Improving blood pressure control in primary care: feasibility and impact of the ImPress intervention

Abstract of a paper presented at he 2015 PHC Research Conference, 29-31 July, Adelaide, Australia

The heteronomy of choice architecture

Choice architecture is heralded as a policy approach that does not coercively reduce freedom of choice. Still we might worry that this approach fails to respect individual choice because it subversively manipulates individuals, thus contravening their personal autonomy. In this article I address two arguments to this effect. First, I deny that choice architecture is necessarily heteronomous. I explain the reasons we have for avoiding heteronomous policy-making and offer a set of four conditions for non-heteronomy. I then provide examples of nudges that meet these conditions. I argue that these policies are capable of respecting and promoting personal autonomy, and show this claim to be true across contrasting conceptions of autonomy. Second, I deny that choice architecture is disrespectful because it is epistemically paternalistic. This critique appears to loom large even against non-heteronomous nudges. However, I argue that while some of these policies may exhibit epistemically paternalistic tendencies, these tendencies do not necessarily undermine personal autonomy. Thus, if we are to find such policies objectionable, we cannot do so on the grounds of respect for autonomy

A pragmatic cluster randomized controlled trial of early intervention for chronic obstructive pulmonary disease by practice nurse-general practitioner teams : Study Protocol

Background: Chronic Obstructive Pulmonary Disease (COPD) is a leading cause of disability, hospitalization, and premature mortality. General practice is well placed to diagnose and manage COPD, but there is a significant gap between evidence and current practice, with a low level of awareness and implementation of clinical practice guidelines. Under-diagnosis of COPD is a world-wide problem, limiting the benefit that could potentially be achieved through early intervention strategies such as smoking cessation, dietary advice, and exercise. General practice is moving towards more structured chronic disease management, and the increasing involvement of practice nurses in delivering chronic care. Design: A pragmatic cluster randomised trial will test the hypothesis that intervention by a practice nurse-general practitioner (GP) team leads to improved health-related quality of life and greater adherence with clinical practice guidelines for patients with newly-diagnosed COPD, compared with usual care. Forty general practices in greater metropolitan Sydney Australia will be recruited to identify patients at risk of COPD and invite them to attend a case finding appointment. Practices will be randomised to deliver either practice nurse-GP partnership care, or usual care, to patients newly-diagnosed with COPD. The active intervention will involve the practice nurse and GP working in partnership with the patient in developing and implementing a care plan involving (as appropriate), smoking cessation, immunisation, pulmonary rehabilitation, medication review, assessment and correction of inhaler technique, nutritional advice, management of psycho-social issues, patient education, and management of co-morbidities. The primary outcome measure is health-related quality of life, assessed with the St George’s Respiratory Questionnaire 12 months after diagnosis. Secondary outcome measures include validated disease-specific and general health related quality of life measures, smoking and immunisation status, medications, inhaler technique, and lung function. Outcomes will be assessed by project officers blinded to patients’ randomization groups. Discussion: This study will use proven case-finding methods to identify patients with undiagnosed COPD in general practice, where improved care has the potential for substantial benefit in health and healthcare utilization. The study provides the capacity to trial a new model of team-based assessment and management of newly diagnosed COPD in Australian primary care

Recognition and social freedom

In this paper I develop an account of social freedom grounded in intersubjective recognition, which I term the “normative authorisation” account. According to this model, a person enjoys social freedom if she is recognised as a discursive equal who can engage in justificatory dialogue with other social agents about the appropriateness of her reasons for action. I contrast this with Axel Honneth’s theory of social freedom, which I label the “self-realisation” account. Within this model, the affirmative recognition of others is required in order to achieve a positive relation-to-self and hence freedom. I highlight several issues with this account, which challenge the relationship Honneth draws between social recognition and freedom. I demonstrate that the normative authorisation account avoids these problems. I also show how it captures some basic features of our everyday, normative interactions. Finally, I suggest that the account fits well with recent work on epistemic injustice. Specifically, it shows that establishing the social conditions of freedom requires ensuring epistemically-just social relations. In sum, the normative authorisation account is an explanatorily powerful, inclusive theory of social freedom that fits well with wider accounts of justice and freedom. It represents the most promising way of construing social freedom in terms of interpersonal recognition

Conceptual responsibility

Conceptual engineering is concerned with the improvement of our concepts. The motivating thought behind many such projects is that some of our concepts are defective. But, if to use a defective concept is to do something wrong, and if to do something wrong one must be in control of what one is doing, there might be no defective concepts, since we typically are not in control of our concept use. To address this problem, this paper turns from appraising the concepts we use to appraising the people who use them. First, I outline several ways in which the use of a concept can violate moral standards. Second, I discuss three accounts of moral responsibility, which I call voluntarism, rationalism, and psychologism, arguing that each allows us to find at least some cases where we are responsible for using defective concepts. Third, I answer an objection that because most of our concepts are acquired through processes for which we are not responsible, our use of defective concepts is a matter of bad luck, and not something for which we are responsible after all. Finally, I conclude by discussing some of the ways we may hold people accountable for using defective concepts

Does Non-Moral Ignorance Exculpate? Situational Awareness and Attributions of Blame and Forgiveness

In this paper, we set out to test empirically an idea that many philosophers find intuitive, namely that non-moral ignorance can exculpate. Many philosophers find it intuitive that moral agents are responsible only if they know the particular facts surrounding their action. Our results show that whether moral agents are aware of the facts surrounding their action does have an effect on people’s attributions of blame, regardless of the consequences or side effects of the agent’s actions. In general, it was more likely that a situationally aware agent will be blamed for failing to perform the obligatory action than a situationally unaware agent. We also tested attributions of forgiveness in addition to attributions of blame. In general, it was less likely that a situationally aware agent will be forgiven for failing to perform the obligatory action than a situationally unaware agent. When the agent is situationally unaware, it is more likely that the agent will be forgiven than blamed. We argue that these results provide some empirical support for the hypothesis that there is something intuitive about the idea that non-moral ignorance can exculpate