Miles Little

Justifying Knowledge, Justifying Method, Taking Action: Epistemologies, Methodologies, and Methods in Qualitative Research

In this article, the authors clarify a framework for qualitative research, in particular for evaluating its quality, founded on epistemology, methodology, and method. They define these elements and discuss their respective contributions and interrelationships. Epistemology determines and is made visible through method, particularly in the participant— researcher relationship, measures of research quality, and form, voice, and representation in analysis and writing. Epistemology guides methodological choices and is axiological. Methodology shapes and is shaped by research objectives, questions, and study design. Methodologies can prescribe choices of method, resonate with particular academic disciplines, and encourage or discourage the use and/or development of theory. Method is constrained by and makes visible methodological and epistemic choices. If we define good quality qualitative research as research that attends to all three elements and demonstrates internal consistency between them, standardized checklists can be transcended and innovation and diversity in qualitative research practice facilitated.

‘Better than numbers…’ a gentle critique of evidence-based medicine

Evidence‐based medicine (EBM) has achieved cult status in the last 10 years or so. It is an altogether admirable movement in medicine, capable of a great deal of good. Its privileged status, however, has prevented critics from being heard, and there are problems with EBM. Eight features need further discussion if EBM is not to be discredited and superseded. They are its reductionism; its unwitting paternalism; its privileging of restricted kinds of evidence; its dependence on the questionable concept of equipoise; the instability of the ‘truths’ it produces; its capacity to eliminate individuals in favour of categories; its historical arrogance; and its contempt for the wisdom and integrity of our predecessors. Evidence‐based medicine is here to stay; for the moment, at least. It is sufficiently well established to withstand critique. It needs criticism if it is to survive and flourish.

Discourse Communities and the Discourse of Experience

Discourse communities are groups of people who share common ideologies, and common ways of speaking about things. They can be sharply or loosely defined. We are each members of multiple discourse communities. Discourse can colonize the members of discourse communities, taking over domains of thought by means of ideology. The development of new discourse communities can serve positive ends, but discourse communities create risks as well. In our own work on the narratives of people with interests in health care, for example, we find that patients speak of their illness experiences as victims of circumstance; policy makers construct adverse experiences and challenges as opportunities to be taken; health care workers speak from a mixed perspective, seeing themselves as both victims and opportunists depending on context. To be trapped within the discourse of a particular community is to put at risk the ability to communicate across discourses. Membership of a discourse community can impair the habit of critique, and deny opportunities for heteroglossic discourse. Privileging critique as a mode of discourse perhaps might define the ethical community, suggesting that ethical community may be an antidote to the constraining effects of conventional discourse community.

Assignments of meaning in epidemiology

Epidemiology works in a public domain, gathering the results of surveys and trials into forms of knowledge which are made available to many stakeholders. Health policy makers, lawyers, the media, medical technology companies, and those who use and deliver health services all have legitimate interests in epidemiology. There is unfortunately no common language in which each of these stakeholders can express their interest in the outcomes of epidemiological studies. The largest and most important gap exists between those who use computational data and those who use cultural and linguistic models to generate their explanations. Methods have been described, however, which allow the identification of all legitimate stakeholders before epidemiological studies are undertaken. Identifying the stakeholders, however, will serve no purpose unless there is a prior commitment by epidemiologists to respect both reductionist and narrative accounts of truth.

From advance directives to advance care planning: current legal status, ethical rationales and a new research agenda

Abstract

Is there an Aboriginal bioethic

It is well recognised that medicine manifests social and cultural values and that the institution of healthcare cannot be structurally disengaged from the sociopolitical processes that create such values. As with many other indigenous peoples, Aboriginal Australians have a lower heath status than the rest of the community and frequently experience the effects of prejudice and racism in many aspects of their lives. In this paper the authors highlight values and ethical convictions that may be held by Aboriginal peoples in order to explore how health practitioners can engage Aboriginal patients in a manner that is more appropriate. In doing so the authors consider how the ethics, values, and beliefs of the dominant white Australian culture have framed the treatment and delivery of services that Aboriginal people receive, and whether sufficient effort has been made to understand or acknowledge the different ethical predispositions that form the traditions and identity of Aboriginal Australia(ns).

The Fivefold Root of an Ethics of Surgery

Surgical ethics have generally been framed as general medical ethics applied to surgical contexts. This model is helpful, but may miss some of the special features of the surgical process and relationship. It is suggested in this paper that there are five categories of experience and relationship which are especially important in surgery--rescue, proximity, ordeal, aftermath, and presence. The sense of rescue, the feeling of relational proximity, the ordeal and aftermath of surgery are things which the patient experiences. Understanding these experiences allow surgeons to understand what may be asked of them in an ethical sense. Recognition of the reality and validity of each category in the surgical process highlights the importance of presence, the acts by which the surgeon demonstrates that he is present to the patient throughout the surgical process and its aftermath. While the teaching of communication skills may never compensate for insensitivity, the ideal of presence as virtue and duty can be taught by precept and example.

VALUES-BASED MEDICINE AND MODEST FOUNDATIONALISM

Philosophically, values refer to the basic commitments that justify judgements, beliefs and practices, both at the community and personal levels. The study of these kinds of values is axiology. We suggest that all people subscribe to three foundational values - survival, security and flourishing - and that these foundational values are expressed by way of concepts, systems, principles and practices that may differ substantially from culture to culture. Values can stand on their own as foundational justifications for health care and medicine. Many ethical quandaries can be better understood, even though they may remain unsolved, by reference to the foundational values that people can agree upon. This version of values-based health care has strong claims to prior logical status as a justification for the whole enterprise of health care, and values-based medicine is a part of this larger domain.Philosophically, values refer to the basic commitments that justify judgements, beliefs and practices, both at the community and personal levels. The study of these kinds of values is axiology. We suggest that all people subscribe to three foundational values – survival, security and flourishing – and that these foundational values are expressed by way of concepts, systems, principles and practices that may differ substantially from culture to culture. Values can stand on their own as foundational justifications for health care and medicine. Many ethical quandaries can be better understood, even though they may remain unsolved, by reference to the foundational values that people can agree upon. This version of values-based health care has strong claims to prior logical status as a justification for the whole enterprise of health care, and values-based medicine is a part of this larger domain.

Cancer as Rubbish: Donation of Tumor Tissue for Research

Tissue banking (or biobanking), thought by many to be an essential form of medical research, has raised a number of ethical issues that highlight a need to understand the beliefs and values of tissue donors, including the motivations underlying consent or refusal to donate. Data from our qualitative study of the legal, social, and ethical issues surrounding tumor banking in New South Wales, Australia, show that participants’ attitudes to donation of tumor tissue for research are partially captured by theories of weak altruism and social exchange. However, we argue that the psychological rewards of value transformation described by Thompson’s rubbish theory provide additional insights into participants’ attitudes to tumor donation. We believe our data provides sufficient justification for an approach to regulation of tumor banking that is aimed at fostering a relationship based on the notions of virtuous reassignment and social exchange.

Vulnerability in the Narratives of Patients and their Carers: Studies of Colorectal Cancer:

Vulnerability is susceptibility to any kind of harm, whether physical, moral or spiritual, at the hands of an agent or agency. It is related to disempowerment and loss of autonomy. It is also a relational category that appears repeatedly in the narratives of colorectal cancer patients and their carers. Although one conventionally associates vulnerability with being ill and needing health care, the practice of health care has its own vulnerabilities that emerge as important in the biographies of health care workers. Vulnerability needs to be recognized and negotiated in health care transactions. This article examines a process of ‘reading-for’ vulnerability, and suggests a classification of vulnerability, at least as it appears in the narratives of cancer patients and their carers. Methods of managing vulnerability are also examined and categorized. Reading for vulnerability brings insight into an important aspect of the health care process. Recognition of its importance should translate into changes in medical education and patient information.