Engagement and suffering in responsible caregiving: On overcoming maleficience in health care

The thesis of this article is that engagement and suffering are essential aspects of responsible caregiving. The sense of medical responsibility engendered by engaged caregiving is referred to herein as ‘clinical phronesis,’ i.e. practical wisdom in health care, or, simply, practical health care wisdom. The idea of clinical phronesis calls to mind a relational or communicative sense of medical responsibility which can best be understood as a kind of ‘virtue ethics,’ yet one that is informed by the exigencies of moral discourse and dialogue, as well as by the technical rigors of formal reasoning. The ideal of clinical phronesis is not (necessarily) contrary to the more common understandings of medical responsibility as either beneficence or patient autonomy — except, of course, when these notions are taken in their “disengaged” form (reflecting the malaise of “modern medicine”). Clinical phronesis, which gives rise to a deeper, broader, and richer, yet also to a more complex, sense than these other notions connote, holds the promise both of expanding, correcting, and perhaps completing what it currently means to be a fully responsible health care provider. In engaged caregiving, providers appropriately suffer with the patient, that is, they suffer the exigencies of the patient's affliction (though not his or her actual loss) by consenting to its inescapability. In disengaged caregiving — that ruse Katz has described as the ‘silent world of doctor and patient’ — provides may deny or refuse any ‘given’ connection with the patient, especially the inevitability of the patient's affliction and suffering (and, by parody of reasoning, the inevitability of their own. When, however, responsibility is construed qualitatively as an evaluative feature of medical rationality, rather than quantitatively as a form of ‘calculative reasoning’ only, responsibility can be viewed more broadly as not only a matter of science and will, but of language and communication as well — in particular, as the task of responsibly narrating and interpreting the patient's story of illness. In summary, the question is not whether phronesis can ‘save the life of medical ethics’ — only responsible humans can do that! Instead, the question should be whether phronesis, as an ethical requirement of health care delivery, can ‘prevent the death of medical ethics.’     

Clinical wisdom in psychoanalysis and psychodynamic psychotherapy: a philosophical and qualitative analysis

To precisely define wisdom has been an ongoing task of philosophers for millennia. Investigations into the psychological dimensions of wisdom have revealed several features that make exemplary persons "wise." Contemporary bioethicists took up this concept as they retrieved and adapted Aristotle's intellectual virtue of phronesis for applications in medical contexts. In this article, we build on scholarship in both psychology and medical ethics by providing an account of clinical wisdom qua phronesis in the context of the practice of psychoanalysis and psychodynamic psychotherapy. With the support of qualitative data, we argue that the concept of clinical wisdom in mental healthcare shares several of the key ethical dimensions offered by standard models of phronesis in medical ethics and serves as a useful, albeit overlooked, reference point for a broader development of virtue-based medical ethics. We propose that the features of clinical wisdom are pragmatic skills that include, but are not limited to, an awareness of balance, the acceptance of paradox, and a particular clinical manner that maintains a deep regard for the other. We offer several suggestions for refining training programs and redoubling efforts to provide long-term mentorship opportunities for trainees in clinical mental healthcare in order to cultivate clinical wisdom.     

Phronesis, Poetics, and Moral Creativity

At least since Aristotle, phronesis (practical wisdom) and poetics (making or creating) have been understood as essentially different activities, one moral the other (in itself) non-moral. Today, if anything, this distinction is sharpened by a Romantic association of poetics with inner subjective expression. Recent revivals of Aristotelian ethics sometimes allow for poetic dimensions of ethics, but these are still separated from practical wisdom per se. Through a fresh reading of phronesis in the French hermeneutical phenomenologist Paul Ricoeur, I argue that phronesis should be viewed as at least in part poetic at its very core. That is, phronesis deals with the fundamentally tragic human situation of moral incommensurability, and it responds to this by making or creating new moral meaning. Such a poetics of practical wisdom helps phronesis stand up to significant and important critiques made of it by a range of modernists and post-modernists, pointing a way forward for some important contemporary moral debates.     

Why the Practice of Medicine is Not a Phronetic Activity

This essay argues that the practice of medicine is not a phronetic activity in the original Aristotelian sense of that term. Jonsen and Toulmin are two philosophers who have conflated the techne of medicine with phronesis. This conflation ignores Aristotle's crucial distinction between techne and phronesis and his use of the medical analogy. It is argued that medical reasoning is similar to phronesis but does not exemplify it. Phronesis will not save the life of medical ethics. The concept could be utilized as a moral prosthetic.     

Reckoning with the last enemy

Developing the ethics of palliative sedation, particularly in contrast to terminal sedation, requires consideration of the relation between body and soul and of the nature of death and dying. Christianly considered, it also requires attention to the human vocation to immortality and hence to the relation between medicine (as aid for the body) and discipline (as aid to the soul). Leaning on Augustine’s rendering of the latter, this paper provides a larger anthropological and soteriological frame of reference for the ethics of palliative sedation, organized by way of nine briefly expounded theses. It argues that palliative sedation, like other elements of medicine, is appropriate where, and only where, it properly orders care for the body to the requirements of care for the soul.     

The destiny of modern virtue ethics

The revival of Aristotelian virtue ethics since the 1980s does not signify that it goes back to its original form; rather, it is generally manifested in three different variations: The first is a variation of what is known as communitarianism, the second is universalism, and the third is phronesis. On the social level of morality, the serious attempt of modern virtue ethics towards improving the moral spirit of society is laudable. However, its method and reasoning deviates greatly from the demands of modern society’s integration of its operating rules and regulations, and concept of values; hence all of its attempts can hardly escape the fate of becoming just a fantasy. Yet, on the level of dealing with ethic conflicts and moral paradox, modern virtue ethics—via interpreting the theory of phronesis by Aristotle—proposes the valuable thought of a balanced morality that principlism should concern itself with and nourish itself from.     

晚期癌症患者宁养疗护与伦理

晚期癌症患者宁养疗护强调人的生活质量与生命价值,其在实践中得到了长足的发展,正成为姑息医学中的重要部分。随着医学向生物心理社会医学模式转变和姑息医学快速发展,宁养疗护伦理问题日益凸显。宁养疗护伦理在医疗方面强调适度治疗与合理用药,护理方面强调患者生理、心理、灵性、社会和宗教等层面的整体性照顾。梳理宁养疗护伦理有利于在宁养疗护服务中做出最优伦理选择,这种选择需遵循不伤害原则,注重生命质量原则、适度治疗和舒适生存原则、尊重患者意愿原则以及公平正义的原则。     

Liminality: the transforming grace of in-between places

Richard Rohr suggests that the only way out of a person's entrapment in "normalcy, the way things are," is to be drawn into sacred space, often called liminality, where he believes all genuine transformation occurs. Liminality, from the Latin word for threshold, is the state of being betwixt and between where the old world has been left behind but we have not yet arrived at what is to come. This article attempts to develop an understanding of liminality using metaphors of wilderness, tomb, and exile as found in the Jewish and Christian Scriptures. It seeks to reconcile the paradox of the apparent hiddenness of God and the concurrent opportunity to see Him in new ways that occurs in these times. Pastoral care and counseling applications for those working with people in liminal space are briefly engaged.     

Out of the Loop: (In)access to Health Care for Migrant Workers in Canada

Drawing on a survey of nearly 600 migrant farm workers in Ontario, Canada, we investigate the ways in which the liminality of temporary migrants is both conditioning and consequential in terms of health for these migrants. In particular, we demonstrate how the liminality inherent in managed temporary migration programmes creates the conditions for heightened vulnerability, which also have consequences for the health of migrant workers and their access to care. We discuss common barriers to health care access experienced by migrant workers, including employer mediation, language differences, and hours of work.     

ICU临终患者治疗抉择的伦理问题

医生面对ICU临终患者很难抉择是应该积极治疗到底还是提供舒适的保守治疗,目前相关的伦理及法律问题仍尚需完善,伦理指导是一项解决纠纷、政善沟通有效的工具,成立伦理委员会对医生进行合理的建议和指导是非常必要的。     

Do Confucians Really Care? A Defense of the Distinctiveness of Care Ethics: A Reply to Chenyang Li

Chenyang Li argues, in an article originally published in Hypatia, that the ethics of care and Confucian ethics constitute similar approaches to ethics. The present paper takes issue with this claim. It is more accurate to view Confucian ethics as a kind of virtue ethics, rather than as a kind of care ethics. In the process of criticizing Li's claim, the distinctiveness of care ethics is defended, against attempts to assimilate it to virtue ethics.     

Out of the depths

A fundamental approach of theology as practiced within the palliative setting is care for the whole human being, with particular focus on spirituality and the spiritual dimension. Theology and medicine come together in palliative care in which the spiritual aspect is an important component together with the physical, psychological, and social. This article is based on a mixed methods study of spirituality among persons receiving palliative care. Findings revealed the importance of spirituality and its multidimensional elements by which spirituality was perceived as a complex phenomenon relating to religious and non-religious aspects of human life. Theological reflection based on the present findings indicates that a sharp distinction between the concepts of religion and spirituality is not beneficial. It also reveals the significance of the spiritual dimension and that theology has an important role in creating a deeper understanding of this complex part of human existence. Spiritual needs, expressed in various ways, were evident among the participants receiving palliative care. The findings confirm that the theological approach in palliative care, with its focus on the whole human being and emphasis on spirituality and the spiritual dimension, continues to be the hallmark of practicing theology within palliative care.     

Revisiting Confucian Jen Ethics and Feminist Care Ethics: A Reply to Daniel Star and Lijun Yuan

At two fronts I defend my 1994 article. I argue that differences between Confucian jen ethics and feminist care ethics do not preclude their shared commonalities in comparison with Kantian. utilitarian, and contractarian ethics, and that Confucians do care. I also argue that Confucianism is capable of changing its rules to reflect its renewed understanding of jen, that care ethics is feminist, and that similarities between Confucian and care ethics have significant implications.     

姑息治疗及其在肿瘤学中的地位

本文对姑息治疗的历史及概念作了详细的介绍,解释了其不同阶段的内涵,作为医学学科之一,姑息治疗的内容主要包括了疾病伴随或治疗所致症状的诊断评估、预防和治疗,心理和非癌性躯体疾病的预防和治疗,姑息治疗的科研、教学和教育以及终末期病人的治疗和护理等,特别纠正了对“安乐死”的看法。在肿瘤学中,经过40多年,它已从治疗中的辅助角色迅速成为肿瘤综合治疗中的主角,且贯穿于始终。它倡导多学科协作,与抗癌治疗完整结合,对无法治愈的晚期癌症患者以缓解症状、改善生活质量为主要目标,在全球范围内,很大一部分晚期肿瘤病人已从姑息治疗中明显获益。它的有力实施,也是我们创建和谐社会的重要反映。     

I Believe I Am So Called: Reflections on a Vocation in Medical Education

This essay is concerned with the fulfillment of ordination commitments through a pastoral role in medical education and review of medical research with human subjects. Stylistically, it combines memoir with the genre known as “creative non-fiction.” Its major issues have to do with the identity formation and transformation of the author, the function and ethics of institutional review boards, the teaching of medical ethics to medical students, and courses involved in the doctor–patient relationship and in palliative care intended to increase the sensitivity and self-awareness of physicians-in-becoming. This essay was presented in its initial form at the Annual Fellows Meeting of the Society for Values in Higher Education in 2010.     

志愿者在晚期肿瘤适度治疗中的重要作用

对于晚期肿瘤患者,舒缓治疗和宁养服务是WHO推荐的适度治疗,更是一种“积极治疗”,特别体现在提供社会、心理、灵性关怀及支持系统,帮助患者尽可能以积极的态度活着,直到死亡。本文探讨了志愿者在晚期肿瘤适度治疗中的重要角色,发挥作用的机制,并提出对我国舒缓治疗和宁养志愿服务发展的思考与建议。     

The Ethic of Care vis-â-vis the Ethic of Rights: A Problem for Contemporary Moral Theory

Carol Gilligan has delineated two ethics, the ethic of rights and the ethic of care. In this article I argue that the two ethics are part of one overall system, the ethic of care functioning as a necessary base for the ethic of rights. 1 also argue that the system is seriously flawed. Because women are held accountable to both ethics and because the two ethics frequently conflict, women recurrently find themselves in a moral double bind.     

The case of Peter: reflections on applied ethics in a neonatal intensive care unit

The case of Peter is reflected upon in order to highlight some of the moral theorising that could be brought to bear in the process of providing palliative care for sick neonates. The situation will be discussed using the theoretical lenses of deontological and virtue ethics. Nursing practice is considered as engaged moral reasoning where the nurse brings his/her beliefs, knowledge and experience into the situation and engages in reflexivity to provide appropriate ongoing patient care. The care should be provided in culturally sensitive manner and tailored to the needs of the newborn and their family. Nurses should initiate early consultations with colleagues, medical staff and families to address concerns about patient well-being in order to enhance the well-being of patients and families and to improve the work environment making it more conducive to care.     

Imagining ethical globalization: The contributions of a care ethic

Approaches to global ethics have drawn on a number of diverse theoretical traditions, such as Kantianism and utilitarianism. While emerging frameworks contribute to a growing awareness of and interest in ethics within a global society, the values that they prioritize are not adequate for realizing a just, equitable and fair system of global governance. This article considers the possibilities of an alternative ethic—a feminist ethic of care—and explores how it can bear on present circumstances, including global inequity and injustice. This care ethic has been put forward as a viable normative approach to politics and policy. Little attention, however, has been paid to the potential of a care ethic within the globalization and ethics debate. This article illustrates how the values and corresponding principles of care, grounded in relationships and responsibilities, are essential to responding adequately to the current challenges of globalization. By examining the relevance of care in this context, the article seeks to broaden dominant ethical worldviews and contribute to the articulation of normative tools for examining globalization while at the same time avoiding the trappings of conventional universality—the abstract and a priori thinking typically associated with conceptions of global ethics.     

面对死亡，医学仍有责任

1998年,李嘉诚先生捐建了中国大陆第一家宁养院,为贫困的晚期癌症病人提供免费的疼痛控制,心理辅导和生命伦理的关怀。三年后,李嘉诚基金会将这一项目推向全国,创立“全国宁养医疗服务计划”,提出了“以人为本,全人服务”的服务宗旨,给国内的医疗工作开启了一个新的视野。宁养疗护以“五全照顾”充分体现了以人为本,尊重生命的医学本质。医学不仅仅是科学,它更应该是研究人的“仁”学;面对迈向死亡的末期病人,协助病人坦然面对,减少身、心、灵的痛苦,协助其放下万缘,安详往生也是我们医者的责任。