Theoretical medicine最新文献

The negative consequences of physicians' failure to establish and maintain personal relationships with patients are at the heart of the "humanistic crisis" in medicine. To resolve this crisis, a new model of doctor-patient interaction is proposed, based on the ideas of Martin Buber's philosophy of dialogue. This model shows how the physician may successfully combine the personal (I-Thou) and impersonal (I-It) aspects of medicine in three stages. These "Three Stages of Medical Dialogue" include: 1. An Initial Personal Meeting stage, which initiates the doctor-patient relationship and involves mutual confirmation; 2. An Examination stage, which requires a shift from a personal to an impersonal style of interaction; 3. An Integration Through Dialogue or "Healing Through Meeting" Stage, which involves the integration of the impersonal medical data into the ongoing dialogue between doctor and patient, as a basis for shared decision-making. The use of the model, as well as common failures of doctor-patient dialogue are discussed.

Many physicians have found that the traditional approach to bioethics fails to account for important aspects of their moral experience in practice. New approaches to bioethics theory are challenging the traditional application of universal moral principles based in liberal moral theory. At the same time, a shift in both the goals and methods of bioethics education has accompanied its "coming of age" in the medical school curriculum. Taken together, these changes challenge both bioethics educators and theorists to come closer to the details and nuances of real clinical encounters. The emerging trend emphasizes the importance of context in bioethics education and in the moral theory and research undergirding it. This article introduces one research approach examining the practical life contexts of medical students' ethical experiences and learning. It calls for increased attention to research and theory in bioethics that more adequately accounts for the ways different contexts produce significant changes in meaning and understanding in medical encounters.

Medicine is arriving at a new millenium. One of its most urgent tasks is to reconcile social health demands with a renewed medical paradigm capable of including them. This challenge requires a reexamination of the definition of medicine. This work takes up the original greek definition of medicine (Tekhne Iatrike) and the Medical Act according to P. Lain Entrago, and analyzes Heidegger's interpretation of Tekhne. It points out the two main ways in which current medical practice is sustained: the Instrumental Medical Act (IMA), which organizes medical production, and the Productive Medical Act (PMA), which motivates it. An overwhelmed Medical Act, fighting but incapable of optimizing an insufficient medical production, is observed. This medical act is searching for foundations: an hegemonic IMA, associated disciplines and a new medical hierarchy.

It is generally accepted today that the biomedical model's exclusive focus on the patient's somatic condition is too narrow. The biomedical model, however, has additional shortcomings. In the first place, resources are left out of the diagnostic perspective. Secondly, the automatic interpretation of symptoms and deviations from normal as present or potential threats to the individual's health. In this paper it is claimed that these characteristics of the biomedical model can lead to medicalization. To elucidate these claims, an alternative approach to antenatal care, is presented in which the psychosocial conditions of pregnant women are integrated. Some practical problems that follow from this approach are discussed.

The authors examine recent arguments purporting to show that mental incompetence (lack of decision-making capacity) is not a necessary condition for intervention in a person's best interests without consent. It is concluded that these arguments fail to show that competent wishes could justifiably be overturned. Nonetheless, it remains an open question whether accounts of decision-making capacity based solely on the notion of understanding and appreciation can adequately deal with various complexities. Different possible ways of resolving these complexities are outlined, all of which need further exploration.

This paper makes the assumption that organ transplantation is, under some conditions at least, a proper use of communal medical resources. Proceeding from this assumption, the author: (1) sketches the history of the problem; (2) briefly examines the prevalent models of communal structure and offers an alternate version; (3) discusses notions of justice and obligation derived from these different models; (4) applies these to the practice of harvesting organs for transplantation; and then (5) offers a different process for harvesting organs from the newly dead. If community is viewed as united by a set of shred goals and common values among which the value of community itself is important, then certain reciprocal obligations among members obtain. I suggest that routine salvage of organs from the newly dead be instituted but that it be routine salvage "with a twist": rather early in life all members of the community are given the opportunity to refuse but their refusal carries the reciprocal condition that they cannot later become the recipients of that which they refuse to others.

Should the nation provide expensive care and scarce organs to convicted felons? We distinguish between two fields of justice: Medical Justice and Societal Justice. Although there is general acceptance within the medical profession that physicians may distribute limited treatments based solely on potential medical benefits without regard to nonmedical factors, that does not mean that society cannot impose limits based on societal factors. If a society considers the convicted felon to be a full member, then that person would be entitled to at least a "decent minimum" level of care--which might include access to scarce life-saving organs. However, if criminals forfeit their entitlement to the same level of medical care afforded to all members of society, they still would be entitled to a kind of "rudimentary decent minimum" granted to all persons on simple humanitarian grounds. Almost certainly this entitlement would not include access to organ transplants.

It is necessary to recognize the variety of levels at which values and norms may inappropriately affect the equity of the transplantation process, including candidate selection. Using a revised, richer concept of objectivity, adopted from Longino's work in the philosophy of science and empirical studies of candidate selection, this paper examines what sort of objectivity can be obtained in the transplant candidate selection process, and the closely related question of how selection can occur in an equitable manner. This concept of objectivity requires that transformative criticism occur so that (1) the conceptual and normative commitments underlying selection may be articulated and perhaps challenged, and (2) the relationship between those commitments and criteria for candidate selection may be examined and justified, or revised. Through such transformative criticism, a greater degree of objectivity may be attained, which in turn will increase the likelihood of equity.

In recent years, the need for infant organs for transplantation has increased. There is a growing recognition of the potential use of anencephalics as sources of organs. Prevalent arguments defending the use of live anencephalics for organ sources are identified and criticized. I argue that attempts to deny the applicability of the "dead-donor rule" are either question-begging or based on false premises and that attempts to skirt the Kantian dictum against treating others as a means only are not successful. I contend that the apparent utilitarian justification for live anencephalics as organ sources is unsatisfactory for two reasons: first, because it ignores the undermining effect the policy would have on parental values and sentiments central to social welfare; and second, because attempts to respond adequately to the slippery slope argument against live anencephalic use are unconvincing.

The severe shortage of organs for transplantation and the continual reluctance of the public to voluntarily donate has prompted consideration of alternative strategies for organ procurement. This paper explores the development of market approaches for procuring human organs for transplantation and considers the social and moral implications of organ donation as both a "gift of life" and a "commodity exchange." The problematic and paradoxical articulation of individual autonomy in relation to property rights and marketing human body parts is addressed. We argue that beliefs about proprietorship over human body parts and the capacity to provide consent for organ donation are culturally constructed. We contend that the political and economic framework of biomedicine, in western and non-western nations, influences access to transplantation technology and shapes the form and development of specific market approaches. Finally, we suggest that marketing approaches for organ procurement are and will be negotiated within cultural parameters constrained by several factors: beliefs about the physical body and personhood, religious traditions, economic conditions, and the availability of technological resources.