医学阐释学——医学哲学研究新视角

医学阐释学是哲学阐释学在医学领域的应用,是医学与哲学交叉的一个新领域。简述哲学阐释学的发展以及其主要观点,并集中讨论了医学阐释学研究的范畴,其中包括人体的现象学、健康和病患的意义、医患关系、生命伦理学、医学的目的。指出医学阐释学对医学哲学、医学人文科学研究的影响。     

伽达默尔解释学在医学中的应用

对话和视域融合是伽达默尔解释学的核心问题,也是其医学解释学的基本观点。伽达默尔指出了技术医学在医疗实践中的局限性,并认为医学是一种治疗艺术,其目标是病人整体生活的美好,而不仅仅是治疗局部的疾病。在这种观念下,治疗过程被其视为一场医生和病人之间的解释性对话,目的是通过对话为病人健康提供服务的解释,而这种对话则是医生和病人的两种不同生活世界的融合。伽达默尔的医学解释学虽然同样面临着主体间性困难,但有助于反思现代医学的技术理性困境,并揭示一种医学帮助人寻求善的实践维度。

     

Clinical interpretation: The hermeneutics of medicine

I argue that clinical medicine can best be understood not as a purified science but as a hermeneutical enterprise: that is, as involved with the interpretation of texts. The literary critic reading a novel, the judge asked to apply a law, must arrive at a coherent reading of their respective texts. Similarly, the physician interprets the text of the ill person: clinical signs and symptoms are read to ferret out their meaning, the underlying disease. However, I suggest that the hermeneutics of medicine is rendered uniquely complex by its wide variety of textual forms. I discuss four in turn: the experiential text of illness as lived out by the patient; the narrative text constituted during history-taking; the physical text of the patient's body as objectively examined; the instrumental text constructed by diagnostic technologies. I further suggest that certain flaws in modern medicine arise from its refusal of a hermeneutic self-understanding. In seeking to escape all interpretive subjectivity, medicine has threatened to expunge its primary subject — the living, experiencing patient.     

Clinical ethics as medical hermeneutics

There are several branches of ethics. Clinical ethics, the one closest to medical decisionmaking, can be seen as a branch of medicine itself. In this view, clinical ethics is a unitary hermeneutics. Its rule is a guideline for unifying other theories of ethics in conjunction with the clinical context. Put another way, clinical ethics interprets the clinical situation in light of a balance of other values that, while guiding the decisionmaking process, also contributes to the very weighting of those values. The case itself originates ideas, not only about which value ought to predominate in its resolution, but also provides the origin of clinical rules that can be used in other cases. These are interpretive rules. Some examples of these rules are presented as well.     

Medical hermeneutics: Where is the “text” we are interpreting?

The present paper is a commentary on an article by Drew Leder [1]. Leder identifies a series of texts in the clinical encounter, emphasizes the central role of interpretation in making sense of each of these texts, and articulates ordering principles to guide the interpretive work.The metaphor of clinical work as textual explication, however, creates the expectation that there is a text somewhere to be found. Such an expectation invites doctors and patients to search for the text and runs the risk of conceptualizing patients as more static than they are. If one is to use the textual metaphor, one must appreciate the radical extent to which the clinical encounter is a mutually produced and shifting entity. The qualities of mutuality and indeterminacy are not those one usually associates with texts. One might ultimately be better served by a different metaphor based more directly on uncertainty.     

Hermeneutics of Medicine in the Wake of Gadamer: the Issue of Phronesis

The relevance of the Aristotelian concept ofphronesis – practical wisdom – for medicine and medical ethics has been much debated during the last two decades. This paper attempts to show how Aristotle’s practical philosophy was of central importance toHans-Georg Gadamer and to the development of his philosophical hermeneutics, and how,accordingly, the concept of phronesiswill be central to a Gadamerian hermeneutics of medicine. If medical practice is conceived of as an interpretative meeting between doctor and patient with the aim of restoring the health of the latter, then phronesis is the mark of the good physician, who through interpretation comes to know the best thing todo for this particular patient at this particular time. The potential fruitfulness of this hermeneutical appropriation of phronesis for the field of medical ethics is also discussed. The concept can be (and has been) used in critiques of the conceptualization of bioethics as the application of principle-based theory to clinical situations, since Aristotle’s point is exactly that problems of praxis cannot be approached in this way. It can also point theway for alternative forms of medical ethics, such as virtue ethics or a phenomenological andhermeneutical ethics. The latter alternative would have to address the phenomena of healthand the good life as issues for medical practice. It would also have to map out in detail the terrain of the medical meeting and the acts of interpretation through which phronesis is exercised. This revised version was published online in June 2006 with corrections to the Cover Date.     

循证医学与临床实践

循证医学是９０ 年代诞生的新兴医学科学。其要点是将临床医学领域的研究结果进行系统、全面的综合评价,为临床医疗实践、科研、卫生决策和医学教育提供可靠的科学证据。在发达国家的运用表明它已经对临床实践产生了重大而深远的影响,并将继续在临床医学领域发挥重要的作用。     

胃部恶性肿瘤临床实践中的医疗艺术

医学是一门讲求艺术性的科学.随着社会的发展,医疗艺术在整个医学临床实践中的重要性越来越突出.医疗艺术体现了医生对生命的尊重和伦理的理解.讲求医疗艺术对于建立和谐的医患关系具有重要意义.因此,如何在过硬的现代医学技术基础上提高临床医疗的艺术性,是医学教育和临床实践领域都应该思考的问题.本文以胃部恶性肿瘤的临床实践为例,从态度、语言、表情以及医患互动等细节方面入手,探讨在初诊、术前、康复以及面对晚期临终患者的不同情况中应该如何提高医疗艺术.     

Interpretation and the Problem of Domination: Paul Ricoeur's Hermeneutics

Hermeneutics, or the science of interpretation,is well accepted in the humanities. In thefield of education, hermeneutics has played arelatively marginal role in research. It isthe task of this essay to introduce thegeneral methods and findings of Paul Ricoeur'shermeneutics. Specifically, the essayinterprets the usefulness of Ricoeur'sphilosophy in the study of domination. Theproblem of domination has been a target ofanalysis for critical pedagogy since itsinception. However, the role of interpretationas a constitutive part of ideology critique isrelatively understudied and it is here thatRicoeur's ideas are instructive. Last, theessay radicalizes Ricoeur's insights in orderto realize their potential to disruptasymmetrical relations of power in education. To this extent, the author contributes to thebuilding of a critical brand of hermeneutics,or the interpretation of domination.     

目前医疗执业环境对临床实习带教的影响和对策

现有的医师执业制度和不完善的医疗保障体制使医疗环境复杂化,为临床实习带教带来新的问题和挑战。探索新的教学意识和带教模式是提高临床实习质量的关键。文章分析了目前医疗执业环境对临床实习带教的影响,提出加强带教意识,在建构主义教学理论指导下,应由“教”转为“学”,采用“互动式”教学模式提高临床实习水平。     

临床医学教育中的医学哲学

医学哲学是现代医学教育中的重要组成部分,医学科学必须与医学哲学相结合才是未来医学教育的发展方向。在以岗位胜任能力为导向的医学教育转型中,培养医学生的哲学思维无疑是其重要环节之一。为适应全球卫生事业的迅猛发展,医学教育务必在临床思维上进行整合。本文从培养合格医学毕业生的角度出发,阐述了医学与哲学的关系、医学教育中的哲学地位及哲学在临床医学教育中的具体应用。旨在提高医学生的哲学理念,促进现代医学教育的转型发展。     

The (impossible) Future of Hermeneutics

ABSTRACT

This paper argues that the negativity of hermeneutic experience is revelatory for the following reasons. Hermeneutic failure is not the equivalent of making an erroneous step in a closed circuit of reasoning. Neither is it a refutation. It concerns becoming conscious of an omission, an oversight, an unjustifiable claim to completeness and even the displacement of one interpretation by another more suggestive. The negative dimension of hermeneutic failure is incontrovertibly connected with becoming progressively aware of how, contrary to expectations, a different way of seeing is possible: something comes to light which displaces one’s former judgement. Consciousness of failure is, then, indissociable from an emergent awareness of overlooked and unremarked ways of thinking: “I should have been alert to this” or “I failed to take account of that”. Consciousness of failure is revelatory precisely because something else and something other than my expectation has shown itself to be decisive and in so doing has displaced my former understanding. This is the basis of the claim that the educative and spiritual importance of hermeneutics lies precisely in the practical pursuit of the impossible. It is a key contention of the paper that hermeneutic understanding expands and extends itself as a consequence of its impossible quest for completion.     

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.     

医学生对医学人文临床践行情况认知的调查分析

为了解医学生对目前临床医疗实践中医学人文的认知情况, 调查了924名正在临床实习的七年制学生和五年制学生以及已有临床实习经历的在读研究生。调查结果显示, 虽然大多数被调查者对目前医生的医学人文素养持肯定态度, 但也存在医学人文精神欠缺的问题;目前医师在临床实践中践行医学人文, 是“被动”需要而非“主动”提供;医院转变以营利为目标的经营理念是医学人文精神建设的前提;患者应成为临床工作医学人文关怀行为监督的主体。     

Medical Ethics Research Between Theory and Practice

The main object of criticism of present-day medical ethics is the standard view of the relationship between theory and practice. Medical ethics is more than the application of moral theories and principles, and health care is more than the domain of application of moral theories. Moral theories and principles are necessarily abstract, and therefore fail to take account of the sometimes idiosyncratic reality of clinical work and the actual experiences of practitioners. Suggestions to remedy the illnesses of contemporary medical ethics focus on re-establishing the connection between the internal and external morality of medicine. This article discusses the question how to develop a theoretical perspective on medical ethical issues that connects philosophical reflection with the everyday realities of medical practice. Four steps in a comprehensive approach of medical ethics research are distinguished: (1) examine health care contexts in order to obtain a better understanding of the internal morality of these practices; this requires empirical research; (2) analyze and interpret the external morality governing health care practices; sociological study of prevalent values, norms, and attitudes concerning medical-ethical issues is required; (3) creation of new theoretical perspectives on health care practices; Jensen's theory of healthcare practices will be useful here; (4) develop a new conception of bioethics that illuminates and clarifies the complex interaction between the internal and external morality of health care practices. Hermeneutical ethics can be helpful for integrating the experiences disclosed in the empirical ethical studies, as well as utilizing the insights gained from describing the value-contexts of health care practices. For a critical and normative perspective, hermeneutical ethics has to examine and explain the moral experiences uncovered, in order to understand what they tell us.     

Hermeneutics and Experiences of the Body. The Case of Low Back Pain

The purpose of this paper is to elaborate on the notion of clinical medicine as a hermeneutical enterprise and to bridge the gap between the general perspectives of hermeneutics and the particularities of medical practice. The case of a patient with low back pain is analyzed. The discussion centers around the metaphor of the patient as a text and a model of five social discourses about low back pain. The problems addressed are: (1) the nature of a moral experience, (2) the variety of available texts, (3) the difference between the doctor's and patient's narratives, and (4) the patient's and doctor's responsibility regarding the existential, biographical meaning of an illness. Although many problems are left unsolved, it is argued that from a philosophical point of view the notion of medicine as a hermeneutical enterprise opens up the possibility of gaining insight in the foundations of the clinical encounter.     

Hermeneutics and the Philosophy of Medicine: Hans-Georg Gadamer'sPlatonic Metaphor

Taking as our starting point Plato'smetaphor of the doctor as philosopher we reflect on some aspects of the epistemological status of medicine. The framework to this paper is the hermeneutics of Hans-Georg Gadamer which shows the paradoxical nature of Western medicine in choosing the body-object as its investigative starting point, while in actual fact dealing with subjects. Gadamer proposes a model of medicine as the art of understanding and dialogue, which is capable of bringing together its various constituent parts, i.e. knowledge, knowing how to do and knowing how to be, in medical practice and in the physician'straining. The paper concludes with a brief discussion of the dyadic figure of the physician as Platonic master of the living totality and wounded healer, capable of activating the patient'sself-healing capacity.     

从超越“在场”到洞悉“不在场”的临床思维——以急诊科为例

围绕哲学中“超越在场”的理论分析,探讨其与临床实践之间的联系,结合急诊科的特殊之处和具体案例,从临床实践角度出发,阐述从超越“在场”到洞悉“不在场”的临床思维。强调医者在临床实践过程中,不应只着眼于在场的东西,而是应通过思维和想象,努力摆脱主-客关系的桎梏,超越“在场”,探寻无穷无尽的“不在场”。同时也强调临床实践过程中,医者应该具备整体观,视患者为一个完整的“人”,借助想象,努力达到“在场”向“不在场”的超越和统一,努力融合为一个共时性的整体。最终旨在为医者在临床实践中提供一种新的思维模式。     

The Role of Science in Evangelical Hermeneutics

In this article, I argue that evangelical Christians can accommodate science within the limits of strict Biblical exegesis governed by grammatical-historical hermeneutics. To this end, I describe the grammatical-historical method to show how science enters into it. I then distinguish between theological and exegetical uses of science. Next, I use Lakatos’ philosophy of science to distinguish between ad hoc and well-motivated exegetical moves. Based upon these criteria, I then present the gap- and day-age theories as examples of hermeneutical failure in the accommodation of science. Finally, I use the framework interpretation to illustrate a hermeneutically successful accommodation of science.     

医学生临床实习应掌握的几种哲学思维方式

为适应全球卫生事业的迅猛发展,面对医学教育落后于医学发展的现状,转化医学教育迫在眉睫。在第三代“以系统为基础”的教育改革中,培养医学生的哲学思维无疑是其重要环节之一。思维方式必须在医学生步入临床时就要开始正确培养,一旦开始阶段就养成不正确的思维方式、不但会导致医疗过程中的失误,而且再想改变将会有很大难度。本文通过对医学哲学重要性的探讨,剖析医学生哲学思维的不足,阐述了医学生,临床实习过程中应掌握的几种哲学思维方式。旨在提高医学生的哲学理念,促进以岗位胜任能力为导向的医学教育转型发展。