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“The only thing necessary for these diseases to the triumph is for good people and governments to do nothing.”


   


 

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

Abstracts

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. 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)

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 self-medication 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, 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 non-maleficence, 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)

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 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 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.

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 1st 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 1st 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. 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 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 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 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.

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 three- dimension 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) 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 sub-society 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 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 20th 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 Confucian-Buddhist folk notions of the body.

Why should we stop the practice of non-religious circumcision of male newborns?

Dekkers, Wim (The Netherlands)

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 self-healing 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 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.

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 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 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 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 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.

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, 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 t