Personhood as projection: the value of multiple conceptions of personhood for understanding the dehumanisation of people living with dementia

We examine the concept of personhood in relation to people living with dementia and implications for the humanity of care, drawing on a body of ethnographic work. Much debate has searched for an adequate account of the person for these purposes. Broad contrasts can be made between accounts focusing on cognition and mental faculties, and accounts focusing on embodied and relational aspects of the person. Some have suggested the concept of the person is critical for good care; others suggest the vexed debates mean that the concept should be abandoned. We argue instead that the competing accounts illuminate the very tensions in personhood which are manifest for all of us, but especially for people living with dementia, and argue that our account has explanatory power in shedding light on how precisely dehumanisation and constraints on agency may arise for people living with dementia, and for staff, within an institutional context.

Pad cultures: An ethnography of continence care and its consequences for people living with dementia during a hospital admission

BACKGROUND

There is little research examining how continence care is organised and delivered to people living with dementia across an acute hospital admission, despite the prevalence of this patient population and their vulnerability within these settings.

OBJECTIVE

To explore how continence care is delivered to people living with dementia during an acute hospital admission.

DESIGN

Ethnographic.

SETTING(S)

Acute medical units and wards within three hospitals across England and Wales.

PARTICIPANTS

People living with dementia and ward staff (registered nurses and care assistants) on participating wards.

METHODS

Ethnographic fieldwork collected over a period of 12 months (180 days of non-participant observation) focussing on the organisation and delivery of continence care to people living with dementia. Observations were supported with in situ ethnographic interviews (n = 562) with patients, visitors and staff within the six observed wards. Data collection and analysis drew on the theoretical sampling and constant comparison techniques of grounded theory.

RESULTS

The findings comprised of five overall themes: (1) visibility of continence; (2) rationales of continence care; (3) containment and contagion; (4) consequences of continence care and (5) supporting continence.

CONCLUSIONS

We introduce the term 'pad cultures' to refer to the established routine use of continence pads in the care of a wider group of people living with dementia (regardless of continence status and independence), with the rationale to provide safeguards, ensure containment and prevent 'accidents' or incontinent episodes. There was an expectation within acute wards that people living with dementia not only wear continence pads but that they also use them.

Presentation of the clothed self on the hospital ward: an ethnographic account of perceptual attention and implications for the personhood of people living with dementia

This study contributes to our understanding of the 'medical gaze' and its impact on the ways in which people living with dementia experience care during a hospital admission. Visual perception has a powerful effect on our emotional and moral reactions to others. One aspect of how we perceive and respond to others is through clothing, which relates strongly to class and social position. Our focus is on exploring the ways in which patient clothing may affect the perceptions and response of others, and self-perception and resulting behaviour. We draw on ethnographic research within acute hospital wards in five hospitals across England and Wales, examining the everyday organisation and delivery of care to people living with dementia. People living with dementia are a significant population who have poor experiences and outcomes of care within the acute setting. Our data suggest that the twin aspects of clothing and appearance-of self-perception, and of perception by others-may be especially important in the fast-paced context of an acute ward environment, where patients living with dementia may be struggling with the impacts of an additional acute medical condition within in a highly timetabled, regimented, and unfamiliar environment of the ward, and where staff perceptions of them may feed into clinical assessments of their condition and subsequent treatment and discharge pathways.

Using Signs and Symbols to Label Hospital Patients with a Dementia Diagnosis: Help or Hindrance to Care?

Signs and symbols may be used in attempts to direct attention to particular aspects of patient care and hence affect how the patient is seen. An ethnography within five hospitals across England and Wales explored how everyday technologies are enrolled on acute wards to drive attention to the existence, diagnosis, and needs of people living with dementia within their ageing population. We explore how signs and symbols as everyday "technologies of attention" both produce and maintain the invisibilities of people living with dementia and of the older population within those wards and bring about particular understandings of the classification of dementia. The use and reliance on signs and symbols to aid recognition of people living with dementia may inadvertently lead to misclassification and narrow attention onto particular aspects of bedside care and "symptoms," competing with a wider appreciation of the individual care needs of people living with dementia and restricting expertise of ward staff.

The canary in the coal mine: Continence care for people with dementia in acute hospital wards as a crisis of dehumanization

Continence is a key moment of care that can tell us about the wider care of people living with dementia within acute hospital wards. The spotlight is currently on the quality of hospital care of older people across the UK, yet concerns persist about their poor treatment, neglect, abuse, and discrimination within this setting. Thus, within hospitals, the care of people living with dementia is both a welfare issue and a human rights issue. The challenge of continence care for people living with dementia can be seen as the 'canary in the coal mine' for the unravelling of dignity within the acute setting. This paper draws on an ethnographic study within five hospitals in England and Wales, selected to represent a range of hospital types, geographies and socio-economic catchments. Observational fieldwork was carried out over 154 days in acute hospitals known to admit large numbers of people living with dementia. This paper starts to fill the gap between theory and data by providing an in-depth ethnographic analysis examining the ways in which treatment as a person is negotiated, achieved or threatened. We examine how the twin assaults on agency of a diagnosis of dementia and of incontinence threaten personhood. The acute threats to this patient group may then act to magnify perils to treatment as a person. Our findings suggest that personal dignity and the social construction of moral personhood are both threatened and maintained in such a setting. We show how empirical ethnographic data can lend weight to, and add detail to, theoretical accounts of moral personhood and dignity.

Consent forms in genomics: the difference between law and practice

Consent forms are the principal method for obtaining informed consent from biomedical research participants. The significance of these forms is increasing as more secondary research is undertaken on existing research samples and information, and samples are deposited in biobanks accessible to many researchers. We reviewed a selection of consent forms used in European Genome-Wide Association Studies (GWAS) and identified four common elements that were found in every consent form. Our analysis showed that only two of the four most commonly found elements in our sample of informed consent forms were required in UK law. This raises questions about what should be put in informed consent forms for research participants. These findings could be beneficial for the formulation of participant information and consent documentation in the future studies.

Identifiability, genomics and U.K. data protection law

Analyses of individuals' genomes--their entire DNA sequence--have increased knowledge about the links between genetics and disease. Anticipated advances in 'next generation' DNA-sequencing techniques will see the routine research use of whole genomes, rather than distinct parts, within the next few years. The scientific benefits of genomic research are, however, accompanied by legal and ethical concerns. Despite the assumption that genetic research data can and will be rendered anonymous, participants' identities can sometimes be elucidated, which could cause data protection legislation to apply. We undertake a timely reappraisal of these laws--particularly new penalties--and identifiability in genomic research.

Relative responsibilities: is there an obligation to discuss genomics research participation with family members?

One of the many ethical challenges presented by research in genomics is that, although informed consent to research has traditionally been a matter for the individual participant, genomics research carries potential implications for genetic relatives. There are specific issues that arise when research is focused around populations or around family groups; this paper deals with the place of relatives of participants in genomics research more generally. Recently, in response to this challenge, recommendations have attempted to tread a middle ground by retaining traditional models of informed consent whilst suggesting that potential research recruits should be encouraged to discuss participation with their families. It is argued here that this may produce an unfair account of the responsibilities of research participants, that it may ignore the very many difficulties of communication within families about genetics and health, and that it may create unrealistic hurdles to the ethical conduct of research. Research conducted in the context of clinical genetics and on health communication more widely is drawn upon to illustrate these points. A clear recommendation is made that providing materials that may assist research participants to communicate with family members may be beneficial and may raise ethical standards, but that it may be unwise to burden participants with the suggestion that they owe specific obligations to genetic relatives to discuss research participation with them.

Assessing the privacy risks of data sharing in genomics

The protection of identity of participants in medical research has traditionally been guaranteed by the maintenance of the confidentiality of health information through mechanisms such as only releasing data in an aggregated form or after identifying variables have been removed. This protection of privacy is regarded as a fundamental principle of research ethics, through which the support of research participants and the public is maintained. Whilst this traditional model was adopted for genetics and genomics research, and was generally considered broadly fit for purpose, we argue that this approach is increasingly untenable in genomics. Privacy risk assessments need to have regard to the whole data environment, not merely the quality of the dataset to be released in isolation. As sources of data proliferate, issues of privacy protection are increasingly problematic in relation to the release of genomic data. However, we conclude that, by paying careful attention to potential pitfalls, scientific funders and researchers can take an important part in attempts to safeguard the public and ensure the continuation of potentially important scientific research.

Ethical implications of the use of whole genome methods in medical research

The use of genome-wide association studies (GWAS) in medical research and the increased ability to share data give a new twist to some of the perennial ethical issues associated with genomic research. GWAS create particular challenges because they produce fine, detailed, genotype information at high resolution, and the results of more focused studies can potentially be used to determine genetic variation for a wide range of conditions and traits. The information from a GWA scan is derived from DNA that is a powerful personal identifier, and can provide information not just on the individual, but also on the individual's relatives, related groups, and populations. Furthermore, it creates large amounts of individual-specific digital information that is easy to share across international borders. This paper provides an overview of some of the key ethical issues around GWAS: consent, feedback of results, privacy, and the governance of research. Many of the questions that lie ahead of us in terms of the next generation sequencing methods will have been foreshadowed by GWAS and the debates around ethical and policy issues that these have created.

Planning for translational research in genomics

Translation of research findings into clinical practice is an important aspect of medical progress. Even for the early stages of genomics, research aiming to deepen understandings of underlying mechanisms of disease, questions about the ways in which such research ultimately can be useful in medical treatment and public health are of key importance. Whilst some research data may not apparently lend themselves to immediate clinical benefit, being aware of the issues surrounding translation at an early stage can enhance the delivery of the research to the clinic if a medical application is later found. When simple steps are taken during initial project planning, the pathways towards the translation of genomic research findings can be managed to optimize long-term benefits to health. This piece discusses the key areas of collaboration agreements, distribution of revenues and recruitment and sample collection that are increasingly important to successful translational research in genomics.

The ethics and regulation of direct-to-consumer genetic testing

A report of the workshop 'Direct-to-consumer genetic testing: ethical and regulatory issues', Oxford, UK, 21 May 2009.

Data sharing in genomics--re-shaping scientific practice

Funding bodies have recently introduced a requirement that data sharing must be a consideration of all funding applications in genomics. As with all new developments this condition has had an impact on scientific practice, particularly in the area of publishing and in the conduct of research. We discuss the challenges that must be addressed if the full benefits of data sharing, as envisaged by funders, are to be realized.

Heart disease and social inequality: ethical issues in the aetiology, prevention and treatment of heart disease

Heart disease is a complex condition that is a leading cause of death worldwide. It is often seen as a disease of affluence, yet is strongly associated with a gradient in socio-economic status. Its highly complex causality means that many different facets of social and economic life are implicated in its aetiology, including factors such as workplace hierarchy and agricultural policy, together with other well-known factors such as what passes for individual 'lifestyle'. The very untangling of causes for heart disease thus inevitably raises social, moral and political issues. These include the proper role of the individual and of larger social forces in its aetiology, prevention and treatment. The construction of risk factors for heart disease likewise is enmeshed with questions of distributive justice in the responsible targeting of those at risk for heart disease, a debate which has received much overt attention in the medical literature, but less attention within the ethical literature. Strategies for addressing a condition of such complex causality can be highly diverse, from pharmaceutical to social interventions, and value issues attach to the choice and presentation of such strategies. For example, prevention strategies may raise complex issues of responsibility and of judgements of what it is to 'live well'. Further ethical debate on this highly political disease would be welcome.

Theoretical and practical issues in the definition of health: insights from Aboriginal Australia

This paper discusses attempts to define health within a public policy arena and practical and conceptual difficulties that arise. An Australian Aboriginal definition of health is examined. Although there are certain difficulties of translation, this definition is prominent in current Australian health policy and discourse about health. The definition can be seen as broadly holistic in comparison to other holistic definitions such as that of the World Health Organization. The nature of this holism and its grounding within the context of Aboriginal Australia is discussed. In particular, its implications for the phenomenon of medicalization, which may be associated with a holistic notion of health, is critically explored, as is the link of notions of health to culture and the question of the possibility of a universal definition of health. The question of to what extent a definition of health is inspirational or operational is also raised.

Communicating genetic information in the family: enriching the debate through the notion of integrity

Genetic information about one individual often has medical and reproductive implications for that individual's relatives. There is a debate about whether policy on transmitting genetic information within the family should change to reflect this shared aspect of genetic information. Even if laws on medical confidentiality remain unchanged, there still remains the question of professional practice and whether, to what extent and by what means professionals should encourage disclosure within a family. The debate so far has tended to focus on who has a right to genetic information, or has a right to decline genetic information, frequently drawing on the notion of individual autonomy. There are significant divergences within this debate, and difficulties with the use of autonomy in this context have been noted. This paper draws on theoretical considerations as well as on qualitative empirical data to show that shifting from talk of autonomy to talk of integrity will greatly enrich and illuminate the issues. It becomes possible to gain deeper insights into the ethical significance of the timing and the manner of such communication, the character of recipients of knowledge, and the nuanced nature of communication and different levels of understanding within a family.

Communicating about haemophilia within the family: the importance of context and of experience

This study examines communication within families affected by haemophilia, focusing especially on communication about carrier status. A qualitative study using semi-structured interviews with family members in the UK revealed recurrent patterns in communication strategies and styles. Participants drew a marked contrast between the nature of communication within the clinic and within the home. In families, it is notable that communication usually occurs within the context of concrete experience of the condition. Noticeable differences existed in families with obligate carriers when compared with families with non-obligate carrier daughters. In families with affected sons, daughters may have more experience of haemophilia and consequently more understanding of their possible carrier status than in families with an affected father. Families also typically make value judgements and comments on coping strategies when they communicate about the condition. Readiness to receive information is very variable, and depends upon factors such as personality and life stage. Information may seem to be successfully communicated but the recipient may sometimes actually comprehend much less, only understanding more fully later or when the information becomes directly relevant to them. Periodic checking of understanding of different family members, and the provision of written information, may be helpful.

Troubles with biocitizenship?

Genetic and other biotechnologies are starting to impact significantly upon society and individuals within it. Rose and Novas draw on an analysis of many patient groups to sketch out the broad notion of biocitizenship as a device for describing how the empowered and informed individual, group or network can engage with bioscience. In this paper, we examine critically the notion of biocitizenship, drawing on both sociological fieldwork that grounds the debate in the views of a large and varied group of concerned actors. Using work within green politics, we identify shortcomings in the concept of biocitizenship as it has so far been explicated. The value assumptions lying behind an account of biocitizenship, and its tendency to see issues through a reductive lens, are examined. Alternative views of values and goals, which may undermine any alleged rights and duties, are explored using interviews and other ethnographic data that illustrates the complexity of the terrain. The reductive lens of biocitizenship is explored through contrast with the wider scope of concerns emanating from various sources, including many within green politics. If such complexities are not recognised, there is a danger that a concept of biocitizenship may serve to create and amplify inequalities. Problems with identity issues are key: the construction of identity is complex and many groups are explicitly rejecting the 'biological' label. We discuss the multiple relations of citizens with the biotech and pharmaceutical industries. Arguably, existing inequalities in power relationships, exploitation, commodification and ownership patterns are being perpetuated in novel ways through the new biosciences. We pose the question of whether it is possible to construct a concept of biocitizenship that overcomes these problems.

The rhetorical construction of ethical positions: policy recommendations for nontherapeutic genetic testing in childhood

Nontherapeutic genetic testing in childhood raises many ethical concerns within and beyond the clinic. We examine six key position statements from Canada, the United Kingdom, and the United States that present ethical guidelines for good practice in clinical nontherapeutic childhood testing. Using a discourse-analytic perspective that focuses on the use of rhetorical contrasts, we identify how these statements argue for recommendations with distinctly different modalities for different types of nontherapeutic genetic testing. This comes about because of the interaction between a number of contrastive descriptions. It is dependent on how the genetic information resulting from testing is differentiated on a cline of seriousness, how such an evaluation is premised on a network of assumptions about the status of reproduction in people's lives, and the related selective deployment of ethical principles that foregrounds the self over others.

Working Up Policy: The Use of Specific Disease Exemplars in Formulating General Principles Governing Childhood Genetic Testing

Non-therapeutic genetic testing in childhood presents a "myriad of ethical questions"; questions which are discussed and resolved in professional policy and position statements. In this paper we consider an underdiscussed but strongly influential feature of policy-making, the role of selective case and exemplar in the production of general recommendations. Our analysis, in the tradition of rhetoric and argumentation, examines the predominate use of three particular disease exemplar (Huntington's disease, Tay-Sachs disease and sickle cell disease) to argue for or against particular genetic tests (predictive testing and testing for carrier status). We discuss the influence these choices have on the type and strength of subsequent recommendations. We argue that there are lessons to be drawn about how genetic diseases are conceptualised and we caution against the geneticisation of medical policy making.

The causation of disease - the practical and ethical consequences of competing explanations

The prevention, treatment and management of disease are closely linked to how the causes of a particular disease are explained. For multi-factorial conditions, the causal explanations are inevitably complex and competing models may exist to explain the same condition. Selecting one particular causal explanation over another will carry practical and ethical consequences that are acutely relevant for health policy. In this paper our focus is two-fold; (i) the different models of causal explanation that are put forward within current scientific literature for the high and rising prevalence of the common complex conditions of coronary artery disease (CAD) and type 2 diabetes mellitus (T2D); and (ii) how these explanations are taken up (or not) within national health policy guidelines. We examine the causal explanations for these two conditions through a systematic database search of current scientific literature. By identifying different causal explanations we propose a three-tier taxonomy of the most prominent models of explanations: (i) evolutionary, (ii) lifecourse, and (iii) lifestyle and environment. We elaborate this taxonomy with a micro-level thematic analysis to illustrate how some explanations are semantically and rhetorically foregrounded over others. We then investigate the uptake of the scientific causal explanations in health policy documents with regard to the prevention and management recommendations of current National Service Frameworks for CAD and T2D. Our findings indicate a lack of congruence between the complexity and frequent overlap of causal explanations evident in the scientific literature and the predominant focus on lifestyle recommendations found in the mainstream health policy documents.

Policy Recommendations for Carrier Testing and Predictive Testing in Childhood: A Distinction That Makes a Real Difference

The genetic testing of children raises many ethical concerns. This paper examines how five position statements from Canada, UK and USA, which present guidelines for good practice in this area produce different recommendations for carrier testing and predictive testing. We find that the genetic information generated through carrier testing is routinely presented as less serious than that generated from predictive testing. Additionally, the reproductive implications of predictive testing are also routinely erased. Consequently, the papers argue strongly against predictive testing but advise caution against carrier testing in somewhat weaker terms. We argue that these differences rest on assumptions about the status of reproduction in people's lives and on an ethical stance that foregrounds the self over others. We propose that questioning the crude and sharp distinction between carrier and predictive testing in principle may enable practitioners and parents/families to make more nuanced decisions in practice.

Returning to the Alder Hey report and its reporting: addressing confusions and improving inquiries

The Royal Liverpool Children's Inquiry investigated the circumstances leading to the removal, retention, and disposal of human tissue, including children's organs, at the Royal Liverpool Children's NHS Trust (the Alder Hey Hospital). It recommended changes to procedures for obtaining consent for postmortems and retaining organs and tissues for research or education. However, the report contains five areas of confusion. Firstly, it allowed the cultural and historical traditions of horror over the use and misuse of body parts to suffuse the logical analysis of past wrongs and future rights. Secondly, it makes an inappropriate conflation between seeking redress for past wrongs and shaping future policy. Thirdly, the report takes a muddled stance over the value of bodily integrity at burial. Fourthly, the report is inconsistent over the justification for future organ and tissue collections. Fifthly, the notion of "respect" is used with troublesome looseness. The extent to which subsequent policy work has furthered the search for greater ethical clarity over these difficult issues is discussed, together with reflection on three particular improvements that could be made to the process of such an inquiry.

Measuring quality of life in theory and in practice: a dialogue between philosophical and psychological approaches

Measuring quality of life is of concern to both philosophers and psychologists, yet the two disciplines typically approach the question in very different ways, ways so diverse that it may look as if they are engaged in such disparate activities that no dialogue between them is possible. In this paper we aim to construct the beginnings of a dialogue between the two disciplines which will show how they could serve each other and yet also show how, from the dialogue, difficult and previously unconsidered issues emerge for both sides.