Philosophy and ideology

Kindness is both a virtue and a principle. Whichever definition is preferred, the term is no more than a placeholder in ethical discourse, unless qualified by reference to the agents and circumstances expressing it. ^{Reference Beauchamp and Childress13,Reference Hursthouse, Pettigrove, Zalta and Nodelman14} The situational flexibility implicit definitions allow ^{Reference Sokol8} inevitably create uncertainty. The LCP and intelligent kindness ^{Reference Campling9} (pp. 87–97) possess similar delivery structures, so both can be regarded as examples of ‘boundary objects’, ^{Reference Star and Griesemer15} which can translate knowledge between different domains, but with the price of enabling different, and possibly incompatible definitions across them. So, far from being scale-free, organisational principles may be radically redefined by scaling, and policies live or die by their ideology, not effectiveness. ^{Reference DeLeon16} At the local level, the LCP progressively lost its pathway facilitators, who had the key role of ensuring palliative care capability (thus including its ideology and ethical framework) was disseminated among staff using the LCP. At the national level, the LCP’s status as a boundary object eventually made it a lightning rod for competing ideologies around end-of life care, such as the ‘pro-life’ movement and even, in the USA, those opposing the Affordable Care Act. Intelligent kindness applies a psychopathological (‘perversion’) approach to attempts to disrupt its policies and procedures, so failures in kindness may be framed as expressions of mental distress ^{Reference Ballatt, Campling and Maloney2} , which leaves no space to consider the impact of opposing but equally moral principles, and thus undermines the dialectic proposed by Beauchamp and Childress ^{Reference Beauchamp and Childress13} as a solution to resolving such incompatibilities.

Society and institutions

It is commonly believed that the LCP failed because it failed to engage or consult families, but these were core components of the model, ^{Reference Jack, Gambles, Murphy and Ellershaw17} and lack of consultation was not an issue while it was deployed in hospice care. Multiple streams theory is helpful in situating policies in society. It argues that problems, the policies designed to address them and the politics that enable the policies form multiple streams, each requiring its own level of analysis. ^{Reference Winkel and Leipold18} In this model, policy entrepreneurs who seek to take advantage of favourable political circumstances (‘policy windows’, defined as structures of opportunity) to promote their own favoured policies, are key policy enablers. Both the rise and fall of the LCP can be attributed to different groups of these. The first policy entrepreneurs were in the health service and academia, and their authority enabled them to persuade the UK Government that the LCP solved a problem around end-of-life care. However, their influence in the non-academic press was limited by countervailing press opinion and personal testimony, reflecting the expansion and transformation of meaning of the LCP from a focused programme to a metaphor for all end-of-life care. As discussed above, the needs of the LCP also required policy entrepreneurs at the local level to ensure that its specific policies were not crowded out by others, but the need for these was not understood until too late. As its weaknesses became publicised, other policy entrepreneurs saw opportunities to promote their own incompatible structures of opportunity, leading to LCP’s UK demise. When belated randomised controlled trials were conducted, little difference was found between the LCP and other end-of-life policies, supporting both the importance of implementation (and thus the low-level pathway facilitators as policy entrepreneurs) and DeLeon’s foregrounding of ideology, not evidence, as the political driver of policy. ^{Reference DeLeon16}

Behind the description above lies the fundamentally self-serving nature of public or private organisations. The moral basis of this can be situated in virtue ethics. ^{Reference Fernando and Moore19} Individuals express virtue (including kindness) through practices and give rise to goods through striving for excellence in them. However, to survive, these practices need to be hosted, giving rise to a practice–institution admixture. Thus, although the institutions contain a moral project, a tension arises between internal goods (the excellence of the practices) and external goods (the success of the institution). The latter, although theoretically only justified in the context of promoting the intended practices, also inevitably engage other policies and politics, but cannot simply be disregarded if incompatible. Thus, organisations cannot serve those they intend without first serving themselves. Alone, practitioner altruism cannot overcome this. ^{Reference Niskanen20} They will, inevitably, know less about the needs of those they wish to serve than the necessary requirements of their own roles. There will thus be less random error in judgements made about the organisation than judgements made about individual clients, and thus self-serving decisions, marginalised across the whole organisation, will dominate. Although there are external limiters to this, especially publication of reliable information to legislatures, ^{Reference Makris21} the LCP was unable to provide reliable and differentiated information outside specific academic sites, and so was vulnerable to dismantling in the interests of competing organisational goals, e.g. by the loss of its internal policy advocates (entrepreneurs).

It seems unlikely that intelligent kindness could survive as a management model without being embedded in a supportive policy and administration framework, for which kindness, however intelligently provided, seems insufficient.

Psychology and anthropology

As observed above, kinship is a much broader concept than family, and Dunbar ^{Reference Dunbar22} has argued that our processing of this is limited by our cognitive capacity, leading to segmentation into nested groups who are engaged differently; an example of satisficing, where our ability to process limits what we can achieve. ^{Reference Tamarit, Cuesta, Dunbar and Sánchez23} Although its biological basis has been challenged, ^{Reference Lindenfors, Wartel and Lind24} human communications do pattern themselves approximately according to Dunbar’s predictions; in particular, his most intimate circle maximum of 5 and his outer circle maximum of 150. ^{Reference Mac Carron, Kaski and Dunbar25} It seems plausible that this accounted for some of the gap between the academic studies and family accounts of the LCP in practice, that did so much to discredit it. What it meant to care and be kind differed between family and staff, and Dunbar’s number predicts that family-type caring can easily break down with increasing cognitive load, as might come with reduced resources and enlarged caseload. The idea of family is not infinitely extensible, even when translated to ‘kin’.

Although our decisions might seem determined in retrospect, prospectively, we must make them under conditions of uncertainty. The LCP is a good example, as only 50% of hospital deaths are correctly predicted, which led to considerable uncertainty in when it should be applied. Kindness should be universally applied, but discerning what is kind in any situation can be difficult, as people may not express themselves clearly and may interpret the same message differently. Decision-making research suggests that two key dimensions are the time available to make a decision (a proxy for cognitive processing) and prior biases, with the biases being reinforced by time pressure. ^{Reference Teoh, Yao, Cunningham and Hutcherson26} So, although kindness might be inculcated as a social good, appropriate cognitive and economic resources will be needed to ensure its effective application, and intrapsychic dynamic processes will not entirely account for its failure.