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Biomedical subjects

Miles Little

Publications and source records attributed to Miles Little.

10 recordsLinked to original sources
PubMed2006

Pragmatic pluralism: mutual tolerance of contested understandings between orthodox and alternative practitioners in autologous stem cell transplantation.

High-dose chemotherapy and autologous stem cell transplantation (ASCT) is used to treat some advanced malignancies. It is a traumatic procedure, with a high complication rate and significant mortality. ASCT patients and their carers draw on many sources of information as they seek to understand the procedure and its consequences. Some seek information from beyond orthodox medicine. Alternative beliefs and practices may conflict with conventional understanding of the theory and practice of ASCT, and 'contested understandings' might interfere with patient adherence to the strict and demanding protocols required for successful ASCT. The present study, conducted in Sydney, Australia, examines narrative-style interviews with 10 sequentially recruited ASCT patients and nine of their carers conducted at the time of transplant and three months later. Transcripts were read for instances of mention of alternative advice, and for instances of contested understanding of information relevant to the transplant. Patients and carer pairs expressed closely concordant views about alternative advice. Five pairs were consulting alternative practitioners. Contested understanding was expressed in four domains--understandings of the transplant itself and its underlying theory, of the relationship between the components of the 'transplant', of the nature and role of stem cells, and of beliefs about bodily function and life-style. Contested understandings of the transplant treatment were expressed as predominantly personal interpretations of orthodox information. Patients and carers seemed to recognise that alternative and conventional systems were discordant, yet they were able to separate the two, and adhere to each practice without prejudicing their medical treatment. A single case of late, post-transplant repudiation of Western medicine is discussed to emphasise some of the possible determinants of dissonance when it does occur.

Choice Behavior↗
PubMed2006

The Gordon Gordon-Taylor Memorial Lecture: surgical giants and giants among surgeons--the case of Abraham Colles.

Sir Gordon Gordon-Taylor was a surgical giant and a giant among surgeons. There's a distinction between the two. Surgical giants are technical geniuses who pave the way for others and set the standards against which others can measure their performance. Giants among surgeons contribute other things to the science and practice of surgery and sometimes to fields outside surgery. By these measures, Abraham Colles was not a surgical giant. He thought, wrote and taught about his interests. He enhanced the reputation of Irish surgery. In retrospect, his science and his ethics seem flawed by modern standards, but by the measures of his own time he was a model investigator and a man of outstanding moral probity. He is remembered for the eponymous Colles's fracture and for Colles's fascia and ligament. He held the Chair of Anatomy and Surgery in Dublin for 32 years and drew the admiration and affection of his contemporaries, colleagues and students. He was a giant among surgeons, and his name deserves commemoration.

Anatomy↗
PubMed2004

The skull beneath the skin: cancer survival and awareness of death.

Terror management theory predicts that people made aware of their own mortality (mortality salience) will seek to boost their self-esteem in order to buffer the anxiety they feel. One common resource to achieve this is strengthening social bonds with an admired in-group. It would also seem to predict that cancer survivors and those close to them would be driven to a greater closeness. A similar closeness might be predicted between those with terminal illness and their families and other supporters. Some empirical observations suggest that there are other forms of death-related salience which do not conform to the predictions of terror management theory. We suggest that some of those who have recovered from cancer may be made death salient, while those close to them remain mortality salient. Death salience seems to turn people inward to the resources and challenges of their deep (subconscious and unconscious) minds, and confronts them with the realities of their deep identities. A third form of salience, dying salience, affects those who have terminal illness. Distinguishing between death salience and mortality salience provides one explanation for the frequency with which close relationships break down after recovery from cancer. The distinctive nature of dying salience raises important questions about the inappropriateness of survivors as providers of support for the dying.

Death↗
PubMed2004

While there's life ... hope and the experience of cancer.

Hope is the subjective probability of a good outcome for ourselves or someone close to us. During mortal extreme experience, observers and participants in the experience hope for life over death. In cancer, the illness/treatment experience is similar to the experience of dying, but with the redeeming element of hope for cure, for life over death. If cure is not obtained, hope for the participant moves to a 'good death'. If the outcome is cure, however, the hope for life has been realised for both participant and observer. Hope, which is always for the future, may now diverge between participant and observer. Observers hope for a return to normality, and use a discourse of normality which emphasises such things as 'getting over it', 'moving on' and 'getting back to normal'. Survivors may not find the realisation of hope for life to be as comfortable as might be expected. After the euphoria of being declared free of disease, about 30% of survivors develop post-cancer distress with death salience. They recognise, whether they want to or not, that they have confronted their own annihilation, and that they will at some stage have to do so again. We all know that we will die, but there is a greater vividness and proximity in that knowledge for someone who has been through mortal extreme experience. Death salience provokes a confrontation with meaning in a person's life. Thus survivors turn inward to their deep selves in order to establish an understanding of what their life projects might become. Observers, on the other hand, find death salience hard to live with, and may turn away from the distressed survivor. The hopes and discourses of survivors and those close to them may have different structures and different objects. These differences may help to explain the frequency with which stress and disruption affect close relationships after cancer and other life-threatening experiences.

Adaptation, Psychological↗
PubMed2004

"In this scenario, I do this, for these reasons": narrative, genre and ethical reasoning in the clinic.

Narrative analysis has been applied by health researchers to investigate (among other things) clinical reasoning, clinical ethics and human identity. The term 'narrative' is often used as a broad category that covers a variety of spoken genres, however, and it thereby lacks delicacy as an analytic tool. We introduce genre theory, which enables us to differentiate more clearly between story genres and other spoken genres. We then apply the theory to ten narrative-style interviews with clinicians involved in the treatment and management of colorectal cancer in Sydney, Australia. We characterise the narrative-style interview as a macro-genre, and draw attention to the occurrence of spoken genres other than stories. We focus our analysis on a policy genre that occurred naturally and frequently in the spoken discourse of the informants, but which has not been described before in either the literature of social linguistics or the health and medical literature. We analyse two examples of this genre in detail in order to characterise its main semantic features, and differentiate it from story genres. We then discuss the genre with reference to Aristotelian interpretations of ethical reasoning in the clinic. We conclude that the policy genre is both the unfolding of practical wisdom in speech, and the appropriate choice of genre where a display of ethical identity is called for. Finally, we discuss the implications of our findings for ongoing research, for ethics education, for bioethical theory, and for communication between some of the different stakeholder groups in clinical medicine.

Colorectal Neoplasms↗
PubMed2003

'Better than numbers...' A gentle critique of evidence-based medicine.

Evidence-based medicine (EBM) has achieved cult status in the last 10 years or so. It is an altogether admirable movement in medicine, capable of a great deal of good. Its privileged status, however, has prevented critics from being heard, and there are problems with EBM. Eight features need further discussion if EBM is not to be discredited and superseded. They are its reductionism; its unwitting paternalism; its privileging of restricted kinds of evidence; its dependence on the questionable concept of equipoise; the instability of the 'truths' it produces; its capacity to eliminate individuals in favour of categories; its historical arrogance; and its contempt for the wisdom and integrity of our predecessors. Evidence-based medicine is here to stay; for the moment, at least. It is sufficiently well established to withstand critique. It needs criticism if it is to survive and flourish.

Evidence-Based Medicine↗
PubMed2002

Discourse in different voices: reconciling N = 1 and N = many.

When groups are convened to discuss the making of policy, people are chosen to represent particular interests because they have relevant experience. Different stakeholders, however, may use differing discourses, and particular discourses may be privileged in particular contexts. This means that important contributions to the discussion may not be reflected in final reports. Discursive incommensurability is particularly seen when individual, personal experience is presented in meetings where quantification or "numbers talk" is privileged. While pooled personal experience may carry some weight in such a context, individual anecdote does not. The inclusion of 'consumers' in policy making groups may result in their dysempowerment. Their presence promises that they will have influence, but their voices disappear from the final document. The promise of empowerment is not realised. Dysempowerment may translate into empowerment with time, as it has done with feminism and the HIV/AIDS lobby. In order to speed the process, we suggest some practical means whereby mixed discourses may be generated and monitored. For constructive interchange, each party to the discourse needs to express the interests and arguments relevant to the group he or she represents. Supporting this principle of representation are principles of implicature and radical respect. Implicature is the act of implying what is relevant to others involved in the discourse. Radical respect is a fundamental and foundational respect for others in their roles as representatives of stakeholders with legitimate interests in the topic of the discourse.

Australia↗
PubMed2002

The fivefold root of an ethics of surgery.

Surgical ethics have generally been framed as general medical ethics applied to surgical contexts. This model is helpful, but may miss some of the special features of the surgical process and relationship. It is suggested in this paper that there are five categories of experience and relationship which are especially important in surgery--rescue, proximity, ordeal, aftermath, and presence. The sense of rescue, the feeling of relational proximity, the ordeal and aftermath of surgery are things which the patient experiences. Understanding these experiences allow surgeons to understand what may be asked of them in an ethical sense. Recognition of the reality and validity of each category in the surgical process highlights the importance of presence, the acts by which the surgeon demonstrates that he is present to the patient throughout the surgical process and its aftermath. While the teaching of communication skills may never compensate for insensitivity, the ideal of presence as virtue and duty can be taught by precept and example.

Colorectal Neoplasms↗
PubMedDate not supplied

Survivorship and discourses of identity.

Personal identity is self-evidently important to us all. Identity is a philosophically complex subject, but there is some agreement that memory, embodiment and continuity are essential components. The sense of memory includes 'future memory', the kind of memory we would like to construct for ourselves as our lives proceed. While the sense of personal identity is internal to the individual, a sense of that person's identity exists in the minds of others. Extreme experiences threaten the element of continuity, because they may bring bodily changes as well as cognitive changes that challenge central values. Restoring or preserving continuity is a major task for survivors. The ways in which people experience discontinuity because of cancer illness, and the ways in which they manage this experience emerges from the narratives of the survivors of cancer and in the narratives of health care workers who look after them. People manage discontinuity by reference to stable 'anchor points' in their beliefs and values; by re-constructing versions of their pre-experience identities, drawing on past memory and finding ways to preserve a continuity between past memory, present experience and constructions of the future; by using the experience to develop established facets of identity; and by imbuing the experience with meaning and recognising the enlarged identity made possible by survival. Those who cannot achieve a sense of continuity may feel alienated from themselves, their friends and family. All these methods of management may be used by one person to negotiate the post-experience identity in its different social interactions. The experience of the survivor can be further understood by recognising the challenge posed by extreme experience to the sense of continuity of both embodied self and memory. A satisfactory discourse of survival has yet to enter the public domain. This lack adds to the burdens of survivors, including those who have survived cancer.

Adaptation, Psychological↗