Quality-Adjusted Life-Year: a Threat to Humanistic Thinking?

 

 [paper presented to the Society for Ethics Across the Curriculum, 2003]

 

Grasping a concept is not a matter of knowing how to group things under that concept; it is being able to participate in life-with-the-concept.  What kinds of descriptive concepts there are is a matter of the different shapes life-with-a-concept can have.  Life with the concept human being is very different from life with the concept member of the species Homo sapiens.  To be able to use the concept ‘human being’ is to be able to think about human life and what happens in it; it is not to be able to p;ick human beings out from other things or recommend that certain things be done to them or by them.  [Cora Diamond, Losing Your Concepts, Ethics,  98, Jan 1988, p. 266]

 

Narrative is built on concern for the human condition. [Bruner AMPW  1986. p. 14]

 

Introduction

 

Recent advances in science and technology within the field of medicine have resulted in strange new forms of decision-making about the use of resources.  One such technology, the concept of the Quality-Adjusted Life-Year (QALY0, a tool originally designed to compare treatments of specific disease, has now been adopted as an accounting tool to measure cost-effectiveness of treatments for specific diseases and as a means to ration health care.  This raises the question of the appropriateness of the use of business decision-making in matters of health care.  The question of interest to those pursuing a Liberal Arts education is whether various methods of rationing health care can be informed by methods of thinking peculiar to the disciplines of the Humanities.  Of course, even in these disciplines there are tensions between approaches focused on formal systems which seek the rigour of scientific method and approaches attuned to the individual and to messiness of storied lives.

 

Polarized discourses abound in our society and we do not wish to increase such polarization.  Teaching students to think well about life in such a complex society requires that we offer strategies for bridging chasms and blending technical rigour with responsiveness to variablity, mechanism with experience.  Reminded by Aristotle that an educated person knows what degree of precision to demand of the subject matter we look to recent insights from Narrative Ethics for strategies both to resist inapproapriate uses of formulaic thinking and to recognize how best to incorporate such thinking in dealing with complex social and moral problems. 

 

In this paper we look at ethical issues that arise when rationing is viewed as a matter of applying algorithms, and we contrast such thinking with richer more responsive forms of problem solving.  The Oregon case of health care rationing provides us with an interesting contrast to the unadulterated use of formulaic thinking.  This issue is of particular interest to Canadians whose public health care system is currently under threat by the trend toward privatization and the increasing power of the Free Trade agreements.  For about the same proportion of government spending Canadians receive ‘a wide range of high-quality basic services’ [Armstrong, 2001, 176] which are not so widely available in the US.  But Canadians are moving increasingly toward for-profit practices in the public sector.   The danger with this trend is that once services are privatized it becomes almost impossible to return them to the public sector.  Governments, both provincial and federal, risk huge law suits on the part of firms seeking to turn public services into private profits. [177]

 

‘Humanistic’ Thinking

 

       The argument of this paper is that what we call ‘humanistic thinking’ is under threat by powerful techniques for processing complex decisions according to reductive formulae. It is our view that the antidote to the erosion of humanistic thinking lies in the expansion of Liberal Arts programs so as to expose students in other fields to valuable sources of understanding of issues affecting the lives of people.   And, while we recognize that none of this is new, we believe that the tensions between these approaches have taken on many new forms with the emergence of new techniques of rationing such as QALY and the Oregon method.

 

 The problem of humanizing discourse, or recovering ‘lost spirit’ [Beiner, Philosophy in a Time of Lost Spirit] that is to say, of returning to the ‘sources’ of normative values, can be met, to a certain extent, by having recourse to the insights developed in the last few decades in ‘revisionist’ ethical theorizing which attempts to provide alternatives to strictly utilitarian and deontological approaches.  Contemporary work in ethics is replete with valuable insights concerning intelligent responses to human problems.  Virtue Ethics, a revived and renewed reading of Aristotle, and the Ethics of Care derived from feminist thought can both be combined with recent work on narrative to provide students with the means to assess the normative adequacy of our social practices.

 

Our perspective is that people, when given the chance, prefer to openly ponder and to participate in decisions concerning the provision of health care, their own and that of other members of society, rather than endure the consequences of covert choices made either by members of government, the medical profession, or for-profit businesses engaged in the provision of care.  We also begin with the assumption that having large numbers of people without medical insurance creates social tensions in democratic societies where citizens are imbued with the ideal of equality.  But healthcare in the US is big business and business aims at maximization of profit for owners and managers.  Two time-honoured ways of increasing profit include: selling more products and services, and  reducing labor cost by eliminating jobs or streamlining work so that it can be done by less skilled workers.  Without a strong vision of the humanistic values underlying the practice of healthcare the fallout from the profit motive leads to consequences that are at odds with this vision. 

 

In healthcare, this means an even greater emphasis on treatments through drugs and technology and a declining emphasis on care of the whole person.  … [An approach which] places heavy burdens on women and families [since] women provide most of the care in the community and the home. [Armstrong 178]

 

The Quality-Adjusted Life-Year

 

            In the same way that miles per gallon measures the effectiveness of a vehicle, QALY measures improved health status achieved by a medical intervention.  It is an excellent tool for measuring health-related quality of life in clinical trials.  Applied as an accounting tool QALY’s are used as an index combining changes in survival rates and quality of life of patients in order to assess the benefit of various funding programmes with a view to the efficient allocation of resources. [Spiegelhalter, 12] .

 

         The technique to calculate the increment of improved health status requires data to be used in equations developed within the formal mathematical framework of health care economics [Weinstein and Stasson, 1977] [mg].  Gathering data to establish the number of QALYs involves surveying a sample of healthy individuals and asking them to imagine themselves in an impaired health state.  Without treatment you will live Y years in imperfect health.  With treatment the probability is (p) that the outcome will by Y years in perfect health with (1-p) risk of sudden death.  To quantify the number of QALYs the probability (p) is varied until people respond with indifference between some health improvement and the risk of sudden death.  On a continuum from O (death) to 1 (perfect health) this indifference probability value is interpreted as a measure of the utility of being in imperfect health for the specified time period (Bleichrodt and Johannesson, 1977) [mg].  Assuming that immediate improvements in health are of higher utility than future improvements, the time period Y is discounted to obtain a net present value of QALYs  for the proposed therapy (Culyer and Wagstaff, 1993, Loomes and McKenzie, 1989)[mg]. 

 

         But problems arise from accepting that QALYs are empirical measures of actual utility obtained from receiving imagined medical therapies.  These are the problems associated with standardization of treatment over large populations of individuals.  “There is a growing concern with measuring ‘quality’ in terms of outcomes’ [Armstrong 82] when outcomes are measured from the point of view of cost-effictiveness.  Two US studies Arnold, Hammond and Oakes [1995] and Oakes, Considine and Gould [1994] have pointed out that there is bias in the process of identifying costs that favour the one who pays for the benefit over the one who receives the benefit.  Furthermore, the identification of costs is frequently inconsistent.  The notion of cost is notoriously value-laden and politically charged.  As Robert Heilbroner explains many costs to society, to individuals and to the environment figure as ‘externalities’ to business accounting [Heilbroner].  Thus the values and objectives of those who dominate the cost identification processes bias the costs imputed to medical treatments.  Bias in both the measures of beneficial outcomes and the costs of treatment will result in biased accounting and in cost/benefit measures that lead to unfair rationing decisions unless these are informed by some moral justification.

 

         The problem of bias in the use of QALYs is merely a particularly complex version of the problems of standardization in the interests of cost reduction in healthcare. “Outcomes are often defined in the terms of shorter stays, increased turnover, greater use of outpatient services, and reduced expenditures” [Armstrong 82].  When outcomes are defined with this focus in mind anything non-standard is excluded as a source of unacceptable expense.  Quality is defined mainly in terms of the extent to which everyone is treated the same and the idea is that variation should be eliminated [Armstrong 83].  In the words of two Canadian researchers:

 

         Elimination of variation may be the best stategy when chocolates are being made but this is not the case when individuals are being treated.  …. Medicine is an art as well as a science.  Single causes and single solutions cannot be scientifically determined for whole people.  And people do not come in standard packages with standard responses.  [Armstrong, 83]

 

Variation results not only from individual physiology but also from

particular  social, environmental and psychological conditions [Armstrong

84].  When data are processed using standardized diagnostic cases as a

basis for accounting for costs, the focus is always on the number of

people processed and not on how well individuals are when released. 

HMOs have been criticized for discharging patients ‘quicker and sicker’

and creating an unprecedented  burden on families [MG ref*8].

Furthermore what gets measured are things that are easily measured such as the number of hours spent in the unit, hours spent in surgery, and number of drugs used.  Patients’ needs, levels of comfort, degree of social support and lasting relief are ignored [Armstrong 84].  One study of cardiac patients showed appaling contradictions in care such that patients with heart disease were given meals contraindicated by the disease because the food services were controlled by an outside commercial company and could not easily be aligned with the patients’ needs for education and encouragement with regard to proper diet [MT].  In the same study it was found that patients suffered intense psychological reactions to their experience of heart trauma and surgery without any acknowledgement on the part of the institution of these experiences.  Any hopes of educating such patients into a new lifestyle were defeated and it was found that 50% of patients undergoing open heart surgery return a few years later for a similar treatment. 

 

The following story is used by Armstrong and Armstrong to

Illustrate the deleterious effects of standardization in the context of cost cutting. 

 

           I had an operation to remove the lower bowel because it had ruptured.  After three weeks in the hospital, I was in terrible condition.  I was feeling sick.  And the pain – it was so severe that I was bringing up from it.  I was wishing I could die to get out of it ….

         They wanted to discharge me but everything still hurt.  I was still weak, weak, weak and there was something wrong.  But never mind.  They were telling me I was fine and it was time for me to go home.  I was so sick on that day that I couldn’t hold my head up, couldn’t get out of bed or get dressed and I was heaving on and off.  [She was sent home but a month later she was taken to emergency with a massive infection resulting from a suture.  She has a second operation and a long recovery].

 

         I still feel terrible and I’m angry.  Just because you can’t heal as quickly as they think you should doesn’t mean that you should be treated like this.  They just want you out, out, out.  They don’t listen to you when you say you’re still sick and they won’t take you seriously to find out what’s the matter because they just want your bed.  It doesn’t make sense if I had to stay in hospital longer the second time around. [cited in Armstrong, 84]

 

        

 

         Although the idea of QALYs seems to address the problem of combining quantitative measures with measures of quality, the appearance of satisfactory integration of these two dimensions is illusory.  Used as a way to distinguish among medical treatments, to report the type and amount of medical benefit achieved from the use of new treatments in randomized clinical trials where most of the variables are held constant. exept for a controlled change in the treatment provided to patients, the method is relatively unproblematic [Sackett, Rosenberg, Gray, Haynes, et al, 1996].  Within this confined experimental setting, the causal relationship between treatment and medical benefit becomes more apparent and measurable using QALYs, and it is thought that the QALY measures medical effectiveness. 

 

         When these studies are applied to cost-effectiveness analyses in clinical practice the individual variation in patients creates a mismatch for this type of measurement.  Patients rarely conform to the narrow homogeneous profile of those who volunteered, a homogeneity necessary for the comparisons in clinical trials. In the context of health care utilitarian thinking eradicates the distinction between permissible and non-permissible action, replacing legitimation based on kind with legitimation based on matter of degree.  Critics of utilitarianism argue that once no decision can be ruled out as too terrible to consider people become desensitized and are willing to consider such acts if the quantity of satisfaction is deemed to outweigh the quantity of dissatisfaction. The problem is confounded when the assumed preferences people might have are assigned a dollar value.   Furthermore, in utilitarian ethics even the discomfort of contemplating terrible consequences of a particular system of calculation is included, when it is considered at all, as merely another negative factor to be computed, rather than as a sign of something being terribly wrong with the system. [* Anscombe]  In other words the QALY, developed and applied within the ethical context of utilitarianism, not only obscures the diversity of individual reaction but also sidesteps the issue of what actions may not be undertaken to maximize utility.   

 

 Our aim, in this paper, is not to eliminate the use of QALYs but to explore ethical thinking that goes beyond the limitations of utilitarian thinking and the homogeneity of the cost-benefit application of QALYs to put this form of measurement within a larger, more humane social context.  Ethical decisions require, first of all, the recognition that the question of values not be taken as settled once and for all.  They also require moral imagination or, in the case of economic decisions, “the ability to perceive that a web of competing economic relationships is, at the same time, a web of moral or ethical relationships” [Werthane 1999].

Our concern is to propose ethical considerations that can protect the values of both justice and care in medical accounting.  To do this we need to go beyond the utilitarian framework which underlies  current practices and make use of a model of thinking which leaves room for a broader range of moral ideals which move away from a theory based on a single comprehensive ideal.  “For example, many have held that one component of a good life consists in being a self-determined or autonomous agent, and that this is part of a good life for a person even if he or she is no happier as a result and has no desire to be autonomous.” [Dan Brock, 1997, Quality of Life Measures in Health Care and Medical Ethics, in The Quality of Life, Ed. Martha Nussbaum & Amartya Sen, Oxford: Clarendon, p. 97]   

 

 

The Oregon Experiment

 

         To ration is to restrict access within some rules or system governing the use of scarce resources.  The act of rationing presupposes irremediable scarcity, value based on some shared conception of the good and control, i.e., conscious withholding of resources.  Rationing can be done covertly so that the principles and the process by which rationing decisions are made are not disclosed to the public, or it can be done overtly.  The Oregon experiment illustrates the attempt by the people of that state to meet the criterion of open rationing. This involved widespread public discussion, in the late 1980’s, of the degree of scarcity of public funds, the value of various forms of healthcare and the implications of consciously withholding resources from some segments of the population.  

 

          The Oregon Health Plan is the result of the state’s initiative in attempting to expand access to health insurance for uninsured Oregon citizens and its aim of ultimately establishing universal coverage by means of an employer mandate to cover all of Oregon’s workers and their families [Jacobs 1999]. The idea was to expand coverage while keeping costs relatively constant by simply rationing services which low-income citizens could have access to.  The Health Services Commission was set up to identify the costs and benefits of 10,000 medical services, to examine the medical outcomes of these services and to engage in extensive public consultation so as to rank these services to a prioritized list of condition-treatment pairs, such as appendicitis-appendectomy.  Once the services were prioritized and the cost identified for these services statewide, the existing health care budget was divided up and applied to the list. The idea was to cut state funded services off at whatever point the money was depleted. That point turned out to be at the service which was ranked 709.  This attempt, to make explicit the principles of rationing and to base it on extensive consultation represents an unusual attempt to engage in ethically sound rationing which evolved amidst heated controversy and strong opposition,  [Jacobs 1999, p. 2 of 16]

 

         The plan, in place now for over a decade, has  achieved widespread political support despite two unexpected consequences: expanded health insurance, with the result being more money spent on healthcare by the state, and a series of developments which resulted in a move away from the use of the prioritized cut-off point on the list.  Critics of the plan from the outset argued that it would be impossible to conflate thousands of complex diagnoses and treatment plans into fewer than a thousand homogeneous categories.  Furthermore, it was argued, “moral and professional judgment would be replaced with the detached logic of cost-benefit analysis” [Jacobs 1999,p.4 of 16].  But the plan to set priorities and to draw a cut-off point was never carried out in a mechanical way as an unquestionable formula. Professional judgment and public consultation were not replaced with a  formula apllied mechanistically.   While some services were limited, the state engaged in  several initiatives to increase its healthcare budget, notably with funds from an increased tobacco tax and an increase in general funds [10% for the former and 17% for the latter].  It encouraged citizens to enrol in managed plans.  “Far from representing a radical new step toward systematic rationing of medical care, the OHP has been funded the old-fashioned way and familiar way: by raising revenues and contracting with managed care plans [Jacobs, p. 5 of 16]

 

         The experience of rationing in Oregon turned out to have departed from the paradigm of strict rationing and the list, which expanded with added hitherto unfunded services, such as mental health care, functioned more as a definition of a benefits package than a list of exclusions.  The remarkable thing about the process of attempting to ration according to a strict list, is that all parties who provide services, doctors, hospitals and private insurance companies regularly provide and pay for services ‘below the line’ when they are deemed appropriate or medically necessary.  This is partly due to the unanticipated fact that many people with conditions below the line are being treated for other conditions which are covered and the treatment includes the comorbities.  It is also due to the general popularity of the endeavor to extend health care coverage to all citizens and the strong sense of participation by citizens in the process.

 

         The innovation in Oregon is that while starting out with a technical plan designed to eliminate ambiguity and the need for judgment with a rational scientific instrument, the move toward overt explicit discussion of medical priorities, carried on by means of extensive public consultation lead to a changed political process whereby more funds were generated for health care.  Resource allocation decisions were made, not as originally intended, by a strict formula and a line that would move up and down according to available resources.  Instead  adjustsments to the list were made ‘by hand’ on the basis of judgments made by the Health Services Commission [Jacob, 1999, p. 7 of 16]. 

 

“By the time its founding legislation passed in 1989, OHP had ample support from the general public the Oregon Medical Association, large business organizations, and the AFL-CIO.  Members of the Oregon house and senate gave the legislation nearly unanimous approval” [Jacobs, 1999, 7 of 16]. And years later the legistature added new funds to the program.  One of the main reasons for this paradoxical turn of events is that the policy entrepreneurs who promoted the OHP were strongly committed to the ideal of expanding health insurance and to having an open process of decision-making.  The idea of using a formula for priority setting was merely a tool in the larger vision of health care.  Oregon’s health leaders made use of the language of rationing as a tool in the wider goal of health reform [Jacob 1999, p. 9 of 16].  And while the critics were right to focus on the problems of a prioritized list which they thought would be used mechanistically, the people of Oregon supported the process by which the list was produced because it fit in with the existing political climate of participation.  People felt that their views were heard by policy makers.

 

Narrative Ethics, Liberal Education and Cost-Benefit Thinking

 

            The lesson we draw from our discussion of QALYs and the Oregon case is that if the rationing procedure can be situated within a larger ethical context it will not function as a mechanistic and dehumanizing method for sorting people into problem categories.  It is our  contention that the rationing criterion may lead to acts which instantiate justice wherein the criterion enables patients to receive what they deserve, but only if the moral objective is to instantiate an ethic of care wherein decisions of appropriate treatment are made in response to varying circumstances and to publically expressed concern.  To do this is to move a long way from  impersonal bureaucratic systems, the iron cage that  Weber thought to be inevitable a century ago.  Meyer [1986] observed that accounting is only worth while when its serves a moral purpose.

 

         The common view is now that health care decision-making should be a process of shared decision-making between patient (or the patient’s surrogate in the case of an incompetent patient) and physician. Each is seen as indispensible to sound decision-making.  The physician bring his or her training, knowledge, and expertise to bear for the diagnosis of the patient’s conditions, the estimation of the patient’s prognosis with different alternative treatments, including the alternative of no treatment, and a recommendation regarding treatment.  The patient brings the knowledge of his or her aims, ends, and values that are likely to be affected by different courses of treatment, and this enables a comparative evaluation of different possible outcomes to be made.  … What [is to be rejected] is the claim that the only proper goal of medicine is health.  Instead, medicine’s goal should be to provide treatment that best enables patients to pursue successfully their overall aims and ends, or life-plans. It is the relative value of health, and of different aspects of health, as compared with other ends, that varies for different persons and circumstances. [Dan Brock, p. 102]

 

         The Oregon case is a reminder that “following one good to the end may be catastrophic, not because it isn’t a good, but because there are others which can’t be sacrificed without evil” [Taylor SS 503].  To make use of any algorithm to deal with human problems in a way that is impervious to local meanings moves us back into the iron cage, to what Ritzer calls ‘the McDonaldization’ of society.  In the words of Michael Oakeshott “great achievements are accomplished in the mental fog of practical experience” [cited in Beiner, 183]. The idea is that difficult social problems such as the distribution of healthcare resources “must be tackled at the level of shared experience and solidarities of praxis in all their concreteness” [Beiner 177]. 

 

         But what does this mean for philosophy, and in particular, for the teaching of ethics in liberal arts programs?  There is a good deal to be learned from contemporary writings on virtue theory and on narrative.  These writings, when combined together with an Ethic of Care can yield a way of thinking that is sometimes called Narrative Ethics.

 

         What are the main features of such an approach to ethics?  The basic idea of the combination of approaches is that ‘real moral knowledge comes to life at the moment when the wise or virtuous person concretizes his or her abstract understanding of ethical requirements in particular situations; in that sense there is no antecedent moral knowledge that awaits application” [Beiner 180].  Living in a society dominated by the power of science, technology and bureaucratic systems, philosophers, novelists, and poets have their work cut out for them.  We need constant reminders of the ubiquitous presence in all our lives of creative responses to moral dilemmas.  We need to sensitize our students to discursive texts that show people finding flexible imaginative solutions to interpersonal and social problems.  We need to make use of texts that display nuanced appreciation of particular situations and detailed description of the ways in which we can function, in the face of uncertainty and vulnerability.  In short, what liberal arts students are more suited than others students to grasping is the need for narratives of moral discernment as a counterbalance to the dominance of instrumental and algorithmic thinking.  In the phrase of Oliver Sachs  in A Leg to Stand On, existential medicine includes some form of recognition of what meaning the condition has for the patient.  In the ideal of Patient-Focused Care, practiced at Sunnybrook Hospital in Toronto, the idea is that one of the main shortcomings of medical institutions is that patient’s are not listened to.  If these observations have any truth then any philosophy of education which inculcates listening to the particular stories and interpretations of experience of those who will be affected by the treatment, will be a move in the right direction.  The Oregon experiment differs significantly from the current use of QALYs as a means of rationing health care insofar as it found a way to listen to people and to respond to the specific concerns that arose during its implementation.  The QALY method, unfortunately, risks being removed from the lived experience of sick people, especially insofar as the measures of quality of life are derived from the estimates of well people about how they would feel if they were to experience various forms of disease, which estimates are then transformed into monetary measures.   

 

         Good philosophy liberates us from the stanglehold that certain pictures have on our thinking.  At the present time the dominant picture, in philosophy and in society is of the rational decision-maker who applies general rules to particular situations.  The current ideal of ‘a compact, propositionally codifiable, impersonally action-guiding code’ [Walker, 1998, 61] leaves no room for embedded moral understanding and ‘encumbered’ second-persons, persons whose identity and understanding is shaped by other persons whose own identity and grasp of values is shaped by others, and so on. [Baier, Taylor]

 

         There are many formulations of the contemporary version of the ideal of phronesis , or practical reason, which cannot be captured in rules and formulae. I will cite ten of these formulations as a way of providing justification for teaching that cultivates moral imagination and narrative understanding without falling into moralizing discourse, a form of mental browbeating and coercion, on the one hand, or the mechanical application of computational discourse, both  antitheses of the ‘liberal’ approach we have tried to explicate in the context of the social problems of health care.

 

 

Elements of Phronesis  within the context of Narrative Ethics

 

1.  Uncodifiable knowledge: 

The knowledge possessed by the virtuous person is uncodifiable.  … To be a quietist about ethics is to invoke the positive image of the bearer of this ideal, though uncodified knowledge.  In effect it is to install this image in the place that might otherwise have been occupied by ethical theory. … What we cannot make fully explicit are not … ‘mere’ ideals, but are presented to us through actula persons –individuals whose cognitive powers are no different in kind, but at least superior in quality, to our own.  The uncodifiability of what is apparent to the morally exemplary person is offset, according to this different (and positive) line of thought, by the endless availibility of real-life material from which the spirit of their thinking can be reconstructed. [Lovibond, Sabina, 2002. Cambridge, Mass.: Harvard University Press, p. 50]

 

2.  Emotional intelligence:  Goleman, Nussbaum

Emotions may … in many cases be an invaluable guide to correct judgment; … general and universal formulations may be inadequate to the complexity of particular situations. ... [Nussbaum, Perceptive Equilibrium: Literary Theory and Ethical Theory, LK 180]

 

Emotions are cognitive and … a process of practical deliberation that omits them leaves out material of rich informationational value….Narratives are essential to the process of practical deliberation: not just because they happen to to represent and also evoke emotional activity, but also because their very forms are themselves the sources of emotional structure, the paradigms of what, for us, emotion is .    The whole story of an emotion, in its connections with other emotions and forms of life, requires narrative form for its full development.  [Nussbaum, Narrative Emotions: Beckett’s Genealogy of Love, LK, 296]

 

3.  Moral imagination:  Nussbaum, Murdoch,

 

4.  Connected knowing: Murdoch: in contrast to “reasons which do not in any way connect or tie the agent to the world or to special personal context within the world” [SG 35]

 

5.  Narrative knowing:  Ricoeur: Gadamer:

“The hermeneutical experience is the experience of the difficulty that we encounter when we try to follow a book, a play or a work of art, in such a way as to allow it to obsess us and lead beyond our own horizon”. [cited in Beiner]  The fundamental of Gadamer’s hermeneutics is that the really decisive insights in the humanistic pursuits like art, history, and philosophy exceed what we are able to establish by methodical reasoning and demonstrable proof. [Beiner, Ronald, 1997. Philosophy in a Time of Lost Spirit: Essays on Contemporary Theory. Toronto: University of Toronto Press. P. 50]

 

Narratives embody forms of human life and desire, …[and] certain types of human understanding are irreducibly narrative in form. [Nussbaum, Narrative Emotions: Beckett’s Genealogy of Love, in Love’s Knowledge, 291].  

 

6.  Moral sensitivity: Kekes: involves breadth and depth of understanding of our moral concepts.  Breadth to cover the range of their application and depth to be able to identify possibilities of enacting these concepts in one’s own life [to read oneself into the situation].

 

7.  Being ‘finely aware and richly responsive’ [Nussbaum] Edwards: situations with an attitude of care or even love:

 

       Love is constantly seeing through, not just seeing: it is constantly developing new images for appraisal and understanding, enlarging the mind’s stock of lenses for gathering and focusing light.  Such a sensibility … distrusts any ethical principle designed to guide the will, for … it can through its generality blur the very individual realities that give moral reflection its characteristic importance and difficulty. [Edwards, J.C, 1985. Ethics Without Philosophy. Tampa: University Presses of Florida, p. 238].

 

      

9. Openness: Mason-Lugones: willingness to have your most cherished ideas and values challenged so that your very idea of your self undergoes change.

+ Nussbaum: surprise

 

10. Semantic realism: Platts:

‘many concepts exceed our full grasp of them at any one time, and our grasp can, and should improve without limit. [Mark de Breton Platts, 1979, Ways of Meaning: An Introduction to the Philosophy of Language, London: Routledge & Kegan Paul, p. 262]

 

11.Civic Love:

Henry] James suggests that if, as members of moral communities, we are to achieve shared perceptions of the actual, we had better love one another first, in all our disagreements and our qualitative differences.  Like Aristotle, he seems to say that civic love comes before, and nourishes civic justice.  … Perception … motivates and sustains the whole enterprise of living by a shared general picture. [Nussbaum Literature and the Moral Imagination, LK 160]

 

12. Narrative Ethics:

 

Texts that narrate the experiences of beings committed to value. [Nussbaum Literature and the Moral Imagination, LK 149]

Literature that talks of human lives and choices as if they matter to us all. [Perceptive Equilibrium: Literary Theory and Ethical Theory, LK 171]

 

 

Stories cultivate our ability to see and care for particulars, not as representatives of a law, but as what they themselves are. [Nussbaum, Perceptive Equilibrium: Literary Theory and Ethical Theory, LK 184]

 

[A literary theory that ] confronts the reigning models of political and economic rationality with the consciousness of Strether.  Silence, in these matters, is a kind of capitulation. If these alternatives are not brought forward and described, we will go on being governed from day to day by conceptions of rationality that seem impoverished next to the ones we know well and care about in novels that we love. Worse, most people will not perceive, and therefore not really have, the choice among conceptions.  The hungery will be fed, (or not fed) according to some idea of the person; patients will be treated; laws and policies will be made –all according to some conception … of human personhood and huma rationality.  If we do not take a hand in these choices, they will be made by default without us. [Perceptive Equilibrium: Literary Theory and Ethical Theory, LK 192]

 

Is there any reason at all to suppose that entrenched conceptions (of rationality, of value) that currently govern our daily lives through their reception in economic theory and public policy will be modifiede by contact with Lambert Strether, or that the holders of these concdeptions will pay any attention at all to Henry James and related authors…? Can any possible practicable goal be achieve by subtle and precise writing about books that most people in public life do not read anyway?  …can any  writing … that is responsive and delicate and committed to perception, impose itself upon the form of our American culture… with its strange combination of Utilitarianism and religious moralism…[Nussbaum, Perceptive Equilibrium: Literary Theory and Ethical Theory, LK 193]

 

Some additional notes:

 

Taylor: Sources of the Self, 1989, HUP, 47-48

what I am has to be understood as what I have become and how I have come there

 

Compassion:  is a kind of narrative understanding … This understanding is like that of reading a novel, in which the reader can be both detached from imposing the personal attitudes that my distort judgment, while at the same time being empathetically engaged with the person in the narrative.  … [In Nussbaum’s view] compassion is the basic social emotion…  [Oatley on Nussbaum’s Therapy of Desire, Book Review, 322]