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.     

Openness with patients: a categorical imperative to correct an imbalance

This paper examines the concept of ‘openness with patients’ from the stand-point of the limitations of biomedical ethics. Initially we review contemporary critiques of bioethics and, in particular, of principlism; we relate how other; somewhat neglected, forms of medical ethics can yield useful information and provide moral guidance. The main section of the paper then shows how a bioethical approach to openness misses the social context in our example, the viewpoints of patients; we present some of the increasing wealth of research evidence which points towards patients wanting more information and a greater degree of openness. Finally we put forward that a principlist’s objection to active encouragement of openness might be based on the risk of infringing upon the ‘right not to know’. We reject this by arguing how rights can be trumped. Dr. Anthony S. Kessel, BSc, MBBS, Mphil, MSc, is a general practitioner, medical ethicist and currently specialist registrar (Barking & Havering Health Authority)/Honorary lecturer in public health medicine in the Epidemiology Unit, London School of Hygiene & Tropical Medicine, London, UK.     

Conflict of interest in Croatia: doctors with dual obligations

There is an emerging awareness of the possibility of conflicts of interest in the practice of medicine in Croatia. The paper examines areas within the medical profession where conflicts of interest can and have occurred, probably not only in Croatia. Particularly addressed are situations when a doctor may have dual obligations and how independent ethics committees can help in decreasing the influence of a conflict of interest. The paper also presents extracts from the Croatian Code of Ethics for the medical profession that address problems of conflict of interest. An earlier version of this paper entitled was presented at an International Conference on “Conflict of Interest and its Significance in Science and Medicine” held in Warsaw, Poland on 5–6 April, 2002.     

Laying medicine open: understanding major turning points in the history of medical ethics

At different times during its history medicine has been laid open to accountability for its scientific and moral quality. This phenonmenon of laying medicine open has sometimes resulted in major turning points in the history of medical ethics. In this paper, I examine two examples of when the laying open of medicine has generated such turning points: eighteenth-century British medicine and late twentieth-century American medicine. In the eighteenth century, the Scottish physician-philosopher, John Gregory (1724-1773), concerned with the unscientific, entrepreneurial, self-interested nature of then current medical practice, laid medicine open to accountability using the tools of ethics and philosophy of medicine. In the process, Gregory wrote the first professional ethics of medicine in the English-language literature, based on the physician's fiduciary responsibility to the patient. In the late twentieth century, the managed practice of medicine has laid medicine open to accountability for its scientific quality and economic cost. This current laying open of medicine creates the challenge of developing medical ethics and bioethics for population-based medical science and practice.     

Health Care Reform: What History Doesn’t Teach

The paper begins by tracing the historical development of American medicine as practice, profession, and industry from the eighteenth century to the present. This historical outline emphasizes shifting conceptions of physicians and physician ethics. It lays the basis for showing, in the second section, how contemporary controversies about the physician’s role in managed care take root in medicine’s past. In the final two sections, I revisit both the historical analysis and its application to contemporary debates. I argue that historical narratives can function as “master narratives” that suppress or leave out historical facts. I bring to the surface what is covered up by the master narrative approach, and show its relevance to contemporary ethical debates. I conclude by proposing that preserving the integrity of medicine will require modifying the master narratives we tell about physicians. The integrity of medicine also offers new perspectives for thinking about managed care and the broader topic of health care reform.     

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.     

WHY BIOETHICS NEEDS THE PHILOSOPHY OF MEDICINE: SOME IMPLICATIONS OF REFLECTION ON CONCEPTS OF HEALTH AND DISEASE

Germund Hesslow has argued that concepts of health and disease serve no important scientific, clinical, or ethical function. However, this conclusion depends upon the particular concept of disease he espouses; namely, on Boorse's functional notion. The fact/value split embodied in the functional notion of disease leads to a sharp split between the “science” of medicine and bioethics, making the philosophy of medicine irrelevant for both. By placing this disease concept in the broader context of medical history, I shall show that it does capture an essential part of modern medical ideology. However, it is also a self-contradictory notion. By making explicit the value desiderata of medical nosologies, a reconfiguration of the relation between medicine, bioethics, and the philosophy of medicine is initiated. This, in turn, will involve a recovery of the caring dimensions of medicine, and thus a more humane practice.     

The origins and evolution of bioethics: some personal reflections

Bioethics was officially baptized in 1972, but its birth took place a decade or so before that date. Since its birth, what is known today as bioethics has undergone a complex conceptual metamorphosis. This essay loosely divides that metamorphosis into three stages: an educational, an ethical, and a global stage. In the educational era, bioethics focused on a perceived "dehumanization" of medicine by the rising power of science and technology. Remedies were sought by introducing humanities, ethics, and human "values" into the medical curriculum. Ethics was one among the humanistic disciplines, but not the dominant one. In the second era, ethics assumed a dominant role as ever more complex dilemmas emerged from the rapid pace of biological research. As such dilemmas were applied to medical practice, the need for a more rigorous and more formal analysis of their moral status was clear. Philosophically-trained ethicists had an obvious role. They began to teach, write, and profoundly influence medical education and practice. In the third -- and present -- period, the breadth of problems has become so broad that ethicists must, themselves, draw on disciplines well beyond their expertise -- e.g., law, religion, anthropology, economics, political science, psychology, and the like. The era of bioethics as a global enterprise is upon us. The original hope for humanizing medicine has not been overtly successful; however, much has been accomplished of value to patients, the profession, and society. Medical morality has been transformed into a formal, systematic study of a whole range of issues of the greatest significance to humanity. Now the major challenge is one of identity, or inter-relationships and connections between the theoretical and the practical. Bioethics has outgrown its beginnings.     

Towards a Confucian Virtue Bioethics: Reframing Chinese Medical Ethics in a Market Economy

This essay addresses a moral and cultural challenge facing health care in the People’s Republic of China: the need to create an understanding of medical professionalism that recognizes the new economic realities of China and that can maintain the integrity of the medical profession. It examines the rich Confucian resources for bioethics and health care policy by focusing on the Confucian tradition’s account of how virtue and human flourishing are compatible with the pursuit of profit. It offers the Confucian account of the division of labor and the financial inequalities this produces with special attention to China’s socialist project of creating the profession of barefoot doctors as egalitarian peasant physicians and why this project failed. It then further develops the Confucian acknowledgement of the unequal value of different services and products and how this conflicts with the current system of payment to physicians which has led to the corruption of medical professionalism through illegal supplementary payments. It further gives an account the oblique intentionality of Confucian moral psychology that shows how virtuous persons can pursue benevolent actions while both foreseeing profit and avoiding defining their character by greed. This account of Confucian virtue offers the basis for a medical professionalism that can function morally within a robustly profit-oriented market economy. The paper concludes with a summary of the characteristics of Confucian medical professionalism and of how it places the profit motive within its account of virtue ethics.     

Statistics is Essential for Professional Ethics

All professional ethics are dependent on the epistemology of the profession. The possibility of following a code of ethics, whether the official one or an alternative code, is dependent on being able to obtain knowledge and understand the world. Professional knowledge has to be based on inferences from limited information. Statistics provides the optimal methods for making such inferences, and thus ethical professional conduct requires individual or collective understanding of some statistical thcory and practice. This is demonstrated using the medical profession as an example. Statistical methods are essential in all areas of medicine, in routine medical practice, in screening for disease and in research. Evidence from medical journals, textbooks and research bodies shows that the statistical basis for ethical conduct is lacking. However, there are attempts to improve the situation.     

Taking Representation Seriously: Rethinking Bioethics Through Clint Eastwood��s Million Dollar Baby

In this article, I propose a new model for understanding the function of representation in bioethics. Bioethicists have traditionally judged representations according to a mimetic paradigm, in which representations of bioethical dilemmas are assessed based on their correspondence to the "reality" of bioethics itself. In this article, I argue that this mimetic paradigm obscures the interaction between representation and reality and diverts bioethicists from analyzing the tensions in the representational object itself. I propose an anti-mimetic model of representation that is attuned to how representations can both maintain and potentially subvert dominant conceptions of bioethics. I illustrate this model through a case study of Clint Eastwood's film Million Dollar Baby. By focusing attention on the film's lack of adherence bioethical procedures and medical science, critics missed how an analysis of its representational logic provides a means of reimagining both bioethics and medical practice. In my conclusion, I build off this case study to assess how an incorporation of representational studies can deepen-and be deepened by-recent calls for interdisciplinarity in bioethics.     

Limits to doubt

Supported by Ian Hacking’s concept of “intervention,” and Charles Taylor’s concept of “intentionality,” this article argues that doubting is acting, and that doubting is therefore subject to the same demands of responsibility as any other action. The argument is developed by using medical practice as a test-case. The central suggestion is that the demand of acting responsibly limits doubt in medicine. The article focuses on two such limitations to doubt. Firstly, the article argues that it is irresponsible to doubt that our actions can harm other people. Secondly, the article argues that it is irresponsible not to strive for coherence between our utterances of doubt and our other actions. Incoherence here can cause “cultural impoverishment.” In a larger context this article also argues that medicine can enrich our epistemology, because medical knowledge displays important traits of knowledge that are downplayed in traditional epistemology derived from mathematics and physics. In particular, medicine makes it possible to get the relation between ethics and epistemology into sharper focus. The endpoint in medical epistemology is “responsible action,” and not certainty in and of itself.     

Medical ethics' appropriation of moral philosophy: the case of the sympathetic and the unsympathetic physician

Philosophy textbooks typically treat bioethics as a form of "applied ethics"-i.e., an attempt to apply a moral theory, like utilitarianism, to controversial ethical issues in biology and medicine. Historians, however, can find virtually no cases in which applied philosophical moral theory influenced ethical practice in biology or medicine. In light of the absence of historical evidence, the authors of this paper advance an alternative model of the historical relationship between philosophical ethics and medical ethics, the appropriation model. They offer two historical case studies to illustrate the ways in which physicians have "appropriated" concepts and theory fragments from philosophers, and demonstrate how appropriated moral philosophy profoundly influenced the way medical morality was conceived and practiced.     

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.     

Ethical androcentrism and maternal substance addiction

In this paper, I argue that bioethics suffers from a masculinist approach--what I call "ethical androcentrism." Despite the genesis of other legitimate approaches to ethics (such as feminist, narrative, and communicative ethics), this masculinist tradition persists. The first part of my paper concerns the problem of ethical androcentrism, and how it is manifest in our typical ways of "doing" bioethics (as teachers, ethicists, policymakers, and medical practitioners). After arguing that bioethics suffers from a masculinist ethic, I consider the case of maternal substance addiction to show how this ethic negatively affects the treatment of pregnant addicts. I argue that by treatment maternal substance addiction from an androcentric approach, we fail to serve both pregnant addicts and their fetuses; furthermore, we misrepresent the intentional state of pregnant substance addicts and label them "prenatal abusers." If maternal substance addiction is to be ethically addressed--and if pregnant substance addicts are to be effectively treated--we cannot tacitly accept an androcentric ethic.     

论中国多元化医疗公正的选择

生命伦理学面对的最大的道德困惑是公正问题,其中最为尖锐的问题是生命权利与医疗公正.公正原则在实际医疗领域运用中存在着种种误区.公正观的多元化是现代社会包括现代医疗的必然结果,体现在医疗公正方面合理的伦理选择就在于在不同的医疗境遇中,使用不同的公正原则,从而选择现实的生命伦理学道路.     

The context as a moral rule in medical ethics

A purely deductive medical ethics cannot properly account for the varieties of circumstances which arise in medical practice. By contrast, a purely inductive medical ethics lacks sufficient guidance from ethical principles. In resolving ethical dilemmas in medicine, most often an appeal is made to middle-level axioms and methodological rules to mediate between theory and practice. I argue that this appeal must be augmented by considerations of context, such considerations, in effect, constituting a moral rule based on the social structure of medical practice. A contextual grid is proposed which assists the process of weighing values in resolving cases.     

The gastroenterologist and his endoscope: The embodiment of technology and the necessity for a medical ethics

The purpose of this essay is to argue for the necessity of an ethics of the practice of the specialist-technologist in medicine. In the first part I sketch three stages of medical ethics, each with a particular viewpoint regarding the technology of medicine. I focus on Brody's consideration of the “physician's power” as a example of contemporary medical ethics which explicitly excludes the specialist-technologist as a locus of development of medical ethics. Next, the philosophy of Heidegger is examined to suggest an approach to the problem, and, finally, some of Levinas' contributions regarding the “other” are introduced to suggest a preliminary approach to a medical ethics of the specialist-technologist.     

Clinical pragmatism: bridging theory and practice

This response to Lynn Jansen's critique of clinical pragmatism concentrates on two themes: (1) contrasting approaches to moral epistemology and (2) the connection between theory and practice in clinical ethics. Particular attention is paid to the status of principles and the role of consensus, with some closing speculations on how Dewey might view the current state of bioethics.