Why the Practice of Medicine is Not a Phronetic Activity

This essay argues that the practice of medicine is not a phronetic activity in the original Aristotelian sense of that term. Jonsen and Toulmin are two philosophers who have conflated the techne of medicine with phronesis. This conflation ignores Aristotle's crucial distinction between techne and phronesis and his use of the medical analogy. It is argued that medical reasoning is similar to phronesis but does not exemplify it. Phronesis will not save the life of medical ethics. The concept could be utilized as a moral prosthetic.     

Some aspects of medical ethics from the perspective of bioengineering

The problem of ethics in medical care as seen from the bioengineering results from the almost incredible technological achievements based on scientific research: On the one hand there is inadequate handling of technology and fear on the part of the patient; on the other hand there is admiration on the part of the physicians and the nursing staff. This article will survey the points of criticism concerning ethical behavior and will present and evaluate general problems of mechanization in medical care. General phenomena of human interaction, and especially problems related to medical care, will be discussed. It will be necessary to develop clinical medical technology, aiming primarily at ‘realizing the patient's concern’. After analyzing these concerns, it is necessary for the clinical medical engineer to develop an ‘invisible’ technology. Criteria for such an ‘invisible’ technology (function, design, automatic control, methods of implantation, whether chronic application is necessary) are being demonstrated by particular devices (artifical heart, functional electro-stimulation, diaphragmatic pace-maker).     

Attention,People of Earth! Aristotelian Ethics and the Problem of Exclusion

Abstract

Growth in human happiness seems to do in part with insights gained through attentive emotional engagement with fictional characters and their identities. For this reason it is important to pay attention to the critique that founding ethics on what we cannot but affirm of ourselves, our identity (rationality and sociability, in Nussbaum’s reading of Aristotle), amounts to a moral elitism, excluding those who fail to meet these marks of human identity. This objection throws light on the importance of the shift towards thematizing ‘subjectivity’ in modern and contemporary philosophy. Ethics takes place at the level of the deliberating subject, intending the good. The foundational element is grasped through moral commitment and not at all ‘neutrally’, in a disengaged attitude alien to human aspirations – something disturbingly overlooked in much normative ethics today. The criteria picked out as essential to our humanity are clarifications of this commitment, and involve an attitude of inclusivity. In our own non-classical philosophical framework this needs spelling out, in a manner not made clear in Nussbaum’s ‘self-validating’ arguments, in terms of the exigencies of self-enactment and personal identity. This also answers critics who would disallow the conflation of identity and judgments of value.     

Autonomy,Reciprocity, and Responsibility: Darwall and Levinas on the Second Person

Abstract

Stephen Darwall’s The Second‐Person Standpoint converges with Emmanuel Levinas’s concern about the role of the second‐person relationship in ethics. This paper contrasts their methodologies (regressive analysis of presuppositions versus phenomenology) to explain Darwall’s narrower view of ethical experience in terms of expressed reactive attitudes. It delineates Darwall’s overall justificatory strategy and the centrality of autonomy and reciprocity within it, in contrast to Levinas’s emphasis on the experience of responsibility. Asymmetrical responsibility plays a more foundational role as a critical counterpoint to ‘mean‐spirited’ reciprocity than Darwall’s laudable distinction between accountability and revenge, and responsibility even founds this distinction. The experience of being summoned to asymmetrical responsibility amplifies the meaning of ‘authority’, which is a presupposition for Darwall. Finally, asymmetrical responsibility helps develop decentred reasoning, invites risk beyond the boundaries of reciprocity at moments when autonomy appears endangered, reconciles respect and care at the experiential level, and presses to extend the scope of moral obligation.     

Building an Environmental Ethics from the Confucian Concepts of Zhengming and Datong

From the ‘DuPont factory’ case in China, one can see that contemporary ecology is faced with two underlying problems: A lack of responsibility toward the environment beyond being economically profitable, and a lack of care for what is outside of one’s immediate environment. For the purpose of confronting these two problems, I suggest two Confucian concepts: 1. zhengming 正名 (Rectification of names) and 2. datong 大同 (Great Harmony). These two concepts can be used to develop an environmental ethics and thus play a crucial role in solving the two above-mentioned problems. Zhengming is originally a political concept that was put forward by Confucius. According to this concept, everyone should fulfill their duty to the utmost in accordance with their individual roles. Datong is Confucius’ political ideal and emphasizes gong 公 (public) as a spirit for caring for tian xia 天下 (all under Heaven). A Confucian-style harmonious society is achieved by ‘letting every being manifest its mandate to the full’ (ge jin xing fen 各盡性分). When we turn toward the natural environment instead of political affairs, these concepts of zhengming and datong can become a proactive view of environmental ethics. From this view, zhengming emphasizes that ‘humans fulfill their responsibility of being humans’ (ren ren 人人). This means that humans should take responsibility toward the natural world, and one might say that ren ren implies an impetus for protecting the environment. Similarly, datong emphasizes caring for tian xia, by not limiting oneself to certain races, species, national boundaries, or geographical regions. Because of this, I believe that zhengming and datong can certainly resolve the above-mentioned problems: A lack of a sense of responsibility toward the environment, and a lack of a sense of care for what is outside of the confines of one’s immediate environment.     

A quality assurance programme for psychotherapy — The finnish experience

In many respects the status of psychotherapy in public health-care systems is similar to that of alternative medicine. The roots of training are outside universities. Legitimation and public funding have been non-existent or insufficient as compared with other fields of health care. Also a great deal of mysticism is attached to both. It is therefore relevant to study the role of psychotherapy from the frame of reference given by research into alternative health care.

Formal health care is characterised by (1) legalised status, (2) access to public funding and (3) integration in the formal medical curriculum. On the other hand there are several treatment philosophies which remain as outsiders from the point of view of formal health care. Informal health care approaches are characterised by (1) lack of legalised status, (2) no access to public funding and (3) no integration in the medical curriculum. Alternative medicine is a term usually attached to forms of informal health care like acupuncture, Spa-culture etc.

Psychotherapy in the public health sector lies somewhere between formal and informal health care. While it has no legalised status, anyone may call himself ‘psychotherapist’. Its definition remains obscure and its public accountability poor.

In this paper I have tried to show how one country — Finland — has tried to grapple with this problem as it attempted to set up psychotherapy services whose quality could be properly monitored — ‘Quality Assurance’ — allowing for public accountability. Now that psychotherapy is well established as a valuable treatment in the field of mental health it is possible to consider future expansion as a cost-effective way to improve the general mental health of the country.     

Exploration of Ethical Debates through Desai’s The Inheritance of Loss,Ishiguro’s Never Let Me Go and Smith’s On Beauty

This essay examines debates over alternative ethical formulations that break from the Kantian model through contemporary fiction—Kiran Desai’s The Inheritance of Loss (2006), Kazuo Ishiguro’s Never Let Me Go (2005) and Zadie Smith’s On Beauty (2005). The essay returns to the theory, the ethics of care, put forward by Carol Gilligan in In a Different Voice (1982), which has regained significance in the context of questions surrounding care in contemporary ethical thinking. While the three novels are concerned with ideas of care, beauty, justice and the tyranny of the mainstream, this essay examines particular themes in particular texts which suggest that ideas with otherwise subversive potential—like care or beauty or justice—lose their radicalism when they are incorporated within the impersonal, masculinist mainstream. Carol Gilligan’s feminine ethics of care, with its respect for the particular, is not only still important as the stimulus to thinking about alternatives to overarching ethical discourses, but it could also re-confer these concepts of care, beauty and justice their revolutionary potential.     

Feminist directions in medical ethics

I explore some new directions—suggested by feminism—for medical ethics and for philosophical ethics generally. Moral philosophers need to confront two issues. The first is deciding which moral issues merit attention. Questions which incorporate the perspectives of women need to be posed—e. g., about the unequal treatment of women in health care, about the roles of physician and nurse, and about relationship issues other than power struggles. “Crisis issues” currently dominate medical ethics, to the neglect of what I call “housekeeping issues.” The second issue is how philosophical moral debates are conducted, especially how ulterior motives influence our beliefs and arguments. Both what we select—and neglect—to study as well as the “games” we play may be sending a message as loud as the words we do speak on ethics.     

Simone Weil: The Ethics of Affliction and the Aesthetics of Attention

ABSTRACT

For Simone Weil the invocation of ‘rights’ to address extreme human suffering–what she calls ‘affliction’–is ‘ludicrously inadequate’. Rights, Weil argues, invite a response, whereas what the afflicted require is not dialogue but simply to be heard. For Weil, hearing the ‘cry’ of the afflicted is the basis of all justice. The task of such a hearing is given over to Weil’s concept of attention, which demands an ethics of creative silence. This paper will argue that central to Weil’s ethics of attention, and thus the way she thinks we should show compassion and act justly, is the Kantian aesthetic concept of disinterestedness. I will argue that whilst Weil is influenced by Kant in multiple ways, it is his aesthetics, rather than his normative moral theory, that is most at play in her own ethical theory of attention.     

Stories of family caregiving: Case studies in moral reasoning

Family relationships are complex, interdependent, multifactorial, cultural, and sociopolitical. In instances of family caregiving, the dynamics of these relationships influence the well-being of all members. This paper will address one dynamic of family relationships, moral reasoning, as set forth in the theories of Carol Gilligan. Gilligan's theories about two patterns of reasoning, based on the ethics of justice and care, will be examined within “stories” from fiction and interviews with family caregivers. This examination will raise issues about Gilligan's theories as well as about the literary works themselves and will suggest new ways for health professionals to work with family caregivers.     

Theological Ethics, Moral Philosophy, and Natural Law

The article deals with the relationship between theological ethics and moral philosophy. The former is seen as a theoretical reflection on Christian ethics, the latter as one on secular ethics. The main questions asked are: (1) Is there one and only one pre-theoretical knowledge about acting rightly? (2) Does philosophy provide us with the theoretical framework for understanding both Christian and secular ethics? Both questions are answered in the negative. In the course of argument, four positions are presented: theological ‘unificationism’, philosophical ‘unificationism’, theological ‘separationism’ and Lutheran ‘dualism’. It is argued that the latter position is most convincing. It is dual in the sense of being both a theory of Christian ethics and of including a recognition of natural law. Hence, it unites a particularistic and a universalistic point of view. In the last section a reformulation of the Lutheran position is attempted in making use of the ethical theory of Knud E. Løgstrup's The Ethical Demand.     

Spinoza and mental health

With the proviso that Spinoza's concerns were philosophical, not medical, we examine the Ethics with a view to bringing out those aspects of it which are of import for mental health. We find that the Ethics surrounds the idea that man can be egoless in the Buddhist sense of that term. This concept provides a criterion of mental health. Further, according to Spinoza's theory of the Affections, those which are passive include some which are based on pain. These he ‘enumerates among the diseases’. And for them he provides, in Part V, specific ‘remedies’. This in turn leads him to equate ‘Mental Freedom or beatitude’ with a ‘healthy Mind’. We thus have in Part V additional possible criteria of mental health. Finally, there is the suggestion that philosophy for Spinoza was a kind of therapy.’

There is not a philosophical method, though there are indeed methods, like different therapies. — The philosopher's treatment of a question is like the treatment of an illness. — A main cause of philosophical disease — a onesided diet . . .

Wittgenstein

This doctrine of knowledge first and action later is not a minor disease . . . My present advocacy of the unity of knowledge and action is precisely the medicine for that disease.

Wang Yang‐ming

When asked by two disciples which of the views of each was correct, Wang replied: both are. Which is used depends on the kind of person you are trying to help. Some persons need this one, others that.     

The demand for effectiveness,efficiency and equity of health care

Effectiveness, efficiency and equity in health care are discussed in this article against the background of concerns that ‘cost containment’ may lead to reductions in quality of care. It is suggested that effectiveness is best seen from the patient's point of view and that it relates to more than simply improved health status. Efficiency and equity are better viewed from a societal stance. The paper discusses the role of the medical profession in effectiveness, efficiency and equity and argues that the role of medical doctors needs to be constrained.     

Phronesis, Poetics, and Moral Creativity

At least since Aristotle, phronesis (practical wisdom) and poetics (making or creating) have been understood as essentially different activities, one moral the other (in itself) non-moral. Today, if anything, this distinction is sharpened by a Romantic association of poetics with inner subjective expression. Recent revivals of Aristotelian ethics sometimes allow for poetic dimensions of ethics, but these are still separated from practical wisdom per se. Through a fresh reading of phronesis in the French hermeneutical phenomenologist Paul Ricoeur, I argue that phronesis should be viewed as at least in part poetic at its very core. That is, phronesis deals with the fundamentally tragic human situation of moral incommensurability, and it responds to this by making or creating new moral meaning. Such a poetics of practical wisdom helps phronesis stand up to significant and important critiques made of it by a range of modernists and post-modernists, pointing a way forward for some important contemporary moral debates.     

On Hannah Arendt: The Worldly In-Between of Human Beings and its Ethical Consequences

Abstract

In this paper, I show how a concept of ethics can be derived from Hannah Arendt’s theory of action in The Human Condition, which contains from her call for action. When she looks at the ‘political actor’, as well as at the concept of ‘political situation’, her ethical claim is first of all the need to take initiative, to act. Hence, ‘political situations’ as she defines them are discussed as common responsibilities. But common responsibility is rooted in the in-between of human beings, rather than in individual human nature and is determined by Arendt’s principle of humanity. Therefore, at the centre of an implicit Arendtian ethics stands the world and the in-between of human beings.     

No Blame No Gain? From a No Blame Culture to a Responsibility Culture in Medicine

Healthcare systems need to consider not only how to prevent error, but how to respond to errors when they occur. In the United Kingdom’s National Health Service, one strand of this latter response is the ‘No Blame Culture’, which draws attention from individuals and towards systems in the process of understanding an error. Defences of the No Blame Culture typically fail to distinguish between blaming someone and holding them responsible. This article argues for a ‘responsibility culture’, where healthcare professionals are held responsible in cases of foreseeable and avoidable errors. We demonstrate how healthcare professionals can justifiably be held responsible for their errors even though they work in challenging circumstances. We then review the idea of ‘responsibility without blame’, applying this to cases of error in healthcare. Sensitive to the undesirable effects of blaming healthcare professionals and to the moral significance of holding individuals accountable, we argue that a responsibility culture has significant advantages over a No Blame Culture due to its capacity to enhance patient safety and support medical professionals in learning from their mistakes, while also recognising and validating the legitimate sense of responsibility that many medical professionals feel following avoidable error, and motivating medical professionals to report errors.     

Understanding Peace within Contemporary Moral Theory

In this essay, I continue Nicholas Wolterstorff’s work of developing a rights-based theory of ethics called eirenéism, which maintains the good life only occurs when justice—as a moral state of affairs where agents enjoy the goods to which they have a right—is achieved. As a result, justice is eirenē (the Greek word for peace). In the process of developing eirenéism I explain how eirenē differs from other conceptions of peace, and I offer several interpretive arguments for how best to understand eirenéism in relation to better-known competing ethical theories, like utilitarianism, virtue ethics, duty ethics, and care ethics.