Alan Cribb

Supporting Patient Autonomy: The Importance of Clinician-patient Relationships

Personal autonomy is widely valued. Recognition of its vulnerability in health care contexts led to the inclusion of respect for autonomy as a key concern in biomedical ethics. The principle of respect for autonomy is usually associated with allowing or enabling patients to make their own decisions about which health care interventions they will or will not receive. In this paper, we suggest that a strong focus on decision situations is problematic, especially when combined with a tendency to stress the importance of patients’ independence in choosing. It distracts attention from other important aspects of and challenges to autonomy in health care. Relational understandings of autonomy attempt to explain both the positive and negative implications of social relationships for individuals’ autonomy. They suggest that many health care practices can affect autonomy by virtue of their effects not only on patients’ treatment preferences and choices, but also on their self-identities, self-evaluations and capabilities for autonomy. Relational understandings de-emphasise independence and facilitate well-nuanced distinctions between forms of clinical communication that support and that undermine patients’ autonomy. These understandings support recognition of the value of good patient-professional relationships and can enrich the specification of the principle of respect for autonomy.

Towards the reflexive medical school: The hidden curriculum and medical education research

ABSTRACT In this article it is argued that the agenda and culture of reform about teaching and learning in UK medical schools needs to be underpinned by a similar liberalisation of medical education research, and in particular by the fostering of more interpretative and reflexive research paradigms. The authors draw upon the sociology of medical education to illustrate how the key tensions inherent in the professional socialisation of doctors—between ‘objectifying˚s and ‘humanising˚s currents—construct and limit both the capacity to change medical schools and the capacity for medical schools to understand themselves. By illuminating the parallels and interactions between the contests that lie behind curriculum and research the authors indicate one possible way forward.

Shared decision making: trade-offs between narrower and broader conceptions.

Shared decision‐making approaches, by recognizing the autonomy and responsibility of both health professionals and patients, aim for an ethical ‘middle way’ between ‘paternalistic’ and ‘consumerist’ models of clinical decision making. Shared decision making has been understood in various ways. In this paper, we distinguish narrow and broader conceptions of shared decision making and explore their relative strengths and weaknesses. In the first part of the paper, we construct a summary characterization of an archetypal narrow conception of shared decision making (a conception that does not coincide with any specific published model but which reflects features of a variety of models). We show the shortcomings of such a conception and highlight the need to broaden out our thinking about shared decision making if the ethical (and instrumental) goals of shared decision making are to be realized. In the second part of the paper, we acknowledge and explore the advantages and disadvantages of operating with broader conceptions of shared decision making by considering the analogies between health professional–patient relationships and familiar examples of ‘open‐ended’ relationships (e.g. friendships). We conclude by arguing that the illustrated ‘trade‐offs’ between narrow conceptions (which may protect patients from inappropriately paternalistic professionals but preclude important forms of professional support) and broad conceptions (which render more forms of professional support legitimate but may require skills or virtues that not all health professionals possess) suggest the need to find ways, in principle and in practice, of taking seriously both patient autonomy and autonomy‐supportive professional intervention.

Plural conceptions of social justice: implications for policy sociology

Concern with multi-faceted or ‘plural’ conceptions of justice has grown within policy sociology. This paper briefly summarizes some of the dimensions and facets of such plural models and considers their implications for policy sociology. Three implications, in particular, are considered. It is suggested that: first, plural models of justice substantially enlarge the agenda of evaluation; second, tensions within and between different facets of justice need to be acknowledged and responded to; and third, plural models entail a collapse of the distinction between evaluation and action. The paper argues that the latter two implications are frequently overlooked in policy sociology, particularly in work with a dominant focus on critiquing educational and social reproduction in a style the paper labels ‘sociology from above’. By contrast, the paper discusses examples of scholarship that meet the challenges of plural models — scholarship that has more in common with the cultural studies tradition. In so doing, the paper indicates the importance of a ‘sociology of just practices’, and a modified ‘reflective equilibrium’ approach is identified as one means of developing such a sociology.

What to do about values in social research: the case for ethical reflexivity in the sociology of education

This paper is intended as a contribution to the longstanding debate about the best way of handling value judgements in social research. In it we make a case for more ‘ethical reflexivity’ in the sociology of education and argue that a systematic attention to value questions should be viewed as a taken‐for‐granted component of methodological rigour. We elucidate what we mean by ethical reflexivity, why we think it is important and suggest what it entails in practice. Our arguments are developed through a discussion of, and in contrast to, Martyn Hammersley’s analysis of the role of values in social research. The central problematic that the paper addresses is the tension between, on the one hand, the goal of insulating the research process from ‘value bias’ and, on the other hand, the goal of contributing to political and social change through research. We suggest that the reason for the intractability of the problem of values in social research is a persistent failure to recognise that, in practice, these two goals are inseparable. We argue that rigour in research demands that both these goals are taken seriously and we set out some of the challenges involved in trying to combine them.

Prescribers, patients and policy: the limits of technique.

What is good prescribing? In this paper we will look at the kinds of criteria which are relevant to evaluating prescribing. In particular we wish to challenge, or at least re-frame, the picture of prescribing as an essentially technical process. In so doing we hope to indicate something more general about the power, and limitations, of technical rationality in health care, and to contribute something to work in health care technology assessment. Finally we hope this discussion will act as a stimulus towards a much needed revision of the way ‘good’ prescribing is defined by current policies, guidelines and protocols.

Unpacking Autonomy and Control in Education: some conceptual and normative groundwork for a comparative analysis

To make meaningful comparisons of the consequences of new modes of regulation in education for local autonomy in different national settings we need to a) be clear about what is meant by local autonomy and state control, b) be clear about why the balance between local autonomy and state control matters and c) produce good quality empirical data and analysis. The purpose of this article is to make a contribution to the first two of these tasks which are relatively neglected in the education research literature. The authors begin by unpacking some conceptual complexities involved in debating issues of autonomy and control, distinguishing between three dimensions of autonomy-control: loci and modes of autonomy, domains of autonomy-control and loci and modes of control. They then go on to illustrate some of the normative complexities surrounding issues of autonomy-control, using the case of individual teacher autonomy to explore arguments about the value of autonomy and control. Finally, the authors discuss the implications of these complexities for the task of policy analysis. In doing so, they seek to: ‘trouble’ the presumption that autonomy is necessarily good; challenge the notion that control and autonomy are discrete entities in some simple zero-sum relationship to one another, drawing attention to the ways in which control can be seen as ‘productive’ as well as ‘destructive’ of autonomy; and sketch out the multi-dimensional nature of cross-national comparative evaluation of regulation in education.

Doing teacher research: a qualitative analysis of purposes, processes and experiences

In this paper we draw upon 14 semi‐structured interviews with the participants in a teacher‐researcher project on the theme of ‘ensuring African Caribbean attainment’ with the aim of shedding light on the purposes, processes and lived experiences of teacher research in a difficult and contentious intellectual and practical domain. After briefly reviewing the history and policy background of teacher research in England, we introduce the project and the specific purposes and motivations of its various stakeholders. In the second half of the paper we analyse the challenges and the rewards of participating in the project, including the challenges of facilitating teacher research, and we review the key implications of the research for policy and practice. We conclude that, in trying to make teacher research happen in a way that is meaningful and productive for those involved (whether as facilitators or teacher researchers), three things have to be negotiated at once: new roles for academic facilitators, new dimensions of teacher roles, and a viable conception of research that is authentically teacher research. All of these things involve rethinking assumptions about what it means to be a teacher and an academic and what is meant by research. Drawing on the lessons of this project, we suggest that the central challenge of building successful teacher research is the creation of genuine partnerships, characterised by respectful and critical dialogue, between university staff and teacher researchers.

Taking Identity Seriously: Dilemmas for Education Policy and Practice.

If we are to fully understand and adequately respond to the multicultural question in European education, it is necessary to develop rich empirical descriptions and theoretically rigorous explanations of policy processes and effects. For example, we need to be able to characterise and explain the differentiated ways in which education policies and practices do or do not recognise, support or undermine diverse cultural identities and do or do not reproduce various kinds of educational and social inequality. But we also need to be able to produce some kind of account of what ought to be going on. The latter involves confronting a number of important questions: Why does identity matter? What is ethically entailed by — and what are the limits to — recognising and supporting diverse cultural identities? In what ways are the various currents of multiculturalism an adequate response to these complex normative questions? In this article, the authors begin to respond to these questions by mapping out some of the dilemmas involved in taking both identity and equality seriously.

Towards An Ethical Audit of the Privatisation of Education

ABSTRACT:  We argue that the privatisation of education needs to be understood through an ethical lens, and suggest a broad framework through which privatisation policies and practices might be ethically audited. These policies and practices – it is suggested – are creating new ethical spaces and new clusters of goals, obligations and dispositions. Whatever the merits of our particular reading of these changes, we would call for an urgent public debate on these questions – one that looks beyond broad ideological questions to consider the effects of privatisation on the nature of the services provided.