FUTILITY AND THE VARIETIES OF MEDICAL JUDGMENT

Pellegrino has argued that end-of-life decisions should be based upon the physician's assessment of the effectiveness of the treatment and the patient's assessment of its benefits and burdens. This would seem to imply that conditions for medical futility could be met either if there were a judgment of ineffectiveness, or if the patient were in a state in which he or she were incapable of a subjective judgment of the benefits and burdens of the treatment. I argue that a theory of futility according to Pellegrino would deny that latter but would permit some cases of the former. I call this the “circumspect” view. I show that Pellegrino would adopt the circumspect view because he would see the medical futility debate in the context of a system of medical ethics based firmly upon a philosophy of medicine. The circumspect view is challenged by those who would deny that one can distinguish objective from subjective medical judgments. I defend the circumspect view on the basis of a previously neglected aspect of the philosophy of medicine -- an examination of varieties of medical judgment. I then offer some practical applications of this theory in clinical practice.     

THE VIRTUES IN PSYCHIATRIC PRACTICE

Using as a guide Pellegrino and Thomasma's “end-oriented beneficence model” of the virtues in medical practice, the author derives from the cardinal forms of psychiatric treatment a set of virtues particular to this field. Prior work from Jung, Havens and Menzer-Benaron helps to clarify the analysis.     

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.     

WHY “DO NO HARM”?

Edmund Pellegrino has argued that the dramatic changes in American health care call for critical reflection on the traditional norms governing the therapeutic relationship. This paper offers such reflection on the obligation to “do no harm.” Drawing on work by Beauchamp and Childress and Pellegrino and Thomasma, I argue that the libertarian model of medical ethics offered by Engelhardt cannot adequately sustain an obligation to “do no harm.” Because the obligation to “do no harm” is not based simply on a negative duty of nonmaleficence but also on a positive duty of beneficence, I argue that it is best understood to derive from the fiduciary nature of the healing relationship.     

PHRONESIS,CLINICAL REASONING,AND PELLEGRINO's PHILOSOPHY OF MEDICINE

In terms of Aristotle's intellectual virtues, the process of clinical reasoning and the discipline of clinical medicine are often construed as techne (art), as episteme (science), or as an amalgam or composite of techne and episteme. Although dimensions of process and discipline are appropriately described in these terms, I argue that phronesis (practical reasoning) provides the most compelling paradigm, particularly of the rationality of the physician's knowing and doing in the clinical encounter with the patient. I anchor this argument, moreover, in Pellegrino's philosophy of medicine as a healing relationship, oriented to the end of a right and good healing action for the individual patient.     

Lessons for experimental philosophy from the rise and “fall” of neurophilosophy

Experimental philosophy is a recent development whose broader aims and goals are still being debated. Some prominent experimental philosophers have articulated an attitude toward perennial philosophy that is reminiscent of an early explicitly defended goal of neurophilosophy, a field that predated experimental philosophy by at least one decade. But relative to that early goal, neurophilosophy quickly “fell” within broader philosophy, and came to assume its current status, a technical specialty within the philosophy of science (now more commonly referred to as “the philosophy of neuroscience”). In this paper I document the revolutionary goal of early neurophilosophy, provide a novel explanation of its “fall,” and suggest that analogous goals of some experimental philosophers set that field up for a similar “fall.” I document recent published evidence that experimental philosophy is trending in this direction.     

Rationality,power, disruption: Framing Foucault's geneological agenda

This paper situates and examines the project of genealogy as articulated by the philosopher, Michel Foucault, and draws out from that examination educative implications both in terms of research and school practice. Following Foucault, the genealogist's primary challenge, it would seem, is both to acknowledge and to respond to the entwinement of rationality and power. This paper also considers critiques which have clustered around Foucault's work, and, more specifically, his genealogical work, which argue that Foucault leaves us with no hope for a better, more humane future and no positive agenda for change. Despite this “lack” in Foucault's work, I argue, here, that his genealogical agenda is philosophically, politically, and educatively significant.     

L’écriture limite: Kristeva's Postmodern Feminist Ethics

In this essay, I trace the development of Julia Kristeva's theory and practice of “the subject in procession trial” from her semiotic works of the 1960s to her psychoanalytic writings of the 1970s and 1980s. I read Kristeva's exploration of this “subject in procession trial” as contributing to a postmodern feminist ethics.     

Donna Haraway's Cyborg Touching (Up/On) Luce Irigaray's Ethics and the Interval Between: Poethics as Embodied Writing

In this article, I argue that Donna Haraway's figure of the cyborg needs to be reassessed and extricated from the many misunderstandings that surround it. First, I suggest that we consider her cyborg as an ethical concept. I propose that her cyborg can be productively placed within the ethical framework developed by Luce Irigaray, especially in relationship to her concept of the “interval between.” Second, I consider how Haraway's “cyborg writing” can be understood as embodied ethical writing, that is, as a contemporary écriture feminine. I believe that this cyborgian “writing the body” offers us a way of both creating and understanding texts that think through ethics, bodies, aesthetics, and politics together as part of a vital and relevant contemporary feminist ethics of embodiment. I employ the term “poethics” as a useful way to describe such a practice.     

Day,Night, or Dawn: Commentary on Paper by Steven Stern

It was in the years immediately following World War II and through the 1950s that the psychoanalytic establishment officially defined psychoanalysis as a subspecialty of psychiatry, and it was in that context of the professionalization of American medicine that they codified the distinction between psychoanalysis and (psychoanalytic) psychotherapy. In this commentary on Steven Stern's “Session Frequency and the Definition of Psychoanalysis,” I deconstruct a series of binaries that was built into the analysis/therapy distinction and that has plagued our discipline. It is argued that psychoanalysis identified itself with the culturally “masculine” and heterosexual values of autonomous individuality (the intrapsychic), while it split off all that was relational and social (interpersonal), marked as “feminine,” homosexual, and “primitive,” onto psychotherapy, which it then devalued. The paper then examines the implications for practice and psychoanalytic education.     

PHILOSOPHY OF MEDICAL PRACTICE: A DISCURSIVE APPROACH

In spite of the seminal work A Philosophical Basis of Medical Practice, the debate on the task and goals of philosophy of medicine still continues. From an European perspective it is argued that the main topics dealt with by Pellegrino and Thomasma are still particularly relevant to medical practice as a healing practice, while expressing the need for a philosophy of medicine. Medical practice is a discursive practice which is highly influenced by other discursive practices like science, law and economics. Philosophical analysis of those influences is needed to discern their effect on the goals of medicine and on the ways in which the self-image of man may be changed. The nature of medical practice and discourse itself makes it necessary to include different philosophical disciplines, like philosophy of science, of law, ethics, and epistemology. Possible scenario's of euthanasia and the human genome project in the USA and Europe are used to exemplify how philosopy of medicine can contribute to a realistic understanding of the problems which are related to the goals of medicine and health care.     

“DAMAGED HUMANITY”: THE CALL FOR A PATIENT-CENTERED MEDICAL ETHIC IN THE MANAGED CARE ERA

Edmund Pellegrino claims that medical ethics must be derived from a perception of the patient's “damaged humanity,” rather than from the self-imposed duties of professionals. This essay explores the meaning and examines the challenges to this patient-centered ethic. Social scientific and bioethical interpretations of medicine constitute one kind of challenge. A more pervasive challenge is the ascendancy of managed care, and especially investor-owned, for-profit managed care. A list of questions addressed to patients, physicians and organizations is offered as one means of assessing this threat and moving toward morally trustworthy relationships.     

Turning Men into Machines? Scientific Management,Industrial Psychology,and the “Human Factor”

In the controversy that broke out in 1911 over Frederick W. Taylor's scientific management, many critics contended that it ignored “the human factor” and reduced workers to machines. Psychologists succeeded in positioning themselves as experts of the human factor, and their instruments and expertise as the necessary complement of Taylor's psychologically deficient system. However, the conventional view that the increasing influence of psychologists and other social scientists “humanized” management theory and practice needs to be amended. Taylor's scientific management was not less human than later approaches such as Human Relations, but it articulated the human factor differently, and aligned it to its own instruments and practices in such a way that it was at once external to them and essential to their functioning. Industrial psychologists, on the other hand, at first presented themselves as engineers of the human factor and made the human mind an integral part of management.     

Can Multimodal and Rational Emotive Behavior Therapy be Reconciled?

The purpose of this article is to determine whether two distinct modes of cognitive-behaviour therapy—Rational Emotive Behaviour Therapy (REBT) and Multimodal Therapy (MMT)—can be reconciled. This quest in the spirit of integrationism is pursued along three lines of inquiry: Do we talk about schools, approaches, or techniques? A reconciliation between MMT and REBT as systems seems not to be feasible, just because of the simple fact that MMT is not a new school with an idiosyncratic theory, whereas REBT is. However, REBT is also a congenial approach consisting of various eclectic techniques, as is MMT. It is explained how the A-B-C format and firing orders of the BASICI.D. modalities stem from an S-O-R model. Furthermore, the circular character of the various modalities (thinking, feeling, and behaving) is recognised both in MMT and in REBT. The techniques used in REBT and MMT overlap for 65–80%, according to a comparative perusal of Ellis's and Lazarus's presentations of preferred techniques. This means that MMT and REBT, as an approach with distinct techniques, “must” be very similar in practice. The conclusion is that philosophically Ellis and Lazarus see eye-to-eye and that MMT and REBT overlap a great deal. But a fusion is not yet at hand. At best the two can be described as two sides of one coin. “When you wake up in the morning, Pooh,” said Piglet at last, “what's the first thing you say to yourself?” “What's for breakfast?” said Pooh. “What do you say, Piglet?” “I say, I wonder what's going to happen exciting today?” said Piglet. Pooh nodded thoughtfully. “It's the same thing,” he said. “What's that?” the Unbeliever asked. “Wisdom from a Western Taoist,” I said. “It sounds like something from Winnie-the Pooh,” he said. “It is,” I said. From The Tao of Pooh Benjamin Hoff (1982)     

Renewing Medicine’s basic concepts: on ambiguity

Background

Edmund Pellegrino lamented that the cultural climate of the industrialized West had called the fundamental means and ends of medicine into question, leading him to propose a renewed reflection on medicine’s basic concepts, including health, disease, and illness. My aim in this paper is take up Pellegrino’s call. I argue that in order to usher in this renewal, the concept of ambiguity should take on a guiding role in medical practice, both scientific and clinical. After laying out Pellegrino’s vision, I focus on the concept of normality, arguing that it undergirds modern medicine’s other basic concepts. I draw on critiques by scholars in disability studies that show the concept of normality to be instructively ambiguous. Discussing the cases of Deafness and body integrity identity disorder (BIID), I argue that if medicine is to uphold its epistemic authority and fulfill its melioristic goals, ambiguity should become a central medical concept.

Methods

In this theoretical paper, I consider how central concepts in the philosophy of medicine are challenged by research on experiences of disability. In particular, the idea that medical knowledge produces universal truths is challenged and the importance of historical, cultural, and otherwise situated knowledge is highlighed.

Results

I demonstrate how experiences of disability complicate dominant theories in the philosophy of medicine and why medical practice and the philosophy of medicine should make ambiguity a central concept.

Conclusions

If medical practitioners and philosophers of medicine wish to improve their understanding of the meaning and practice of medicine, they should take seriously the importance and centrality of ambiguity.

     

Revisiting the need for virtue in medical practice: a reflection upon the teaching of Edmund Pellegrino

Edmund Pellegrino considered medicine as a skill, art, and perhaps most importantly, a moral enterprise. In this essay, I attempt to exemplify how the legacy and contributions of Edmund Pellegrino, as a teacher and a physician, could allow for a renaissance of medical practice in which physicians engage intellectual and moral virtue to both effect sound care, and do so in a humanitarian way, rather than in simple accordance with a business model of medicine. The virtues are viewed in a renewed light as being key characteristics of physicians, and important to patient centered care.     

I Love to Tell the Story: Reshaping the Narrative of Adoption

Abstract : This article argues that a Christian theological understanding of adoption can be a helpful corrective to some of the negative interpretations and assumptions around adoption that continue to circulate in secular culture. The article proceeds as follows: First, I argue that the way in which Christians understand and describe the experience of being adopted into God's family counters the idea that one's birth family is one's “real” family. Second, I argue that a Christian understanding of adoption mitigates the tendency to view adoption as a sort of “Plan B.” Finally, I argue that because of the value Christians place on caring for those in need, and the replacement of kin relationships with relationships of love and faith, the metaphor of adoption can and should be used more widely, to create broader networks of family that encompass far more than mere blood ties.     

Reflex and reflectivity: Wuwei in the Zhuangzi

I will explicate Zhuangzi's conception of wuwei as it is articulated in the image of the ‘hinge of dao.’ First, I will discuss the few actual instances of the term “wuwei’ in the Zhuangzi. Second, I will show that the text uses this imagery to suggest an adaptive or reflective mode of conduct. Third, I will analyse the metaphor of the hinge, and show how this metaphor can illuminate Zhuangzi's notion of wuwei and the behaviour of the realised person. I will show that the hinge represents the way in which the ideal person responds to inevitability, and that Zhuangzi's ideal person could be described as “perfectly well‐adjusted”. Finally, I will demonstrate that this reading offers new meanings and textures to a text that has long been read in only certain ways, so that many of its subtleties have been overlooked.