Social science & medicine. Part F, Medical & social ethics最新文献

Recent publications by a number of critics of health care raise substantial questions about the benefits which derive from new medical technologies. The response of those who advocate these new technologies has broadened the argument, adding quality of life (QOL) considerations to previous claims which emphasize increased longevity. Unfortunately, the studies which purport to demonstrate an improved QOL do not incorporate relevant findings from a wide range of studies which emphasize the complex interplay of many subjective factors in the quantitative assessment of the QOL.

There have been numerous studies of a wide range of medical interventions which employ QOL criteria. In the main, the inadequate research designs employed in these studies contrast with the sophisticated technology they purport to assess. A review of these studies indicates that few if any, procedures may be defended on the grounds that they improve the QOL.

There is a need for studies involving adequately controlled samples using objective and subjective QOL indicators which address the manner in which objective QOL changes are subjectively interpreted. Until these studies become available, arguments for the impact of medical technologies on the QOL will be speculative and remain unconvincing.

Physicians and their professional organizations often distinguish between ordinary and extra-ordinary means of treatment. The moral relevance of this distinction, which has recently been defended by the philosopher Bonnie Steinbock (The Intentional Termination of Life. Ethics Sci. Med. 6, 59, 1979.). is challenged. It is argued that neither this nor the “overlapping distinction” between intention and foresight is morally significant. If deliberate cessation of ordinary treatment, resulting in the foreseen death of the patient, is the intentional termination of life—so is the deliberate cessation of extraordinary treatment.

Two interrelated arguments are advanced in support of the claim that the distinction between ordinary and extraordinary means of life-support has no moral significance. The first is based on Steinbeck's own criterion for the intentional termination of life (“if one acts intentionally, foreseeing that a particular result will occur, one can be said to have brought about the result intentionally”), the second suggests that the distinction between ordinary and extraordinary means is a distinction not between different means but between lives judged worthy of prolongation and those not: it is a quality-of-life criterion. This explains why the concept of extraordinary means is “flexible”, why “what might be considered ‘extraordinary’ in one situation might be ordinary in another”.

But if we do not admit that quality-of-life considerations rather than “means” are at issue, then we cannot give an adequate answer as to why it may. for example, be morally permissible to switch off the respirator when it sustains an irreversibly comatose patient but not when it sustains a patient with a respiratory disease. It is argued that when the physician intentionally flicks the switch to turn off the respirator, foreseeing the death of the patient, then he has brought about the death intentionally and it does not matter whether we call the respirator in the first case an “extraordinary” and in the second case an “ordinary” means. The deliberate cessation of life-prolonging treatment is the intentional termination of life—either passive euthanasis or. if the patient against his doctor's advice, refuses further treatment. passive suicide.

While the practice of medicine is ideally suited for the expression of paternalism, outside of the age-appropriate parent-child relationship, such expression is clearly inappropriate.

Previous publications concerning medical paternalism fail to consider the deep psychosocial roots of paternalism. As a result, there is no differentiation between appropriate physician attitudes of parental concern and inappropriate, uncounscious paternalism. Psychoanalysis, as a paradigmatic method of treatment, focuses on distinguishing inappropriate, transference-countertransference attitudes, from realistic physician and patient expectations.

It is not paternalistic to empathically withold information from patients. Rather, this is sensible and skillful medical practice. What is unconscionable, is a ‘father knows best’ physicianly attitude which is chronically and inappropriately applied and justified. This is poor patient care and clearly unethical.

This paper considers the relationship between the crisis of experience in chronic illness and the crisis of legitimation in medicine. Clinical approaches to chronic illness characteristically apply medical technologies to highly uncertain diseases. The many social problems that result from this technologically-dominated approach are evident in the dynamics of illness experience. Therapeutic ‘solutions’, however, attempt to set technical boundaries to the definition of health problems and largely redefine the social component of the medical problem. Success is defined as the effectiveness of treatment and failure as largely due to individual deficiencies of unsuccessful patients in an attempt to establish the legitimacy of quasi-experimental medical technologies.

The example presented here is the problem of kidney failure (end-stage renal disease), a chronic disease which requires treatment by dialysis (three times per week, six hours per treatment) or kidney transplantation. In the United States this is the only chronic illness for which a federal program (since 1972) pays virtually all treatment costs for over 40,000 patients. Over 1 billion dollars a year are expended on these medical technologies. This disease is representative of the technical approach which dominates chronic illness care. In this paper problem definitions in end-stage renal disease that are derived from clinical practice and technical break-throughs will be analyzed in terms of their appropriateness for the social dynamics of the illness experience. The divergence between the technological approach and the dynamics of experience will be illustrated by an analysis of the activities of a renal treatment program. Excerpts from staff and patient interviews, observation in the clinic and medical record abstracts will contrast the extreme tension and uncertainty engendered in the treatment of this disease with the narrow problem definition of the technological model.

The two central questions raised are the following: (1) To what extent does the credibility of clinical practitioners in highly ambiguous settings depend on denying legitimacy to the patient's illness experience? and (2) How do these dynamics intensify the crisis in medical credibility and exacerbate the tragedy of catastrophic illness?