Abstract
The quality of human existence is becoming an increasingly visible and vocal political and social concern. Yet, many of the approaches to this problem do not include a discussion of how the judgment of quality itself is made. This book addresses this issue describing an approach that relies on examining the language used and the cognitive processes involved in a qualitative judgment and assessment. This chapter provides the background to this effort, and describes issues in the assessment of quality-of-life or health-related quality-of-life that once clarified will lead to a model of how a qualitative judgment occurs.
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Notes
- 1.
The terms, quality, quality-of-life and HRQOL will be distinguished throughout this book. The term “quality,” or the phrase “qualitative assessment,” will be the most general form of expression, referring to all types of qualitative assessments. As stated in the Preface, I will use the term “qualitative” to refer to those instances involving the judgment of quality, and not limit it to a set of qualitative, as opposed to psychometric, methods. There are phrases, such as “qualitative research” which refer to a particular research orientation, but my use of the term “qualitative” refers to a class of judgments and not these methods. Of course, qualitative judgments can be studied using both qualitative and psychometric research approaches.
The phrase “quality-of-life” will be differentiated from the phrase “HRQOL” in that one refers to the general population, while the other refers to persons who are medically or psychiatrically ill.
- 2.
The distinction being made here, whether quality-of-life is a reflection of a person’s current state or a basis for future action or decisions, is an important one that is often overlooked by investigators. If a quality or quality-of-life assessment is a reflection of a person’s past or current state, then it need not lead to action or a decision, but action or a decision will usually imply a projection of a person’s future quality-of-life. This, I suggest, is an important difference between a standard quality-of-life assessment and a utilities-based assessment of quality-of-life (see Torrance et al. 1995) that may encompass the past and current state but also project to the future.
- 3.
The SF-36 is a shorter version (36 items) of a questionnaire originally developed at the Rand Corporation, by John Ware and his colleagues as part of the Medical Outcome Study.
- 4.
Clearly, there are medical, political and religious conditions under which a person will have limited or no opportunity to decide what is best for themselves. However, in many of these instances a person will be able to participate in these decisions if given the opportunity. This issue has been previously discussed in a medical care context (Barofsky 2003).
- 5.
Implicit in this statement is the belief that no man is wise enough to capture all of the thoughts, wishes and values of all people and that only empirical observation will provide the reassurance that the relevant data have been approximated by an appropriate measure of quality-of-life or HRQOL. I will address this issue again when I speak about Hayek’s contribution to the assessment of quality (Chap. 3).
- 6.
Wittgenstein provides some examples of a language game; for example, giving orders and obeying them, describing an object and giving its assessment, speculating about an event, presenting the results of an experiment in tables, making up a story and reading it, guessing riddles, asking, thanking, cursing, greeting and praying are all examples of language games (Wittgenstein 1953; p. 11–12).
- 7.
Daston and Galison (2007; p. 168) point out that the idea of “family resemblance” came from the early work of Galton who traced the images of members of a family and then generated a composite representation of the entire family. Galton labeled this composite a “family resemblance,” which it literally was. Wittgenstein also attended the Vienna group of logical positivists where he was exposed to current psychological research on psychophysics.
- 8.
It is useful to review the relationship between Hume and Wittgenstein, since both contend that “some truths or realities are created by our linguistic practices” (Bloor 1996; p. 356). The extent to which this notion can be extended to a quality assessment, which is based on a “linguistic practice,” is something I will be concerned about throughout this book.
- 9.
It is also possible that a culture exists where a person may not have any experience with attaching numbers to feelings or other types of states. This would only be relevant if it could also be demonstrated that the members of this culture could not learn to do this task. If this were so, then these people would join the large group of challenged persons who remain an unresolved task for quality-of-life assessment.
- 10.
This discussion will focus mostly on the single global self-assessed items, including the SAHS or self-assessed quality-of-life items. I do this because the global items come closest to approximating the experiential and cognitive origins of a qualitative assessment. Understanding how an impression of quality emerges will be a key element in the approach to be discussed. I have already hinted at how this might occur as the non-linear emergence of a complex cognitive entity.
- 11.
The SAHS item is sometimes referred to as a quality-of-life self-report, but this would be a clear example of using the phrase “quality-of-life” as a label, since the item is a descriptive statement which lacks the valuation component needed for a complete qualitative indicator. I will review the literature that deals with the SAHS item, since it is particularly complete, but the item itself is most accurately considered a health status indicator.
- 12.
In Chap. 8, I make clear how a health status and HRQOL item differ. The information summarized in this chapter is actually more about the value of a single global health status item, but is not informative about whether a single global quality-of-life item is a good predictor of mortality.
- 13.
Sometimes multi-item assessments include global self-report items along with domain-specific items. In this case, it may be possible to disaggregate the multi-item assessment and study the single global self-report item separately.
- 14.
Accessed at the Wikipedia website (http://en.wikipedia.org/wiki/Qualia; last modified 5/4/2006; accessed 5/31/2006).
- 15.
Accessed at the Stanford Encyclopedia of Philosophy website (http://plato.stanford.edu/entries/qualia/; accessed 5/31/2006).
- 16.
A linear model would state that what I experience when I report seeing something involves having me receive a visual input followed by the activation of the visual cortex leading to some visual experience. A non-linear model could involve the reprocessing of the visual input in such a way that what I experience is not necessarily predicted by the physical characteristics of the stimulus (e.g., Miichotte 1968), but involve other cognitive processes.
- 17.
A Turning Machine provides a set of instructions (e.g., an algorithm) presented in symbolic form that relates the input and output of some system. Thus, a Turing Machine output is computation.
- 18.
Clearly there are cognitive processes that I may not be aware of, such as appraisal, which may influence what I am aware of, but in this context I am not dealing with all the factors that might determine what I am aware of, only those qualities that I have already attached to the experience.
- 19.
- 20.
In Chap. 6, I introduce the notion that people process information in two basic ways: automatically or after due consideration. Dual processing of this sort may yet account for the difference between aesthetic and functional quality. For this to be confirmed will require clarification of the relation of emotions and cognition to determine which comes first, who influences whom and so on. These issues will be discussed in Chap. 11.
- 21.
An example of a preventative practice that is not widespread and would have a qualitative consequence, is assessing quality-of-life during a Phase I clinical trial.
- 22.
Physicians engage in many activities that are designed to ensure quality control. Medical case conferences, in which specific cases are discussed, would be one example of a quality control effort. Another example is the procedure a department of surgery established to prevent “wrong site, wrong procedure and wrong patient outcomes” (Michaels et al. 2007). Quality control activities, however, does not ensure that the patient has an optimal qualitative outcome. Thus, when I discuss quality control there are multiple levels of application.
- 23.
As is often the case, some other author previously stated the same basic idea. Robert Pirsig in his book “Lila” (1991) ends it by stating the following:
Good is a noun. That was it. That was what Phaedrus had been looking for. That was the homer, over the fence, that ended the ball game. Good is a noun rather than an adjective is all that the Metaphysics of Quality is about. Of course, the ultimate Quality isn’t a noun or adjective or anything else definable, but if you had to reduce the whole Metaphysics of Quality to a single sentence, that would be it (p. 409).
Each individual, community, or nation doing good – making quality a primary objective of their activities – is what is required for ethical outcomes.
- 24.
Paul Kind (October 2005, personal communication) has indicated that Rachel Rosser’s husband was an operations researcher and he felt that his background influenced the model that was developed.
- 25.
Matching the expectations of a buyer is not a simple process, since a person’s expectation may not be in concordance with the manufacturer’s estimate of the cost of the product. There is obviously an entire topic of interest here, the ethics of material exchange.
- 26.
I use the word “entity” to refer to the subjective experience I am assessing, since the quale has become infused with the mind–body debate and I want to avoid implying that what will be presented supports a dualistic perspective. In fact, in Chap. 10 I provide several examples of how mind–body or capacity–performance dichotomies can be presented in non-dualistic terms.
Abbreviations
- EQ-5D:
-
EuroQual-5 Dimensions (Brooks et al. 2003)
- HRQOL:
-
Health-related quality-of-life
- SAHS:
-
Self assessed health status
- TMS:
-
Transcranial magnet stimulation
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Barofsky, I. (2012). The Difficulty of Assessing Quality or Quality-of-Life. In: Quality. Springer, New York, NY. https://doi.org/10.1007/978-1-4419-9819-4_1
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