Quality, Quality of Care, and Ethics: Some Notes.

‘Quality’ is a curiously amorphous word that has, nevertheless, become a major policy driver, particularly in regards healthcare where we find a ubiquitous concern for the ‘quality of care.’ Akin to ‘choice,’ quality is held to be a self-evident good yet, at the same time, as there is little that is not in fact ‘a quality’ and the word offers very little specification. In fact its significance lies not in naming any particular quality or qualities of (health)care but in suggesting first, that there are some aspects, properties or qualities of healthcare that are good (whilst others are not so good or downright bad) and second, that those qualities that are good can be improved. This being the case then the idea of the quality of care must be unpacked and its specific meanings explored. Obviously ‘quality of care’ might mean different things in different contexts and to different people – particularly to professionals and patients. Obviously the care required and, therefore, the qualities that constitute such care differs in A&E, primary care, care of the elderly in a hospital setting compared to a community setting may well be differ in specific instances of care. The specifics of ‘care’ and the particular qualities on which its overall quality are to be judged can be variable. Given a particular case a clinical team might foreground particular aspects, the management some other (measurable) aspects, the patient some other aspects, and the patients family still others. 

In all this it remains unclear whether explicit attempts to increase ‘quality’ in fact do so. For example, consider ethical decision-making, an intrinsic aspect or property of contemporary healthcare practices. At the same time this quality can be done in better or worse ways. We might think that unreflective judgments on cases that present troubling ethical concerns are of significantly less quality that a judgment formed through reflection, discussion with colleagues or, where appropriate, through a deeper engagement with an clinical ethics committee. In both cases the actual decision made may well be the same, however one is said to have a greater sense of quality that the other. The supposition might be that because they exhibit a greater degree of ‘quality’ decisions made through a process of reflection will lead to healthcare practice being more ethical over all. Some intuitions may remain unreformed (or ‘confirmed’) by the process of reflection whilst others will be reconstructed and lead to different decisions or approaches. One could also claim that what it is to do ethics is to come to a decision through a process of reflection. Thus actions undertaken in the absence of such reflection are not properly or ‘ethically’ undertaken. 

This concern will take us into deep philosophical waters and the distinctions between moral cognitivism, non-cognitivism and emotivism. However we might simply point to the fact that the ethical concerns that arise in medical practice are rarely idiosyncratic. As such, common ethical dilemmas that have been previously experienced by individual clinicians or clinical teams may not require extensive formal reflection in every case. Rather it may be that individuals are capable of giving reasons for their actions but it is not always necessary for them to be explicit considered. In such cases we might suppose that clinicians have their reasons ‘at hand’ if not actually ‘in hand.’ In this more expansive diachronic view of ethics in professional practice the concerns for the quality of decision-making become concerns for ensuring that clinicians know when further ethical reflection might be required. The concern then becomes ‘second-order’ and focused on whether professionals are aware when a case is such that they rightly consider themselves to have reasons ‘at hand’ and when it is such that those reasons need to be taken ‘in hand’ and subject to further scrutiny.

Such activity implies a process of self-monitoring achieved through what we might consider as a set of second-order dispositions that facilitate self-monitoring. Increasingly ‘the (professional) self’ is an object of professional reflection. Many have claimed that modernity itself is marked by an increase in ‘reflexivity’[1] and this claim extends not only to ‘the self’ but to our institutions. Concern for the quality of care is one example of such reflexive practices. The result of this concern is an increase in the monitoring of contemporary healthcare practices, most obviously expressed in the setting of targets. Concern for quality of care becomes translated into a focus on particular facets of healthcare practice that can by quantified, monitored and audited. Indeed contemporary healthcare is a prime example of what has been called the ‘audit society.’ [2] In such a view we might characterize the demands placed on professionals for ethical reflection to be a demand for professionals to ‘audit’ their own thinking and, when required, to justify their actions and render themselves audit-able. The creation of targets, monitoring and audit structures does not leave the original task untouched. The practices of audit result in reflexive changes to the practices audited and there is no guarantee that those changes will be positive. 

One obvious example is the way in which target monitoring in A&E has created imperatives that have been seen to provoke disingenuous responses. In the case of ethical reflection the consequences are a. less obvious and b. less obviously negative. Certainly, from a particular point of view, to be ethically aware is to be self-aware and to engage in self-reflection. However one can see how easily a contemplative practice such as ethical reflection can become rote or perfunctory in the face of repeated experience of comparable cases. We can also appreciate that, as an aspect of professional practice, ethical reflection must, in some sense, become routine or rote. Therefore we come to rely on second-order self-monitoring to ensure that whilst our ethical reflections might become rote they do not become perfunctory. In this view the ethical commitments of professional medicine cease to be, simply, the responsibility of particular individuals or clinical teams and more obviously an aspect of the field. As such we might concern ourselves with how ‘ethics’ and ‘ethical governance’ is institutionalized across the organizations of modern healthcare from primary institutions like hospitals to ‘secondary’ institutions like the GMC, the BMA, the RCN and the royal colleges. It is often the case that the ethical justification individual professionals have ‘at hand’ are, in no small part, the guidelines issued by such institutions. 

In the last few paragraphs we have, already, come a long way from a focused concern with ‘quality’ and ‘quality of care.’ It is clear that beneath such terms lies an incredible degree of complexity not just in specifying what they might mean but also concerning how we might assess and monitor such specifications and what impact doing so will have. Concern for ‘quality’ often results in quantitative monitoring however, as the very term implies, it may well be that it is only through qualitative assessment that we can truly grasp what it is that concerns us. Nevertheless, as is the case in our discussion of the practice of ethical reflection, it may be that practical concerns over-ride the necessity of consistently engaging in practices of the highest quality as, if we concern ourselves with the configuration of the field, the quality of individual practices can be given structural support. We must recognize the limitations of an ‘audit culture’ to produce and maintain quality of care as, of necessity, it must focus on some specific qualities of practice whilst neglecting others. Such practices cannot be accomplished in a manner that will allow them to remain neutral from the qualities of (health)care that are subject to audit. Whilst we might legitimately design healthcare in such a way as to include the practice of ‘audits’ we should not rely on them over and above the (re)construction the system itself. 

[1] I use reflexivity here in something close to its most basic sense. There is a strong sense in which virtually everything human beings do is ‘reflexive.’ Playing a game of tennis involves exercising our ability to play tennis and so will affect – possibly positively, possibly negatively – our subsequent tennis playing. Considering modernity to be ‘marked by reflexivity’ is to make a further claim involving the conscious self reflecting on our own practices and thus impacting on our future actions - the difference is,  one might say, between the reflexivity of simply playing tennis and that engendered by being coached in tennis. This should not be taken as the reintroduction of the rational subject. There is no expectation that engaging in reflexivity will result in the ‘rational actor’ of rational action theory (and so often assumed in the philosophical analysis of 'applied (bio)ethics). Indeed if one places this idea of the reflexive subject into the feedback processes described by cybernetic theory there is every justification to see it as an inherently complex and non-linear.

[2] Strathern, M. (Ed). Audit Cultures: Anthropological Studies in Accountability, Ethics and the Academy. Routledge. 2000. This is a brilliant book and if you have any inclination to read it, you should.