The crisis of medicine: philosophy and the social construction of medicine

During the past decade there has been a debate about the field of philosophy of medicine. The debate has focused on fundamental questions about whether the field exists and the nature of the field. This article explores the debate and argues that it has paid insufficient attention to the social dimensions of both philosophy and medicine. The article goes on to argue that by exploring this debate one can better understand some of the difficult questions facing contemporary medicine and health care.     

The anthropological tradition in the philosophy of medicine

The tradition of anthropological medicine in philosophy of medicine is analyzed in relation to the earlier interest in epistemological issues in medicine around the turn of the century as well as to the current interest in medical ethics. It is argued that there is a continuity between epistemological, anthropological and ethical approaches in philosophy of medicine. Three basic ideas of anthropologically-oriented medicine are discussed: the rejection of Cartesian dualism, the notion of medicine as science of the human person, and the necessity of a comprehensive understanding of disease. Next, it is discussed why the anthropological movement has been superseded by the increasing interest in medical ethics. It is concluded that the present-day moral issues cannot be interpreted and resolved without clarification of the underlying anthropological images.     

The philosophy of medicine in Europe: Challenges for the future

Two challenges face European philosophy of medicine. The first is to counterbalance what is seen as an overemphasis on social analysis of medicine with greater attention to its personal and individual dimensions. The second, related challenge, is to more fully understand the clinical realities of modern medicine, which in turn, give rise to the scope and limits of physician duties, patient obligations, and social concerns.     

Introducing philosophy of medicine: three new books

Theoretical Medicine and Bioethics -     

The potential of medicine as a resource for philosophy

In addition to the neglect of philosophy by medicine, emphasized in a recent editorial in this journal, there has been an equally important neglect of medicine by philosophy. Philosophy stands to gain from medicine in three respects: in materials, the conceptual difficulties arising in the practice of medicine being key data for philosophical enquiry; in methods, these data, through their problematic character, being ideally suited to the technique of linguistic analysis; and in results, the practical requirements of medicine placing a direct demand for progress on philosophical theory. The future of the relationship between philosophy and medicine depends on the development of a positive two-way trade between them.     

Toward a systematic philosophy of medicine

Can Pellegrino and Thomasma's book, A Philosophical Basis of Medical Practice (1981), rightfully claim to be a step forward towards a systematic philosophy of medicine? We try to answer this question by focusing our comment upon three related aspects of the book, namely (1) the problem of philosophical method(s), (2) the alleged Aristotelian-Thomistic orientation, (3) the view of philosophical anthropology of the authors. It is first argued that it is doubtful whether there is as much philosophical method in the authors' book as their reflections on philosophical method suggest. Second, we argue that if Aristotelian-Thomistic philosophy is important to the authors, it is not so much because of its methods and content, as because it supplies them with a very convenient framework for didactically ordering and transmitting their views about what they consider to be — philosophically speaking — basic about medicine. Third we argue that the authors' conception of philosophical anthropology bears (in point of method and ontology) more resemblance to the humanistic naturalism of John Dewey, than to any of the European philosophical traditions (Aristotelism, (Neo)Thomism, Merleau-Pontyian phenomenology) listed in support of their philosophical enterprise.     

道家哲学对现代医学的启示

一、现代医学模式转型自20世纪后半叶以来,由于现代社会和医学实践的长足进展,使人类的疾病谱和死亡谱发生了根本变化。比如中国在20世纪前半叶,居于前四位的疾病是呼吸系统疾病、急性传染病、结核病和消化系统疾病,死亡率最高的也是这四种疾病;20世纪后半叶,居于头四位的疾病则是脑血管病、心脏病、恶性肿瘤和呼吸系统疾病,死亡率最高的也是这四种疾病。由于中国和世界疾病谱和死亡谱的根本变化,使传统的西方生物学医学模式不得不被现代的“生物—心理—社会”医学模式所代替,开始由单一的生物模式向综合性的医学模式转变,这是人类医学健康…     

临床决策:医学哲学研究的一个重要领域

临床决策研究已成为临床医学中的一个重要领域.当下的临床决策问题涉及到医学信息学、循证医学、费用-效益评估、卫生技术评估、医学伦理与法律等学科领域.因此在临床决策中单一的经验-描述的研究纲领已不适应当代医学发展的需要,需要引入综合的决策方法.临床决策问题也为医学哲学研究提供了一个极佳的思想实验场所.临床决策的多维度研究,对于打通学科之间的壁垒,架构科学与人文之间的桥梁,更深刻地理解和把握医疗保健的整体性,使临床医疗达到最佳疗效具有重要意义.     

Response: Clinical wisdom and evidence-based medicine are complementary

A long-debated question in the philosophy of health, and contingent disciplines, is the extent to which wise clinical practice ("clinical wisdom") is, or could be, compatible with empirically validated medicine ("evidence-based medicine"--EBM). Here we respond to Baum-Baicker and Sisti, who not only suggest that these two types of knowledge are divided due to their differing sources, but also that EBM can sometimes even hurt wise clinical practice. We argue that the distinction between EBM and clinical wisdom is poorly defined, unsupported by the methodology employed, and ultimately incorrect; crucial differences exist, we argue, not in the source of a particular piece of clinical knowledge, but in its dependability. In light of this subtle but fundamental revision, we explain how clinical wisdom and EBM are--by necessity--complementary, rather than in conflict. We elaborate on how recognizing this relationship can have far-reaching implications for the domains of clinical practice, medical education, and health policy.     

The role of philosophy and ethics at the edges of medicine

Background

The purpose of this study is to make a philosophical argument against the phenomenological critique of standardization in clinical ethics. We used the context of clinical ethics in Saudi Arabia to demonstrate the importance of credentialing clinical ethicists.

Methods

Philosophical methods of argumentation and conceptual analysis were used.

Results

We found the phenomenological critique of standardization to be flawed because it relies on a series of false dichotomies.

Conclusions

We concluded that the phenomenological framing of the credentialing debate relies upon two extreme views to be navigated between, not chosen among, in the credentialing of clinical ethicists.

     

Psychosomatic medicine and the philosophy of life

Basing ourselves on the writings of Hans Jonas, we offer to psychosomatic medicine a philosophy of life that surmounts the mind-body dualism which has plagued Western thought since the origins of modern science in seventeenth century Europe. Any present-day account of reality must draw upon everything we know about the living and the non-living. Since we are living beings ourselves, we know what it means to be alive from our own first-hand experience. Therefore, our philosophy of life, in addition to starting with what empirical science tells us about inorganic and organic reality, must also begin from our own direct experience of life in ourselves and in others; it can then show how the two meet in the living being. Since life is ultimately one reality, our theory must reintegrate psyche with soma such that no component of the whole is short-changed, neither the objective nor the subjective. In this essay, we lay out the foundational components of such a theory by clarifying the defining features of living beings as polarities. We describe three such polarities:

Expertise in evidence-based medicine: a tale of three models

Background

Expertise has been a contentious concept in Evidence-Based Medicine (EBM). Especially in the early days of the movement, expertise was taken to be exactly what EBM was rebelling against—the authoritarian pronouncements about “best” interventions dutifully learned in medical schools, sometimes with dire consequences. Since then, some proponents of EBM have tried various ways of reincorporating the idea of expertise into EBM, with mixed results. However, questions remain. Is expertise evidence? If not, what is it good for, if anything?

Methods

In this article, I describe and analyze the three historical models of expertise integration in EBM and discuss the difficulties in putting each into practice. I also examine accounts of expertise from disciplines outside of medicine, including philosophy, sociology, psychology, and science and technology studies to see if these accounts can strengthen and clarify what EBM has to say about expertise.

Results

Of the accounts of expertise discussed here, the Collins and Evans account can do most to clarify the concept of expertise in EBM.

Conclusions

With some additional clarification from EBM proper, theoretical resources from other disciplines might augment the current EBM account of expertise.

     

Beyond medical ethics: New directions for philosophy and medicine

A unique relationship exists between physicians and philosophers — one that expands on the constructive potential of the liaison between physicians and, for example, theologians, on the one hand, or, social workers on the other. This liaison should focus in the scientific aspects of medicine, not just the ethical aspects. Philosophers can provide physicians with a perspective on both the philosophy and the history of medicine through the ages — a sense of how medicine has adapted to the social cultural and ethical needs of each period. This perspective, while emphasizing medicine asscience, should not be limited to matters of methodology, or to criteria for distinguishing science from other intellectual pursuits, but should be concerned also with the history, sociology and politics of science. Both physicians and philosophers stand to gain from a strengthening of their active liaison now as never before; but most of all, the public will be the beneficiary.     

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.

     

The history of philosophy in contemporary philosophy: The view from Germany

Conclusion I have frequently mentioned objective problems and topics in the preceding sections. But what exactly is the force of objective here? As my remarks should have made clear I have been using objective to contrast with purely historical. A purely historical approach never gets beyond reproduction, commentary, and interpretation. I call an approach objective when it involves a philosopher who advances his own theses and claims.This minimal understanding of objectivity (in the context of my remarks in this paper) by no means implies that there are problems and topics, systems of concepts, methods, and similar factors that are eternal, completely independent of the contingencies of history (of philosophy, of the sciences), that are not relative to a language, to a logic, to a model, etc. Indeed whether there are problems, etc., in just this absolute, atemporal sense is itself a question for systematic philosophy. It seems clear that the formulation of a problem can only take place against a cognitive background of some sort and within some conceptual scheme.³⁴ Such an assumption is made by most if not all analytic philosophers. But the fact that a philosophical tradition recognizes conceptual schemes does not make it a purely historical, non-objective philosophy, in the sense already introduced and described. A philosopher who explicitly accepts a certain conceptual scheme proceeds in an entirely objective and systematic (and not purely historical) manner when, within this framework, he formulates his own theses.This paper is the text of a talk. the title is due to Barry Smith.