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Dedifferentiation describes a change that occurred in many developed countries during the 1990s: away from regarding people with intellectual disabilities as having particular needs resulting from ...

Children's naïve theories about causal regularities enable them to differentiate factual narratives describing real events and characters from fictional narratives describing made-up events and characters (Corriveau, Kim, Schwalen,Harris, Cognition 113 (2): 213-225, 2009). But what happens when children are consistently presented with accounts of miraculous and causally impossible events as real occurrences? Previous research has shown that preschoolers with consistent exposure to religious teaching tend to systematically judge characters involved in fantastical or religious events as real (Corriveau et al., Cognitive Science, 39 (2), 353-382, 2015; Davoodi et al., Developmental Psychology, 52 (2), 221, 2016). In the current study, we extended this line of work by asking about the scope of the impact of religious exposure on children's reality judgments. Specifically, we asked whether this effect is domain-general or domain-specific. We tested children in Iran, where regular exposure to uniform religious beliefs might influence children's reasoning about possibility in non-religious domains, in addition to the domain of religion. Children with no or minimal schooling (5- to 6-year-olds) and older elementary school students (9- to 10-year-olds) judged the reality status of different kinds of stories, notably realistic, unusual (but nonetheless realistic), religious, and magical stories. We found that while younger children were not systematic in their judgments, older children often judged religious stories as real but rarely judged magical stories as real. This developmental pattern suggests that the impact of religious exposure on children's reality judgments does not extend beyond their reasoning about divine intervention. Children's justifications for their reality judgments provided further support for this domain-specific influence of religious teaching.

Across diverse cultural contexts, children and adults believe in the existence of religious and supernatural unobservables (e.g., gods, angels) as well as scientific and natural unobservables (e.g., germs, oxygen). In this article, we explore the role of cultural input and testimony in children’s developing beliefs in supernatural and natural unobservables as real. We review cross-cultural research with children and adults on their beliefs about the ontological status of religious and scientific unobservables and the epistemic patterns associated with these beliefs. Based on the evidence, we argue that cultural input plays a central role in the development of belief about supernatural unobservables as real, whereas it plays a less critical role in the development of belief about natural unobservables as real. In the latter case, we argue that direct experiences with the natural world combine with children’s naive theories to generate beliefs about natural unobservable entities and processes as real.

PurposeThe purpose of this paper is to further understand the needs of carers when a relative with dementia is admitted to an organic impatient ward.Design/methodology/approachA constructivist grounded theory approach was employed to generate a substantive theory to understand the needs of carers and how staff perceive carer needs when a relative is admitted to a dementia ward. Five relatives and six members of staff were interviewed using purposive and theoretical sampling. Interview transcripts were analysed using initial, focused and theoretical coding using constant comparative methods to develop the end theory.FindingsThe grounded theory concluded that carers have three categories of needs: “The Safe and Cared for Relative”, “The Informed Carer and “The Understanding, Responsive and Available Service”. Underpinning the needs are the relationships between carers, their relative and staff. Three barriers were identified which can impact on these needs being effectively met. These identified barriers were: Loss, Time and Ineffective Communication.Originality/valueThe grounded theory demonstrates that carers needs fundamentally relate to their relatives being safe and cared for and being included and informed during the admission. Relationships can be ruptured when a barrier prevents the needs from being effectively met. Recommendations are made to aim to reduce the impact of the barriers and to aid staff in developing their understanding of the carer experience.

Intellectual disability scholarship tends to defend a fragile knowledge base by erecting barriers and refusing to look beyond them. This generates a sense of certainty that allows people in a diffi...

Neoliberalism is a transatlantic free market ideology based on individual liberty and limited government, developed by Hayek and von Mises. In its third wave (1980–2008), commitment to deregulation, privatization, and individual freedom moved beyond the economy into politics and culture. The citizen was recast as a consumer, and public servants became required to satisfy consumer choice. This addressed 1970s social turmoil and improved economies, but the increased wealth went to elites while resources declined for the poor. Hayek had argued for social welfare safety nets initially, but these were rejected by peers in the Mont Pelerin Society. Business-funded transatlantic think tanks promulgated the neoliberal tenets that markets are wiser than any government and state interference makes things worse. Yet, despite these rhetorical claims, neoliberalism has actually been imposed, driven, and underwritten by governments that claim their policy is nonintervention. Neoliberalism soon influenced the political economies of most countries in the developed world, but the degree of separation engendered between rich and poor is a political choice: most extreme in the United States, with the United Kingdom a close second. Establishing neoliberal values like autonomy and choice as taken for granted occurred by “hollowing out” organizations and communities in ways that block dissent and drastically narrow the scope for debate. Psychology is both an academic and applied discipline, with applied psychologists significantly outnumbering academics throughout the 20th century. Expansion was particularly marked during third-wave neoliberalism (1980–2008) in the United Kingdom, when the British Psychological Society grew more than fivefold to over 40,000 members. Two special editions of journals in 2018 and 2019 raised concerns about the relationship between psychology and neoliberalism. In sum, they argued that applied psychology’s self-presentation as a discipline that can solve the problems experienced by individuals glosses over the social origin of most human difficulties, and that modern psychology’s alienated and individualist epistemology makes it a potent neoliberal institution rather than a discipline that can generate alternatives.

Treanor's (2017) wide-ranging article seeks to stimulate conversation about how service systems could become indelibly marked with integrity. It covers much ground. Frequent reference to “flourishi...

The Care Quality Commission's annual report described their purpose: “We make sure health and social care services provide people with safe, effective, compassionate, high-quality care and we encou...

© 2017 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group. Dedifferentiation describes a shift away from regarding cognitive impairments as the origin of difficulties experienced by people with intellectual disabilities and, instead, regarding their difficulties as socially produced and common to all people with disabilities. This article reviews research evidence concerning the advantages and disadvantages of dedifferentiated policy and service systems for people with intellectual disabilities, the bulk of which addresses education and health service systems. Advantages of dedifferentiation include its avoidance of assumptions about homogeneity, and the stigma of being labelled intellectually disabled; and its support for strong collectives and advocacy that enable people with all types of disabilities to live in the presence of others. For young children, dedifferentiated school and mental health services have positive outcomes not found in similar services for older children and adults. Disadvantages of dedifferentiation include inaccurate or absent representations of unique needs arising from intellectual disability, failure to reduce marginalisation, poor-quality non-specialist mainstream secondary education and health services, and deteriorations in social care. Arguments that dichotomies such as dedifferentiation/differentiation encourage simplification and misconception are reviewed: instead, twenty-first-century thinking negotiates between diverse parties and perspectives. The article makes the case for treating people with intellectual disabilities as members of the broad disability group wherever possible, and for protecting and developing differentiated opportunities, services and research whenever necessary. This requires policymakers and practitioners to balance conflicting ideas more effectively, but it also requires reflection and debate that allow new conceptual tools to emerge. The article concludes by posing three questions intended to encourage reconceptualisation.

Article as accepted for publication in Philosophy, Psychiatry, and Psychology published by John Hopkins University Press

Successful critiques of health policies for people with impaired cognition identify a need for alternatives that go beyond individualism. ‘Choice’ policy was examined as young people with severe intellectual disabilities moved from special schools to adult services. We draw on three cases from a longitudinal cohort study to examine the way decisions with and for these young people were made and accounted for. It was not a simple matter of parents and transition workers hearing about these young people’s choices and facilitating what they wanted. The data raise questions about discourses of choice in ID when referring to people with severe intellectual disabilities: few ‘choices’ could be considered informed nor made by young people with capacity to make them and many decisions were informed by other ethics. Findings were interpreted through a Deleuzean ethical–relational lens. We identify implications for theory and practice to show how Deleuzean thinking can reinvigorate intellectual disability.

There is growing international concern that people with intellectual disabilities, many of whom have compromised health, are particularly vulnerable to infection by COVID-19. Yet marginalisation ec...

This article examines “imagined constructed thought”: speakers giving voice to the inner world of a non-present other. Drawing on 9 hours of video footage of health-care staff discussing patients with intellectual disabilities (ID) during Discovery Awareness sessions, we explored times when the staff presented a possible version of a patient’s thoughts. They used those versions to take a stance on the patient’s inner world, often as a bridge between description of objectively observable phenomena and subjective interpretation of its meaning. It also projected staff’s own stance on what the patient was thinking, both in first position descriptions and as a competitive resource in those given in second position. The findings suggest that presenting the patients’ thoughts from a first-person perspective can be a versatile way of enacting a variety of complex epistemic and empathic actions in this setting. Data are in British English.

Background. Psychomotor therapy enables people to reflect on the relationship between experiences and feelings by starting from awareness of bodily responses rather than from awareness of emotion. In this study we examine PsyMot (ID), an assessment that directs this psychological therapy. Method. Twelve suitable consecutive admissions were recruited from a specialist intellectual disability (ID) assessment and treatment unit for adults. Video-recordings of PsyMot (ID) allowed assessment of interrater reliability (IRR). Treatment goals indicated by PsyMot (ID) were addressed using psychomotor therapy as part of a comprehensive program of interventions. Results. Psychomotor therapy was both feasible and popular with patients who participated without any adverse effects. Nine patients completed PsyMot (ID). IRR of the treatment goals identified by all 3 raters was good to excellent in 81% cases, but there were discrepancies for individual items. Conclusions. PsyMot (ID) and psychomotor therapy is feasible within this context, and enriched the clinical team's formulation. Further studies of reliability and efficacy should be undertaken.

Legal protection of the rights of people with intellectual disabilities is absolutely necessary, and Douglas, Bigby, Knox, and Browning's (2015) identification of ways to develop their right to aut...

Introduction Patient-Reported Outcome Measurement Information System (PROMIS) instruments were developed using rigorous psychometric methods to assess health and quality of life across the life course. In two studies, we aimed to evaluate the clinical validity of PROMIS measures for children with inflammatory bowel disease (IBD) and to increase the interpretability of scores on these measures. Methods Study 1 recruitment and clinical data collection took place within 14 pediatric gastroenterology practices located across the United States. PROMIS Pediatric measures of Pain Interference, Fatigue, Psychological Stress Experiences, Global Health, and Life Satisfaction were completed by 1,049 children and youth (8–24 years old) with IBD and linked to an IBD registry that included disease activity measures. Study 2 utilized baseline data from a large, multi-center clinical trial to compare the effectiveness of anti-TNF monotherapy versus combination therapy with methotrexate. A total of 199 participants (8–20 years old) across 35 sites completed PROMIS Pediatric measures of Pain Interference, Fatigue, and Positive Affect. PROMIS measures were scored on a T-score metric (mean = 50; standard deviation = 10). Scores on symptom measures were classified as “severe” if they were at or above the 95th percentile, and scores on positive health measures were classified as “poor” if they were at or below the 5th percentile, relative to the United States general population of children ages 8–17. Results For nearly all domains across both studies, PROMIS scores were significantly associated with clinical measures of IBD severity. PROMIS measures indicated worse health and/or functioning with corresponding increases in disease activity (inactive to mild to moderate/severe). Comparisons between inactive and mild IBD groups resulted in medium or large effect sizes (Cohen’s d = 0.5 – 0.96) for Pain Interference, Fatigue, Psychological Stress, Global Health, and Life Satisfaction (Table 1). Proportions of children with IBD who were classified as “severe” or “poor” were higher than in the general population and increased with increasing levels of IBD severity (Table 2). Conclusions These studies support the clinical validity of PROMIS instruments for assessing the lived experiences of children with IBD. Effect sizes associated with differences between inactive and mild IBD translate to 5–10 points on the PROMIS T-scale, suggesting that 5–10 points is a clinically important difference between group average scores. To aid interpretation of an individual’s score, percentiles derived from the general population may be used to determine whether the score falls within the range of severe/poor scores for the measure.

This final issue for 2019 elaborates existing ideas, introduces a discipline that is relatively new to intellectual disability, and interrogates existing approaches and beliefs to check whether the...

Current revision of the two major psychiatric classification systems has elicited particular comment on neurodevelopmental disorders, which have seen increased provision of specialist clinical services, user group activity, fictional and biographical accounts, and research. Philosophical scrutiny of autism research and literature provides an additional perspective.Neurodevelopmental disorders show considerable overlap neuropsychologically, physiologically and genetically. They overlap diagnostically with schizophrenia, personality disorders, anxiety and depression. Of the two main diagnostic groups, there is more evidence of change with maturation in autism spectrum disorder than attention-deficit hyperactivity disorder. Interventions should combine cognitive, affective and embodied aspects of these disorders, and encompass the individual and their social environment. There is considerable evidence of the toll that caring for people with neurodevelopmental disorders exerts on parents.Neurodevelopmental disorders are multifaceted: research addressed to connection rather than further Balkanization is more likely to be fruitful. Clinicians should consider which facets are displayed symptomatically to enable people to grow through rather than surrender to their impairments. Social scaffolding optimizes functional well being. Future research should take into account the tensions in the relationship between research and user groups, and examine the experiences of adults and of the spouses and partners of those affected.

An ecological approach to understanding insecure attachments and social isolation among people with an intellectual disability is constructed using Gibson's (1979/1986) affordance-based theory. Although environmental affordances and individual limitations interact to limit the development of social competence, we believe that by focusing on the immediate environment, community-based approaches to helping people with an intellectual disability are often ignored, which increases the burden on individual caregivers. A more comprehensive strategy, which extends Gibson's theory of affordances, allows us to consider how higher level social systems influence the immediate environment and provides the context for understanding why successful change occurs when a multifaceted, holistic approach that works on several levels is adopted. Examining these systems within an ecological framework fundamentally redefines our thinking by shifting the focus from a person's disability to a more nuanced understanding of a pers...

Accessible summary • We asked eight members of staff who were working with people who had a learning disability, and also, complex mental health needs to tell us how they felt about their work. • These workers told us that not having enough staff and having a wide range of patients with different needs to look after made their job difficult. We felt they tried to put a ‘brave face’ on but we felt they worried greatly about working with patients who had complex mental health needs. • We did not feel these workers were given enough opportunity to think and talk about their feelings about their work. Staff tried to cope with these difficult thoughts and feelings about their work by trying to forget them or by thinking about other things. • Staff need to be given time to think and talk about their work and their feelings towards their patients. This may help them to feel less stressed and more able to cope with their patients and their work. Summary Experiences of eight staff working with people who have a learning disability and complex mental health needs were explored by interviews and analysed using the free association narrative interview approach (Hollway & Jefferson 2000). Participants reported that organisational factors such as not having enough permanent staff and having to manage a complex patient mix impacted upon their work. Participants’ unconscious communications were interpreted as evidence that they were experiencing projected anxiety from their patients. Participants did not appear to be given opportunities in work to reflect upon their emotions and often coped by repressing painful experiences or displacing these onto the organisation. Staff would benefit from exploring their conscious and unconscious reactions to their patients.

In contrast to other forms of family caregiving, becoming the parent or carer of a child with an intellectual disability (ID) implies an ongoing responsibility beyond the attainment of chronological adulthood ( Meyers et al., 1985 ; Todd and Shearn, 1996 ). At the same time, a discourse of self-determination pervades policy around transition to adult services in ID in England ( Valuing People, 2001) . In this paper we present a subset of data from a project which aimed to examine how the process of transition from child to adult services in ID is managed. Using data from 8 tape-recorded meetings in which transitions were planned and discussed, we examine what happens when the views of the parent/carer and the young adult are in apparent conflict. Drawing on the growing body of interactional work in the field (eg Rapley, 2004 ; Finlay, Antaki and Walton, 2008 ), we use conversation analysis to examine how professionals manage and negotiate this conflict and how some points of view or courses of action ultimately prevail over others. While the discourse of self-determination may prevail in English policy terms, we show how the fact that parents or carers ultimately have a key role in enabling the choices of the young person has a significant impact on these interactions.

Background This study examines how those planning futures for young people with moderate-profound intellectual disabilities invoke, deploy and interpret contrasting definitions of adulthood and perceived capacity for autonomy and self-determination. Methods Twenty-eight young people were followed through transition from children’s to adult services. This paper incorporates data from interviews with young people, their carers and transition staff. Results Two discourses around adulthood were identified. One positioned the young people as adults entitled unequivocally to self-determination, invoking policy injunctions to do so. The second qualified the young people’s adult status and claims to self-determination, emphasising the obdurate reality of intellectual disability. Conclusions Transition to adult services for young people with intellectual disabilities raises difficult questions about the relationship between vulnerable young people, families, professionals and society. Reducing these to rigid moral polarities of ‘right’ and ‘wrong’ creates an unhelpful context for good decision making. A more constructive approach would include all stakeholders in discerning ‘the right thing to do’.

For young people with intellectual disabilities (ID), the transition from children's to adult services has long been recognised as a challenging move. One of the aims of the White Paper Valuing People (2001) was to address some of the problems associated with this transition. This paper reports on data from a project which examines the impact of these service changes, and the ways in which transition is negotiated by carers, professionals and users. It presents a conversation analysis of eight tape-recorded formal review meetings at which transition to adult services is discussed. It takes as its starting point the existing interactional work on ID and the way in which this demonstrates the effects of the local and contextual specifics of particular kinds of interaction on the eventual outcomes (e.g. Rapley 2004, Antaki 2001, Maynard and Marlaire 1992). We show that an attempt to allow self-determination in the context of transitions can paradoxically result in undermining user choice and control. We also argue that, while a rule-based approach to practice may offer moral clarity for professionals, it can result in interactional and practical difficulties which cannot be easily reconciled.

This paper explores the experiences of people with borderline and low intelligence when compared to the general population. The aim was to explore whether people with low intelligence, who are rarely considered apart from the general population, might have particular needs in relation to health or social care. The method was secondary analysis of the ONS survey of psychiatric morbidity, 2000. Variables associated with low intelligence were identified and entered into a logistic regression. We found that a person with low intelligence was significantly more likely to be a smoker, have problems with paperwork and be renting their home, and a significant subgroup was more likely to be friendless. The pursuit of social justice and social inclusion may require greater attention to be paid to the health and well‐being of people with below‐average intelligence.

This paper draws upon parental accounts from a study of the process of transition for a cohort of 28 young people with relatively severe intellectual disabilities who left special schools in 2004 and 2005 in two adjacent English localities. This paper examines how parents negotiate these boundaries and position themselves in relation to risk. A primary concern identified by parents during this transition period focuses on the risk of harm facing these vulnerable young people (whether through accidents or through sexual, emotional, physical or financial abuse) as they move into the adult world. These concerns are juxtaposed with discourses that increasingly promote the possibilities for people with intellectual disabilities to express and follow their own wishes and aspirations. For example, the policy agenda in England and Wales actively endorses the start of adult life as a time of opportunity for young people and promotes the values of independence and choice. In accounting for the management of risk in the young people's lives, we conclude that parents navigate complex boundaries between being seen to be over-protective and ‘letting go’; between trusting others to act in the young adults' best interests and allowing these young people the autonomy to negotiate risk. Copyright © 2008 John Wiley & Sons, Ltd.

Background Recently, the frequency of audit inspections of health services for people with intellectual disability (ID) in the UK has increased, from occasional inquiries to a systematic audit of all services. From 2008, a process of continuous audit ‘surveillance’ of specialist health services is to be introduced. Similar regimes of inspection are in place for social care services. Aim To explore the conceptual positions which inform audit, through detailed examination of the investigation into the learning disability service at Sutton and Merton. Findings Audit is distinct from evaluation because it neither provides opportunities for service staff to give an account of their work nor represents a search for knowledge. Audit investigates adherence to government policy. In ID, audits measure aspirations derived from normalisation, despite research showing that some of these aspirations have not been achieved by any service. As audit consumes significant public resource, it is questionable whether the dominant finding of the Healthcare Commission's investigation into Sutton and Merton, that the ID service was chronically under-funded, represents value for money. Discussion and conclusions While basic checks on minimum standards will always be necessary, service excellence requires not audit but research-driven evaluation. Audits inhibit rather than open-up debate about improving support to people with ID. They impose an ideology, squander resource, and demoralise carers and staff. Evaluations challenge the implicit management-versus-professional binary enacted by audit, and can inform new care systems which make effective use of all those engaged with people with ID.

Background Theoretical literature in the intellectual disability (ID) field identified a mismatch between professional codes of practice (which assume clients to be ‘autonomous’) and the reality of fostering autonomy for people with ID (who at times are completely dependent on others). This research aimed to understand how professionals bridged this disjunction and actually provided ethical services with this client group. Method Nine professionals from adult ID services who had consulted with local Ethical Advisory Groups were interviewed about their experience of addressing an ethical issue within their work. Accounts were subjected to narrative analysis. Results Professionals' narratives featured the following themes: differing sources of conflict, professional vulnerability and seeking validation around resolution, centrality of relationships, fragility of resolutions and maintaining moral integrity. Conclusions Findings revealed systemic pressure on professionals to find ‘definitive’ solutions to ethical dilemmas when the issues were not open to such resolution. Findings were reviewed in light of ethical literature that shows how professionals' work inevitably features close and enduring relationships with people with ID. We suggest professionals need to draw on ethical frameworks that can accommodate relational aspects of their practice.

BackgroundPrevious research investigating post-traumatic stress disorder assumed that adults with intellectual disabilities would react to trauma in the same way as those in the non-disabled population. This study explored the personal experience of trauma in a small group of adults with intellectua

Background Research using the concept of Post-Traumatic Stress Disorder (PTSD) with adults with intellectual disability (ID)assumes they perceive and react to traumatic events in a similar way to non-disabled adults. Reactions to trauma displayed by children may be relevant to adults with ID as well. Methods Two focus groups were held with professionals and practitioners to explore the relevance of criteria from child as well as adult literature to adults with ID who experience trauma. Descriptive thematic analysis was carried out. Results Abuse, parental bereavement, and having children removed were considered common sources of trauma. Similarities identified between disabled and non-disabled adults were flashbacks and nightmares; distressed by reminders; avoidance; hypervigilance and increased arousal. Differences were the frequent occurrence of multiple rather than single events, which were considered significant in generating chronic problems similar to those described as PTSD; also the occurrence of physical health problems and behavioural re-enactments. Discussion and conclusions Experienced professionals and practitioners considered most of the ideas from PTSD research with non-disabled adults to be relevant to adults with ID who experience trauma, but that some behaviour reported in research with children was also relevant. Topics and questions for use in clinical and research practice with individuals who have experienced trauma were proposed.

Summary This article argues that the interpretative and negotiating approach of hermeneutic ethics can inform research into the experiences of people with learning disability more usefully than bioethics. Terms and ideas are defined; philosophers and researchers who have employed them are described; arguments for and against the proposition are considered; it concludes by summarizing the position and its implications. Two final reflections pose questions researchers may find it fruitful to consider, or to discuss with users, carers and professionals.

Mourning exists at the nexus between individual experience, professional discourses, research, and culture, making it a complex issue for health services that has shown vibrant change in recent years. By contrast, bereavement discourse in intellectual disability is suffused by dogmatic assertions about correct intervention: we describe four vignettes to illustrate bereavement issues in intellectual disability. Suggestions concerning issues and management are made, but the article focuses primarily on the conceptual issues that underpin clinical intervention. The analysis shows how challenges to the meaning of the disabled life, and to the understandings carers and staff draw on, tend to be resisted. We hypothesize this is most likely to surround issues that evoke cultural uncertainty, such as bereavement. The thesis is that the field of intellectual disability tends to be isolationist because meaning is difficult to create and easily dissolved, especially when addressing culturally contested topics. Dialogue with other disciplines is necessary to stop the field from atrophying, but needs to be carried out in ways that enable carers and clinicians to continue providing the support that people with intellectual disability require.

Summary A small group of experienced community workers providing risk management for men with learning disabilities who sexually offend was studied. Attribution statements participants made about their risk appraisals were analysed using the Leeds Attributional Coding System (LACS). Results highlight the effort participants made to obtain sufficient information. They focused on factors external to the service-user for most effective risk management, but their confidence was undermined by other staff minimizing the importance of such risks. Services that fail to develop specialist risk assessment skills and to address the modest ‘economics of effort’ required for effective practice may compromise risk management by community staff.

Background The present authors investigated a database about people with severe intellectual disability (ID) to explore whether secure/insecure attachment plays a role in challenging behaviour. Methods The study took the form of a survey of staff and carers involved with a cohort of 54 school-leavers with severe ID. Results Thirty-four per cent of students were rated by placement staff as ‘over-investing in one or a few relationships which become a source of jealousy’. Students without such problems were significantly less likely to show challenging behaviours, while those with them were significantly more likely to be living outside the family home. Conclusions These preliminary results justify more detailed and longitudinal research into the relationship between attachment status and challenging behaviour.

This commentary outlines research in the UK, briefly counterpointed against approaches used in the USA and Italy, to show how the Dutch position is distinct. Potential hurdles to translating Dutch ideas to the UK include the discomfort many staff express when invited to consider how they relate to clients and an increasingly legalistic culture which encourages people to want more certainty than an ethics committee can properly deliver. It concludes by identifying two issues that practice ethics committees might also consider: preventative work at a societal level, and going beyond residential situations to consider the complex ethical issues encountered in service relationships with people who live at home with their families.