Ethical decision making in the National Health Service: A theoretical analysis of clinical negligence with reference to the existential writings of Søren Kierkegaard, Emmanuel Levinas, and Jean-Paul Sartre.
Jean Paul Sartre proposed that: Historical situations vary…What does not vary is the necessity for him to exist in the world, to be at work there, to be there in the midst of other people, and to be mortal there. The limits are neither subjective nor objective, or rather, they have an objective and a subjective side. Objective because they are to be found everywhere and are recognizable everywhere; subjective because they are lived and are nothing if man does not live them, that is, freely determine his existence with reference to them (Sartre 1987: 38, 39). The Existential philosophy as outlined by Sartre, Levinas, and Kierkegaard cares about the lived experiences of individuals. Such a view is in contradistinction to other philosophical views which have a tendency to reduce human experience, or to lose the individual in abstraction. This thesis has a central concern for the ethical care of patients in the National Health Service. In order to explore the concrete experiences of patients it is necessary to consider the care providers. To that end, the individual health professional then becomes the focus of study. To assist in this approach a double narrative runs through the thesis, which comprises exploring ethical decision making in the NHS, and also on the legal concept of clinical negligence. These two concepts are intertwined in that legal hearings and rulings have a normative influence upon health care practice, and also influence public expectations. The explicit purpose of this approach was to ensure that the theory was explored and developed; grounded upon everyday clinical NHS practice, which includes legal and political influences. The first four chapters of the thesis constructs the three main areas of analysis; Philosophical, legal, and political. With this framework established, the critical analysis of five legal cases of clinical negligence (Chapters Five and Six), establishes convergences in the work of Sartre, Levinas, and Kierkegaard in relation to the subject, freedom and the ethical. The Kierkegaardian concept of kinesis is applied to explore the transition from possibility to actuality in ethical action. During this process a range of dynamics are identified in creating the concept as best described by Levinas as totalisation . Where previously the argument was located at the individual (subject) and organisational (system) level, in Chapter Seven it moves outwards to consider how the authentic individual can create a civil society. Given the recalcitrant barriers identified in the analysis, Chapter Eight considers existentialism as a theory of community and as contributing to epistemology. Together these theories are proposed as addressing the real needs of individuals, by promoting their freedom, and achieving unity in diversity. The recommendations in Chapter Nine are based upon the interplay of two main dialectics uncovered in the body of the thesis concerning ethics and epistemology. Deontology, Utilitarianism, and Virtue ethics were found to all contribute towards professional conduct. However, they were found to be insufficient because they reduce patients and health professionals’ existence to the same as everyone else. Further, Virtue ethics reverses the way in which ethical behaviour is evaluated in comparison to the other two main normative theories. That is, behaviour is evaluated against the virtue being foundational, as opposed to the act performed. However, there is no discussion on how the individual health professional would decide which approach to use. All three approaches then lack a crucial factor which is the existential dimension. Existential ethics is then presented as a possible approach to facilitate the development (kinesis) of health professionals to the ethical sphere of care. Existential ethics emphasises the pre-theoretical aspect in caring for patients. That is, it appreciates the individual and their difference, prior to any conceptualization which has the potential to reduce individual difference to sameness. From this perspective recommendations are outlined for facilitating individuals to develop the ethical aspect of care, for health care pedagogy, and for leadership within the NHS.
Existentialism, Kierkegaard, Sartre, Levinas, Hermanaeutics, ethics, clinical negligence, healthcare, existential ethics, whistle-blowing, decision making
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