My title comes from Joseph Conrad who, in his 1913 novel Chance, wrote: You know the power of words. We pass through periods dominated by this or that word - it may be development, or it may be competition, or education, or purity or efficiency or even sanctity. It is the word of the time. Well just then it was the word Thrift which was out in the streets walking arm in arm with righteousness, the inseparable companion and backer up of all such national catch-words, looking everybody in the eye as it were [1]. Today, the word is quality, out in the streets walking arm in arm with righteousness, with all the self-satisfaction that implies. The fundamental problem with all such national catch-words is that they all too seldom have real substance and all too often become slogans used in the exercise of power. The challenge is that there will never be authentic quality within healthcare unless the word explicitly accommodates the truth that a human being is simultaneously both a subject and an object. Within a consultation both doctor and patient need to oscillate between perceiving the body as an object and as a subject. When the body is perceived as an object, the gaze of biomedical science sees only what the particular patient has in common with other patients: the perspective is normative and monological. When the body is perceived as a subject, we see what is unique about this person: their life context, its story and the meanings that adhere to both. The perspective is dialogical and intersubjective involving two unique subjects: the patient and the doctor. Issues of quality need to be addressed within both of these perspectives. Yet, to date, quality in relation to the human being as an object has predominated because this is infinitely the easier option as it is possible to create a normative standard that is able to completely ignore the difficult issues of subjectivity [2]. A stone or a bird Systems engineer Paul Plsek compares throwing a stone with throwing a live bird. The trajectory of a stone can be calculated precisely using the laws of mechanics, and it is possible to ensure that the stone reaches a specified target [3]. However, it is absolutely not possible to predict the outcome of throwing the live bird, even though, in truth, the same laws of physics govern the bird’s motion through the air. As Plsek points out, one solution would be to tie the bird’s wings, weight it with a rock and then throw it. This will make its trajectory nearly as predictable as that of the stone, but in the process the capability of the bird is completely destroyed. This seems very close to what happens when we try to measure the quality of healthcare using measures that ignore the presence of human subjects either as patients or as healthcare professionals. The anthropologist Clifford Geertz touches on the same contrast - The contrast … is … between those who believe that the task of the human sciences … is to discover facts, set them into propositional structures, deduce laws, predict outcomes, and rationally manage social life, and those who believe that the aim of those sciences … is to clarify what on earth is going on among various people at various times and draw some conclusions about constraints, causes, hopes, and possibilities - the practicalities of life [4]. And he argues the need to hold these polarities in the sort of constructive balance that seems so far to have eluded us in the assessment of quality in healthcare. The flight into scientism, or, on the other side, into subjectivism, is but a sign that the tension cannot any longer be borne, that nerve has failed and a choice has been made to suppress one’s humanity or one’s rationality. These are the pathologies of science, not its norm. So far, in the pursuit of quality, we have exploited rationality at the expense of humanity [5]. The great German philosopher Hans Georg Gadamer writes: - the progress of technology encounters an unprepared humanity. It vacillates between the extremes of an affect-laden opposition to rational innovation and a no less affect-laden craving to ‘rationalize’ all forms and sectors of life, a development which more and more acquires the form of a panic flight from freedom [6]. Today, much of the assessment of quality in healthcare feels like this panic flight from freedom and we are more and more subjected to ‘the tyranny of what can be measured’ [7]: the endless ticking of boxes and completion of forms and entertaining of teams of inspection and regulation [8].