Medical ethics in an era of bioethics: Resetting the medical profession’s compass

What it means to be a medical professional has been defined by medical ethicists throughout history and remains a contemporary concern addressed by this paper. A medical professional is generally considered to be one who makes a public promise to fulfill the ethical obligations expressed in the Hippocratic Code. This presentation summarizes the history of medical professionalism and refocuses attention on the interpersonal relationship of doctor and patient. This keynote address was delivered at the Founders of Bioethics International Congress (June, 2010).     

Ethik in der Psychotherapie

This contribution discusses some fundamental questions of medical ethics in psychotherapy. The problems discussed arise when ?care ethics“, which is based mainly on the Hippocratic Oath as the basis of medical ethics, is rejected. After a short overview of the relevant ethical theories, we ask for values and principles which might serve as a foundation for philosophical reasoning on the doctor-patient-relationship. In particular, we discuss the role of autonomy and informed consent in this relationship, following Beauchamp’s and Childress’ ethical principlism. We try to show the limited scope of the principle of autonomy in psychotherapy. Finally, we make a plea for a dynamic conception of patient autonomy for which we offer some pragmatic reasons. To round this conception off it is illustrated by the metaphor of the lighthouse.     

The question is: what is medicine supposed to be all about?

The Hippocratic Oath has survived, with overriding power, the test of time. Written somewhere between 600 B.C. and 100 A.D., it addresses the intrinsic nature of medicine. Even those of us who know little of it or reject parts of it acknowledge it to be a symbol of the values of medicine. Such "canonization" is unlikely to be arbitrary; it is more likely that the oath strikes some key chord of truth. I suggest that it is its drive to the heart of medicine that makes the Hippocratic Oath inspiring today.     

Psychotherapy through the Group Process by Dorothy Stock Whitaker and Morton A. Lieberman

Ethics deals with right and wrong behavior. It can be used to check whether group therapists with their patients “abstain(s) from whatever is deleterious and mischievous,” an Hippocratic concern, and whether they safeguard their personhood, a Kantian requirement. Therapists' paternalism weakens the patients' moral agency and challenges their autonomy. Personal therapy lessens this tendency.

The group models Plato's and Socrates' ancient dialectic. Both see the end point, self-knowledge, as a virtue and seek it. Increased care of group members for each other is the modus operandi of treatment. This, with the therapist's clinical input, brings about patient wholeness. Reduction in the distorted treatment relationship returns autonomy to the patient. Group therapy is an ethical way to change patients psychologically. Gratuitously, they become more virtuous.     

Scholarship, consensus and advocacy: a comment on Cameron

While Cameron is right about the need for Christians to contribute more visibly to medical ethical debates, he is wrong in his analysis of bioethics. Marsha D.M. Fowler and Andrew Jameton find specific problems in several points of Cameron's argument, particularly where the Hippocratic Oath and patient autonomy are concerned.     

Proportionate palliative sedation and the giving of a deadly drug: the conundrum

Among the oldest extant medical ethics, the Hippocratic Oath prohibits the giving of a deadly drug, regarding this act as an egregious violation of a medical ethic that is exclusively therapeutic. Proportionate palliative sedation involves the administration of a deadly drug. Hence it seems to violate the venerable Hippocratic promise associated with the dawn of Western medicine not to give a deadly drug. Relying on distinctions commonly employed in the analysis and evaluation of human actions, this article distinguishes physician-assisted suicide and euthanasia, as acts that necessarily violate the prohibition against giving a deadly drug, from proportionate palliative sedation, as an act that does not.     

Should we study the Hippocratic Oath?

In this commentary on a study by H. Steven Moffic, et al., of the current status of the Hippocratic Oath in medical education, Veatch discusses the relation of the oath to ethical conduct, the meaning of primum non nocere ("do no harm"), and the limitations of practicing Hippocratic ethics.     

Post-Christian bioethics

Agreeing in large part with Cameron, Robert D. Orr nonetheless raises some questions. He points out the theological origins of bioethics in the 1960s, while admitting that the field has since become secularized. Autonomy's challenge to Hippocratic paternalism has brought real benefits but also abuses. Bioethics addresses more than procedural matters; it deals in issues of real substance.     

The moral basis of Graeco-Roman medical practice

The physician in the Graeco-Roman world was primarily concerned with perfecting his skills and in establishing his craft as a legitimate profession. The “ethical” treatises in the Hippocratic corpus reflect this need for public acceptance; they stress medical etiquette rather than philanthropic ideals. Overall, philanthropy had no intrinsic connection with the pursuit of medicine. Such works as the Hippocratic oath, which attempt to introduce morality and humanism into the profession, are a rarity. However, as a result of the new morality brought on by Stoic philosophy and the mystery religions, we see medicine in late antiquity frequently identified with humanistic principles.     

The value of an oath of professional conduct: process, content, or both?

...I would suggest that the major objectives of studying the Hippocratic Oath or other pertinent oaths and codes are fourfold. First, studying oaths and codes pertaining to medical conduct and standards enables students to learn about historical changes and cultural influences. Second, choosing an oath or developing one for recitation at graduation enables students to engage in conceptual and moral reasoning. Third, the deliberations and discussions involving students enable them to practice interactional, communication skills about highly charged issues. Fourth, the identified limitations of the Hippocratic Oath or other pertinent oaths and codes enable students to appreciate the value of the broader principles that support medical ethics...The remainder of this commentary is divided into two parts. In the first part, recommendations for an educational program are presented. In the second part, recommendations for future research in this area are offered.     

The Virtue of Piety in Medical Practice

Philosophia - Following the Introduction, the second section of this essay lays out Tom Cavanaugh’s helpful and convincing account of the enduring significance of the Hippocratic Oath in...     

“Of Course All Relationships Are Unique”: How Co-creative Processes Generate Unique Mother–Infant and Patient–Therapist Relationships and Change Other Relationships

The question of the uniqueness of relationships is examined: How do relationships come to be unique? What are some of the features of their uniqueness? And how can relationships, be it the mother—infant relationship or the patient—therapist relationship, have unique rather than archetypical effects on other relationships? A model of relationship uniqueness is presented that argues that mother and infant, and patient and therapist, co-create dyadic states of consciousness—states of making implicit and explicit sense of the world—out of their normally messy exchanges of age-possible meanings. These co-creative processes lead to change in the infant's and child's state of knowing the world, and also change the way the patient makes sense of the world and ways of being with others. Additionally presented are (I) a critique of attachment theory's assumption that the mother—infant relationship is the prototype of later relationships; (2) a critique of models of therapeutic change that see adult analysis as working primarily in the same domain as the workings of the mother-infant relationship; (3) a brain model of co-creative relational processes, Relational Activation Patterns (RAPs); and (4) possible psychodynamic processes in infants.     

The Hippocratic Oath as Epideictic Rhetoric: Reanimating Medicine's Past for Its Future

As an example of Aristotle's genre of epideictic, or ceremonial rhetoric, the Hippocratic Oath has the capacity to persuade its self-addressing audience to appreciate the value of the medical profession by lending an element of stability to the shifting ethos of health care. However, the values it celebrates do not accurately capture communally shared norms about contemporary medical practice. Its multiple and sometimes conflicting versions, anachronistic references, and injunctions that resist translation into specific conduct diminish its longer-term persuasive force. Only when expunged of these elements and reconstructed using values over which there is widespread agreement can the Oath succeed in moving its audience from core values located in past discussions to principled action in the future.     

Commercial contracts and the moral contract: a response to Nigel Cameron

John E. Hare responds to Cameron's article by challenging the adequacy of the Hippocratic Oath as a basis for ethical medicine. The Oath promoted a "guild mentality" that is evident, for example, in modern medicine's resistance to alternative forms of practice. Christians need to "winnow" bioethical views, both those traditionally honored and those that confront us because of new medical developments.     

Who should manage care? The case for patients

After establishing that it is essential that health care be rationed in some fashion, the paper examines the arguments for and against clinicians as gatekeepers. It first argues that bedside clinicians do not have the information needed to make allocation decisions. Then it claims that physicians at the bedside can be expected to make the wrong choice for two reasons: their commitment to the Hippocratic ethic forces them to pursue the patient's best interest (even when resources will produce only very marginal benefit and could do much more good elsewhere) and their values will lead them to calculate the net value of treatments incorrectly. Alternative decision makers are considered. It is argued that both groups of physicians and administrators will also make allocations incorrectly and that leaving the allocation decisions to patients themselves is the best approach. Mechanisms for fair and efficient rationing by patients at the societal and individual level are examined.     

Management of day-to-day organisational human relations: a Henri Rey perspective

Nearly all contributions to applying psychoanalytic understanding to organisational life rely either on a group relations model or observing and commenting on how people impact on each other. In this paper, I use a particular theory of human relations from post-Kleinian psychoanalysis to understand the complexity of the manager/staff relationship which is not unlike the analyst/therapist relationship with a patient.     

Paniksyndrom

According to an ecologically oriented model, a panic syndrome may occur when a patient is blocking an impending and already initiated development in shaping his/her relational niche. Unconsciously he/she may constellate an outer relationship situation, that demands a previous avoided change in relationships, which can be utilized by therapy.     

Pantagruelism: A Rabelaisian inspiration for Understanding Poisoning,Euthanasia and Abortion in The Hippocratic Oath and in Contemporary Clinical Practice

Contrary to the common view, this paper suggests that the Hippocratic oath does not directly refer to the controversial subjects of euthanasia and abortion. We interpret the oath in the context of establishing trust in medicine through departure from Pantagruelism. Pantagruelism is coined after Rabelais' classic novel Gargantua and Pantagruel. His satire about a wonder herb, Pantagruelion, is actually a sophisticated model of anti-medicine in which absence of independent moral values and of properly conducted research fashion a flagrant over-medicalization of human problems. Ultimately this undermines the therapeutic core of medicine itself. We contend that PAS is a case of such over-medicalization and that its institution creates medicophobia. This article does not express an opinion about euthanasia in general. Rather, we claim that physicians should learn from the oath and from Rabelais that they should keep their practice to medical care and not to exploit their expertise and social privileges for the sake of ulterior motives, even when their patients desire those goals.     

Discussion of Craige's “Terminating Without Fatality”

Craige's concept of termination and the related concept of post-termination contact are based on Freud's early, one-person model of analytic therapy as a medical treatment for the cure of a disease. Post-termination contact was considered appropriate only if the patient needed additional therapy. Subsequent development to a two-person model of treatment, which recognizes the critical importance of the patient–analyst relationship, requires modification both of concepts of termination and of post-termination contact. I propose that whether there should be such contact, and what it's nature should be, should be mutually decided by patient and analyst in the termination phase, based on their risk/benefit evaluation of such meetings. The intimate, loving patient–analyst relationship, which has enhanced the patient's development, should be able to continue in some form after the end of treatment unless substantial, unresolved problems of either patient or analyst proscribe such meetings.     

Psychodynamische Kurzzeittherapie mit erlebnisaktivierenden Interventionen

This short-term therapy model with experiential interventions is based on the basic assumptions of psychodynamic psychotherapy. The focus of treatment is the current psychosocial situation, in which dysfunctional emotional patterns are elicited by specific triggers. These emotional patterns are evidence of anconscious intrapsychic conflict, which has biographically relevant precursors. This conflict and the associated dysfunctional relationships are explored in a supportive therapeutic relationship, formulated in cooperation with the patient and then made accessible in an experience-activating process in the present. The effect is, in addition to the reduction of clinical symptoms, the improvement in managing relationships and improved social competence. The transference is noticed, but it is only addressed if it has a lasting compromising effect on the therapeutic relationship. This therapy model is especially suitable for psychotherapy with time limits of 25–40 hours.