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In fast-changing Western healthcare systems, to what extent has the idea of a ‘market’ come into play? And how has this affected and redefined healthcare?

A new book edited by Oxford academics – Marketisation, Ethics and Healthcare: Policy, Practice and Moral Formation – attempts to answer these questions.

The book’s three editors, Dr Joshua Hordern (Faculty of Theology and Religion), Dr Therese Feiler (formerly of the Faculty of Theology and Religion) and Dr Andrew Papanikitas (Nuffield Department of Primary Care Health Sciences), talk to Arts Blog about their work, which was highly commended in the recent British Medical Association book awards.

The project forms part of the Oxford Healthcare Values Partnership.

Where did the idea for the book come from?

The idea for the book came out of conversations with doctors and others working in healthcare. We wanted to work together on understanding the changing ethos of the NHS and other health and care institutions nationally and internationally. So we formed a partnership with the Royal Society of Medicine and approached the British Academy for funding. They were excited about the project and awarded funding which was then renewed for a second year to enable us to bring the different strands of our work together in the book. We ran a conference and some workshops to bring people together and set up some conversations.

Core emphases for us and the British Academy have been on involving early career researchers at every stage and on developing enduring partnerships between healthcare practitioners, social science experts and humanities researchers, drawing especially on those working in theology and religion. From the start we wanted to find out the real issues which were shaping the practice of healthcare and then resituate them in ways which would open up new lines of inquiry. 

How do you define a ‘market’ in relation to healthcare?

In the book we tend to talk about marketisation and market-type processes operative in health and care. Broadly speaking, we’re talking about mechanisms of packaging, selling and paying for healthcare that are neither state-distribution nor solidarity- or charity-based forms of exchange. These are always mixed in with each other. So the key is to discern by which principles a given policy or system is governed.

Examples perhaps bring this out best – more obvious ones include the changing face of general practice with GPs running pharmacies to the role of private hospitals or doctors offering their services in private practice. But there are other important factors in the mix, including the efforts to create a functioning market in personalised social care through initiatives like personal independence payments; the role of pharmaceutical companies in contributing to and shaping the culture of healthcare; and the significance of diagnosis-related groups as a form of financial coding which has all sorts of intriguing implications for the ethos of healthcare.

What were your aims in carrying out this work?

We asked 12 authors from round the world – influenced by everyone from Marx to free market economics; Christian moral theology to analytic moral philosophy – to think together about the place and influence of market-type processes on policy and practice in healthcare. We wanted to look at institutions as organisations and examine the kind of ethic they embody and depend upon; but we also wanted to examine the way that people’s moral outlook and behaviour are shaped by marketisation processes within those institutions – questions of personal and professional formation. Think of trends like ‘defensive medicine’ which emerge for a variety of factors, but which impact medical professionalism at a deep level. All in all, we wanted to stimulate a conversation about policy, practice and moral formation which is worthy of the deep and existential questions that healthcare raises.

What were the key findings?

There weren’t any findings which all the authors shared. We as editors gave our own views in the epilogue of areas for further research. There’s a further clue, though, in the aphorism in Greek we quote at the start of the book – check it out to see what we think. If we are sincere in our respect for people, which is the ostensible basis for democratic society and healthcare ethics, then money should be a means and people should be ends in themselves. And if we understand how the things that should never be bought and sold connect with the material world, there is a chance they remain visible – even to those who now see the price of everything and the value of nothing. 

One overall point which Muir Gray highlighted in the foreword was the question of what will keep money and markets in position to serve health and care rather than distort people’s attention from what matters. A conceptual and policy theme which emerges is the idea of a healthcare covenant, akin to, but distinct from, the military covenant between the people of the UK and armed forces. That’s an idea to be taken into practice in the future. Other approaches include incentives and education.

How can the humanities interact with the medical sciences?

The best way for humanities researchers to make a contribution is in close learning partnerships with medical science researchers and others working in healthcare. Where that is happening, humanities researchers are increasingly in demand for the ways they frame challenges in healthcare. This is partly because of broad cultural transitions in healthcare ecologies which represent a turn from a dependence on a largely or even exclusively biomedical model of conceiving healthcare towards a greater balance between biomedical and social conceptions of healthcare. At the same time, the trajectory towards an ever more high-tech approach to healthcare, with a particular emphasis on the biosciences as key to the UK’s offering to the world post-Brexit, is provoking critical reflection on the very purpose of healthcare. In this context humanities disciplines have the capacity to provide historical perspective, conceptual understanding and other kinds of insight into what helps sustain and restore health for people and communities. Humanities scholars are able to examine and question an entire conceptual edifice that is often taken for granted. Not: ‘How can we solve problem X?’ but rather: ‘Is this even the right way to put the problem?’ When that kind of questioning is done in partnership, everyone may be prompted to try a different path.

All this means there’s a tremendous opportunity for healthcare and humanities researchers to find new and creative ways of understanding the challenges of our time. Humanities researchers are becoming more capable in developing these partnerships and shared agendas with colleagues in healthcare locally, nationally and globally. Mutually beneficial collaborations are enabling more focused and better-informed research which can target the needs and concerns of healthcare organisations. But there remains the strategic need to interweave the agendas of humanities researchers and medical researchers, alongside colleagues in other relevant disciplines, to address challenges which are best tackled in interdisciplinary ways, in partnership with patients, public bodies and private enterprise.

The book's editors express particular thanks to the British Academy for the British Academy Rising Star Engagement Award which made this project possible. They are also grateful for funding from the AHRC (grant AH/N009770/1) and the Sir Halley Stewart Trust.

A previously unknown letter from Annie Kenney, the working-class activist who became the first woman imprisoned for campaigning for the vote, is due to go on public display for the first time after being uncovered by Oxford historian Dr Lyndsey Jenkins during her research.

Revealing the personal impact of this iconic political protest, the letter sheds new light on the first act of militant suffrage and is an exciting contribution to this year’s centenary celebrations of the first women gaining the right to vote in Britain.

Written from the Pankhurst family home at 62 Nelson Street, Manchester, the letter was sent from Annie Kenney to her sister Nell in October 1905, informing her that ‘you may be surprised when I tell you I was released from Strangeways [prison] yesterday morning’. The letter offers an intimate insight into the complex and competing emotions that Annie experienced as she left prison. She expresses delight at the impact her unprecedented act had made in the local community and her gratitude at the support from most of her family, but also records how another sister Alice, was ‘awfully angry’ about the incident.

Annie had been sent to jail after she and Christabel Pankhurst had attended a political meeting demanding to know from minister Sir Edward Grey: ‘Will the Liberal Government give votes to women?’ The speaker refused to answer, and the women were thrown out of the hall before both being jailed after Christabel Pankhurst spat at a policeman. The incident is now widely regarded as the first militant action, and the women became instantly famous around the world, attracting huge public sympathy. With the first use of the demand ‘votes for women’ on a placard, the two women created one of the most memorable political slogans of all time, kick-starting a revolution.

Annie Kenney and Christabel Pankhurst with a 'Votes for Women' sign

Image credit: Wikicommons

The letter has lain unknown for more than a century. Nell Kenney later moved to Canada, and the document was for many years catalogued with general correspondence in the British Columbia Archives in Victoria. It was listed only as part of a collection belonging to Sarah Ellen Clarke, Nell’s full and married name, and, as such, had until now escaped wider attention. It was recently located by Dr Jenkins, who was researching the lives of the seven Kenney sisters as part of her DPhil research in Oxford’s Faculty of History.

Annie Kenney went on to become one of the most prominent leaders of the Women’s Social and Political Union (WSPU). After Christabel Pankhurst fled to Paris in 1912, Kenney led the organisation through its most difficult and dangerous years. She served several prison sentences, went on hunger strikes that devastated her health, and eventually spent a year on the run from the authorities as a ‘Mouse’ released under the notorious ‘Cat and Mouse Act’. She was not active in politics after the vote was won for some women in 1918, but remained loyal to the Pankhursts and the WSPU for the rest of her life.

Dr Jenkins said: ‘Annie Kenney was one of the leading suffragettes, but, like other working-class women who played a central part in the fight for the vote, her story and significance is often underestimated and poorly understood. This letter provides new insight into Annie’s private thoughts and feelings at this turning point in the campaign for the vote, as well as showing the warm reception she received from the local community and other activists. This is an exciting and revealing document which deepens our understanding of the battle for suffrage and the women who fought it.’

Annie’s letter shows the close and loving relationship among the Kenney family, whose background was in the mills of Oldham in Greater Manchester, and several of whom went on to have important careers in political, professional and public life. The youngest sister, Jessie, was another leading suffragette who also gained notoriety for her acts of daring: dressing as a telegraph boy to attempt to heckle then Chancellor David Lloyd George and as part of a trio who attacked Prime Minister Herbert Asquith on his holiday.

Nell Kenney, who received the letter, organised a mass protest in Nottingham that narrowly escaped becoming a riot. Two other sisters, Jane and Caroline, also supported the suffragettes’ work, but dedicated their lives to becoming some of the first Montessori teachers in the world, studying with Dr Maria Montessori herself and joining forces with Alexander Graham Bell to pioneer Montessori education in the United States. Meanwhile, their brother Rowland was a leading socialist and the first editor of the Daily Herald, before becoming a pioneer of political propaganda in the First World War.

Author Helen Pankhurst, granddaughter of Sylvia Pankhurst and a leading campaigner for women’s rights, said: ‘One hundred years on from the first women winning the vote, we are still learning more about the remarkable women who led the campaign for us all to have that right. As this important and very personal letter from one sister to another shows, the campaign for suffrage involved high risks and huge personal costs – especially in these early stages when the cause was unpopular and the outcome uncertain. As we mark the centenary of their success, it is right that we remember their sacrifices and remind ourselves that women in the UK and around the world are still taking those risks to achieve true equality for all.’

The letter is on display at Gallery Oldham from 29 September to 12 January as part of the Peace and Plenty? Oldham and the First World War exhibition. It is on loan from the British Columbia Archives in Victoria, Canada.

Oldham Councillor Hannah Roberts, Elected Member Champion for the Suffrage to Citizenship Programme, said: ‘I am delighted that this letter has come to light, and how great that we get to see it being exhibited in the birthplace of Annie Kenney herself. We are very lucky to have it on loan from Canada. It will make a lovely addition to the suffrage artefacts already held by Gallery Oldham, and I hope people will go along to see this significant piece of Oldham’s suffrage history.’

Professor Jack Lohman, Chief Executive of the Royal British Columbia Museum and Archives, added: ‘We are so pleased to be able to share this poignant letter with Gallery Oldham and its visitors, and to add something so personal to the important story of the suffrage movement. The British Columbia Archives hold thousands of stories that connect us around the world, and Annie Kenney’s letter is an outstanding example of our shared histories.’

Annie’s letter

62 Nelson Street,
Manchester
Oct 17.05

My Dear Nellie

You may be surprised when I tell you I was released from Strangeways yesterday morning. There were over one hundred people waiting. I had a lovely boquet (sic) of flowers sent me from the Oldham Socialists. Miss Pankhurst is still there untill (sic) Friday. Manchester is alive I can assure you Last night a protest meeting was held for me in Stevenson Square over 2000 people were there Lenard (sic) Hall came to speak on our behalf the only thing I am sorry about is those at home and Kitty and Jennie and You, I cannot tell you how pleased I was to receive your letter and to find you so kind about it, I thought you would have been so indignant with me I cannot tell you anything here as there is so much to tell. I am staying at Pankhurst (sic) for an indefinite time of course I am able to send money home every week. I sent it last week so that is alright. Alice is awfully angry about it but I don’t blame her, I’m living in hope to repay her for it all. She is working for me yet, they are removing to morrow. I can’t be there but Jessie is away from work for a day or so. I will come and spend a weekend with you as soon as possible. I expect being at Middlesbourgh (sic) for a week or so, and I will write you from there,

Ever Your Loving Sis

Nan.

Read about the story on the BBC News website.

Professor Dominic Wilkinson, Professor of Medical Ethics at the University of Oxford and a Consultant in newborn intensive care at the John Radcliffe Hospital, Oxford, discusses the ethical issues around providing medical treatment for children when parents and doctors disagree.

The fraught life and death cases of Charlie Gard and Alfie Evans, reached global attention in 2017 and early 2018. They led to widespread debate about conflicts between doctors and parents, and about the place of the law in such disputes. Changes to the law in response to these high-profile cases are currently being debated in the House of Lords.

In 2016, Professor Savulescu of the Oxford Uehiro Centre for Practical Ethics wrote an editorial for the Lancet medical journal strongly criticizing the court’s decision, and arguing that Charlie Gard should be allowed to travel to America for experimental treatment. He argued that Donald Trump and the Pope were right to support Charlie’s family. In the same issue of the Lancet, I took the opposing view, supporting Charlie’s doctors, and arguing that Charlie should be allowed to die. Professor Savulescu and I are colleagues and long-time collaborators.

Over the ensuing months, while the appeals for Charlie Gard were heard in the courts, Savulescu and I conducted a vigorous debate in academic journals and in the media about the rights and wrongs of the Gard case. Over time, we found areas of agreement, as well as areas of reasonable disagreement.

In a newly published book, Professor Julian Savulescu and I examine the ethics of medical treatment disputes for children, as well as outlining our own professional disagreement on the Gard case. At one level, this is a rigorous analysis of the rights of parents, the harms of treatment, and the vital issue of limited resources. From opposite sides of the debate about treatment for Charlie Gard, we provocatively outline the strongest arguments in favour of and against treatment. We also outline a series of lessons from the Gard case and propose a radical new ‘dissensus’ framework for future cases of disagreement.

This case also illustrates some of the distinctive and challenging features of ethical debate in the 21st century. We have shown that it is possible for those who find themselves at opposite ends of an issue to find common ground. Indeed, disagreement about controversial ethical questions is both inevitable and desirable.

There is a need for sensitive, rational debate within our community about how to fairly address disagreements about treatment between health professionals and families. That debate cannot, now, help Charlie Gard or Alfie Evans. It can, though, help current and future children with serious illnesses.

It can support their families to access desired treatment, within limits. It can help health professionals to be able to advocate for the best interests of their patients. It can help doctors to maintain relationships with families (even if not always seeing eye to eye). It can help society to understand what is at stake, why these disagreements are so difficult, so vexed, and so inevitable.

In difficult ethical debates, there is sometimes a desire to reach consensus or agreement on the right thing to do. But that can be a mistake. On questions of deep ethical values, there will always be disagreement. We need to embrace dissensus, not consensus. We should be prepared to disagree

‘Ethics, conflict and medical treatment for children: from disagreement to dissensus,’ is published by Elsevier.

Professor Julian Savulescu is Professor of Practical Ethics in the Oxford Uehiro Centre for Practical Ethics at the University of Oxford. Professor Dominic Wilkinson is Professor of Medical Ethics at the University of Oxford and a Consultant in newborn intensive care at the John Radcliffe Hospital, Oxford. Wilkinson and Savulescu are medical doctors as well as experts in medical ethics.

New research published in Nature Ecology & Evolution from the Department of Zoology at Oxford University aims to show how big data can be used as an essential tool in the quest to monitor the planet’s biodiversity.

A research team from 30 institutions across the world, involving Oxford University’s Associate Professor in Ecology, Rob Salguero-Gómez, has developed a framework with practical guidelines for building global, integrated and reusable Essential Biodiversity Variables (EBV) data products.

They identified a ‘void of knowledge due to a historical lack of open-access data and a conceptual framework for their integration and utilisation'. In response the team of ecologists came together with the common goal of examining whether it is possible to quantify, compile, and provide data on temporal changes in species traits to inform national and international policy goals.

These goals, such as the Sustainable Developmental Goals (SDG) of the United Nations, have become fundamental in shaping global economic investments and human actions to preserve and protect nature and its ecoservices.

Essential Biodiversity Variables (EBVs) have been proposed as ideal measurable traits for detecting changes in biodiversity. Yet, the researchers say, little progress has been made to empirically estimate how EBVs in fact change through time at the regional and global scales.

To overcome this, Rob Salguero-Gómez and his international collaborators have developed a framework with practical guidelines for building global, integrated and reusable EBV data products of species traits. This framework will greatly aid in the monitoring of species trait changes in response to global change and human pressures, with the aim to use species trait information in national and international policy assessments.

Salguero-Gómez says: 'We have for the first time synthesised how species trait information can be collected (specimen collections, in-situ monitoring, and remote sensing), standardised (data and metadata standards), and integrated (machine-readable trait data, reproducible workflows, semantic tools and open access licenses).'

This latest review provides a perspective on how species traits can contribute to assessing progress towards biodiversity conservation and sustainable development goals. The researchers believe that big data is one of the keys to address the global and societal problems from security food, to preventing ecoservice loss, or effects of climate change. 

They say that the operationalization of this idea will require substantial financial and in-kind investments from universities, research infrastructures, governments, space agencies and other funding bodies. ‘Without the support of the Max Planck Institute for Demographic Research, NERC, Oxford, and the open-access mentality of hundreds of population ecologists, our work with COMPADRE & COMADRE would not have been possible,’ says Salguero-Gómez.

The integration of trait data to address global questions in ecology, evolution, and conservation biology is one of the main themes in Salguero-Gómez’ research group, the SalGo Lab.

This work was funded primarily by the Horizon 2020 project GLOBIS-B of the European Commission.

 Read the full paper in Nature Ecology & Evolution.

How did the ancient Middle East transform from a majority-Christian world to the majority-Muslim world we know today, and what role did violence play in this process? These questions lie at the heart of Christian Martyrs under Islam: Religious Violence and the Making of the Muslim World (Princeton University Press), a new book by associate professor of Islamic history Christian C. Sahner. In a guest post for Arts Blog, Professor Sahner, from Oxford's Faculty of Oriental Studies, explores his findings. 

Although Arab armies quickly established an Islamic empire during the seventh and eighth centuries, it took far longer for an Islamic society to emerge within its frontiers. Indeed, despite widespread images of “conversion by the sword” in popular culture, the process of Islamisation in the early period was slow, complex, and often non-violent. Forced conversion was fairly uncommon, and religious change was driven far more by factors such as intermarriage, economic self-interest, and political allegiance. Non-Muslims were generally entitled to continue practising their faiths, provided they abided by the laws of their rulers and paid special taxes. Muslim elites sometimes even discouraged conversion, for when non-Muslims embraced Islam, they no longer had to provide these taxes to the state, and thus the state’s fiscal base threatened to contract. Compounding this was a belief among some that Islam was a special dispensation only for the Arab people. Thus, when non-Arabs converted, they were sometimes treated as second-class citizens, despised as little better than Christians, Jews, or other “infidels”.

This combination of factors meant that the Middle East became predominantly Muslim far later than an older generation of scholars once assumed. Although we lack reliable demographic data from the pre-modern period with which we could make precise estimates (such as censuses or tax registers), historians surmise that Syria-Palestine crossed the threshold of a Muslim demographic majority in the 12th century, while Egypt may have passed this benchmark even later, possibly in the 14th. What we mean by the “Islamic world” thus takes on new meaning: Muslims were the undisputed rulers of the Middle East from the seventh century onward, but they presided over a mixed society in which they were often dramatically outnumbered by non-Muslims.

It is against this backdrop that the phenomenon of Christian martyrdom took place. We know about these martyrs thanks to a large but understudied corpus of hagiographical texts written in a variety of medieval languages, including Greek, Arabic, Latin, Syriac, Armenian, and Georgian. Set in places as varied as Córdoba, the Nile Delta, Jerusalem, and the South Caucasus, they tell the lives of Christians who ran afoul of the Muslim authorities, were executed, and were later revered as saints. The martyrs were participants in this broader culture of conversion, but as their deaths make clear, they were also dissenters from this culture, individuals who protested Islamisation and attempted to reverse the tide of religious change.

The first and largest group consisted of Christians who converted to Islam but reneged and returned to Christianity. Because apostasy came to be considered a capital offence under Islamic law, they faced execution if found guilty. The second group was made up of Muslim converts to Christianity who had no prior experience of their new religion. The third consisted of Christians who were executed for blasphemy; that is, publicly reviling the Prophet Muhammad, usually before a high-ranking Muslim official. The martyrs were small in number – not more than around 270 discrete individuals between Spain and Iraq – a testament to the relative absence of systematic persecution at the time.

As a collection of texts, the lives of the martyrs represent one of the richest bodies of evidence for understanding conversion in the early medieval Middle East. Yet these sources must be treated with great caution. Saints’ lives are a notoriously formulaic genre, filled with reports of miracles, literary motifs, and theological polemics which can make it difficult to know what “really happened”. Reading the sources alongside contemporary Islamic texts, the book argues that many biographies have a strong basis in reality. At the same time, they were shaped by the literary, social and spiritual priorities of their authors, who were determined to create models of resistance for their flocks, who were increasingly tempted by the faith and culture of the conquerors.

Christian Martyrs under Islam describes a lost world in which Muslims and Christians rubbed shoulders in the most intimate of settings, from workshops and markets to city blocks and even marital beds. Not surprisingly, these interactions gave rise to overlapping practices, including behaviours that blurred the line between the Islam and Christianity. To ensure that conversion and assimilation went exclusively in the direction of Islam, Muslim officials executed the most flagrant boundary-crossers, and Christians, in turn, revered some of these people as saints.