Theoretical medicine最新文献

The article briefly analyzes the concept of a person, arguing that personhood does not coincide with the actual enjoyment of certain intellectual capacities, but is coextensive with the embodiment of a human individual. Since in PVS patients we can observe a human individual functioning as a whole, we must conclude that these patients are still human persons, even if in a condition of extreme impairment. It is then argued that some forms of minimal treatment may not be futile for these patients; they may constitute a form of respect for their human dignity and benefit these patients, even if they are not aware of that. Moreover, it is important to consider the symbolic significance of care: while many believe that PVS is a kind of imprisonment, for others providing food and fluids is the only way to testify our proximity to these persons. The best policy would be to provide, as a general rule, artificial nutrition and hydration to PVS patients: this treatment could be withdrawn, after a period of observation and reflection by the family and proxies, on the basis of the proxies' objection to the continuation or of the patient's advance directives specifically referring to this situation.

This article evaluates the potential role of advance directives outside of their original North American context. In order to do this, the article first analyses the historical process which has promoted advance directives in recent years. Next, it brings to light certain presuppositions which have given them force: atomistic individualism, contractualism, consumerism and entrepreneurialism, pluralism, proceduralism, and "American moralism." The article next studies certain European cultural peculiarities which could affect advance directives: the importance of virtue versus rights, stoicism versus consumerist utilitarianism, rationalism verus empiricism, statism versus citizens' initiative, and justice versus autonomy. The article concludes by recognising that autonomy has a transcultural value, although it must be balanced with other principles. Advance Directives can have a function in certain cases. But it does not seem adequate to delegate to advance directives more and more medical decisions, and to make them more binding everyday. It is indispensable to develop other decision-making criteria.

Coma, vegetative state, lock-in syndrome and akinetic mutism are defined. Vegetative state is a state with no evidence of awareness of self or environment and showing cycles of sleep and wakefulness. PVS is an operational definition including time as a variable. PVS is a vegetative state that has endured or continued for at least one month. PVS can be diagnosed with a reasonable amount of medical certainty; however, the diagnosis of PVS must be kept separate from the outcome. The patient outcome can be predicted based on etiology and age. Using outcome probabilities and etiology as criteria, patients can be subdivided in 5 groups and reasonable management guidelines can be suggested. Three levels of care can be provided to PVS patients: high technology, supportive and compassionate care. Pragmatic options for the various subgroups of patients are suggested. Management decisions will remain difficult for both the family and the health-care team. The role of the physician in these difficult cases is to share the decision-making with the family.

The problem of developing a moral philosophy of medicine is explored in this essay. Among the challenges posed to this development are the general mistrust of moral philosophy and philosophy in general created by post-modernist philosophical and even anti-philosophical thinking. This reaction to philosophical systematization is usually called antifoundationalism. I distinguish different forms of antifoundationalism, showing that not all forms of their opposites, foundationalism, are alike, especially with regards to claims made about the certitude of moral thought. I conclude that we are correct to mistrust absolutist principles in a moral philosophy of medicine, but can find some center within the practice of medicine itself for a moral foundation.

A dialogue between virtue and care ethics is formed as a step towards meeting Pellegrino's challenge to create a more comprehensive moral philosophy. It is also a dialogue between nursing and medicine since each practice draws on the Greek Virtue Tradition and the Judeo-Christian Tradition of care differently. In the Greek Virtue Tradition, the point of scrutiny lies in the inner character of the actor, whereas in the Judeo-Christian Tradition the focus is relational, i.e. how virtues are lived out in specific relationships, particularly unequal relationships where vulnerability of one of the members is an issue. In a care ethic relational qualities such as attunement rather than inner qualities are the point of scrutiny. A dialogue between these two traditions makes it possible to consider the relational virtues and skills of openness and responsiveness that are required for a respectful meeting of the other.

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