Patients with chronic pain who are tapering prescription opioids report a need for greater support for coping with symptoms of pain and withdrawal. Mobile health  technologies (SMS text messaging– or app-based) have the potential to provide patients with educational, emotional, and motivational support for opioid tapering beyond what is offered by their health care provider. However, it is not known whether patients with chronic pain who are tapering opioids would be willing or able to engage with technology-based support.This study aims to examine patients’ use of mobile technologies in health care, interest in using mHealth support, preferences for the form and content of mHealth support, and potential barriers to and facilitators of engagement with mHealth support for opioid tapering.A total of 21 patients  with chronic noncancer pain on long-term opioid therapy who had recently initiated a voluntary opioid taper were recruited from primary and tertiary care clinics in metropolitan and regional Australia for a larger study of patients’ experiences of opioid tapering. Participants had been taking prescription opioids for a mean duration of 13  years at the time of the study. Survey items characterized participants’ typical mobile phone use and level of interest in mobile technology–based support for opioid tapering. Semistructured interviews further explored patients’ use of mobile technologies and their interest in, preferences for, and perspectives on potential barriers to and facilitators of engagement with mHealth support for opioid tapering. Two researchers collaborated to conduct a thematic analysis of the interview data.dosing, responsivity, and familiarity with pain self-management strategies would increase user engagement.All participants reported owning and using a mobile phone, and most  participants reported using mobile apps. The majority of participants expressed interest in SMS text messaging–based  and app-based  support for opioid tapering. Participants expected that messages delivering both informational and socioemotional support would be helpful. Participants expected that access to technology, mobile reception, internet connectivity, vision impairment, and low self-efficacy for using apps may be barriers to user engagement. Patients expected that continuity of care from their health care provider, flexible message The results of this study indicate that patients with chronic noncancer pain may be willing to engage with SMS text messaging–based and app-based mHealth interventions to support opioid tapering. However, the feasibility and acceptability of these interventions may depend on how patients’ preferences for functionality, content, and design are addressed. Chronic pain is one of the leading causes of disability worldwide, affecting approximately 1 in 5 adults . Historiflare-up of their pain condition  can [come] at two in the morning and you need a response...It can be an automated thing.P01, male, 60 years, pain clinic, regional areaOne participant reported that an mHealth intervention would be beneficial as she had “nobody checking in to see how I am” over the Christmas period:I think the mobile system would be good for that because it feels like you have some way of reaching someone or some way of someone reaching you to check in.P08, female, 32 years, pain clinic, metropolitan areaAlthough participants were, in general, interested in using SMS text messaging–based or app-based support for opioid tapering, they also expressed a strong preference for clinician-delivered support either face-to-face or over the phone:I like being able to I guess just talk...I tend to kind of ignore my texts sometimes if I’m busy.P12, male, 46 years, pain clinic, metropolitan areaNo I think it’s better to talk to somebody...No, I’d sooner talk over the phone.P11, female, 83 years, primary care, regional areaI think the phone call thing is better than any social media, better than anything you just type in or anything because it’s human.P04, male, 57 years, pain clinic, metropolitan areaThere were concerns about how this would be interpreted if it was clear that the support was computer delivered:If it’s just a text message, I’m not dumb, I know it’s just a computer sending it. If it gets sent out the same time every day, it’s a computer sending it.P06, female, 59 years, pain clinic, metropolitan areaParticipants reported some skepticism that automated messages would feel genuine:If I think I’m getting just some random “great you’re doing well” and I know it’s been automatically generated, I probably wouldn’t be that tickled by it.P02, female, 61 years, pain clinic, metropolitan areaParticipants who did not express an interest in an mHealth intervention to support opioid tapering reasoned either that they had a strong desire for face-to-face support  or a preference for alternative sources of information and support:I would probably prefer just reading information or just talking to someone before using an app. If there was a web page, I’d probably be likely to use the web page more.P02, female, 61 years, pain clinic, regional areaHowever, one participant reported a preference for SMS text messaging rather than a phone call or face-to-face check in:The text messaging I think would be really good because the thing that probably scares me most is to speak to someone about it.P08, female, 32 years, pain clinic, metropolitan areaIn line with the preference for face-to-face and nonautomated services outlined earlier, several participants recommended that an option for personal follow-up be built into the service:I think the mobile system would be good for that because it feels like you have some way of reaching someone or some way of someone reaching you to check in.P08, female, 32 years, pain clinic, metropolitan areaMost participants did not express a strong preference for either SMS text messaging–based or app-based support. Participants who expressed a preference for SMS text messaging–based support indicated a higher level of familiarity with text messaging:I can use [SMS] easier...because I don’t use my phone much for that sort of thing [apps].P09, male, 61 years, primary care, regional areaParticipants who expressed a preference for app-based support reasoned that apps may provide access to more content:I’m guessing inside that app there would be probably more information than in the texts.P18, male, 41 years, pain clinic, regional areaOne participant stated that, although they were willing to read texts, they did not like to respond to them:I just hate texting.P16, female, 46 years, pain clinic, metropolitan areaParticipants provided recommendations for content that they believed would be helpful in an mHealth intervention. Specifically, they expressed interest in receiving information about pain management during flare-ups and about withdrawal from opioid medications  and messages of encouragement, motivation, and validation .Several participants expressed a desire for information related to pain self-management strategies:I think it would be really useful to have maybe different things on there like techniques to help. “If you’ve got really bad pain, why don’t you try this?”P08, female, 32 years, pain clinic, metropolitan areaI think it would be nice to have like an app or texting or whatever that did embody like the mindfulness and the meditation and the feedback, so it’s all in one place.P20, female, 63 years, pain clinic, metropolitan areaIt’s about thought and relaxation...thought management.P03, female, 29 years, pain clinic, regional areaOne participant recommended tailoring the information to reflect the user’s stage of tapering to reassure them that what they were experiencing was normal:Maybe “You’re on week 4 of your taper and you’re on this dose. Be mindful that you may experience this, this, and this.” So, give them a bit of warning. And “good ways to deal with those things are...” Then people know that they’re normal. Once people go “oh okay this is normal,” you take the fear out of it.P08, female, 32 years, pain clinic, metropolitan areaAnother participant agreed that knowing what to expect, particularly with regard to withdrawal symptoms, would be empowering:I didn’t know what to expect. I thought it might just get worse and worse and worse for weeks. If I just had a time frame and it might be different...If I had been warned that you could get constipation and you’ll need to take precautions.P02, female, 61 years, pain clinic, regional areaA number of participants commented more generally on the importance of social support when tapering, either from friends and family, a group within a treatment program, or clinicians. One participant recommended integrating electronic social support for patients who were tapering their opioid medication:If you can push for a forum or something, I think that would be awesome.P16, female, 46 years, pain clinic, metropolitan areaParticipants’ views regarding the acceptability of mHealth interventions for opioid tapering were influenced by factors such as the frequency of the messages and pattern of delivery. One participant preferred receiving messages at night , whereas another was concerned about receiving too frequent or too repetitive messages. Their suggestion to counter this was for the digital service to be responsive to the needs of the user:So maybe there is a text that’s in response to a word we send out. Like we need some affirmation...It could be geared to that more.P01, male, 60 years, pain clinic, regional areaSeveral participants described perceived barriers toward phone-based digital interventions including limited phone reception or access to internet:I don’t have Wi-Fi. I can’t afford it.P06, female, 59 years, pain clinic, metropolitan areaI don’t think my old phone will support it.P14, male, 56 years, primary care, regional areaSome participants spoke about vision impairment:I use glasses and my phone is a very cheap phone. If it’s in the middle of the day I can’t read them.P14, male, 56 years, primary care, regional areaFor the older ones they can’t see stuff on their phone properly.P16, female, 46 years, pain clinic, metropolitan areaSome participants reported that low confidence in using mobile devices and apps may be an obstacle to engagement with app-based interventions:No, I wouldn’t know how [to use apps]...I’m not tech savvy.P09, Male, 61 years, primary care, regional areaRelatedly, some participants suggested that ease of use and simplicity of content would facilitate engagement:If it’s not too time consuming and it’s not complicated...your average person isn’t [so tech savvy] so it can’t be complicated.P05, female, 58 years, pain clinic, metropolitan areaAt the same time, one participant suggested that their confidence in using mHealth interventions could be improved if provided with technical support .Participants in the study had varying levels of familiarity and experience with pain self-management strategies, and one participant suggested that it may be difficult to engage with digitally delivered pain self-management advice if one is not already experienced in using them:You don’t go driving on your own for the first time. You have to get the license. You need your lessons first...I would hate to have to do this [pain self-management] and not know how.P01, male, 60 years, pain clinic, regional areaParticipants predicted that their level of interest and engagement with mHealth support may fluctuate over the course of their taper depending on their mood, pain, and state of mind:Whether I looked at it or not would depend I guess on my mood—how I’m feeling, where I am.P18, male, 41 years, pain clinic, regional areaAt the time you receive it you mightn’t be that open to it but in a few hours’ time when you’re starting to struggle a bit or the next day it may be something you open up again and read through.P10, male, 64 years, pain clinic, metropolitan areaWhether the content was automated, personalized, and integrated with face-to-face treatment was identified as a potential barrier to engagement. Participants were concerned that receiving impersonal (automated and standardized) messages may not have the same impact as receiving individualized messages from a person in real time:The text message, in reality that’s still a computer sending it, there’s not someone at the end of it that’s sending it. I don’t know whether it would just get irritating after a while because I know nothing is going to come of it, like there is no one at the other end. Or whether it would just jolt me out of feeling sorry for myself or something. I guess it depends how it’s worded.P06, female, 59 years, pain clinic, metropolitan areaThe results revealed that all participants owned and used mobile phones. Most participants reported using smartphone apps. The majority of participants expressed interest in SMS text messaging–based and app-based support for tapering prescription opioids. Mostly, participants held no strong preference for either SMS text messaging or app support. Variables potentially influencing acceptability included message simplicity, messaging frequency, time of delivery, responsivity to user needs, individual stage of tapering, and mental state There was a strong preference for clinician-delivered, individualized, real-time support over automated and standardized mHealth support. At the same time, however, a perceived benefit of mHealth was increased accessibility of opioid tapering support. Content recommendations included pain self-management and opioid withdrawal information as well as encouragement, motivation, and validation. Perceived barriers included limited phone or internet reception and low confidence in using mobile devices and apps. These results suggest that SMS text messaging–delivered or app-delivered support may be acceptable, feasible, and even helpful to individuals living with CNCP who are tapering opioids. However, participants identified a number of barriers to engagement that may be critical to address in the development of such an mHealth intervention.mHealth interventions are typically delivered via an app or SMS text messaging. Participants identified barriers such as access to technology, mobile reception, internet connectivity, vision impairment, and low confidence in using apps. Most of these obstacles can be overcome by using an SMS text messaging–based intervention rather than an app-based intervention. SMS text messaging–based interventions are very simple and easy to use and do not require an internet connection, and messages tend to be shorter and therefore less burdensome to read.Participants suggested a number of factors that might influence engagement with mHealth interventions for prescription opioid tapering. In particular, participants expressed a desire to continue to receive care from their health care provider, pointing to the importance of ensuring that mHealth interventions are used as an adjunct to, rather than a replacement of, the patient-provider communication. Relatedly, some participants expressed concern that support received via text messages would feel impersonal or ingenuine. In response to this (common) concern, many mHealth interventions now personalize SMS text messaging content by, for example, addressing users by their preferred name or by tailoring messaging to the interests of the user  These personalization strategies have been found to increase engagement with mHealth interventions ,38.dosing—the ability to change the frequency of messages they receive depending on their mood, symptoms, coping, and need—may enhance the acceptability of an mHealth intervention for opioid tapering. It was also suggested that responsivity—the ability to request support on demand—would enhance the acceptability of an mHealth intervention. These concerns are not uncommon, and research suggests that user engagement can be enhanced by allowing users a degree of control over the frequency of messages they receive, either up front  or after a standardized loading dose [Participants also indicated that their engagement with text messages may fluctuate and suggested that flexible message ing dose .on-demand messages can be determined by the user based on established keywords. For example, in response to texting pain, the user might receive a message offering pain coping strategies  or informational reassurance . This functionality is common and feasible in mHealth technology [Another method of tailoring the frequency of messages to user demands is to allow users to text prompts to the program when they wish to receive a message. The content of chnology ,30.cognitive reassurance and pain management outcomes. The results of a systematic review found that patients who were provided with an explanation for their pain condition and reasons for their treatment advice experienced less distress and showed greater symptom improvement [Participants made 2 key recommendations for the content of an mHealth intervention to support people similar to them who were tapering opioids that were prescribed for CNCP. First, they recommended that users would benefit from messages about chronic pain management, opioid tapering, and strategies for coping with pain and withdrawal symptoms. This perspective concords with research demonstrating the positive association between giving patients informational or rovement ,40.At the same time, however, participants also noted that it may be difficult to understand and engage with information about coping with pain and symptoms of withdrawal via text if one does not already have some familiarity with these concepts. This concept is in line with previous research that demonstrated reduced opioid medication use in a group of patients who received automated telephone voice messages following an 11-week group pain management program . This hiParticipants also suggested that messages offering social or emotional support may be beneficial and expressed a need for encouragement and validation. This is consistent with research demonstrating that validation—having one’s feelings and experience acknowledged without judgment—significantly reduces distress, elevates positive mood, and increases pain tolerance . It is texpectations of the feasibility and acceptability of mHealth interventions to support prescription opioid tapering rather than their actual experiences with an mHealth intervention. Likewise, the experience of tapering that an individual participant had, both their previous experiences of tapering and the stage of tapering when they were interviewed, may have influenced their responses regarding perceptions toward mHealth support. It is possible that participants’ expectations are not congruent with their experience [A key limitation of this study is that participants reported their perience , and futWe acknowledge that the interview guide contained prompt questions that were closed ended . Although interviewers were trained to follow up any closed-ended questions with an open-ended question, it is possible that closed-ended or leading questions may have biased patients’ responses.This study was conducted within the context of a larger study, which determined the sample size of this study. Certainly, the results of our descriptive (quantitative) survey would be strengthened with further sampling. However, the goal of qualitative data collection was to canvas a variety of perspectives on mHealth support for opioid tapering rather than to evaluate the proportion of people living with chronic pain who share certain perspectives. For this purpose, our sample size was adequate.This study was conducted before the COVID-19 pandemic in Australia. As a result of the pandemic and associated social distancing measures, Australians have become more familiar with digital health technologies . It is possible that in the interests of maintaining social distancing and leveraging some of the efficiencies of digitally delivered health care, Australians may be more willing to engage with digital health interventions now more than ever.The results of this study will be used to inform the development of a user-centered mHealth intervention to support people who are tapering prescription opioids for CNCP. Consistent with the existing guidelines for the development of mHealth interventions, the next stage of our research will involve co-designing and testing of intervention content (messages) in partnership with clinical experts as well as end users . Table 3The results of this study indicate that patients with CNCP expressed interest in engaging with an mHealth intervention to support prescription opioid tapering. Interviews with this diverse group of potential users revealed barriers to feasibility and acceptability to be addressed and offered insights into factors that may increase engagement with this mHealth intervention. Future research will evaluate whether mHealth interventions improve patients’ confidence in their ability to manage their pain and maintain their quality of life while tapering opioid medications.


This article outlines how the historical human sciences see ‘culture’ and its dynamic developments over time and over generations. The operations of human culture are systemically self-reflexive and, as a result, exhibit a complexity that sets them apart, as a semiotic system, from mere communicative information transfer. Peculiar to this complexity is the two-way interaction between the ‘etic’ substance of the cultural exchanges and their ‘emic’ function. Cultural signals require parallel etic/emic processing at stacked levels of complexity. As a result of this complexity, the homeostasis and autopoiesis of human culture, including its dynamics and development over time, cannot be explained fully in terms of responses to the physical environment. How, this article ponders by way of conclusion, can an evolutionary approach be reconciled with these characteristics of human culture, or the notion of culture be applied to evolutionary modelling?This article is part of the theme issue ‘Foundations of cultural evolution’. Being aware of being aware of being. In other words, if I not only know that I am, but also know that I know it, then I belong to the human species. All the rest follows.. 1Die Kultur der Renaissance in Italian (1860), drawing on still older scholarly traditions: literary history and art history. It is still thriving today  selection’ and by environmental, external factors. Again, to capture that commonsensical semantic base-line, I turn to the OED: ‘The development or growth […] of anything that may be compared to a living organism […] Also, the rise or origination of anything by natural development, as distinguished from its production by a specific act; ‘growing’ as opposed to ‘being made’’ .Beyond this commonsensical, fairly rough-and-ready distinction between Culture and Nature, the application of Culture to Evolution, or Evolution to Culture, appears (to a historian's eye) highly varied . WitThe tendency for historians to see their preoccupation with diachronic developments as something not quite identical to the notion of ‘evolution’ ties in with their long-established method of collecting their data, not from empirical experimentation , but from culturally produced documentary evidence, for the analysis of which an important set of procedural validations has been elaborated known as ‘source criticism’ –25.(b)Die Erkenntnis des Erkannten, ‘the understanding of understanding’ [5There is, then, a robustly established orientation in the humanities to use cultural causes in order to explain cultural effects: what happens in human culture is often caused by the ways in which humans choose to organize their lives, reflecting, in the process, on their lives and on its organization. Culture is often caused by other forms of culture; and the humanities are aware of themselves as also a form of culture . The humanities as a scientific discipline are an academically organized way of human self-reflection: human culture looking at human culture. (Hence August Boeckh's definition of philology as tanding’ ). The exStarting with Vico himself, some evolutionary models have been formulated on the basis of a long-term comparative study of human cultural productivity . Two are worth mentioning here: the rise-and-fall model and the centre-periphery model.a priori working assumption or ideologeme.Vico's idea of a cyclical development of succeeding civilizations in world history saw each civilization emerge from an inarticulate pre-civilized stage into literacy, flourishing, and eventually declining and being overtaken by a different one . ThisAnother tenacious evolutionary model has been developed for the distinction between ‘high’  culture and ‘low’  culture. Tynjanov  and othe6 are well established. Their validation does not proceed by way of a formalized experimental procedure where tests are set up to verify or falsify working hypotheses; as I have hinted, the reproducibility of experiments cannot apply in historical research since the past, by definition, is not reproducible. The Popperian criterion of falsifiability is met in two other ways. Any historical analysis before being put to the forum of scholarly opinion needs to be rigorously and source-critically tested against the available data ; and its acceptance is always provisional, pending the possible adduction of contradictory data from different sources.7 For this reason, evolutionary modelling in the historical sciences has remained tentative and implicit, a matter of ginger consensus rather than explicit assertion, and often more stringently formulated by critics than by proponents. Even so, a few consensual insights from the historical humanities may be summarized as follows, and these may well meet with nods of recognition from evolution researchers in the natural sciences.Within the varied palette of the historical humanities, these models for describing cultural history in systemically evolving terms and attempting to formulate a ‘dynamics of cultural history’,(c)(i)Culture has been defined, in a pithy summary of the culture/nature divide, as ‘anything one could also do differently’ . While While cultural practices can, in their differentiation, set different societies apart, they can also be objects of ‘cultural transfer’  and be eWhile culture is habitually and universally invoked to identify ‘national’ differences between societies, culture is in fact never a trustworthy proxy for population demarcation. Thus, in archaeology and paleolinguistics, correlations between DNA markers and different cultural traits  rarely converge into a contradiction-free model (cf. ). Cultur(ii)Culture will as often be marked by the re-emergence of old, dormant practices as by the emergence of new ones. Cultural history develops as a cumulatively expanding repertoire rather than as a successive replacement. Even abandoned cultural practices  leave vestigial cultural memories and can be resuscitated; and the old is merely superseded, never wholly abolished.Examples of culturally highly conservative societies (e.g. China during the Tang and Ming dynasties) are much rarer than examples of cultural change. Since societies need to maintain continuity, culture has a fundamentally preservative, traditionalist component . NonetheThese dynamics are generated from within culture itself, not as a response to outside forces; and they do not work in a linearly predictable direction but generate erratic and unpredictable developments. It would be hard, in a historian's vocabulary, to call such dynamics ‘evolution’.Entzauberung der Welt [It studying these dynamics, historians face an ongoing challenge to establish which evolving innovations are part of deep paradigmatic transitions and which ones are ephemerally transient and inconsequential in a more long-term context. At what point does a series of hot summers betoken a systemic climate change? Historians have attempted to distinguish between explanatory time-frames of short, medium and long duration , withoutder Welt  or the ‘der Welt . And is der Welt  in otherHistorical change in human societies and human cultures is always marked by the concurrent effects of multiple interacting causes. Historians eschew ‘monocausality’, the idea that a single cause can be identified as the sole agent of historical change. Historical changes can in many instances be derived from a limited number of ‘necessary causes’ , but to confuse these with ‘sufficient causes’  imposes from hindsight a teleological determinism. As in other sciences, historians –57 rejec(iii)Culture is transgenerational. It involves communication between generational cohorts and ensures the survival of its artefacts and practices across them . As such, culture establishes a non-physiological or ‘symbolic’ diachronic community for the population, communicatively rather than genetically maintained . As suchper se. Jakobson's [reductio ad absurdum. What matters in each of these is precisely what lies beyond their bare communicative functions. A historical case in point is the notorious episode of the 1870 Ems Telegram: Bismarck, in summarizing a diplomatic exchange, suppressed some courtesy circumlocutions which, without altering the substance, changed its flavour, and in so doing soured public opinion and materially hastened the outbreak of the Franco-Prussian War [Culture is a specific function or application of communication rather than communication kobson's  classic sian War ,65. Thessian War  and cf. sian War ).Some of these elements may meet with recognition, other with reservations, among scientists working in Cultural Evolution; but all of them, including all of their complexities, are crucial to culture as that concept is used in the Humanities.. 3Following on from proposition (iii) in the preceding section—the sentient self-awareness of the actors involved—this section elaborates briefly on the entanglement between culture and meta-culture: the fact that culture is not just an interaction with the environment, but also an interaction with itself. This self-thematization of culture in meta-culture is in fact recursive, and can loop through multiple iterations of reflexivity. The result is a systemic complexity that is characteristic of (though not exclusive to) human cultural systems.(a)Central to culture is its capacity to generate meta-culture, ‘cultural reflection or practices conceptualizing cultural reflections or practices'. The humanities and indeed the academic sciences are themselves part of this meta-culture and spend a good part of their time in self-reflexive pursuits . This looping recursivity characterizes culture as a complex system, in the technical sense of that word (rather than just a fancy way of saying that ‘it's complicated’). As a complex system, there is no linear correlation in culture between input and output. ‘The’ system when seen as a whole consists of sub-systems, each following their own input–output dynamics as part of the larger whole, and each system is ‘itself’ enmeshed as a subsystem in a larger whole affecting its functionalities. This nesting stack of ‘systems forming part of other meta-systems while themselves containing sub-systems' has no obviously identifiable outer edges, either in an ultimate superimposed container system (short of this being ‘the universe’) or in a fundamental, indivisibly simple building block. The complexity of such an open-ended stacked system also involves multiple, nesting feedback loops and reciprocal transactions within and between sub-systems, generating homeostasis  and (in the case of culture) self-reflexive and symbolical cognition. All this tends to be subsumed under the Luhmann-derived term of autopoiesis  systems—physiological ones such as the human body, with its organs, cells, organelles and molecular interactions, or inanimate ones such as the weather on planet Earth. I would suggest that there is such a difference and that it is has something to do with the fact that its iterative back-looping self-reflexivity involves what anthropology calls the etic/emic distinction (to be addressed in §4).In human cognition and interaction, viewed systemically, reflexivity is a key factor: the fact that communicative interactions are not only carriers of information but can become objects of communication, contemplated as actions in their own right. Any question may in response elicit an answer, or the meta-counterquestions ‘What do you mean?’, or ‘Why are you asking me this?’—or all of these at the same time. This reflexivity can loop through multiple feedback iterations. To use a word is not the same as to mention or quote a word, and discussions of the use–mention distinction (e.g. by Sperber & Wilson ) can in habitus for making sense of the world and structuring its symbolic cohesion (the sort of thing one does without thinking about it [structure structurante and structure structurée), as object of a ‘cultivation of culture’ [In their historical dynamics, cultural systems often perform increasing loops through the iteration of reflexivity, with gestures and practices become progressively more ‘aware’ at higher levels of complexity of themselves . Language gives rise to rhetoric and poetics—i.e. reflections on which stylistic figures or formal rules best convey information or narratives, or achieve an aesthetic surplus value. Combat and self-defence are formalized into martial arts, and some of these (like fencing) are performed as sports or displays to acquire social prestige. Nutrition becomes haute cuisine, music becomes a craft (the art of counterpoint and harmony) and then spawns musicology. Traditionalism, once it is consciously experienced as such against the forces of modernity, becomes conservatism  and cultabout it ), but anculture’ .. 4Having established the complex, recursively self-observing nature of culture, this section introduces the relationship between what culture consists of  and what functional meaning it carries for its performers. Substance and function of these communicative signals are addressed in the well-known heuristic duality of etic versus emic. In the light of the preceding section, I will argue that the emic function is more than a mere processing of the etic signals as such, but also involves, at recursively nesting meta-levels, meta-reflections on those signals, on the etics and emics of the communicative context of which they form part, and on the act of communication in which they are activated.Phonetics studies phones as physiologically generated acoustic phenomena, in all their variability of how speech organs produce them and what their acoustic qualities are. It was established early on that some phonetic differences are much more important than others, in that they establish differences between words and their separate meanings. In each language, certain phonetic differences are disregarded as being incidental and non-meaningful , while others carry a meaning-differentiating function: the difference between ‘alive’ and ‘arrive’ or between ‘bed’ and ‘bad’. These latter are called phonemes, and it is from the distinction between phonetics and phonemes that we derive the more generalized differentiation between the –etic and the –emic. The former refers to the physical features constituting a cultural signal, the latter to its generation of meaning as it is being processed. This etic/emic differentiation, it should be stressed, is system-dependent and system-internal, neither universal nor externally determined. The phonemic differentiation between ‘alive’ and ‘arrive’, having no analogue in Japanese phonetics, poses a challenge to Japanese speakers using English; the one between ‘bed’ and ‘bad’, for similar reasons, to Dutch speakers. English speakers, for their part, may fail to notice or pronounce the difference between Russian мат (checkmate) and матъ (mother) with their different end-t's.The distinction between the etic and emic aspects of human culture has been adopted from the linguistic analysis of human speech-sounds . Theetic is the ‘hardware’ level of the bare substance of the cultural signals, and the emic is the symbolic or social function (meaning) of those signals.As a generalized heuristic duonym, ‘etic’ and ‘emic’ were adopted and widely discussed in anthropology following the work of Kenneth Pike (2nd edn. ), by thea-priori processing of the etic signal. To be aware whether we understand 〈verflucht〉 as a Dutch or German word affects whether we process its disyllabic structure as verf-lucht or ver-flucht, its 〈v〉 grapheme as signifying a /v/ or /f/ sound, and the 〈u〉 vowel as in the Dutch name 〈Gullit〉 or in the German name 〈Schubert〉. There is nothing within the word itself to specify all this: not just the understanding, but even the processing of the etic form depend on the meta-information ‘what language are we dealing with here’?8Two important principles are at work here. One is that the emic function of a signal is an intrinsic part of a communicative system, and is conventionally governed by the differentiation structures of that system. At the same time, it is not wholly embedded within its etic substance. The emic meaning of the word 〈verflucht〉 is not determined by what it consists of . The meaning is, rather, system-dependent: whether we read it as a Dutch word (meaning ‘the smell of paint’) or an German one (damned); and it would be a meaningless gargle if read as part of a sentence in Basque. At the same time, emic awareness governs our fundamental a priori, cannot be parsed or processed and becomes indistinguishable from random noise. In the analysis of culture, we cannot strip culture down to its mere etic components. This is why the etic–emic distinction has become such a major issue in anthropological theory. In the Humanities, the paradox that we need to have some understanding of the overall meaning of a text to in order to make sense of its individual parts, while we need to make sense of the individual parts in order to gain an understanding of the overall meaning, is known as the ‘hermeneutic circle’.9This trivial micro-example illustrates more than that ‘meaning depends on context’; it means that in culture, exchanges are never unidirectional and always involve as much emic sense-processing as etic signal-emission. Establishing the meaning of things  is an eCultural exchanges take place concurrently at three different, interlinked systemic levels: the etic signal as such is sandwiched between the underlying collateral information about its systemic context  and the superimposed meta-levels of reflexivity . The emic function takes shape as human subjects perform a dynamic parallel processing of these nesting, stacked levels.. 5This section addresses the issue of systemic scalarity, which is raised by the combination of (a) the recursive complexity of human culture (§3) and (b) the etic–emic dualism of meaning-generation (§4). This section argues that human cultural artefacts are nested in recursive loops of increasing systemic aggregation and complexity, not only as regards their etic components but also as regards the emic functions of these nesting components. These ‘layered’ meanings are operative, and processed, at multiple levels simultaneously. This section also suggests that in the analysis of human cultural artefacts and exchanges, the scalar location of the etic–emic interplay is meaningful. An analysis of high-complexity emic functions (e.g. poetic techniques in a love poem) in terms of etic components embedded at deeply nested systemic levels  would appear reductive precisely because it ignores this wide scalar gap.(a)War and Peace, or Michelet's Histoire de la Révolution française) the relative occurrences of the letters 〈m〉 and 〈d〉 in those texts is situated at such deep-down systemic levels that their emic function is negligible. Such lengthy and complex texts are read and discussed in terms of their large-scale features: narrative themes and techniques, discursive arguments and rhetoric (which at a more fine-grained level involve the tropes and stylistic choices (which at an even more fine-grained level involve the arrangement of statements and events (which involve choices of words (which happen to contain letters like 〈m〉 and 〈d〉)))). Scalarity, in other words, matters.This interaction between the stacked systemic levels is so tight that it is habitually perceived and performed as a single action. In human practice, the stacked levels that are co-processed are, accordingly, mutually adjacent: so close as to allow instantaneous cross-overs. A brief poetical text (e.g. Gerard Manley Hopkins's sonnet ‘The Windhover’) is commonly read and discussed in terms of the aural effects of its (deliberate) use of assonance involving sounds like /m/ and /d/. But in lengthy texts  being a type of comprehension proper to the natural sciences, the latter (understanding) specific to the humanities, the former concentrating on the question ‘how’, the latter gravitating to the question ‘why’.I am merely and diffidently suggesting, as a hypothesis to consider, that this stacked multi-level interplay between etic features and emic functions is particular to human-constructed cultural systems. But I am confident that the systemic characteristics identified here single out the humanities, rather than the empirical sciences, as the best-equipped discipline to investigate culture's twinning of complexity and multiply embedded emic functions. Culture cannot, I feel, be studied adequately on the basis of a mechanical registration of its etic operations, as if it were a set of thermal currents in a volcano, or molecules arranging themselves into a polymer or protein. This, I think, is what Dilthey  meant wh(b)War and Peace for mechanical purposes , but this approach would not amount to literary criticism since the literary features of the identical text might be fruitfully discussed on the basis of wholly differently composed letters or typesettings, or a handwritten copy, or even a translated version. Much as we do not discuss novels in terms of the letters or ink pixels that make up books, so too Michelin stars are awarded to restaurants, not on the basis of what nutrients their dishes contain, but for their highly structured presentation of dishes (that are prepared in complex procedures (making use of ingredients (containing those nutrients))).I draw another inference. The nesting, stacked and scalar logic of culture, which at each level involves emic functions in the processing of etic signalling, makes it problematic to discussing highly structured cultural phenomena or artefacts by processing the etics of their component sub-systems at deeply subordinate structural levels. It might make sense to analyse the letters (or even ink pixels) as components of haute cuisine, or Digital Rights Markers in audio datasets. But the way in which the artefact as a whole is processed, its meaning and historical presence in the culture  is not ‘explained’ thereby. While we can now process Big Data, i.e. the quantitative plethora of such low-level components, that does not yet take into account the complex structures from which we extract those Big Data. Seeing culture as Big Data reduces it to Flat Data. We no longer discuss novels, dinner menus or musical compositions, but merely printed matter, food or sustained concatenations of structured noise.Much as it is trivial to define the human body as consisting of protons, neutrons and electrons, so too it is question-begging to define developments in modern/Western musical culture not on how people chose to resolve diminished-ninth chords or emically perceived dissonants (cf. ), but at. 6terminus technicus. It is embedded in the human experience of the world rather than an analytical concept applied to operations in the world. It is both older and more specific in its Begriffsgeschichte than more technical and recently coined words like ‘behaviour’ or ‘communication’. When applying the word ‘culture’ to ‘evolution’, this historically accreted specificity of meaning should, I feel, be factored into the analysis, which accordingly should take account of its inherent complexity and emic, meaning-making functions.‘Culture’ is not a neologism or a behavioural or communicative, rather than ‘cultural’ processes. Many of these processes undoubtedly affect natural selection pressures on coevolutionary processes, without being either strictly physiological or, strictly speaking, ‘cultural’ . In sucal’ (cf. ), ‘cultual’ Improved recording devices make it possible to study the etics and emics of human interaction objectively at a very fine-grained level. The registration of pupil dilation or (in infants) pacifier-sucking when experiencing verbal stimuli has helped our understanding of ‘deep’, physical–habitual semantic and phonemic processes considerably. Computer modelling such deep-structural processes across repeated iterations (as a proxy for human generations) may, in well-chosen experimental cases, be equally useful for evolutionary theories of language. (2)Digitization has exponentially increased the production of cultural signals (from tweets to Internet memes) and exponentially enlarged the corpus of analysable data. These very large and often ephemeral cultural corpuses (Big Data in the true sense) would traditionally  have been impervious to data capture or analysis, but can now become fertile objects for computerized searches and analytical modellings. (3)Computer modelling has also vastly extended our power to analyse complex systems in all their nonlinearity and nesting structuration. That holds out very exciting prospects also for the modelling of cultural dynamics; and for all the caveats sounded in the foregoing pages I would by no means wish to exclude the possibility that these cultural dynamics do exhibit ‘evolutionary’ patterns over time. That burden of proof demands more than a single-instance, simplified proof of concept; but the perspectives are enticing.That being said, there are exciting new vistas being opened by the application of very powerful empirical methods and data analysis, also when applied to human culture; and the use of iterative modelling does indeed raise the potential of seeing cultural patterns evolve, in the true sense of the words ‘culture’ and ‘evolution’. By way of example I point out a few.


Is the world quantum? An active research line in quantum foundations is devoted to exploring what constraints can rule out the postquantum theories that are consistent with experimentally observed results. We explore this question in the context of epistemics, and ask whether agreement between observers can serve as a physical principle that must hold for any theory of the world. Aumann’s seminal Agreement Theorem states that two observers  cannot agree to disagree. We propose an extension of this theorem to no-signaling settings. In particular, we establish an Agreement Theorem for observers of quantum systems, while we construct examples of (postquantum) no-signaling boxes where observers can agree to disagree. The PR box is an extremal instance of this phenomenon. These results make it plausible that agreement between observers might be a physical principle, while they also establish links between the fields of epistemics and quantum information that seem worthy of further exploration. Aumann’s agreement theorem states that observers of classical systems can’t “agree to disagree." Here, the authors show that the same epistemic consistency holds for observers of quantum states, but not for observers of post-quantum no-signalling boxes, hinting at its potential status as a physical principle. It is highly counterintuitive and, almost a century after its introduction, it still sparks much conceptual and philosophical discussion. Indeed, an active line of research in quantum foundations deals with the problem of singling out quantum theory from other post-classical physical theories. This field is a delicate balance between proposals for new theories that are ‘tidier’ than quantum mechanics8. A slightly more general restatement of Aumann’s theorem, which we will refer to as the classical agreement theorem, states that, if Alice and Bob, based on their partial information, assign probabilities qA, qB, respectively, to perfectly correlated events, and these probabilities are common certainty between them, then qA = qB. “Certainty” means assigning probability 1, and “common certainty” means that Alice is certain about qB; Bob is certain about qA; Alice is certain about Bob being certain about qA; Bob is certain about Alice being certain about qA; and so on infinitely.In the domain of classical probability theory, Aumann proved that Bayesian agents cannot agree to disagree9, to prove “no-trade” theorems for efficient markets10, and to establish epistemic conditions for Nash equilibrium11.This result is considered a basic requirement in classical epistemics, which is the formal study of the knowledge and beliefs of the agents in a system. The classical agreement theorem has been used to show that two risk-neutral agents, starting from a common prior, cannot agree to bet with each other12. This implies that the classical Bayesian model does not apply, so the classical agreement theorem need not hold. The question then arises: Can observers of quantum mechanical phenomena agree to disagree?Focusing on the quantum domain, a fundamental result of quantum mechanics is that no local hidden-variable theory can model the results of all quantum experiments3 is of this kind—i.e., it displays extremal disagreement in the above sense. Since the PR box is also an extreme instance of a no-signaling box as a non-local resource13, our findings suggest a deeper relation between the quantification of disagreement and the quantification of non-locality.In this work, we answer the above question in the negative. We define two notions of disagreement inspired by Aumann’s theorem. One is a direct analogue to the classical agreement theorem, and the other one relaxes the common certainty condition while requiring that the probability estimates differ maximally. We find that neither kind of disagreement occurs for classical or quantum systems. However, both kinds of disagreement do occur in postquantum environments. In fact, we characterize no-signaling distributions displaying these behaviors. We then put our two characterizations together and search for distributions that satisfy both notions of disagreement: We find that the PR box11 could happen. This is why the impossibility of agreeing to disagree is a desirable feature for all physical theories, and why we propose that it should be elevated to a physical principle. Its simplicity makes it convenient for testing the consistency of new postquantum theories.If a physical theory were to allow agents to agree to disagree, then undesirable consequences in the settings of refs. We start with an intuition about the setup behind the classical agreement theorem. Suppose that Alice and Bob share a classical system, which can, thus, be described by a local hidden-variable model . But the observers do not know which value of the hidden variable is the one that holds . Instead, each observer can perform only one local measurement on the system. Each measurement corresponds to a partition over the values of the variable, and the result reveals which partition element contains the value that holds. The probability of each outcome is the sum of the probabilities of the values in the corresponding partition element.Suppose, also, that Alice is interested in estimating the probability of an event  that does not correspond to an element in her partition. Then, she can calculate only the conditional probability of the event given the outcome of her local measurement by Bayesian inference. The same applies for Bob. Suppose that Alice and Bob are interested in events that are perfectly correlated . Then, the classical agreement theorem says that, if their estimates are common certainty, they must be equal.Common certainty means that Alice is certain of  Bob’s estimate, Bob is certain of Alice’s estimate, Alice is certain of Bob’s certainty of Alice’s estimate, and so on.14) also contain a set of preparations underlying the distribution over the probability space, and the partitions are usually phrased in terms of measurements and outcomes. However, we consider preparations implicit and use the language of partitions to bridge the gap between classical probability spaces and no-signaling boxes more smoothly.When formalizing these notions, we refer to a probability space, together with some given partitions, as a  ontological model. Ontological models appearing in the literature .For the sake of simplicity and following Aumann, we restrict our analysis to two observers, Alice and Bob. Aumann’s original theorem considers common knowledge of one single event of interest to both observers. We provide a slight generalization with common certainty about two perfectly correlated events of interest, one for each observer. This allows us to move to the framework of no-signaling boxes that we will use later. This is what we call the classical agreement theorem. This terminology can be further motivated by the fact that, for purely classical situations, both statements—the original Aumann’s theorem and our formulation with perfectly correlated events—can be proven to be equivalent  = P(EB\EA) = 0. Consider a probability space ω ∈ Ω, ω. For each qA, qB ∈  and consider the following sets:A0 is the set of states ω such that Alice assigns probability qA to event EB; the set B1 is the set of states ω such that Bob assigns probability qB to event EA and probability 1 to the states in A0—i.e., states where Bob assigns probability qB to EA and is certain that Alice assigned probability qA to EB; and so on, and similarly for B0, A1, etc.Fix partitions ω* is in sets An and Bn, for all ω*, Alice assigns probability qA to EB, Bob is certain that Alice assigns probability qA to EB, and Alice is certain that Bob is certain that Alice assigns probability qA to EB, and Alice is certain that Bob is certain that... and so on indefinitely, and also vice versa about Bob assigning probability qB to EA. In sum, there is common certainty at ω* that Alice assigns probability qA to EB and that Bob assigns probability qB to EA.If a state of the world ω* ∈ Ω that Alice assigns probability qA to EB and that Bob assigns probability qB to EA ifn ≤ N for a certain Nth-order mutual certainty.More formally, it is common certainty at a state We now state the classical agreement theorem that will be the basis of our work. All proofs are given in the Supplementary Material.EA and EB are perfectly correlated events. If it is common certainty at a state ω* ∈ Ω that Alice assigns probability qA to EB and Bob assigns probability qB to EA, then qA = qB. Fix a probability space We now map the classical agreement theorem into the no-signaling framework, in order to explore its applicability beyond the classical realm.3, of the formx, y and a, b are Alice’s and Bob’s input and output, respectively, and We consider no-signaling distributions, or boxespλ: λ ∈ Λ}, a, b, x, y, where Λ is an index set. It is quantum if, for each x, y, there exist POVMs ρ such thata, b. The set of local boxes is strictly included in the set of quantum boxes, which is, in turn, strictly included in the set of no-signaling boxes. No-signaling boxes that are not quantum are termed postquantum.A no-signaling box is local if there exist probability distributions {ω ∈ Ω where ω ∈ Ω, where We now show that we can associate a no-signaling box with any ontological model, and vice versa. Let p are non-negative, normalized, and no-signaling.With all the above, 17.  This makes it possible to translate results from one framework to the other, something that might be of interest in order to establish further connections between epistemics and quantum theory. However, from now on, we focus on no-signaling boxes and leave this digression aside in the rest of the main text.The converse process of finding an ontological model starting from a no-signaling box can be also performed, as we show in Supplementary Note With the association between ontological models and no-signaling boxes in mind, we next define common certainty of disagreement for no-signaling boxes. The idea is to reinterpret the definitions in Section 2.1 in this latter setting.EA, EB) in the present setting. Now, these events correspond to some set of outcomes, given that the no-signaling box was queried with some particular inputs. For the sake of concreteness, we fix these inputs to be x = 1, y = 1 and the outcomes of interest to be a = 1, b = 1. This motivates us to consider the events FA and FB are perfectly correlated whenWe first propose a meaning for the events of interest  is in the sets An and Bn, for all qA to FB (assuming that Bob input y = 1), Bob is certain that Alice assigns probability qA to FB, Alice is certain that Bob is certain that... and so on indefinitely, and vice versa. That is, there is common certainty at  that Alice assigns probability qA to FB and that Bob assigns probability qB to FA.With this in mind, we can build a chain of mutual certainties, in a manner similar to the classical agreement theorem. If the event  that the observers obtain.Notice the relationship between this definition and the previous one: the equation , at whica, b, x, y). For that, one just has to consider the appropriate changes in the preceding paragraphs. The only case that might seem different is that in which Alice and/or Bob’s input is the same as that corresponding to the event of interest; that is, x = 1 and/or y = 1. This is allowed but uninteresting: It is easy to see that the fact that FA and FB are perfectly correlated precludes the possibility of common certainty of disagreement in this case. Therefore, for the sake of concreteness, we fix x, y both different from 1 and, in particular, equal to 0.In complete generality, we can also consider disagreement at arbitrary inputs and outputs  need not offer any information about the outcome of an incompatible measurement on the same system . However, some consistency remains: common certainty of disagreement is impossible, even for incompatible measurements.While some no-signaling distributions can exhibit common certainty of disagreement, we find that probability distributions arising in quantum mechanics do satisfy the agreement theorem. This is surprising: It is well-known that a given measurement of a quantum system  that belongs to AN ∩ BN will also belong to An ∩ Bn for all n; that is, Nth-order mutual certainty implies common certainty. So, for any finite no-signaling box, one needs only Nth-order mutual certainty to characterize it. As the number of outputs grows unboundedly, one needs common certainty to hold20. These observations will be relevant to extending Theorem 4 beyond two inputs and outputs.As the number of outputs grows, first-order mutual certainty is no longer sufficient. However, since the number of outputs is always finite, there exists an No quantum box can give rise to common certainty of disagreement.To prove the theorem, we show that any no-signaling box with common certainty of disagreement induces a two-input two-output no-signaling box with the same property. Thus, if there existed a quantum system that could generate the bigger box, it could also generate the smaller box. Then, Theorem 3 implies that no quantum box can give rise to common certainty of disagreement.qA = 1, qB = 0. We ask whether this new notion holds for observers of classical, quantum, and no-signaling systems. We find the same pattern as before: Singular disagreement does not hold for observers of classical or quantum systems, but can occur in no-signaling settings, where we characterize the distributions that feature it.Next, we ask if observers of no-signaling quantum systems can disagree in other ways. We define a new notion of disagreement, which we call singular disagreement, by removing the requirement of common certainty and, instead, imposing qA to the event FB, and Bob assigns probability qB to the event FA. Suppose that this happens at event . If qA = 1 and qB = 0, these probabilities differ maximally: Alice is certain that FB happens, while Bob is certain that FA does not happen. If, in addition, FA and FB are perfectly correlated, then there is singular disagreement at . This time, there is no need for chained certainties—we just require that Alice’s and Bob’s assignments differ maximally.Suppose that Alice and Bob share a no-signaling box. As before, Alice assigns probability More formally, there is singular disagreement about the probabilities assigned by Alice and Bob to perfectly correlated events Similarly to the previous section, we refer to the above definition simply as “singular disagreement.”We restrict ourselves first to boxes of two inputs and outputs and show that local boxes cannot exhibit singular disagreement. Then, we characterize the no-signaling boxes that do satisfy singular disagreement and show they cannot be quantum. Finally, we generalize to boxes of any number of inputs and outputs.There is no local two-input two-output box that gives rise to singular disagreement.21 in the system; therefore it cannot be local.It turns out that singular disagreement induces a Hardy paradoxWe now lift the local restriction and characterize the no-signaling boxes in which singular disagreement occurs.A two-input two-output no-signaling box gives rise to singular disagreement if and only if it takes the form of Table x = y = 1.The definition of singular disagreement gives rise to the zeros in the second and third rows of Table However, singular disagreement cannot arise in quantum systems. This is another way in which quantum mechanics provides some consistency between (possibly incompatible) measurements, just as in the case of common certainty of disagreement.No two-input two-output quantum box can give rise to singular disagreement.22, the boxes of Theorem 7 are either local or postquantum. But Theorem 6 implies they cannot be local.By ref. Finally, the above results can be generalized to any finite box:No quantum box can give rise to singular disagreement.The proof is very similar to that of Theorem 5.3 satisfies both Theorems 3 and 7, and this makes it an example of both kinds of disagreement.Additionally, the PR boxWe have defined two notions of disagreement inspired by notions from epistemics. Both notions of disagreement imply immediate tests for new theories—namely, the tables in Theorem 3 and Theorem 7. These tests are very general in the sense that they are based only on the capability (or not) of a theory to realize undesirable correlations between non-communicating parties. Also, both principles have their roots in epistemics, with common certainty of disagreement closer to Aumann’s original idea and singular disagreement permitting a simpler description.3, establishing that it is an extremal resource both in the sense of being an extreme point of the polytope of no-signaling distributions and in the sense of inducing the strongest possible disagreement between two parties.These two notions of disagreement are compatible in that it is possible to find examples displaying both kinds of disagreement at once. Strikingly, a prime such example is the Popescu-Rohrlich box23 for some specific connections along these lines in the classical case.On a speculative note, we suggest that it would be also very interesting to explore the application of the concepts introduced in this paper to practical tasks in which consensus between parties plays a role, such as the coordination of the action of distributed agents or the verification of distributed computations. See ref. 11), while very practical, might, to some communities, be considered less appealing than deeper physical consequences. These could be explored by exploiting the newly built bridges between quantum mechanics and epistemics.Further work could be dedicated to constructing physical paradoxes arising from the possibility of agreeing to disagree. The examples in the literature . Studying similar extensions in the quantum and no-signaling settings is an interesting avenue for future work.Furthermore, one of the aims of studying physical principles is to find out whether quantum theory can be deduced from a set of such principles. Our findings open new directions for the exploration of such a programme. However, there are two main challenges in doing so. First, in order to assess this, it would be desirable to compare this principle to existing ones in the literature30 examine Aumann’s theorem when observers are assumed to use Born’s rule to update probabilities. The authors conclude that Aumann’s theorem does not hold for this type of observer. Instead, our setting assumes that the observers are macroscopic and merely share a quantum state or a no-signaling box. Our setting is appealing in quantum information for its applications to communication complexity, cryptography, teleportation, and many other scenarios. Reference 31 introduces a different notion of disagreement in a no-signaling context. Here, disagreement concerns pieces of information about some variables, and agreement refers to consistency in the information provided about the variables. Hence, it is unrelated to the epistemic notion of disagreement in Aumann’s theorem or in the present work. Disagreement is also a feature of ref. 18. However, there, one of the observers ignores the fact that a certain measurement has taken place, while another observer takes this into account, and disagreement arises over the outcomes of a different measurement. In our work, the events that take place are the same according to all observers.Finally, we compare our results with others in the physics literature that call on Aumann’s theorem. References Supplementary Information


Vaccination is an essential strategy for mitigating the COVID-19 pandemic. Besides its significance as a public health measure, vaccination is a sophisticated example of modern biotechnology. Since vaccination gives the human body an ability that it does not naturally possess, the question arises as to its classification as Human Enhancement.N = 67 participants revealed that vaccinations are perceived neither as a clear nor poor example of Human Enhancement.Exemplified on a selection of different definitions, we conclude that vaccinations may indeed be classified and treated as a form of Human Enhancement. This raises some ethical issues that are notorious in the broad field of Human Enhancement. A study with  We argue that qualifying vaccination technology as Human Enhancement does not provide convincing arguments to reject vaccination. By examining the Human Enhancement debate and the similarities to the issue of vaccination shown here, policymakers can learn valuable lessons regarding mass vaccination programs’ current and future handling. Human Enhancement.Vaccination against SARS-CoV-2, if scientifically tested for effectiveness, approved by respective health authorities, and regularly administered, is a promising tool for mitigating this pandemic and future epidemics , 2. BesiThere are several definitions of Human Enhancement, but in a fairly broad conception, it is seen as creating better people by means of technology , 7. WhenAlthough the debate about Human Enhancement is carried out with great passion, the term has no standard definition. Table to someone, to a particular individual. Human Enhancement requires a person to be enhanced and, as such, this phenomenon encompasses an extensive range of possibilities, methods, techniques, and technologies.Which capacity must be enhanced, and when is any improvement so significant that the intervention in question qualifies as Human Enhancement? Juengst  mentionsBefore going into detail about whether or not vaccination reflects a form of Human Enhancement, its classification as technology must be discussed. Even if the term “technology” is not distinctly mentioned in some of the aforementioned definitions, it is clear that ethical concerns directed at enhancement interventions may be based on the applied means rather the desired outcome , 18. Thefunction (I.) related to a specifically designed or afterward identified purpose (II.) that will eventually lead to some sort of benefit (III.). Another important aspect is the ability to comprehend and appreciate the notion of technology, described as reflexivity. Accordingly, this ability is contingent on and carried out through these essential features [But what is technology? Carroll  carried features . Technolfeatures  emphasizA discussion about the general usability of this admittedly abstract definition is outside the scope of this paper. Nethertheless, Carroll’s approach offers a fascinating perspective for the assessment of the status of vaccination regarding Human Enhancement: Depending on the type of this health intervention, different natural occurring entities and processes are exploited and sometimes deliberately altered to provoke an immune reaction , 26 to aSeveral scholars , 27–29 hBy administering a vaccination, we aim to strengthen our immune system, making it better than it was. This intervention is carried out through bio-technology, directly acting on the human body and its species-typical functioning. The latter part is important. If the human immune system responded adequately to the COVID-19 causing SARS-CoV-2 infection, there would be no need for enhancement. Hence the “normal functioning” allows no conclusion about the adaptiveness of the same function in the face of different environmental threats. The human immune system may work completely inside its normal parameters but may be unable to neutralize a pathogen. There are, furthermore, serious difficulties in determining the “normal” or the “human” , 17. ImmThis improvement is realized by technology, here bio-technology. Vaccination teaches the human immune system about specific characteristics of the pathogenic agent. This strategy does build on already known mechanisms of the body and improves it by adding new capacities. In their approach, Allhoff et al.  differenpotential infection but not as a response to an actual infection. Thus, vaccination should not be categorized as an immediate treatment but as a general enhancement for the unfortunate case of needing such enhanced capabilities.There is a comprehensive debate whether or not a treatment-enhancement distinction is suitable for the Human Enhancement issue , 27, 33.Some authors make a distinction between “historical/conventional/natural” and “biomedical/unconventional” forms of Human Enhancement , 12, 28.With such conflicts in differently assessing enhancement in general, we have to conduct thorough case-by-case examinations of respective technologies in order to be able to qualify whether a concrete enhancement method should be applied or not. For example, swords certainly enhance one’s ability to fight against an offender and are among the oldest pieces of technology human civilization has produced. Yet, most societies agree that swords should be regulated in some way. Thus, the question of whether a technology is a conventional or an ethically problematic extension of human capabilities urgently requires clarification by both proponents and critics of enhancements .Given the explicit and implicit notion of vaccination as Human Enhancement, it is not surprising that some aspects of the ethical debate about these phenomena are similar. There are some concerns about the gene-changing potential of the new and revolutionary mRNA technology. Implementation depth, here on a genetic level, may be a source of intuitive ethical unease towards some enhancement technologies. This unease holds, even if the transformative potential does not differ among different technologies and their respective depth of implementation , 40, 41.In contrast, biomedical interventions act directly on the human body and mind to bring about their effects on a subject who is not merely passive but who plays no role at all. He can at best feel their effects without understanding their meaning in human terms (p. 22).totally transparent [On the other hand, vaccinations are nearly nsparent  in the sbioconservatives [This was impressively shown by recent news coverage of the German protest group “Querdenker” , who oppose not only public health measures but also reject vaccination against SARS-CoV-2 . It was rvatives , 48–50. rvatives .Overall, new and revolutionary vaccination technologies are bearing the brunt of a fair amount of uncertainty. It is up to scientists and scientific journalism to communicate the function, benefits, and limitations of these Human Enhancement technologies. Otherwise, frustration due to unrealistic expectations may hinder the global effort in fighting the pandemic. The same is true for Human Enhancement technologies in general. Here, expectations about their transformative potential may be misled, resulting in unsubstantiated fears, hopes, and deadlocked debates –55. AnotThe question of how any enhancement technology will be distributed is a recurring topic within the debate –59. The free rider. Strictly speaking, this enhancement-by-others or “network effect” [not having this enhancement [The positive sides of getting a vaccination are manifold. It is crucial not only to consider the direct effect on the individual human immune system but also proximal outcomes of various kinds . Here, h effect”  does notancement . Howeverancement  has discAs COVID-19 has severe negative impacts on social-economic parameters , interveThe current COVID-19 pandemic is a highly complex and dynamic situation. On a medical and individual level, the course of the disease may vary enormously. Some infected individuals will experience little to no symptoms , while oIn a medically and technologically advanced world, excluding Human Enhancement ideas from measures to mitigate a deadly pandemic is an ethical problem. The history of epidemiology shows that several pandemics with very different pandemic severity indices were all survived by humankind, even without vaccination technology available , 65. Yetin re. Ethical issues regarding vaccination merely arise from individual attitudes, non-sufficient scientific communication, and distributive justice concerns, not from an inherently vicious nature. Overall, policymakers and scientists will get some helpful input from studying the general ethical debate on Human Enhancement.As we have shown in various examples, definitions of Human Enhancement include vaccination technology. Depending on the individual attitude towards this issue, this may not be a problem. However, some voices fear the widespread application of Human Enhancement , 9. UndeWhen developing or researching technologies and their ethical implications, one should always ask whether that technology might be a form of Human Enhancement and, if so, how might ethical discomfort be grounded due to that status. This is especially of concern when the target audience of that technology is vast. Scholars and policymakers are well-advised to examine the ethical debate surrounding so many ground-breaking technologies such as smartphones, psychopharmaceuticals or emerging biotechnologies from an explicit Human Enhancement point of view. This also affects medical professionals as they often act as gatekeepers who are expected to regulate the access to various enhancements and respond to the demand of enhancements in different contexts , 67. EmpExamining vaccination against SARS-CoV-2 as a practical example of Human Enhancement shows the difficulties in defining the latter kinds of technologies. However, it provides an excellent example for the debate as to whether or not we should pursue these technologies. Moreover, this example demonstrates the need to take a step back and consider not only the technology in its own right but also its potential social and political impact . Note thVaccination against SARS-CoV-2 is a practical example of Human Enhancement. This supports the notion that Human Enhancement is not a phenomenon of a distant, dystopian, or even utopian future but is already widely applied. Therefore, rejecting Human Enhancement per se is unjustified, as it would mean to condemn technologies that were used for hundreds of years. Instead of engaging in an overly alarmist or optimistic debate, Human Enhancement technologies suspected of having negative consequences should be examined on a case-by-case basis, taking various factors into account. There are valuable lessons to be learned for any mass vaccination program by comparing the concerns raised with the broader Human Enhancement debate.


Chronic obstructive pulmonary disease (COPD) is a prevalent chronic disease that requires comprehensive approaches to manage; it accounts for a significant portion of Canada’s annual healthcare spending. Interprofessional teams are effective at providing chronic disease management that meets the needs of patients. As part of an ongoing initiative, a COPD management program, the Best Care COPD program was implemented in a primary care setting. The objectives of this research were to determine site-specific factors facilitating or impeding the implementation of a COPD program in a new setting, while evaluating the implementation strategy used.A qualitative case study was conducted using interviews, focus groups, document analysis, and site visits. Data were deductively analyzed using the Consolidated Framework for Implementation Research (CFIR) to assess the impact of each of its constructs on Best Care COPD program implementation at this site.Eleven CFIR constructs were determined to meaningfully affect implementation. Five were identified as the most influential in the implementation process. Cosmopolitanism (partnerships with other organizations), networks and communication (amongst program providers), engaging , design quality and packaging (of the program), and reflecting and evaluating (throughout the implementation process). A peer-to-peer implementation strategy included training of registered respiratory therapists (RRT) as certified respiratory educators and the establishment of a communication network among RRTs to discuss experiences, collectively solve problems, and connect with the program lead.This study provides a practical example of the various factors that facilitated the implementation of the Best Care COPD program. It also demonstrates the potential of using a peer-to-peer implementation strategy. Focusing on these factors will be useful for informing the continued spread and success of the Best Care COPD program and future implementation of other chronic care programs.The online version contains supplementary material available at 10.1186/s12913-021-06636-5. The prevalence of chronic diseases in Canada has increased dramatically within the last few decades , 2. The The use of team-based primary care has been explored to manage and combat the rise of chronic illnesses . ChronicCanada has a universal health care system delivered under provincial jurisdiction. Ontario, Canada’s most populous province (14.7 million), implemented family health teams (FHTs) as a collaborative primary care model consisting of providers from multiple disciplines including primary care clinicians and allied health professionals . Since tAccessibility limits the impact of FHTs in general, and on patients with COPD specifically, as only approximately 20% of the population in Ontario has access to team care within an FHT , 18. TheIn order to effectively implement chronic disease management programs context-specific guidance is needed . The impUsing an evidence-based implementation framework for evaluation ensures research is theoretically grounded . There aDetermine the enabling and impeding factors to implementation and spread of an interprofessional team-based primary care model, andExplore the peer-to-peer approach to implementing a team-based primary care model.In Ontario, a team-based COPD management program (BCC) based in primary care focusing on patient self-management through education, skills training and case management, was spread from the region where it was originally developed and implemented, to a neighbouring region using a peer-to-peer implementation approach. While current literature lacks a clear definition, or common name for peer-to-peer approaches in implementation, in general terms, peer-to-peer approaches involve using peer-led education and peer assessment as a method to support learning about the intervention –28. UsinCurrent literature lacks context empirical examples of the implementation of team-based primary chronic care models specifically for patients with COPD  as well . Program standardization and evaluation was supported by a program specific technology solution that guided every encounter and captured performance and outcome metrics  came in, they knew what the expectations were, they knew what the outcomes would look like. They had that experience, where we were just fishing and hoping we would get the outcomes we were hoping for, but we didn’t really have the experience with that to confidently approach all those physician groups Participants believed previous program success translated to a smooth process for B-FHT staff in terms of program implementation. “Right away we were sold … it’s an easy sell because they… drop a program and a person attached to it in your lap. It is zero work” . The participants further discussed the low complexity of the implementation. “Once… the patients were being seen, there’s not a lot of other admin, oversight really required. It’s the simplest honestly. So simple… everything just fell into place.” . Providers elaborated on how they felt the implementation was done effectively and efficiently. “It seems really simple … it didn’t really disrupt … your everyday (Provider #1). If we could roll out every single program that way, it’d be great” .Providers felt the recruiting of patients into the program was smooth and effective. Patients concurred with this statement, saying: “[I] flowed right through [into the new program]” (Patient Focus Group #1). Even though patient awareness of the transition into the program was low; providers believed this facilitated implementation because it did not disrupt usual patient appointments. Providers appreciated being able to spend more time focusing on patient transition and less on other aspects of implementation.Providers discussed that prior to implementation of the BCC program, B-FHT had been unsuccessful in their attempts to create their own COPD management program. The relative advantage of the BCC program offered a successful and adaptable solution for their patients..There [were] challenges. One, that there wasn’t an established program, for [the RRT] to mimic. And two … we are a multi-site organization, and with a 0.5 [full-time equivalent RRT] position it is really hard to establish any programming without a consistence presence. Which … just wasn’t possible Physician #1 echoed this explaining the advantage of having a comprehensive COPD specific care program in “free (ing) me up to focus on other things during appointments” (Phone Interview #1). Providers agreed this was a clear benefit of the program. The physician was confident in the abilities of the newly educated RRTs to provide COPD-specific care to the patients. As a result, they were able to focus their time on a patient’s other concerns and needs, allowing for more efficient use of time during appointments.Patients also appreciated the coordinate afforded by the BCC program explaining how they prefer this program to alternatives they have previously experienced. “I’ve got a specialist that I’m not agreeing with and that’s not helping me, I might as well not even go to him. [The RRT in this program] is doing [more for me] than he is” . From the patient’s view, the RRT was delivering better care for their COPD than was the specialist working external to the program.Providers discussed the challenges of adding the program’s new reporting technology on top of existing technology. “They have their own system … I hate adding systems. That was the one thing probably that I really was not happy about … we have an [electronic medical record] (EMR). We’re seeing our patients but will be documenting in [the BCC’s system]” .Providers discussed the patient needs in the community as one of the reasons B-FHT proceeded with program implementation. “COPD was a problem. And COPD patients are complex, time-consuming, and costly. There’s plenty of patients and ongoing work to keep you busy full-time” .Participants described B-FHT’s cosmopolitanism efforts  to be instrumental in implementing the program. There was a shared agreement amongst providers about how “[the BCC’s] guidance was key for us being successful so quickly” . In addition to working with the BCC program team, the B-FHT had the chance to learn from the PCIC and strengthen their coordinated efforts with the local hospital..We actually built it to [be] part of one [program] to refer hospital discharges... with the COPD diagnosis... to automatically send a message to the RRT saying that, that person was discharged B-FHT had a pre-existing relationship with the local hospital, which had been responsible for performing diagnostic lung function testing (spirometry). The collaboration was challenged because the BCC program standard was for the RRT to complete the spirometry in the local B-FHT office. Transferring spirometry from the hospital to the B-FHT office was a concern because it meant shifting care away from the hospital. A compromise was reached allowing B-FHT to maintain the relationship with the hospital and respecting the requisite program fidelity.In implementing BCC, a network of RRTs was created to enhance communication and facilitate a peer-to-peer approach. This was discussed as a key factor for implementation success because it facilitated information sharing across a broad context which informed practice. This peer-to-peer approach facilitated the training of providers within B-FHT and supported implementation of the program. “The RRTs have their own network where they communicate with each other” . “It’s an opportunity for them to … say what’s working, what’s not working, what are they finding out there in the field. They [also] have a [messaging] group” . The peer-to-peer approach strengthened communication between providers within the program. BCC Program leads were seen as a highly valued resource for providers. “[She is] always available if we run into any problems or have questions … [we] just reach out to her directly” .Occasionally, poor communication amongst leadership and providers acted as a barrier to implementation. One provider noted “if [meetings are announced] last minute or we forget… it’s just not going to be priority to move all our other appointments around … . This was especially significant when the meetings included training or were meant to connect new providers.Resource support was also discussed as a factor for successful implementation. Typically, RRTs were newly hired to support program delivery, however “[B-FHT] (used) their existing [RRT] to deliver [the BCC] model” . This was both seen as a facilitator  and as a barrier . With the BCC program, the current RRT role was expanded into a full-time position, making it easier to implement the program in B-FHT’s multi-site clinical setting.Administrative support including affirmation from senior management, secretarial/scheduling support, and chart audit support from the BCC leads was particularly important during the initial stages of implementation. Without this support, RRTs believed they would have had to spend excessive time doing administrative work rather than focusing on patient care. “If you’re rolling a program like this into a [FHT] office without a lot of allied health, those cold calls … for [a patient’s] first visit might be time-consuming if they didn’t have that support” .However, the providers discussed how data in the primary care EMR, distinct from the program electronic health record, was of poor quality. This hampered the ability for the program RRT to identify high risk individuals. Providers felt “better data in [the EMR] would’ve helped. But that’s not… likely or possible” .Peer-to-peer implementation allowed providers to learn about the program and its intended implementation first-hand from experienced RRTs. Providers felt this increased their confidence in program delivery. “I really appreciate having people who are experts in COPD care that can give me recommendations. The more knowledge I start to feel comfortable with … in COPD in particular is because of [the RRT]” .Throughout focus group discussion, patients remarked how “you follow what [the RRT] says and [what] the doctor says and … my quality of life is better” . This trust built between the providers and patients was important for implementation success. Patients reported they felt empowered to manage their care and talked about sharing that with peers and family members.Providers and patients valued the program from the start. This buy-in of the program enhanced implementation. Providers and patients highly valued the RRT role and expressed many positive views about the RRTs: “If we could clone [the B-FHT RRT], that’s part of what has … made it so successful for us is that she was able to just come in” .Support from senior leadership was essential during the implementation process. The initial impetus to implement the program stemmed from collaboration between RRTs, however, the executive director of the site fully supported and actively facilitated implementation. Participants reported buy-in from senior leadership as a major facilitator to implementation. In addition, other primary care providers engaged with the program throughout the implementation process by learning about program offerings and supporting patient recruitment into the program..Initially… we were reminded to refer any of our COPD patients for the [RRTs] to make sure that there was a demand. I would really emphasize the importance of frequent reminders to … everyone who would refer patients to the program, reminding them of what kinds of [patients] they can and should refer Providers praised the BCC’s intensive approach to early implementation. They explained how it resulted in buy-in from the start..That initial, really strong blitz on talking to, providing the education to the physicians, speaking with the physician groups individually, getting the searches ready to go... It seemed like that period was probably short, but intense, and necessary Providers also reported the peer-to-peer approach enabled rapid implementation the program. Peer-to-peer training was conducted by an RRT and supported by a respirologist. Provider #1 said that she “sat with somebody who’d been doing it for twenty, five, and three years” respectively (Provider Focus Group #1). Provider #2 elaborated: “the training piece was also big … that training then does ensure that there’s a consistency in [program delivery]” (Provider Focus Group #1).In an effort to collect data on the implementation and performance of the BCC management program, feedback data was collected by B-FHT and the PCIC. Data was collected using patient satisfaction surveys as well as regular debriefing with stakeholders. This data was then used to facilitate adjustments to the implementation and execution of the program as needed.When discussing the results of this data during reflection of the implementation process, many participants boasted at its success. “I don’t have a single criticism about the program. I really can’t think of how it could have been done better” . “We always look at outcome measures, which are always really positive.” . Providers explained that not only is patient satisfaction increasing but “hospital admissions had been decreased” . When asked to provide advice to other teams considering implementing the program, a key informant said:.Take advantage of this program it is zero work on your end. They will come in and do everything and they will also return. If you are struggling at any point... having trouble identifying patients or... with physician buy-in, if you’re having process issues, they are happy to return... my only advice actually, is “say yes” Patients echoed provider’s positive views of the program and focused their conversation on the care they received from the program. Patients reflected on their own care and found value in their improved overall quality of life: “[The RRT] was very thorough … with their explanations of your puffers [and] your medication … [the RRT] gave you [advice]… I find it very good, helpful (Patient Focus Group #1).This implementation case study was the pilot site to evaluate the opportunity for program spread to multiple sites across multiple regions. All of the CFIR constructs analyzed affected implementation, however five were determined as key enabling constructs (based on the frequency of their occurrence in participant comments and in documents) to consider when implementing a team-based chronic care program such as the BCC program: cosmopolitanism, networks and communication, engaging, design quality and packaging, and reflecting and evaluating.CFIR constructs acting as barriers to be managed during implementation were also identified. These were: complexity (of the new patient reporting system); communication ; and lack available resources .In a systematic review, Kadu and Stolee  evaluateThe strong cosmopolitan relationship developed between B-FHT and the BCC leadership was supported by the evidence-based characteristic of the program. Participants could easily align cognitively and philosophically on evidence-based treatment standards. It also facilitated networking with external organizations. When implementing a chronic care management program, it is important to first consider collaboration with external organizations . The estLiterature on the implementation of chronic care models states that when a collaborative effort is made with external organizations, implementation and sustainability efforts are more effective  and factNetworks and communication or information and communication as termed in Davy et al.  are faciEngaging champions in implementation efforts is a key factor to success . ChampioThe excellent design and packaging of the intervention positively influenced B-FHT’s decision to implement and supported the ease of implementation. The BCC structured program coupled with the support from BCC program team, the PCIC and other RRT networks infused quality within the whole implementation. Literature has shown that poor design quality or lack of attention to packaging can be a barrier to implementation –49. WellIn our study, evidence-based data, specifically regular reflecting on performance metrics and peer-to-peer feedback methods were used effectively to support implementation. Integrating regular monitoring and evaluation throughout program delivery can support implementation efforts . RegularComplexity: When stakeholders believe an implementation is simple, the program is more easily implemented into practice [Patient Needs and Resources: There is consensus in the literature around the importance of considering context in implementation efforts - this should consider factors at multiple levels including patient, provider, team, organization, and community [Relative Advantage: Providers believed the program had a relative advantage to what was currently being offered to patients; this, combined with the perceived need within their community, facilitated implementation. Our results echo the findings of Greenhalgh et al. and others [Readiness for Implementation – Available Resources: There is consensus in the literature that a lack of resources, or a misuse of available resources  can hinder implementation [Self-Efficacy/Knowledge and Beliefs about the Intervention: Ensuring providers possess the necessary skills to achieve implementation goals is essential [There were other CFIR constructs found to be supportive of implementation, but not necessarily as impactful as those already discussed. practice ; overly practice . In our ommunity , 51–53. d others , 51 who entation , 55. In ssential . Low selssential , 57. WheLiterature describes peer-led education as a powerful approach to achieving program goals and objectives –28. To oOur small sample size and in depth look at one case meant there was a potential for both social desirability bias and the Dunning-Kreuger effect  . The latThis study was conducted to understand the facilitators and barriers that affect the implementation of a chronic care management program for patients with COPD in a primary care context. Our aim was to determine enabling factors of implementation and spread of an interprofessional team-based primary care model to support future spread efforts. The five most influential constructs to implementation according to CFIR were cosmopolitanism, networks and communication, engaging, design quality and packaging, and reflecting and evaluating. Our results align with those from the literature including Kadu and Stolee ‘s systemThis study provides a practical example of the various factors that facilitate the implementation of the BCC management program. It also demonstrates the potential of using a peer-to-peer implementation strategy. Focusing on these factors will be useful for informing the continued spread and success of the BCC program and future implementation of other chronic care programs.Additional file 1. Consolidated Framework for Implementation Research Constructs. This document provides an organized list including the categories and constructs of the consolidated framework for implementation research, as well as a short definition for each construct.