Fidelity, pragmatism and the "grey line" in between-exploring the delivery of a pragmatic physical activity randomised controlled trial-a secondary analysis.

BACKGROUND: Intervention fidelity in health services research has been poor with a reported lack of understanding about what constitutes pragmatic adaptation of interventions and what constitutes failure to maintain intervention fidelity. However, the challenges facing those delivering such interventions have not been thoroughly explored. The aims of this study were to critically explore the challenges in maintaining fidelity experienced by physiotherapy staff and support workers when delivering a complex intervention for older people living with frailty. METHODS: This study is a secondary analysis of data from a process evaluation of a large randomised controlled trial (RCT). The process evaluation employed qualitative methodologies with mixed methods including a variety of data collection methods, including participant observation, semi-structured interviews and documentary analysis. Thematic analysis was used to make sense of the data. RESULTS: Many therapy staff felt ongoing confusion about what was acceptable to adapt and what needed to follow the protocol exactly. We found that some therapy staff were able to embrace the challenges of pragmatically adapting interventions while maintaining intervention fidelity, others stuck rigidly to the protocol and failed to adapt interventions where it was necessary. CONCLUSION: It was clear that the understanding of fidelity and pragmatism was poor. While pragmatic trials are vital to replicate real world clinical practice, further guidance may need to be developed in order to guide the level of adaptation that is acceptable before fidelity is undermined.

Developing a living lab in ethics: Initial issues and observations.

Living labs are interdisciplinary and participatory initiatives aimed at bringing research closer to practice by involving stakeholders in all stages of research. Living labs align with the principles of participatory research methods as well as recent insights about how participatory ways of generating knowledge help to change practices in concrete settings with respect to specific problems. The participatory, open, and discussion-oriented nature of living labs could be ideally suited to accompany ethical reflection and changes ensuing from reflection. To our knowledge, living labs have not been explicitly trialed and reported in ethics literature. In this discussion paper, we report and discuss four initial issues that marked the process of setting up a living lab in ethics: (1) determining the goals and expected outcomes of an ethics living lab; (2) establishing operational procedures; (3) selecting communities and defining pilot projects; and (4) adopting a lens to tackle emerging questions and challenges. We explain these four issues and present the paths taken based on the novel and specific orientation, that is, living ethics, at the basis of this project. In alignment with living ethics and É-LABO, we approach challenges as learning opportunities to ask not only "how" questions but also "why" questions. We hope that this discussion paper informed by our experience helps to clarify the theoretical, methodological, and practical approaches necessary to successfully adopt and employ living labs in ethics.

Exploring health and disease concepts in healthcare practice: an empirical philosophy of medicine study.

In line with recent proposals for experimental philosophy and philosophy of science in practice, we propose that the philosophy of medicine could benefit from incorporating empirical research, just as bioethics has. In this paper, we therefore take first steps towards the development of an empirical philosophy of medicine, that includes investigating practical and moral dimensions. This qualitative study gives insight into the views and experiences of a group of various medical professionals and patient representatives regarding the conceptualization of health and disease concepts in practice and the possible problems that surround them. This includes clinical, epistemological, and ethical issues. We have conducted qualitative interviews with a broad range of participants (n = 17), working in various health-related disciplines, fields and organizations. From the interviews, we highlight several different practical functions of definitions of health and disease. Furthermore, we discuss 5 types of problematic situations that emerged from the interviews and analyze the underlying conceptual issues. By providing theoretical frameworks and conceptual tools, and by suggesting conceptual changes or adaptations, philosophers might be able to help solve some of these problems. This empirical-philosophical study contributes to a more pragmatic way of understanding the relevance of conceptualizing health and disease by connecting the participants' views and experiences to the theoretical debate. Going back and forth between theory and practice will likely result in a more complex but hopefully also better and more fruitful understanding of health and disease concepts.

Between Technological Utopia and Dystopia: Online Expression of Compulsory Use of Surveillance Technology.

This study investigated people's ethical concerns of surveillance technology. By adopting the spectrum of technological utopian and dystopian narratives, how people perceive a society constructed through the compulsory use of surveillance technology was explored. This study empirically examined the anonymous online expression of attitudes toward the society-wide, compulsory adoption of a contact tracing app that affected almost every aspect of all people's everyday lives at a societal level. By applying the structural topic modeling approach to analyze comments on four Hong Kong anonymous discussion forums, topics concerning the technological utopian, dystopian, and pragmatic views on the surveillance app were discovered. The findings showed that people with a technological utopian view on this app believed that the implementation of compulsory app use can facilitate social good and maintain social order. In contrast, individuals who had a technological dystopian view expressed privacy concerns and distrust of this surveillance technology. Techno-pragmatists took a balanced approach and evaluated its implementation practically.

Pragmatism and Experimental Bioethics.

Pragmatism gained considerable attention in bioethical discussions in the early 21st century. However, some dimensions and contributions of pragmatism to bioethics remain underexplored in both research and practice. It is argued that pragmatism can make a distinctive contribution to bioethics through its concept, developed by Charles S. Peirce and John Dewey, that ethical issues can be resolved through experimental inquiry. Dewey's proposal that policies can be confirmed or disconfirmed through experimentation is developed by comparing it to the confirmation of scientific hypotheses, with a focus on the objection that the consequences of following a moral view or policy do not provide guidance on choosing among competing ethical perspectives. As confirmation of scientific hypotheses typically relies on evidence gathered from observation, the possibility of ethically relevant observation is then explored based on Peirce's views on feelings as emotional interpretants. Finally, the connection between Dewey's experimental ethics and democracy is outlined and compared to unfettered ethical progressivism.

Living ethics: a stance and its implications in health ethics.

Moral or ethical questions are vital because they affect our daily lives: what is the best choice we can make, the best action to take in a given situation, and ultimately, the best way to live our lives? Health ethics has contributed to moving ethics toward a more experience-based and user-oriented theoretical and methodological stance but remains in our practice an incomplete lever for human development and flourishing. This context led us to envision and develop the stance of a "living ethics", described in this inaugural collective and programmatic paper as an effort to consolidate creative collaboration between a wide array of stakeholders. We engaged in a participatory discussion and collective writing process known as instrumentalist concept analysis. This process included initial local consultations, an exploratory literature review, the constitution of a working group of 21 co-authors, and 8 workshops supporting a collaborative thinking and writing process. First, a living ethics designates a stance attentive to human experience and the role played by morality in human existence. Second, a living ethics represents an ongoing effort to interrogate and scrutinize our moral experiences to facilitate adaptation of people and contexts. It promotes the active and inclusive engagement of both individuals and communities in envisioning and enacting scenarios which correspond to their flourishing as authentic ethical agents. Living ethics encourages meaningful participation of stakeholders because moral questions touch deeply upon who we are and who we want to be. We explain various aspects of a living ethics stance, including its theoretical, methodological, and practical implications as well as some barriers to its enactment based on the reflections resulting from the collaborative thinking and writing process.

Toward a new clinical pragmatism: method in clinical ethics consultation.

In this paper, I leverage the pragmatist tradition in philosophy, the collective wisdom of scholarship in clinical ethics consultation, and earlier attempts to apply pragmatism in clinical ethics to develop a new vision of clinical ethics practice called New Clinical Pragmatism. It argues that clinical ethics methodology, from the New Clinical Pragmatist's perspective, amounts to the recommendation that consultants should customize a methodological approach, drawing on the various available methods, depending on the demands of the specific case, and should avoid attempts to identify a 'true' methodology but to the incoherence and inevitable failure of those attempts. I argue that pragmatism's emphasis on practical wisdom and experimentation allow the New Clinical Pragmatist to do this while avoiding irrationality in choosing methods. I discuss how the New Clinical Pragmatist gives a unique, constructive perspective on key aspects of clinical ethics consultation such as the choice of common morality vs. internal morality of medicine approaches, process standards, bioethics mediation, and narrative ethics, and suggest how New Clinical Pragmatism's relaxed approach to choice of methodology encourages consultants to balance attention to the particulars of the case with knowledge of what the many insightful scholars of clinical ethics methodology have found useful in the past. I also argue that New Clinical Pragmatism is consistent with efforts to professionalize clinical ethics consultation.

Language as social action: Gertrude Buck, the "Michigan School" of rhetoric, and pragmatist philosophy.

In the late 19th and early 20th centuries, Gertrude Buck and collaborators developed a sociologically and pragmatist-informed approach to language that has been neglected in later scholarship. Buck approached the study of language from the standpoint of pragmatist functional psychology, which is indebted to John Dewey's pragmatism at the University of Michigan, and which views language as a normal, dynamic action of human organisms engaged in necessary cooperative relations with one another. Her approach overcomes the small-minded pragmatism that would criticize figurative or poetic language as impractical, and instead shows how figuration is essential to the particular ways in which language is action that conveys meaning to others and serves broader social functions. Buck's forgotten work helps overcome criticisms of the application of pragmatic action theory to language and literature, sketching how language structure may be explained on the basis of language as a natural social-communicative act, how figurative language is inherent in the normal act of communicating situated bodily experiences to others, and how rhetorical speech and writing contributes to participation in democratic social processes. This paper also indicates how Buck's work has been partially rediscovered in Composition Studies, as well as prefigures later reader-response esthetics and feminist analyses of language.

On compatibility between realism and fictionalism: A response to Suárez' proposal.

In a series of articles, Mauricio Suárez defends the neutrality of fictionalism with respect to the scientific realism-anti-realism debate. Suárez understands fictionalism from a strictly methodological point of view, linked to the practice of model building in the context of the philosophy of science. He moves away from the type of fictionalism analysed in other areas of philosophy such as metaphysics, the philosophy of language, aesthetics or the philosophy of mathematics. Following Vaihinger's position, he emphasizes the inferential role of fiction in scientific modelling and argues that scientific fictionalism is not incompatible with scientific realism, as is often believed. We argue against Suárez's position and reject the ubiquitous character assigned to fictions in scientific discourse, as well as the deflationary view of scientific realism defended by Suárez. We conclude that when the semantic, epistemic, and metaphysical aspects at stake in the realism-antirealism debate are taken into account, the alleged compatibility between scientific realism and fictionalism starts to generate some tension.

The Classical Stance: Dennett's Criterion in Wallacian quantum mechanics.

David Wallace's 'Dennett's Criterion' plays a key part in establishing realist claims about the existence of a multiverse emerging from the mathematical formalism of quantum physics, even after decoherence is fully appreciated. Although the philosophical preconditions of this criterion are not neutral, they are rarely explicitly addressed conceptually. I tease apart three: (I) a rejection of conceptual bridge laws even in cases of inhomogeneous reduction; (II) a reliance on the pragmatic notion of usefulness to highlight quasi-classical patterns, as seen in a decoherence basis, over others; and (III) a structural realist or 'functional realist' point of view that leads to individuating those patterns as real macroscopic objects at the coarse-grained level, as they are seen from the Classical Stance (analogous to Dennett's Intentional Stance). I conclude that the justification of Dennett's Criterion will be intimately tied up with the fate of strong forms of naturalism, and in particular that Wallacian quantum mechanics is a key case study for concretely evaluating his 'math-first' structural realism (Wallace 2022).

The Pragmatist roots of scientific medicine: Reassessing Abraham Flexner's report on medical education.

Abraham Flexner's 1910 report on medical education is widely regarded as a watershed moment in the history of modern medicine in the US and beyond. Most commentators focus on its administrative and managerial impact, despite Flexner dedicating a sizeable portion of his report to a theoretical account of the kind of medicine that he seeks to implement. Close attention to these sections reveals a surprisingly coherent account of medicine that, based on a Deweyan Pragmatist philosophy of science, unites scientific investigator and medical practitioner in a new experimental paradigm of science. Flexner can develop an account that goes beyond a mere epistemic redefinition of medicine, providing the profession with a social, cultural, and ethical identity that avails itself of the extremely wide purview that Dewey granted to modern science. Due to the subsequent narrowing of philosophy of science to a delimited academic subdiscipline, these broad Pragmatist philosophical commitments at the roots of Flexner's scientific medicine remained a largely unexplored intellectual legacy.

Toward a Values-Informed Approach to Complexity in Health Care: Hermeneutic Review.

Policy Points The concept of value complexity (complexity arising from differences in people's worldviews, interests, and values, leading to mistrust, misunderstanding, and conflict among stakeholders) is introduced and explained. Relevant literature from multiple disciplines is reviewed. Key theoretical themes, including power, conflict, language and framing, meaning-making, and collective deliberation, are identified. Simple rules derived from these theoretical themes are proposed.

The Targeted Agent and Profiling Utilization Registry Study: A pragmatic clinical trial.

The conceptual framework of pragmatism in clinical trials is explored using the American Society of Clinical Oncology's pragmatic, non-randomized, phase II, multi-center basket clinical trial, the Targeted Agent and Profiling Utilization Registry Study (NCT02693535) as a model. The Targeted Agent and Profiling Utilization Registry Study aims to identify signals of drug activity when Food and Drug Administration approved drugs are matched to pre-specified genomic targets in patients with advanced cancer outside of their approved indication(s). The objectives of the study are to generate evidence of potential signals of activity in targeted therapies prescribed in an off-label setting as well as to expose and educate community cancer centers to genomic testing and precision medicine through the study protocol. The principles of pragmatic trial design can be applied across a broad spectrum of evidence-generation strategies, from explanatory trials to real-world evidence studies, and are briefly discussed. American Society of Clinical Oncology's Targeted Agent and Profiling Utilization Registry Study falls closer to the pragmatic end of this spectrum as it seeks to assess the efficacy of Food and Drug Administration approved drugs used outside their approved indications under usual care conditions, yielding results generalizable to the population that would likely receive the intervention in practice, while still adhering to rigorous data quality standards. The Targeted Agent and Profiling Utilization Registry Study's pragmatic objectives, characteristics, strengths, and limitations in its implementation are discussed and demonstrate that a large, multi-center, precision medicine basket trial can be mounted in the context of community practice and can generate clinically useful information with minimal burden to patients and clinical trial sites.

The experiences of family members witnessing the diminishing drinking of a dying relative in hospital: A narrative inquiry.

BACKGROUND: The optimal management of diminishing drinking at the end of life is contentious. Clinicians and family members may understand the phenomenon differently and hold divergent priorities regarding care. Family members can be distressed by diminishing drinking and its management, particularly when in a hospital environment. AIM: To explore the experiences of family members when witnessing the diminishing drinking of a dying relative. DESIGN: A narrative inquiry methodology, derived from pragmatism. SETTING AND PARTICIPANTS: Thirteen recently bereaved family members were recruited through the bereavement services of three UK hospitals. Inclusion criteria included having an adult relative who died in hospital of any diagnosis more than 48 hours from admission and who had had noticeable diminishing drinking. FINDINGS: Participants experienced diminishing drinking as an unfolding process that was part of overall decline. They all believed it to be detrimental. Three groups of responses were identified: promoting, accepting and ameliorating. Supportive measures included offering equipment to support drinking, staff being present and communicating about expectations and care management aims. CONCLUSIONS: There is potential to improve family members' experiences through re-conceptualisation of diminishing drinking aligned to their experiences, supporting family members by listening to their experiences with insight and strengthening their agency within the management of their relatives with diminishing drinking.

All the good care: Valuation and task differentiation in older person care.

Task reallocation is increasingly foregrounded as a promising solution for capacity problems. Numerous studies show, however, that task reallocation between medical professionals is a highly contested issue and difficult to institutionalise. Conflicts are omnipresent and often arise from 'intraprofessional competition': Zero-sum games between professionals from different disciplinary backgrounds where one party's gains require another party's losses. In this article, we build on calls to enrich the sociology of professions with new concepts and theories. We analyse a case of task reallocation between medical professionals in a nursing home using concepts from empirical ethics and valuation studies. We argue that modes of good care offer a valuable framework for analysing the reorganisation of professional work because they provide an empirically grounded and fine-grained conceptual toolkit for understanding the dynamics among professionals and between professionals and managers. Enactment of different modes of good care inspires innovation in service provision but at the same time creates new tensions between those involved. We show how, in times of scarcity, a dynamic emerges between professionals attempting to stave off and reallocate work, thereby restricting their professional domains.

Stories of restitution: Family experiences of diagnosis and help-seeking for a child with cerebral palsy.

BACKGROUND: The experience of living with children with CP is dominated by the voice of the mother while others are rarely reported. Incorporation of the voices of other family members is important for a holistic understanding. METHODS: Drawing on the philosophical perspectives of pragmatism, generic qualitative methodology, and Frank's narratives, this article highlights how restitution was constructed by 30 family members. FINDINGS: They constructed restitution by hoping for a cure through either biomedical and/or alternative models of treatment, followed by intransitive and transcendent restitution. DISCUSSION: This appears to be the first time that restitution has been extended to families living with children with chronic illnesses. APPLICATION TO PRACTICE: This would mean that paediatric nursing professionals and other health professionals dealing with family members living with children with CP could attend to their stories in an open and focused manner to honour and validate their stories as well as their experiences.

Critically Appraising Pragmatist Critiques of Evidence-Based Medicine: Is EBM Defensible on Pragmatist Grounds?

Significant contributions to debates in the philosophy of evidence-based medicine (EBM) have come from a variety of different philosophical quarters, yet mainstream discourse in the field has been largely devoid of contributions from scholars working in the pragmatist tradition. This is a particularly conspicuous omission, given pragmatism's commitment to the melioristic view that philosophy both can, and should, be about the business of concretely bettering the human estate. Two exceptions to this oversight come from Brian Walsh and Maya Goldenberg. Unfortunately, in both cases, the misapplication of pragmatist thinking leads to the mistaken view that EBM is committed to some form of pernicious objectivism. This article aims to revise these pragmatist critiques in order to bring them more consistently in line with pragmatist values and commitments. Doing so shows that EBM is defensible on pragmatist grounds against objectivist attacks.

Implications of philosophical pragmatism for nursing: Comparison of different pragmatists.

Pragmatism emphasizes practical consequences and empirical explanations rather than introspective contemplations. However, the arguments of pragmatists are not uniform, as shown by the four prominent pragmatists presented in this article. The major difference between them is that Peirce and Haack acknowledge an objective truth, whereas James and Rorty do not. Thus, for a fuller understanding of the pragmatist view of our knowledge, both camps must be consulted. In the nursing field, pragmatism is occasionally referred to as a guiding philosophy. However, the influence of James and Rorty has been greater than that of Peirce and Haack on pragmatists, which may risk leading to a skewed understanding of pragmatism by nursing scholars. Still, the four pragmatists share naturalism, which rejects a metaphysics that defines the nature of knowledge before our enquiry and emphasizes experience and practice. Pragmatic naturalism can help ensure that nursing theory does not deviate from clinical practice. This article also explores the broad adaptability of the ideas of all four pragmatists to philosophical issues in nursing, such as mixed-methods research, epistemic relativism and realism. By showing that pragmatism can be relevant and stimulating to each of these topics, the article demonstrates that the different approaches to pragmatism can provide more inspiration for nurses and nursing researchers in the future.

Consistent histories through pragmatist lenses.

This article adopts a bottom-up approach to theory interpretation, following the slogan "meaning is use", and applies it to quantum mechanics. I argue that it fits very well with the Consistent Histories formulation of quantum mechanics, interpreted in a particular way that is not the interpretation favoured by original proponents of the formulation. I examine the difficulties and advantages of this interpretation.

[Obesity, a multifactorial, chronic disease]. / L'obésité, une maladie multifactorielle et chronique.

A pathology of modernity, obesity is developing rapidly in the population, linked to multiple risk factors and somatopsychic disturbances. The healthcare system's responses have been enriched by specialized programs and centers, but we mustn't forget basic clinical pragmatism.