Who Can Blame Who for What and How in Responsibility for Health?

This paper starts by introducing a tripartite conception of responsibility for health consisting of a moral agent having moral responsibilities and being held responsible, that is blamed, for failing to meet them and proceeds to a brief discussion of the nature of blame, noting difficulties in agency and obligation when the concept is applied to health threatening behaviours. Insights about the obligations that we hold people to and the extent of their moral agency are revealed by interrogating our blaming behaviour, and to facilitate this my own blaming attitudes and actions are analysed in respect of an imagined adult son who seeks thrills by jumping from a pier into the sea, an activity common around coastlines and intended to be analogous in varying degrees to a range of health-threatening behaviours. I consider my responses to this imagined act in relation to some features of moralism, the excess of morality, concluding that blame can be justified when it is proportionate and within interpersonal relationships. There is evidence that some nurses hold negative blaming attitudes towards groups of patients considered to have caused or contributed to their illness, but this is not justified, not only because of impaired agency, but because if there is responsibility for health, associated obligations are owed to those who share our lives, and it is those people who are entitled to hold individuals responsible. Nurses who hold negative blaming attitudes towards groups of patients are invited to identify the status of moral agency, the precise natures of their (failed) obligations and of the patient / nurse relationship. It is concluded that reflection on these matters, and the difference between justified blame and moralism demonstrates that blaming behaviour in the context of professional health care is built on nothing stronger than prejudice

The metaethics of psychotherapy codes of ethics and conduct

Codes of ethics and conduct are important documents in health care practice, and must be evaluated alongside an understanding of the role of the organisations which write and publish them. In the UK, established professions like medicine and nursing are subject to statutory regulation and codes which delineate ethical best practice from minimum conduct. However the regulation of psychotherapists in the UK has been the subject of changes in government policy during the last decade, resulting in a fragmented regulatory environment where a number of organisations function both as regular and professional body. There are about 40 codes of ethic and/or conduct in the UK relating to the various professions of psychotherapy. The chapter details the regulatory framework in the UK, and the places of codes within it. The codes’ regulatory role in establishing minimum practice is difficult to assess because so few cases of malpractice are brought, and their role in guiding practice is questioned by using disclosure of confidential information as an example. Psychotherapists are invited to assess whether the codes and associated guidance they operate under are sufficiently detailed to guide practice

Is there a professional responsibility to adopt a healthy lifestyle?

Recently released documents consulting on a new pre-registration curriculum in the UK contain the following clause: At the point of registration, the registered nurse will understand the professional responsibility for adopting a healthy lifestyle… The document falls short of requiring that students do actually adopt the prescribed lifestyle, but requiring understanding in this manner only makes sense if there is such a responsibility. In this sense, and regardless of the outcome of the consultation this clause is significant: The professional regulator in the UK claims that nurses have a responsibility – that is an obligation – to adopt a healthy lifestyle. This presentation challenges this claim. Responsibilities in this context have three component parts: the actor, obligation and consequences, and each of these are problematic in this context. Generally, the notion of ‘professional responsibility’ is difficult outside the boundaries of a code of conduct. Specifically, the notion of a professional (moral) responsibility to adopt a healthy lifestyle is challenged by examining arguments in favour, which are a mixture of the normative and empirical. It is concluded that there is no such responsibility, professional or otherwise

Education not regulation: Why you can’t regulate for virtuous compassion

In the aftermath of the scandal of poor care at Mid Staffs and the Francis reports that followed, there were calls for more compassion in nursing. The Prime Minister wanted to reward it with increased pay, and the Government nursing strategy is centred around it as one of the ubiquitous 6Cs. As well as renewed interest in education in the virtues in general and compassion in particular, there has also been interest in regulation for compassion, and for the first time the word appeared in the UK regulators code in 2015. This paper argues that any attempt to regulate for compassion is misguided, and three arguments will be presented. First there is a mismatch between ethical aspirational codes and quasi-legal conduct codes. Virtuous compassionate practice is a feature of aspirational codes but not conduct codes which are designed to protect the public from not-good-enough nurses rather than require good nursing. This distinction survives the conflation of the two types of code within regulatory the NMC code. Second, compassion requires an emotional response and this cannot be under conscious control. Patients report that small acts of kindness are perceived as compassionate, but I argue that they need not be. Education and regulation focussing on these behaviours rather than their motivation promotes acts that look like compassion rather than fully compassionate acts. People cannot be required to be emotional and you cannot make people be what they are not. You can make people write with their left hand but this doesn’t make them left handed. Thirdly, it has been argued that requiring compassion in regulation simply does not work. It promotes faux compassion of the sort which, it is claimed, is similar to the forced bonhomie of the coffee ship waitress. This has the potential of harming professionals who are forced to have a disconnection between how they feel and how they act, and also promotes cynicism in patients who believe that professionals behave in the prescribed way just because they have to. In the UK the word compassion is found only in regulatory code written by the nursing and midwifery regulator. Its inclusion is in response to severe failures in nursing practice but is ill considered and incoherent and should be removed when the code is next reviewed

Shame as a Public Health Intervention

The bioethicist Daniel Callahan has recently argued for ‘stigmatisation lite’ as a way to reduce the incidence of obesity. ‘The force of being shamed and beat upon socially’ worked for him when he stopped smoking, and a positive application of social pressure has been influential in behaviour change related to, for example, the reduction of drink driving, so why can’t we shame people into losing weight? Criticism of the paper was swift and multifaceted, but it turned out that he didn’t intend to stigmatise the obese at all – only to use social pressure (if that is possible) on the not-yet-obese or just a little overweight. Nevertheless his paper provides an opportunity to re-evaluate the use of stigma and shame as interventions in public health policy. Public health policy is an enterprise which outwardly promotes personal choice, but encouraging and facilitating decision making based on capitulating to social conformity seems at odds with respecting personal autonomy. Health professionals spend a good deal of time and energy trying to increase self-esteem in stigmatised groups, and so a suggestion that we deliberately increase stigma, lite or otherwise, seems odd. Public health policy which aimed to increase stigma might be acceptable if it worked, but Callahan offered no evidence that it would. But the rejection of stigma and shame as public health tools to reduce obesity does not necessarily reject the use of social emotions in public health policy. Differences between guilt and shame are discussed and I argue that in some circumstances fostering guilt for direct harms to others may be ethically acceptable. Television anti-smoking campaigns are used as examples it is tentatively concluded that Callahan’s ill-received paper promoting obesity shame should not obscure the possibility of using social emotions in public health policy elsewhere

Mill, advocacy and the tobacco endgame

Though its stricture has not been universally followed in modern liberal states, Mill’s harm principle remains important in public health ethics. Banning an individual from doing something because it’s bad for him requires stronger reasons than banning it because it harms others. In England, justification for smoking bans in enclosed spaces was firmly presented in terms of preventing harms to others, even if its subsequent evaluation also included health gains to smokers. The legal ban did not cover smoking outside where harms to others are less. Care homes and hospices were granted exemption but in mental health units this was temporary, so that when they expired, the ban became de facto a complete ban where patients cannot go outside. During legal challenges in England, justification for the ban was sought in health gains for patients, including regarding the habit as self-harm. Recent NICE guidelines recommend total smoking bans inside and outside hospital for the benefit of smokers. For smokers, Mill’s principle has been overturned. The supremacy of personal autonomy is central to nursing ethics, though less so in public health ethics. Smoking bans and their effect on individual patients is one area where these disciplines collide. Nursing claims (or requires) a role for patient advocacy but this can be variously interpreted and nursing can no longer prevaricate. It must choose to advocate for patients’ health (in favour of a ban) or for patients’ choice (against a ban), and the direction it takes clearly identifies where the profession’s values lie

Personal responsibility for health: meaning, extent and consequences.

Like the rest of the western world, the UK faces a significant increase in the prevalence of diseases associated with lifestyle. Smoking rates have reduced, but increasing obesity has contributed to alarming increases in diabetes. Discovery of the correlation between behaviour and poor health has, since the 1970s, resulted in public health policies emphasising behaviour change, and personal responsibility; an emphasis that survived later research which demonstrated social, genetic and psychological determinants on behaviour and health. The latest version of the NHS constitution exhorts us to ‘recognise that you can make a significant contribution to your own, and your family’s, good health and wellbeing, and take personal responsibility for it.’ This thesis seeks to clarify the meaning and extent of personal responsibility for health, and at its core are four papers published in peer-reviewed journals. The first clarifies the concept concluding that it is best understood in a tripartite conception of a moral agent having obligations and being held responsible if he fails to meet them. The following two papers discuss the nature of the obligations, using utilitarian reasoning and arguments from analogy. First, an exploration of the moral obligations for our own health is undertaken via an analysis of the practice of tombstoning, jumping from height into water. I conclude that the obligations are of process rather than outcome, consisting of an epistemic duty to determine the health related consequences of our acts, and a reflective duty to consider these consequences for us and for those who share our lives. Second, following an examination of the moral status of blood donation, I conclude that despite its presentation as a praiseworthy and supererogatory act, it is more properly regarded as a prima facie obligation, supported by arguments from beneficence and justice. The final paper discusses the final part of the tripartite conception of personal responsibility for health: being held responsible. I discuss the nature of blame and extend the tombstoning analogy as a way of testing my own intuitions in response to an imagined adult son who has undertaken this dangerous activity. I argue that the notion of blame is not generally allowed as part of the patient – professional relationship, and yet without considering blame, the concept of personal responsibility for health is incomplete. I conclude that if the epistemic and reflective duties, individually applied, conclude that an obligation is owed, it is owed to those within personal relationships, and holding people responsible for their health-effecting behaviour is also best undertaken within these relationships.I conclude the thesis by considering the implications for professional practice. Inevitably this leads to consideration of the promotion of personal autonomy in health care. A more relational account of autonomy is suggested. Facilitating the epistemic duty so that individuals are better able to understand the risks of their behaviour requires rethinking of the way that health promoting material and information are presented

Four decisions for a middle-aged man.

Advancing years brings questions about my prostrate, my cholesterol and my lifestyle choice and a surgical procedure into sharp focus, as well as the methods nurses use to educate patients to support decision making The most regulated information giving is for operative procedures. A recent English legal case recognised the availability of information on the Internet and found that the test of adequate knowledge is no longer what the professional judges, but what a particular patient would want to know. A minority opinion suggested that the information given – in relation to vaginal delivery – was partly driven by a view that normal delivery was morally preferable, but that the woman was entitled to take her own values into account. This is consistent with guidance from the National Institute of Health and Clinical Excellence which sets out ways of giving information which are most easily understood, including using absolute rather than relative risk, frequency instead of percentages, and both negative and positive framing. This presentation assesses the information given to me to make decisions on operative risk, prostrate screening, whether to take a statin and whether to reduce alcohol intake. For the first three, there is a genuine attempt to present information in a format that can best be understood. However, in relation to alcohol consumption, both for the patient and within educational resources for nurses, information is not presented following the NICE guidance. It is difficult to escape the conclusion that this is because it is driven by value judgements and not by a desire to assist individuals make informed decisions. This may be in line with policies seeking to reduce behaviours, but does not value individual autonomy, or respect persons, both of which are claimed to be fundamental tents of the nursing profession