Sunday 26 February 2017

Meaning, Multiple Description and Organisational Risk in Healthcare

There's a fascinating passage in Von Foerster's paper on "Perception of the future and the future of perception" where he speculates (with the help of Herbert Brün):
"Wouldn’t it be fascinating to contemplate an educational system that would ask of its students to answer “legitimate questions” that is questions to which the answers are unknown (H. Brün in a personal communication). Would it not be even more fascinating to conceive of a society that would establish such an educational system? The necessary condition for such an utopia is that its members perceive one another as autonomous, non-trivial beings. Such a society shall make, I predict, some of the most astounding discoveries. Just for the record, I shall list the following three:
  1. “Education is neither a right nor a privilege: it is a necessity.” 
  1. “Education is learning to ask legitimate questions.” 

A society who has made these two discoveries will ultimately be able to discover the third and most utopian one:
  1. “A is better off when B is better off.” (Von Foerster, Understanding Understanding, p209)
There are occasions in education where "legitimate questions" are asked. When they are asked, the responses are always meaningful. That this should be the case is partly a function of what a "legitimate question" is: by being a question about which the answers are unknown, it is also - by definition - an invitation to the production of many possible descriptions. The meaningfulness lies in the synergising of these many possible descriptions into some kind of formulation which satisfies the questioner that the complexity of the issue has been captured. It is, however, difficult to analyse what all the possible descriptions are: we tend not to have them available to us, and so our ability to analyse the meaningfulness of the answers to legitimate questions is hampered.

One domain of inquiry which is more specific in its identification of the multiplicity of description is in the realm of Organisational Risk in healthcare.

In the wake of a serious incident in a hospital, there is a process of making descriptions about the different dimensions of causal factors which might have led to the incident. So descriptions are made about the actors involved - doctors, patients, nurses, etc. Then there are descriptions about the protocols they should follow, the routine on the wards, the labelling of drugs, the medical experience of each individual, the assumptions of knowledge of each actor, power relations, and so on. From these multiple descriptions, a judgement is made about the causes of the accident and recommendations are eventually made which aim to prevent the accident happening again.

Recommendations are often ineffective - which raises a question as to how it is the judgements about the causes are seen to be satisfactory and plausible to the investigating team. The processes whereby the judgement about the incident becomes meaningful cannot relate to the causal relations between the different factors partly because there are many descriptions of each of those different factors. The meaningfulness must arise from the diversity of possible descriptions: the judgement must have generative power in being able to produce the multiplicity of descriptions which are made about the incident. Meaning arises at a boundary between synergies of multiple descriptions of events, and the multiple descriptions of that synergy. Meaning is a function of constraint.

Because meaning is a function of constraint, and because the constraints which produce an incident are different from the constraints which produce a judgement about the causes of that incident, particular care must be taken in understanding the dynamics of constraint. To understand these dynamics, it is important that "legitimate questions" are asked. The asking of a legitimate question like "Why did x do this?" is an invitation to generate multiple descriptions which contribute to the generation of a constraint. The problem with incident investigation processes is that they seek to reduce the number of descriptions when they should increase them.

The same problem applies to education. Educational processes seek to attenuate descriptions of the world to those which appear in a textbook. But questions which appear in a textbook are not legitimate questions. The asking of questions which aren't in the textbook are legitimate questions.

How do we get from that to "A is better off when B is better off"? The reason is, I think, that B is A's means of opening up new legitimate questions, and that the more legitimate questions which are raised, and the more descriptions which are generated, the better the judgements which will be formed.

Von Foerster tells this story about the interaction between a Great Inquisitor and a Holy man performing miracles:
Maybe you remember the story Ivan Karamazov makes up in order to intellectually needle his younger brother Alyosha. The story is that of the Great Inquisitor. As you recall, the Great Inquisitor walks on a very pleasant afternoon through his town, I believe it is Salamanca; he is in good spirits. In the morning he has burned at the stakes about a hundred and twenty heretics, he has done a good job, everything is fine. Suddenly there is a crowd of people in front of him, he moves closer to see what’s going on, and he sees a stranger who is putting his hand onto a lame person, and that lame one can walk. Then a blind girl is brought before him, the stranger is putting his hand on her eyes, and she can see. The Great Inquisitor knows immediately who He is, and he says to his henchmen: “Arrest this man.” They jump and arrest this man and put Him into jail. In the night the Great Inquisitor visits the stranger in his cell and he says: “Look, I know who You are, troublemaker. It took us one thousand and five hundred years to straighten out the troubles you have sown. You know very well that people can’t make decisions by themselves. You know very well people can’t be free. We have to make their decisions. We tell them who they are to be. You know that very well. Therefore, I shall burn You at the stakes tomorrow.”The stranger stands up, embraces the Great Inquisitor and kisses him. The Great Inquisitor walks out, but, as he leaves the cell, he does not close the door, and the stranger disappears in the darkness of the night.

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