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)
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)
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)
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)
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)
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)
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 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)
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)
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.
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.
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)
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.
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)
This short comment on the Court of Protection decision in W v M draws attention to the primacy the judge gave to the preservation of life and discusses the relative lack of weight accorded to M's previously expressed views.
The case of W v M and Others, in which the court rejected an application to withdraw artificial nutrition and hydration from a woman in a minimally conscious state, raises a number of profoundly important medico-legal issues. This article questions whether the requirement to respect the autonomy of incompetent patients, under the Mental Capacity Act 2005, is being unjustifiably disregarded in order to prioritise the sanctity of life. When patients have made informal statements of wishes and views, which clearly—if not (...) precisely—apply to their present situation, judges should not feel free to usurp such expressions of autonomy unless there are compelling reasons for so doing. (shrink)
The famous Russian historian V. O. Kluchevsky had been constantly interested in literature. In this article, the author considers Kluchevsky’s observations on M. Yu. Lermontov’s creativity through the analyses of sadness motives in the article ‘Sadness‘ published in the journal ‘Russian Thought‘. Kluchevsky tried to understand how sadness motives were appeared in the Russian literature and how these motives influenced Lermontov’s self-reflection. Literary analyses is constructed on famous Lermontov’s lyrics, such as ‘Sail‘, ‘The golden cloud slept…‘, ‘Dream‘ and ‘July the (...) 11th of 1831‘. Analyzing the lyrics ‘I go out alone on the road…‘ the author of this article paying attention to ‘hidden sadness‘, which is expressed impressively in melodious Lermontov’s lyric without ‘arrangement for notes‘. Kluchevsky had expressed it on the 50th anniversary of Lermontov’s death. The position of the historian reflected in his comparison of sad Lermontov with meek and devout Russian tsar Alexey Mikhailovich. For this comparison, he was reproached by writer and literary critic N. M. Mikhailovsky, but Kluchevsky thoroughly considered sadness motives in poet’s creativity based on examples from the lyrics and disagreed literary critic’s reproaches. The origins of sadness motives studied in the historian’s article are in lesser degree connected with the biography of young Lermontov and rooted in the ‘moral history‘ of all Russian society. (shrink)
El presente trabajo tiene por finalidad analizar el componente estilístico y enunciativo del discurso filosófico de M. Heidegger. Para ello se vale de la interpretación de la función poética del lenguaje de V. Shklovski y R. Jakobson. La tesis que se intentará justificar radica en que el discurso heideggeriano de los años 1919 a 1927 apela a recursos estilísticos poéticos tales como los pleonasmos y las paradojas. Esta elección se justifica en el plano de la enunciación. En efecto, el estilo (...) tiene como propósito crear una nueva perspectiva sobre los fenómenos que permita destruir los automatismos del discurso filosófico académico. (shrink)