Grounding medical ethics in philosophy of medicine: problematic and potential

After considering two of Pellegrino’s papers that address the relation between philosophy of medicine and medical ethics, I identify several overarching problems in his account that revolve around his self-described essentialism and the lack of a systematic attempt to relate clinical medicine to biomedicine and public health. I address these from the critical realist position of Bernard Lonergan, who grounds both metaphysics and ethics on the normative structure of human inquiry and seeks to understand historical development, such as we are witnessing in health science and health care, in terms of the dynamic structure of the human good. I conclude that Lonergan’s generalized empirical method and hierarchical account of world order provide a potentially dynamic framework on which to build a more comprehensive philosophy of medicine than one whose foundations rest primarily on a phenomenology of the clinical encounter and the telos of medicine.

     

<Emphasis Type="Italic">Recta Ratio Agibilium</Emphasis> in a medical context: the role of virtue in the physician-patient relationship

Acting for the good of the patient is the most fundamental and universally acknowledged principle of medical ethics. However, given the complexity of modern medicine as well as the moral fragmentation of contemporary society, determining the good is far from simple. In his philosophy of medicine, Edmund Pellegrino develops a conception of the good that is derived from the internal morality of medicine via the physician-patient relationship. It is through this healing relationship that rights, duties, and privileges are defined for both physicians and patients. Moreover, this relationship determines the characteristics or virtues that are necessary to engage in the medical telos. This paper addresses the role of the moral virtues in clinical medicine and the physician-patient relationship. First, it provides a brief background of the Aristotelian foundations of virtue-ethics. Second, it delves into Pellegrino’s philosophy of medicine understood as a practice oriented towards a teleological goal. Third, it relates the telos of medicine to the notion of the medical community as a fundamentally moral community. Finally, it concludes with a section that creates a dialogue between virtue ethics and principlism.     

Nuancing the Healer's art — The epistemology of patient competence

The programmatic thrust of Thomasma and Pellegrino [5] is clarified and underscored and is interpreted as an attempt to introduce a fixed point into the ethical dimension of medicine by specifying some regulative principles for the medical profession. Two important features of this type of enterprise are noted: on the one hand, it may lead the profession to distinguish between technically identical actions on the basis of the normative principles it produces, thus excluding some morally permissible actions as duties constitutive of the art. It is argued that the formulation of the grounds for this ethic given by Thomasma and Pellegrino is insufficient. In order to speak to the clinical situation, medical ethics must not be based on merely the ‘living human body’ alone, but on the patientqua person.     

Pluralism,philosophies of medicine and the varieties of medical ethics: A commentary on Thomasma and Pellegrino

Some problems that arise in the account given by Thomasma and Pellegrino [6] of the foundations of medical ethics in a philosophy of medicine are addressed, in particular questions of a conceptual character about treating therelatum of medicine as health. Which concept of health is appropriate and which will bear the burden of the position thomasma and Pellegrino advance? It is argued that the proper relationship of medicine is one between a healer and developing embodied minds. As a consequence, the project of providing a univocal account of the nature of medicine fails. Instead, pluralism infects philosophy and medicine, resulting in different philosophies of medicine. From these philosophies of medicine will follow not a single medical ethics but a variety.     

Justice and care: The implications of the Kohlberg-Gilligan debate for medical ethics

Carol Gilligan has identified two orientations to moral understanding; the dominant ‘justice orientation’ and the under-valued ‘care orientation’. Based on her discernment of a ‘voice of care’, Gilligan challenges the adequacy of a deontological liberal framework for moral development and moral theory. This paper examines how the orientations of justice and care are played out in medical ethical theory. Specifically, I question whether the medical moral domain is adequately described by the norms of impartiality, universality, and equality that characterize the liberal ideal. My analysis of justice-oriented medical ethics, focuses on the libertarian theory of H.T. Engelhardt and the contractarian theory of R.M. Veatch. I suggest that in the work of E.D. Pellegrino and D.C. Thomasma we find not only a more authentic representation of medical morality but also a project that is compatible with the care orientation's emphasis on human need and responsiveness to particular others.     

Renewing Medicine’s basic concepts: on ambiguity

Background

Edmund Pellegrino lamented that the cultural climate of the industrialized West had called the fundamental means and ends of medicine into question, leading him to propose a renewed reflection on medicine’s basic concepts, including health, disease, and illness. My aim in this paper is take up Pellegrino’s call. I argue that in order to usher in this renewal, the concept of ambiguity should take on a guiding role in medical practice, both scientific and clinical. After laying out Pellegrino’s vision, I focus on the concept of normality, arguing that it undergirds modern medicine’s other basic concepts. I draw on critiques by scholars in disability studies that show the concept of normality to be instructively ambiguous. Discussing the cases of Deafness and body integrity identity disorder (BIID), I argue that if medicine is to uphold its epistemic authority and fulfill its melioristic goals, ambiguity should become a central medical concept.

Methods

In this theoretical paper, I consider how central concepts in the philosophy of medicine are challenged by research on experiences of disability. In particular, the idea that medical knowledge produces universal truths is challenged and the importance of historical, cultural, and otherwise situated knowledge is highlighed.

Results

I demonstrate how experiences of disability complicate dominant theories in the philosophy of medicine and why medical practice and the philosophy of medicine should make ambiguity a central concept.

Conclusions

If medical practitioners and philosophers of medicine wish to improve their understanding of the meaning and practice of medicine, they should take seriously the importance and centrality of ambiguity.

     

On the metaphysical presuppositions of Aristotle's Nicomachean Ethics

Conclusion In what precedes, I have argued that Aristotle does not, in his ethics, commit three metaphysical errors sometimes imputed to him: he does not define the good as a fact; he does not claim that human beings move by nature towards their telos; he does not claim, in the ergon argument, that human beings are fixed rather than versatile. Instead, I have shown, he does the opposite in each case: he argues that the good cannot be defined as a fact; he claims that human beings move towards their telos only if they have virtue and virtue is not by nature; he locates, in the human ergon, that which is responsible for human versatility. Finally, I have shown by example that the metaphysical commitments of Aristotle's account of human happiness are not as controversial as they seem.If all of this is true, then perhaps the disorder that has existed in ethics since the enlightenment has been misdiagnosed. Perhaps it is not due to an unhappy choice between end-neutral emotivism on the one hand and Aristotle's bad metaphysics on the other. Perhaps instead it is due, at least in part, to a too hasty rejection of Aristotle's ethics on the grounds of a rejection of his biology.     

Sartre and the Doctors

Abstract

This paper considers how the experience of illness fits within Sartre’s account of embodiment in Being and Nothingness. Sartre makes some remarks about illness, but does not develop a full account. I show that the anti‐naturalistic ontological framework in which Sartre’s discussion of the body is placed, which opposes my ‘being‐for‐Others’ to my ‘being‐for‐myself’, imposes a revisionary account of illness, and how Sartre’s model of interpersonal relations affects his view of doctors, and their role in the illness experience. I note and discuss the connection Sartre draws between illness and bad faith. I also point out that recent phenomenologically inspired criticisms of the medical establishment that draw on Sartre’s account of the body are limited by their failure to engage with Sartre’s ontology.     

Healing relationships and the existential philosophy of Martin Buber

The dominant unspoken philosophical basis of medical care in the United States is a form of Cartesian reductionism that views the body as a machine and medical professionals as technicians whose job is to repair that machine. The purpose of this paper is to advocate for an alternative philosophy of medicine based on the concept of healing relationships between clinicians and patients. This is accomplished first by exploring the ethical and philosophical work of Pellegrino and Thomasma and then by connecting Martin Buber's philosophical work on the nature of relationships to an empirically derived model of the medical healing relationship. The Healing Relationship Model was developed by the authors through qualitative analysis of interviews of physicians and patients. Clinician-patient healing relationships are a special form of what Buber calls I-Thou relationships, characterized by dialog and mutuality, but a mutuality limited by the inherent asymmetry of the clinician-patient relationship. The Healing Relationship Model identifies three processes necessary for such relationships to develop and be sustained: Valuing, Appreciating Power and Abiding. We explore in detail how these processes, as well as other components of the model resonate with Buber's concepts of I-Thou and I-It relationships. The resulting combined conceptual model illuminates the wholeness underlying the dual roles of clinicians as healers and providers of technical biomedicine. On the basis of our analysis, we argue that health care should be focused on healing, with I-Thou relationships at its core.     

Evil in the Fine‐Tuned World

If the world has been fine‐tuned for human life, why does that life encompass such calamity and suffering? It seems that in so far as we are impressed by the fine‐tuning intuition that the world has been designed for human life, the problem of natural evil gains in urgency. I propose that observing the world from the anthropic point of view is the source of theists’ challenge which arises from this tension. Dealing with this challenge I suggest perhaps the world is fine‐tuned for God’s telos, which may be His manifestation of love through sentient beings’ pains and emotions.     

PHILOSOPHY OF MEDICAL PRACTICE: A DISCURSIVE APPROACH

In spite of the seminal work A Philosophical Basis of Medical Practice, the debate on the task and goals of philosophy of medicine still continues. From an European perspective it is argued that the main topics dealt with by Pellegrino and Thomasma are still particularly relevant to medical practice as a healing practice, while expressing the need for a philosophy of medicine. Medical practice is a discursive practice which is highly influenced by other discursive practices like science, law and economics. Philosophical analysis of those influences is needed to discern their effect on the goals of medicine and on the ways in which the self-image of man may be changed. The nature of medical practice and discourse itself makes it necessary to include different philosophical disciplines, like philosophy of science, of law, ethics, and epistemology. Possible scenario's of euthanasia and the human genome project in the USA and Europe are used to exemplify how philosopy of medicine can contribute to a realistic understanding of the problems which are related to the goals of medicine and health care.     

WHY “DO NO HARM”?

Edmund Pellegrino has argued that the dramatic changes in American health care call for critical reflection on the traditional norms governing the therapeutic relationship. This paper offers such reflection on the obligation to “do no harm.” Drawing on work by Beauchamp and Childress and Pellegrino and Thomasma, I argue that the libertarian model of medical ethics offered by Engelhardt cannot adequately sustain an obligation to “do no harm.” Because the obligation to “do no harm” is not based simply on a negative duty of nonmaleficence but also on a positive duty of beneficence, I argue that it is best understood to derive from the fiduciary nature of the healing relationship.     

Wittgenstein,Quasi-fideism,and Scepticism

In the discussion of certainties, or ‘hinges’, in Wittgenstein’s On Certainty some of the examples that Wittgenstein uses are religious ones. He remarks on how a child might be raised so that they ‘swallow down’ belief in God (§107) and in discussing the role of persuasion in disagreements he asks us to think of the case of missionaries converting natives (§612). In the past decade Duncan Pritchard has made a case for an account of the rationality of religious belief inspired by On Certainty which he calls ‘quasi-fideism’. Pritchard argues that religious beliefs are just like ordinary non-religious beliefs in presupposing fundamental arational commitments. However, Modesto Gómez-Alonso has recently argued that there are significant differences between the kinds of ‘hinges’ discussed in Wittgenstein’s On Certainty and religious beliefs such that we should expect an account of rationality in religion to be quite different to the account of rational practices and their foundations that we find in Wittgenstein’s work. Fundamental religious commitments are, as Wittgenstein said, in the foreground of the religious believer’s life whereas hinge commitments are said to be in the background. People are passionately committed to their religious beliefs but it is not at all clear that people are passionately committed to hinges such as that ‘I have two hands’. I argue here that although there are differences between religious beliefs and many of the hinge-commitments discussed in On Certainty religious beliefs are nonetheless hinge-like. Gómez-Alonso’s criticisms of Pritchard mischaracterise his views and something like Pritchard’s quasi-fideism is the correct account of the rationality of religious belief.

     

From Normative Spheres to Normative Practices: New Prospects for Normative Theory after Habermas

Abstract

In this paper I argue against Jürgen Habermas’s theoretical dualism between ethics and morality. I do this by showing how his account of normativity is vitiated by an unnecessary superposition of a social-evolutionary and a theoretical-linguistic account of normativity, and that this brings about theoretical problems that in the end cannot be overcome. I also show that Rainer Forst’s attempt at salvaging Habermas’s distinction is equally doomed to failure, but that his attempt nevertheless invites new and more fruitful avenues for normative theory that are worth exploring. The conclusion of this paper is that traditional notions of ethics and morality can be preserved provided we heavily redefine their meanings and release them from some of the theoretical work they have been expected to accomplish, but that to complete this transition we also need to supersede Forst’s pluralization of normative contexts toward a theory of normative practices that in the end makes the distinction between ethics and morality workable but useless. I begin by first locating the debate about ethics and morality within the context of recent normative theory (§1), and proceed to examine the two main strategies through which Habermas has elaborated his idea of a sharp dualism between ethics and morality (§2). I then introduce a theoretical distinction between what I call a horizontal and a vertical integration of ethics and morality (§3) and contend that whilst only the horizontal is viable, Habermas decidedly prefers the idea of a vertical integration (§4). With this work done, I proceed to complete my critique of Habermas’s argument and show how, by recovering the pragmatist roots of his thought, an alternative solution based on a functionalist understanding of morality could be envisaged (§5). I then conclude by examining Rainer Forst’s attempt at salvaging Habermas’s account, and show that the failure of Forst’s attempts opens the way for new and more fruitful approaches to normative theory which are more likely to recover the pragmatist roots of Habermas’s thought (§6).     

Temporal Finitude and Finitude of Possibility: The Double Meaning of Death in Being and Time

Abstract

The confusion surrounding Heidegger’s account of death in Being and Time has led to severe criticisms, some of which dismiss his analysis as incoherent and obtuse. I argue that Heidegger’s critics err by equating Heidegger’s concept of death with our ordinary concept. As I show, Heidegger’s concept of death is not the same as the ordinary meaning of the term, namely, the event that ends life. But nor does this concept merely denote the finitude of Dasein’s possibilities or the groundlessness of existence, as William Blattner and Hubert Dreyfus have suggested. Rather, I argue, the concept of death has to be understood both as temporal finitude and as finitude of possibility. I show how this reading addresses the criticisms directed at Heidegger’s death analysis as well as solving textual problems generated by more limited interpretations of the concept.     

Medicine as a form of practical understanding

This paper is an attempt to reframe the debate of whether medicine is an art or a science in the Aristotelian sense. The recent book of Pellegrino and Thomasma, A Philosophical Basis of Medical Practice, serves as the starting point. Taking clinical interaction as the distinctive feature of medicine, the resemblances of medicine with the characteristics of practical reasoning in the Aristotelian sense are further explored. This comparison proves especially useful in discussing the special status of medical knowledge. Clinical reasoning, resulting in clinical judgments, shows strong similarities with practical reasoning. The application of general principles, instead of deduction from them as in science is essential to both. The ancient concept of practical rationality may therefore be more appropriate while trying to ascribe rationality to medicine than the modern concept of rationality, associated solely with scientific reasoning.     

Educating pain

Abstract

In times in which we ask ourselves how political cruelty and torments can be forgotten, Nietzsche’s pleadoyer for pain to serve the purpose of education, surprises. What might sound like a mere provocation, rather lies at the heart of the Nietzschean philosophy. As is pointed out, Nietzsche’s contention that pain is the most powerful aid to mnemonics, originates from his philosophy of pain as the main condition of all forms of creation. The title “educating (bilden) pain” expresses Nietzsche’s advocacy of an education towards pain as the dynamo of creation. In this paper I explore how Nietzsche’s notion of pain is linked to two concepts of Bildung. In the first part I investigate the relation between pain and “Bildung” in the sense of “creation”, and in the second part I link this to the relation between pain and “Bildung” in the sense of “education”. By these means, I try to answer the question: how far can pain, which is seen as the condition of creation, be linked to conditions of education.