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.     

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.     

Action theory as a source for philosophy of medicine

The article tries to demonstrate how the tools and perspectives of action theory may be used in philosophy of medicine and medical ethics. In the first part, some concepts and principles of action theory are reconstructed and used to sketch a view of medicine as a ‘science of actions’. The second part is a contribution to the discussion on medical ethics in the same issue of this journal and consists in a detailed analysis of the main arguments and critical remarks from the point of view of action theory.     

Authenticity as a foundational principle of medical ethics

Increasingly, contemporary medical ethicists have become aware of the need to explicate a foundation for their various models of applied ethics. Many of these theories are inspired by the apparent incompatibility of patient autonomy and provider beneficence. The principle of patient autonomy derives its current primacy to a large extent from its legal origins. However, this principle seems at odds with the clinical reality. In the bioethical literature, the notion of authenticity has been proposed as an alternative foundational principle to autonomy. This article examines this proposal in reference to various existentialist philosophers (Heidegger, Sartre, Camus and Marcel). It is concluded that the principle of autonomy fails to do what it is commonly supposed to do: provide a criterion of distinction that can be invoked to settle moral controversies between patients and providers. The existentialist concept of authenticity is more promising in at least one crucial respect: It acknowledges that the essence of human life disappears from sight if life's temporal character is reduced to a series of present decisions and actions. This also implies that the very quest for a criterion that allows physicians to distinguish between sudden, unexpected decisions of their patients to be or not to be respected, without recourse to the patient's past or future, is erroneous.     

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.

     

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.     

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.     

Reflections on a medical ethics for the future

Recently, the attitude and performance of the physician have been questioned and new codes of medical ethics have been introduced. Any ethics proposed for the future is a scenario reflecting the composer's selectivity. Envisaged ethics of truthful, non-paternalistic, responsible physician-patient interaction will have far-reaching implications for autopsy, euthanasia, abortion, suicide, genetic engineering, transplantation, clinical trials, status of the psychiatric patient, physician immunity and liability. Conflicts between personal and societal medical ethics may continue to be insoluble. A possible projection of the physician's ethics on that of the politician is discussed. A new medical ethics should encompass principles of different creeds and be supranational.     

Philosophy of medicine in the Netherlands

This report explores the relationship between philosophy and medicine in the Netherlands. In Section 1 we outline the ups and downs of medico-philosophical research in our country: pre-war flourishing, post-war decline, and modern renaissance. In Section 2 we review recent Dutch literature in the philosophy of medicine. The topics dealt with include methodology of medical science, alternative medicine, the basic concepts of medicine, anthropological medicine, medicalization, medicine and culture, and health care ethics.     

A methodology for teaching ethics in the clinical setting: A clinical handbook for medical ethics

The pluralism of methodologies and severe time constraints pose important challenges to pedagogy in clinical ethics. We designed a step-by-step student handbook to operate within such constraints and to respect the methodological pluralism of bioethics and clinical ethics. The handbook comprises six steps: Step 1: What are the facts of the case?; Step 2: What are your obligations to your patient?; Step 3: What are your obligations to third parties to your relationship with the patient?; Step 4: Do your obligations converge or conflict?; Step 5: What is the strongest objection that could be made to the identification of convergence in step 4 or the arguments in step 4? How can this objection be effectively countered?; and Step 6: How could the ethical conflict, or perceived ethical conflict, have been prevented?     

The development of computer ethics: Contributions from business ethics and medical ethics

In this essay, we demonstrate that the field of computer ethics shares many core similarities with two other areas of applied ethics, Academicians writing and teaching in the area of computer ethics, along with practitioners, must address ethical issues that are qualitatively similar in nature to those raised in medicine and business. In addition, as academic disciplines, these three fields also share some similar concerns. For example, all face the difficult challenge of maintaining a credible dialogue with diverse constituents such as academicians of various disciplines, professionals, policymakers, and the general public, Given these similarities, the fields of bioethics and business ethics can serve as useful models for the development of computer ethics. A version of this paper was presented at ETHICOMP98, the Fourth International Conference on Ethical Issues of Information Technology, March 25–27, 1998, Erasmus University, the Netherlands. Kenman Wong, Ph.D., is an Associate Professor of Business Ethics; Gerhard Steinke, Ph.D., is Professor of Management and Information Systems. Both authors are at Seattle Pacific University's School of Business and Economics.