Theoretical medicine最新文献

This paper explores the relationship between the bonds of practitioner/patient trust and the notion of a justified lie. The intersection of moral theories on lying which prioritize right action with institutional discretionary power allows practitioners to dismiss, or at least not take seriously enough, the harm done when a patient's trust is betrayed. Even when a lie can be shown to be justified, the trustworthiness of the practitioner may be called into question in ways that neither theories of right action nor contemporary discourse in health care attends to adequately. I set out features of full trustworthiness along Aristotelian lines.

Semiotics, the theory of sign and meaning, may help physicians complement the project of interpreting signs and symptoms into diagnoses. A sign stands for something. We communicate indirectly through signs, and make sense of our world by interpreting signs into meaning. Thus, through association and inference, we transform flowers into love, Othello into jealousy, and chest pain into heart attack. Medical semiotics is part of general semiotics, which means the study of life of signs within society. With special reference to a case story, elements from general semiotics, together with two theoreticians of equal importance, the Swiss linguist Ferdinand de Saussure and the American logician Charles Sanders Peirce, are presented. Two different modes of understanding clinical medicine are contrasted to illustrate the external link between what we believe or suggest, on the one hand, and the external reality on the other hand.

The rationale of patients on transgenic organisms leads to the startling notion of the human qua infringement. The moral reasons by which we may tenably reject such notion are not conclusive as to human life forms outside the body. A close look at recombinant DNA experimentation reveals ingenious processes, but not entities that the body lacks. Except for artificial genes, the genes of biotechnology are found on chromosomes, albeit nonconsecutively, and their uninterrupted transcripts appear in messenger RNA. An enhanced form of protection for ingenious processes, the "human methods patent," is proposed and defended as a replacement for product patents. The proposed patent would pertain to biotechnology manufacturing and genetic intervention in somatic and germ cells. A counterpart could govern nonhuman life forms. It is argued that compulsory licensing protections should be a condition of such patent. Contrary to the conservative assumption that statutory sobriquets suffice, the reckoning of what qualifies as a patentable ingenious process will continue to require systematic scientific guidance.

Working retrospectively in an uncertain field of knowledge, physicians are engaged in an interpretive practice that is guided by counterweighted, competing, sometimes paradoxical maxims. "When you hear hoofbeats, don't think zebras," is the chief of these, the epitome of medicine's practical wisdom, its hermeneutic rule. The accumulated and contradictory wisdom distilled in clinical maxims arises necessarily from the case-based nature of medical practice and the narrative rationality that good practice requires. That these maxims all have their opposites enforces in students and physicians a practical skepticism that encourages them to question their expectations, interrupt patterns, and adjust to new developments as a case unfolds. Yet medicine resolutely ignores both the maxims and the tension between the practical reasoning they represent and the claim that medicine is a science. Indeed, resolute epistemological naivete is part of medicine's accommodation to uncertainty; counterweighted, competing, apparently paradoxical (but always situational) rules enable physicians simultaneously to express and to ignore the practical reason that characterizes their practice.

There has been a growing interest in casuistry since the ground breaking work of Jonsen and Toulmin. Casuistry, in their view, offers the possibility of securing the moral agreement that policy makers desire but which has proved elusive to theory driven approaches to ethics. However, their account of casuistry is dependent upon the exercise of phronesis. As recent discussions of phronesis make clear, this requires attention not only to the particulars of the case, but also to the substantive goods at stake in the case. Without agreement on these goods attention to cases is unlikely to secure the productive consensus that Jonson and Toulmin seek.

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

This essay will argue for the centrality of empathy in the doctor-patient relationship-as a core of ethically sound, responsible therapeutics. By "empathy," I intend an explicitly hermeneutic practice, informed by a reflexive understanding of patient and self. After providing an overview of the history of the concept of empathy in clinical medicine, I discuss current definitions and the use of Balint groups in residency training as a way to develop empathic competence in novice physicians.

This article reviews the historical and current controversies about the nature of clinical ethics consultation, as a way to focus on the place and responsibility of ethics consultants within the context of clinical conversation--interpreted as a form of dialogue. These matters are approached through a particularly compelling instance of the controversy that involves several major figures in the field. The analysis serves to highlight very significant questions of the nature and constraints of clinical situations, and the moral responsibility and legal accountability that are especially important for clinical ethics consultants.

At least four different frameworks--psychiatric, cognitive, functional and decision-making--are used in the evaluation of competence, all of which remain more or less unrelated in the literature. In the first section of this paper we consider various meanings of "competence," in order to arrive at a definition of the term relevant to the medical and legal setting. Patient or client "competence," we conclude, refers to the practical abilities that individuals employ in pursuing their own autonomous goals in life. We then show how a systematic categorization of these practical abilities--which we call a taxonomy of practical judgment--allows us to show when the traditional frameworks for the evaluation of competence may or may not be useful in the evaluation of a particular competence. In the final section we explore some of the normative considerations underlying the taxonomy. For instance, competence is not only related to intrinsic abilities but to resources available in the community. Here we touch on questions related to the fair distribution of community resources.