Patient no more: why did the golden age of medicine collapse?
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Biomedical subjects
Publications and source records attributed to K W Wildes.
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During the past decade there has been a debate about the field of philosophy of medicine. The debate has focused on fundamental questions about whether the field exists and the nature of the field. This article explores the debate and argues that it has paid insufficient attention to the social dimensions of both philosophy and medicine. The article goes on to argue that by exploring this debate one can better understand some of the difficult questions facing contemporary medicine and health care.
The changing world of health care finance has led to a paradigm shift in health care with health care being viewed more and more as a commodity. Many have argued that such a paradigm shift is incompatible with the very nature of medicine and health care. But such arguments raise more questions than they answer. There are important assumptions about basic concepts of health care and markets that frame such arguments.
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The role of an expert witness in ethics, as part of a legal proceeding, is examined in this essay. The essay argues that the use of such expertise rests on confusions about normative and non-normative ethics compounded by misunderstandings about the challenges of moral argument in secular, morally pluralistic societies.
In 1994, the National Conference of Catholic Bishops revised the "Ethical and Religious Directives for Catholic Health Care Services." A goal of the Directives is to maintain the moral integrity of Catholic health care institutions and to address controversies in bioethics and health care. The Directives represent a shift to an exclusively principle-based approach to moral reason. This shift threatens to undermine the very tradition that the bishops seek to protect.
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Several recent attempts to develop models of moral reasoning have attempted to use some form of casuistry as a way to resolve the moral controversies of clinical ethics. One of the best known models of casuistry is that of Jonsen and Toulmin who attempt to transpose a particular model of casuistry, that of Roman Catholic confessional practice, to contemporary moral disputes. This attempt is flawed in that it fails to understand both the history of the model it seeks to transpose and the morally pluralistic context of secular, postmodern society. The practice of casuistry which Jonsen and Toulmin wish to revive is a practice set in the context of a community with a shared set of moral values and structures of moral authority. Without a set of common moral values and rankings, and a moral authority to interpret cases the casuistry of the postmodern age will be pluralistic, that is, there will be many casuistries not just one.
Practices such as physician assisted suicide, even if legal, engender a range of moral conflicts to which many are oblivious. A recent proposal for physician assisted suicide provides an example by calling upon physicians opposed to suicide to refer patients to other, more sympathetic, physicians. However, the proposal does not address the moral concerns of those physicians for whom such referral would be morally objectionable.
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The advent of moral pluralism in the post-modern age leads to a set of issues about how pluralistic societies can function. The questions of biomedical ethics frequently highlight the larger issues of moral pluralism and social cooperation. Reflection on these issues has focused on the decision making roles of the health care professionals, the patient, and the patient's family. One species of actor that has been neglected has been those institutions which are part of the public, secular realm and which have a particular moral heritage.
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