Editors' introduction to 3rd thematic issue on philosophy of medicine.

Last year saw the 20th anniversary edition of JECP, and in the introduction to the philosophy section of that landmark edition, we posed the question: apart from ethics, what is the role of philosophy ‘at the bedside’? The purpose of this question was not to downplay the significance of ethics to clinical practice. Rather, we raised it as part of a broader argument to the effect that ethical questions – about what we should do in any given situation – are (...) embedded within whole understandings of the situation, inseparable from our beliefs about what is the case, what it is that we feel we can claim to know, as well as the meaning we ascribe to different aspects of the situation or to our perception of it. Philosophy concerns fundamental questions: it is a discipline requiring us to examine the underlying assumptions we bring with us to our thinking about practical problems. Traditional academic philosophers divide their discipline into distinct areas that typically include logic: questions about meaning, truth and validity; ontology: questions about the nature of reality, what exists; epistemology: concerning knowledge; and ethics: how we should live and practice, the nature of value. Any credible attempt to analyse clinical reasoning will require us to think carefully about these types of question and the relationships between them, as they influence our thinking about specific situations and problems. So, the answers to the question we posed, about the role of philosophy at the bedside, are numerous and diverse, and that diversity is illustrated in the contributions to this thematic edition. (shrink)

Something important is happening in applied, interdisciplinary research, particularly in the field of applied health research. The vast array of papers in this edition are evidence of a broad change in thinking across an impressive range of practice and academic areas. The problems of complexity, the rise of chronic conditions, over-diagnosis, co- and multimorbidity are serious and challenging, but we are rising to that challenge. Key conceptions regarding science, evidence, disease, clinical judgement, health and social care, are being revised and (...) their relationships reconsidered: boundaries are indeed being redrawn; reasoning is being made 'fit for practice'. Ideas like 'person-centred care' are no longer phrases with potential to be helpful in some yet-to-be-clarified way: theorists and practitioners are working in collaboration to give them substantive import and application. (shrink)

When the editorial to the first philosophy thematic edition of this journal was published in 2010, critical questioning of underlying assumptions, regarding such crucial issues as clinical decision making, practical reasoning, and the nature of evidence in health care, was still derided by some prominent contributors to the literature on medical practice. Things have changed dramatically. Far from being derided or dismissed as a distraction from practical concerns, the discussion of such fundamental questions, and their implications for matters of practical (...) import, is currently the preoccupation of some of the most influential and insightful contributors to the on‐going evidence‐based medicine debate. Discussions focus on practical wisdom, evidence, and value and the relationship between rationality and context. In the debate about clinical practice, we are going to have to be more explicit and rigorous in future in developing and defending our views about what is valuable in human life. (shrink)

There is now broad agreement that ideas like person-centred care, patient expertise and shared decision-making are no longer peripheral to health discourse, fine ideals or merely desirable additions to sound, scientific clinical practice. Rather, their incorporation into our thinking and planning of health and social care is essential if we are to respond adequately to the problems that confront us: they need to be seen not as “ethical add-ons” but core components of any genuinely integrated, realistic and conceptually sound account (...) of healthcare practice. This, the tenth philosophy thematic edition of the journal, presents papers conducting urgent research into the social context of scientific knowledge and the significance of viewing clinical knowledge not as something that “sits within the minds” of researchers and practitioners, but as a relational concept, the product of social interactions. It includes papers on the nature of reasoning and evidence, the on-going problems of how to 'integrate' different forms of scientific knowledge with broader, humanistic understandings of reasoning and judgement, patient and community perspectives. Discussions of the epistemological contribution of patient perspectives to the nature of care, and the crucial and still under-developed role of phenomenology in medical epistemology, are followed by a broad range of papers focusing on shared decision-making, analysing its proper meaning, its role in policy, methods for realising it and its limitations in real-world contexts. (shrink)

Power is an inescapable aspect of all socialrelationships, and inherently is neither goodnor evil. Doctors need power to fulfil theirprofessional obligations to multipleconstituencies including patients, thecommunity and themselves. Patients need powerto formulate their values, articulate andachieve health needs, and fulfil theirresponsibilities. However, both parties canuse or misuse power. The ethical effectivenessof a health system is maximised by empoweringdoctors and patients to develop `adult-adult'rather than `adult-child' relationships thatrespect and enable autonomy, accountability,fidelity and humanity. Even in adult-adultrelationships, conflicts and complexitiesarise. Lack of (...) concordance between doctors andpatients can encourage paternalism but may bebest resolved through negotiated care. Afurther area of conflict involves the `doubleagency' of doctors for both patients and thecommunity. Empowerment of all players is notalways possible but is most likely where eachparty considers and acknowledges power issues. (shrink)

Person-centered care offers a promising way to manage clinicians’ conscientious objection to providing services they consider morally wrong. Health care centered on persons, rather than patients, recognizes clinicians and patients on the same stratum. The moral interests of clinicians, as persons, thus warrant as much consideration as those of other persons, including patients. Interconnected moral interests of clinicians, patients, and society construct the clinician as a socially embedded and integrated self, transcending the simplistic duality of private conscience versus public role (...) expectations. In this milieu of blurred boundaries, person-centered care offers a constructive way to accommodate conscientious objection by clinicians. The constitutionally social nature of clinicians commits and enables them, through care mechanisms such as self-care, to optimize the quality of health care and protect the welfare of patients. To advance these conditions, it is recommended that the medical profession develop a person-centered culture of care, along with clinician virtues and skills for person-centered communication. (shrink)

Modern technologies sanction a new plasticity of physical form. However, the increasing global popularity of aesthetic procedures produces normative beauty ideals in terms of perfection and symmetry. These conditions limit the semblance of freedom by people to control their own bodies. Cultural emancipation may come from principles in Eastern philosophy. These reveal beauty in authenticity, including imperfection. Wabi-sabi acclaims beauty in common irregularity, while kintsugi celebrates beauty in visible signs of repair, like scars. These principles resist pressure to medicalize dissatisfaction (...) with healthy bodies and invite multi-sited interventions to educate taste and aesthetic choices. (shrink)

Despite its potential hazards, the activity of questioning theoretical frameworks and and proposing solutions is necessary if progress is even to be possible. Intellectual history has by no means ended so we cannot expect to have all the answers, and from time to time the activity of critical questioning will be frustrating. But intellectual progress requires us to continue the process of asking fundamental questions. The alternative to thinking in this way is indeed unthinkable.

Cooperation and conversation in the public sphere may overcome historical and other barriers to rational argumentation. As an alternative to evidence-based medicine (EBM) and patient-centered care (PCC), the recent development of a modern version of person-centered medicine (PCM) signals an opportunity for a conversational pluralogue to replace parallel monologues between EBM and its critics, and the calls to EBM to debate its critics. This article draws upon elements of Habermas’s theory of communicative action in order to suggest the kind of (...) pluralogue that is required for stakeholders in modern medicine to benefit more from publicly conversing with each other than speaking alone or using debate to argue against each other. This reasoned perspective has lessons for all discourse when deep value-based and epistemological differences cannot be easily adjudicated. (shrink)

Progress is being made in transitioning from clinicians who are torn between caring for patients and populations, to clinicians who are partnering with patients to care for patients as people. However, the focus is still on what patients and others can do for patients, however defined. For clinicians whose interests must be similarly respected for their own sake and because they are integrally related to those of patients, what can and should patients do? Patients can be exempted from some normal (...) social roles but are generally recognized to have moral obligations in health care. One of these obligations is caregiving to clinicians within the limits of each patient's capability. My paper moves this obligation beyond the ceremonial order of etiquette characterizing public statements on how patients should relate to others. It goes beyond a patient‐centred ethic that is consumerist in nature, to a person‐centred one that recognizes patients typically as moral agents who are dignified by recognizing the obligation to give as well as receive care as sincere benevolence. This obligation derives objective justification from divine command. It is also consistent, however, both with what people, if ignorant of their social role, would objectively produce for a hypothetical social contract, and with virtues constitutive of human nature and a relational and communitarian understanding of what it is to be a person. Including sentiment (intuition) and personal conscience, this relational identity makes caregiving intrinsically meaningful, yet caregiving also has an instrumental value to patients and clinicians. Its self‐enforcement by patients will depend on their moral code and on society making caregiving achievable for them. A moral obligation for patient caregiving may then be specified to require patients to reflect on and invest in relationships in which they can feel and show care for others sincerely and respectfully. (shrink)

The expressions ‘high quality care’ and ‘low quality care’ are cognitive and linguistic artefacts that help to structure people’s lives and thinking; for example, moves are now afoot internationally to pay bonuses to health professionals for delivering high quality care. United States programmes, most conspicuously, are assuming that high quality care can be validly distinguished from low quality care, and incentivised through bonuses. This distinction is always at least implicit, for high quality care has no meaning without low quality care. (...) Through a ‘deconstructionist reading,’ this article discusses limitations of categorising the quality of care as either high or low. The limitations of this ‘binary opposition’ can include a lack of defining attributes; vagueness and fuzziness at the ‘boundaries’ between high quality care and low quality care; concealment of quality as a continuum; and use of the binary opposition to effect social order and control. Health policy implications of our analysis are discussed. Drawing upon the general medical services contract in the United Kingdom, we suggest an approach to overcoming the oversimplification and imprecision that categorisation tends to produce. (shrink)

Body image research focuses almost exclusively on women or overweight and obesity or both. Yet, body image concerns among thin men are common and can result, at least in part, from mixed messages in society around how men qua men should dress and behave in order to look good and feel good. Stand-alone interventions to meet these different messages tend to provide men with little therapeutic relief. This conceptual paper draws on literature from the medical humanities; gender and body image (...) studies; the social psychology of clothing; and the author’s own lived experience to address this contemporary problem. The paper embraces visual culture as a resource that can frame discussion of how two sets of ‘performativity’ might reduce male anxiety about thinness. First, thin men could choose repeatedly to wear masculine-looking clothing, which could create their masculinity as a personal aesthetic that strengthens the confidence to harness masculine traits in healthy ways. Secondly, health and allied health service providers could promote and reinforce such dress behavior by offering advice that integrates aesthetic and functional aspects of clothing. Empirical studies are needed to test this dual model of performativity. (shrink)

New Zealand and United Kingdom governments have set new directives for increased consultation with the public about health care. Set against a legacy of modest success with past engagement with public consultations, this paper considers potentially adverse ethical implications of the new directives. Drawing on experiences from New Zealand and the United Kingdom, and on an Orthodox Jewish perspective, the paper seeks to answer two questions: What conditions can compromise the ethics of public consultation? How can the public respond ethically (...) to consultation? In answering these questions, the paper considers how Orthodox Judaism, as a specific positive morality, can aid the development of public policy. It is suggested that an Orthodox Jewish perspective does not require limiting the content of public consultations and helps to define a common procedural morality binding Jews and non-Jews. This procedural morality requires avoiding two conditions that, as shown from Jewish texts, make public consultation unethical. These are overpreparation and underpreparation. Members of the public who deem a consultation unethical should give feedback not on the proposal but on the conditions they perceive to prevent the consulting party from considering their viewpoints on the proposal. (shrink)