffrey Stout’s argument in favour of immanent criticism of religious convictions in public reasoning by examining the affective dimension of religious loyalty and conscience. To this end, a conversation between Jonathan Edwards and Martha Nussbaum is undertaken to explore the basis on which the shared evaluations of religious citizens, especially Christians, should inform public discourse. Whereas the affections of Edwards’s sense of the heart are shown to be epistemologically over-realised and in unsustainable tension with the political implications of his contested social ontology, Nussbaum’s cognitivist theory of emotions improves on Edwards’s by providing a basis for social criticism of religious convictions, but is then found incompatible with her own commitment to a Rawlsian overlapping consensus. Moreover, the political appeal of the Protestant-Stoic conscience she advocates is cast into doubt by considering how Protestant and perhaps Islamic concepts of conscience structure eschatological loyalties that foster not Rawls’s overlapping consensus or even Nigel Biggar’s ‘tense consensus’ but rather the ‘tense communion’ appropriate to twenty-first-century democracies

The implausibility of the ‘impracticality’ and ‘professional role’ arguments. A commentary on Lauren Notini and Justin Oakley, ‘When (if ever) may doctors discuss religion with their patients?’

In their paper, Lauren Notini and Justin Oakley aim to show that it is neither practical nor professionally required or permissible for doctors to have substantive engagement with the religious beliefs of patients with decision-making capacity. This critical engagement rejects their two arguments - the impracticality argument and the professional role argument. It notes in particular the interdependence of the two arguments over against the authors' claim that they are independent. The impracticality argument, when placed under pressure leans on the professional role argument; and the professional role argument draws on the alleged strength of the impracticality argument. Moreover, the impracticality argument is committed to excluding far too much from professional competence, including substantive engagement with any kind of belief at all. Just as there are no good reasons to exclude a competence for substantive religious discussion from the definition of medical professionalism so there is no reason to exclude engagement with belief generally. The practicality argument is furthermore inherently parochial and unstable. Defences of it are unconvincing. Moreover, the implications of their claim that doctors, unlike social workers or psychologists, should not engage in substantive religious discussion, are harmful to inter-professional teamwork. The professional role argument is criticised for, among other things, depending on an implausibly restrictive notion of medicine. Positively, this response explores a wider range of possibilities for substantive religious discussion than Notini and Oakley overtly consider and takes up the question they helpfully pose about possible obligations on doctors to refer patients to religiously competent colleagues

“A knife into my heart”: cries, compassion and ethical life

The subtitle to the conference upon which this journal issue is based invited us to ‘follow Crowter’. This paper does so primarily by following the person and only thereby attends to the legal judgment. In particular, it will attend to her comment that When mum told me about the discrimination against babies like me in the womb, I felt like a knife had been put into my heart. It made me feel less valued than other people. The argument is that (I) there are strong reasons for such an approach from the field of theological ethics and that this is valuable for pastoral theology and for bioethics. With this case made, the argument proceeds (II) by following and building on three elements of Heidi Crowter’s words concerning (a) the knife (b) the heart and (c) the person. The argument concludes (III) with theological reflection and deliberation regarding institutions, practices and actions which will make for ‘ethical society’, principally focussed on ecclesial life

Religion, culture and conscience

Religion, belief and culture should be recognized as potential sources of moral purpose and personal strength in healthcare, enhancing the welfare of both clinicians and patients amidst the experience of ill-health, healing, suffering and dying. Communication between doctors and patients and between healthcare staff should attend sensitively to the welfare benefits of religion, belief and culture. Doctors should respect personal religious and cultural commitments, taking account of their significance for treatment and care preferences. Good doctors understand their own beliefs and those of others. They hold that patient welfare is best served by understanding the importance of religion, belief and culture to patients and colleagues. The sensitive navigation of differences between people's religions, beliefs and cultures is part of doctors' civic obligations and in the UK should follow the guidance of the General Medical Council and Department of Health and Social Care. In particular, apparent conflict between clinical judgement or normal practices and a patient's culture, religion and belief should be considered carefully. Doctors' own religion or culture may play an important role in promoting adherence to this good practice. In all matters, doctors' conduct should be governed by the law and arrangements for conscientious objection that are in effect. The strongest ethical arguments in favour of conscientious objection provisions concern the moral integrity of professionals, the objectives and values of the medical profession, the nature of healthcare in liberal democracy and the welfare of patients. In practice, arguments mounted against conscientious objection have not been found persuasive