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XXth EUROPEAN CONFERENCE
ON PHILOSOPHY OF MEDICINE AND HEALTH CARE
“Medicine, philosophy
and the humanities”
Organised by
The European Society for Philosophy of Medicine and Healthcare
(ESPMH) and the Finnish Society for Philosophy of Medicine.
August 23-26, 2006
House of Sciences,
Helsinki, Finland
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Abstracts
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The arts and the humanistic sciences in medicine - a case of synergism
Ahlzén, Rolf (Sweden)
The rise of medical humanities as a field of study may be seen as a continuation and an extension of the booming
medical ethics project of the eighties and the nineties. The latter was largely an answer to what was in wide
circles seen as shortcomings of modern scientific medicine, where patients were said to be reduced to objects by
the impersonal medical gaze. When the expectations attached to clinical ethics proved to be somewhat
exaggerated, demands increased for a broader perspective. The answer once again came from the west, where in
the US medical humanities in the nineties was already institutionalized and at work at several places.
The introduction of medical humanities into medical curricula, and the attempt to use methods and experiences
from this broad field in the analysis of modern medicine, has in many respects been successful. It has no doubt
deepened our understanding of what goes on in clinical medicine. However, there has been and still is a
fundamental uncertainty as to what shall count as medical humanities.
If we look at common interpretations of the word “humanities” we realize that it is broad enough to comprise
areas of knowledge and experience that are strikingly different. Somewhat simplified, “humanities” may be seen
as both the critical and scientific study of human matters (fields like philosophy, history, literary theory, history
of art, anthropology, semantics etc etc, with a very unclear delimitation against the social sciences), and the arts
proper – that is: music, art, literature, drama. The contributions that these two general fields of experience and
knowledge may give to clinical medicine differ in kind.
It will be argued that the humanistic sciences have a critical task to perform in relation to clinical medicine. The
study of these fields contributes to our analytic understanding of what goes on in clinical medicine. Conceptual
clarity, consistency of thought, historical relativisation are goals that are served by the humanistic sciences. By
contrast, and complementary to this, the arts themselves have what I prefer to call an imaginative contribution to
make. The arts invite us to see fictive reality as suggestions as to how things could be: our imagination is moved
by this. This does not, however, mean that there are no imaginative elements in humanistic sciences and no
critically analytical in our encounter with the arts. These fascinating interrelations will be further explored in the
presentation.
Looking into Medical Scores
Andronikof, Mark & Légaut, Côme (France)
Medical practice for the last decades has been continuously irrigated by new scoring tools. But who uses them?
For what purpose? What are the underlying concepts? To answer these questions we tried to look into all the
scores we could find by searching medical databases and books.
Skor from Norse origin, stood for “cut”. In 2005 we found 650 scoring tools in use in the medical field. Mostly
in anaesthesiology (70), gastro-enterology (83) and psychiatry (96) but every medical field develops its own (59
found for emergency practice). The 650 scores we assessed are only part of the everyday expanding universe of
scoring tools. They are intended for three main but different purposes: epidemiological or statistical, diagnostic,
decision making. Whether the score user is clearly aware of these fundamental differences is unsure.
The reason for the growing interest in their use may be their claim to expose plainly in numbers, almost for the
lay person, what beforehand was attained by hard work or long experience. Implications are multiple.
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Communication is thought to be better between health care providers themselves and between doctors and their
patients (or their family). These tools are profitable for research, publication and, unmistakably, for legal matters
too.
As each tool must be named, a new medical vocabulary appears: Glasgow, RLS85, APACHE, NYHA, etc. etc.
but whether these are scores, indexes, rules or scales is left to their author’s opinion… It seems that several
words are linked to the same concept and that a clear nomenclature has yet to be defined. The pitfall in the use of
scoring tools is to think that any good medicine is of quantitative nature (can be put in numbers) or that the use
of scoring tools guarantees a good medicine. When any human being can be cut into pieces using scoring
criteria, is thus the cognition enhanced or, on the contrary, is the jigsaw becoming more complex? Here, as often,
what is put at stakes is the art of caring for the human being as a whole.
The Trials and Tribulations of Teaching Philosophy and Other Courses in Medical Humanities
Aultman, Julie M. (USA)
As a philosopher and medical educator, I have experienced the angst of teaching medical humanities, namely
philosophy, to those students who believe and openly voice that such courses are “a waste of their time” and are
ineffective in teaching them how to be good doctors. While there are a handful of students who do appreciate
having courses in the humanities and enter the classroom with open minds and an overall desire to learn as much
as they can, my concern rests with those students who enter the classroom with negative attitudes, wrongfully
assuming that we are here to tell them how to feel, act, think, and believe in order to be good doctors. Upon
confronting my disinclined students, I have learned that much of their negativity stems from a learned
misinterpretation and misunderstanding of what philosophy is and what it can do, along with the disbelief that
philosophy, literature, and other courses in the humanities can impact their professional and moral development.
I have also learned that even among medical educators who teach courses in the humanities, these areas of
inquiry and application are ostensibly taught under the assumption that students do not need to know, for
example, the theoretical basis for understanding such concepts as “autonomy”. In this paper presentation, I will
explore why students resist humanities courses, especially philosophy, and some of the various approaches I
have used to engage students, to develop their critical thinking skills and moral imagination, and to foster their
understanding and appreciation of the concepts and practices of medicine on a deeper, more theoretical level. For
example, in teaching fourth year medical students, I use John Rawls’ Wide Reflective Equilibrium to show how
ethical theory, our judgments about the world, and our background beliefs and theories (such as our culture and
religion) can all cohere so that our decisions, actions, and beliefs about who we are and who we would like to be
can be better understood and applied to real-life situations. Using this approach gives students the ability to see
how their own worlds can connect with their patients’ worlds, and how moral dilemmas can be resolved. I will
also explore how we educators can teach each other to appreciate the value of philosophy and other areas within
the humanities so that we become better role models for our students.
Legal paternalism: Friend or foe? Fundamental tensions in therapeutics
Badcott, David (UK)
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For many societies, particularly those within Europe and North America, medical practice and certain other areas
of health care are rigorously controlled by legislation. There are seemingly good reasons for this: members of the
public are protected from charlatans or incompetent practitioners and importantly the inherent risks of selfmedication with potent and sometimes hazardous medicines. In the latter respect, not only medical practitioners
but also regulatory authorities can act as gatekeepers for potent medicines having evolved their pivotal status
since the thalidomide tragedy of the early 1960s. And health authorities may limit access to what are often
expensive new therapies by blocking availability of medicines or refusing reimbursement.
But the last few decades or so have been characterised by change and an increasing refusal to simply submit to
regulatory “authority” or the strictures of public bodies. Probably the best example has been the success by
AIDS activists through aggressive lobbying to obtain access to experimental treatments. And such pressures
have resulted in rethinking the often taken-for-granted basis of placebo controlled clinical trials. More recently
individuals in the UK have bucked a presumed presumption of the necessity of mass lobby and overcome initial
refusals for access to expensive and unlicensed medicinal treatments thereby setting precedent.
Are these circumstances (special access programmes, compassionate release and fast tracking) indicative of the
inadequacy of previous “rational” therapeutic policies? The paper will examine the fundamental issues and
consider the implications.
Nozick's Experience Machine and Palliative Care: revisiting Hedonism
Barilan, Y. Michael (Israel)
This presentation focuses on Nozick's argument against hedonism. Whereas Nozick offered a hypothetical
thought experiment, known as the Experience Machine, I argue that end of life suffering provides a
philosophically equal experiment which validates Nozick's observations and conclusions. The fact that the most
patients do no wish for euthanasia or terminal sedation show that people in general are not hedonist. Moreover,
although all three options are hedonistically equivalent, those who choose not to go on with conscientious
existence express a clear preference of death to sedation or permanent vegetative states. This constitutes strong
evidence against hedonism. I explore its implications on the philosophical foundations of palliative care.
The Centrality of Dignity, Solidarity and Vulnerability in Bioethics. Reflections of a North American
Physician
Barnet, Robert (USA)
These comments will be based on the reflections of a North American physician who has been involved in
medical ethics for almost 25 years. This presentation will critique, among others, the approach of Physician and
Ethicist Edmund Pellegrino, who described the classic understanding of the healing encounter between
physicians and the patient with an emphasis on virtue. Principalism, which has a dominant force in bioethics for
more than thirty years will also discussed. The need to re-examine the Kennedy mantra of non-maleficence,
beneficence, autonomy and justice will be emphasized.
As manifestation of the changing reality, new insights and the need to re-examine the early approaches to
bioethics, The Charter on Professionalism, The Tavistock Statement of Ethical Principles and The UNESCO
Statement on Bioethics will be examined. Finally, the Barcelona Declaration with its emphasis on autonomy,
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human dignity, vulnerability and integrity will be discussed. The importance and relevance of the concepts of
dignity, solidarity and vulnerability will then be explored in more detail.
I will propose, from my perspective as a physician, a set of five ethical principles to guide health care in the
future. I will argue that they are foundational and appropriate to our times. The framework will include nonmaleficence, beneficence, respect for the dignity of the human person, solidarity and recognition of the
vulnerability of the Other.
Biomedicine as an ontological whole: the intersections of scientific reason, cultural meaning and social
power
Baronov, David (USA)
Biomedicine is the most fundamental concept informing Western medicine. Commonly, biomedicine and
Western medicine are simply conflated as if one and the same. At the same time, the concept of biomedicine
(and its ontological status) is highly contested. For some, the term is merely a predicate for scientific medicine.
Others treat biomedicine as just another local ethnomedicine. Still others, describe it as a kind of social
institution. To grasp biomedicine, it is, therefore, necessary to first determine what type of phenomena, forms
and categories constitute it as an object for investigation? Biomedicine occupies three ontological spheres—
corresponding with three levels of abstraction. As a thing, biomedicine consists of concrete facts (truths) that are
observable and verifiable. As a symbol, biomedicine is a cultural representation whose meanings faithfully reify
the predominant social values and beliefs. As a social relation, biomedicine is a social institution that is itself a
historical abstraction—an expression of underlying social power relations.
Each interpretation reflects a unique set of ontological forms and categories and corresponds to a specific level
of abstraction. Each reveals a particular facet of biomedicine and thus all are necessary for a full understanding
of biomedicine. As a product of the dynamic interaction (and creative tension) between ontological spheres,
privileging one facet above another reduces biomedicine to a flat, three-sided figure—a figure comprised of
three discrete sides versus a figure constituted by the ongoing articulation of its three sides.
Integrating these three ontological spheres necessarily results in a conceptual representation that sustains internal
contradictions as a premise of its being. Thus, understood as an Ontological Whole, biomedicine contains
multiple, embedded ontological spheres. Representations of biomedicine neglecting any one of these spheres will
be distorted and one-sided. Representations of biomedicine incorporating all of these spheres will be
contradictory and subject to constant revision. The task is not to combine (nor reconcile) these three spheres.
Positivist logic (of biomedicine as a thing) and hermeneutic interpretation (of biomedicine as a symbol), for
example, are not compatible. The task is to simultaneously develop each of these spheres as (interdependent)
reflections of the multi-faceted nature of biomedicine as an Ontological Whole. The purpose of this paper,
therefore, is to outline and navigate a basic strategy for representing biomedicine as an Ontological Whole and to
consider the theoretical-conceptual consequences thereof.
Arguments from Rationality and Morality: The Case of Reproduction
Bennett, Rebecca (U.K)
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Matti Häyry argues in his “A Rational Cure for Prereproductive Stress Syndrome” (JME 2004) that not only is
the choice to have children always an irrational choice but it is necessarily an immoral choice. Thus, for Häyry
“human reproduction is fundamentally immoral”. In this paper I consider the arguments put forward by Häyry in
order to assess his claim that it is always wrong to reproduce. I will argue that even though the choice to bring to
birth a child is, on many levels, a highly irrational and an invariably a selfish choice this does not necessarily
make our choices to reproduce morally unacceptable. In fact I will argue that if we create a world governed by
the principles Häyry advocates, not only would we fail in his aim to produce a world morally superior to our
current world, but we would also produce an inferior grey and joyless world where individual autonomy is
completely disregarded.
Attributions of responsibility within health care policy: sharing out responsibility within a situation of
inequity
Boddington, Paula & Räisänen, Ulla (UK)
In health care policy documents and discussion, responsibility for different aspects of health is frequently
attributed to various involved parties but this can be highly problematic. Responsibility may be parcelled out for
various different factors involved in explaining or addressing a situation, such as responsibility for providing
health care facilities to one party, and responsibility for dietary behaviour to another. With considerably more
difficulty, various degrees of responsibility for a situation may be assigned. Health care policy may attempt to
link attributions of responsibility with a causal analysis of the sources of health and ill-health, and with evidence
of effective treatment and prevention.
However other factors are also involved, such as ideological, historical and ethical ideas about responsibility and
blame for current situations, as well as views on the relative responsibilities of different agents and groups in
situations of social inequality and cultural difference. Attributions of responsibility may be made relative to the
power and resources an agent has for addressing a situation. Hence the situation of individuals and groups of
people who are relatively lacking in power and resources is of particular interest. This paper aims to use
philosophical and discourse analysis to explicate notions of shared and mutual responsibility for health in such
situations of social inequity.
Our work is largely concerned with accounts of causality and responsibility for preventable chronic
multifactorial diseases, such as coronary heart disease and Type 2 Diabetes. We examine how policy documents
concerning these and other preventable health problems discuss the responsibilities of different parties, such as
individuals, communities, health care providers and government agencies. We are particularly looking here at
communities where issues of greater disease prevalence and of social and economic inequalities present
themselves. These include for instance, South Asians within the UK and indigenous populations such as
Australian Aboriginal peoples.
For example, the Australian government has recently initiated shared responsibility agreements with various
Aboriginal communities, such as an agreement with the Mulan community of Western Australia providing petrol
pumps in exchange for behaviours such as washing and showering aimed at lowering high rates of trachoma
infection. These ‘shared responsibility agreements’ are intended by the government to cohere with a philosophy
of welfare reform that shifts ‘passive’ recipients of welfare to become partners with responsibilities and
obligations, allegedly fostering a greater sense of self-reliance amongst Aboriginal peoples. Such agreements are
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said to be based upon mutual obligation and reciprocity, yet this is highly contentious within a situation of power
imbalance and consequently these agreements have been subject to heated and divisive discussion.
Issues debated include whether such agreements can really be reciprocal and truly autonomous; whether they are
empowering or patronising; social engineering and coercion; notions of parental and community responsibility
and irresponsibility; links between notions of responsibility and of blaming and victim status; and the lack of any
logical link between the rewards offered for certain behaviour changes.
Illusions and Diversions: Critiquing Evidence-based Medicine
Borgerson, Kirstin (Canada)
The question of what counts as good evidence in medicine is of critical importance to physicians, philosophers
and, ultimately, patients. Given the current move toward integrative medicine and the vast increase in the
number and methodological diversity of clinical research trials being produced and published, determining what
counts as good evidence in medicine is becoming more challenging. One attempt to determine standards of
evidence for medicine has been made by proponents of the evidence-based medicine (EBM) movement, as
outlined in the ground-breaking 1992 article, “Evidence-based Medicine: A new approach to teaching the
practice of medicine” ( JAMA (1992) 268 17: 2420-5). Critical debate on the nature and value of EBM within
medical journals has been extensive since this initial proclamation. This has prompted revisions of some
elements of the proposed framework for medical decision-making, though the original ‘hierarchy of evidence’
devised by the EBM movement has been left intact. As the movement is rapidly and rather uncritically adopted
into medical settings around the world, as well as into new domains (‘evidence-based practice’ is now common
in nursing, public health, and some divisions of complementary and alternative medicine, for instance), concern
about the assumptions and epistemological limitations of such an approach are mounting. Brian Haynes, one of
the leading proponents of EBM, has issued a challenge: “One hopes that the attention of philosophers will be
drawn to…the continuing debate about whether EBM is a new paradigm and whether applied health care
research findings are more valid for reaching practical decisions about health care than basic pathophysiological
mechanisms and the unsystematic observations of practitioners.” (Haynes, RB, “What kind of evidence is it that
Evidence-Based Medicine advocates want health care providers and consumers to pay attention to?” BMC
Health Services Research (2002) 2: 3).
I will take up some elements of Haynes’ challenge in this paper. Philosophers of science have written
extensively on the nature of good scientific evidence. At the same time, the question of what counts as good
evidence in the context of medicine has yet to be fully addressed by contemporary philosophers. In this paper, I
identify and critically analyze the foundational assumptions of the EBM movement. In order to do this, I make
use of recent work in philosophy of science on the nature of evidence, the role of uncertainty, the importance of
diverse perspectives, and the function of values in scientific inquiry and decision-making. In addition, I suggest
lessons for philosophy of science on the need for greater attention to the contexts in which scientific principles
are adopted and applied and on the ways in which the sciences and humanities are combined in complex
practical domains such as medicine. On the basis of this analysis, I argue that EBM 1) enables and even
encourages false and potentially dangerous illusions of objectivity, generalizability, and certainty within
medicine, and 2) diverts attention from viable and valuable sources of evidence, thereby distorting medical
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practice and decision-making. I suggest that these claims have both philosophical and practical implications for
attempts to institute the methodology of evidence-based practice in a variety of contexts.
An experiment in practical philosophy: grasping the concept of autonomy
Boury, Dominique & Dreuil, Daniel (France)
A patient’s therapeutic education, in its most ambitious forms, is synonymous with a radical modification in
traditional care patterns. The aim of carers is no longer to adapt knowledge to a particular pathological condition
as a way to curing, remitting or diminishing an illness, a handicap or an infirmity. As a pedagogue, the carer
aims at sharing his knowledge and his values so that the patient can manage his illness more effectively. Carers
have an acute perception of this modification in respective roles within their team and in relation to patients.
Several elements account for this feeling: the timing and duration of responsibility, the lack of quantifiable
success in curing, the confrontation of different ideas and perceptions between carers, the patient and his/her
near-and-dear, and finally, the difficulties linked to articulating both pedagogical and caring aims. To give
stability to the framework of this new field of medical and nursing action, theoretical tools and acknowledged
institutional dispositions which would register it as legitimate, are lacking (unlike for palliative care). A regional
diploma aimed at the therapeutic education for carers (doctors, nurses, physiotherapists, health professionals,
orderlies...) has given us the opportunity to boost this essential collective reflection with conceptual elements
drawn from philosophical tradition, and this within a pedagogical framework encouraging professionals to
engage in critical reflection.
The concept of autonomy is at the heart of our vision of therapeutic education. In situations of vulnerability,
which are often characteristic of caring situations, creating conditions for the other to display his/her autonomy
presupposes the unconditional postulate that the other is capable of autonomy. This is not only the recognition of
a “quantifiable” physical or psychological capacity, but pertains to the domain of moral decision. Our
experiment in philosophical training aims above all at grasping the concept of autonomy. Grasping a concept
means for us not only understanding it as an idea and a representation but also inscribing it as an effective
guideline in the contexts of different practices. With this in mind, we are exploring different situations in which
the concept can be “thought out in practice”. The concept of autonomy is therefore addressed, from a
philosophical angle, according to three distinct situations: that of the patient suffering from a chronic illness, that
of the carer in the action of caring and that of the carer in training. The relationships between the different
concepts in situation have been made explicit. A carer’s acknowledgement of a sick person’s autonomy is all the
easier as the carer him/herself has moral autonomy at work. Likewise, to grasp this concept of autonomy in
health-care when one is still a student, the value of autonomy must be present in the teacher-student relationship.
This approach through concepts in situation favours a desire in carers to transform themselves and their caring
practices. Centred on the idea of an essential congruence between training and caring, it places the whole of the
interdisciplinary mechanism, not only as regards training but also content, on the way to autonomy.
During this experiment, health-care professionals, whose initial reticence linked to an elitist representation of
philosophy and its teaching was considerable, discovered that the philosophical work of grasping concepts can
help not only to orient oneself but to orient oneself in action. In this way they have validated our approach
towards philosophy in action.
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Methodological reflections on the coherence of teaching the humanities and ethics in a medical faculty: a
French experiment
Bouvet, Armelle de; Boitte, Pierre; Aiguier, Grégory; Boury, Dominique; Cobbaut, Jean-Philippe & Jacquemin,
Dominique (France)
This presentation deals with the implication of the CEM team in the students’ medical training as a whole at the
Faculté Libre de Médecine (FLM) at the Catholic Institute in Lille (ICL). For over ten years, the teaching of the
humanities and medical ethics has taken root in the three university cycles and the seven years’ training of
doctors. The aim of this intervention is to specify the purpose of such training, the coherence of a mechanism
consolidated over seven years, making it possible to draw up a balance-sheet and indicate ways of improving
initial medical training.
This teaching found its beginnings in the FLM’s decision to teach medical students the philosophy of medicine
and medical ethics in a context specific to France, where compulsory teaching of the humanities to 1 st Year
students has existed for over ten years, and where large-scale reflection on the introduction of medical ethics
training for all health professionals has been pursued. The specificity of this teaching is to open the way to
ethical reflection which has its roots in the humanities: thus, teaching the humanities in 1 st Year should from the
start offer elements which will form a continuity with the ethical reflection proposed later on.
Our teaching methods had to be adapted to conform to certain legal and regulatory restrictions (respect of the
official curriculum, both in content and means of assessment), to accompany the gradual increase in ethical
questioning from future doctors (along with the realisation of what their professional practice really implies) and
to satisfy the institutional requirements of active pluridisciplinarity. This training mechanism, the coherence of
which is guaranteed by the CEM’s lecturers/researchers, therefore requires the mobilisation of multiple
pedagogical methods to take into account the diverse objectives we have to aim for, according to the different
training levels involved.
A Philosophy of Life Stages: Lessons from Other Traditions
Brannigan, Michael C. (USA)
Is it possible to engage in intercultural dialogue in bioethics? The more fundamental question concerns the
possibility (or impossibility) of intercultural conversation and understanding, that is, discourse, as a preliminary
to dialogue. Is intercultural discourse possible? If so, on what basis? If not, we lack sufficient grounds for a
global bioethics and appear to be left with the current state of disconnected pluralism, a patchwork approach to
bioethics, nonetheless one that continues to be dominated by a U.S. biomedical paradigm.
I situate the above challenge within the context of the need for a coherent philosophy of life stages. That is,
intercultural discourse is not possible so long as Western, typically U.S. bioethics conveys the impression that its
various perspectives have universal merit and ought to be recognized as having such, thus enforcing the
dominance of a biomedical model in bioethics with its attendant biases, some of which I go on to examine. The
most prominent and profoundly far-reaching bias this biomedical model pertains to perspectives regarding
mortality. That is, a deep-rooted problem in our U.S. cultural ethos is the lack of a sufficiently coherent
philosophy of life stages. This is reflected in our healthcare as well as in societal views toward death and aging.
The general inability to assign an intrinsic value to aging and death poses significant issues in healthcare ethics.
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A coherent philosophy of life stages is critical, now more than over. I propose that we can learn valuable lessons
along these lines from other traditions, most notably Hindu and Buddhist. Lessons from these traditions may
help us to cultivate a more sensible outlook on the continuous spectrum of life and death.
This discussion is situated within the dynamic nexus among culture, values, beliefs, and views toward health and
illness. This nexus also embodies the interplay between metaphysics, ontology, and ethics. It does so through
disclosing worldviews that reflect perspectives regarding the primary dimensions of space, time, and
communication. It is clearly the case that with respect to this nexus of culture, values, and beliefs, all three
modes of space, time, and communication – components of relationality – interact symbiotically so that cultural
boundaries (as signs of distinctions or differences) exist. In setting forth a methodology that resembles a sort of
intercultural moral synergy, encompassing the recognition of both common ground and boundaries, I propose
that this may help to set the stage for intercultural discourse as a precondition for dialogue.
Living will: On the normative bearing of autonomous choices
Brauer, Susanne (Switzerland)
The scope of autonomy, to which modern individuals consider themselves to be entitled, is broadening. One does
not only want to determine one’s way of living but also one’s way of dying. Writing a living will seems to be the
appropriate action for achieving the latter purpose. This action, however, brings up philosophical issues of the
following kind: Given that setting up a living will is an example of autonomous choice-making it seems to be
undisputed that this choice has to be respected by others. This choice, however, is quite unique in its costs since
it determines what kind of live-saving measures should be taken in order to continue the life of the individual.
Therefore, one could conclude, it is important to give the individual the possibility to change her mind – and to
revise the living will according to her new order of preferences. But to double check, whether the individual still
holds on to her choice made earlier, before acting on her living will, is often difficult, for instance in case of
Alzheimer disease or other illnesses which lead to a destruction of what is called personhood or personal
identity. The philosophical puzzle hence occurs what normative bearing one’s autonomous choice can have for
the future – and how it commits others to take certain actions, and oneself to accept these actions as the
volitional consequences of one’s autonomous choice.
The "healthy" cut. The problem of male circumcision in the public health system
Brusa, Margherita (Italy)
Infant male circumcision is a worldwide practice that has progressively acquired medical status, mainly in the
USA, where it is performed on most male children regardless of religious affiliation. Yet, experts still debate
whether it bears any medical value whatsoever. In the past few years pressure has been growing, mainly in EU
countries, to incorporate circumcision of infants belonging to communities adhering to the practice. This
situation poses a few ethical challenges. Many physicians wish to respect parental values and choices, but they
are also reluctant to violate bodily integrity, of non-consenting babies. Even those who do not censure the
practice, feel uncomfortable about the extension of public medicine to non medical demands. Utilitarian
considerations of public health seem to support circumcision within public hospitals as a safer alternative to that
carried out privately and in non-professional hands. In this presentation I offer an analysis, mainly from a
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historical perspective, of the medicalization of male circumcision, as a problem in its on right and as a
paradigmatic case study of the interaction between medical services and cultural values in a multicultural
society.
Empiricism and the Philosophy of Medicine
Buller, Tom (USA)
Traditionally, scientific disciplines such as medicine have been realist and have framed the world in terms of the
stuff that it is made of. Scientific progress has been understood, therefore, as a process of empirical discovery –
as providing a greater understanding of what is “really going on.” Furthermore, these scientific facts of the
matter have played a central role in our moral discussions. For example, arguments about the morality of
abortion are often framed in terms of the moral status of the fetus as determined by the presence or absence of
certain neurological capacities such as sentience. A similar appeal to neurological function often occurs in
discussions regarding our obligations towards patients in persistent vegetative state or the moral status of
animals. A related appeal is made in discussions about the genetic basis or race or sexual orientation: the lack of
any “genetic” basis for these differences in race or behavior is seen as a prima facie reason to qualify the moral
weight of these differences.
However, our increasing ability to modify ourselves and the world around us challenges this “Scientific Moral
Realist” view. Advancing medical technologies such as xenotransplanation, genetic engineering, cloning, and
neurological enhancement necessitate caution in appeals to what is “really going on”, for what is “really going
on” is being defined less in terms of the underlying structure and more in terms of normative functional role. For
example, our ability to modify the genome, or to enhance cognition through the implantation animal or synthetic
elements suggests that what matters fundamentally is the role that that part of the genome or brain plays, rather
than the stuff that is it made of. If this is correct, then the more that we are to able to modify human nature the
less we can appeal to human nature as means to adjudicate the morality of our actions.
Encountering the Other’s Suffering in Illness Diaries and Memoirs
Burlea, Suzana Raluca (Canada)
What characterizes writing about the suffering and pain experience, either in social sciences or philosophy is the
impossibility to escape their paradoxical indeterminacy. They are viewed as a profound subjective and/or
intersubjective experience (see the oscillation among M. Merleau–Ponty, M. Henry, F. Buytendijk, D. Leder, A.
Kleinman, B. Good, E. Cassell etc.).
An ethical perspective following E. Lévinas inclines to an intersubjective definition of suffering (A. Frank, S.
van Hooft) as the sufferer’s condition becomes an embodied call for the Other’s testimony either in co-presence
or through the act of writing and reading illness self-narratives. In the case of serious illness, as Th. Couser
specifies, bodily impairment can elicit or obstruct autopathography as it orients consciousness and reflection
towards one’s own experience, and at the same time impedes writing acts.
However, one can observe that the Other’s bodily impairment can function as a call to writing about the Other’s
illness experience as an act of sharing and testifying her or his suffering. Th. Couser argues that illness memoirs
do not give access to the subjective experience of illness, but illuminate other specific dimensions of illness that
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are not encapsulated by autobiographical genre. Our hypothesis challenges this view restricting access to the
subjective experience of the sufferer. What we intend to demonstrate is specifically the intersubjective
possibilities opened by collaborative autobiographies of serious ill patients and illness memoirs and diaries
recounted by persons close to the sufferers. Writing is not only a means of the embodied self asking for the
listener’s ethical response, but a dialogical performance of the answer itself. Writing the Other’s suffering story
provides a means of sharing his/her embodied experience, engaging in an expressive encounter with the sufferer
through which the Other’s presence calls out the Same’s transcendence towards what eludes him constantly. The
relation to the Other is then necessarily an ethical one interrogating the self-sufficiency of the Same. The latter
engages in passing through an infinite distance towards the Other under the imperative of the Other’s presence.
The Other’s way of being present is that of his expression, of his revelation through discourse because the
Other’s infinite would go beyond any tentative at manifesting it through an objectifying thematisation. Opening
towards the Other’s encounter would mean consequently opening towards his expressiveness through discourse.
Discussed from A. Schütz’s perspective on intersubjectivity, writing memoirs or diaries of the Other’s suffering
implies also, a temporal derivation of a “vivid present” interpellation addressed to the Other in a face-to face
discourse.
Our aim in this paper is then to analyse, through means offered by narrative analysis of personal writing (the
interplay between narrative perspective, voice, and temporal framing), the intersubjective dimension of the
suffering experience as re-presented in collaborative writing, illness memoirs and diaries written by the close
others about sufferers. Two texts will be the principal concern of our presentation: S. Butler and B. Rosenblum,
Cancer in Two Voices (1991) and F. Davey, How Linda died (2002).
Silent potency: health as praxis of freedom
Calinas-Correia, Joao (UK)
I present three claims: that health is the 'taken for grantedness' of our causal efficacy; that health is necessarily
ineffable; that health is the praxis of freedom. With this discussion I progress towards the grounding of health in
freedom, and ultimately towards an analysis of the politics of the medical act in terms of the opposition between
liberation and freedom.
Regarding the first claim, I will look at Heideger's analysis of causality and discuss its relation to our situation of
embodied entities. From here, I will analyse the relation between the concept of health and the causal relations
between self and otherness. I will conclude that health is not a distinctive or well delimited state of affairs, but it
is the assumption that the self, while embodied self, is causally efficient, and therefore eminently agent, in its
relations with the world, claiming the world as his. Health losses convey a sense of loss of agency before the
world, towards a relation to the world as patient and therefore living the world, including one's own body, as
eminently otherness. This possibility of the body as otherness shows that the self transcends the physiology of a
mere 'animated corpse'.
Regarding the second claim, I will discuss the phenomenology of health against common sense understandings
of what it means to be healthy. The 'potency' claim implicit in the claim to be healthy is not related to a presence
of certain potency factors, but precisely a claim of absence of extraneous constraints. To be healthy is to be able
to act without having to interrogate one's body about the capacity to act. Within Leriche's 'silence of the organs'
the healthy asks 'what will I do next?', taking for granted his capacity to cause upon the world; the unhealthy
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asks 'what will happen next?', because the 'noise' from his organs undermines his agency and highlights his
condition as patient, as otherness within and against himself.
Regarding the third claim, I will return to Heidegger's account of the grounding of causality in a primal freedom,
distinct from the existentialist understanding of freedom. The ontological primacy of freedom regarding our
apprehension of the world is discussed in parallel with the ontological primacy of health regarding our agency
within the world. Along Heidegger's claim that 'the factuality of freedom is praxis', I will present health as the
praxis of freedom.
What the humanities offer medicine
Carson, Ronald A. (USA)
My starting point is a provocative claim made by intellectual historian William Bouwsma in an essay published
more than two decades ago titled “Socrates and the Confusion of the Humanities. There Bouwsma baldly asserts
that “Rhetoric, not philosophy, gave us the humanities,” alluding to the ancient rivalry between two modes of
knowing—philosophy’s rational pursuit of universal truths, and rhetoric’s attempt to make tentative sense and
practical use of the concrete, contingent, and shifting quotidian world.
It was this latter effort which constituted the educational ideal and program that came to be known as the
humanities, a program that returned to cultural prominence in the Renaissance after a period of decline in the
Middle Ages. Beginning in the late nineteenth century, another period of dormancy followed upon the rise of
various positivisms. Today, subsequent to the collapse of late twentieth century foundationalism, we find
ourselves in the midst of a movement to retrieve the rhetorical tradition of “engaged humanities.” Nowhere is
this more evident than in recent work on hermeneutics, narrative, and virtue theory in the medical humanities.
Drawing on relevant writings of Hans-Georg Gadamer, Isaiah Berlin, Stephen Toulmin, Annette Baier, Alasdair
MacIntyre, and Richard Rorty, I will try to show how the reemergence of a humanist vision--with its eschewal of
universal claims, its openness to a diversity of perspectives, its attention to practices (the practice of medicine, in
particular), and its commitment to dialogue as a means to mutual understanding and to the resolution of pressing
moral problems--is a fitting response to the widespread contemporary experience of insecurity, not only in the
examining room when illness threatens but more generally in our risk-ridden culture.
Philosophy as a resource for Medicine
Chakravorty, Meera (India)
In a world in which people suffer and have no hope that anything or anyone can make a difference, we will have
to imagine what it would be like to live in such a world of people who will have no wish to feel better. This
strange philosophy of despair and the related discovery of medicine have changed the scenario towards a
tolerable world though. However, the connection goes further than any chronological incidences in either of this
area. Researchers and scholars in the area of philosophical studies in India took a deep and direct interest
regarding the questions of health care as this was needed to pursue the philosophical interests further. Texts by
Charaka and Shushruta do not display merely the talking shops. They have studied and analysed diseases and
evaluated methods of treatment and attempted to compare their methods with ‘clinical’ diagnosis.
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There are good reasons for the concerns of health care that have acted in this way. Not only the damage that
diseases caused to the body was of grave concern but that it also affected the mind turning people away from the
positive thinking and action frightened the philosophers. The situation was considered grave especially when the
context was that of pursuing the path of moksha or liberation. Hence, it was vital to set things right. In the Indian
school of Sankhya philosophy, this concern has been raised seriously. Drugs are a phasic solution to the physical
problems no doubt. Yet what is important is to find the root cause and get at the final solution. How these
concerns can be dealt with are significant issues explored ingeneously by this school of thought.
Epistemological obstacles in psychiatry
Chiriţă, Roxana; Chiriţă, Vasile (Croatia)
The desire to explain and to master the mechanisms of mental activity functioning has always existed and, in
time, this has generated various theories. The evolution of psychiatry can be regarded both from the perspective
of a collection of speeches and practices referring to “madness” and in the light of knowledge accumulated in the
field of natural sciences as well as in that of human studies. Philosophy provides specific approaches to the
mental phenomena and the way they can be subject to knowledge. In this way, we may also refer to the
axiological dimensions of human behavior, as the spirit relates to such fundamental values as truth, justice,
freedom or beauty as well as recognition of spiritual imperatives.
If we are to admit the fact that psychiatry has a problem of specification and delimitation of its area, we can
undertake an epistemological approach towards the clarification of its heterogeneous theoretical sphere and
medical subject. However, apart from social connotations, we might say that the main epistemological obstacle
to the assertion of psychiatry as a science remains, to this day, the absence of a general concept regarding
psychological functioning as a whole, which could generate an explanatory system concerning mental pathology.
Even for contemporary psychiatry there are references to the dualistic perspective of mind-body dichotomy and
there are further examples in psychiatric practice reflective this old dilemma of the difference between cerebral
and mental events. As a matter of fact, we seldom wonder these days whether we could consider, the human
ontological status in a much wider context, including an undesirable spiritual dimension besides the threedimension bio-psycho-social system supported by the instruments of classical gnoseology.
Banned kanon and orphaned irony: a technique to teach professional ethics
Cooper, M. Wayne (USA)
Current Bioethcs has come to utilize stories to inform professional ethics instruction. However, the choice of the
appropriate story remains open to dispute. In this paper I explore a technique to assist in the choice and analysis
of stories for ethics training. I begin by examining texts banned by a universally condemned society, National
Socialist Germany. The texts examined are Klaus Mann's Mephisto, Stefan Zweig’s Twentyfour Hours in the
Life of a Woman, Alfred Doeblin’s Berlin Alexanderplatz, and Bertold Brecht’s Threepenny Opera. It is seen
that specific texts, though sharing the property of being banned, illustrate different theories of ethics, thus
confirming the weakness of theory-based ethics study. Comparing the source (banned) text in one language
(German) with the target (rescuing) text in a second language (English) it is seen that each text displays in
varying degrees: 1) Cross-cultural ethics propositions, 2) Cross-translational ethics propositions, and 3)
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Orphaned Irony. This term designates the loss of a cross-translational ethics proposition – an ethics proposition
is present in the source text (banned text), but absent in the target text (rescuing text). This technique can be
utilized to analyze texts in a single language where a text describes a characteristic of a sub-society. If this subsociety rejects (banns) this characterization then the characterization must be rescued by the larger (rescuing)
society. The ironic characterization in the banned text (Orphaned Irony) can be used to illustrate features of the
behavior of the sub-society (the professional society) which warrants ethical attention. This technique is
illustrated by discovering Orphaned Irony first cross-translationally (from German to English), then in a single
language (English). The English text examined is Herman Melville’s characterization of the medical doctor in
White Jacket. This characterization was rejected (banned) by the contemporary members of the American
medical profession (the banning society) in their professional Code of Ethics. By thus comparing and contrasting
contemporary characterizations of professional behavior a broader understanding of the intra-societal
professional relationships are possible. These relationships and the manner in which they reveal self-reflection of
professional groups can be pursued and exploited to inform professional Bioethics instruction.
Governance and Interdisciplinary Bioethics: A learning curve?
Cutter, Anthony Mark (UK)
The IAB defines “bioethics” in as an interdisciplinary discipline as “the study of the ethical, social, legal,
philosophical and other related issues arising in health care and in the biological sciences”. This paper considers
this question of “interdisciplinary” in a regulatory or governance context, and looks at the interplay between
these myriad of disciplines and the implementation of policy and practice in the science medicine setting.
In so doing, it suggests a “relativistic model of governance” that requires an interplay between the sciences
(specifically in a medical research context) and the non-sciences (specifically socio-legal based studies and
philosophy/ethics), and as such suggests that interdisciplinary research models form the most appropriate
methods for exploring the questions raised by new medical technologies.
In its exploration of this interplay between disciplines, the paper will also draw on and respond to: Cowley, C “A
new rejection of moral expertise” ; Crosthwaite, J “In Defence of Ethicists: A commentary on Christopher
Cowley’s Paper” & Twine, R “Constructing Critical Bioethics by Deconstructing culture/nature Dualism”. All
from Medicine, Health Care and Philosophy Vol 8. No 3.
Transformations in the disease concept: from causal ontology to the ontogenesis of the body
Czeresnia, Dina (Brazil)
The objective of this work is to analyze the contemporary medical discourse and how in the recent medical
literature on allergy and autoimmune diseases, elements that signal changes in the rationality of disease theories
are present. Medicine in the 20th century was characterized by a spectacular technological development in terms
of diagnoses, treatment and prevention of diseases. Biology has constructed a new conception for life processes,
describing smaller and smaller structures and functions more and more essential. Particularly, molecular biology
has guaranteed a vast and fecund application field. However, it was only recently possible to glimpse that
medicine could surpass the hegemonic conception that defines diseases through physiological alterations and
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anatomical lesions caused by specifics agents or risk factors. This was the basis of the modern medicine
emergence in the19th century.
There is no doubt that tensions have always been present in medical thought. However, the initiatives of
explaining the disease through the understanding of the constitution of the body individuality didn't reach a
larger legitimacy as object of investigation of the basic scientific research. Immunology, for instance, has
favored specific researches on antigen-antibody reactions instead of searching for a general body reactivity
theory. This tendency has brought as a consequence, difficulties to explain the origin of some diseases, such as
the allergic and autoimmune ones. It is in the context of the recent research on these diseases that the change
studied in this work is signaled. It is interesting to point out that these researches rescue the study about
phenomena like the clinical importance of the intestinal microflora, as described in the early 20 th century, by
Metchnikoff, but that only in the last ten years the interest in studying them has been increasingly highlighted.
In the discussion, for instance, of the so called ‘hygienic hypothesis’ – that investigates the etiological link
between the increasing incidence of allergic and autoimmune diseases and the decreasing incidence of infectious
diseases in the industrialized countries of the Western world – the following transformations in the
understanding of the etiology of diseases can be signalized: the change in the understanding of the role of
microorganisms in the evolutionary and ontogenetic constitution of the organism; the emergence of the
description of the molecular biological phenomena occurring in the interfaces of the body, in an intermediate
domain between organisms; the shift in the etiological explanation of diseases from the identification of causal
agents producing anatomical lesions related to signs and symptoms to the ontogenetic process constituting the
organism and producing the ‘programming’ of susceptibility to disease; the shift from the idea of specificity to
that of modulation. What matters is not only the specificity of the biochemical mechanisms involved, but how
they integrate and harmonize, according to quantitative thresholds that regulate the times and intensities of
biological processes.
Western and Confucian Perspectives on Cloning and Identity
Davis, Dena S. & Nyitray, Vivian-Lee (USA)
This paper contrasts ethical and social concerns about human reproductive cloning in the West and in Confucian
societies. In the West, concerns about cloning emphasize the independence of the child, and the maintenance of
appropriate boundaries between parent and child. Children are unique and independent individuals with the right
to work out their own destinies. Parental motivations for cloning are criticized as narcissistic, overly controlling,
and making children into commodities. In Confucian perspectives, the concerns are radically different.
Confucianism lacks “rights talk;” rather, the individual is seen primarily in terms of obligations and duties. Most
of the complexities that arise from reproductive cloning stem from specific intersections of the general
imperative to produce an heir, son-preference, filial and familial demands, ancestral veneration, and ConfucianBuddhist folk notions of the body.
Why should we stop the practice of non-religious circumcision of male newborns?
Dekkers, Wim (The Netherlands)
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Each year around 13 million boys are circumcised for (1) medical-therapeutic, (2) preventive-hygienic, (3)
religious, and (4) cultural (that is non-specific religious) reasons. Since a few decades male circumcision is
increasingly under discussion. Especially the practice of routine circumcision of newborn boys for non-religious
reasons - which is a widespread phenomenon in English speaking countries, especially the United States - is
heavily debated. Although it is not possible to make a sharp distinction between the four reasons mentioned, this
paper focuses on routine male circumcision on preventive-hygienic grounds.
The current view on routine circumcision of male newborns can be summarized as follows. (a) From a
methodological perspective, the medical and psychosocial benefits and harms are difficult to assess. (b) There is
only thin scientific evidence that neonatal circumcision lowers the risk of acquiring certain diseases such as
penile cancer and sexually transmitted diseases such as HIV infections.
In this paper, I will argue that the possibly minimal benefits do not counterbalance the harms and potential risks.
Moreover, even if the alleged medical benefits counterbalance the harms and risks, this is not a sufficient
justification. Reasons to stop the practice of routine male neonatal circumcision are: the ideal of Evidence Based
Medicine, economic and utilitarian considerations, human (childrens’) rights arguments, and especially the
notion of the integrity of the body. The current policy that the final decision should be made by parents with a
balanced counsel from attending physicians is too ‘liberal’. Neonatal circumcision for non-religious reasons
should be discouraged as much as possible, if not forbidden. However, because neonatal circumcision on
preventive grounds can be seen as a ‘social ritual with a grain of medical origin’, this statement opens the door to
debates on (the authority on) culturally bound norms and values. Referring to S. Holm (JME 2004;30:237) I will
try to transform ‘cultural prejudices’ into ‘ethical arguments’.
Tissue engineering
Derksen, Mechteld-Hanna (The Netherlands)
In this paper I present part of my PhD project on philosophy and ethics of Tissue Engineering (TE). Inspired by
phenomenological work on the body, I start from the idea that if we take the embodied human seriously, we must
study body techniques in terms of how they reconfigure bodies. With body I do not mean the objective body of
biomedicine described in terms of causal processes, but the 'lived body': I who smiles at a familiar face, caresses,
or dances as a black rapper. Body techniques may influence embodiment in several ways. Stuart Blume, for
example, showed that the cochlear implant may give bodies the ability to hear to some extend. But the implant
also reinforces the idea that deaf bodies are not normal but handicapped bodies and in need of treatment. In the
case of TE I will show that understanding TE in terms of reconfiguring bodies may improve the way TE affects
embodiment.
To learn about TE I have done fieldwork on Dutch-Swiss collaboration that develops an autologous aortic heart
valve for neonates. Autologous tissue engineering is the field that makes human tissue in the laboratory using the
recipients own cells. In the studied case neonatals are seen as the most needy patients, because current heart
valve alternatives cannot grow. But the largest group of patients that are supposed to benefit are elderly people.
The ideal body of TE is a body consisting only of its own tissue. Autologous TE theorises bodies as
regenerating: the objective is functional tissue that can grow and repair itself by using cells as the body's selfhealing capacities to engineer tissue. However, my fieldwork shows that making this self-healing theory work,
takes cumbersome engineering. I also found that researchers on the one hand had difficulties with talking about
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their work in terms of 'making' body parts, while on the other hand felt very responsible for the risks of their
products.
Clearly, for patients a TE heart valve affects the lived body if it changes certain capabilities. But how will ideas
about the body from the TE practice affect embodiment? I suggest that the ideal of self-healing has a tendency to
promote a body image of the body as functional and unchanged. This may strengthen the image of the normal
body as young and stable. A body ideal criticised by authors on the lived body, for it makes it harder to live as
ageing and vulnerable bodies. In this light I argue for overcoming fear of speaking of TE as making body parts in
order to improve bodies that are considered as needy and vulnerable. For sure also in this case, TE implants like
the cochleair implant materialise body ideals. But these are open to discussion about how best to reconfigure
lived bodies, something which is not possible with ideals of self-healing bodies seemingly unaffected by
technologies.
Logotherapy: the borders between psychotherapy and philosophy
Echarte, Luís E. (Spain)
Psychotherapy involves a set of techniques to cure or improve mental disorders by psychological means. The
goals of psychotherapy include realizing what patients are saying or how they are behaving, and enhancing their
insight or behavior in order to get a healthier life. Logotherapy, a sort of psychotherapy developed first by Viktor
Frankl, emphasizes the search for meaning as one of the primary human motivations and. In this context, persons
who experiencing a meaningless and purposeless life could respond to this experience with unhealthy behaviors.
Accordingly, it is one of the objective of the psychotherapist to come along with clients (patients) on the way to
finding possibilities for concrete meanings and, if it is possible, empower them to live a meaningfully life. This
paper discusses the limits of the psychiatry and psychology to manage the goals and contents of logotherapy and
how philosophy could be a good resource for medicine.
Two issues are considered about that topic. First at all, psychiatry and psychology could notice the importance of
meaning for health. However, it is much more difficult to counsel patients which the better sense of life is. For
this end, it would be necessary to be able to study not only the effects of isolate and quantifiable train of thoughts
or behaviors, but also to compare the existential consequences of different global anthropological views.
However, this purpose seems out of reach of the experimental psychiatric method. In this context, philosophy
and social sciences, another kind of ways to analyze and evaluate such existential perspectives, emerge as
alternative for logotherapy.
On the other hand, criterion in psychiatry to decide what thoughts, behaviors and sense are better circle around
the concept of health. In contrast, the main referent in the human search of meaning is based on the concept of
truth. The controversy here is whether or not health and truth are necessarily exchangeable terms. If the answer
is not, logotherapy does not always have to be medically favorable. Such discussion implies to think about
another important question. To what extent meaning could be sacrifice for health? In the conclusions I argue that
logotherapy is advantageous in the majority of times, not only in psychiatry but also in general medicine. In the
rest of cases, the use of strategies of “false meaning “could only be temporally indicated as a manner to restore
patient’s competency of autonomy. The existential decision of giving priority to health over truth must be
exclusively chosen by every responsible person.
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The last point consider in this paper is the medical risk of identifying “mental health” or “integral health” with
“true meaning”. This mistake caused by the extrapolation of “experimental method” could cause paternalistic
interferences. The best way to avoid this medical malpractice is by means of right interrelations among
medicine, philosophy and social sciences.
The Art of Useless Suffering
Edgar, Andrew (UK)
The purpose of this paper is to explore the role that the arts, including painting, music and literature, have in
articulating the uselessness and incomprehensibility of physical and mental suffering. The paper is concerned to
challenge the idea that art has a primary role in health care as a resource through which patients and medical
practitioners might make sense of and share the experience of illness. It is rather argued that the experience of
illness is frequently resistant to interpretation, and as such, it will be suggested, to conventional forms of artistic
expression and communication.
Conventional narratives, and other beautiful or conventionally expressive aesthetic structures, that presuppose
the possibility and desirability of an harmonious resolution to conflicts and tensions may be oppressive from the
view point of the patient. Arthur Frank, for example, (in The Wounded Storyteller) has raised this problem in
relation to what he calls the 'restitution narrative' of modern medicine. There dominance inhibits medicine from
dealing with chronic illness, where they is no cure or restitution of good health. The use and promotion of such
conventional aesthetic structures implicitly or explicit presupposes that the patient should be able to make sense
of their experience of experience, by constructing a good story about their suffering and their ability to overcome
it or otherwise live with it. This paper will argue that such conventional, and largely pre-modernist, aesthetic
structures are not merely potential oppressive to the sufferer, but also do the sufferer a moral wrong, in so far as
they presuppose that suffering is comprehensible and communicable. This is because these conventional
structures presuppose some form of theodicy (through which suffering can be explained away).
By drawing on the work of Emanual Levinas (on useless suffering) and the aesthetic theory and negative
dialectics of T. W. Adorno, it will be argued firstly that such faith in a theodicy is misplaced and does violence
to the experience of suffering. Secondly, it will be argued that the expression of suffering lies not in finding
words or images that communicate the experience of that suffering to others, but rather in the persistent and
radical disruption of any illusion of meaning and coherence that might be imposed upon the experience, so that
the very possibility of communication is also disrupted. The paper will draw on a critical examination of
particular art works, such as Goya's Black Paintings, and Munch's images of a sick child, in order to suggest that
there exist models in the Western artistic traditions that make possible this disruptive articulation of the
experience of suffering.
Race as a Variable in Medical Research
Efstathiou, Sophia (USA)
“Human populations differ one from another almost entirely in the varying proportions of the allelic genes of the
various sets of hereditary factors, and not in the kinds of genes they contain. The extreme positions held by those
who on the one hand maintain that there are no significant genetic differences between human races, and those
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who on the other hand hold that certain races are ‘superior’ and others ‘inferior’, require drastic modification in
the light of the accumulated data on the gene frequency dynamics of human populations.” (Laurence Snyder,
Former President of the American Society of Human Genetics). These words were spoken in 1951, at a
celebration of the first fifty years of modern genetics. More than fifty years later, despite accumulating an
extensive pool of genetic information and mapping both within and between population allelic distributions, the
tension between biological and social conceptions of race has not been settled. Should ‘race’ be used as a
category in medical research?
Scholars such as philosopher Michael Root argue that races are socially defined groups that have been found
lacking as markers of biologically significant variation at the genotypic level. Instead of contributing to science,
race-specific medical research fosters lay conceptions of race as biologically essential and involves substantial
risks for all members of the populations identified. Proponents of the inclusion of racial classifications in
biomedical research stress the usefulness of these categories in “generating and exploring hypotheses about
environmental and genetic risk factors”. Philosopher Peter Singer argues that erecting barriers to the collection
of race-specific information would function against the interest of racial groups to an equal and successful
medical treatment. The sociopolitical risks that race-specific research runs for certain populations are seen as
outweighed by the benefits that informed clinical practice will offer them. The purpose of this project is to
examine the use of the concept of ‘race’ in recent medical, epidemiological and genetics literature in the US. I
agree with Troy Duster that getting rid of the concept of ‘race’ in medicine is “not practicable, possible or even
desirable”. Given the actual use of ‘race’ in medical research to make striking observations, how do we interpret
our findings?
The first section of the paper (The Symptoms) discusses the use of ‘race’ as a category in medicine, focusing on
the US. I present the current debate in popular medical journals and then outline the main areas in which the use
of ‘race’ appears and where and how it is disputed –i.e. (1) disparities in common complex disease outcomes
between ‘racial’ groups, (2) disparities in drug response between population groups, (3) pharmacogenetics and
population genomics research. The second section (Diagnosis) applies the conceptual tools to establish the
source of the dispute described in the first section. My thesis is that the current discourse on race-specific health
outcomes conflates two concepts of race: a 1) biological race concept and 2) a social race concept, or to use
Michael Hardimon’s neologism, socialrace. I argue that the racial classifications determined by the Census
Bureau refer to population groups that are taken to be races in an American society; they are capturing
socialraces. So, when researchers stratify populations according to ‘census categories’, they are stratifying
populations according to socialrace. Since socialrace is a social concept, this classification seems to only warrant
claims about how the different social standing of these groups relates to their health –claiming that there is
medically significant, genetic variability that corresponds to socialraces can [at this point] only be based on an
educated guess at best. The last section (Past History) is historical. To evaluate the girth of these concepts I
apply them to the case of medicine during the Nazi era. I argue that aesthetic values determined what ‘race’ was
deemed to be healthy in Nazi medicine. The operative conception of ‘race’ was in theory an essentialist,
biological race concept, although what stratified individual health outcomes in practice was their socialrace.
Further, the type of aesthetic norms that lay at the heart of the Nazi regime and the rigidity with which they were
executed evoke a rigidity in which has not yet eclipsed. I argue that the urge to dismiss social/ environmental
conditions as causally relevant to a physical system has its roots in a long tradition of ‘isolating systems’ in order
to study them - reducing the immaterial to the material, and distal causes to proximal ones. Alas! As Nancy
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Cartwright argues, shifting our focus from the “messiness” of concepts such as ‘race’ cannot be permanent nor
complete. Orderliness can (maybe) be found when running an algorithm [called ‘structure’] to derive clusters of
alleles, but clinging to this rigid aesthetic norm at the expense of completeness ultimately leaves us powerless to
deal with environments wherein we get sick.
Inroducing medical humanities to undergraduates: an Asian perspective
Fernando, Anoja (Sri Lanka)
During the past two decades, courses on medical humanities have been introduced into the curricula of most
medical schools in Western countries. While these courses were originally introduced to rectify perceived
deficiencies of current undergraduate medical education, they have proved to be very popular with the students.
The primary aim of such courses is to promote the development of humane attitudes in the young
undergraduates, who are compelled to pursue their medical courses in an increasingly complex technical milieu.
Many of the courses on medical humanities are offered as optional electives, while some have been incorporated
into existing ethics courses.
While ethics education is well established in most Sri Lankan medical schools, teaching of arts and humanities is
a very recent innovation. In my presentation, I will describe the initial efforts at introducing medical humanities
to undergraduates of the Faculty of Medicine, University of Ruhuna. Sri Lankan medical students belonging to
the present generation are not very familiar with Western literature, music or art. Therefore it was quite a
challenge to design a medical humanities module that would be attractive as well as easily understood.
Topics for teaching were selected from both Western and indigenous sources. While the major proportion of the
syllabus was drawn from Western sources, and taught in English, a fair amount was drawn from indigenous
sources. This approach resulted in exposing the students to a hitherto unappreciated alien culture as well as to the
realization of the universality of human values, emotions and struggles, of people all over the world. Evaluation
of the course revealed that the students had deeply appreciated and enjoyed the exercise.
Phenomenology and Psychiatry – Influences and Challenges
Fialová, Lydie (Scotland, UK)
Phenomenology has arisen as a dialogical response to previous philosophical traditions, which can be described
as the search for Being (dating from Ancient Greece), presupposing that our material world is a mere
resemblance to that one very real, accessible to our mind only. This has shaped way for the methodological split
of mind and body (as seen in Renaissance and Enlightenment Philosophy), which has become extremely
powerful in shaping the advancement of science and technology. Unfortunately this methodological reduction
has became ontology of new order, fortifying this split in very fundamental way - shifting the image of man as
rooted in metaphysics and theology to its secular and thus materialistic and deterministic interpretations. The
Biomedicine is the exemple par excellence of this. Yet there are limits to this approach, and as this can be most
clear on the example of Psychiatry, this shall be explored in further analysis.
Contemporary Psychiatry is finding itself using concepts of various discourses – be it the scientific one of
neuroscience, the clinical one which can not be seen apart from its historical and cultural contexts and being
strongly influenced by psychology, be it the lived experience of patients. These systems are far from being
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coherent, yet the Psychiatry has to deal with all of them on everyday basis. Striving for certainty, the biological
psychiatry is often the most prominent approach, although on a closer look the various causal explanation
offered are far from being grounded in solid knowledge, we know close to nothing about the brain, which in the
Modern Age became the center of the mind, soul or spirit or self.
The Phenomenology, as in the works of Edmund Husserl, Martin Heidegger and Jan Patočka, offers means of
analysis of all these concepts, focusing on human condition in this world of complex processes and multiple
meanings. Our Being-in-the-World, with features of temporality, embodiment, intentionality, is not about Being,
but about Becoming. We are not mere “things among things”, as the approaches of neuroscience would try to
convince us: although we belong to particular time and space we belong there in a way that we understand this
condition and relate to it. Being-in-the-World and the World itself are sustained by Care, and our participation
creates the space of freedom, of Authenticity. Thus we are anchored in this World, we move towards things,
relate to our neighbors and re-create our world and gift it with meaning. And these are the moments that the
condition of mental disease discards, and the very core of suffering that Psychiatry is aiming to respond to.
Although we might understand some parts of genetical, molecular, and physiological changes taking place in
conditions that we call “mental disease”, this explanations does not suffice to help us understand the changes in
experiencing self relating to world and others that our patients go through. Phenomenology might offer much
solid bases that would make us rethink some basic concepts underlying both theory and practice of Psychiatry,
and the works of neuroscientists like Oliver Sacks or V. S. Ramachandran prove this.
Is There a Public Conception of Health and Disease? Political Liberalism and the Philosophy of Medicine
Garrett, Jeremy & Robichaud, Philip (USA)
An altogether familiar approach to debates regarding which concepts of health and disease should frame public
health policy is to derive substantive conclusions about the state’s authority to medically intervene in certain
ways rather than others from analyses of what health and disease are essentially. These essentialist analyses of
health and disease can take a variety of forms, but each shares a common commitment to the belief that a correct
of analysis of the concepts can deliver politically significant conclusions.
Whatever insights these various modes of analysis might yield in private meditations upon the nature and
(dis)value of health and disease, they seem to uniformly fail when treated as reasons supporting some particular
policy of public health within a politically liberal society. This is because the standards for success or failure in
liberal political discourse do not always supervene on the discursive standards one might ordinarily employ in
the philosophy of medicine. To put the matter simply, at least at first, political liberalism is grounded in what
persons can agree to in some actual or idealized process of dialogue, not always in what is, in fact, true or
laudable. Hence, any strictly religious, metaphysical, semantic, or conceptual analysis of health and disease will
normatively underdetermine questions of liberal political morality.
Instead of being established in the philosopher’s, theologian’s, or physician’s armchair, the particular concepts of
health and disease that will shape liberal public health policy are determined within the suitably circumscribed
channels of liberal political discourse. Accordingly, a necessary condition for any ostensibly liberal position
regarding public health policy is that it be derivable from adequate public conceptions of health and disease.
However, this places political liberals supportive of some policy regarding public health in a rather difficult
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quandary, for it is not obvious, prima facie, that there are any adequate candidates to serve as public conceptions
of health and disease.
This prima facie conclusion is supported by a dilemma that arises in articulating the function of a public
conception of health or disease. Put simply, this function is to inform public health policy with clear standards
regarding which medical conditions and interventions it should care about and which it should not; or, in other
words, to cleanly determine when conditions and interventions are medical in character and when they have been
overmedicalized. If political liberalism operates with an empirical or natural conception of health or disease
(e.g., Boorse’s biostatistical account), then, while the conception can be sufficiently determinate, it will lack the
normative resources to give an adequate treatment of overmedicalization. On the other hand, if the operative
conception of health or disease is normative in character (e.g., Engelhardt’s account), then, while it can
satisfactorally make sense of overmedicalization, it will prove too thin and open-ended to uniquely recommend
determinative public health policies. The provisional conclusion we draw from this dilemma is that no adequate
public conception of health or disease and, hence, no politically liberal basis for employing these concepts in
public health policy can be located.
The Human Face of Religious Doctrine: Buddhist Narratives of Creation in Medieval Tibet
Garrett, Frances (Canada)
This paper discusses the issue of human fetal development in medieval Tibetan literature as a way of
investigating the boundaries of medicine and its relationship to religious thought. A richly varied literary
tradition, writings on Tibetan embryology are linked to issues of fundamental importance in Tibetan Buddhist
thought and culture: to cosmology and astrology, to causality, salvation, ethics, and the complexities of Buddhist
practice. While Tibetan histories typically mark medicine as a “secular science,” by the fifteenth century certain
topics within medical literature, notably embryology, anatomy, and physiology, had been largely absorbed into
religious conceptual frameworks. As it turns out, it appears to be less the case that religious traditions borrowed
embryology from medical traditions, as is generally assumed by Western scholars, than the reverse—that is,
embryology is most fruitfully a religious topic. For religious writers, embryological narratives were a means of
embedding doctrinal messages into human identities: such embryologies are religious doctrines that are
narrativized into human lives. For medical writers by the fifteenth century, embryological narratives became a
forum for religious theorizing—the topic allowed medical scholars the opportunity to theorize about issues of
vital importance in Buddhist literature. As medieval Tibetan scholars sifted through texts and theories inherited
from India, embryology fell clearly to the side of religion, eventually becoming a place for religious and medical
theorists alike to contemplate metaphysical questions of being and becoming, while topics such as pharmacology
and nosology were left to shape the domain of “secular” medicine. Such observations remind us that the
inclusion of the study of the human body in the field of medicine at all—in the form of physiology, anatomy, or
embryology, for example—is a particular historical occurrence in our own intellectual history. This paper clearly
identifies medicine as a player in a far larger discourse than simply that of medicinal healing. It thus questions
the validity of superimposing our own epistemological taxonomies on classical Asian thought, pointing also to
the value of an interdisciplinary approach.
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Is there any overlap between research ethics and ethics of researchers?
Gefenas, Eugenijus (Lituania)
Even if the title of the paper might sound like a simple play of the words, it refers to two distinct fields of
normative issues. On the one hand, research ethics first of all concentrates on the rights and welfare of research
participants. On the other hand, issues attributed to the field called “ethics of researchers” or “research integrity”
are mainly those dealing with the quality of research data and the relationship between the researchers
themselves (e.g., scientific misconduct, questionable research practices, sloppy or careless research, conflict of
interest). This seemingly clear distinction is however rather complicated one. Even if we could separate the
problem areas of research ethics and the ethics of researchers, there are some important overlaps. For example,
the issue of conflict of interest should be analyzed from the both mentioned perspectives because a researcher
who is involved in the conflict of interest (if s/he acts both as a principal investigator as well as a treating
physician) might distort or manipulate the results of the study. At the same time it is likely that such a researcher
will also interfere with the autonomy and welfare of the research subjects because of the incentive to enroll a
sufficient number of research participants. This issue is, of course, one of the central topics of research ethics.
There are also other important overlaps between research integrity and research ethics which will be discussed in
the paper.
End-of-life decisions at a neonatal intensive care unit
Gerber, Andreas (Germany)
Background: If the beginning of life (birth) coincides with end-of-life decisions, a morally “correct decision is
not at all possible (Gerber 2004, 229f). Any decision is grounded in the ethical reflections of all who work in the
neonatal intensive care unit. Thus, an inquiry into the modes of ethical argumentations becomes essential as
conscious, and thus viable, decisions can only be attained if one and the others consciously know and understand
their attitudes. Henceforth, hermeneutics may contribute to an awareness of hidden ethical argumentations as it
confers „a process of perception (and self-perception) that is settled in the prescientific context of traditions and
modes of symbolic interaction into a mode defined by sound methodology“ (Habermas 235; translated from
German by myself).
Material und Methods: Persons: Physicians from a neonatal intensive care unit were interviewed by the author
while working there as a colleague. Methods: Open interviews on the issue of terminal care lasted about 30 to 60
minutes. Interviews were performed at either the interviewees’ or interviewer’s home. Interviewees were neither
guided nor confronted with particular topics, but solely encouraged when they seemingly could not continue
without an empathetic corroboration (Mayring 1990, 50ff).
Analysis: All interviews were transcribed and then analyzed with regard to the following question: Which basic
patterns of ethical argumentation could be detected on the question of life and death in neonatal intensive care?
Crosscultural Analysis: Patterns of ethical argumentation were compared to patterns from other inquiries
(Brinchmann 2000: Norway, Rebagliato et al 2000: 10 European countries).
Results: The following patterns could be detected among German physcians in one neonatal intensive care unit:
1) Inhuman behavior towards the neonates: As there is a lack of appreciation and care for the neonates, the
physicians’ activities neglect the neonates’ lives. Neonates are tormented by interventions or measures and, thus,
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their suffering is increased. The intensity of therapy should be guided by a split between extremely premature
newborns or severly neurologically affected neonates on the one hand and term newborns with severe acute
problems, eg meconium aspiration, or premature newborns to whom bonding has been established due to an
already ongoing stay on the NICU. Rejection of any cost- effectiveness- calculations, of any argument that relies
on whether the physicians’ output is profitable.
In contrast to patterns of ethical argumentation relying on religious feelings (as can be found in Rebagliato et al
2000) solely “secular” arguments were found in our inquiry. These included a general notion of what should be
„humanity“ as well as „concrete“ arguments, eg torture.
Philosophy as a resource for medicine
Gregory, Maggie & Boddington, Paula (UK)
Genetic information about one individual often has medical and reproductive implications for that individual’s
relatives. There is a debate about whether policy on transmitting genetic information within the family should
change to reflect this shared aspect of genetic information. Within the United Kingdom (UK), where the study
which has given rise to this paper is based, the current policy is that the client who attends genetic counselling
has the right to act as gatekeeper to the information they have been given and withhold it from other family
members who might otherwise benefit from advice and testing for a particular genetic disorder. Even if the law
on medical confidentiality remains unchanged, there still remains the question of professional practice and
whether, to what extent and by what means professionals should encourage disclosure within a family. Genetic
counsellors in the UK are currently advised to try to “persuade” their client to provide information to other
family members. Much of the UK debate so far has tended to focus on who has a right to genetic information, or
has a right to decline genetic information, frequently drawing on the notion of individual autonomy and on
utilitarian notions of harm and benefit.
This paper provides an analysis of philosophical and ethical underpinnings of recommendations in selected
policy documents and discussion, in the UK and elsewhere. It is supplemented by empirical data based on
interviews with individuals from families affected by specific genetic diseases, chosen to reflect different
transmission patterns and thus having differential impacts on males and females and children and grandparents.
These are haemophilia, Becker muscular dystrophy, myotonic dystrophy, polycystic kidney disease and
chromosomal mutations for a number of disorders which have been diagnosed in utero, followed by a live birth.
This interview data is used to enrich and challenge the argumentation of the policy debate. It focuses especially
on the need to consider the impact on relationships, family dynamics and individual and family integrity.
The theoretical policy debate would benefit from a more nuanced appreciation of the realities and intricacies of
family dynamics and inter-personal communication.
Ethics and Law in Medicine. With Special Focus on the Concepts of Sex and Gender in Intersex
Management
Gruber, Natascha & Bain, B. (USA)
With my contribution I would like to present my recent research project I conduct at the University of Berkeley,
California, at the B. Bain Research Group on Gender. I investigate on the interrelations of the socio-cultural
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concepts of sex and gender in medical treatment protocols for Intersexuals, and especially I focus on the ethical
implications of so called “normalization surgery”, conducted on newborns and children with intersexed
conditions (ambiguous genitalia). Intersexed born children undergo during their early life and childhood various
and often difficult and medical dramatically procedures to fit their bodies into the one or the other (male/female)
category, to adjust their sex to the assigned gender. As important as it is, to provide the medical and legal
preconditions and options for a self chosen sex/gender change as best as possible, it is important at the same time
to question a range of medical practices many intersexed born babies and children have to undergo, and to
discuss and promote alternative models in medical treatment.
The critiques on the current treatment canon stress the irreversibility of such operations, as in many cases it turns
out that the “wrong” gender was assigned, when the patient grows up and identifies with the opposite sex.
Another line of argument is: Whereas there is no question for the necessity of medical intervention in cases
where health is harmed, it has to be criticized that “normalization surgery” follows widely aesthetical norms and
ideas about how the “right sex”/ the “right body” should look like. Meanwhile many intersex advocates wish a
society and culture that accepts bodies as they are. This kind of vision would make some of the heavy medical
surgeries, which often go along with psychological traumas, superfluous. The claim is, to dispense with
operation where it is not necessary, where it is done mostly out of aesthetical reasons, and that subjects born with
intersex conditions should be able to choose their sex and gender identity freely.
The contribution of Philosophy in this applied field of Medicine, or medical Ethics is to accomplish a very
sensitive but in-depth analysis of the categories and concepts involved and a objective intermediation between
the parties affected: patients, parents, physicians, the educational system and the socio-cultural ideas of
sex/gender and bodies in general.
Does evidence-based medicine apply to psychiatry?
Gupta, Mona (Canada)
Evidence-based medicine (EBM) is a concept that has come to dominate the medical literature in the last ten
years. In their authoritative account of EBM, Sackett and colleagues define evidence-based medicine as ‘…the
integration of best research evidence with clinical expertise and patient values.’ (Sackett D.L., Straus S.E., et al
(2000) Evidence-based medicine: How to practice and teach EBM, p.1). EBM’s stated purpose is to improve
individual and population health outcomes through the deployment of the most effective health interventions.
EBM aims to achieve this goal by applying research data concerning the effectiveness of medical interventions,
to decision-making about whether to use those interventions in clinical practice. In order to determine which
research data will provide the ‘best evidence,’ EBM utilizes an ‘evidence hierarchy’, which ranks research
methods from most to least valid.
EBM makes the empirical claim that it is more effective in improving health outcomes than previous models of
clinical practice. However, EBM has been criticized for not substantiating this claim. This lack of substantiation
has forced EBM to justify itself philosophically, which it does through an implicit ethical mandate – that we
should practice EBM – without specifying any ethical theory to justify it. According to its own rationale, EBM is
the most likely path to knowledge about which medical interventions are effective. Thus, to practice anything but
EBM would abrogate the ethical duty of practitioners to provide the most effective means of achieving health.
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However, scholars have questioned this conclusion by pointing out serious flaws in the generation,
dissemination, and interpretation of research data.
Evidence-based psychiatry (EBP) arises through the application of EBM principles to psychiatry. EBP is
vulnerable to the general criticisms leveled against EBM. However, there are also reasons, particular to
psychiatry, to be concerned about EBP. EBM makes certain assumptions about the nature of medical disorders
and their treatments, which may not be applicable to psychiatry. To the extent that psychiatry does not conform
to these assumptions, the application of EBM to psychiatry is more likely to be fraught with epistemological
problems as compared to other branches of medicine. The difficulties in using EBM techniques to research nonmanualized psychotherapies (e.g. psychodynamic psychotherapy) exemplifies EBM’s constraint on psychiatric
research. Under such circumstances, wholesale adoption of EBP may not be ethically supportable. The purpose
of this paper then, is to understand some of the conceptual problems arising from EBP, and the ethical
implications that might follow from these problems. This paper will conclude by discussing the possible
responses psychiatry could offer to these ethical concerns.
The noble madness of Don Quixote
Hagen-Lautrup, Carlos F. W. B. von (Iceland)
On this paper the author discusses – from the viewpoint of four of his professional areas of activity and training,
Psychotherapy, History, Anthropology, Literature – pertinent aspects of the immortal work by Miguel de
Cervantes y Saavedra, Don Quixote.
That novel by Cervantes is written merging two contrasting styles. One, the most obvious, represents of course
the comic element. Episodes abound where comedy, satire, ridicule and sarcasm are mixed and viewed with a
detached view of the human condition. But, on another level – in between the lines style --, we see the sad yet
immensely honest and idealistic personality of a delusional character. Living, as he imagines, in a far more
idealistic and heroic time, he tries to apply to his present time the eternal ideals of justice, intervening as
prescribed, by the noble and ancient codes of chivalry. That is, defend and rescue the weak and innocent, seek
the actual facts and truth above all else, and – the most dangerous task – becoming the sort of character known
today as the “whistle blower” --, i.e., expose untruths, falsehoods, corruption and malfeasance, in a word, “right
the wrongs” of this world.
That incredibly idealistic task is undertaken by two characters having two contrasting physiques as per the
concepts of modern Kinesiology. One, the” knight errant”, is an ektomorphic. Often referred to in Spanish as “el
caballero de la triste figura” (“the knight of the sad countenance”) is tall, lanky, sad, philosophical and
meditative, consummed by his passion to bring justice, truth, and “right the wrongs”. The other, the “esquire”, is
Sancho Panza, the endomorphic. He is short, stout or rather obese, an uneducated rustic, yet still a bon-vivant,
always ready to enjoy a good meal. But he is good-natured, jovial, and very astute and cunning. He also has the
deepest admiration, loyalty and protectiveness towards the naive and idealistic mission of his master. In Spanish
his name, Sancho, rhymes with “ancho”, that is ”ample”, having a wide girth. And “panza” is the colloquial term
for “stomach”, or rather, the slang term “tummy”.
This author, for about two decades has researched and observed delusional syndromes and has already written an
exhaustive paper on some of these syndromes (Truth-Fantasy-Reality, Los Angeles, California, 1990, 63 pp). On
this proposed paper, the author presents a sympathetic evaluation of one of those delusional syndromes, the one
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affecting Don Quixote, a syndrome that he feels is far more common than we tend to realize and that can be
traced way back even into Antiquity. He also makes a number of pertinent disquisitions touching into areas of
philosophy and medical ethics. Presenting this paper, the author would also like to include a few short recorded
illustrations taken from a most remarkable musical setting for one of the episodes of Don Quixote. It is a
composition by Manuel de Falla, El Retablo de Maese Pedro, that was originally premiered privately in 1923
(Paris) and for that occasion using an unusual small orchestral ensemble, actors-singers and two sets of puppets.
Psychiatry and dialectical philosophy
Heinänen, Hannu (Finland)
Does the dialectical philosophy as such have a therapeutic effect? The dialectical behavioral psychotherapy has
proved to be effective on individual level. The dialectical philosophy of J.V. Snellman was effective on
community or Gemeinschaft level (making difference between society and community, Gesellschaft Gemeinschaft) in the Finnish national movement of the 19 th century. The both applications have as their central
problem the dialectical process of identity and the dialectics as a philosophy of (human cultural) development.
Marsha Linehan has developed the dialectical behavioral therapy on the basis of dialectical philosophy. We find
the process thesis – antithesis – synthesis (Fichte) or affirmation – negation – negation of negation (Hegel) in the
basis of the therapy as validation – change – autonomy. This dialectical therapy is applied especially to
borderline or emotionally unstable personality disorders. Dialectical philosophy is used to overcome a.o. the
black-white or either-or thinking in these disorders. Linehan refers a.o. to the dialectical philosophy (’philosophy
of spirit’) of Hegel and to the ’dialectical materialism’ of Marx and Engels. As a Hegelian philosopher J. V.
Snellman dealt with Gemeinschaft level problems on identity and the dialectical tension of national and
international. His dialectical philosophy was effective on community level and it also had a therapeutic effect (of
overcoming alienation) in understanding the relation of national – international and also understanding a persons
situation in this relation. He developed dialectical philosophy, especially the philosophy of the s.c. subjective
spirit. In this paper my aim is to compare the aspects of development and identity in dialectical philosophy with
the related aspects of s.c. developmental psychiatry and psychotherapy in psychiatry.
What Is Philosophical Bioethics?
Hellsten, Sirkku Kristiina (U.K.)
There is no comprehensively shared understanding of what bioethics really is even among those who are in one
way or another involved in bioethics. Further, there is no clear agreement on who “does” or “practices” bioethics
– or should do so. “Bioethicists” themselves have different ideas on what it is that they actually do – or are
supposed to do. There are debates on whether bioethics is – or should be – descriptive or prescriptive; what
methodology is to be used in bioethical inquiry; and what the goals of “bioethics” are.
This diversity of views and approaches to bioethics has led into a situation in which discussions on bioethical
topics easily lose their focus and turn into non-argumentative accounts of diverse views on different ethical
questions. “Bioethics” as an academic discipline has gradually lost some of its earlier reflective edge. Instead, it
has a tendency to fall into epistemological and ethical relativism – it has a tendency to uncritically support all
possible approaches to bioethics. It no longer matters whether different views are validly argued for or not;
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whether they use analytical, empirical or intuitive methodologies of verification. These are all considered as
“valuable” and thus “right”.
This paper argues that if we cannot define what “bioethics” is all about in the first place, we cannot expect to
have a proper discussion on one or another form of bioethics as normatively more plausible or logically more
coherent. However, if we want to make bioethical research “meaningful” again we need to return to more
analytical philosophical reflection on the issues of definitions, arguments, and logic.
A philosophical approach to the concept of history of medicine
Hernandez, Justo (Spain)
The concept of two term subjects such as History of Medicine, for example, represents a high risk of
misunderstanding. Is it History? Is it Medicine? Is it History and Medicine? Is it History or Medicine? And
finally, is it neither History nor Medicine? In this paper, we have studied the true and genuine concept and
meaning of History of Medicine by means of some classical Greek myths and the doctrines of several
philosophers such as Aristotle, Hegel, Kierkegaard, Marx, Nietzche, Ortega, Heidegger, etc., concluding History
of Medicine is the right answer to the essential and capital question: what is Medicine? Moreover, in order to
avoid that abovementioned misunderstanding we have suggested two other names which could be also idoneous
to History of Medicine.
The Reality of Universals and the Scientific Foundation of Holism in Medical Anthropology
Heusser, Peter (Switzerland)
Despite undisputed advances of conventional medicine (COM), complementary and alternative medicine (CAM)
has become increasingly popular over the last decades, even if the evidence base for the effectiveness of many
CAM practices are lacking or controversial. Among the reasons for this phenomenon is a growing dissatisfaction
of patients with the dominantly mechanistic and technical orientation of COM as opposed to the more holistic
and humanistic approaches of CAM to diagnosis and therapy. However, from the viewpoint of mainstream
science, the holistic concepts of CAM often seem irreconcilable with rationality of empirical science; “science”
is restricted to the reductionistic methodology which is so successful in the analysis of matter, whereas the
holistic immaterial entities postulated in CAM as being responsible for the phenomena of life, soul and spirit are
dismissed as speculative, irrational or at best philosophic “beliefs”. This view is quite misleading, however, and
not helpful in the attempt to reconcile the equally justifiable needs of patients and demands of science. Thus, a
scientific approach to holism in medicine is warranted.
On the basis of epistemology, it is possible to formulate a scientific form of holism which is based on empirical
facts and rational thinking, and which is equally compatible with the physical properties and the non-material
humanistic aspects of the human being. Historically, such a form of holistic science was first practiced by
Goethe in his work on morphology and colour phenomenology and epistemologically justified by Steiner, but its
principles are clearly applicable to today’s facts of physics, chemistry, molecular biology, histology, anatomy,
sensory physiology, psychology, and other areas relevant to medicine. The central feature of this form of holism
lies in the epistemologically justifiable notion that the laws of nature are not only subjective entities or
constructions of the human mind, but objective principles, inherent in and governing nature. In this sense,
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although they appear as “ideal” entities, they can ontologically be considered as real. This notion is identical
with the position historically known as realism of universals, put forth in varying forms by philosophers such as
Plato, Aristotle, Anselm of Canterbury, Thomas Aquinas, Albert the Great, Spinoza, Schelling, Hegel, and
Steiner, and which today can be applied to basic sciences and medicine. This results in a scientific methodology
where phenomena of nature are not reductionistically explained by the laws of their subcomponents, but by the
laws of their own emergent level of organization. This consequently leads to an acknowledgement of a holistic
hierarchical organization of nature, and, in the human being, to an account of four differentiated, interdependent
but equally real domains of laws and forces, those of matter, life, soul and spirit. This view is compatible with
20th century philosophy (e.g. N. Hartmann) and allows for a scientific dialogue between holistic CAM practices
and mainstream medicine. For this reason we have implemented an experimental elective curriculum “Holistic
Thinking in Basic Sciences and Medicine” at the University of Bern.
Fallacies in moral inference: How we implement new biotechnology
Hofmann, Bjørn (Norway)
New technologies incite profound moral challenges. This is most obvious in fields such as reproductive
technologies, transplantation, and human enhancement, but is also relevant in many other fields of health care
technology. Transgressive technologies appear to create a wide span of reactions and debate: from enthusiasm
and hope to skepticism and denunciation – from passionate promotion to fierce rejection. Despite major
opposition most such new technologies are accepted after some time. The dynamics of the process is quite
interesting in an ethical perspective: What makes people change their mind about new technologies? In many
cases it turns out to be one particular case, a person’s face in the newspaper, or a family’s story in the headlines.
There are many ethically interesting aspects of this moral modification of attitudes to and regulations of new
technologies, e.g. that this is a strong case for the ethics of proximity (moral appeal of the face) and for
deontological ethics (especially the duty to help suffering people). However, at the heart of the moral
amendment there is a particular form of moral reasoning: one case of useful application of a technology is
sufficient to overthrow a skeptical stance, and that general moral rules can be based on the solutions of a few
cases. These patterns in moral inference parallel inference patterns in scientific reasoning, such as falsification
and induction, and this paper assess whether challenges in the latter field are also relevant in the former. That is,
to what extent are inference patterns from science applied in moral reasoning, and how is this legitimized?
Furthermore, are the objections to these types of inference in scientific reasoning also relevant in moral
reasoning? Hence, the paper investigates the relationship between moral and epistemic forms of inference in the
field of new biotechnology.
Teaching Skills and Bioethics, the use of the Community of Inquiry
Hunter, David (UK)
In this presentation I will discuss teaching bioethics focusing on improving students skills as bioethicists. I will
give some brief arguments about why this should be the way we teach and then discuss one technique for
improving the students skills, the community of inquiry. This model has enjoyed great success in other contexts
such as work with Philosophy in Schools and has been shown to be more effective than any of the other teaching
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methodologies for increasing students critical thinking skills. I argue that not only can it be used to increase
students critical thinking skills, it can also be used to improve students ethical reasoning skills. As such it is a
useful technique for teaching in bioethics.
Human relationships; creating – justifiable – injustice in the allocation of health care resources
Igoumenidis, Michael; Athanasakis, Konstantinos & Kostakou, Panagiota (UK)
The reflections presented in this essay stream from a real situation and deal with human values like compassion
and bonds of love, but also with injustices which these values can create.
A person of great prestige in a hospital, let us say the manager, arranges for his father to be treated there. His
father suffers from leukemia and is in need of frequent blood transfusions. His condition is irreversible and
getting worse day by day; the blood transfusions can only offer him a few more months of life. Nevertheless, his
son gathers all the employees of the hospital, explains the situation, and urges them to donate blood for his father
– without any kind of obvious coercion. He thus manages to make a list of employees who are ready to donate
blood at any point his father has a need for it. A janitor in this hospital has a relative with a similar condition and
a similar need for blood, but he does not have the ability to ask for it from the employees as easily as the
manager did. His list comprises of only two or three persons ready to donate blood and he finds it difficult to get
more. However, we should note that the manager does not know about the janitor’s relative.
Even if in the end both patients are treated equally and get all the blood that they need, this is a case which
reflects a common problem in the field of health care. Persons of prestige, like physicians for example, are in a
position to provide better care for their friends and relatives. The allocation of resources is based on certain wellknown criteria, but sometimes the criterion of a personal relationship can influence the way patients are taken
care of. If we are inclined to decide immediately that this is wrong, we should consider that in the above
described case the blood was donated after the manager’s personal plea; therefore, these resources would not
have existed if his father were not in need for them. Would it be fair for other patients to have a demand on
them? Or maybe the fact that the manager took advantage – even unconsciously – of his position of prestige in
order to create these resources, refutes his absolute right on them?
Every aspect of this case shall be examined, and similar issues shall be considered, like the by-pass of some
waiting-lists, or simple things like personal favors. In the end, an obvious injustice can be traced in the field of
health care, which is however unavoidable; for there are bonds of love which cannot be denied, as they form the
basis of human society, and these bonds of love justify injustice. Absolute justice and equality demand an
impossible impersonality.
The changes of medical thinking and the attitudes of medical students in Lithuania
Jakusovaitė, Irayda & Blazevicienė, Aurelija (Lithuania)
Medicine has always been considered to be the most humane science, and no questions concerning the values in
the content of education have been raised. The application of new technologies in medicine (reproductive
medicine, the discovery of genome, death control, etc.), democratization of the society, the defence of patients’
rights, and the development of market relationships in medicine resulted in the emergence of urgent ethical
dilemmas that will have to be solved in the setting of the broadening Europe.
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The biomedical paradigm of thinking and medical practice based on this paradigm, both having dominated for
nearly a century, brought about a revolution in a person’s life through prolonging life expectancy, eradicating a
number of infectious diseases, enabling the diagnostics of genetic anomalies, etc. However, in the second half of
the 20th century the character of diseases changed, and the ageing population faced problems that cannot be
solved by biomedicine. The main changes in medical thinking are related to the transfer of the emphasis from
disease to health, from a hospital to the community, from acute diseases to the chronic ones, from treatment to
prevention, from interventions to monitoring, and from a patient to a personality. This change in emphasis is the
basis for transition from the biomedical normative definition of health and illness to the functional adaptive one
that emphasizes the importance of personal attitudes and a person’s socio-cultural status. In Lithuania the
standards of professional training are made up on the epistemological grounds. There is an insufficiency of the
humanistic aspect in professional medical training, and a lack of axiological (of value system) content. The aims
of professional training are underpinned by social order and training is more instrument–oriented.
This report presents a review of changes in the system of medical education in Lithuania in the context of the
above-mentioned alterations and integration into Europe. In 2004-2005 it was done research of medical students’
attitudes in Kaunas University of Medicine (Lithuania), University of Krakow (Poland) and University of St.
Petersburg (Russia). The attitudes of medical students in Eastern and Central Europe cover the beginning of life,
the death and dying, limitations of the technological interventions into the human body, the place of moral
competence within the expression of the profession and the contribution of humanitarian-social subjects in the
shaping of the moral competence. The main problem is how to integrate humanities and social sciences into the
content of professional disciplines and to pass from subject-teaching to problem-based teaching.
Polish Physicians' Reflection upon Health and Beauty
Kałamacka, Ewa (Poland)
The source of beauty lies in the health; beauty is therefore created by health behaviour. These mechanisms
became the subject of reflection since 16th-century Poland. Physicians began to promote exercise among adults
as an essential condition of health and beauty. With the advent of Renaissance thinking, positive prescriptions
for a healthy living made their appearance in which beauty played a prominent role. Physicians simply described
the appearance of a healthy man, which was intended to subsume the medical and the popular accounts of health.
They painted a vivid – not to say graphic – image of an active man, whose physical attractiveness, intellectual
capacity and health allowed him to enjoy life to the full. They intended to portray convincingly a healthy and fit
man, to whom he invariably ascribed good looks and favourable traits of character. Their readers were thus
expected to build up a chain of associations, linking health (physical attractiveness, desirable personality traits)
with physical activity. The broadly construed attractiveness of the active man was intended to make the reader
emulate the proposed model. Physicians in later epochs struck nearly identical tones, associating health with
external beauty.
Therefore, they were keen to share with the Poles their reflections on beauty, concentrating on the link between
health and physical activity, although, admittedly, they differed both in the postulated explanation of this link
and in the degree of emphasis they placed on it. Their reflection on beauty was extremely important, as it
increased the awareness of the relationship between lifestyles and health.
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Pathogenesis, Salutogenesis and the idea of existential freedom
Kalbitzer, Jan & Neitzke, Gerald (Germany)
Since the 1970s Aaron Antonovsky developed and presented a new concept of health and disease. He argued that
the traditional pathogenic concept of stressors inducing illness was not coherent with reality. He assumed that
stressors are omnipresent. Consequentially Antonovsky focussed on the question: why does somebody stay
healthy in spite of the stressors present? Believing in the revolutionary importance of this idea, Antonovsky
developed a whole new system called Salutogenesis. Since then the salutogenic theory has become one of the
most important and influential models of potential reforms of the concepts of health and disease. A well known
criticism of the pathogenic model is, that it produces illness, stigmatises people and leaves no space for an
individualised concept of health. In other words: the positivist and reductionist way people are diagnosed and
treated in western medicine diminishes personal liberty: someone who is ill unquestionably is ill, no alternative
concepts are applicable. One of the objectives of salutogenic theorists is to overcome this problem. But does
Salutogenesis really provide more personal liberty? And what kind of freedom are we talking about?
In this presentation we develop a model of personal liberty in accordance with the idea of freedom we find in the
philosophy of existence. Therefore we will introduce the concept of freedom in the writings of Kierkegaard,
Heidegger and Jaspers. According to this analysis, one of the main features of their idea of freedom in the
context of health/illness is the independence of the self to decide whether he or she assumes and understands
him- or herself as ill or not. Having defined freedom from this existential point of view, we will investigate in
what ways the pathogenic and the salutogenic models contain or provide this idea of freedom. The conclusion is
that the salutogenic model does not increase freedom, but even reduces it in a specific sense. While the
conceptual core of the pathogenic model is to provide tools we use to understand certain phenomena we call
diseases, the salutogenic model contains strong assumptions about the self of a person. One of the main
assumptions is that doubts and existential fears correlate with a low health-status. In contrast to this the
philosophy of existence recognises fears and doubts as a substantial aspect of the human being on its personal
way towards liberty. To summarise: Salutogenesis might widen our understanding of health and disease but
despite all promises made it does not offer more freedom to the individual, but even undermines its radical
dimension.
A Relational Ethic for the Clinical Encounter: Levinas & the Physician-Patient Dyad
Karimuddin, Ahmer A. (Canada)
Through a careful examination of the clinical encounter as conceptualized by Pellegrino & Thomasma, parallels
and areas of concordance with the relational ethic of Levinas are highlighted. Of prime importance is the
physician’s responsibility to respond to the evolving needs of the patient, to ensure that the good of the
individual patient is always kept in the forefront. Through recasting the physician-patient encounter, as
envisioned by Pellegrino & Thomasma, in light of Levinas’ relational ethic, the importance of the evolving
nature of the needs and goods of the patient and the primacy of heteronomy in the physician-patient encounter is
highlighted. Levinas’ work serves to inform the clinical encounter, by making the physician’s very identity and
self dependent upon an infinite responsibility towards the needs and good of the patient. While heteronomy is a
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challenge to the autonomy of the individual position, it is only through such a heteronomous stance, can the
needs and good of the individual patient be optimally fulfilled and realized.
Representing ageing in New Zealand: the value of literary and narrative studies in health education.
Keeling, Sally & Ritchie, Lorraine (New Zealand)
This paper arises out of a project in which an elective course exploring literary representations of ageing was
offered to student health professionals (nurses and occupational therapists). It is argued that the use of narrative
and literary studies opens up effective learning in attitudes and values for health professionals, along with selfawareness and reflection relevant to practice with older people.
The paper will present and discuss New Zealand perspectives on the experience of ageing and old age, through
analyses of selected examples from two genres of narrative. Firstly, recorded and published narratives arising
from oral history, autobiographical writing, and personal memoirs will be considered, seeking distinctive New
Zealand representations of these experiences. Then we will follow a literary turn, exploring writing in New
Zealand short fiction and poetry, and analyzing selected works in terms of fictional and poetic exploration of key
attitudes, experiences and interpretations of becoming and being old. Common themes identified in these genres
will be discussed, through an exploration and interpretation of the linguistic and discursive devices used. Finally,
the discussion will explore aspects of how living in an ageing body, gendered experiences, and intergenerational
relationships are described, before evaluating the tensions expressed between “succeeding or succumbing” in
later life.
Assessing the cochlear implant correctly: a matter of cooperation between medicine and the humanities
Kermit, Patrick Stefan (Norway)
The technology of cochlear implants has raised a large discussion in the field of medical ethics. This is a bit
strange, given that comparatively few people are affected by deafness. The reason for all the publicity and
interest is rather the intriguing fact that the division between those in favour of the new technology and those
opposed to it is unusually sharp: The proponents of the technology express the optimistic view that the implant
will rid us of deafness in the future. Holding a different view, a lot of deaf people reject the implant. They claim
to be primarily members of a linguistic minority and not a group of disabled people in need of repair. Some even
accuses the proponents of attempting to commit ethnocide and eradicate the deaf culture. This has triggered both
the curiosity and interest of many philosophers working in different fields of medical ethics. In the field of health
technology assessments, the debate over cochlear implants is used as an illustrative case. Traditional methods of
assessing new medical technology are challenged when some of the patients not only reject the technology, but
also claim it is a tool of oppression.
In the field of reproductive medicine, it is debated whether or not reproduction of deafness is ethical. Deaf
people not only reject the implant, some of them procreate with the clear intention of conceiving a deaf child. In
the spring 2004 I was part of a research team doing an empirical study of two deaf boys, age between seven and
nine and both implanted. One important objective of the study was to develop a deeper understanding of the
ethical issues involved in the case of cochlear implantation. Our findings suggest the theoretical discourses using
the cochlear implant as an illustrative case, fails to recognize the real nature of the ethical problems involved.
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Briefly presenting this study, I want to make some remarks on how the correct assessment of new medical
technology as the cochlear implant, presupposes a close dialogue between the field of medicine and the
humanities.
Pharmacogenetics: A New Era in Philosophy and Medicine
Kettlewell, Ann Catherine (Mexico)
The new era of genetics has initiated the discussion of new topics. Experts have considered the applications of
genetic knowledge and the human genome concerning medicine. Moreover, society is also interested in
discussing the ethical and legal implications of such technology. Some examples of these discussions have been
use of genetic information, cloning, and stem cell research. However, it is not constraint to these matters. This
paper will approach another area of discussion: pharmacogenetics.
The first part of this paper will concentrate on a brief explanation on how pharmacogenetics is the possibility to
develop safe and effective medications for certain group of people. The information that could be obtained from
the DNA of individuals will help doctors prescribe the correct drug for that individual. There are certain genetic
characteristics within a group of individuals that make them unique for the response of certain drugs. Specific
information about that group will avoid any kind of secondary effects and will achieve the effective result which
is the purpose of prescribing certain drug.
This paper will consider the ethical and legal implications of pharmacogenetics. There are a myriad of issues
concerning the discussion of pharmacogenetics. The second part of this paper will discuss issues on informed
consent, justice on drug therapy, health care access, among others.
The third part of this paper and the conclusion will explore the possibilities of applying such technology in
developing countries and the different type of discussion that this matter brings to these countries. Even though
developing countries might not see the direct applications of pharmacogenetics, there are still some matters to be
considered. Issues such as informed consent might raise issues of effective and comprehensible communication
to the subjects that will be brought into clinical trails.
It is clear that some groups of population will take advantage from pharmacogenetics over other groups.
Moreover, the pharmaceutical industry might be interested in some type of illnesses over others. The access to
drugs for only a part of the population raises questions of justice. Matters such as this are important to discuss
before the fact. Even though we do not have the benefits of pharmacogenetics now, we need to foresee some of
these matters in order to provide for a benchmark for the society’s actions.
This paper would like to pose these questions and provide a point of discussion where philosophy and medicine
meet to find an answer. I would not be looking for a universal answer but I would like to provide for the basis for
the discussion on this matter.
Medicine – as all-embracing science: the cosmist explanation
Khroutski, Konstantin S. (Russia)
In my presentation I am going to substantiate that Health is the realization of the nature of a person. The chief
goal of medicine is the health of a person. Hence, the nature (essence) of medicine is the comprehension of
individual's nature (Individual's health) – a universal substance (which is, from the point of view of the proposed
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Cosmist episteme and the derived theory, – a rational, scientifically comprehensible substance). The term
"episteme" has, in my context, as much the accepted meaning (of Foucault) in the philosophy of science, as
much the substantive macro-evolutionary (Cosmist) significance – of realization the next natural macroshift
(macro-evolutionary stage) in the unfolding of the world civilization. In this Cosmist perspective, I draw the
parallel between my conception and the theoretical notions of Ervin Laszlo – a leading modern systems theorist
and futurologist. By virtue of the Cosmist episteme, the real (biomedical) world is naturally self(macro)evolving
and functionally universal on the subjective (personalist) level. Therefore, as distinct from the modern, generally
accepted standpoint, I intend to claim and substantiate the triadic (cyclic, macro-evolutionary) essence of the real
world. This means that every subject of life (a person, first of all) has its/his/her own (macro)evolutionary Past,
Present and Future of subjective wholesome development (ontogenesis).
My intention is to argue that the main vice, fundamentally, of the modern, world guiding (Western) episteme
and, conformably, of the derived global (scientific) biomedicine – is their 'natural-artificial' essence: of
considering the real (objective) phenomena and processes on the basis of a priori artificial principles (the
postulates of Western philosophers). Nowadays, the challenge has emerged to the advancement and realization
of the evolutionary next, no longer Western – 'natural-natural' (hence, universal) – episteme and the new
derivative, civilizationally self-dependent philosophic and scientific foundations, as well as the evolutionary
novel – integrated universal – health-centric bioethical paradigm. This might be precisely the basis for the new –
universal, comprehensive health-centric biomedicine, which will treat a patient primarily as the person, whose
first-rate responsibility is the self-realization of his/her healthy ontogenesis, and who will be integrally treated
both on the physical and sociological (psychological) levels, as well as in his/her personalist (the main and selfdependent) sphere of human ontogenesis.
The main point of my prospective presentation is that Russian (but not soviet!) civilization (philosophy, first of
all) alone has the potential to realize a new rationality for the evolutionary next, in great demand, universal stage
of the world civilizational evolution, including the required derivative foundations for the all-embracing
biomedicine. Thus, the Cosmist approach substantively differs from the accepted views on the human nature and
the true nature of medicine, which (the views of modern anthropology and biomedicine) follow the fundamental
(Western epistematic) principles of anthropocentrism (anti-cosmism), subject-object relation to the world
(cosmos), presentism, adaptationism and pathocentrism. Precisely basing on the Russian (but not soviet!)
primordial philosophy, I have proposed the Cosmist conception of the needed rational – universal episteme (and
the deduced philosophy and theory). Simultaneously, my theorization is strictly based on a posteriori (verified
by natural sciences) fundamental natural truths (principles) of: (1) cosmism; (2) universalism; (3) subject-subject
interrelation with the world; (4) subjective (personalist) evolutionary functionalism; (5) emergent
(macro)evolutionism.
In this line, my special evaluation is the topic of holism in biomedicine and bioethics. Herein, I necessarily
analyze the current achievements, especially the holistic theorizing by Lennart Nordenfelt and the Lonergan
perspective of interdisciplinarity exposed by Russell J. Sawa. The other point of attentive consideration is the
chief theoretical and methodological principles of the Cosmist conception. My main theses are exposed in the
World Futures 60(8), 2004; EJAIB 15(1), 2005 (available on-line); Journal of Futures Studies 9(4), 2005 (the
latter two are freely available on-line).
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Humanities in Medical Education: Teaching Social Medicine
King, Nancy M. P. (USA)
Since 1978, the Department of Social Medicine at the University of North Carolina has taught a required course,
“Medicine and Society”, which meets for 90 minutes each week for first year of medical school. It is taught in
small seminar groups. Faculty teach from an extensive and well-developed syllabus. A compilation of syllabus
materials, The Social Medicine Reader, is now in its second edition (Duke University Press, 2005).
This presentation describes how this course integrates the teaching of medical humanities and medical social
sciences, from the perspective of a humanities-trained faculty member who has taught it for 20 years. The course
surveys key topics, including: the patient’s experience of illness; social factors and their effects on health
(family, race and ethnicity, gender, culture, religion, socioeconomic status); the physician-patient relationship;
medicalization, labeling, and stigma; chronic illness and disability; the boundaries and limits of medicine; the
culture of medicine and medical education; a wide range of basic issues in medical ethics; death and dying;
resource allocation; health care financing in the United States; and the problem of providing treatment for those
without health insurance.
First-year medical students spend almost all of their time in lecture halls, expected to memorize great quantities
of information. The Medicine and Society course stands out by emphasizing critical reflection on the profession
of medicine and its relationship to modern society. Teaching students to value complexity and to accept the
absence of clear answers poses an ongoing challenge. Effective use of the medical humanities in teaching is
essential to meeting this challenge, so that students may become thoughtful and resourceful clinicians.
The Medicine and Society course successfully makes use of the disciplinary rigor of the humanities to promote
student learning. It incorporates literary analysis, critical reading of the medical literature, and examination of
history and philosophy to address key course questions. The Social Medicine Reader includes poetry, fiction,
literary nonfiction, and selections from law, anthropology, philosophy, political science, and history, among
others, to help demonstrate to students how medicine shapes and is shaped by the society in which it is practiced.
Essential to the effectiveness of medical humanities teaching is its multidisciplinary character. For example,
ethical issues are not segregated from their social context, or from the scientific questions with which they are
entwined; poetry and fiction are just as valuable in discussion of the end of life as they are in examining the
effect of poverty on health status; and data on the cost of health care are important to inform both discussions of
the ethics of physician-assisted suicide and of the political feasibility of health care reform.
Examples of course readings and syllabus materials will be provided and discussed. The Medicine and Society
course is taught from the context of American medicine; it is of particular interest to consider how it might be
adapted to European and other contexts.
Scientific Greek medicine: a fruit of the cultural and philosophical flourishing in ancient Greece
Kontopoulou, Theano D.; Vaidakis, Emmanouel A. & Marketos, Spyros G. (Greece)
Aim: In this presentation we try to investigate the influence of the cultural and philosophical flourishing in
ancient Greece on the formation of the scientific character of the Greek medicine.
Elements - Methods: The Hippocratic Collection, the writings of the pre-Socratic philosophers and the
bibliography concerning ancient Greek medicine, philosophy, civilization and culture were thoroughly studied.
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Results: Greek medicine cannot be separated from culture and philosophy throughout its history. Hippocrates is
hold to be the father of the Greek scientific medicine. His name is connected to the most creative period of
scientific medicine in Greek antiquity. Hippocrates’ major contribution to the history of medicine was that he
dissociated medicine from religion and witchcraft and set it off as a pure science, based on clinical observation
and rationalism. Intellectual ancestor of Hippocratic medicine was the famous brilliant pre-Socratic philosophy
that is Greek philosophy before Plato and Aristotle. The early cosmological speculators, coming from Asia
Minor and the Greek colonies of Southern Italy or Sicily, sought to explain the universe by pure reason and not
by supernatural forces. Some of them explained the world process by monistic theories, while others projected a
dual or multifaceted version of phenomena. Thales of Miletus propounded the principle that water is the cause of
all things. Pythagoras of Samos held the universe to be based on the harmony of numbers. Empedocles of
Agrigentum, the precursor of the Hippocratic humoral system, proposed that plants and animals –including manconsist of four basic “rizomata” (i.e. basic elements). He was the first to acknowledge common roots between
plants and animals and to accept a genetic and hereditary biology based on the mixture of the “rizomata”. Both
sciences and arts were cultivated to an incomparable degree in the so called “golden age of Pericles”, that was
contemporary to the appearance of the scientific Hippocratic medicine. Sublime monuments, such as Parthenon,
were constructed; unique works of art, such as Phidias’ sculptures, were created; Herodotus and Thucydides
wrote their immortal historic texts; the great tragedians, Aeschylus, Sophocles and Euripides led the souls of the
public to catharsis with their impressive tragedies. Mathematics, astronomy, biology and many other sciences
were studied on the basis of experiment, observation and logical reasoning.
Conclusion: The dawn of the Greek scientific medicine, that is Hippocratic medicine, is developed in close
relationship with ancient Greek philosophy and culture. The interplay between medicine and culture is always
close and reciprocal. Every country’s medicine epitomizes the cultural history in a given historical period.
A pilot study to determine the influence of a problem-based curriculum on medical students’ preparation
for ethical reasoning.
Kruger, Mariana & Bergh, Annemarie (South Africa)
Introduction: The complex ethical dilemmas created by advanced technological medicine and problematic doctorpatient relationships have lead to an increasing interest in medical ethics education since the 1980’s. The Medical
School of the University of Pretoria has embarked on a new undergraduate medical curriculum in 1997. Ethics is
educated in a longitudinal fashion over the six years of the medical curriculum and has focussed largely on the
principal-based approach as described by Beauchamp and Childress.
Aim: To investigate the undergraduate medical students’ ethical reasoning skills and knowledge after five years
of medical studies.
Participants and methods: The research participants were the first final year class of this new curriculum, while
the facilitators were medical educators or philosophers. The 184 students were divided in ten groups with ten
facilitators, who each dealt with a different ethical topic or principle. Each group spent an hour with a facilitator
discussing specific case studies around a particular ethical issue. The data collection process included flip chart
summaries of the group discussions, a focus group discussion with the facilitators and two independent
observers, who attended two sessions of each group, to document attitudes of the students to ethics in a semi-
41
structured manner. The data was analysed according to acknowledged data analysis strategies in qualitative
research. The three different types of data sets served as triangulation.
Results: The major finding of the curriculum was that the students were not yet able to identify ethical dilemmas
with ease, although they were successful in the application of the principal-based approach to the vignettes of the
study. The students did not cope well with the uncertainty created by ethical dilemmas and sought to solve the
situation by creating boundaries provided by medical law.
Recommendations: The recommendations of the study are that the theoretical component of the ethics
curriculum should: 1) introduce more approaches to ethics, than only the principal-based approach; 2) address
daily experienced ethical dilemmas during the study years in small group discussions; 3) and introduce a
portfolio assessment which can serve as a tool for students to track their own development in reflection on
ethical dilemmas.
Conclusion: The question remains whether medical students are currently ready to come ““face to face” with the
“other” (patient) as Levinas argues or are we still divided into “only two classes of mankind in the world doctors and patients” as remarked by Kipling in the 19th century.
Jonas’ Contrubution to the Notion of Care
Kuře, Josef (Czech Republic)
Hans Jonas, coming from “ancient creed” (his early works on gnosis) to technological man (philosophy of
science), is well-known for his late work The Imperative of Responsibility. In Search of an Ethics for the
Technological Age. The idea of care is incorporated in his concept of responsibility which is a caring
responsibility in fact. The paper comparing two models of responsibility used by Jonas, analyzing relation
between responsibility and care, and investigates the possibility of contribution of Jonasian (conservative?)
notion of care to virtue ethics and to ethics of care - relevant tools for the contemporary bioethics discourse.
Disease: Disturbance in the Demarcation between the Same and the Other
Kurki, Janne (Finland)
The WHO defines health as following: “Health is a state of complete physical, mental and social well-being and
not merely the absence of disease or infirmity.” According to this definition, health is “not merely the absence of
disease” – which implicates that the absence of disease is necessary presupposition for health. However, the
absence of disease presupposes, again, that we could define what a disease is. This is, indeed, the intention of
this paper: I try to formulate as universal and thus as formal definition for the concept of disease as possible.
Briefly, I define disease as a disturbance in the demarcation between the Same and the Other. It has to be
emphasised that this is a purely formal definition: as such, it is empty of particular contents. Thus the examples
that I present both 1) clarify the concrete meaning of this definition and 2) tie this hypothetical universal
definition to the existing diseases.
My definition of disease implicates a new definition for health care: if a disease is a disturbance in the
demarcation between the Same and the Other and if health presupposes the absence of such a disturbance, then
the base of health care is formed by caring of this demarcation.
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Exceptional disease courses after use of complementary and alternative treatment - a research field
between medical science, humanities and social science
Launsø, Laila (Norway)
An individualization process is taking place in modern society that constantly imposes new demands on the
individual person. In this perspective, the concept “individual choice” is attributed a prominent role along with a
development of broader understandings of disease, treatment and outcomes in the population than offered by the
medical science. Individual choice of treatment options on the private market consisting of complementary and
alternative treatment (CAT) has increased dramatically during the last decades.
Although research on CAT has expanded in the past decade, research funding for CAT has most often been
directed to supporting randomized clinical trials (RCT) on specific effects of interventions. Most often the
medical research communities have conducted RCTs using standardized single-modality interventions. These
RCTs often show little or no effect. Despite these results, CAT providers are becoming increasingly popular as
treatment options for persons with chronic diseases and many patients and therapists report positive treatment
outcomes. There thus seems to be a paradox between “evidence-based” knowledge produced by RCTs and metaanalyses on the one side and experienced-based knowledge of treatment outcomes reported by patients and
therapists.
The paper will focus on research in the CAT field relating to this paradox. Researchers from medical science,
humanities and social sciences have globally addressed the paradox by making systematic collections of case
histories where there seems to be a disease development much better than could be expected from the clinical
and the research based knowledge within the conventional health care system. Globally different approaches
have been chosen in this endeavour. The National Research Center in Complementary and Alternative Medicine
(NAFKAM), University of Tromsø, Norway has established the first registry of exceptional disease courses
(RESF) that collect data from Scandinavian patients having experienced an exceptional disease course. The aim
of the registry is to collect data for research projects.
Further the paper will outline different research approaches to clarify exceptional disease courses and different
definitions of what is understood by the concept “exceptional” and relate these understandings to different
theoretical and methodological frames of reference. The paper will further discuss strengths and weaknesses
regarding the knowledge production of research on exceptional disease courses.
Compassion as a basis for ethics in medical education
Leget, Carlo (The Netherlands)
Many students study medicine because they want to ‘help people’. They have good intentions and a real
commitment to fellow human beings who suffer. When it comes to ethics, however, few know how to relate to
their own inspiration to this discipline. Teaching ethics to medical students is often frustrated by emotivism,
legalism, consequentialism and libertarianism. Because these phenomena are so deeply rooted in contemporary
Western culture, one should address them adequately in ethics education. We think that in this respect emotivism
can be seen as an opportunity rather than a curse. In order to use this opportunity adequately we propose to
follow the phenomenological analysis of compassion of Emmanuel Housset (L’intelligence de la pitié.
Phénoménologie de la communauté. Paris: Cerf, 2003). In his analysis Housset discerns both various forms and
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more or less inadequate analyses of compassion. According to his view, a phenomenological analysis of this
phenomenon can distinguish compassion from ‘auto-affection’ and show the intrinsic ‘otherness’ in an emotion
as subjective and personal as compassion. This analysis can help elucidating (1) that it is important to understand
the inner feelings of one’s own, (2) that compassion can be a source of morality and (3) that compassion relates
to a sense of community. These three insights stress the importance of monitoring personal moral development
during medical education. Monitoring this development can be realised by portfolio learning in which both
clinical experiences and input from various arts (literature, poetry, film) are integrated. Our argument relates to
recent pleas to assess the learning process of students during their clerkships more accurately and therefore
demonstrates the chances of a more valuable medical education in ethical respect, both before and during the
clerkships.
Is human and animal health the same and how is it related to other concepts in medicine and veterinary
medicine?
Lerner, Henrik (Sweden)
The aim of this study is to map different conceptual ideas about the concepts of health, well-being and welfare in
the fields of medicine and veterinary medicine. A total of 8 veterinarians and 7 physicians have participated in
qualitative interviews. This paper presents how the concept of health was defined by the interviewees and how
they viewed the relations between health and other concepts such as well-being and welfare. The differences
between the two sciences are of two different kinds. The first difference concerns how the science has evolved
and the second concerns perceived differences between animals and humans. I will here argue that these
differences are of minor importance. Some of the interviewees state that there are definitions of these concepts
that will function in both sciences. I will in this paper try to analyse such definitions to see not only if they are
applicable to both sciences but also if they are fruitful for these sciences.
Using Biology as a Liberal Discipline to link Philosophy and Medicine
Lewis, Stephen (UK)
That the tendency to think of medicine as resting upon a scientific biological foundation is not strictly accurate is
often put down to medicine really being an art rather than a science. But, where centred on the human being,
biology itself only appears to be dealing in the same terms as medicine. In practice, medicine seeks to cure
whereas biology seeks to understand. Significantly, while various aspects of biological science have supplied
technical support and innovations aimed at providing objective information about the human body, there has
been less conceptual transfer from biology to medicine than might have been expected. Now potential exists for
this to change.
Changes in the British Higher Education system, for example, have meant that a non-clinically orientated
academic interest in disease and health is now evident, catered for by departments of biological science and
social studies. Whereas previously in the biological sciences, many of our notions about disease and health have
been adopted somewhat uncritically from medicine’s long and often unscientific tradition, now a uniquely
biological understanding of such concepts is becoming necessary as a philosophy of ‘health science’ emerges.
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One such application of biological ideas has been through Darwinian medicine which seeks to apply
evolutionary theory to understanding our vulnerabilities to disease. This, and the extent to which evolutionary
theory is now being applied more broadly, suggests that, in certain respects, biology might, given the way in
which it provides a basis for influencing our worldview, be used as a more liberal discipline than it is at present.
In this respect, biology has the potential to serve as a conceptual bridge or conduit between philosophy and
medicine. New biological philosophies – providing comprehensive understandings of the human organism –
rather than mere materialistic descriptions are possible.
In this respect, certain terms used by both medicine and health science are in need of revision from a
fundamentally biological philosophical perspective. As an example, it will be suggested that the clinical term
‘illness’ has greater biological significance than is usually realised, especially in terms of individual survival;
that the term ‘pathology’ needs to be more clearly distinguished from ‘disease’. It will also be suggested that
‘disease’ and ‘health’ are better understood as labels that represent sets of experientially subjective and
physiologically objective phenomena that contribute to alterations in the overall biological state of an individual
as an organism.
Approaching clinical decision-making: a medical perspective
Lickiss, Norelle; Malpas, Jeff & Chalmers, Don (Australia)
Clinicians are faced with significant and often difficult decisions virtually every hour of the working day, and
also frequently late at night and in emergency situations. It is essential that the processes of decision-making are
facilitated and underpinned by the internalisation of key relevant philosophical, legal and ethical concepts so that
a balanced approach becomes intuitive. Sound clinical decision-making and practice may then contribute to
human flourishing and throughout life, and especially at critical periods, and community cohesiveness may be
enhanced.
An approach to clinical decision-making has been developed in the course of practice and teaching in a Sydney
teaching hospital. An attempt has been made to base this approach on:
a)
concept of cost/benefit analysis, with recognition of the complexity of the costs and benefits under scrutiny
b) an adequate anthropology, with an ecological view of the person which takes into account current
environment (including personal field),personal history(not merely medical facts), and inheritance
(biological and cultural), and
c)
an amalgam of some features of ethical traditions, notably principle-based, rule-based and consequentialist,
with the incorporation of the core notions of virtue ethics.
Note is taken of the "values in the air" (so conditioned by historical and cultural factors, and worthy subjects of
research), and of the factual basis (medical, including evidence base, relevant law, and resource limitations), the
analysis of the implications of autonomy, beneficence, non-maleficence and justice (individual and social), while
the central task is undertaken of making a decision, on the balance of probabilities, by the exercise of wisdom.
Such an ecological portrayal of the process of decision-making emphasizes the complexity of the personal.
This approach has not been formally evaluated, but appears to be welcomed by medical students as well as
graduates as a useful piece of furniture for the mind, and a basis for discussion, research, and further refinement.
It is to be stressed that attention to the various aspects of this model need to become intuitive, if such an
approach is to be a practical clinical tool.
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Philosophical appraisal may demonstrate the fruitfulness of exploring the interface of philosophy and medicine,
and recognising the usefulness of casting the light of both disciplines on some aspects of the human condition, to
facilitate human flourishing by enhanced understanding of complexity. The law is a necessary presence in the
scheme of clinical decision-making, not to define morality or what is correct to do, but to underpin the
legitimacy of the whole exercise, to clarify limits of possibility, and ensure accuracy in analysis of factors
pertaining to the human good.
Potentiality and Persons at the Margins of Life
Lizza, John P. (USA)
The concepts of potentiality and personhood have figured prominently in the debates over the moral status of
human embryos, the minimally conscious, individuals in permanent vegetative state, and the whole-brain dead.
Some bioethicists have concluded that because of irreconcilable differences over the concept of person and the
meaning and significance of potentiality continued focus on these concepts will be of little help in reaching any
kind of consensus on the moral status of these individuals. In this paper, I challenge this conclusion by proposing
that, although we may ultimately have to accept a pluralistic solution to the issue of moral status, some progress
toward greater consensus can be made if we recognize (1) an asymmetry in the significance of potentiality at the
beginning and end of life; (2) that potentiality is dependent on external factors and choices; and (3) how
biological, psychological, moral, and cultural factors contribute to our understanding of persons.
Analysing our qualms about “designing” future persons: autonomy, freedom of choice and interfering
with nature
Malmqvist, Erik (Sweden)
Actual or conceivable uses of germ-line genetic intervention and preimplantation genetic diagnosis (PGD) in
assisted reproduction seem to offer increasing possibilities of choosing the kind of persons that will be brought to
existence. While these technologies have given rise to a wide range of moral objections, the prospect of using
them for enhancement (i.e. non-therapeutic) purposes seems particularly troubling. How can we make sense of
this worry? Why are our thoughts about therapeutic genetic interventions and non-genetic enhancement not
accompanied by the same intuitive uneasiness?
In bioethical discussions, the concepts of autonomy and freedom of choice are typically invoked to delimit the
morally acceptable uses of these technologies. In this paper, I will argue that these concepts provide us with a
partial understanding of our reluctance to the idea of enhancement by germ-line genetic intervention and PGD,
but that they fail clarify our more general qualms about “designing” future persons. I will suggest that
approaching the deeper level of our worries about genetic interventions on future persons might require
reflection on the notion of interfering with nature. Admittedly, the concepts of nature and the natural are
problematic. However, I will argue that the way nature is understood by Martin Heidegger in his critique of
modern technology contains insights that might be useful for understanding why the idea of “designing” future
persons is intuitively troublesome. Such understanding is an essential first step towards reaching a reasonable
normative ethical position on PGD and germ-line genetic intervention.
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Approaching clinical decision-making: a philosophical perspective
Malpas, Jeff (Australia)
Norelle Lickiss provides us with a rich set of reflections on the clinical decision-making process. They are
reflections that arise out of her own clinical practice, and in this respect are paradigmatic of what makes for good
philosophy, while also informing and enabling decision-making. Some of the key features of Norelle Lickiss'
approach will be considered against a more explicitly philosophical background with particular emphasis on the
hermeneutical context of decision-making. A conception of the ethical will be articulated that is not merely an
element in the decision-making process, but as integral to that process; a conception that takes ethics to be
essentially holistic and negotiatory, and that is itself closely intertwined with the 'ecological' conception of the
person referred to by Norelle Lickiss. The outcome will be a rich conception of clinical decision-making that is
informed by the philosophical tradition, but which is nevertheless also embedded in the realities of clinical
practice.
Not only will the nature of decision-making be explored in this presentation, and, along with this, an account of
both the ethical and the personal, but so too will the character of possible engagement between medicine and
philosophy be at issue. Indeed, what will be advanced will be a conception of that engagement that involves a
certain methodology of philosophical practice that takes our ordinary practices and intuitions as the primary data
for philosophical reflection; that does not seek to organise those practices or intuitions according to some preexisting philosophical theory, but rather looks to develop philosophical theory out of the structure of those
practices and intuitions as such.
What is medicine? A philosophical analysis of the biomedical and humanistic models
Marcum, James A. (USA)
The metaphysical, epistemological, and ethical boundaries of the biomedical and humanistic models of medicine
are analyzed in order to address the question, “What is medicine?” The biomedical model’s metaphysical
boundary is demarcated by mechanistic monism, reductionism, and physicalism or materialism. For the
biomedical practitioner, the patient is a material body that is reducible to a diseased body part and is cured by
treating it. The humanistic model’s metaphysical boundary, however, consists of dualism or holism,
emergentism, and organicism. The humanistic practitioner encounters the patient as a person composed of both
mind and body, within a socioeconomic environment. The patient is more than simply the sum of separate body
parts and thereby exhibits properties that surpass the aggregation of those parts. Healing encompasses the whole
person.
The biomedical model’s epistemological boundary is constrained by objective knowledge, which relies on the
technological developments in the natural sciences. There is generally no room in this model for the physician’s
intuitions or the patient’s feelings about the illness experience. The humanistic model’s epistemological
boundary, however, incorporates subjective knowledge. The physician’s intuition is a key component in
obtaining and judging the patient’s personal information, especially the meaning the patient attaches to the
illness experience. Such information is obtained through the patient’s narration of the illness experience and is
critical for diagnosis and therapeutics.
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The value of neutrality and the scientific problem-solving aspect of modern medicine define the biomedical
model’s ethical boundary. The practitioner’s ethical stance is a concern to cure the patient and is detached from
the emotions of either patient or physician. Moreover, the patient’s relationship to the physician is passive. The
physician is the authority figure with the knowledge and power to save the patient. The humanistic practitioner,
however, cares both rationally and emotionally for the health of the patient qua person. The underlying value is
empathy, through which the physician gains insight into the patient’s suffering. The humanistic practitioner is no
longer the locus of authority but a first-among-equals, a co-participant with the patient. The patient-physician
relationship is one of mutual respect, for the role and contribution of each other in the healing process.
In conclusion, the answer to the question concerning the nature of medicine depends on the model of medicine
under scrutiny. Although the present philosophical analysis provides an apposite description of medicine’s
nature, especially in terms of the two models, it begs the normative question of how medicine should be
practiced. In the paper, I argue that the answer to the latter question is not either/or but involves the synthesis of
both models. For example, the physician’s intuitions are not necessarily impediments to sound medical judgment
and practice. But when judiciously utilized and constrained by the epistemic and empirical boundaries of the
biomedical model, they enable the physician to access, especially through allowing the patient to narrate the
illness experience, information and meaning about the patient’s illness that often exceeds laboratory test results
and aids in healing.
The concept of human being in Friedrich Schiller’s Aesthetic Letters: relevant to medicine?
Marian, Florica (Switzerland)
Although Schiller’s celebration of play as the highest human activity is well known, his treatise and concepts
upon which it is based has been neglected. In this paper, I will first describe the polarity of the sense- and formdrive (“Stofftrieb” and “Formtrieb”), proceeding from the physical and rational nature of the human being.
Operating within the material world, the sense-drive is subject to time, change and individual variability. The
form-drive, on the contrary, invokes the power of reason and the possibility to create harmony and universal
laws. The play-drive, bringing together and transcending both the senses and the reason, allows to reconcile
being with becoming and nature with freedom. According to Schiller, the play-drive expresses itself in aesthetic
activities, allowing individuals both to feel themselves as physical beings and to act as rational beings. The playimpulse is not only considered as the essential moment of all art, it is also claimed as the foundation of “the
much more difficult art of living”. In the second part, I will explore some of the implications of Schiller’s
anthropology and concept of human being for medicine. The Letters are not only a theoretical foundation of arttherapy, they also offer important insights with respect to actual developments in medicine such as the increasing
importance of patient autonomy and empowerment. Furthermore, integrating different dimensions (physical,
cognitive, emotional, ethical and spiritual) into a dynamic concept emphasizing the autonomy and freedom of the
individual, Schiller’s Aesthetic Letters contribute to a holistic approach to health, illness and healing.
The Glorified Body: A Reterritorialization of Death
Meaney, Mark E. (USA)
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In this paper, I employ the methodology of Gilles Deleuze and Felix Guattari in an analysis of the interface
between nanomachinery and the human body. I am particularly interested in DG’s account of how modes of
production affect the human body. Based on their methodology, I first show how tribalism and feudalism “mark”
the human body. This will then lead to an analysis of the ways in which machines “mark” the human body under
capitalism. A general consideration of the machine/human interface in the capitalist mode of production sets the
stage for a specific consideration and critique of the interface between nanomachinery and the human body.
Specifically, I use the concepts of territoriality, deterritorialization and reterritorialization in tracing the
recurrence of the medieval notion of the “glorified body” in contemporary reflections on the ultimate
consequences of advances in nanotechnology. In the first part of the paper, I show how the primitive tribe
exerted control over tribesmen through debt relations. The territory of the primitive tribe is clearly marked out to
such an extent that human bodies bear the external markings of territorial boundaries through ritual piercings,
elaborate tattoos, and torture.
In contrast, the feudal social formation exerted control over subjects through an “infinite debt of existence.”
Specifically, I use medieval Christian eschatological literature to explore briefly how the axiom of an “infinite
debt of existence” leads to notions of the “glorified body.” Medieval theologians thought that the “glorified
body” maintained eternally differences that were found naturally on earth between male and female, layperson
and priest, married and chaste, leader and follower, among the races, and so forth. I argue that, in addition to the
production of Foucault’s or Baudrillard’s disciplined subject, the feudal social axiom of deification also
encompasses human microbiology.
In the next section of the paper, I use DG’s methodology to disclose how the ‘civilized capitalist machine’ marks
the human body. I discuss the recurrence of medieval eschatological notions of the “glorified body” within the
“civilized capitalist machine,” which represents the emergence of new technologies that are the practical
manifestation of a deep possession of the human by capital. Where the feudal Despot could only dream of a
control of human microbiology in achieving stasis, capitalism is in the process of realizing that dream at the
molecular level through the application of nanobiotechnologies to the human body.
Of course, the goal of DG’s methodology is not merely to understand but to change. In the conclusion of the
paper, I draw on Paul Virilio’s ‘dromology’ as well as his notion of an “ethics of perception” in a critique of the
nanomachine/human interface. For Virilio, the revolution following that of transportation and of transmission is
that of transplantation, which involves the almost total collapse of the distinction between the human body and
technology. Virilio proposes a way in which to respond to the compartmentalization of scientific discourse and
scientific reductionism in the advance of nanotechnologies. In what he labels an “ethics of perception,” or the
“ethics of immediate perception,” Virilio proposes an alternative, radical new ecology as a means of critique.
Can Complementary Medicine be ethically justified?
Mertz, Marcel (Switzerland)
Background: In the recent decades, the use of complementary and alternative medicine (CAM) has become an
everyday issue in health care. The same is true of debates concerning whether CAM is justified on individual and
societal level. Common discussions are often focussed on political, “ideological” or scientific levels, whereas
there is only little academic work dedicated to questions of ethical justification of use, offer and promotion of
CAM: Which principles may collide with the use of CAM, also regarding epistemological reflections of the
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philosophy of science? Where might be limits of justification? What kind of normative consequences could
follow for the clinical situation? Does CAM actually play a significant role in clinical ethical decision making?
Such questions should be adressed, and added to the more scientific and epistemological focus already
mentioned.
Method: The paper will focus on a philosophical analysis of the possible and plausible ethical justifications for
and against the general use of CAM. Possible conflicts with accepted principles in bioethics will be discussed
using central ethical concepts in order to show whether they are useful to justify the use of CAM. It is not an
issue of the paper to finally conclude whether the use of CAM is generally justified. Rather, the paper should
offer a systematical analysis of what principles, concepts and perhaps even values can be considered relevant in
this debate, and how they might conflict with each other.
Hypotheses: The central ethical principle for the use of CAM on an individual level of ethical reflection is
respect for patient autonomy and the principle of benevolence. On a societal ethics level, it is religious freedom
and free speech, which are granted in democracy. On the other hand, the use of CAM could collide with the nonmaleficence-principle, with justice and the concept of informed consent. Scientific and epistemological
reflections could be relevant for the non-maleficence-principle. This is because the non-maleficence-principle is
violated if CAM-therapies or remedies are ineffective or even harmful. Also, in the case of ineffectiveness, there
might be indirect harm due to not considering or engaging in traditional therapies. Furthermore, CAM might
collide with the physician’s ethos and the ethos of science. Some proponents of CAM try to justify the use
ethically by postulating metaphysical absolute values, thus rendering them “critic-immunized”, which some
people think is problematic. Finally, there might be conceptual confusion in debates concerning the justification
of CAM: are political and legal justifications mistaken for ethical or even epistemic justification?
Perspectives: The paper as a conceptual approach should be a productive contribution of philosophy to the topic
of CAM. The epistemic goal of the paper is not to give final answers to all the above mentionend questions and
hypotheses, but to reveal and to systematize assumptions and principles involved, in order to develop a better
basis for further inquiries. The practical goal of the paper should be the proliferation of the ethical dimension in
CAM-related debates, and finally to provide some help for the actual clinical situation.
Does the moral theory of Gewirth support a broad concept of health?
Miller, Jane (UK)
The moral theory of Alan Gewirth is not widely known, but it contends that every person or agent, by the fact of
engaging in purposive action and by virtue of knowing themselves to be purposive agents, is logically committed
to the acceptance of certain evaluative and deontic judgements and ultimately of a supreme moral principle – the
Principle of Generic Consistency which also requires that he (each agent) respect his recipient’s (i.e. all other
agents) necessary conditions of action. In exploring and trying to utilise this theory in terms of health, it can be
seen that it endorses the broad concept of health articulated by the World Health Organisation in their famous (or
infamous) definition of health as ‘a state of complete physical, mental and social well-being and not merely the
absence of disease.’
The model that I have chosen to further expound this broad concept of health details a number of so-called health
determinants, all of which affect and interact to produce the individual’s state of health. These can be broken
down into social factors: the environment in which one lives; the material resources at your disposal; the social
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community in which one exists; the culture that defines what is healthy or sick; and the technology that shapes
perceptions of health. Additionally there are personal factors: trauma or injury; infection; psychological factors;
biological processes within your body; and your genes. Health is constructed at the interface of all these
components.
As I said earlier, Gewirth’s moral theory notes that there are basic, necessary preconditions for action as an
agent. He contends that the ‘necessary content of morality is to be found in action and its generic features’ and it
is these generic features that are required for action. He goes on sub-divide these generic features into basic,
additive and non-subtractive goods, with the basic goods being those that are the necessary preconditions for
action. He lists these as comprising of ‘certain physical and psychological dispositions ranging from life and
physical integrity (including such of their means as food, clothing and shelter) to mental equilibrium and a
feeling of confidence as to the general possibility of attaining one’s goals.’ This neatly mirrors the combination
of factors that I have just proposed as health determinants and also the WHO definition with its physical, mental,
social and well-being components.
Gewirth’s moral theory thus does endorse a broad model of health as being a necessary precondition for action
and agency.
Inidividualized music and the need for standardization: reflections from a nursing home project
Myskja, Bjørn & Myskja, Audun (Norway)
The project Music in the late stages of life was conducted in the period 2002-5 at three nursing homes run by
Church City Mission in Oslo, Norway. During the project, a systematic method was developed that enabled staff
with no previous musical training to chart music preferences in patients with dementia, develop active and
passive music programs on the basis of preference tools (validated questionnaires and preference CDs with
standardized rules for evaluation), measure results of the intervention and adjust music interventions on the basis
of the patient`s response.
Pilot studies on agitation, well-being and depression indicated positive results of the method individualized
music. Particular strong effect size was found for depression, and applications were made for a larger controlled
study on the effect of individualized music on depression. The application was rejected, on the grounds that
individualization of an intervention cannot be accepted in a controlled study, and that the intervening variable
(music) would have to be standardized to allow for controlled conditions. This decision raises philosophical and
ethical issues that will be discussed in this presentation, a collaboration between a medical clinician and music
therapist active in geriatrics palliative care and a philosopher specialized in applied ethics. The presentation will
cover the following central issues:

The ethical dilemma between demands for precise research tools and the need to ensure personal integrity in
persons suffering from dementia or other debilitating disease, who are often intimidated by research
instruments such as MMS (Mini-Mental Status).

The research dilemma between the need for a standardized intervention and investigations on music in
geriatrics that indicate that music needs to be individualized to be effective. Alternative methodological
frameworks for studying individualized therapies will be explored.
51

The implications of research indicating that standardized interventions based on our own presumptions of
what the other person needs may aggravate symptoms, for example playing “relaxing” or “uplifting” music
as a standardized intervention.

The need for an integrative model of diagnosis and treatment based on state-of-the-art medical knowledge
and also an ethical framework based on a coherent view of the human being. Tom Kitwood`s theory of
personhood will be explored as a possible framework for safeguarding against infringement of personal
integrity in contact with persons with advanced disease.
The embryonic stem cell debate: religion and rationality in a post-metaphysical democracy
Myskja, Bjørn (Norway)
The debate concerning research on embryonic stem cells is a paradigmatic example of the significance of
religious views in modern secular democracies. Although many have non-religious motivation for their
arguments against research on stem cells derived from surplus IVF embryos or from embryos created by
therapeutic cloning on a strictly secular basis, it is evident that many active participants in the debate, as well as
leading politicians, have a religious world view that is relevant for their position on this issue. The strict
regulation of this research in the USA is usually regarded as motivated by a religious conception of human life.
Although few of the debaters refer explicitly to religion in their arguments, and voice a Kantian or a secular
virtue ethical approach, their opponents may be justified in suspecting that this is a mere disguise for a different
agenda: A religious based political regulation of biomedicine. A crucial feature of modern democracies is the
fact of pluralism, making our kind of society “post-metaphysical”, according to Jürgen Habermas. In such a
society, the legitimate basis for political regulation must be views that everybody can have access to, effectively
ruling out religious arguments.
According to Habermas, deliberative democracy is based on the political participation of the citizens and that
laws and regulations must be based on a rationally grounded discourse open to every citizen. This presupposes
mutual respect of equality and freedom, and is often taken to mean that arguments based on world views not
shared by everybody, such as religious beliefs, must be “translated” to secular, political arguments to be
considered rational. In his recent work, Habermas counters this understanding, claiming that we cannot at the
present time know whether we prevent valuable truths and insights by rejecting arguments informed by religious
world views. Instead, both religious and secular citizens must take part in self- reflective learning processes that
enables us to partake in an open discussion including religious views. This openness to religious arguments in
public debate does not imply that the political decisions can be based on religious arguments. Here the demand
of legitimacy means that everybody must have equal access to the basic views.
The presentation explores the significance of Habermas’ view on the legitimacy of religiously based arguments
for debates on the regulation of biomedical research, in particular the stem cell debate. It will be argued that
including religious views in these debates is not only legitimate, but even required in order to avoid a myopic
utilitarian scientist approach to these decisive ethical and political issues.
Difficulties in drawing up advance directives
Nagaoka, Shigeo (Japan)
52
It is well known that many people, even the patients with serious illnesses, do not execute advance directives,
and that only when decisions about end of life issues are widely reported in popular media, many start looking
into the standard forms and sign the documents, as is shown in the recent Schiavo case in US.
One of the main reasons often mentioned for the low rate of having advance directives is the aversion to
discuss death, both on the part of medical providers and patients. But for the patients, there may well be
deeper reasons, i.e. the uncertainties about their own future conditions and, further, about what they would
want, should they be in the situations. First, cases which attract national attention are more or less clear -cut to
many people, and therefore they do not hesitate to express their preferences, should they be in those
situations, but in reality there are quite a variety of cases where people around the patients have difficulties
making decisions about the treatments. It is beyond lay people's capacity to imagine they would be some day
in each one of all such cases. Second, people with some life experiences must have und ergone the changes in
their wishes, hopes and aspirations until now. They can not be confident that their present wishes about their
own future treatments and cares will remain unchanged, yet the advance directives, especially the living wills,
by definition, force them to plan ahead what they would want in various hypothetical situations.
Discussions on advance directives are mainly concerned with their justifiablity, i.e. whether it is permissible
to respect the wishes written in the documents, be it a wish to terminate the treatment, or to continue the
aggressive treatment. For instance, R. Dworkin, in his Life's Dominion, tries to justify advance directives by
means of the concepts of "critical interests" and "autonomy as integrity," and many defenders follow his
insight. On the other hand, the different-selves (or, stranger) theory takes the form of the best-interest theory,
which considers the patient's present best interests to be most important, rather than her past wishes.
This presentation, assuming that the advance directives system is well established and that we can visualize to
some extent the possible diverse situations we might be in, focuses on the question how we can bind our
future selves and wishes by our own present preferences. This will take up the examples cited by the
defenders of advance directives, such as "Margo's Logo" in JAMA, 1991, and examine whether their
arguments are convincing enough to allay the concerns of those who hesitate to execute advance directives.
Chronic pain, suffering and chaos.
Nordemar, Rolf & Nordemar, Kristina. (Sweden)
We have earlier described chronic pain beeing connected to chaos and thus disturbing most areas of the persons
life. We need a deeper understanding of the process of ordering chaos, finding new strategies and structures in
thinking, feeling and acting, thus reducing suffering and pain. We will describe a process where patients with
chronic pain, mostly of fibromyalgic origin have been studied for 1- 2 years. They have all had traumatic and
stressful lifeevents. They have answered a painquestionnaire and been given musictherapy with guided imagery,
cognitive support and physical terapy in order to structure and order thinking, feeling and acting. Therapy also
was directed against nociceptive and/or neurogenic input (acupuncture, local anaestetic blocks and
antidepressants, TCA). Evaluation was mainly done with qualitative data and the process followed via repeated
interviews.
All patients described chaos in terms of lack of structure and meaningful coherence in their present life situation.
To begin with, an explanation of the pain and diagnosis was given, which served as a confirmation of their
experience and suffering. During receptive musictherapy the chaotic thoughts and feelings were allowed to be
53
expressed and cognitively processed. Gradually they diminished or were less threatening. By means of medical
treatments and storytelling the chaotic feelings came under a certain control. The existential questions connected
to suffering were allowed to be expressed and meaningful connections to the persons earlier lifehistory were
made. During musictherapy the feelings were differentiated, ordered and could be met under forms which were
acceptable to the person. Important persons in the social network were discussed and problematic bonds to the
patient were analyzed. Posttraumatic memories were allowed to come up. Cognitive techniques were used to
diminish dysfunctional basic beliefs. Acupuncture and other somatic actions were a help for the person to
integrate and control the mass of bodily sensations that overwhelmed them. After 1-2 years most patients could
express new feelings of freedom and meaning in their life with reduced pain even if was not abolished.
Remaining pain was not the same problem any more and their ability to control pain had increased considerably.
Vital Mimesis ~ imitation or animation: between ergonomics and ensoulment.
O’Neill, Fiona (UK)
Clinically, medical technologies are ergonomically designed to minimise the physical, and often consequently
social, effort and discomfort of the body which is considered disordered, disabled or different.
This paper considers how such technologies can be understood as ‘belonging’ to their recipients. Do medical
technologies merely imitate the ‘healthy’ body? How do they effect and affect one’s experience of embodiment?
Might they in some cases animate the body and the person? And if so, what are the clinical, philosophical and
socio-ethical consequences?
With both Hayles and Turner in mind ~ embodiment as performative, improvisational and in contrast to the
objectified body which can disappear into information, alongside the having, being and doing of bodies which
move from body projects to body options ~ this paper draws on the clinical and sociological literature of
transplantation, genetics and psycho-pharmacology, and research finding following interviews with hearing aid
users; to consider the vital lived experiences of medical technologies’ recipients.
In drawing conclusions, Aristotle’s psuchē is considered. Do in fact some medical technologies animate the body
synonymously, as with original body parts; where as others only imitate the original homonymously. And if we
are to use ‘flesh’ as a resource that reanimates ~ as with transplantation and gene therapy ~ are recipients
therefore heterogeneously ensouled?
However vital they may be in saving lives or lifestyles, these mimetics change the sense of belonging for the
individual beyond issues of identity. As enhancements they significantly question an individual’s sense of
personal and social authenticity. Hence, clinically and socio-ethically these mimetics can be problematic for our
sense of bodily and embodied integrity.
What they talk about when they talk about medical humanities. Humanities in medical education as seen
from the viewpoints of doctors and medical students
Ousager, Jakob (Denmark)
Introduction: The investigation presented here is part of a study aimed at gaining knowledge concerning decision
makers’, medical teachers’, and students’ expectations about the outcome of integrating humanities in medical
54
education. The objective is to provide an empirical foundation for developing and refining a set of concepts
useful in discussing if, why or why not and possibly how humanities should play a role in medical education.
A Critical Discourse Analysis (CDA) approach
The method used in the project consists in gathering texts – written or spoken – arranging the texts in corpora
(clusters), and analyzing the corpora using analytical tools from the critical discourse analysis (CDA) toolbox.
Discourse is seen as social phenomena with textual appearances that both reflect and contribute to constructing
(social) reality. When applied to this investigation it means the way medical humanities is discussed both reveals
something about the talkers’ or author’s conception of the subject and at the same time works back on the subject
concerned, in this case medical education.
Results: A previous work (under submission) examined discursive constructions of medical humanities in a
series of articles in the Journal of the Danish Medical Association and in course descriptions from the medical
curriculum at University of Southern Denmark. This analysis pointed to some opposing tendencies: Markedly
divergent understandings were represented in texts that on a first reading had much in common in presenting
humanities as essential in medical education. Digging deeper into the way “humanities in medicine” was
discursively constructed suggested the existence of contrasting ideas about the ontological status, the function,
and the justification of humanities in medical education.
Results from the abovementioned investigation are now being supplemented by conducting and analyzing
qualitative interviews with medical students, teachers, registrars, and consultants in charge of clinical
departments’ educational programs. The objective is to further illuminate the construction of humanities in
medicine – taking the conceptual framework generated in the first part of the project as it starting point, and
focusing initially on students’ and teachers’ contribution to the discursive construction of humanities in
medicine.
Preliminary results amplify the impression of teachers and students having mixed feelings about and
expectations to humanities in medical education. For example, many informants initially speak of humanities in
very positive terms, denoting it as interesting, fun, and highly relevant. Eventually though, as interviews progress
the enthusiasm sometimes gives way for more reserved attitudes towards integrating humanities in medical
education. Humanities are in many cases denoted as a passing fad, a surplus to requirements, or even as posing a
threat to the professional standards in medicine.
Social science and humanities – a support for medical and health care
Paliwal, Anjana & Chaudhary, B.R. (India)
"Health for All "is the universal global target of health. Set by world health Assembly, in 1977, it was stamped
by representation from almost all countries of the world and international Health Agencies. Like World Health
Organization, Unicef etc at Ahna Ala conference on "Primary Health Care" in 1978. It is defined as "Attainment
of a level of health that will enable every individual to lead a socially and economically productive life". This
component has also been incorporated in the original definition of health given by World Health Organization.
Concepts in public health has been changing with the changing pattern of the disease load, health needs of the
society and the broad based philosophical understanding incorporating medical, social, cultural, economical,
environmental, nutritional, psychological, geographical & life style factors annovates with health and disease.
The Alarming increasing incidence of non communicable crippling diseases like Diabetes, Hypertension, IHD,
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Cancers, Drug and Alcohal addiction, Neurosis HIV & Aids and other degenerative disease, high cost treatment
wide gap in the health status of people and the unequal distribution of health care resources has necessitated the
genesis and adoption, of the above strategy of HFA where in achievement of health has been accepted as a
global social goal to be achieved through the strategy of primary health care with "Equitable distribution of
resources, community participation, intersectional co-ordination and appropriate technology application.
Human beings besides being a biological entity are also social beings and diseases besides having medical
causes also have social and humanities science related causes socio economic consequence at family, national
and international level. Their management requires medical as well as social therapy medicine is not only the
science and art of diagnosing and treating disease. It is also ethically responsible for prevention of diseases and
promotion of community health. Therefore besides clinical skills medical professionals also require management
and counseling skills to act as catalytic agent for social change. All this necessitates the knowledge and
understanding social and behavioral sciences and humanities like Sociology, Economics, Political science,
Psychology, Philosophy, Environmental science, and statistic by the health planners, administration, health care
takers and treatment providers at all levels besides the knowledge of medical subjects. It will broaden the
treatment providers horizon of understanding of the medical personnels for better planning, micro planning,
execution, administration and evaluation of science, Medical professionals are the most knowledgeable persons
of health and disease issues and their advice is most acceptable by the masses. Effective and science
communication by them on disease prevention and health promotion issues would enable strengthening the
community, individual participation for health to promote standard of community health.
Together all these efforts would also fortify the power of clinicians, presentation and would add to better doctor
patient relationship. Understanding the society you serve, should also stimulate specialists and super specialists
to device cheaper and appropriate technologies and modalities for treatment and health care. Strengthening of the
teaching of social & behavioral science & humanities in the medical curriculum would improves the planning,
management and communication skill of the actual implementers of the programme at middle level, Most of,
whom do not go for specialized courses in health hospital management. Allocation of these tasks to non-medical
managers has the fear of personality conflict.
The value of the “pathological.”
Papagounos, Georgios (Greece)
The term “health” does not denote a physical state since the criteria which determine it, first, are not always the
same, second, the assessment of the various indicators used to ascertain it is not carried out consistently and,
third, the descriptions of the various conditions which are labeled “states of health” vary. Similar difficulties
exist in defining the terms “normal” and “pathological” despite the fact that they are employed to demarcate the
state of being “healthy”. I argue that these terms are not descriptive and that they denote values which are
ascribed to desirable states of affairs, conditions and characteristics. As a result, people value whatever state they
refer to as that of “health” and, thereof, the “normal” and they disvalue the “pathological”. I argue also that the
theoretical construct, on the one hand, which is used to distinguish the above two states and a specific social
milieu, on the other, may allow characteristics or conditions which are considered non-normal, i.e. pathological,
to be preferred to normal ones. Since people value that which satisfies their needs and their desires, it is indeed
the case that some characteristics which are neither typical nor common such as, e.g., a high IQ or a certain
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height, are preferred, under certain circumstances, to the average ones which are considered the normal. I further
argue that the process of valuation of the normal or the pathological entails dangers since it is on the basis of its
results that personal decisions concerning one’s physical and mental condition are made. However, it is also on
the basis of the valuation of the normal and the pathological that public health policy is designed as well as
decisions concerning the allocation of resources for health are made.
A Miracle – between Medicine and Theology
Pawlikowski, Jakub & Marczewski, Krzysztof (Poland)
The belief in miracles has always been an inseparable element of human culture. This issue is also present in the
contemporary great religions. It profoundly concerns that domain of human activity that is occupied by
medicine, for a miracle is often described as inexplicable health restorations. Doctors become embroiled in the
problems with miracles also when they are requested to perform as experts in the courts of law to corroborate a
health recovery as miraculous during beatification and canonization procedures held by the Roman Catholic
Church. The role of an expert is establishing whether a specific fact of health recovery can be given a scientific
explanation on the basis of the current medical knowledge.
In all definitions of miracle (Augustine of Hippona, Thomas Aquinas, D. Hume) we can distinguish two
elements: a natural factor, which is inexplicable in the light of the currently possessed knowledge and
acquaintance with the laws of nature, and an invisible factor whose result is perceivable in the world of nature,
which is considered the driving force behind the miraculous event.
By theological standards, the miraculous event is always referred to God as a direct cause. The objectivistic
concept of miracle claimed that during a miraculous event God suspends or changes the laws of nature. The
contemporary supporters of this idea (H. Dolch, W. Kunneth, also among the physicists – P. Jordan, H.
Rohrbach, W. Schaaffs) invoke the indeterministic and probabilistic character of the laws of nature. The
adherents of the subjectivistic concept of miracle, claim that it is the subjective interpretation in a religious
manner the inexplicable events by assigning them to God, however, the objective (external) structure of a
specific event does not have a direct reference to God as its cause (R. Bultmann, some phisicists – e.g. M.
Planck). In the present-day theology, the most widespread interpretation of miracle is a sign of God directed to
people, which can be only understood by a believing individual. The material medium of this sign is an event
that is impossible to interpret scientifically. Some philosophers (e.g. R. Guardini) attempt to explain the
empirical element of a miraculous event by accepting the idea of different degrees of reality that may be
mutually intertwined.
Some of the contemporary thinkers suggest that belief or disbelief in miracles depends on the attitude towards
accepting the determinism or indeterminism of scientific laws. In the light of the indereministic theory
supernatural events are only the manifestation of non-determined and creative nature (Stempsey). In Medline
Base literature the word “miracle” is included in about 789 articles, in most of them it is used as a metaphor.
Some articles describes miracles which occurred in the past, trying to find scientific explanation based on
contemporary medical knowledge. Some authors look for the causes of miraculous recoveries in diagnostic
errors and neurotic reactions. The issue of miracle is a mystery. Should medicine change it? Regardless of the
discussion on the essence of miraculous phenomena, medicine as science should adopt a research-oriented
approach to the instances of miraculous health restorations that will focus on the examination of measurable
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factors (physical and psychical by means of psychometric methods) which accompany and facilitate the
appearance of medical miracles, as well as the examination of certain statistical interdependencies that are
observable among those factors.
“The golden mean” in teaching of Ethics – just to teach or help to learn
Peicius, Eimantas (Lithuania)
It is widely recognized that the purpose of humanities is not only to educate people but also to develop their
value overview. While improving the more qualified teaching of Ethics, Bioethics and other related disciplines in
Lithuania (similarly, as in other new EU member states) we have been experienced that ethical questions were
still understood as moralistic and rather sophisticated in the context of our society. Despite the recognized
feeling of the lack of moral competency in general, the public there is quite skeptical and sometimes ironic about
“ethical issues”. The wide-spread believe is that money, power and high social status can easily deny all moral
principles, thus they see no point to discuss or learn Ethics at all. On the other hand, the actual ethical problems
do not disappear and new confusions come on the surface again and again, such as the crisis of health care
recourses, unofficial hidden euthanasia or misuse of biotechnologies etc.
Students of medical professions as well as health care professionals, officers or lay-people express their need for
more practical and pragmatic results of all kind of discussions, teaching sessions or open debates. They require
not mere theoretical overview or hypothetical cases studies, but also the tools or instruments to improve their
practice more efficiently and somehow to resolve ethical dilemmas in their daily life. The same request comes
from the decision-makers - politicians, businessmen and managers.
Using a number of examples this paper will discuss the question of how to create attractive educational
environment and to achieve the deeper perception as well as better analytical skills while teaching Ethics and
other related disciplines. Some methodological innovations and the results of teaching experience of Ethics and
Bioethics in Kaunas University of Medicine will be also presented explicitly. Based on it we will argue that to
improve the demands for “new and constructive” Ethics we should employ a more active participation approach
in the teaching classes or public debates on ethical dilemmas. Consequently, the curriculum of Medical
Humanities should involve not mere the traditional text readings and cases analysis, but, more importantly, the
tools and strategies for ethical decision-making.
Professional ethics in Medicine and Public Administration
Pevkur, Aive (Estonia)
According to Aristotle good person and good citizen might have not the same qualities. Applying this to medical
ethics we can ask is the good doctor should also be a good and moral person. I’ll look at this question through
comparison two fields of practical ethics – medicine and public service, for two reasons. On one hand medicine
and governing have both extensive influence to our everyday life. On the other hand ethics decisions in these
fields are important because they involve citizens’ rights and interests, and public money.
Preston has said that if ethics is inter- or intrapersonal, public sphere is supra- or impersonal. I argue that
consideration of practical ethics dilemmas belongs in the public sphere rather than in then domain of abstraction
theory. Public institutions like law, education, health care, medicine, government and economics influence a
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whole society. Freedom of personal belief in relation to ethics issues is in practice restricted by supra-personal
societal expectations.
Applied Ethics from the middle of 20 century has provided Medicine with solutions for new types of ethical
dilemmas where traditional ethical theories came under challenge. One reason for that could be the fact that in
Medical Ethics the influence of society in looking for acceptable universalisable solutions was significant or
determinative, but in traditional ethics theories the role of society is weak or non-existent. By comparison, in
Public Administration the focus is on providing solutions to problems within one society. Theories are not
intended to be universal.
In my presentation I will analyse differences in Professional Ethics applicable in Medicine and Public
Administration, and argue that if we will make clear distinctions between theory and practice in questions of
professional behaviour, the finding of solutions will be more clear and achievable. To analyse different subjects I
use values-clarification as an epistemological framework for theoretical implications. In conclusion I draw point
to the results of my analysis from the point of view of ‘the public interest’.
The moral identity of healthcare organizations
Pijnenburg, Martien (The Netherlands)
At the one hand our moral judgments are ‘our own’, at the other hand we reach these judgements by referring,
implicitly or explicitly, to frameworks that transcend a strictly individualistic perspective. In that respect human
beings always exist in dialogues. In this lecture we will argue that within the realm of a healthcare organisation
(HCO’s) like a hospital, this institution itself can be perceived as a partner in this dialogue and a source for
ethical reflection.
First, a healthcare organisation is a partner because it can be perceived as a moral subject at its own, having its
own ends, its own moral commitments, and its own life-story. Despite all different nuances and concretizations
in different times, cultures and societies the identifying characteristics of an HCO always are to institutionally
organize the healing of the sick, the protection of the vulnerable and the comforting of the suffering and dying.
This identity functions as a measure for all who work within the hospital and as a framework for clinical ethical
decisions. Second, institutions exist of a multitude of moral subjects: they all have their own moral responsibility
towards patients and families. To unify the institutional and the individual level the HCO should strive to be a
moral community, bound together by the quest and the articulation of commonly shared values and ends.
The relevance of this approach will be illustrated at the problem of the uninsured. At first sight they confront
HCO’s with a potential financial problem. However, a more fundamental issue is at stake, directly related to how
to understand the moral identity of a HCO: a shift in the view of man and society from one based on human
vulnerability towards one based on the exchange of services.
The conflict in the constitutional interpretation of the fundamental right tot life
Pintos, Guillermo Diaz (Spain)
This presentation discusses the North American and European models of Constitutional interpretation of the
Fundamental Right to Life. Unlike the American model, the European interpretation is based on "vitalism" as a
conception of life that lacks a full philosophical justification. This interpretation in proposed as an alternative to
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a constitutional redefinition of the legal concept of a person. This address tries to ground this fundamental right
in a "realistic" formulation of live which may guarantee living beings their right their own organism and thus to
fulfil their whole naturallife cycles. This conception of life avoids discriminating between living beings on the
basis of the lives they lead.
Free will and nature of addiction
Poikolainen, Kari (Finland)
It is argued that addiction is more likely a dimensional phenomenon than a typological phenomenon, and more
likely a strong habit than a disease. There is no convincing evidence for a specific biologic defect causing
addiction, there is no way to make a definite distinction between addicts and non-addicts, a good deal of addicts
can become non-addicts, and many succeed in this change without any treatment. Addicts have a free will and
they are free to change behaviour. The change, however, is not likely as long as the subjective value of benefits
from the addictive behaviour exceed the subjective value of costs. Addicts have learned to expect that the
addictive acts bring about immediate and strong benefits that they value more than possible costs. Addiction will
continue as long as the positive value of the addictive behaviour is greater than the negative value. When the
balance of values changes, motivation becomes ambivalent. There is a conflict between a strong will to abstain
from the addictive behaviour and a strong will to continue that behaviour. It may appear as the addict lacks free
will.
The Biopsychosocial Model: a Critical Review and a Proposed Reformulation
Rabinowitz, David (Israel)
The biopsychosocial (BPS) concept is examined in its varied modes of expression in the literature, with
reference to its clinical, organizational and conceptual dimensions. The concept is critically reviewed using the
original publication in 1977 as the reference point, with particular regard to its historical development,
evolutionary changes and current status. It is proposed that the BPS model has failed to achieve a significant
status in medicine, despite islands of successful implementation, and the possible reasons are analyzed. It is
further proposed that the BPS concept is in need of contemporary reformulation and the contours of such a task
are set out. A neo-BPS endeavor is required with special attention given to the need for a multi-tiered conceptual
structure and the bridges required for its implementation in a post-modern yet technological medicine. A multitiered BPS approach extending on a spectrum from the most practical and clinical stratum to a high-level
theoretical stratum has major implications for medical education, ethics, clinical practice and administration and
the patient-physician relationship.
Moral philosophy as resource for medical decision-making: Specification of norms or describing morally
relevant features of cases?
Rauprich, Oliver (Germany)
Insofar as medical ethics claims to be of any use for decision making in medicine, it has to elaborate a systematic
way to link general normative considerations to concrete cases. One idea that is especially prominent among
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proponents of principlism (e.g. Beauchamp and Childress, Richardson, DeGrazia) is the method of
“specification”, i.e. the progressive development of context-specific norms by enrichment of general norms with
detailed substance.
Bernard Gert et al., who are major critics of principlism, attacked recently the method of specification. He argues
that there is no instruction as to how to specify general norms, so that one is free to choose whatever seems
appropriate from one’s own personal or cultural perspective. In addition, specification leads to a constant change
and modification of norms that make the normative system increasingly complex and hard to know.
Gert claims that his approach, in contrast, provides a clear and comprehensive procedure for medical decision
making. Instead of specifying general norms, one should describe the cases in terms of their morally relevant
features. These features cannot be chosen as one see fit from one’s own perspective but are related to harms that
every rational person wants to avoid: death, pain, disability, loss of freedom, and loss of pleasure. Once the case
in question is described in terms of features that every rational person regards as relevant with respect to these
harms, it becomes immediately clear how certain norms apply to this case. In this way, Gert avoids, or so he
beliefs, the need for specification of general moral norms and is able to keep the normative system simple. He
suggests, in other words, to work on the facts of the specific context rather than the norms of the moral system,
in order to connect both.
In this presentation, I will introduce the method of specification within the account of principlism and the idea of
morally relevant features in Gert’s alternative account. It will be argued that Gert’s method is in many respects
analogous to the method of specification and therefore faces similar problems. His account provides no generally
superior application to concrete cases. How to use moral philosophy as resource for medical decision making
remains a work in progress and a challenge for both philosophy and medicine.
Normativity reconsidered. The methodological significance of empirical research for bioethics
Rehmann-Sutter, Christoph & Scully, Jackie Leach (Switzerland)
The ethical dilemmas of modern biomedicine present as issues of substantial social and theoretical complexity.
One strategy for dealing with this is to address them empirically within an interdisciplinary methodological
framework, working towards “thick descriptions”: However, this presents an obvious methodological problem: a
description does not logically imply selection criteria for normative conclusions or ethical recommendations.
That data acquired by empirical investigation can contribute to the deliberations of normative ethics seems
intuitively clear, but the theoretical question of how remains contentious.
We argue that one difficulty here is a certain idea of normativity that is identifiable in the history of moral
philosophy: that moral statements are true if and only if they are universally true, ie true for every reasonable
actor in similar circumstances. An alternative view does not fall back on descriptivism and (strong) relativism,
but takes another idea of normativity based on the appeal of normative statements in communicative
relationships. This idea is tied to a practice of engaged subjectivity, is methodologically bound to a rich
perception and interpretation of contexts, and can be placed systematically between objective reason and the
purely subjective rationality of some postmodern approaches.
The paper will draw on data obtained in two projects, funded by the Swiss National Science Foundation, which
had the aim of exploring the patient-centred views of the ethics of somatic gene therapy and of genetic testing.
Based on this material we identify four distinct areas where qualitative and quantitative empirical information,
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from the practice of medicine and from the experience of the patient, is needed as substantive input to normative
ethics.
Methods in Bioethics
Rhodes, Rosamond (USA)
Issues in bioethics are approached from many practical and theoretical perspective. Some bioethicists appeal to
theories, some call upon a principlist approach, others invoke virtues. Yet, theories, principles, and virtues alone
often fail to clarify the moral issues. Frequently, the conceptual problem in a bioethical dilemma lies in
identifying the salient issues, clarifying concepts, or explaining a conceptual mistake. This presentation will
demonstrate how an edifying philosophical response to bioethical dilemmas can be achieved by applying the
“Socratic method.” With skilful employment of carefully crafted vivid examples to promote theoretical
investigation, and with pointed and probing questions, a bioethicist can advance moral understanding. By
challenging others to respond to exaggerated or extreme cases, a bioethicist can promote eye-opening insight or,
at least, prompt them to formulate their views with more clarity and precision.
Performable Case Studies. Dramatic Arts Casuistry in Medical Humanities Education
Robeson, Richard (USA)
In Academic Year 1989-90, the Department of Social Medicine, University of North Carolina-Chapel Hill
School of Medicine, introduced a radically new pedagogical strategy into its Humanities and Social Sciences
(HSS) curriculum. “Medicine and Theater,” a course in the Second Year, is designed to engage issues in
biomedical ethics, research ethics, the physician-patient relationship and numerous other ancillary topics through
the development and presentation of dramatic literature.
Students at UNC-CH School of Medicine are required to finish their humanities requirements having either
acquired or enhanced a skill set that includes writing, teaching, research, and verbal communication. Herein is a
proposal to introduce the strategies – methodological and pedagogical – by which this is accomplished; and the
ways in which this course is particularly well-suited to accomplish these goals.
Although it is possible to place the dramatic dialogue at or near the beginning of literary casuistry, these two
traditions have long since become separate, and do not typically coexist in contemporary pedagogy, medical
humanities or otherwise. The Literature and Medicine arena of the medical humanities is quite sophisticated in
making use of literary genres which, either by virtue of the authors’ renown, or an exceptional commercial
success or topical currency, happen to enter its orbit. There is also an increasing focus on pathography, patient
histories, and even informed consent documents as fields of inquiry for Literature and Medicine. “Medicine and
Theater,” remains unique, however, in originating, rather than anthologizing, dramatic works (cases) that both
reflect and provoke the level of careful argument required in bioethics analysis and pedagogy. Furthermore, the
genre of dramatic literature makes it possible to refer in whatever ways may be necessary to all of the above
genres and sub-genres as well as others (e.g. case law; local, state and national statutes; popular and peer-review
publications; and the general body of bioethics literature) in ways which are inherent in the genre, placing it in
sharp contradistinction to any other mode of inquiry.
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In the years since its inception, this course has confronted a wide range of topics, from taking a fresh look at
some of the discipline’s earliest issues (e.g. Tuskegee) to some which remain emblematic of bioethics’ concerns
(e.g. surrogate decisionmaking; faith-based treatment refusal) to others that bioethics is only beginning to
consider in a thoroughgoing manner (e.g. sports medicine). Although officially designated a seminar, it is in
some respects a laboratory, in others a workshop; and is, I submit, a pedagogical model that can have success in
other medical humanities curricula.
Anthropology of ageing: a proposal of dialogue between philosophy and medicine
Russo, Maria Teresa (Italy)
One of the most significant social changes, nowadays, due to the improvement of living conditions and to the
progress of medicine, is the phenomenon of longevity. Considering the progressive falling birth rate, more and
more evident, it comes easy that the average life expectancy is rising and soon the society will be made up
especially by adults and old people. Even in the past some cases of exceptionally long age, sometimes in large
quantity, have been registered; what we mean today with the word longevity, though, is not just a longer life, but
also a higher quality of this.
Besides, it is true that the progress of medicine constantly makes the expectancy of a healthy and wealthy life
rise, so that the guaranteed quality of life is always inferior to the desired one. This means that we live in a
society which lives longer, but feels it is inexorably becoming old and takes part in the process with a sensation
of impotence and defeat.
The presence of old people is more and more numerous and visible, but at the same time, because of the
ambiguity of postmodern culture, old age is also hidden. The preoccupation of medicine in order to heal and take
under control lots of the old age diseases is not joint to an equal attention of the humanities in order to establish a
theory of old age, dedicated to evaluate this particular age of life in all its characteristics. Studies have been done
about this subject, but they are all inspired by a sort of “juvenilism”, floating between the ingenuity of the people
who denies the weight of these changes and the pessimism of the ones who do not know how to justify them.
The analysis of the physiology related to old age, centred on the process of becoming old and on the physical
changes is more and more accurate; the psychology of ageing seems to gain importance; an anthropology and
ethic of old age are almost absent, and they can only grow into ontology, that is a precise vision of the essence of
the human being.
In our medicalized society there is too much physiology of old age and little anthropology of old age. Medicine
can only answer few questions about old age, the ones related to the “whens” and the “hows”. The question
about the “whys”, about the significance of ageing, belongs to philosophy.
The Man is always searching for the meaning, and he is not satisfied with a simple, physiologic delucidation
about the process of cells ageing, neither with a sociologic enquiry, even if it is coherent and precise. The
excessive medicalization of old people, which involves their bodies but does not heal their loneliness, or the
insistence of euthanasia as an extreme solution, denotes the difficulty to answer these questions. Questions which
are asked not only to old people, but also to the ones who look after them because they are equally involved in
the change. An anthropology of old age will lead to an ethic of old age, which means seeing ageing not only as
our doom, but also as a task. A task for the old man, who has to learn the ars senescendi, made of acceptance and
resources, but also a task for who cares about him, who cannot just give him a strictly pharmacologic and
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medical assistance, but has also to evaluate his person, to make sure that he gains an adequate place in the family
and the society. Philosophy can thus help medicine to avoid the risk of radical health fanatism and “juvenilism”,
in advantage of a culture that appreciates the value of life in its wholeness, even when it appears fragile and
wounded.
Influence of role behaviour on health care professionals` decisions about life-sustaining treatment. An
ethical analysis based on an empirical study.
Sahm, Stephan (Germany)
Decisions about initiation, maintaining or foregoing life-sustaining treatment at the end of life may be influenced
by role behaviour, i.e. professionals may act more according to their roles and professional ethical codes as
opposed to their own ethical judgements. An example of that would be the claim that professionals are or would
be ready – at least in some cases - to perform medical acts (e.g. to forego life-sustaining treatment; euthanasia
etc.) that are against respective laws or professional codes. Vice versa, it is held that professionals should be
protected so that they should not be forced to act against their ethical conviction.
In the first part results of an empirical study about the influence of role behaviour on physicians` and nurses`
decision with respect to life-sustaining treatment and binding nature of advance directives are presented. In the
second part an ethical analysis on the conflict between persons` ethical judgements and professional demands is
outlined.
A: In a vignette study physicians (n= 100) and nurses (100n=100) were confronted with five cases in which
decisions about initiation, maintaining or foregoing life-sustaining treatment had to be made. In all cases their
was an advance directive with respect to the treatment at stake. Professionals were asked to judge whether they
would agree or deny the decision made in the case. In addition they were explicitly asked about their judgement
as a professional and about their own treatment preference would they be in a similar condition. Comparisons
between the groups as well as associations were calculated using standard statistical methods (chi2-test,
Wilcoxon- as well as Kruskal-Wallis-test).
The results show a close association of the subjective and professionals judgements in all vignettes (p<0.001).
Yet, the tendency to follow the instructions in patients` advance directive is very low.
B: The results of the empirical study serve as a starting point of an ethical analysis of the relationship and
tensions between subjective ethical judgements and professional duties. In Germany, local High Courts have
sentenced that nursing staff may not be forced to stop nutrition and hydration in patients in a persistent
vegetative state (demanded by patients` surrogates) if it is against their declared ethical conviction. This ruling is
said to be an infringement of the principle of autonomy. The empirical study gives insights in an anthropological
approach to solve this conflict. Appropriate procedures have to be implemented to secure patients` autonomy as
well as professionals moral integrity.
The Problem of Distinction between Health and Illness in the Contemporary Medicine
Sak, Jarosław (Poland)
Setting the border between health and illness is one of the major problems that the contemporary medicine faces.
It is most frequently resolved through the activities in the domain of doctor-patient relations and has a strictly
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practical, or even pragmatic dimension for a doctor, and existential dimension for a patient. Identifying or even
suspecting a concrete disease causes the initiation of the diagnostic and therapeutic ‘cascade’. Such a standard
medical procedure aiming to identify the pathological problem and recover the healthy condition perfectly fit the
scope of tasks of the present-day medicine. However, these tasks are not determined solely by the medical
practices implemented during some isolated doctor-patient relations. A crucial factor that sets the paths of
development and contributes to the formulation of general medical challenges in a given historical period was
and still is a philosophical reflection over the general state of health and illness, or the character of medicine and
its goals. Such a philosophical reflection with its climax in the 19th and 20th century in the writings of the
representatives of the Polish School of Medical Philosophy (T. Chałubiński, E. Biernacki, W. Biegański) is
invariably present in the medicine of today.
Through this paper I intend to join the contemporary stream of considerations on the general character of disease
(G. Canguilhem, H. T. Engelhardt Jr, Ch. Boorse, W. E. Stempsey) with particular pressure put on the distinction
between the condition of health and illness. The discussion concerning the issue of health and illness point to the
limitations of a one-dimensional explanatory model taking into account only one explanatory ‘reality’ (for
example, the ontological or only physiological sphere). An essential question that is worth answering concerns
the sources of determination of pathological condition in the present-day medicine. The experiencing of the
patient as a person in the diagnostic and therapeutic relation makes a doctor aware of the clash of two ways of
approaching an illness: ‘subjectivistic’ (existential) style of a patient and ‘objectivistic’ style of a doctor. A
disease in general, and also as an isolated instance, does not indicate the same particularities for a doctor and for
a patient (not only in the normative sphere but also in the logical one). This fact should constitute on of the
premises for the modern philosophy in its struggles to clarify the essence of health and illness. Thus, presently,
one of the sources of definitions of a disease is an ‘objective’, scientistic paradigm, while another is the influence
of the socially-coined image of a healthy person; finally, the third source is the ‘subjective’, existential reality of
the transience of human life with the individual experiencing of suffering. The deliberation over the point of
setting the medical standards empirically should be perceived through the prism of social mechanisms of
constituting medical facts.
Vistas from the interior. Notes on the pictorial in contemporary medical imaging
Salonen, Johanna (Finland)
A medical imaging unit, such as a radiology department of a hospital, functions with the purpose of creating
visual tools for seeking and verifying medically adequate explanations for physical disorders. Consequently it
aids making decisions on the treatment of a patient. The department serves medical practice by creating and
interpreting pictorial documents on a patient’s anatomy, physiology, and pathology. The official value of
pictures used in medicine is in their information and practical use. Pictorial production meets questions about
sickness, health, and healing in medical imaging.
While medical practice, medical engineering, and imaging technology set the conditions for imaging, they also
constitute the terms of its reception and interpretation. The pictorial information, which an image conveys, is
more than the sum of its subject matter and a modality’s technology. An imaging department is a lively
organization where visiting patients, professional experts, other staff, specialized technological equipment and
other material surroundings come together for the takes. In some ways an individual shot is a framed instant of a
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complicated combination of social customs, professional traditions, personal histories, histories of visualization
techniques – revisions of the gaze – and the medical trade. It is interesting what aspects become visible in
images, and in what ways.
Being a visual worker myself (artisan, graphic designer) some actions at the department catch my eye in
particular. The preparations, pictorial work and adjustments carried out by radiology technicians relate directly
to the modality in use. Another detail is the radiologists’ search through the image plains for clues to information
that would either support or diminish suspects concerning disease. These actions demand converged use of the
senses in an apparently trained way.
What about the patient who is in position the very target of imaging? The relationship of the image to the imaged
person is an exceptionally challenging question, and I cannot say how far from simple accounts on reference and
visual indicators I can get in my research. For various reasons, the hospital setting maintains a distance between
the patient and the visual documents. Medical pictorial products are subordinated to the outwardly quiet domain
of medicine, where professional silence, discretion, privacy and diminished personal identity link. However,
medical visualization – as one specific area of cultural pictorial production – also draws attention to the general
significance and particularized meanings images have and get in human existence.
Embodied ethics: disability and the limits to moral imagination
Scully, Jackie Leach & Rehmann-Sutter, Christoph (Switzerland)
It has become orthodoxy within moral psychology that moral reflection involves the capacity to imaginatively
engage with the perspective of others, that is to try to see the world from their point of view in order to
understand their moral priorities. However, while recognising the importance of such imaginative projection to
moral thinking, it would clearly also be misleading to consider that this ability is unlimited. It is also vital to
delineate the epistemic limits to imaginative projection into very different experiences.
For most nondisabled people, ‘very different experiences’ would include the experience of various kinds of
impairment. If we take seriously the notion that subjectivity is embodied then just as one’s gender shapes one’s
embodied experience, so too do impaired hearing, vision or mobility. This model is supported by evidence from
several sources. For example, recent work in cognitive science substantiates the idea that the specificities of
physical embodiment influence the ways we think – including how we notice moral difficulties and navigate our
way through them. If it is true that physical embodiment conditions some very basic and common patterns of
moral cognition, then there are ways in which having/being a non-normative embodiment can influence a
person’s moral understanding. However, to avoid a reductive essentialism it is important to stress that this
differential experience of embodiment is not simply a matter of biological differences; it arises from the complex
interplay between the social, cultural and bodily dimensions of identity, and this necessarily includes the way in
which others respond to one’s embodiment.
In this paper we develop an account of the ethical significance of disabled embodiment that draws on
phenomenological theories of embodiment, especially the work of Merleau-Ponty, and pioneer feminist
phenomenology. We then explore the implications of this idea for the status of moral imagination in ethical
discourse, arguing that moral imagination here requires genuine engagement with the diverse lived experience of
people with disabilities. Our aim is not to argue that the moral imagination is so circumscribed by the epistemic
limits arising from differences in embodiment that attempts at empathic imagining of another’s situation are
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worthless, but rather to show why judgments about the lives of disabled people, and particular judgements on
their quality of life, need to be especially attentive to the particularities of embodied subjectivity, as perceived by
those directly concerned.
Womb politics: Assisted reproduction in a pronatalist society.
Simonstein, Frida (Israel)
In Israel, the situation of women regarding fertility treatment seems ideal: Assisted reproduction (AR) is
subsidized as a standard part of the basic basket of health services by the Israeli national insurance. Every Israeli
(regardless of religion and marital status) is eligible for unlimited rounds of IVF treatment free of charge, up to
the birth of two children – even if the woman already has children. The policy of AR in Israel is presented as
protecting women’s rights to become mothers; and this generosity towards women’s rights might be seen as an
exemplary policy. A closer examination, however, reveals that in contrast to the extraordinary situation of
support for AR, treatments that limit family size in Israel remain unsubsidized. Family planning services do not
receive state support and are funded only on a charitable basis. Contraceptives are generally not part of the basic
basket of medical services covered by Israeli health insurance, and abortion is illegal. These policies reflect a
strong pro-natalist society. Moreover, in Israel, neither a non-familial lifestyle in general, nor a rejection of
parenthood in particular, is an acceptable option for women; and rejecting assisted reproduction when it is
available and completely free of charge is considered as refusing treatment; and it is equivalent to choosing not
to have children. It follows that a woman’s choice for the RTs in Israel is for herself, and for many reasons;
however, we can hardly regard this choice as completely ‘free’. This paper questions the context and extent of
medical intervention in this scenario.
The dubious uniqueness of genetic information
Skrikerud, Anne Maria (Norway)
In discussions about ethics and regulation of present biobank research health data is often divided into two
subgroups, genetic and non-genetic information. This applies to genetic and non-genetic information both as
legal terms and technical/scientific terms. This split is combined with a stronger emphasis in biobank-regulations
on genetic information in the Informed Consent sheet. Typically the donors are informed in excess of security
measurements that are put into practice to secure the handling of the genetic data and the donors rights regarding
this data, while information about security and rights regarding to other health data are compressed into a single
sentence.
The question arises whether the practise of emphasising genetic information in the Informed Consent sheet is
putting the ethical rights of the donors at risk. In addition less awareness in ethical committees of the rights of
the donors regarding non-genetic information may influence negatively how biobanks handle this information.
While stricter regulations reflect one viewpoint on what should be handled as sensitive information, modern
technologies ability to process huge databases for a lot of information puts a different standard for what might be
sensitive. Databases are mainly of either of the following; publicly available databases and non-public databases.
Information from a biobank may be combined with obvious information like name and address, or information
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like the customer files in a private company. Are present Informed Consent regulations good enough to secure
the interests of donors?
Regulating PGD – the lack of philosophical arguments in medical common sense
Solberg, Berge (Norway)
The PGD-technique has been difficult to regulate. Norway is probably an extreme case here: First this year, in
2006, after 12 years of regulation, there was found a political solution that seems to be ethically sustainable for
the future.
PGD raises difficult ethical and philosophical challenges. The typical medical approach is to distinguish between
a medical and a non-medical use of pgd, as well as between serious and not so serious diseases. Many countries
have regulated PGD along these distinctions.
There is nothing seriously wrong with the medical approach. The problem is that it is unreflective. Take for
instance the idea that to select embryos is justifiable only if you are trying to avoid a serious disease. Seriousness
is the criteria. But we do not kill persons in our society with a serious disease. The reason why we can select
embryos and destroy those embryos that carry a serious disease is of course primarily not because the disease is
so serious, but rather because the embryo is not a person.
It is easy to forget this. But some people don’t forget. And the next argument could be, that since we can do
embryo selection for serious diseases primarily because embryos are not persons, we also can do sex selection on
embryos since we still are dealing with non-persons. Suddenly, we have moved far away from the common sense
in medical practice. And the medical community alone lacks the resources to deal with the philosophical
challenges.
In this paper I will give several examples from the Norwegian and the Nordic debate on PGD, on what kind of
fundamental philosophical and non-medical challenges regulating PGD raises. Again, the point is not that
philosophy can create fundamentally new moral solutions to our challenges that are much better that the intuitive
solutions that are found in the clinical setting. Rather, the point is that when the common morality is attacked,
you need philosophical reflection in order to defend sound insights and experiences. Philosophy is a resource for
medicine in this way.
Supervenience in medicine: an attacking or compressing one?
Soosaar, Andres (Estonia)
A slogan “there cannot be an A-difference without a B-difference” shortly represents supervenience or the
relation when set of properties A supervenes on the set of properties B. The supervenience relation has been
widely discussed in different areas of philosophy, especially in the philosophy of mind and metaphysics. Brian
McLaughlin and Karen Bennett have written in SEP that supervenience is a central notion in analytic philosophy
and has been invoked in almost every corner of the field. We know that several eminent philosophers have
expressed the idea that mental phenomena are supervenient on neural phenomena to save some materialistic
solution for the mind-body issue. In some sense supervenience seems very much to be a theoretical product of
influence of the pragmatic modern correlation based science where we stand in face of empirical facts without
knowing how to interpret them. How about supervenience in medicine? At first look it seems to fit nicely with
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medical knowledge, e.g. thinking about the concept of health, it supervenes well on some physical design of
body. It works good in both approaches to health (health as lack of disease or a special mental quality) but its
explanatory power seems to be not very high. Supervenience can produce analogy between mind-body issue and
health-body issue. If one combines supervenience with manipulability causation, the explanatory power and
practical utility of an approach to the issue under investigation will clearly increase. Thus pure supervenience
provides not so much knowledge about nature of things but rather ways of compromise how to be satisfied
without that knowledge.
The ‘Economic Gaze’ of the World Bank
Sridhar, Devi (UK)
This paper investigates the construction of nutrition and the malnourished body within the World Bank using the
case study of the Tamil Nadu Integrated Nutrition Project (TINP). TINP was a Bank-funded, state-run project
that was initiated in 1980 to improve the nutritional and health status of preschool children, primarily those 6-36
months old, and pregnant and nursing women. The first phase of the project, TINP-1, ended in 1989; in the early
1990s, funding was resumed for a period of eight years, TINP-2. The primary purpose of TINP was behavioural
change of mothers through nutrition education using the Bank ‘toolkit’ of growth monitoring and
communication; the programme also included supplementary feeding for extremely malnourished children but
only for short periods. The Bank heralds the TINP as a success and emphasizes its ‘cost-effectiveness’ and its
superiority over the central government sponsored Integrated Child Development Services Programme.
In this paper I attempt to demonstrate how in TINP, the World Bank mechanised and commodified the
malnourished body in India through both programme design and discourse. Specifically, I examine the problems
that arise when economists attempt to bring their assumptions and models to public health and phenomenological
concerns. Issues addressed include the Bank emphasis on individual risk over structural violence, the absence of
discussion in key Bank documents on intrahousehold gender dynamics and caste, the ambiguity of the Bank’s
flagship symbol ‘cost-effectiveness’ and the re-enforcement of dualities such as men vs. women: culture vs.
nature: normal vs. deviant. This culminates in the creation of a new framework of the body which describes an
‘economic gaze’ drawing on Foucault’s ‘clinical gaze.’
The Canons of Therapeutic Responsiveness
Sulmasy, Daniel P. (USA)
Several years ago, there was a flurry of writing in the philosophy of medical practice regarding diagnostic
reasoning. Apart from the work of Pellegrino and Thomasma, however, few have paid attention to therapeutic
reasoning. In this paper, I will build upon their work, presenting and defending four prescriptive “meta-rules” of
therapy that I will call “The Canons of Therapeutic Responsiveness.” The justification for these rules will be
both inductive, based upon reflection regarding the experiences of clinicians, and deductive, based upon a notion
of disease as a class of disturbances in the biological law-like generalizations and typical biological history that
characterize biological natural kinds and inhibit individual members of those kinds from flourishing as the kinds
of things that they are. If disease is thus defined, the central task of human medicine may be specified as
healing—the relief of the human suffering occasioned by disease through the correction or amelioration of these
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disturbances. The Canons of Therapeutic Responsiveness, I argue, are the norms that govern how medicine
intervenes therapeutically in a manner consistent with that goal. The Canon of Proportionality states that the
therapeutic response must “fit” the disease. This proportionality has two dimensions. There should be proportion
between the means employed and the therapeutic end (e.g., one does not use a cautery to make a skull incision
and excise a gliobastoma multiforme). More familiarly, there should also, as a general rule, be a proportion
between the burdens and the benefits expected from the treatment, such that one would not undertake an
extremely painful procedure if it had almost no chance of success. The Canon of Parsimony states that one
should strive never to use more therapy than is necessary to achieve the therapeutic end, for as Gadamer states,
when therapy goes awry, it is usually not “because physical force or power was lacking or too little was exerted,
but actually because there was too much force in play.” The Canon of Restoration states that there is a restorative
intent in all therapy—either complete (cure), or partial (mitigating the disease or its effects), or partly directed
towards restoring the individual and partly for the benefit of others who might be restored in the future
(“therapeutic research”). The Canon of Discretion states that good therapy is respectful of the limits of medicine,
and recognizes indiscretions of degree (over-estimating medicine’s prowess), indiscretions of scope (expanding
medicine’s discretionary space beyond its reasonable place in society) and indiscretions of expertise
(expansionist views of an individual’s expertise). While these four simple Canons must be considered rules of
thumb and may not be exhaustive, they have never been articulated previously as a set, and are surprisingly
robust in their ability to explain the therapeutic errors one most commonly encounters in medical practice and in
illuminating a number of contemporary controversies in medical ethics.
The phenomenology of falling ill: an explication and critique of Sartre’s theory of embodiment and
alienation
Svenaeus, Fredrik (Sweden)
In the second chapter – “The body” – of the third part of Jean-Paul Sartre’s famous work Being and Nothingness
we find a kind of outline of the phenomenology of falling ill. Sartre asks how we are to understand the process
by which we gradually come to realize that we are ill and might need the attention and advice of a doctor. His
attempt to analyze this process has caught the attention of quite a few phenomenologists interested in the ways of
the body and medical knowledge, among them Kay Toombs, and it therefore merits a more thorough
examination.
After having defined and explicated the dual structure of being – being-for-itself (consciousness) and being-initself (thingness) – in Being and Nothingness Sartre wants to show how these two forms of being are not only
opposed to each other, but also necessarily conjoined in the human way of existing. The main idea is that the
gaze of the other has the power to objectify me; I turn into a thing for another consciousness by being looked
upon and thereby discover my body as an in-itself, which is yet me. This is an experience, which, for Sartre, is
primarily characterized by feelings of shame, humiliation and even nausea. To become oneself by way of the
direct or indirect gaze of the other appears to be a fundamentally alienating experience (the self is separated
from its true essence – freedom – in becoming itself).
The lived body thus appears to be the place where the being-for-itself finally confronts its being-in-itself,
although these two forms of being are necessarily opposed. Things (including the own body) are always things
for a consciousness, and therefore different from this consciousness. Consciousness is by way of its being
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nihilation: it negates the things it constitutes in the sense of always being different from them, but it also negates
itself in the sense of lacking any essence – consciousness, for Sartre, is pure existence devoid of any essence.
Only the other can offer me facticity by objectifying me, his gaze is felt at the heart of my contingent, but yet
necessary, embodiment. Thus in a rather paradoxical way I am fundamentally alienated by being something, and
not nothing.
In his attempts to uncover the structure of the lived body, Sartre now turns to medical examples. When my body
is examined and understood as a malfunctioning biological object by the doctor, it is, according to Sartre,
objectified in an analogous manner to when I am exposed to the gaze of the other in everyday life. Yet, it
appears, the objectifying quality of the scientific gaze is different from everyday objectification in many ways. In
discussing the process of falling ill, Sartre also turns to ways in which the lived body can be affected by
attunements that interfere with activities we are engaged in before the doctor has entered the scene. His most
well know example is the tiredness and headache involved in reading a book late at night.
In this paper my aim is to explicate Sartre’s phenomenology of falling ill in Being and Nothingness and also
offer a critique of it, based upon a more thorough understanding of what it is like to suffer illness and encounter
the other. A main point of my critique will be that alienation is a phenomenon, which is not only dependent upon
the gaze of the other, but which is constitutive of embodiment itself as a pre-reflective self-awareness in action.
We are not only factual beings by power of the look of the other, but by power of our very embodiment, and we
can therefore suffer genuine alienation at the pre-reflective level of existence, where this basic otherness of the
own body is neither seen nor reflected by the other or myself. My critique of Sartre will culminate in an attempt
to present a more nuanced and unbiased phenomenology of the different steps of falling ill, and maybe, also, in a
few suggestions on the relevance of this analysis for clinical practice.
Theoretical, therapeutic and utilitarian aspects of patient – doctor relationship
Tanasiewicz, Marta & Bednarski, Jacek (Poland)
One of the most important elements of the healing process is the ability to communicate with patient, in such a
way that both parties: the patient and the doctor understand the meaning of the communication that is passed. A
conversation usually commences with the appointment. Language is a tool, thanks to which the patient may
express subjective experiences and interpret on his own the symptoms of the illness that torments him. For the
doctor on whom lies the professional duty of establishing the mutual understanding, the first stage, the lowest
level within his skills, is the ability to notice the affective problem, at the foot of which lies the emotional
sensitivity related to some of the doctor’s personality traits. This particular ability may develop during the
process of gaining life experience, education, and contacts with specific persons. It enables the observation of
patients’ fear, grief or impatience as well. The perception of those states takes place, in most of the cases,
through the nonverbal contact. The next stage of the doctor’s work encompasses the internalization of the
patient’s feelings through learning and understanding his affective condition. The most important meaning
during this stage of establishing the doctor – patient contact have the acknowledged systems of values and the
gained experience. The advantage of the symbolic world of language over the real one manifests itself in the
possibility of manipulation with reality. The doctor may influence the patient and his perception of the world
through the conversation and conscious communication. This has the key meaning in the process of therapy,
specially in the terminal stages. Nowadays it has been already known and emphasized that skills which had been
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acquired during the didactic process of medical studies embrace several fields. The first discipline is an
intellectual area consisting of medical knowledge concerning the basic disciplines, pre-clinical and clinical. The
second discipline embraces the basics, the motivations to learn about one’s own and the patient’s emotional
problems, recognition of psychological needs and expectations of patients, and development of sensitivity. The
third discipline is an area of practical skills. What is interesting, some authors state that dental studies in a less
extent than the general medical specializations do, teach social aspects of the profession, interaction with patient
and cooperation with other specialists.
The contribution of philosophy to current bioethical thought in medical genetics
Teles, Natália Oliva (Portugal)
Technological innovation in biomedicine is currently proceeding very rapidly, in terms of both of investigation
and commerce and it is increasingly based on the incessant search for the “perfect” human being. With these
developments more (and more severe) ethical problems are being created and this generates moral discomfort in
relation to bioethics. On one hand it is difficult to admit that we only want perfect children but, on the other
hand, we cannot tolerate the opposite. The potential for beneficence created by each genetic test will create in
generations to come conflicts between rights and duties. The definition of the limits within which we may,
should, must, must not, etc., is neither clear nor consensual.
A study of the evolution of thought in ethics throughout history permits us to state that although the word
bioethics has not been used before the 20th century, many of the factors involved have already been analysed –
circumstances, people, beliefs, desires, available alternatives, etc. The consequences, more or less sophisticated
or evolved, will continue to be felt; first individually and secondly by society. Choice will clearly become more
difficult as methods, means and ends proliferate.
Current ethical principles, understood as the duties or moral obligations of human beings, should help to
interrelate and resolve some situations of conflicts of values that arise in Genetics. However, it is important to
understand that these principles are utilized by everyone, users and professionals of Genetics alike. Although
professionals are restricted in their behaviour by their specific rules of conduct, they are obviously not
disqualified from consideration as human beings and therefore will feel even more conflict, concerning
themselves and other people. In our understanding, they should act as mediators between the wishes of the users
and their duties as professionals, without however making any final decision.
Knowledge, information and mode of transmission of diseases, calculation of genetic risks and the possibility of
foreseeing the future of children makes genetics a powerful but dangerous weapon. Some workers may be
tempted to use these techniques without restriction, but at the same time they will fear them for their
unforeseeable future effects.
Ethical issues in designing patient clothing
Topo, Päivi & Iltanen, Sonja (Finland)
In Finland, patients are often provided with clothes, footwear and assistive devices for use in everyday care
environments. These products are especially designed, manufactured and marketed for care environments, and
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they are purchased and maintained by the care institution. They are a part of the care environment and they shape
the care culture and are shaped by care practices. They can be used either alone or with one's own clothes.
In the study called “Close to the Body: The Ethics and Practice of Designing Patient Clothing and Assistive
Technology” (2004–2007) we are looking at ethical issues that emerge in designing patient clothing. The main
question asks 'How are ethical issues intertwined in the design of the functional, aesthetic and expressive
features of the products used in the care environments?' The study is based on surveys and interviews for
designers, producers, care staff and patients. It also includes analyses of products and photographs, and
observations of use in real-life situations. The study is funded by the Academy of Finland's Research Program on
Design.
We here present findings from our study on patient clothing, footwear and supports. We analysed all products
(n=260) from the catalogues of 19 companies that design clothes and footwear for the care environments in
Finland. According to our survey in 2004, we have been able to include nearly all companies working in this
field in Finland. The analyses were made against the background of individuality and privacy, autonomy,
competence, beneficence and efficiency. The main questions explored were: 1) How individuality such as gender
is shown in the products. 2) How the products are designed to perceive the user as a competent adult. 3) How the
products are stimulating the user i.e. how aesthetic experiences are valued. 4) How the ability to use one's skills
is shown in the products. 5) How the value of efficiency is taken into account in the design of the products.
Our results show that individuality such as gender is often ignored. Several products restricted the person from
being active and using skills and some products are associated with children, i.e. an infantilization of the adult
users. The products communicate the importance of efficiency: They are designed to be easy for staff and
laundry services. Also present alongside the idea of efficiency in the products was the idea of beneficence: the
seams in clothes and shoes, or the hems of skirts did not press on the user. These products are used in care
environments day in day out, night and day by the residents, and will often underline the role of the patient and
restrict the use of their abilities. The products seem to say that 1) autonomy, independence and privacy are not
central for people staying or living in a care environment, and 2) efficiency and beneficence are valued more
highly than individuality in care practice and culture.
Géza Csáth, an artist and a scientist
Tóth, Anita G. (Hungary)
Géza Csáth was an „enfant terrible” of his time, at the beginning of 20th century in Hungary, but he was an
incomprehensible phenomenon, too. A neurologist – psychiatrist who was a composer and a musician for his
childhood and after an unsuccessful entrance exam to Music Academy in Budapest became a music critic. He
was a psychiatrist who worked as journalist; his best short stories were born as short articles. Dissection is
habitual in a report of a newspaper, but disgrace of a cadaver in a dissection room - this theme is very shocking
in literature. Csáth was a psychiatrist and a painter as well, but he stopped painting, though his writings are full
of powerful colours. He was a psychiatrist and a sincere and scandalous diarist, too; he made a list of his
adventures with women, a lot of coituses. He was a psychiatrist who experimented with psychoactive drugs and
became addicted to morphine. This addiction caused the change of his personality and drove him to kill his wife
and then himself. Finally he came to the limit of the human being and he knew that it is too fragile to separate
normality and abnormality, daydreams and nightmares.
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His short stories give evidence of this like The Surgeon, Encountering Mother, Murder, Little Emma, The Black
Silence and Opium whose characters go to the dangerous fields of psyche. Miss G. is another evidence. She was
not a fictitious woman, but a patient of the psychiatrist Csáth. The study of this ambitious 25-year-old doctor was
written about her. Composition and reception of The psychic mechanism of mental disorders are irregular. In the
case history Csáth included the diary of this schizophrenic young woman with an excellent sense for literature.
Her diary is more expressive than any description. At the beginning of this study Csáth explained and developed
the theory of psychoanalysis from complexes. He followed the theses of Freud when just few literary men and
doctors knew and accepted them in Hungary. Csáth took his developed system as a basis of his analysis and
diagnosis. In the summary he came to the revolutionary conclusion that this lonely poor and psychotic young
lady had an eventful life and more enjoy than any other healthy one.
Medicine forgot this study before the 70’s. Literature thought it interesting so in spite of the fact that it is written
in a special terminology, it became famous with the title Diary of a psychotic woman and it is ranked among the
literary works of Csáth. The story of the girl who listens to the voice of a male God inspired a playwright, the
title of his drama is Animus and Anima which is a reference to Jung in whose theories complexes lived longer.
These days there is a plan for a film adaptation of this study as a screenplay. The time has come to explore this
exciting work of Csáth in the point of view of psychiatry and to examine the aspects of the synthesis of art and
science in his personality.
Medicine and the definition of death: between science and humanities
Turoldo, Fabrizio (Italy) presented by Renzo Regoraro
In my paper I’d like to address the problem of death, which is, at the same time, a scientific and a humanistic
matter: when medicine faces the problem of death we can really say that we are between science and humanities.
In fact, regarding death, we can distinguish three levels of consideration:
1) The definition of death. At this level, we can define death in philosophical terms, as, for example (according
to the Aristotelian-Thomistic philosophical tradition), «loss of substantial unity of the body, caused by the
privacy of the soul, that is the substantial form of the body». In other philosophical traditions, for example in the
platonic one, death occurs when the soul, intended as a pure spirit, leaves the body, in which is imprisoned. In
the philosophy of Descartes, moreover, death occurs when the soul, intended as a conscious mind, leaves the
body, that becomes a purely organic machine. These different points of view have direct implications regarding
the way through which we choose the anatomic criterions that instantiate the definition and the clinical signs to
determine the occurrence of that anatomical criterion in concrete cases. Persistent vegetative state, for example,
could satisfy some definitions of death (as it happens in our last example), but not others (as we see in our first
example). At this level we can have also theological definitions of death. The Catholic Church, for example, has
clearly defined death in recent magisterial pronouncements, particularly by pope John Paul II in his address to
the 1989 Working Group of the Pontifical Academy of Sciences, who said that «[Death] occurs when the
spiritual principle which ensures the unity of the individual can no longer exercise its functions in and upon the
organism, whose elements, left to themselves, disintegrate». There are, moreover, sociological and political
definitions of death, where death can be intended as «loss of conferred membership in human society». Is this
the case of dissidents in the USSR at the times of Stalin, who were declared mad and sent to death in Gulags, as
a consequence of their social death. There are also psychological definitions of death, as «loss of essential human
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properties or personhood». These definitions are independent of the vital status of the body and may be used to
justify euthanasia: if many cognitively disabled human beings fulfil this definition of death, someone could say
that causing their biological death is not a murder.
2) The anatomical criterion which instantiates a definition, that is a hybrid humanistic and scientific matter. We
can choose, among the different definitions of death, for example, the brain-based ones, but, nevertheless, in this
way, we have not already solved the problem of the criterion choice: is better the United States «whole brain»
criterion (The President’s Commission, 1981), or the British «brainstem» formulation of brain death (The Royal
College of Surgeons)? What about cortical death?
3) The clinical signs or tests to determine the occurrence of the anatomical criterion, which is a purely scientific
matter: Apnoea test? (target pCO2 50/60 mmHg? Disconnection from ventilation?); Observation time? (2h?
24?); Confirmatory test? (EEG?).
Holism as a basis for humanised health care
Tyreman, Stephen (UK)
It is commonly heard, particularly from advocates of complementary and alternative medicine (CAM), that in
health care, holistic equates with humanise. This is normally contrasted, albeit covertly and simplistically, with
the Western medical model’s focus on biological explanations of human function, illness and disease. The
inference is that focussing primarily on biological explanations inevitably dehumanises patients by reducing
them to mechanisms. Holistic practices, on the other hand, are person focused and able to recognise and take
account of the idiosyncrasies that constitute the ill person.
This paper questions that assumption by pointing out that there is neither a clear definition nor practice of
‘holistic’, and there are at least three distinct ways in which the term is used: therapeutic pluralism, which may
additionally be linked with ‘whole-person’ treatments; a bio-psycho-socio-spiritual interpretation of health and
illness; and as a way of linking and contextualising a complex array of health-related factors. Although all three
have the potential to provide person-centred humanised health care, there is no necessary relationship. It is
argued that what currently passes for holistic care is neither better nor worse than that offered by Western
medicine in providing humanised care and that what is required is a clear sense of the purpose of health care
linked to human values and the purpose of human life.
The Argument from Social Consequences
Ursin, Lars Øystein (Norway)
Benefits are balanced against harms in the evaluation and regulation of the use of biotechnology. In the case of
non-human organisms, harm is among other factors assessed in terms of environmental risk. In the case of
humans, harm is among other factors assessed in terms of social and societal risk. The potential harms of
biotechnology will then evaluated in terms of the long-term effects it might have on (the basic values and
institutions of our) society. By contrast, the potential benefits of biotechnology (better health, increased control,
less vulnerability) is typically evaluated in terms of the direct advantages it might have for the individual. The
invocation of biotechnological instant individual utopias and future societal dystopias is omnipresent in
bioethical reflection. The practice of sex selection, for instance, might give some parents a benefit of procreative
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control on the one hand. On the other hand, it is said be harmful in promoting sex discrimination, weaken the
unconditioned love which should define the parent-child relationship, and lead to a society of intolerance.
I refer to arguments for or against certain uses of biotechnology on the basis of future social consequences as the
“Argument from Social Consequences”. This paper will explore the use and validity of this type of argument in
reflections on bioethics in general, and for legal regulations of biotechnology. How should the Argument from
Social Consequences itself be assessed? The social effects of the practice of sex selection are now examined
empirically in a controversial American study. But is this a matter of empirical findings? The British House of
Commons Committee of Human Reproductive Technologies and the Law stated in a report published on the
24th of March 2005: “We do not see why the area of human reproductive technologies should do anything other
than proceed under a precautionary principle currently prevalent in scientific, research and clinical practise. This
means (…) that alleged harms to society or to patients need to be demonstrated before forward progress is
unduly impeded.” The question is then: Which burdens of proof does the forwarding of arguments from social
consequences imply? These questions will be addressed in this paper.
Complementary and Alternative Medicine in North America: negotiation of competence and the
hierarchy of conviction.
Vinogradov, Andrei (Canada)
The paper focuses on the negotiation of CAM of its place within North American culture. Contrary to postmodernist view, the author considers North American “common sense” or worldview, not only science or
biomedicine, as being materialist and positivist. Many fundamental aspects of CAM paradigms radically conflict
with this worldview. As a result, CAM has to negotiate its area of competence not only with, or against,
biomedical HMOs, but also with the North American cultural substratum. The worldviews that many CAM
modalities represent by no means have equal standing with materialism and positivism within the North
American culture. At the same time, CAMs popularity in North America is dramatically rising. To analyze its
place and role within North American culture, this paper uses the concept of disease-illness dichotomy
introduced by A.Kleinman, arguing that this concept has played not only a descriptive, but also a prescriptive
function that has defined, if not determined the culturally and legally acceptable limits of competence and
ambition for CAM in North America. Another concept that is going to be used in this paper is the hierarchy of
conviction. It is used to analyze the consistent patterns of health-seeking behavior that determine the choice
between biomedicine and CAM among North American patients. The main goal of this presentation is to initiate
a discussion, aimed at comparative analysis of the place of CAM in North America and other parts of the world.
Defining the Nature of Medicine from Its Ends: Teleological and Phenomenological Perspectives
Virdis, Andrea (Italy)
The aim of this paper is to inquire into the different theories about the ontological foundation of medical
practice, according to two specific perspectives that come from teleological and phenomenological approaches.
Describing the way that those different types of analysis uses to define the ends of medicine, the Author shows
how both can be very useful to underline how the nature of medicine can be defined from its own ends.
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Teleological approaches start from an Aristotelian way to intend medicine as an end-oriented act: this views are
rooted in the assumption that a good inherent to medicine exist, which defines the proper ends of medicine itself.
Medicine is not considered as a “mixed marriage” between its own value-neutral technique and some extrinsic
moral principles, but as an inherently ethical activity, in which technique and conduct are both ordered in
relation to an all-encompassing good, the naturally given end of health.
Phenomenological approaches (in their realistic current), concentrating their attention on describing how
medicine appear, point out how medicine manifests its essential being in the clinical encounter between a patient
(that got sick and needs help) and a doctor (that has the skill and can help him). In the context of the
vulnerability of that particular patient, the clinical encounter is the “moment” in which medicine and its healing
end are put in being.
Both perspectives - teleological and phenomenological - reveals that what medicine is, depends on what its end
is, that is to say, that the knowledge of the nature of medicine is not the starting point of medical ethics, but its
result: we must know the end of medicine (i. e., the good inherent to), to know what medicine exactly is.
Moreover, they demonstrate that the existence of an internal morality of medicine - that morality which is
derived from the nature of medicine itself and not from the application of pre-existing moral system to medicine
- is fundamental to determine duties, virtues and obligation of the physician in accordance whit the nature of
medicine itself.
Altruism and the Profit Motive in Medicine
Walsh, Adrian (Australia)
Does the pursuit of profit jeopardise the other-regarding ideals that are often regarded as essential to the proper
pursuit of medicine? Can altruism and commercial medicine co-exist? In this paper I argue that our thinking on
this issue is confounded by a model of the profit motive in which it is regarded as singular and indivisible and by
an overly rigorist view of the nature of altruism. This model fails to recognise the possibility of mixed or
mingled motives in this area. Accordingly, I develop a taxonomy of distinct commercial medical motives, some
of which involve an admixture of pecuniary and ethical motives. Such a model enables us to admit the moral
legitimacy of much commercial medicine whilst simultaneously recognising the 'ethical hazards' that money
places before medical practitioners.
Biometric identifiers and entitlement to healthcare
Wickins, Jeremy (UK)
In many countries in the EU, possession of a valid identity card is a prerequisite of receiving state health care,
free at the point of delivery. In other countries, such as the UK, this is likely to be the case in the near future.
This requirement causes few problems where the identity card is nothing more than a card with a photograph, but
the advent of widespread use of biometrics has the potential to alter this.
Healthcare is a basic social good, and to be wrongfully deprived of it is social exclusion. The use of biometrics
as a guardian of access to healthcare is problematic, because the identifiers most commonly used or likely to be
used – facial-, iris-, and fingerprint-recognition – are unreliable in certain groups of people. The UK Passport
Service Biometrics Trial published in 2005 shows that certain groups, such as the elderly and people with
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physical and mental disabilities, are more likely to fail to enrol biometric data, and, if enrolled, have greater
difficulty verifying the data. These identifiable groups are more likely to require access to healthcare than the
average person. There is also evidence that certain disease processes can affect biometric identifiers – for
instance, rapid weight loss would clearly affect the accuracy of facial recognition, but also certain physiological
changes such as pregnancy can produce recognisable changes in the iris. This suggests that some people in need
of healthcare are going to have difficulty proving their entitlement to that healthcare as a result of the problem
that requires them to seek healthcare in the first place.
Social exclusion is an ethical issue. It requires a willingness to sacrifice some people in the interests of others, or
negligence in considering the possible deleterious effects of a policy. The justification for biometrics is
essentially utilitarian – public interest (i.e. the collective right of a group of rights holders, or society at large) is
balanced against the rights of the individual, who is therefore simply a means to the ends of the majority. This is
the wrong argument – almost anything can be justified by saying that the accumulated rights of the many
outweigh the rights of the individual. On the contrary, public interest must be judged by considering the balance
between individuals, i.e. the rights of a single individual must be balanced against other single individuals if
individuals are not to be used instrumentally. The test, therefore, should be whether the rights of an actual
individual, if upheld, would cause greater damage to a reasonably foreseeable potential individual than to the
actual individual whose rights would be overridden. The damage caused by the introduction of biometrics to
control access to healthcare far outweighs the good done to a reasonably foreseeable person who isn’t
disadvantaged by them. The burden of biometrics, if used to control access to healthcare, would fall
disproportionately upon individuals who are ill, where false denial of access will lead to serious consequences in
terms of not getting the healthcare they have a right to.
Philosophy and Medicine - A Healthy Relationship
Wilson, Sarah (UK)
Philosophers and clinicians are often the focus of criticism in a world dissatisfied with the resolution of ethical
dilemmas. Most recently, philosophers working in the field of bioethics have been criticised for presenting
arguments that appear to ‘rubber stamp’ decisions already made, or which are co-opted by policy makers for
political means. Philosophers have also been criticised for presenting populist accounts of bioethics, which then
function to close down the range of arguments. In the clinical arena, clinicians have in recent high profile cases
in the UK been seen as acting in opposition to the wishes of individuals or parents. Media interest in the
provision of IVF treatment and drugs such as Herceptin have brought into focus concerns about equity and
justice in access to healthcare. The medical arena remains the context for some of the most widely disputed
dilemmas in today’s society – the issue of abortion remaining an obvious area of contention, but also end-of-life
care, withholding or enforcing treatment, particularly in relation to newborns and children, and whole new areas
opened up by the developments and promises of genetic technologies.
Yet the very criticism that such decisions and arguments provoke, and the strength of feeling evident in public
discussions of such dilemmas, demonstrate the need not only for clarity and transparency in the decision making
process, but also the synergistic relationship between the fields of philosophy and medicine. Contemporary
developments in both fields have led to a more engaged and less narrowly focused approach to ethics. Medicine
has developed away from a model where the doctor has the central role in the decision making process, to an
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understanding of the need for a less paternalistic approach. Meanwhile, philosophy has begun to develop a more
relational account of the human experience.
Philosophical argument underpins the development and application of Beauchamp and Childress’s four
principles, and philosophy continues to provide a resource for medicine. Philosophy can present alternative
perspectives in the understanding of the ethical issues involved in often complex dilemmas, and ensure that
rigorous argument provide the justification for a particular set of decisions. For philosophy, the medical setting
provides practical applications of theoretical principles, bringing philosophical concepts to life. Medicine is an
area where decisions must be made, whereas philosophy is sometimes seen as a talking shop. Exploring the
methods of practice in the clinical context can support philosophers in developing alternative methods of
consensus and problem solving. Engagement in a clinical context brings to the fore many of the issues
traditionally neglected by mainstream philosophical approaches, such as emotion, relationships, power, and the
body itself. Awareness of clinical practice can provide support for and encourage the development of more
relational philosophical frameworks. These may then feed back into the clinical context to develop clinical ethics
frameworks. This presentation discusses these issues, with particular reference to the relationship between
philosophy and medicine, and the ways in which each may provide a resource for the other.
Philosophy as a resource for medicine: Philosophers alongside scientists in a design study for gene
expression in early human development.
Woods, Simon (UK)
The University of Newcastle is coordinating the EU funded GeneExpress project; a Design Study that aims to
evaluate the most effective ways of overcoming challenges faced by scientists involved in the analysis of gene
expression in early human development. In this paper I will briefly describe this study. I will also describe in
more detail one strand of this project which is exploring the social, legal and ethical issues associated with such
research. This ethics work package aims to:

Map the current ethical context by conducting a review of the social science and bioethics literature in this
area.

Systematically review legislation and regulatory guidelines in place for working with human developmental
samples throughout the EU.

Explore the requirements for governance and ethics training.

Address the policy implications for continued ethical research in this field.

I will use this collaborative research project as a case study in which to explore the relationship between
philosophy and medical science. Issues I will explore in this paper include:

Symbiosis and friction in writing research applications with medical scientists

Scientific and philosophical approaches to ethical problems

An analysis of interdisciplinary working

Added value in collaboration – is there any?

I shall argue that there is a benefit to all disciplines in these collaborations and that there is a healthy future
for both empirical and philosophical bioethics through these partnerships.
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Arts in medical education
Younie, Louise (UK)
Space to engage with the arts within the medical curriculum has been captured by several students with the
metaphor “a breath of fresh air”. But more than providing an arena for greater freedom of thought and
exploration, there appears to be rich learning taking place. Learning includes a greater awareness of the
background medical culture and epistemology, recognition of the value of creative and explorative based
learning (in addition to traditional fact assimilation), engaging with “process” as well as thinking of “outcomes”
in education and re-connecting with self and others at an emotional and more holistic level facilitating personal
and professional development.
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XXIst EUROPEAN CONFERENCE
ON PHILOSOPHY OF MEDICINE AND HEALTH CARE
Ethics, philosophy
and public health
15 – 18 August, 2007
Cardiff, United Kingdom
CALL FOR ABSTRACTS
This conference will be organised by the European Society for Philosophy of Medicine and
Healthcare (ESPMH) and the Cardiff Institute for Society, Health and Ethics. Abstracts
addressing the following topics can be submitted:
The concept of public health
The relationship between individual and population health
The relation between clinical medicine and public health
Health as a public good
Health as a human right
Resource allocation in public health
Social inequalities in health
Personal responsibility for health and (un)healthy behaviours
The role of law in public health
Ethical issues in public health research
Public health and genetics
Philosophical and ethical issues in relation to health systems research; health impact
assessment; health promotion; vaccination / immunisation
The program of the conference includes plenary sessions as well as parallel sessions. Persons
wishing to present papers at the conference are invited to submit an abstract (500 words
maximum) before January 1, 2007. The Conference Program Committee will select abstracts
for oral presentation. Please send abstracts (through E-mail or on diskette in Word) to:
Dr. Bert Gordijn, Secretary of the ESPMH
Dept. of Ethics, Philosophy and History of Medicine
Radboud University Nijmegen Medical Centre
PO Box 9101, 6500 HB Nijmegen, The Netherlands
E-mail addresses: [email protected] or [email protected]
Conference website: http://www.cf.ac.uk/socsi/cishe/pages/ESPMH2007.html
Sponsors: Cardiff Institute of Society, Health and Ethics; Cardiff Law School; Cardiff Centre for Ethics, Law
and Society & the Centre for Economic and Social Aspects of Genomics
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