Osteoarticular Infection in Three Young Thoroughbred Horses Caused by a Novel Gram Negative Cocco-Bacillus.

We describe three cases of osteoarticular infection (OAI) in young thoroughbred horses in which the causative organism was identified by MALDI-TOF as Kingella species. The pattern of OAI resembled that reported with Kingella infection in humans. Analysis by 16S rRNA PCR enabled construction of a phylogenetic tree that placed the isolates closer to Simonsiella and Alysiella species, rather than Kingella species. Average nucleotide identity (ANI) comparison between the new isolate and Kingella kingae and Alysiella crassa however revealed low probability that the new isolate belonged to either of these species. This preliminary analysis suggests the organism isolated is a previously unrecognised species.

The Athletic Body.

This paper seeks to explore the attraction and the beauty of the contemporary athletic body. It will be suggested that a body shaped through muscular bulk and definition has come to be seen as aesthetically normative. This body differs from the body of athletes from the early and mid-twentieth century. It will be argued that the contemporary body is not merely the result of advances in sports science, but rather that it is expressive of certain meanings and values. The visual similarity of the contemporary athletic body and that of the comic book superhero suggests that both bodies carry a similar potential for narrative story-telling, and that their attraction is bound up with this narrative potential. The superhero and athlete live meaningful lives, pursuing clear and morally unambiguous goals. The aesthetic attraction of the body lies in its capacity to facilitate the articulation of a story of a meaningful life, and to do so in the face of the growing anomie and thus meaninglessness of life as experienced in contemporary society. Athleticism offers an illusion of meaning, serving to reproduce dominant justificatory narratives and social stereotypes. Yet, as an illusion of meaning, it may be challenged and negotiated, not least with respect to its bias towards a certain form of the male body. The female athletic body disrupts the illusion, opening up new existential possibilities, new ways of living and being, and thus new, and potentially disruptive, narratives.

Flourishing in Health Care.

The purpose of this paper is to offer an account of 'flourishing' that is relevant to health care provision, both in terms of the flourishing of the individual patient and carer, and in terms of the flourishing of the caring institution. It is argued that, unlike related concepts such as 'happiness', 'well-being' or 'quality of life', 'flourishing' uniquely has the power to capture the importance of the vulnerability of human being. Drawing on the likes of Heidegger and Nussbaum, it is argued that humans are at once beings who are autonomous and thereby capable of making sense of their lives, but also subject to the contingencies of their bodies and environments. To flourish requires that one engages, imaginatively and creatively, with those contingencies. The experience of illness, highlighting the vulnerability of the human being, thereby becomes an important experience, stimulating reflection in order to make sense of one's life as a narrative. To flourish, it is argued, is to tell a story of one's life, realistically engaging with vulnerability and suffering, and thus creating a framework through which one can meaningful and constructively go on with one's life.

Prospects for Flourishing in Contemporary Health Care.

This special issue of Health Care Analysis originated in an conference, held in Birmingham in 2014, and organised by the group Think about Health. We introduce the issue by briefly reviewing the understandings of the concept of 'flourishing', and introducing the contributory papers, before offering some reflections on the remaining issues that reflection on flourishing poses for health care provision.

Interpreting chronic disorders of consciousness: medical science and family experience.

RATIONALE, AIMS AND OBJECTIVES: Chronic disorders of consciousness (CDoC) pose significant problems of understanding for both medical professionals and the relatives and friends of the patient. This paper explores the tensions between the different interpretative resources that are drawn upon by lay people and professionals in their response to CDoC. METHODS: A philosophical analysis of data from 51 interviews with people who have relatives who are (or have been) in a vegetative or minimally conscious state. RESULTS: The medical specialist and the lay person tend to draw on two different interpretative frameworks: a medical science framework, which tends to construct the patient in terms of measurable physical parameters, and an interpretative framework that encompasses the uniqueness of the patient and the relative's relationship to them as a social being. CONCLUSIONS: These differences potentially lead to ruptures in communication between medical professionals and relatives such that that an increased self-consciousness of the framing assumptions being made will facilitate communication and enrich understanding of CDoCs.

The dominance of big pharma: power.

The purpose of this paper is to provide a normative model for the assessment of the exercise of power by Big Pharma. By drawing on the work of Steven Lukes, it will be argued that while Big Pharma is overtly highly regulated, so that its power is indeed restricted in the interests of patients and the general public, the industry is still able to exercise what Lukes describes as a third dimension of power. This entails concealing the conflicts of interest and grievances that Big Pharma may have with the health care system, physicians and patients, crucially through rhetorical engagements with Patient Advocacy Groups that seek to shape public opinion, and also by marginalising certain groups, excluding them from debates over health care resource allocation. Three issues will be examined: the construction of a conception of the patient as expert patient or consumer; the phenomenon of disease mongering; the suppression or distortion of debates over resource allocation.

Integrity and the moral complexity of professional practice.

The paper offers an account of integrity as the capacity to deliberate and reflect usefully in the light of context, knowledge, experience, and information (that of self and others) on complex and conflicting factors bearing on action or potential action. Such an account of integrity seeks to encompass the moral complexity and conflict of the professional environment, and the need for compromises in professional practice. In addition, it accepts that humans are social beings who must respect and engage with the moral position of others. This account is contrasted with a more traditional view of integrity as the rigid maintenance of consistency between professional practice and deeply held, but inflexible, moral principles. While this strong sense of moral conviction may be valuable as a source of moral motivation, e.g. in the case of whistle-blowers, it is equally likely to lead to dogmatism and hubris. Professionals and their organizations are encouraged to foster the more complex and reflective form of integrity.

Professional values, aesthetic values, and the ends of trade.

Professionalism is initially understood as a historical process, through which certain commercial services sought to improve their social status (and economic reward) by separating themselves from mere crafts or trades. This process may be traced clearly with the aspiration of British portrait painters (headed by Sir Joshua Reynolds), in the eighteenth century, to acquire a social status akin to that of already established professionals, such as clerics and doctors. This may be understood, to a significant degree, as a process of gentrification. The values of the professional thereby lie as much in the etiquette and other social skills with which they deal with their clients, than with any distinctive form of skill or value. Professionalisation as gentrification seemingly says little about the nature of modern professionalism. However, if this process is also construed as one in which the goals and achievements of the profession come to be subject to radical reflection, then something significant about professional values emerges. On this account, the profession is distinguished from craft or trade on the grounds that the goals of the profession, and the effectiveness of any attempt to realise them, are not transparent to the client. While a lay person will typically have the competence necessary to judge whether or not a craft worker has achieved their goal, that person will not necessarily be able to recognise the values that determine the success of a medical operation. It will be concluded that the values of a profession are articulated intrinsically to the profession, in terms of the contested understanding that the professionals themselves have of the meaning of the profession and the narratives within which its history is to be told.

The uncanny, alienation and strangeness: the entwining of political and medical metaphor.

This paper offers a critical response to Fredrik Svenaeus' use of the Heideggerian uncanny to analyse the experience of illness. It is argued that the uncanny is part of a culture of concepts through which the condition of modernity has been analysed by philosophers, social theorists, writers and artists. All centre upon the idea of alienation, and thus not being at home in the society that should be one's home. This association will be exploited to offer a reinterpretation of Svenaeus' thesis as a sociological and political, rather than an ontological, one. By reviewing the work of Hegelian philosophers, Georg Simmel, and novelists, represented by Mann, Camus and McCullers, it will be argued that illness is bound up with social alienation, both as something that is caused by conditions of alienation and as an interpretative response to alienation. Seeing illness as a metaphor of the human condition in modernity allows the medical humanities to inform therapy, that would allow the patient to understand their illness, not as the ontological condition of Dasein, but rather as something mediated by modern social, economic and political conditions.

The challenge of transplants to an intersubjectively established sense of personal identity.

Face transplants have been performed, in a small number, since 2005. Popular concern over the morality of the face transplant has tended to focus on the role that one's face plays in one's sense of self or one's personal identity. In order to address this concern, the current paper will explore the significance of face transplants in the light of a theory of the self that draws on symbolic interactionism, narrative theory, and accounts of embodiment. The paper will respond to certain presuppositions concerning personal identity made by Huxtable and Woodley. A theory of the self will be articulated that draws on the work of Merleau-Ponty and G. H. Mead, in order to place embodiment and social interaction centrally to an understanding of self-identity. This will allow an account of the nature of the suffering that a face transplant seeks to remedy, and its worth as an operation, and crucially the impact that it may have on the sense of personal identity of the recipient of the transplant. The conclusion will review the treatment in the context of the prejudices that members of contemporary societies may hold against those with disfigurements.

The hermeneutic challenge of genetic engineering: Habermas and the transhumanists.

The purpose of this paper is to explore the impact that developments in transhumanist technologies may have upon human cultures (and thus upon the lifeworld), and to do so by exploring a potential debate between Habermas and the transhumanists. Transhumanists, such as Nick Bostrom, typically see the potential in genetic and other technologies for positively expanding and transcending human nature. In contrast, Habermas is a representative of those who are fearful of this technology, suggesting that it will compound the deleterious effects of the colonisation of the lifeworld, further constraining human autonomy and undermining the meaningfulness of the lifeworld by expanding the technological control and manipulation of humanity. It will be argued that these opposed positions are grounded in fundamentally different understandings of the consequences of scientific and technological advance. On one level, the transhumanists remain confident that the lifeworld has within it the resources necessary to find meaning and purpose in a society deeply infused by genetic technology. Habermas disagrees. On another level, the difference is articulated by Horkheimer and Adorno in Dialectic of Enlightenment, primarily by challenging what may be understood as a Baconian faith in science as a project for the domination of nature (where nature is an infinitely malleable material, to be dominated and shaped, without adverse consequences, purely for the purposes of human survival). While the transhumanists broadly embrace this faith, Habermas returns to something akin to Horkheimer and Adorno's pessimistic scepticism.

Best interest: a philosophical critique.

On one conception of "best interest" there can only be one course of action in a given situation that is in a person's best interest. In this paper we will first consider what theories of "best interest" and rational decision-making that can lead to this conclusion and explore some of the less commonly appreciated implications of these theories. We will then move on to consider what ethical theories that are compatible with such a view and explore their implications. In the second part of the paper we will explore a range of possible criticisms of these views. And in the third part we will criticise the view that a court is always or even often in a good position to decide what the patient's best interest is. In the fourth and final part we will put forward a reconstructive proposal aimed at saving whatever is sound in the "best interest" conception.

The art of useless suffering.

The purpose of this paper is to explore the role that modernism in the arts might have in articulating the uselessness and incomprehensibility of physical and mental suffering. It is argued that the experience of illness is frequently resistant to interpretation, and as such, it will be suggested, to conventional forms of artistic expression and communication. Conventional narratives, and other beautiful or conventionally expressive aesthetic structures, that presuppose the possibility and desirability of an harmonious and meaningful resolution to conflicts and tensions, may fundamentally misrepresent the patient's experience. By drawing on the work of Emmanuel Levinas (on useless suffering) and the aesthetic theories of Nietzsche and T. W. Adorno, it will be argued first that a faith in the possibility of harmonious resolution of suffering is misplaced and does violence to the experience of suffering. Second, it will be argued that the expression of suffering lies not in finding words, images or sounds that communicate the experience of that suffering to others, but rather in the persistent and radical disruption of any illusion of meaning and coherence that might be imposed upon the experience, so that the very possibility of communication is also disrupted.

The expert patient: Illness as practice.

This paper responds to the Expert Patient initiative by questioning its over-reliance on instrumental forms of reasoning. It will be suggested that expertise of the patient suffering from chronic illness should not be exclusively seen in terms of a model of technical knowledge derived from the natural sciences, but should rather include an awareness of the hermeneutic skills that the patient needs in order to make sense of their illness and the impact that the illness has upon their sense of self-identity. By appealing to MacIntyre's concepts of "virtue" and "practice", as well as Frank's notion of the "wounded story-teller", it will be argued that chronic illness can be constituted as a practice, by building a culture of honest and courageous story-telling about the experience of chronic suffering. The building of such a practice will renew the cultural resources available to the patient, the physician and the rest of the community in understanding illness and patient-hood.

Velázquez and the representation of dignity.

The purpose of this paper is to explore the visual representation of dignity, through the particular example of the seventeenth century Spanish painter Diego Velázquez. Velázquez works at a point in Western history when modern conceptions of dignity are beginning to be formed. It is argued that Velázquez' portraits of royalty and aristocracy articulate a tension between a feudal conception of majesty and a modern conception of the dignity of merit. On this level, modern conceptions of dignity of merit are understood in terms of a struggle to excel in particular activities, and thus to overcome the risk of failure. More radically, Velázquez' portraits of dwarfs and the mentally disabled are argued to be expressive of dignity, not by finding a positive representation of the sitter's dignity, or to find scales of activities by which they can be positively assessed, but rather by grounding their dignity, negatively, in a protest against indignity and humiliation. Drawing on Honneth's analysis of dignity in terms of a theory of recognition, it is argued that the indignity of the court dwarf lies in the fracturing of their communication with the rest of society. The task of repairing that fractured communication is achieved, not by representing a dignified ideal, but rather by drawing attention to the prejudices that serve to exclude the humiliated from full participation in society. In conclusion, it is suggested that the conceptualisation and representation of the elderly today finds effective exemplars in Velázquez' portraits of court dwarfs, rather than in his portraits of the elderly.

Weighting health states and strong evaluation.

The problem of public consultation over the allocation of health care resources is addressed by considering the role that quality of life measures, such as QALYs and the Nottingham Health Profile, could play. Such measures are typically grounded in social surveys, and as such may reflect public preferences for health care priorities. Using Charles Taylor's concepts of "weak" and "strong" evaluation, it is suggested that current quality of life measures are inadequate, insofar as they typically presuppose that survey respondents are mere "weak evaluators", who express only inarticulate preferences. Respondents may, conversely, be understood as strong evaluators, with deeper visions of human nature and the good life informing their health preferences. Space is then created for such respondents to be asked to defend their preferences, and so be encouraged to reflect critically and publicly on the beliefs and prejudices that ground their view of health care priorities.