Toward a Pellegrino-inspired theory of value in health care

Contemporary medical practice and health policy are increasingly animated by the concept of providing high value care. Nevertheless, there can be disagreements about how value is defined and from whose perspective. Individual patients suffering from terminal cancer, for example, may have a different perception of the value of an expensive chemotherapy when compared to health policymakers, insurers, or others responsible for the financial solvency of health care organizations. Thus it seems reasonable to ask what is meant by “value” in high value care. In light of Edmund Pellegrino’s significant contributions to the philosophy of medicine, medical humanities, and bioethics, it seems equally reasonable to examine how he might answer it. This paper describes a Pellegrino-inspired theory of (health care) value that is instrumental, agent relative, and pluralistic. It then compares and contrasts this to the contemporary view and argues that only when individual patients incorporate concern for societal-level value into their conceptions of the highest good can the Pellegrino-inspired and contemporary views of value be reconciled.

     

<Emphasis Type="Italic">Recta Ratio Agibilium</Emphasis> in a medical context: the role of virtue in the physician-patient relationship

Acting for the good of the patient is the most fundamental and universally acknowledged principle of medical ethics. However, given the complexity of modern medicine as well as the moral fragmentation of contemporary society, determining the good is far from simple. In his philosophy of medicine, Edmund Pellegrino develops a conception of the good that is derived from the internal morality of medicine via the physician-patient relationship. It is through this healing relationship that rights, duties, and privileges are defined for both physicians and patients. Moreover, this relationship determines the characteristics or virtues that are necessary to engage in the medical telos. This paper addresses the role of the moral virtues in clinical medicine and the physician-patient relationship. First, it provides a brief background of the Aristotelian foundations of virtue-ethics. Second, it delves into Pellegrino’s philosophy of medicine understood as a practice oriented towards a teleological goal. Third, it relates the telos of medicine to the notion of the medical community as a fundamentally moral community. Finally, it concludes with a section that creates a dialogue between virtue ethics and principlism.     

An integral approach to health science and healthcare

Defining disease and delineating its boundaries is a contested area in contemporary philosophy of medicine. The leading naturalistic theory faces a new round of difficulties related to defining a normal environment alongside normal organismic functioning and to delineating a discrete boundary between risk factors and disease. Normative theories face ongoing and seemingly intractable difficulties related to value pluralism and the problematic relation between theory and practice. In this article, I argue for an integral—as opposed to a hybrid—philosophy of health based on Bernard Lonergan’s notion of generalized empirical method that provides a way to settle these difficulties dynamically and comprehensively, both in theory, by orienting functional and statistical investigation toward an explanatory ecological viewpoint, and in practice, by framing critiques in relation to the normativity intrinsic to all human inquiry.     

Incurable suffering from the “hiatus theoreticus”? Some epistemological problems in modern medicine and the clinical relevance of philosophy of medicine

Up to now neither the question, whether all theoretical medical knowledge can at least be described as scientific, nor the one how exactly access to the existing scientific and theoretical medical knowledge during clinical problem-solving is made, has been sufficiently answered. Scientific theories play an important role in controlling clinical practice and improving the quality of clinical care in modern medicine on the one hand, and making it vindicable on the other. Therefore, the vagueness of unexplicit interrelations between medicine's stock of knowledge and medical practice appears as a gap in the theoretical concept of modern medicine which can be described as Hiatus theoreticus in the anatomy of medicine. A central intention of the paper is to analyze the role of philosophy of medicine for the clarification of the theoretical basis of medical practice. Clinical relevance and normativity in the sense of modern theory of science are suggested as criteria to establish a differentiation between philosophy of medicine as a primary medical discipline and the application of general philosophy in medicine.     

The anthropological tradition in the philosophy of medicine

The tradition of anthropological medicine in philosophy of medicine is analyzed in relation to the earlier interest in epistemological issues in medicine around the turn of the century as well as to the current interest in medical ethics. It is argued that there is a continuity between epistemological, anthropological and ethical approaches in philosophy of medicine. Three basic ideas of anthropologically-oriented medicine are discussed: the rejection of Cartesian dualism, the notion of medicine as science of the human person, and the necessity of a comprehensive understanding of disease. Next, it is discussed why the anthropological movement has been superseded by the increasing interest in medical ethics. It is concluded that the present-day moral issues cannot be interpreted and resolved without clarification of the underlying anthropological images.     

Death,medicine & bioethics

The assumptions of philosophy need scrutiny as much the assumptions of medicine do. Scrutiny shows that the philosophical method of bioethics is compromised, for it shares certain fundamental assumptions with medicine itself. To show this requires an unorthodox style of philosophy — a literary one. To show the compromised status of bioethics the paper discusses some seminal utilitarian discussions of the definition of death, of whether it is a bad thing, and of when it ought to occur.     

Understanding the Trusted Doctor and Constructing a Theory of Bioethics

This paper offers a constructivist account of bioethics as an alternative to previous discussions that explained the ethics of medicine by an extrapolation of principles or virtues from ordinary morality. Taking medicine as a higher and special calling, I argue that the practice of medicine would be impossible without the trust of patients. Because trust is a necessary condition for medical practice, the ethics of the profession must provide the principles for guiding physician behavior and the profession toward promoting trust and being trustworthy. In a phrase, that principle is “seek trust and deserve it.” I sketch out how the concept of trust provides a different justification for common sense principles of bioethics and explain how the concept of trust provides reasonable guidance for resolving moral conflicts within medicine. The trust-seeking approach provides a new and unexpected ordering of some traditional medical values, it reveals the weightiness of previously undervalued bioethical precepts, and illuminates the centrality of some largely ignored obligations of medicine. It also has the power to guide clinical practice and to inform the profession about standards for medical institutions. This revised version was published online in August 2006 with corrections to the Cover Date.     

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.

     

Christian bioethics, secular bioethics, and the claim to cultural authority.

Though the papers in this volume for the most part address the question, "What is Christian about Christian Bioethics", this paper addresses instead a closely related question, "How would a Christian approach to bioethics differ from the kind of secular academic bioethics that has emerged as such an important field in the contemporary university?" While it is generally assumed that a secular bioethics rooted in moral philosophy will be more culturally authoritative than an approach to bioethics grounded in the contingent particularities of a religious tradition, I will give reasons for rejecting this assumption. By examining the history of the recent revival of academic bioethics as well as the state of the contemporary moral philosophy on which it is based I will suggest that secular bioethics suffers from many of the same liabilities as a carefully articulated Christian bioethics. At the end of the paper I will turn briefly to examine the question of how, in light of this discussion, a Christian bioethics might best be pursued.     

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.     

Roles of moral philosophy in appropriated bioethics: a response to Baker and McCullough

Strong arguments support the notion that much of modern bioethics is a result of appropriation rather than strict application of traditional moral philosophy. Nevertheless, it is important to recognize these sources and approaches associated with them, even when working with appropriated theories, since traditional ethical theory does and should influence modern bioethics.     

CURRENT TRENDS IN THE PHILOSOPHY OF MEDICINE

Abstract. The philosophy of medicine, a developing discipline, is defined as critical reflection on the activity of medicine. The clinical encounter is both its central aspect and the focus for philosophical analysis. The most systematic example of this discipline employs a mixture of empiricism and phenomenology. Systems thought presents an organizing schema by which the philosophy of medicine can move toward a more comprehensive and fundamental analysis of its own agenda, which includes four main topics: understanding the patient-physician interaction, concepts of health and disease, foundations of medical ethics, and the dialogue between medicine and the larger culture.     

Making good choices: toward a theory of well-being in medicine

The principle of beneficence directs healthcare practitioners to promote patients’ well-being, ensuring that the patients’ best interests guide treatment decisions. Because there are a number of distinct theories of well-being that could lead to different conclusions about the patient’s good, a careful consideration of which account is best suited for use in the medical context is needed. While there has been some discussion of the differences between subjective and objective theories of well-being within the bioethics literature, less attention has been given to the questions of what work a theory of well-being needs to do in bioethics and which standards of success ought to be used in selecting a theory of well-being for use in medicine. In this article, I argue that traditional theories of well-being developed in philosophy are not well suited to meet the needs of the medical context. For the principle of beneficence to be most useful, the underlying account of well-being should satisfy two conditions: first, it needs to lead to a concrete, action-guiding determination of the patient’s good; and, second, any recommendations it offers need to be justifiable to patients. Standard accounts of well-being have difficulty satisfying both conditions. Exploring the limitations of these theories when applied to treatment dilemmas helps point the way toward the development of an account of well-being better suited to healthcare.     

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.     

Bioethics in the twenty-first century: why we should pay attention to eighteenth-century medical ethics.

Those of us who work in the field of bioethics tend to think that, because the word "bioethics" is new, so too the field is new in all respects, but we are not the first to do bioethics. John Gregory (1724-1773) did bioethics just as we do it, at least two centuries before we thought to do it. He deployed philosophical methods as sophisticated as our own. Indeed, Gregory took up the very best moral philosophy available to thinkers of the Scottish Enlightenment, namely, David Hume's moral philosophy and its core concept of sympathy. Gregory also responded in a conceptually powerful and clinically applicable way to the problems of his time, just as we do. I want here to outline Gregory's accomplishment and to identify some aspects of its importance for bioethics in the twenty-first century.     

给予老年人体面的照护：为什么尊严很重要——欧洲经验

在医学哲学领域以及相关领域中,“尊严”的概念越来越受到关注。最近,在生物伦理学的国际会议中很流行这个概念。同时,在欧洲的许多国家中,“尊严”的概念也被引入到有关卫生保健的国家立法和政策制定中。本文将从检验一个在关于尊严和老年人的欧洲计划中产生的尊严理论模型开始。然后根据参与这个计划的老年人和卫生及社会保健的专业人员那里得到的经验进行研究,有6个国家参加这项研究。结果证明尊严是一个非常重要的事情,尤其是对那些弱势群体来说。本文结论认为对于虚弱的老年人,相对于那种强调自主的医学伦理,长期的保健需要注重一个范围更为广泛的伦理内容。     

论医学哲学范畴

医学哲学范畴是医学哲学理论体系中最基本和最深刻的概念,是人们把握生命和健康问题的认识纲领,是对医学问题进行逻辑归类的思维形式。医学哲学范畴是哲学与医学之间多重学术关系的统一,是抽象性与具体性、普遍性与特殊性、稳定性与变易性的结合,体现了学术价值、实践价值和文化价值的等多重价值。医学哲学范畴研究以创新研究为灵魂,以基础研究为根本,以应用研究为标的。