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Medicine is not only a speciﬁc kind of life sciences or applied biology. The fundamental interest of medicine is not to fabric theoretical knowledge only but to achieve practical goals. Medicine and the art of healing are practiced to be of beneﬁt to humans who are ill or to prevent them from falling ill. This relationship between medical science and medical practice is signiﬁcant for the epistemological status and the structure of medicine that is developed in a philosophy of medicine.
In antiquity the experience of suffering from illness and the feeling of pain on the one hand and the lack of knowledge about physiological causes of diseases on the other led to forge close ties between secular medicine and sacral healing rituals: When a physician successfully brought about healing, he was admired not merely as a secular expert, but also revered as one in touch with the divine. The cult of Imhotep (Egypt) or Asclepius (Greece) may be many centuries distant; something similar nevertheless continues to be practiced as an expression of those desires and hopes that people harbor in respect of medical skills. Both of these phenomena remind us of the degree of importance that people ascribe to medicine on account of their perception of health as a fundamental good. Even though medicine has become increasingly secularized since the time of Hippocrates and more and more an independent science, it still retains a certain status (Hart 2000; Sigerist 1987).
If one considers modern medicine in the context of the origins of medical science, it is clear that certain constitutive factors remain relevant: For characteristic aspects such as practical treatment, consideration of the patient as an individual, an integrative view of nature and social ties are not associated exclusively with the ancient physicians, but equally with modern medicine. And this demands physicians’ technical and ethical intelligence (ethos) in equal measure. Equally, there can be no doubt that dramatic changes have occurred over the intervening centuries. These changes have inﬂuenced the constitutional fabric of medicine and raised both epistemological as well as ethical questions (Baker 1995; Fleischhauer, and Hermerén 2006).
Taking the special status of medicine as its starting point, the philosophy of medicine deals especially with the structural and constitutional aspects of medicine as well as the way they have developed (1), the epistemological foundations of the medical disciplines (2), the relationship between medical science and medical practice (3), and the way the latter determines medical judgment (4). All of these areas have implications in respect of medical ethics.
The Structure And Rationale Of Medicine
The roots of Western scientiﬁc medicine are to be found in Ancient Greece, and they are closely associated with the writings contained in the Corpus Hippocraticum (ﬁfth to fourth century BCE). They deﬁne that the task of the medical arts is “to free the ill entirely from their suffering, to diminish the severity of the diseases and deliberately to refrain from attempting treatment of those who are overwhelmed by the diseases” (De Arte). Reading Hippocrates’ works together with the Platonic and Aristotelian philosophies as well as Thucydides’ historical writings, it becomes obvious that the medicine of those days was by no means seen to be an isolated and special science, but rather a discipline well integrated into the mental framework of the polis: Medicine and philosophical thinking exercised a mutual inﬂuence on each other. A large proportion of the ancient medical writings retained an almost canonical validity up to and including the eighteenth century (Baker 1995).
Even so, the ways physicians have dealt with patients, with human nature, and with the human body have undergone many shifts and changes in the course of the centuries: From Galen’s (126–216) functionalization of the body, the zenith of Arabian medicine with Avicenna (980–1037), the development of medieval cloister medicine (e.g., Hildegard von Bingen (1098–1179)), experimental physiology (William Harvey’s (1578–1657)), the design of a nosological system by Thomas Sydenham (1624–1689) toward the idea of iatrochemistry and iatrophysics (René Descartes (1596–1650), G.A. Borelli (1603–1680), S. Santorio (1561–1631)), and to the cellular pathology of Rudolf Virchow (1821–1902). The increasing tendency toward a naturalistic view of the human body in medicine as well as elsewhere led to countermovement’s such as vitalism. Finally, the twentieth and twenty-ﬁrst-century medicine has been greatly inﬂuenced by the methods of molecular biology such as probabilistic prediction and, more recently, by the imaging techniques being implemented in the neurosciences. These, too, tend to imply scientiﬁc-reductionist procedures that run counter to other medical and philosophical models such as may be encountered in modern psychosomatic or system-theoretical approaches (Porter 2006).
If one reviews scientiﬁc medicine in the light of this historical development, it becomes clear that its orientation is not so much toward theoretical knowledge in the sense of episteme (science), but rather toward goal-oriented action implied by the concept of techne (art). Its primary goal is to heal sick people; the appropriate means are those that serve this aim. Implicit in the interdependencies that exist between technical and ethical actions is the need to consider medical intervention not only from the pragmatic “right or wrong” point of view but also from the moral “good or evil” point of view.
This is what imbues not only medicine as such, but also medical ethics with their special character. Western and Eastern medical ethics have developed the notion of “professional ethics” or “ethos” that includes fundamental rules of conduct such as “salus aegroti suprema lex” or the “principle of nonmaleﬁcence” and ﬁxed attitudes or internalized basic premises such as the duty to provide care or the principle of conﬁdentiality. Such attitudes can be passed on from one generation of doctors to the next in the form of an established master-student relationship. A doctor who has internalized this code of conduct knows how to pursue the right goals in various situations. This is what constitutes his or her ethos. However, such an ethos can only be effective in cases where the framework for a given action is known and can be grasped in its entirety. This presupposes that the group of agents concerned sees itself as a social unit and that they and the society to which they belong more or less share a common set of values that maintains the code of conduct. In the present time, however, there is a widespread degree of disunity in this respect (Francis 2001; Schauer et al. 2001; Fu-Chang Tsai 1999).
Structural Challenges And Changes In Modern Medicine
Even though the structural identities of ancient and modern forms of medicine display a considerable degree of congruency, the present-day framework conditions differ greatly from those of antiquity. And this notwithstanding the fact that even the Greek polis was certainly not an entirely homogeneous society. The plurality of ways of life and convictions, intercultural exchange, and the social fragmentation that characterize modern and globalized societies in the twentieth and twenty-ﬁrst centuries lead to independent subsystems that no longer function according to uniﬁed rules and ends. Also, the discussions that take place between them and the different languages that they employ render mutual understanding difﬁcult. This means that there is not only dissent within the medical profession (intramedical factor) but also the demands made on the profession by society as a whole have become individualized (external factors). Thus not only have the approach of medical science and its appreciation of nature shifted, but also the relationship between medical profession and societal expectations.
Medicine has become a highly organized and in some respects technical and anonymous conglomerate. It still operates within a scope of action determined by scientiﬁc endeavor at one pole and something like the art of healing at the other; nevertheless, developments in science and technology have allowed it dramatically to increase that scope, as evidenced by organ transplantation, in vitro fertilization, human genetics, and others. In addition, the scope of consequence of medical activity has increased correspondingly. With this, not only the form of how we understand nature has changed but also radical interventions in the human constitution, for instance affecting the genome or the brain, have entered a new dimension. The natural order is no longer seen as constituting a limitation, but as an investigable and manipulable object.
These are just some of the recent advances in biomedical science and art that have shed new light on our understanding of human life, on what determines it, on its beginning, and on its end. As well as this, the internal structural framework of medicine and medical activity has undergone considerable change – like societies at all: Individual cases have become anonymized; they are treated with recourse to a division of labor, and they are subject to the economic constraints that to some extent govern healthcare.
The increasing signiﬁcance of scientiﬁc research and its technical implementation has led to a growing tendency to subsume medical activity wholesale in scientiﬁc and technical categories, thereby affecting the discipline’s inherent self-perception and the pattern of its scope of action. Whereas the natural sciences and technologies can be regarded as being “open ended,” medicine has so far been characterized by the targeted mode of action of its agents (medical teleology). However, as such orientation toward clearly deﬁned goals is no longer to be taken for granted, as the scope of action is expanding and as the need to make decisions becomes more pressing, medical activities are affected by new forms of ambiguity (Wieland 1993; Fleischhauer and Hermerén 2006).
Social Desires: Beyond Therapy
The extended set of options now available to modern medicine is causing the traditional goals of medical activity to be broadened or replaced by new ones. Increasingly, medical and technical feasibility predominate in decision-making processes and actual medical activity; parts of medicine are developing into “anthropotechnology.” From the time of the Enlightenment, man’s urge to achieve better and higher performance, to go beyond the restrictions that have pertained so far, and thereby to include his own state of health in that process, has led to the notion that there are, in principle, no limits to the scope of human activity. In the ﬁnal consequence, the traditional marks of natural humanity, namely, contingency and mortality, are being supplanted. The faith placed by many people in what may be medically and technically possible can lead, in the end, to the total medicalization of life with its attendant imputation that social problems, too, can be solved by means of medical techniques. The desire to enhance human nature is fuelled by the utopia of a society that has been released from suffering. Nature is no longer to be provided with medical assistance (by a “magister naturae”), but itself to be improved (Parens 1998; Fleischhauer, and Hermerén 2006).
Medicine As Science: Knowing That And Knowing How
There are legitimate practical interests that demand an answer to the theoretical question as to which epistemological understanding of medicine or its individual disciplines may claim to be binding. On the one hand, it is claimed that medicine should be “evidence based,” notwithstanding the fact that this requirement is very difﬁcult to fulﬁll. For many different forms of therapy for which hard and fast scientiﬁc evidence is lacking have proven themselves to be effective in practice. On the other hand, there is increasing criticism of a certain self-conception prevalent among the professional physicians who practice an orthodox medicine. The critics advocate instead what they refer to as “alternative medicine” or “outsider methods” whose primary aim is to maintain the homoeostasis of the human body (Woodhouse 1997). Hence any attempt to clarify the epistemological status of medicine depends to a great extent upon what kind of understanding of medicine do patients wish to adopt on the basis of their thoroughly well understood self-interest.
At their anthropological core, the perception of pain, suffering from disease, the accompanying dependency on the help of others, and the desire to experience healing and relief undoubtedly exist independently of any given scientiﬁc understanding and its paradigms, as well as independently of a particular cultural context: Man experiences himself through his consciousness of himself and his physical body as a contingent being that is subject to suffering and pain. However, even though their existence is indisputable, the manner by which they can be perceived – and thereby also knowledge about them as well as dealing with them – is to be understood as being dependent of the scientiﬁc standard and as a product of sociocultural transmission.
A number of factors support the view that medicine itself is a natural science or an applied natural science that simply implements scientiﬁc results: The kinship of medical science with biology and other life sciences is borne out by the designations of its sub disciplines such as anatomy, physiology, human genetics, and so forth, but also by the object of study (human organism) as well as the experience that many natural scientists such as biologists, biochemists, physicists, etc., are engaged in medical research. For the successes that medicine can boast since the beginning of the modern age are due not least to the application of the natural scientiﬁc methods, namely, the observation of its subject matter from the theoretical point of view and the investigation of the interrelationship of previously methodologically isolated individual factors with the aim of obtaining an understanding of the regularities in the relationships of what is the case (facts). This is the thought behind Bernhard Naunyn’s (1905) assertion: “Medicine will become a science or it will not be.” This gave expression to a positivist and naturalistic understanding of medicine.
Indeed, on closer scrutiny it transpires that medical research is the investigation of the biological human nature of mankind. In order to understand the functional interrelationships that pertain to the organism Homo sapiens, these are investigated by the same means that are also used in biology: laboratory techniques, statistical and probabilistic methods, the setting up and testing of hypotheses, the generation of models and theories, etc. However, there is a need to consider the life sciences in a different manner than physics – a proposition that is put into question in physicalistic, mechanistic, or system-theoretical models. There, no other form of rationality, certainly no such thing as an objectively existing vitalism ﬁnds a place. The fact remains, however, that the living objects of these areas of research – organisms, groups of organisms, or systems with living and nonliving components – behave in other ways than the nonliving objects of physics. Nonliving objects do not grow, have no metabolism, do not reproduce, and display no form of mental behavior. Therefore there are good reasons for doubting whether the methods of the life sciences can be reduced completely to physical approaches and interpreted by means of a philosophy of science that is oriented toward physics.
Moreover medicine is a speciﬁc kind of life sciences and not just applied biology. Whereas biology – including human biology – is driven through purely epistemic interest and thus of a theoretical nature (knowing that) and only becomes an applied discipline in the guise of biotechnology, for instance, the fundamental interest of medicine is of a practical nature (knowing how). For the purpose of the healing arts is to satisfy a need. They are practiced to be of beneﬁt to people who are ill or to prevent them from falling ill. To achieve these goals it is of course necessary to exploit knowledge that has been gained in the context of modern scientiﬁc activity, and this knowledge may originally have been of a purely theoretical nature – in other words, not oriented toward medical practice (e.g., in the ﬁelds of cytology or physiology). Notwithstanding the common ground that exists in terms of the scientiﬁc methods used, there is an essential difference regarding the objective of this kind of research. This difference is of far-reaching signiﬁcance when it comes to assessing the epistemological status of these disciplines, and it illustrates why in various epistemological approaches medicine is not been merely treated as a ﬁeld of application of human biology. The knowledge gained through deductive methods in the sense of strictly logical reasoning issuing from explicitly formulated premises may lay claim to intersubjective validity within the conﬁnes of medicine itself, but it does not represent a sufﬁcient warrant for medicine with respect to the patient and society. Whereas knowledge may be veriﬁed or invalidated, a course of action must be justiﬁed. A course of action that intervenes so deeply in the integrity of a body and an individual person cannot be justiﬁed only on the basis of the epistemological technique of deductive reasoning, albeit the standards of rationality implied in the practical term “lex artis” play a considerable role when it comes to such justiﬁcation. Even the process of diagnosis contains not only theoretical, descriptive aspects but also practical, normative aspects. Thus a diagnosis cannot be treated in the same way as a scientiﬁc hypothesis, for a diagnosis is a singular statement (about a certain patient at a certain point in time), whereas scientiﬁc hypotheses are essentially universal statements (Sadegh-Zadeh 2012, pp. 11–56; Wieland 1993).
Medicine Between Biomedical Science And Clinical Practice
Modern biomedical science can be seen as a conglomerate of different disciplines or subject areas that are connected with medical action in a number of different ways. However, it is clear that this medical action represents the only unifying element that makes it possible to speak of “medicine” as a coherent science rather than having to refer to individual medical faculties and disciplines. Whereas the fundamental disciplines such as anatomy, physiology, etc. are very strongly oriented toward theoretical knowledge and display a methodological afﬁnity to nonmedical biosciences such as human biology or biochemistry, and disciplines such as medical psychology, psychiatry, and social medicine display elements of the humanities, the “applied” or “clinical” disciplines relate directly to the work that the physician performs with and on the patient. In many cases, the relevance of scientiﬁc research results for medicine and hence for the physician’s work only becomes clear in the course of the research. In the clinical sphere, the transitions between scientiﬁc research and targeted, practically oriented biomedical research are not clearly demarcated. It is the case that the fundamental disciplines (in which not only medical people, but also molecular biologists, biochemists, physicists, psychologists, sociologists, etc., are involved) are only indirectly connected with the daily work of the physician. Therefore the distinction between biomedical science and the art of medicine in clinical practice (Toulmin 1976, p. 43; Cassell 1995, p. 1674) is appropriate to the extent that they do not represent independent systems, but they rather are complementary to each other. Medical practice that is directly linked to individual patients will always remain an integral part of medicine, and it is oriented on the fundamental and generalized principles of biomedical science. These, on the other hand, are an essential element when it comes to laying down medical and clinical modes of practice, but they can only be effective in this respect insofar as they relate to suffering and the treatment of individual patients.
Medicine As Practical Science
The physician treats the patient not merely as a “defective organism,” but as a whole person. Instead of dealing with an “object of investigation,” the physician enters into a relationship with another member of his own species and his social community. In this respect the physician’s scope of competence must be extended beyond that demanded by scientiﬁc standards. Therefore the humanities need to meet the demands of this new biomedical science (Jonsen 1992, pp. 141–160; Wieland 1993).
If one now grasps medicine in this sense as a practical science, then reﬂection on the subject matter of medical ethics entails more than simply “more of the same.” The “practical” part of a practical science consists precisely in that it does not aim to formulate appropriate statements about courses of action, but to enable, to justify, and to explain such courses of action, irrespective of whether these involve speciﬁc and individual actions or more general ones. Where scientiﬁc knowledge is gained in medicine, it is not of central importance that it manifests itself in the form of theorems or systems of theorems (theoretically ideal insights), but rather that an item of knowledge contributes to an opinion that in turn leads to a course of action (practically ideal action). The core element of medicine is the targeted course of action, issuing from and being part of the complex of diagnosis, prognosis, therapy, and healing and involving an individual patient at a certain point in time; it is not the theoretical assertion. This practical character of a science opens the door to an exegesis of those necessary questions as to what should be done from the moral and normative point of view within the purviews of the science itself, to provide justiﬁable answers, rather than being dependent on externally established standards. Thus medical ethics represents more than simply a “technology assessment”; as an applied ethics, it has to do not only with the rules of medical action but also with the ethos of the physician in a certain sociocultural context in which the rules coalesce into the concrete unity of a certain course of action (Schauer et al. 2001).
Medical Research And Medical Treatment
For the philosophy of medicine, research on healthy people represents an excellent example of the ambiguity of the methods and aims, and it gives rise to the need for especially careful ethical reﬂection. This applies both to the research goals being pursued as well as to the possible consequences of the research – particularly in cases where the intended consequences are bound up with risk-laden side effects. Consideration of the different general goals of medical action compared with those of research activities sheds light on the kinds of problem that are associated with medical research on human beings: Medical action serves to diagnose and provide therapy (including preventive therapy) for an individual patient. It is directed toward healing or alleviating the inﬁrmity of the respective patient, is carried out within the framework of the physician-patient relationship, and is therefore strictly for individual beneﬁt. In contrast, research activity serves to discover regularities, ideally to shed light on determining factors and dependencies. The object under investigation is only of interest to the extent that it constitutes a possible instance of that purported regularity. All other factors must be ignored. From the point of view of a researcher, the patient is a test person. Such research might have a potential beneﬁt to an individual; in its essence, it is of use to third parties (Schauer et al. 2001, pp. 159–167).
Practical Judgment And The State Of The Art
Medical practice in the research and clinical contexts demands that special type of decision-making known as phronesis (prudence, practical judgment, or practical wisdom). It is the capacity to subsume knowledge about particular facts – that is derived from experience – into the generality of established rules combined with an assessment of a speciﬁc situation. Practical judgment is a special talent that cannot be taught but only practiced (Kant), and the practice affects the individual (Aristotle).
However, even where the validity of the abstract, general rules is acknowledged in the exercise of the power of judgment and the facts of the case are clear, there may still be debate as to whether the corresponding rule may be applied in the case in question or not. This question of application is particularly liable to provoke disagreement, because categorical, heterogeneous constructs come into contact with each other. The power of judgment includes determining the means (drugs, scalpel, etc.) that the physician employs in treating patients, as well as using them properly and in accordance with the goals that have been made out. For the means themselves are indifferent and ambivalent. They are open to misuse. Thus the power of judgment represents a capacity to apply rules. However, it cannot provide itself with any inevitable rule. For instance, computers can be utilized for diagnostic purposes in some cases and “apply” previously determined rules, but they do not possess any power of judgment. The practitioner acquires the capacity to use that power of judgment correctly with the help of experienced teachers and by being involved in exemplary cases, in other words through practice and experience. The aim of consolidating the power of judgment is not to be able to assess a possible course of action; it is the course of action itself.
The ability to reach practical judgments, resting upon a foundation of knowledge (knowing that) and skill (knowing how), manifests itself in medical action that is simultaneously situation independent and generally applicable as well as situation-dependent and individual. The generalization of the circumstances of a case does not represent any denigration of the individual patient; rather, it is a precondition for a course of action that can both be epistemologically substantiated and ethically justiﬁed. (Sadegh-Zadeh 2012, pp. 109–379; Wieland 1993).
In view of the many unexplained causes of disease, the requirement to take action that arises in medicine on account of the precept to heal renders the need to develop a broad range of methods and theories even more pressing than is the case in a theoretical science. The orientation toward a speciﬁc goal that characterizes medical intervention means – in deﬁance of any paradigms of scientiﬁc rationality – that therapies may be admitted without their having been exhaustively investigated.
Medical skill is not subject to criteria of veracity, but to ones oriented toward a telos. This means that there is a gap between theoretical, scientiﬁc knowledge and practical intervention in medicine (Toulmin 1976, p. 34). There is nevertheless a need to make clear the distinction between justiﬁable intervention and random quackery. For the practical consequences of an alternative method or theory being employed in medical practice have a great deal more potential for harm than is the case in a theoretical discipline. Given that a plurality of methods and theories is to be admitted (and this is already ensured by the wide diversity of individual disciplines such as psychology, human genetics, physiology), then it is inadmissible for the ﬁnal choice of theory to remain purely a matter of taste. The rules of the healing arts deﬁne the scope of medical intervention, and through their claim to be intersubjective valid, they exercise an inﬂuence on the members of the profession in accordance with the code of conduct that the activities of that profession have brought forth. The practitioner is bound by these standards, which at the same time legitimize doctor’s actions and foster the conﬁdence of a patient in need of treatment.
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