Ethical Choices in Contemporary Medicine

Mary Ann Gardell Cutter, Raphael Sassower

• Publisher: Routledge
• Year: 2014
• eBook ISBN: 9781317493181
• Topic: Philosophy
• Subtopic: Philosophy History & Theory

"Ethical Choices in Contemporary Medicine" jettisons the standard medical ethics models of "rights" language and shows how the bioethical problems that receive attention from the media and the public are related to and are explicable in terms of the epistemological foundations of science and medicine. These epistemological concerns include how medical knowledge is established (scientific validity), how medical protocols are administered (checks and balances), how medical certainty is evaluated (probability) and medical responsibility is framed (personal or collective), and how medical knowledge is transmitted (popular media versus professional journals) and how medical care is allocated (insurance policies and government subsides). The book examines the present predicaments of medicine within a broad cultural context and suggests that rational discourse and parochial ethical dialogue may be futile in the face of competing and incommensurable frameworks and agendas, attitudes and wishes. The authors show that, in the postmodern age, two interrelated issues surface when it comes to medicine. On the one hand, there is a strong critique of science and the privileges associated with the scientific discourse and, on the other, there is still a deep-seated quest for certainty in all medical matters.

1
The predicaments of contemporary medicine

The debate over the nature and definition of medicine is as old as our recorded western history. Eighteen hundred years ago, Galen defined medicine as an art (techne) and tried to distinguish between the empiricist and rationalist trends in the field. How much should experience (collected empirical data) influence the practice of medicine? Should reason (rational and logical deduction of effects from a set of causes) play an important role in the theoretical construction of a medical model? Depending on how these two questions are answered, we will have a better idea about how to train students of medicine. These questions have reappeared at the dawn of the twenty-first century because of our increased reliance on technoscience, the confluence and interwoven emergence of scientific theories and models and technological instruments and innovations.

This reliance, as we shall explain in the second section, is not limited to specific breakthroughs in biochemistry or genetics, but is pervasive in the atmosphere in which we come across public health issues. Questions about medicine as art and as science, as the third section will illustrate, are also tied to changing public expectations with regard to the promises of democracy and capitalism. And finally, the questions raised and answered here bring together a multidisciplinary or integrative approach to the widening field of medicine in the twenty-first century.

The art of medicine

In order to appreciate the extent to which medicine is both an art and technoscience, we should also note how medicine relates to biology. If, as Charles Coulston Gillispie reminds us, our conceptions of nature in general and biology in particular were not well articulated centuries ago, then it would make perfect sense that medicine as a field of practice would not have a strict definition or a strict set of parameters within which to operate. Here is Gillispie on biology:

It is, indeed, indicative of the inchoate nature of these subjects that the word “biology” had to await the nineteenth century to be coined. In the sixteenth and seventeenth centuries the subjects it was to embrace scarcely had an independent existence. Anatomy and physiology were rather aspects of medicine than science, and medicine was oriented more toward art and therapy than knowledge. Although human anatomy was studied more by analogy to animals than from cadavers, this practice was the source rather of error than of comparative anatomy, which does not antedate the eighteenth century. Natural history, for its part, was pursued rather in the spirit of the bird-watcher or the moralist than the investigator.

(Gillispie 1960: 58–9)

Medicine as we know it had developed over time to become more rather than less scientific in the senses advocated by the leaders of the scientific revolutions in Europe during the sixteenth and seventeenth centuries. G. E. R. Lloyd (1995) reminds us that, historically, medicine was considered imprecise and therefore a craft and an art whose practice was valued but whose predictive ability was questionable. As he quotes from Plato’s Phaedrus (260e), “the proper practice of medicine as an art is contrasted with its practice merely as a knack and by experience”. He also quotes the Philebus (55e ff.): “where the arts are graded according to their degree of exactness, medicine comes in the lowest category, along with music, farming, navigation and generalship, below carpentry, which makes more use of instruments designed to achieve exactness” (Bates 1995: 35). Whether medicine was considered art or science bothered our predecessors less, according to Luis Garcia-Ballester, than its usefulness. Speaking of the Latin west, he says that:

The concept of usefulness (utilitas) was closely linked to the justification of the physician’s presence in society, both among non-academic social groupings – by demonstrating the efficacy of his knowledge through practice – and in the academic community itself. The presence of physicians in the latter was justified only as long as they were able to train artfices (phisici, cirurgici) who might solve the problems of health arising in the community that the university served.

(Bates 1995: 145)

Utility alone was not what marked medicine as worthy of study and practice. In accumulating medical knowledge, physicians learned how to diagnose diseases and how to treat them. But, as we shall see in Chapter 2, the focus on diseases and their characteristics is itself problematic. According to Andrew Wear (1995), with reference to the sixteenth century, “The learned physician’s trademark was that he took into account the patient, and that it was the individual patient and not the disease that had to be treated, so that one remedy could not cure all who suffered from the same disease” (Bates 1995: 163).

Defining medicine as an art or technique rather than a science makes a difference in how we approach the discipline and the practice. We would not argue that medicine is only an art or that it lacks any scientific basis. Instead, we would suggest that the scientific basis of medicine provides only a provisional starting point for the practice of medicine, and that as such medicine is a techno-scientific practice (Delkeskamp-Hayes & Cutter 1993). This suggestion is encountered daily by those going to their health care provider, a doctor or nurse, a clinician or pharmacist, in order to be diagnosed or receive prescription. There are no clear-cut answers, no absolute certainty, but instead a carefully nuanced response regarding the patient’s medical condition. Why can we not provide clear and simple answers? (More on this in Chapter 4.)

Incidentally, the recognition that medicine is more of an art than a science is most pronounced in the contemporary structure of medical education (Sassower 1990a), where the first two years of rigorous scientific training are followed by two years of rotation among all the subdisciplines of medical practice. Let us be clear here that when we talk about the art of medicine, we do not follow a social science approach that would enumerate case studies in which anecdotal evidence provides the only theoretical foundation, as, for example, Paul Starr (1982) does when describing the changing practices of health care provision in America. A theoretical judgement is being tested in practice, and the practice supports a theoretical conviction. So, what is the status of medical knowledge? Does it have the certitude expected of geometric calculations? Or is it open to the perennial Cartesian doubt (Descartes 1980) and ongoing revisions? If there is an inherent uncertainty concerning medical knowledge, then anything from medical diagnosis to prognosis becomes more nuanced and subtle than if it were wholly scientific. If physicians can only tell patients the probability of some set of variables leading to a particular disease and its treatment potential, then how can patients ever know their own specific fate? What meaning can we ascribe to probability values (Todhunter 1865)? How should they be understood, interpreted and calculated for individual cases (if such a thing is even possible)? What probabilistic answers should patients accept or doubt?

These are real questions that face real participants in the medical community on a daily basis, as was also documented by Bruno Latour in his documentation of the changing practices and attitudes in France in relation to Pasteur’s discoveries (Latour 1988, especially Ch. 3). These are not esoteric concerns but the concerns of us all, because they undermine our belief in the clear-cut answers we expect of medicine as science, not realizing that science itself has been open to critical examination since the latter half of the twentieth century (Sassower 1995). The status of scientific claims has come under scrutiny because theoretical commitments change over time, and the basic assumptions that set the foundation of science remain open to multiple interpretations, if not to radical revisions. Concerns over knowledge claims in general and scientific claims in particular permeate the history of ideas, because much was at stake in making claims about nature without reference to divine revelation. Karl Popper’s (1959) debates with the Vienna Circle in the early part of the twentieth century have only streamlined and raised greater urgency to these debates about the status of scientific knowledge itself. It was David Hume (1978) who in the modern era questioned the principle of induction, our ability logically to move from causes to effects, from a set of empirical data to a generalized conclusion. When Popper followed suit and proposed his principle of falsification, all he attempted to do was resurrect faith in scientific certainty. He likewise criticized some of his disciples and adversaries – Paul Feyerabend (1975) and Thomas Kuhn (1970) come to mind – with regard to their cavalier introduction of irrationalism into the scientific fold, which would ultimately undermine our faith in science.

We recite some of these anecdotes in the modern history of science so as to alert ourselves to the precarious status science itself has had to protect, so that when we speak of the scientific status of medicine we will be doubly cautious. Perhaps the view of medicine as art rather than science would fare better if the public learned to lower its expectations of its performance while still retaining the belief that medicine is a highly valued practice that can save lives (as Engel 1977 and Pellegrino 1976 have already done). We should hasten to add that public expectations of science and of medicine are poorly founded, for they rely on mass media for their highly sensational, inaccurate and (more often than not) positive appeal. High-drama, primetime television series, such as ER, contribute to the misinformation about the workings of medicine, because they focus on the personal lives of physicians and nurses and the drama of the hospital setting, leaving aside (assuming away) the contested scientific status of medicine itself.

As we continue to consider some of the influences on the conceptualization and practice of medicine, we would like to suggest that there is a great deal to be gained from the philosophical context under which medicine is scrutinized. If we limit our inquiry to the advantages and shortfalls in the application of medicine, we are already accepting a utilitarian framework (in which benefits are maximized in the light of pain or suffering; see Bentham 1970) without testing whether it is the appropriate or defensible one to be used here. It seems to us that the development and proliferation of the subdisciplines concerned with medical ethics have poorly served academics and the public with regard to medicine (Sassower & Grodin 1988). If all we focus on is rights or autonomy language in a hospital setting (the conflicting rights of patients, nurses, doctors and insurance companies), we miss too much to be able to make an intelligent choice. For example, the standard issues of the past thirty years revolved, among other things, around reproductive rights, the right to die and the dilemmas of health care delivery. In many cases, these issues were raised as if autonomous and well-informed individuals were in the position of making rational choices given a set of alternatives (Annas 1988). But has this been the case? Have these individuals not been part of a culture whose convictions and ideology (religious and moral) might be alienated from the (capitalist and individualistic) culture of hospitals and physicians? Have we assumed away some differences that would have provided radically different models for discussing alternative choices?

If we consider the question of death in cases of accidents or terminal diseases (rather than what we call natural death), is it reasonable (not to mention accurate) to call organ-sustaining machines life-supporting? The very question at hand – is the patient alive? – is being answered before the question is raised, because stopping the equipment is tantamount to killing the patient. But if the machines are only maintaining the function of certain organs, then we leave open the question of whether the patient is indeed being kept alive or has been dead before being hooked to the machines. It may seem a linguistic quibble to some, but in our view this is a crucial distinction that can circumvent, if not eliminate, some painful controversies regarding death (Sassower & Grodin 1986). Likewise, if we viewed the medical profession through a prism wider than that reserved for science proper, we would appreciate a certain fluidity and uncertainty that is inherent in the practice of medicine. Once again, it might seem relatively unimportant what scientific status we accord medicine on a theoretical or philosophical level, but we suggest that it would make all the difference in the world when it comes to disputes about therapies, expectations about the efficacy of treatment and the inevitable limitations of diagnoses and prognoses.

In this context, then, we wish to plead for a century in which philosophy of medicine takes centre-stage in deliberations concerning health care. Even when biochemical or genetic research is undertaken, we would like to know what assumptions are being used, what philosophical beliefs are being played out and what ideological convictions are being implicitly promoted. On this particular point, the work of Richard Lewontin (1993) is relevant, because he helps to expose the ideological underpinnings of debates in biology. To believe that we merely practise medicine or that we merely build on our medical experiences (as Galen already noted) is to refuse to admit that we have theoretical and ideological commitments that influence how we think and practise our trade. Our theoretical commitments are eventually made explicit, for instance, when we try to map the human genome with the belief that an individual gene causes a specific disease. But what if this turns out to be false, as appears to be the case, and only a certain combination of genes and other DNA matter is more or less likely to contribute to specific diseases? As Lander & Schrok (1994: 2037) convincingly argue, “most traits of medical relevance do not follow simple Mendelian monogenic inheritance”. What they tease out in their survey of the literature and the experimental data is a rejection of a reductionist view of cause and effect (the ability to provide a direct and unitary correspondence between specific items) and instead the adoption of a more complex, evolutionary view of human physiology, genetics, medicine and the environment.

We would like to suggest in this book that medicine has never been nor will ever be an activity undertaken in isolation from the rest of the culture in which it is situated. The success or failure of medical practitioners depends on the support and expectations related to the field. The medical community operates with guidelines that include medical practices, economic considerations, institutional codes and moral obligations. It would, therefore, be misleading to examine medicine apart from its cultural settings and the pressures under which it must operate. For example, we have to examine what questions are being addressed by the medical profession and why these are the questions that are being raised to begin with. Should we address questions about preventive medicine rather than questions about the efficacy of triple bypass operations for overweight white males? What legitimates one set of questions over the other? Who is responsible for putting one set of questions on the research funding agenda of the National Institutes of Health? Does a “right to health care” make any sense without a sustained discussion of who has what responsibility to provide for the resources to satisfy such a right (e.g. kidney dialysis in 1976)? How is it that we have assumed that AIDS only affects gay males? How do we even begin to think about national responses to emerging infectious diseases and bioterrorism?

Examining the questions that make it to the citadels of the medical establishment can shed light on the presumptions used by funding agencies when research proposals flood the gates of these agencies. The disproportional funding of research into the diseases that are more common in white elderly males as opposed to women of colour illustrates our concern. Likewise, examining the culture of technoscience would shed light on certain prejudices we have with regard to the workings of science in general and medicine in particular. A mechanistic view of the world (a machine-like model wherein each part contributes to the functioning of the whole) would lead us to view our own physiology in mechanistic terms, such that medical intervention would parallel that of an engineer fixing a broken machine.

Technoscientific culture

The Enlightenment project, commencing in the eighteenth century, is still with us. By this we mean that the promises of scientific knowledge, as opposed to religious knowledge, are being extended and fulfilled with every new generation of discoveries. Rationalism, the belief in the use of reason to deduce knowledge claims with certainty, and empiricism, the belief in the use of experimental data to induce knowledge claims that are repeatable, have served us to overthrow superstition. Whether we recall the works of Francis Bacon, René Descartes or Immanuel Kant, we remain indebted to three centuries of progress in our knowledge base. Although we have modified their original claims, the spirit of the scientific model still guides us today.

The scientific model carried much weight because of its ability to communicate to the public a certain level of integrity and thereby enjoy the patronage of others in the way the arts enjoyed them in the Renaissance, for example (see Gillispie 1960: 109). As Robert Merton reminds us, the strengths of the scientific enterprise and the values adopted by its practitioners could sway any sceptic to join or support them. The scientific community valued and at times invited the open scrutiny of its research and publications (peer review), a certain level of fraternity or collegiality (appreciating collaboration for the sake of studying vast amounts of data), a notion of universalism or internationalism that transcended geographical and demographic boundaries and as such was less discriminatory than other organizations or institutions, and a great deal of freedom of thought from the state and the church, from anyone in position of authority (Merton 1973: Ch. 13). In some sense, the scientific enterprise became the prototype of the Enlightenment ideals in so far as it advocated equality and freedom, accepting more than rejecting the ideas of those who under previous circumstances of the learned societies were excluded.

One can recall in this context the words of Ernst Mach (1838– 1916), one of the fathers of logical positivism, a powerful European movement between the two world wars devoted to simplification and precision in reporting natural facts and assembling them into meaningful protocol sentences that could easily be tested against natural phenomena:

The belief in occult magic powers of nature has gradually died away, but in its place a new belief has arisen, the belief in the magical power of science. Science throws her treasures, not like a capricious fairy into the laps of a favored few, but into the laps of all humanity, with a lavish extravagance that no legend ever dreamt of! Not without apparent justice, therefore, do her distant admirers impute to her the power of opening up unfathomable abysses of nature, to which the senses cannot penetrate. Yet she who came to bring light into the world, can well dispense with the darkness of mystery, and with pompous show, which she needs neither for the justification of her aims nor for the adornment of her plain achievements.

(Brody & Capaldi 1968: 15 –16)

This belief in the powers of science has overshadowed any scepticism that could have been levelled against anything scientific. Regardless of our deep appreciation of the limits of scientific or medical knowledge, we still hold on to a belief in rationality itself as a principle and method by which we organize our data collection and with which we can be better armed, epistemologically speaking, to handle new natural phenomena and occurrences. Coupled with useful technological applications, science becomes an even more powerful ideal in the eyes of the western public, and because of this, the belief in the power of science and technology is compounded.

Those of us who prefer the term technoscience follow the advice of Jean-François Lyotard (1984) and Bruno Latour (1990), who insist that the old-fashioned division between science and technology is no longer operative in the twentieth century. Technology is not limited to the practical implementation of scientific theories, because technology is constitutive of the theoretical construction of scientific models (see Hesse 1966). Some of the greatest scientific achievements are indebted to the use of sophisticated equipment that could test theoretical speculations a...

Table of contents

• Cover
• Half Title
• Title
• Copyright
• Contents
• Introduction
• 1 The predicaments of contemporary medicine
• 2 Medical epistemologies and goals
• 3 Medical certainty revisited
• 4 A new ethics of medical practice
• Bibliography
• Index