The legalization of euthanasia, both in the Netherlands and in other countries is usually justified in reference to the right to autonomy of patients. Utilizing recent Dutch jurisprudence, this article intends to show that the judicial proceedings on euthanasia in the Netherlands have not so much enhanced the autonomy of patients, as the autonomy of the medical profession. Keywords: allowing to die, criminal law, euthanasia, law enforcement, legal aspects, legislation, medical ethics, medical profession, self determination, the Netherlands, voluntary euthanasia, withholding (...) treatment CiteULike Connotea Del.icio.us What's this? (shrink)

This paper seeks to define and delimit the scope of the social responsibilities of health professionals in reference to the concept of a social contract. While drawing on both historical data and current empirical information, this paper will primarily proceed analytically and examine the theoretical feasibility of deriving social responsibilities from the phenomenon of professionalism via the concept of a social contract.

Increasingly, contemporary medical ethicists have become aware of the need to explicate a foundation for their various models of applied ethics. Many of these theories are inspired by the apparent incompatibility of patient autonomy and provider beneficence. The principle of patient autonomy derives its current primacy to a large extent from its legal origins. However, this principle seems at odds with the clinical reality. In the bioethical literature, the notion of authenticity has been proposed as an alternative foundational principle to (...) autonomy. This article examines this proposal in reference to various existentialist philosophers (Heidegger, Sartre, Camus and Marcel). It is concluded that the principle of autonomy fails to do what it is commonly supposed to do: provide a criterion of distinction that can be invoked to settle moral controversies between patients and providers. The existentialist concept of authenticity is more promising in at least one crucial respect: It acknowledges that the essence of human life disappears from sight if life's temporal character is reduced to a series of present decisions and actions. This also implies that the very quest for a criterion that allows physicians to distinguish between sudden, unexpected decisions of their patients to be or not to be respected, without recourse to the patient's past or future, is erroneous. (shrink)

In the literature three mechanisms are commonly distinguished to make decisions about the care of incompetent patients: A living will, a substituted judgment by a surrogate (who may or may not hold the power of attorney ), and a best interest judgment. Almost universally, the third mechanism is deemed the worst possible of the three, to be invoked only when the former two are unavailable. In this article, I argue in favor of best interest judgments. The evermore common aversion of (...) best interest judgments entails a risk that health care providers withdraw from the decision-making process, abandoning patients (or their family members) to these most difficult of decisions about life and death. My approach in this article is primarily negative, that is, I criticize the alleged superiority of the living will and substituted judgment. The latter two mechanisms gain their alleged superiority because they are supposedly morally neutral, whereas the best interest judgment entails a value judgment on behalf of the patient. I argue that on closer inspection living wills and substituted judgments are not morally neutral; indeed, they generally rely on best interest judgments, even if those are not made explicit. (shrink)

This article examines whether cosmetic interventions by dentists and plastic surgeons are medically indicated and, hence, qualify as medical interventions proper. Cosmetic interventions (and the business strategies used to market them) are often frowned upon by dentists and physicians. However, if those interventions do not qualify as medical interventions proper, they should not be evaluated using medical-ethical norms. On the other hand, if they are to be considered medical practice proper, the medical-ethical principles of nonmaleficence, beneficence, justice and others hold (...) true for cosmetic interventions as much as they do for other medical and dental interventions. It is concluded that most cosmetic interventions do not qualify as medical interventions proper because they do not restore or maintain the patient's health (defined as the patient's integrity) by any objective standards. Rather, cosmetic interventions are intended to enhance a person's physical appearance; more specifically, they intend to fulfill the client's subjective perception of an enhanced appearance. (shrink)

BackgroundOver the past decade, the exponential growth of the literature devoted to personalized medicine has been paralleled by an ever louder chorus of epistemic and ethical criticisms. Their differences notwithstanding, both advocates and critics share an outdated philosophical understanding of the concept of personhood and hence tend to assume too simplistic an understanding of personalization in health care.MethodsIn this article, we question this philosophical understanding of personhood and personalization, as these concepts shape the field of personalized medicine. We establish a (...) dialogue with phenomenology and hermeneutics (especially with E. Husserl, M. Merleau-Ponty and P. Ricoeur) in order to achieve a more sophisticated understanding of the meaning of these concepts We particularly focus on the relationship between personal subjectivity and objective data.ResultsWe first explore the gap between the ideal of personalized healthcare and the reality of today’s personalized medicine. We show that the nearly exclusive focus of personalized medicine on the objective part of personhood leads to a flawed ethical debate that needs to be reframed. Second, we seek to contribute to this reframing by drawing on the phenomenological-hermeneutical movement in philosophy. Third, we show that these admittedly theoretical analyses open up new conceptual possibilities to tackle the very practical ethical challenges that personalized medicine faces.ConclusionFinally, we propose a reversal: if personalization is a continuous process by which the person reappropriates all manner of objective data, giving them meaning and thereby shaping his or her own way of being human, then personalized medicine, rather than being personalized itself, can facilitate personalization of those it serves through the data it provides. (shrink)

This article provides a summary overview of the ideas on medical anthropology and anthropological medicine of the German philosopher-psychiatrist Viktor Emil von Gebsattel (1883–1974), and discusses in more detail his views on the doctor-patient relationship. It is argued that Von Gebsattel''s warning against a dehumanization of medicine when the person of both patient and physician are not explicitly present in their relationship remains valid notwithstanding the modern emphasis on respect for patient (and provider) autonomy.

In this article, I argue that the relationship between patients and their health care providers need not be construed as a contract between moral strangers. Contrary to the (American) legal presumption that health care providers are not obligated to assist others in need unless the latter are already contracted patients of record, I submit that the presence of a suffering human being constitutes an immediate moral commandment to try to relieve such suffering. This thesis is developed in reference to the (...) French philosopher Levinas and the Dutch theologian Schillebeeckx. An expanded version of the biblical parable of the Good Samaritan serves as test case. (shrink)

In the face of managed care and market economies infringing on the practice of medicine, reducing its autonomy and determining the moral guidelines for medical practice, many physicians are calling out for a return to what is perceived as a traditional medical ethic. Many religiously motivated critics of certain modern developments in medicine have made similar appeals. These calls are best understood as an attempt to define medicine as a practice that is necessarily ethical in nature, a practice the moral (...) basis of which is internal to that practice. This article examines and assesses this definition of medicine in reference to Aristotle's division of human undertakings into three distinct categories: theory, poieisis (i.e., production), and praxis. It is concluded that medicine can be understood as a praxis (as opposed to a theory or production, both of which are morally neutral), because the practice of medicine, and all of its constitutive acts, can only be explained and assessed in reference to health, which is itself a final good and hence of moral value. Such an understanding would immunize medicine against usurpation by the free market. However, by the same token it would also dissociate medicine from all other moralities external to it, including those grounded in faith and religion. (shrink)

There are at present 28 Jesuit colleges and universities in the United States, which together offer more than 50 health sciences degree programs. But as the Society's membership is shrinking and the financial risks involved in sponsoring health sciences education are rising, the question arises whether the Society should continue to sponsor health sciences degree programs. In fact, at least eight Jesuit health sciences schools have already closed their doors. This paper attempts to contribute to the resolution of this urgent (...) question by reexamining Ignatius' own views on health sciences education and, more specifically, his prohibition of the Society's sponsoring medical education. It concludes on the basis of an historical analysis of Ignatius' views that there is insufficient support for today's ,Jesuits to maintain their engagement in medical and health care education. (shrink)

Este documento busca revisar el estado actual del pensamiento católico sobre el respeto al agenciamiento del paciente, a la autonomía y al consentimiento. Sin embargo, no se pretende llegar a una revisión definitiva. De hecho, encontraremos un amplio apoyo de estos conceptos dentro de la bioética católica, a pesar de que persiste un importante disenso sobre aspectos específicos. En primer lugar, el artículo ofrece una descripción resumida de algunas diferencias importantes entre el entendimiento prevaleciente de la autonomía del paciente en (...) la bioética secular y en la bioética católica. En la primera, se suele entender que el respeto a la autonomía del paciente considera las necesidades y deseos subjetivos de éste, incluso cuando, o tal vez precisamente, porque quedan fuera del ámbito de comprensión del profesional de la salud. En la segunda, este respeto se fundamenta en la dignidad delpaciente individual, que abarca los deseos y necesidades subjetivas del paciente, pero que es esencialmente un concepto objetivo y, por lo tanto, intersubjetivamente accesible. Para explicar con más detalle cómo puede respetarse el agenciamiento del paciente dentro de ese marco de referencia objetivo, en el documento se examinan diferentes tipos de agenciamiento del paciente dentro de la relación terapéutica. Para que la atención de la salud sea clínicamente óptima y éticamente sólida –como exigen los principios éticos de beneficencia y no maleficencia–, el paciente debe participar activamente en: 1) la evaluación y el diagnóstico; 2) la planificación del tratamiento, y 3) la terapia propiamente dicha. Además –como exige el principio ético del respeto a la autonomía–el proveedor de atención sanitaria debe: 4) proteger la confidencialidad del paciente; 5) proporcionarle información adecuada, y 6) obtener el consentimiento del paciente para cualquier intervención. A continuación, se examinan diferentes tipos de consentimiento. En una sección final, se revisará la cuestión de si es moralmente permisible que los proveedores de atención de la salud obliguen a los pacientes a rechazar los tratamientos que se consideren inmorales. (shrink)

This article starts with a brief historical account of the ongoing debate about the status of clinical ethics: theory of practice. The author goes on to argue that clinical ethics is best understood as a practice. However, its practicality should not be measured by the extent to which clinical-ethical consultants manage to mediate or negotiate resolutions to ethical conflicts. Rather, clinical ethics is practical because it is characterized by a profound concern for the well-being of individual patients as well as (...) the moral parameters of swift and urgent medical action in the face of limited supportive information. (shrink)

On one side of his sign board, a nineteenth century surgeon depicted a physician operating on a patient's leg; the other side showed the Good Samaritan taking care of the victim's wounds. Christ's parable has often been quoted and depicted as a primary example of human compassion, to be followed by all persons and, a fortiori, by so-called professionals such as physicians and nurses. If we grant that the parable has not lost its narrative power for 20th century “postmodern” readers (...) living in a “pluralistic” society, it merits a closer analysis. (shrink)

In the literature three mechanisms are commonly distinguished to make decisions about the care of incompetent patients: A living will, a substituted judgment by a surrogate, and a best interest judgment. Almost universally, the third mechanism is deemed the worst possible of the three, to be invoked only when the former two are unavailable. In this article, I argue in favor of best interest judgments. The evermore common aversion of best interest judgments entails a risk that health care providers withdraw (...) from the decision-making process, abandoning patients to these most difficult of decisions about life and death. My approach in this article is primarily negative, that is, I criticize the alleged superiority of the living will and substituted judgment. The latter two mechanisms gain their alleged superiority because they are supposedly morally neutral, whereas the best interest judgment entails a value judgment on behalf of the patient. I argue that on closer inspection living wills and substituted judgments are not morally neutral; indeed, they generally rely on best interest judgments, even if those are not made explicit. (shrink)

The Patient Self-Determination Act is a fact. Finally, respect for patient autonomy has been guaranteed. At first sight, there seems little reason to object to any measure that intends to increase the autonomy of the patient. Too long, one may argue, physicians have behaved paternalistically; too often, they have been advised to change this habit. If the profession of medicine is unwilling or simply unable to grant the patient the decision-making power that is her due, the law has to step (...) in. One may add, this law in no way hinders professional autonomy; by requiring a hospital official to provide the patient with information about advance directive, the law actually reduces the work load of the physician, who is already overburdened. (shrink)

In order to protect patients against medical paternalism, patients have been granted the right to respect of their autonomy. This right is operationalized first and foremost through the phenomenon of informed consent. If the patient withholds consent, medical treatment, including life-saving treatment, may not be provided. However, there is one proviso: The patient must be competent to realize his autonomy and reach a decision about his own care that reflects that autonomy. Since one of the most important patient rights hinges (...) on the patient's competence, it is crucially important that patient decision making incompetence is clearly defined and can be diagnosed with the greatest possible degree of sensitivity and, even more important, specificity. Unfortunately, the reality is quite different. There is little consensus in the scientific literature and even less among clinicians and in the law as to what competence exactly means, let alone how it can be diagnosed reliably. And yet, patients are deemed incompetent on a daily basis, losing the right to respect of their autonomy. In this article, we set out to fill that hiatus by beginning at the very beginning, the literal meaning of the term competence. We suggest a generic definition of competence and derive four necessary conditions of competence. We then transpose this definition to the health care context and discuss patient decision making competence. (shrink)

This is the first book in healthcare ethics addressing the moral issues regarding ownership of the human body. Modern medicine increasingly transforms the body and makes use of body parts for diagnostic, therapeutic and preventive purposes. The book analyzes the concept of body ownership. It also reviews the ownership issues arising in clinical care (for example, donation policies, autopsy) and biomedical research. Societies and legal systems also have to deal with issues of body ownership. A comparison is made between specific (...) legal arrangements in The Netherlands and France, as examples of legal approaches. In the final section of the book, different theoretical perspectives on the human body are analyzed: libertarian, personalist, deontological and utilitarian theories of body ownership. (shrink)

In reference to historical developments, this article introduces the topic of this special issue of Theoretical Medicine and Bioethics, that is, the relationship(s) between theory and practice. The authors emphasize the need for scientific research in this neglected area for the sake of both clinical practice and medical education.

This book is for those searching for an ethics engine with enough philosophical power to drive healthcare reform toward a balance between medical technology and human compassion. Jos Welie's project is to This is an important goal that has eluded others. Jos Welie has more nearly succeeded in this book than any other author who has come to my attention.

The principle of autonomy presupposes Patient Decision Making Competence (PDMC). For a few decades a considerable amount of empirical research has been done into PDMC. In this contribution that research is explored. After a short exposition on four qualities involved in PDMC, different approaches to assess PDMC are distinguished, namely a negative and a positive one. In the negative approach the focus is on identifying psychopathologic conditions that impair sound decision making; the positive one attempts to assess whether a patient (...) actually has the required abilities and qualities. Characteristic of the latter approach is the use of (or development of) test-like instruments for PDMC assessment. Some of these tests are discussed and commented on. Although they may be useful in investigating aspects of PDMC, none of the described approaches and tests offers a reliable and valid method for PDMC assessment. In response to a potential misuse of tests, the concept of a supportive situation is briefly introduced in order to draw attention to the risk of prematurely deeming patients incompetent on the basis of low test scores, whereas their insufficient performance may be (partly) attributable to alack of situational support. Also, the need for and possibility of an emotionalist concept of PDMC are suggested, as an alternative to the more common rationalist one. In this regard,the legitimacy of competence being conceived as a presumption or fiction of law, deserves further investigation. (shrink)

Roughly speaking, classical statistical physics is the branch of theoretical physics that aims to account for the thermal behaviour of macroscopic bodies in terms of a classical mechanical model of their microscopic constituents, with the help of probabilistic assumptions. In the last century and a half, a fair number of approaches have been developed to meet this aim. This study of their foundations assesses their coherence and analyzes the motivations for their basic assumptions, and the interpretations of their central concepts. (...) The most outstanding foundational problems are the explanation of time-asymmetry in thermal behaviour, the relative autonomy of thermal phenomena from their microscopic underpinning, and the meaning of probability. A more or less historic survey is given of the work of Maxwell, Boltzmann and Gibbs in statistical physics, and the problems and objections to which their work gave rise. Next, we review some modern approaches to (i) equilibrium statistical mechanics, such as ergodic theory and the theory of the thermodynamic limit; and to (ii) non-equilibrium statistical mechanics as provided by Lanford's work on the Boltzmann equation, the so-called Bogolyubov-Born-Green-Kirkwood-Yvon approach, and stochastic approaches such as `coarse-graining' and the `open systems' approach. In all cases, we focus on the subtle interplay between probabilistic assumptions, dynamical assumptions, initial conditions and other ingredients used in these approaches. (shrink)

Psychiatric diagnoses such as Autism Spectrum Disorder (ASD) are primarily attributed on the basis of behavioral criteria. The aim of most of the biomedical research on ASD is to uncover the underlying mechanisms that lead to or even cause pathological behavior. However, in the philosophical and sociological literature, it has been suggested that autism is also to some extent a ‘social construct’ that cannot merely be reduced to its biological explanation. We show that a one-sided adherence to either a biological (...) or a social explanation leads to a moral dilemma, a Catch-22, for autistics and for those living with them. Such explanations close the space for self-identifying as autistic and at the same time being considered to be in good mental health. They foreclose the possibility of making sense of the lived experience of (and with) autistics. In this paper we argue that such lack of space for moral imagination inherently leads to scientific stalemate. We propose that one can only go beyond this stalemate by taking an ethical stance in theorizing, one that enables better intersubjective understanding. Only on such a view can behavior and biology be linked without either disconnecting them or reducing the one to the other. (shrink)