The Philosophy of Medicine Reborn
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The Philosophy of Medicine Reborn

A Pellegrino Reader

Edmund D. Pellegrino, H. Tristram Engelhardt, Fabrice Jotterand, H. Tristram Engelhardt

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eBook - ePub

The Philosophy of Medicine Reborn

A Pellegrino Reader

Edmund D. Pellegrino, H. Tristram Engelhardt, Fabrice Jotterand, H. Tristram Engelhardt

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About This Book

Edmund D. Pellegrino has played a central role in shaping the fields of bioethics and the philosophy of medicine. His writings encompass original explorations of the healing relationship, the need to place humanism in the medical curriculum, the nature of the patient's good, and the importance of a virtue-based normative ethics for health care.

In this anthology, H. Tristram Engelhardt, Jr., and Fabrice Jotterand have created a rich presentation of Pellegrino's thought and its development. Pellegrino's work has been dedicated to showing that bioethics must be understood in the context of medical humanities, and that medical humanities, in turn, must be understood in the context of the philosophy of medicine. Arguing that bioethics should not be restricted to topics such as abortion, third-party-assisted reproduction, physician-assisted suicide, or cloning, Pellegrino has instead stressed that such issues are shaped by foundational views regarding the nature of the physician-patient relationship and the goals of medicine, which are the proper focus of the philosophy of medicine.

This volume includes a preface ("Apologia") by Dr. Pellegrino and a comprehensive Introduction by the editors. Of interest to medical ethicists as well as students, scholars, and physicians, The Philosophy of Medicine Reborn offers fascinating insights into the emergence of a field and the work of one of its pioneers.

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Year
2008
ISBN
9780268161477
I
TOWARD A PHILOSOPHY OF MEDICINE
Philosophical Foundations of Medicine
ONE
What the Philosophy of Medicine Is
I will now turn to medicine, the subject of the present treatise, and set forth the exposition of it. First I will define what I conceive medicine to be.
—Hippocrates, “The Art”
The philosopher is under obligation to study the nature of philosophy, itself….”
—R. G. Collingwood, An Essay on Philosophical Method
Introduction
Philosophical reflections about matters medical are as old as medicine and philosophy. In every era, critical thinkers, both in medicine and philosophy, have sought levels of understanding about medicine and its practice not attainable within the purview of the methodology of medicine itself. Only recently, however, has a debate arisen about whether or not there is, or can be, a legitimate field of inquiry called the philosophy of medicine. If there is such a field, in what does it consist? Can it be distinguished from the philosophy of science? What is its relationship to the emergent field of bioethics? Does any practical consequence follow from these distinctions?
Fr. Giovanni Russo has invited me to set forth my current personal response to these questions based on my interest in this field as presented in my own work as well as my collaborative work with Dr. David Thomasma.1,2,3 I will divide my responses into two parts. Part One deals with three perspectives on the present state of the question “Is there a philosophy of medicine, and, if so, in what does it consist?” Part Two compares, contrasts, and distinguishes four models for conducting philosophical inquiry into medicine, i.e., philosophy and medicine, philosophy in medicine, medical philosophy, and philosophy of medicine.
I shall argue, contra Caplan,4 that there is a defensible and legitimate field of philosophical inquiry that can be termed properly the philosophy of medicine, that it can be distinguished from other forms of philosophical reflection about medicine, and that the distinctions are of more than heuristic value. In doing so, I shall expand on a set of distinctions I proposed more than twenty years ago, but which are even more cogent now than they were then.5
Part One: State of the Question: Three Perspectives—Negative, Expansive, and Specific
The history of philosophical reflections about medicine is long, complex, and parlous. I cannot possibly do justice to its historical development nor to the many versions in which it has appeared in the past and the present. Fortunately, there are several fulsome reviews of that history in the ancient and modern worlds, to which the reader may refer.6,7,8,9,10 These reviews speak to the long duration of the dialogues between medicine and philosophy, the several forms they may take, and the range of topics that may fall within—and between—the domains of each discipline. While I will not repeat that history, I will draw upon it selectively to illustrate some of the distinctions and definitions I hope to make.
What is evident in that history is the apparent inevitability of the dialogue for both positive and negative reasons.11 On the positive side, there is the fact that the preoccupations of medicine with humanity’s complex and urgent problems—like life, death, suffering and disease—could hardly escape the inquiry of critical minds in any era. On the negative side, there is the obvious conflict of methodologies, the observational, empirical and experimental bent of medicine colliding with the analytical, speculative and abstract deliberations of philosophy. Attractions and repulsions notwithstanding, neither physicians nor philosophers could in fact desist from puzzling over such universal human experiences as the nature of illness and healing, the ethics of the professed healer, or the relationship of those phenomena to prevailing philosophical schools of thought.
Until recently, however, these reflections rarely met the criteria for formal, systematic, orderly analysis required to qualify them as a legitimate branch or sub-branch of philosophy. Today, however, physicians and philosophers have begun to speak seriously of the possibility of the philosophy of medicine as a field of inquiry, either to affirm or deny it. Today’s interest in what Engelhardt and Erde have termed “a newly emerging field of philosophical study”12 has several sources.
First is the mutuality of interest in the subject matter of medicine to which I have already referred. In every era, there were physicians who wanted to understand the phenomena they observed and the nature of the art they were practicing. In every era there were philosophers fascinated by the need for a deeper understanding of the phenomena than medicine could afford. To achieve these ends, the critical trans-medical perspective of philosophy has always seemed essential.
A second reason for the current interest in philosophy of medicine is the tremendous emphasis in the last twenty-five years on medical ethics and bioethics. As successive theories of medical ethics have surfaced, it has become apparent that there is need for a grounding for ethics in something beyond principles, virtues, casuistry, care, hermeneutics, etc. The first step in this grounding would have to be the articulation of a theory and philosophy of medicine. Such a theory is necessary if we are to put the competing ethical theories into some proper relationship to each other and resolve some of the contradictions between and among them. In short, we need to move from medical ethics or bioethics to a more comprehensive moral philosophy of medicine and the health professions.
A third factor fostering interest in a philosophy of medicine is the turn to Existential, Hermeneutic, Phenomenological, and Post-Modern approaches to ethics and philosophy. These philosophical perspectives are more open to lived experiences of patient and physician and to the particularities of moral choice, suffering, dying, finitude and compassion. These are phenomena of great interest to philosophers who seek to comprehend them in more concrete ways than is congenial in the analytical mode still dominant in contemporary Anglo-American philosophy. These are also the same phenomena physicians and patients confront experientially every day. Critical reflections on these lived experiences leads naturally to the kind of fundamental and comprehensive grasp that could qualify as philosophy of medicine. To be sure, a post-modern philosophy of medicine would reject ideologies, emancipatory narratives, and absolutism in favor of a diversity of language and concept. But it still would be a philosophy of medicine.
Currently, in response to these forces, three general positions are held regarding the nature and existence of the philosophy of medicine. For convenience of discussion, I will label these the negative, the broad, and the narrow positions.
The negative viewpoint is that of Arthur Caplan, who contends that there is at present no legitimate field of inquiry that warrants designation as philosophy of medicine.13 Engelhardt and Erde,14 Engelhardt and Schaffner,15 and Engelhardt and Wildes,16 on the other hand, recognize a very broad field of inquiry under the rubric of philosophy of medicine. Last is the narrower view of David Thomasma and myself, who hold to a more specific definition of a field we identify as philosophy of medicine qua medicine.17,18,19 In our work, we go further and ground our philosophy of medicine in a theory of the healing relationship. Alfred Tauber builds a philosophy of medicine on the philosophy of Levinas.20 Different combinations and versions of these three perspectives can be found in the issues of the Journal of Medicine and Philosophy and Theoretical Medicine, in the long series Philosophy and Medicine, and in recent books which have included philosophy of medicine in their titles. All qualify as philosophical reflection broadly speaking, but not all qualify as philosophy of medicine. They form a spectrum of philosophical reflections on the matter of medicine, and it is within this spectrum that I wish to locate philosophy of medicine as a distinguishable region of inquiry.
The Negative View: Philosophy of Medicine as Non-Existent
Caplan’s line of argument is as follows: He sets forth the criteria he deems essential to define a legitimate field of inquiry. Then, he shows what he believes to be the failure of current definitions to meet those criteria. Caplan’s own criteria include key books, articles, special journals, and a distinctive set of problems. He admits that, on first inspection, these criteria seem to be met by the field today. But, on further specifying his definition of the philosophy and medicine and the criteria that would give it intellectual stature, he concludes, regretfully, that there is no such field.
Caplan’s evidence against the existence of a field of inquiry is as follows: First, he says, there is no agreed upon definition. He then offers his own definition, which he then proceeds to show is not met by any of the current fields of study. Caplan says philosophy of medicine is not to be equated with bioethics, which is normative, while philosophy of medicine should be metaphysical or epistemological. He likewise rejects identification of philosophy of medicine with humanities in medicine, health care policy, or medical aesthetics. He holds it as evidence against the existence of philosophy of medicine that there is not enough “… debate, anguish, posturing and mutual recrimination.”21
Caplan offers his definition of philosophy of medicine as “… the study of the epistemological, metaphysical, and methodological dimensions of medicine; therapeutic and experimental; diagnostic, therapeutic, [sic] and palliative.”22 But, if this were in fact the case, he argues, philosophy of medicine would deal with “key problems” in the philosophy of science and thus be a subdiscipline of the philosophy of science—not a distinct discipline. Caplan’s position is similar to that taken by Jerome Shaffer twenty years ago in the first volume of the Engelhardt and Spicker Series entitled Philosophy and Medicine23 when the debates began, at least in the United States. It also accords well with the span of topics proposed by Sadegh-Zadeh and Lindahl as the domain of the philosophy of medicine which was the focus of the journal Metamedicine, later renamed Theoretical Medicine.24,25
Caplan admits the existence of a large literature and several organizations identified with philosophy of medicine. He even admits the possibility that there might be a “field” of inquiry but it is not one now because it is not part of a broader field, has no recognizable canon of books and no distinctive set of problems. Caplan laments the non-existence of the philosophy of medicine since he thinks a philosophy of medicine would be important as a foundation for bioethics, for the philosophy of applied science, and for certain special problems in genetics and similar fields.
The Broad View: Engelhardt Et Alia
Caplan’s line of argument against the existence of the philosophy of medicine is circuitous, ambivalent, and based largely on simple assertion. Engelhardt and Erde, and Engelhardt and Schaffner are much more definitive in their assessment of the evidence for the existence of the philosophy of medicine. They define philosophy of medicine, not too differently than Caplan, as “… encompassing those issues in epistemology, axiology, logic, methodology and metaphysics generated by and related to medicine.”26 However, they specify several broad areas of inquiry they see as distinctive to the philosophy of medicine such as models of medicine, concepts of health and disease, the logic of diagnosis, prognosis, clinical trials, artificial intelligence, disease causation, etc. Engelhardt and his coauthors support their contention by a substantial bibliography of works drawn from many eras and countries, covering an extraordinarily wide range of topics at the juncture of medicine and philosophy. It is difficult to see how Caplan could dismiss such an extensive body of work as not constituting a field of inquiry.
The Engelhardt and Erde, and Engelhardt and Schaffner, definitions of philosophy of medicine are close to Caplan’s. But, contra Caplan, their review supports the criteria for a “field,” given the great range and number of books and articles they cite that deal with philosophy and medicine. For their part, however, they have cast their net too widely. Many of the works they cite are at the margin of their own definition. Some, however, are now so often cited as to constitute a beginning “canon.” The Engelhardt, Erde, Schaffner, and Wildes definition embraces every conceivable intersection between philosophy, medicine, and physical and social science. While such studies are important, such a broad definition, which embraces such a wide spectrum of studies, dilutes the specificity of philosophy of medicine and weakens the identification of a definitive set of problems. Yet, this specificity is precisely what needs to be examined more closely if we are to determine whether an independent philosophy of medicine does, indeed, exist.
Much of what Engelhardt, Schaffner, and Erde cite as work in the philosophy of medicine could qualify, just as Caplan suspects, as the philosophy of science or biology or as sub-branches of extant fields of philosophical inquiry like metaphysics, epistemology, or axiology, or, in my terms, as philosophy in medicine. This would not diminish the importance of the questions studied. But it does obscure the outlines of a philosophy of medicine, a field whose focus would be more narrowly on the precepts, presuppositions, concepts, and values peculiar to medicine as medicine and not simply as examples of problems already pursued in science or philosophy.
It is interesting, and somewhat puzzling as well, that the philosophies of many disciplines other than medicine are recognized as legitimate fields of inquiry. The most recently published Dictionary of Philosophy,27 for example, has no entry under “philosophy of medicine.” Neither does the currently available but outdated Encyclopedia of Philosophy.28 Yet both reference works have entries for philosophy of biology, economics, education, language, law, literature, logic, mathematics, mind, religion, psychology, science, and social science. Each of those philosophy of “…” articles speaks of the concepts, methods, theories, presuppositions, and justifications fundamental to the discipline in question. Thus, for every discipline, except medicine, a narrow, specific field of philosophical inquiry is recognized that deals with the “what is” question and the problems “internal” to the discipline but not susceptible to resolution by the method of the discipline itself.
Engelhardt and Schaffner’s article embraces the whole range of philosophical reflection on medicine. Some of their citations would be classified as philosophy of science, much as philosophy in medicine or philosophy and medicine, and some as medical philosophy. To some extent, this is also the case with Van der Steen, who identifies philosophy of medicine with (a) questions “left over” from science, (b) normative questions, and (c) methodological questions.29 Other authors also take the broad or expansive view of philosophy of medicine.30,31 In the remainder of this paper, I shall attempt to define the various regions of philosophy of medicine more clearly, particularly that region of the spectrum I believe to be distinguishable as the philosophy of medicine.
Part Two: Four Modes of Philosophical Reflection on Medicine
In this section, I wish to compare, contrast, and distinguish these four regions in the spectrum of philosophical inquiry into medical matters. I shall not dis...

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