Good Care in Ongoing Dialogue. Improving the Quality of Care Through Moral Deliberation and Responsive Evaluation

Recently, moral deliberation within care institutions is gaining more attention in medical ethics. Ongoing dialogues about ethical issues are considered as a vehicle for quality improvement of health care practices. The rise of ethical conversation methods can be understood against the broader development within medical ethics in which interaction and dialogue are seen as alternatives for both theoretical or individual reflection on ethical questions. In other disciplines, intersubjectivity is also seen as a way to handle practical problems, and methodologies have emerged to deal with dynamic processes of practice improvement. An example is responsive evaluation. In this article we investigate the relationship between moral deliberation and responsive evaluation, describe their common basis in dialogical ethics and pragmatic hermeneutics, and explore the relevance of both for improving the quality of care. The synergy between the approaches is illustrated by a case example in which both play a distinct and complementary role. It concerns the implementation of quality criteria for coercion in Dutch psychiatry

Stable long-term outcomes after cochlear implantation in subjects with TMPRSS3 associated hearing loss:a retrospective multicentre study

Background: The spiral ganglion hypothesis suggests that pathogenic variants in genes preferentially expressed in the spiral ganglion nerves (SGN), may lead to poor cochlear implant (CI) performance. It was long thought that TMPRSS3 was particularly expressed in the SGNs. However, this is not in line with recent reviews evaluating CI performance in subjects with TMPRSS3-associated sensorineural hearing loss (SNHL) reporting overall beneficial outcomes. These outcomes are, however, based on variable follow-up times of, in general, 1 year or less. Therefore, we aimed to 1. evaluate long-term outcomes after CI implantation of speech recognition in quiet in subjects with TMPRSS3-associated SNHL, and 2. test the spiral ganglion hypothesis using the TMPRSS3-group. Methods: This retrospective, multicentre study evaluated long-term CI performance in a Dutch population with TMPRSS3-associated SNHL. The phoneme scores at 70 dB with CI in the TMPRSS3-group were compared to a control group of fully genotyped cochlear implant users with post-lingual SNHL without genes affecting the SGN, or severe anatomical inner ear malformations. CI-recipients with a phoneme score ≤ 70% at least 1-year post-implantation were considered poor performers and were evaluated in more detail. Results: The TMPRSS3 group consisted of 29 subjects (N = 33 ears), and the control group of 62 subjects (N = 67 ears). For the TMPRSS3-group, we found an average phoneme score of 89% after 5 years, which remained stable up to 10 years post-implantation. At both 5 and 10-year follow-up, no difference was found in speech recognition in quiet between both groups (p = 0.830 and p = 0.987, respectively). Despite these overall adequate CI outcomes, six CI recipients had a phoneme score of ≤ 70% and were considered poor performers. The latter was observed in subjects with residual hearing post-implantation or older age at implantation. Conclusion: Subjects with TMPRSS3-associated SNHL have adequate and stable long-term outcomes after cochlear implantation, equal to the performance of genotyped patient with affected genes not expressed in the SGN. These findings are not in line with the spiral ganglion hypothesis. However, more recent studies showed that TMPRSS3 is mainly expressed in the hair cells with only limited SGN expression. Therefore, we cannot confirm nor refute the spiral ganglion hypothesis.</p

(Un)becoming women: Indian factory women's counternarratives of gender

This paper portrays the life stories of five factory workers in Delhi whose life trajectories run counter to normative femininity. As daughters and wives, they are neglected, abandoned or rejected by their families; they live alone, with their parents past the age that is their natal right, with siblings, or with families and men who are not related to them. I explore the circulation of their counternarratives and how their gender transgressions go public through ordinary forms of talk, such as gossip and rumor. I argue that their move out of the normative is not produced by, but produces, their gender politics; that their agency emerges cognitively from the telling of their stories in tandem with their interlocutors' credulity and uptake; and that the site of gender politics for working class Indian women lies in the informal subaltern publics that are formed by the circulation of their stories. Contrary to the notion of a stable unitary subject that precedes the political, these women's counternarratives demonstrate the subject‐in‐process as a political effect. Their alterity does not exist outside the heteronormative gender order but demarcates the boundaries of its historicity, hinting at both the internal contradictions of existing gender relations and their future possibilities.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/112196/1/j.1467-954X.2011.02026.x.pd

Free will and psychiatric assessment of criminal responsibility. A parallel with informed consent

In some criminal cases a forensic psychiatrist is asked to make an assessment of the state of mind of the defendant at the time of the legally relevant act. A considerable number of people seem to hold that the basis for this assessment is that free will is required for legal responsibility, and that mental disorders can compromise free will. In fact, because of the alleged relationship between the forensic assessment and free will, researchers in forensic psychiatry also consider the complicated metaphysical discussions on free will relevant to the assessment. At the same time, there is concern about the lack of advancement with respect to clarifying the nature of the forensic assessment. In this paper I argue that, even if free will is considered relevant, there may be no need for forensic researchers to engage into metaphysical discussions on free will in order to make significant progress. I will do so, drawing a parallel between the assessment of criminal responsibility on the one hand, and the medical practice of obtaining informed consent on the other. I argue that also with respect to informed consent, free will is considered relevant, or even crucial. This is the parallel. Yet, researchers on informed consent have not entered into metaphysical debates on free will. Meanwhile, research on informed consent has made significant progress. Based on the parallel with respect to free will, and the differences with respect to research, I conclude that researchers on forensic assessment may not have to engage into metaphysical discussions on free will in order to advance our understanding of this psychiatric practice. © 2010 The Author(s)

Quality of life in a broader perspective: Does ASCOT reflect the capability approach?

PURPOSE: Economic evaluation of services and interventions in care services tends to focus on quality of life(QoL) based on health-related measures such as EQ5D, with a major focus on health and functioning. The Capability Approach (CA) provides an alternative framework for measuring QoL and challenges some of the conventional issues in the current practice of measurement of QoL. The Adult Social Care Outcomes Toolkit (ASCOT) aims to measure social care-related QoL in a broad sense. This article investigates whether and, if so, how the ASCOT addresses issues put on the agenda by the CA. METHODS: Literature analysis concerning theoretical assumptions and arguments of CA and ASCOT. RESULTS: The Capability Approach (CA) puts three issues on the agenda regarding QoL. First, the focus of evaluation should not be on functioning, but on freedom of choice. Second, evaluation should be critical about adaptive preferences, which entail that people lower expectations in situations of limited possibilities. Third, evaluation should not only address health, but also other domains of life. Our analysis shows that freedom of choice is reflected in the response option 'as I want' in the ASCOT questionnaire. The problem of adaptive preferences is countered in the ASCOT by developing a standard based on preferences of the general population. Third, the ASCOT contains several domains of life. CONCLUSIONS: We conclude that the CA and the ASCOT contribute to the discussion on QoL, and that the ASCOT operationalizes core assumptions of the CA, translating the issues raised by the CA in a practical way

Gender differences in associations of depressive symptoms and anxiety with inflammatory markers in patients with non-obstructive coronary artery disease

Objective: The aim of this study was to examine gender differences of the associations between depressive symptoms and anxiety with inflammatory markers in patients with non-obstructive coronary artery disease (NOCAD). Methods: Depressive symptoms and anxiety (Beck Depression Inventory BDI and Hospital Anxiety and Depression Scale HADS) were examined in 524 patients with NOCAD (52% women, mean age 64 +/- 9 years) as part of the TweeSteden Mild Stenosis (TWIST) observational cohort study. Blood samples were analyzed for neutrophil gelatinase-associated lipocalin (NGAL) levels, high-sensitive C-reactive protein (hsCRP), and leukocyte differentiation. Multivariate analysis for the inflammatory markers with main effects of depressive symptoms or anxiety, gender, and their interactions were observed. Results: Women had elevated levels of hsCRP, and a lower monocyte and eosinophil count than men, with small to medium effect sizes (range eta(2)((p)) = 0.019-0.047). After Holm-Bonferroni correction depressive symptoms according to the BDI were associated with an overall elevated hsCRP level explaining 2.4% of the hsCRP variance. A significant positive association between BDI cognitive symptoms with elevated hsCRP level was observed in men (R-2 = 0.045), but not in women (R-2 <0.001). Adjustment for age, body mass index, smoking, and physical activity attenuated this finding. Conclusion: Small associations of inflammatory markers with depressive symptoms and anxiety were confounded by lifestyle factors, predominantly smoking. The interacting roles of gender, smoking, and psychological factors on inflammatory markers may point toward different behavioral and inflammatory pathways for women and men with NOCAD, which remains to be further explored