This book is a collection of essays by a variety of specialists with a particular interest in palliative care. It contains seven chapters by six different authors. The first chapter Why is the study of ethics important? is by Patricia Webb, a lecturer in palliative care with a background in nursing. She tells us that studying ethics encourages logical reasoned thinking in the face of difficult decisions such as allocation of resources, access to services, best care, clinical research, and rights (...) to life. Webb reminds us that clinical guidelines may not be much help in the face of an ethical dilemma with no clear right or wrong answer. The chapter called Care versus cure by David Jeffrey, a consultant in palliative medicine and writer on medical ethics, reminds us that care is concerned as much with the subjective feelings of the patient as with the physical disease, and aims …. (shrink)

The concept of normal is so familiar that it can be hard to imagine contemporary life without it. Yet the term entered everyday speech only in the mid-twentieth century. Before that, it was solely a scientific term used primarily in medicine to refer to a general state of health and the orderly function of organs. But beginning in the middle of the twentieth century, normal broke out of scientific usage, becoming less precise and coming to mean a balanced condition to (...) be maintained and an ideal to be achieved. In Normality, Peter Cryle and Elizabeth Stephens offer an intellectual and cultural history of what it means to be normal. They explore the history of how communities settle on any one definition of the norm, along the way analyzing a fascinating series of case studies in fields as remote as anatomy, statistics, criminal anthropology, sociology, and eugenics. Cryle and Stephens argue that since the idea of normality is so central to contemporary disability, gender, race, and sexuality studies, scholars in these fields must first have a better understanding of the context for normality. This pioneering book moves beyond binaries to explore for the first time what it does—and doesn’t—mean to be normal. (shrink)

It is a paradox that medical experimentation on individuals, whether patients or healthy volunteers, is now controlled by strict ethical guidelines, while no such protection exists for whole populations which are subjected to medical interventions in the name of preventive medicine or health promotion. As many such interventions are either of dubious benefit or of uncertain harm-benefit balance, such as mass screening for cancers or for risk factors associated with coronary heart disease, there is no justification for maintaining the ethical (...) vacuum in which preventive medicine finds itself at present. (shrink)

Most moral dilemmas in medicine are analysed using the four principles with some consideration of consequentialism but these frameworks have limitations. It is not always clear how to judge which consequences are best. When principles conflict it is not always easy to decide which should dominate. They also do not take account of the importance of the emotional element of human experience. Virtue ethics is a framework that focuses on the character of the moral agent rather than the rightness of (...) an action. In considering the relationships, emotional sensitivities, and motivations that are unique to human society it provides a fuller ethical analysis and encourages more flexible and creative solutions than principlism or consequentialism alone. Two different moral dilemmas are analysed using virtue ethics in order to illustrate how it can enhance our approach to ethics in medicine. (shrink)

This book examines the relationship between law and scientific advancement, with a particular focus on the theory of evolution and medical innovation. Historically, the law has struggled to keep pace with modern medical advances. The authors demonstrate that the laws that govern human behaviour must evolve in response to such advances."--Provided by publisher.

In this article we focus upon the embodiment of vulnerability as an area in which medicine, society and the humanities can be profitably conjoined. We illustrate our argument with two interrelated case studies of narratives of the embodiment of ageing and longevity. First, we draw upon Leoš Janáček’s opera The Makropulos Case (1926) as a locus for debates about human longevity. Second, we discuss 70-year-old Janáček’s decade of unrequited love for a woman 37 years younger than himself, through an examination (...) of their intimate letters. We suggest that both the opera and elements of Janáček’s biography illuminate the passionate emotions that are often hidden behind ‘the mask of ageing’. Finally, we propose that a focus on the embodiment of vulnerability is a productive catalyst for research on narratives of ageing. (shrink)

The conflict in Gaza and Israel that ignited on October 7, 2023 signals a catastrophic breakdown in the possibility of ethical dialogue in the region. The actions on both sides have revealed a dissolution of ethical restraints, with unimaginably cruel attacks on civilians, murder of children, destruction of health facilities, and denial of basic needs such as water, food, and shelter. There is a need both to understand the nature of the ethical singularity represented by this conflict and what, if (...) any, options are available to allow the reconstruction of communication between the warring parties. This article seeks to address these tasks by analysing the conflict as inherently an ethical one, in the sense that it exposes a rupture in the fabric of communicative relationships that has evolved systematically out of the deep cultural structures from which all protagonists have emerged. Drawing on the work of Levinas, Habermas, Arendt, and others, and referring to the specific circumstances in the region, it examines the ethical sources of the crisis and tries to identify conditions for its resolution. The possibility of reconciliation—that is, of refiguring relationships to open up a space for dialogue to create pathways to heal the ruptures—is examined. The dark legacy of the Holocaust is identified as an abiding cultural vulnerability for both societies. It is concluded, however, that the rich history of partnerships and collaborations between Jews and Palestinians provides a robust infrastructure on the basis of which a sustainable peace might be built, providing a much-needed source of hope. (shrink)

An instrument to assess 'ethical sensitivity' has been developed. The instrument presents four clinical vignettes and the respondent is asked to list the ethical issues related to each vignette. The responses are classified, post hoc, into the domains of autonomy, beneficence and justice. This instrument was used in 1990 to assess the ethical sensitivity of students in all four medical classes at the University of Toronto. Ethical sensitivity, as measured by this instrument, is not related to age or grade-point average. (...) Sensitivity increases between the 1st and 2nd year and then decreases throughout the rest of undergraduate medical training, such that the 4th-year students identify fewer issues than those entering medical school. Students expressing a career choice of family medicine identify more issues than their peers. Several problems with the use of the instrument and the interpretation of the data were found. Nonetheless, these findings, if reproducible, are important and their meaning needs further discussion. (shrink)

Two crucial topics in the philosophy of medicine are the philosophy of nature and philosophical anthropology. In this essay I engage the philosophy of nature by exploring Anne Fagot-Largeault's study of norms in nature as a way of articulating a Confucian philosophy of medicine. I defend the Confucian position as a moderate naturalism.

This paper canvasses recent arguments in favor of commercial markets in human transplant kidneys, raising objections to those arguments on grounds of the role of injustice, exploitation, and coercion in compromising the autonomy of those most likely to sell a kidney, namely, the least well off members of society.

Many enhancement technologies are distributed by healthcare professionals—by physicians—who are held to the Hippocratic Oath and the goals of medicine. While the ethics of enhancement has been widely discussed with regard to the social justice, humanism, morals and normative values of these interventions, their place in medicine has not attracted a great deal of attention. This paper investigates the potential for enhancement technologies to fulfil the goals of medicine, arguing that they play a role in promoting the health of individuals, (...) and thus, an unavoidable place in medicine. It also warns of potential dangers, suggesting a set of guidelines to initiate conversations regarding the role and responsibilities of physicians practising in an era of enhancement. (shrink)

This anthology of essays presents a sample of studies from recent philosophy of medicine addressing issues which attempt to answer very general (interdependent) questions: (a) what is a disease and what is health? (b) How do we (causally) explain diseases? (c) And how do we distinguish diseases, i.e. define classes of diseases and recognize that an instance X of disease belongs to a given class B? (d) How do we assess and choose cure/ therapy?

This paper briefly reviews highlights from decades of debates in medicine, law, bioethics, psychology and social research about children’s and parents’ views and consent to medical treatment and research. There appears to have been a rise and later a fall in respect for children’s views, illustrated among many examples by a recent book on the zone of parental discretion, which is reviewed. A return to greater respect for children’s views and consent is advocated.

Although the University of Leeds has attained something of a reputation for the quality of its scholarship in the history of science, few historians are aware of the impressive collection of early scientific and medical books and manuscripts to be found in the University libraries. In order to make the library resources more widely known, we embarked on a systematic survey of the contents of the main historical collections. We wanted not only to give a general impression of the particular (...) strengths and distinctive features of each collection, but also to mention the interesting or rare copies of individual works to be found in them. We have, therefore, examined every book related to the history of science and medicine in the relevant collections, and in doing so we have uncovered a number of important items. For example, we have identified a book which was once in Newton's library, and a previously unrecorded copy of Joseph Black's chemical lectures. More generally, we had not suspected the true size and range of the Chaston Chapman Collection, which makes it a valuable resource for the history of alchemy and early chemistry; nor were we initially aware of the strength of the Historical Collection of the Medical and Dental Library. The wealth of the legacies to the Brotherton and Special Collections also impressed us. (shrink)

Autopathographies are an expanding genre of books and articles that are a potential resource for students interested in the medical humanities. New curricula emphasise the need to familiarise medical students with the patient’s point of view. Different specialities compete for the student’s attention and the medical humanities are not an exception. Some form of assessment is necessary to reflect the importance of the patient’s perspective. One way may be to request students analyse their chosen autopathography. The article presents an example (...) based on one of the better know accounts. The identified themes reflect the sudden disruption in the author’s biography. The topics are connected to the medical disorder and illustrated by quotations. The different categories of autopathography can be helpful in understanding the author’s perspective. In this instance the author was a full time editor before his stroke. The style of the book employs professional distance from the narrative. This is more compatible with the description of metapathography rather than the original classification of autopathogrphies as religious, angry or alternative. (shrink)

The clinical decision is supposed to be based on evidence. In fact, what counts as evidence is far from being established. Some definition of "proof" is needed to distinguish between scientific medicine and charlatanism. My thesis is that unfortunately a clear-cut boundary between evidence and lack of evidence cannot be found, for several reasons that I summarise in the paper. Evidence in medicine very often has fuzzy boundaries, and dichotomising fuzziness and uncertainty can have serious consequences. Physicians and patients should (...) accept the irreducible fuzziness of many of the concepts they use when dealing with health and disease. (shrink)

Galen's æuvre presents a remarkably varied body of texts–varied in subject matter, style, and didactic purpose. Logical tracts sit alongside tomes of drug–lore; handbooks of dietetics alongside anatomical investigations; treatises of physiology alongside ethical opuscula. These differences in type have received some, though as yet insufficient, scholarly attention. Mario Vegetti demonstrated the coexistence of two ‘profili’ or images of the art of medicine: Galen presents the art as an Aristotelian deductive science, on the one hand, and as a technician's craft, (...) on the other. The former image, offering an ambitious elevation of the doctor's cultural status, has medicine as a philosophical episteme analogous to the mathematical sciences, exercised above all to provide causal accounts and logical demonstrations, and centred on the knowledge of anatomy. The second image is that of the clinician, concerned with the body in its pathological manifestations and using as its prime model the ‘pre-anatomical’ theory of the humours. And the content of the treatises shifts in relation to this dual image: ‘profilo alto’ and ‘profilo basso’ are reflected in different types of work. Polemical writings such as the Protrepticus, as well as the great treatises of anatomy and physiology, De usu partium and De naturalibus facultatibus, present medicine in the former light, while works like De temperamentis or Quod animi mores base themselves on humoral pathology and accord with the earlier, artisan-like image. (shrink)

The difficulties of undertaking good quality effectiveness research in palliative medicine are well documented. Much of the ethical literature in this area focuses on the vulnerability of the palliative care population. It is clear that a wider ethical approach will need to be used to justify research in the terminally ill. Some themes of ethical thought are underutilised in considering the ethics of palliative care research. Three arguments to justify the need for effectiveness research in palliative care should be highlighted: (...) there is evidence of an untapped altruism amongst the population of palliative care patients who would be keen to be involved in such research; traditional Aristotelean and Thomistic virtue ethics would point to the need to gain knowledge in and of itself, but especially in palliative medicine for the benefit of patients: virtue also accrues in the acquisition of a stock of research experience which in turn makes further research feasible; most compellingly, justice would dictate that palliative treatments are effective, that futile or useless treatments are avoided and that patients are not party to “n of 1” trials by default. The current state of the evidence base of effectiveness in palliative care leads us to the uncomfortable position where patients are in precisely the position of being unwitting participants in “n of 1” clinical trials by default, without their explicit consent. (shrink)

Dr Kottow in his paper Classical medicine v alternative medical practices (1) places the alternative/orthodox medicine debate within an historical context of anti-quackery literature. My paper explores the nature of science as it is applied to clinical practice and challenges the narrow view of the diagnostic process as outlined by Dr Kottow. Research methodologies more appropriate to 'whole person' medicine are suggested as having more ethical value than those based on the clinical trial.

In Britain doctors and others concerned with the treatment of offenders in prison may consult the Butler Report (see Focus, pp 157) and specialist journals, but these sources are concerned with the system in Britain only. In America the situation is different, both in organization and in certain attitudes. Dr Peter L Sissons has therefore provided a companion article to that of Dr Paul Bowden (page 163) describing the various medical issues in prisons. The main difference between the treatment of (...) offenders in prisons in America and in Britain lies in the nature of the federal system which means that each state may operate a different system in a variety of prisons and prison medical services are as various. Nationally, the prison systems are 'structured to treat and cure the offender'. Therefore it follows that the prison medical officer is only one of the professionals concerned with this 'cure' of the offender. This principle also applies to any form of research: medical research in prisons is part of a programme which covers a wide field of social and judicial research. The prison medical officer (where there is one) has of course to look after sick prisoners, and the American idea of 'cure' is also expressed in the need for more corrective surgery where, for example, it is necessary to remove physical impediments to social rehabilitation. But a doctor is only found on the staff of those institutions which are large: in the smaller prisons there may be only first-aid facilities, and no specially appointed doctor in the community. Moreover medicines are often dispensed by medical auxiliaries who are sometimes prisoners themselves. Finally, in America prisoners are regularly invited to volunteer as subjects for medical and social research for which they are paid. In short, although it is hoped to 'cure' a prisoner he is a criminal first and a patient second. (shrink)

Part 1 shows that 'remedy' destabilizes analysis. It has at least five different meanings loosely grouped around the relationship between disease and medicine. In three of those meanings it is functionally synonymous with 'right', which, for all its own instabilities, ought to be preferred. Blackstone encouraged the use of 'remedy'. He stabilized it by putting 'remedies' in a particular relationship with 'wrongs'. However, he built that relationship on an unsound foundation, namely, the proposition, in which John Austin followed him, that (...) every cause of action was a wrong. Part 2 demonstrates the error of that position. The rights which courts realize arise from wrongs and from not-wrongs. The word 'remedy' cannot easily cope with not-wrongs, and its tendency is to destroy the classification of the events from which rights arise. Part 2 also concludes that the habit of thinking of the law in terms of wrongs and remedies encourages a malignant, criminal model of the civil law, here called discretionary remedialism. In that model 'rights' dissolve. Instead, 'liability', as the equivalent of guilt, invites the court to respond with an appropriate remedy, selected by itself, by way of sentence. (shrink)

Spanish influence in the New World was particularly acute in the areas of medicine and medical education. From the time of Columbus forward prominent medical experts journeyed to Latin America establishing medical schools and research centers. This essay chronicles the history of Latin America with a strong focus on the physicians and scientists who brought modern scientific medicine, as it wag then known in Western Europe, to the Americas.

The use of the term `disease' in medicine is discussed, with particular reference to the issues raised by Kennedy (I) and the definition proposed by Campbell, Scadding and Roberts (2). Certain difficulties arising from this definition are considered, and a revised set of definitions is suggested, based on a distinction between diseasedness, contrasted both with health and with other sorts of problems, and nosological categories used to distinguish conditions calling for different treatments. The difference is stressed between those aspects of (...) medical decision-making which call for judgment on scientific grounds and those of the sort referred to by Kennedy, which involve ethical and political judgments. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Burma’s Healthcare Under Fire: My Experience as an Exiled Medical ProfessionalP. P. KyawI used to work as a medical doctor in a less developed state than many big cities in Burma1 that experienced prolonged civil wars and current similar atrocities decades before the urban areas of the country experienced them. Before everything started, I was responsible for the medical management of the most vulnerable communities and had been struggling (...) with pandemic-related medical activities. Those were the happiest years of my life. I was with one of the best international organizations, where every effort I made was directly delivered to the patients with no unnecessary paperwork. The system was efficient, my colleagues were supportive, and I had a good work-life balance. I supported my family and whoever needed temporary financial support, played music weekly, met good friends who I hung out with every weekend, and [End Page 164] found hobbies like gardening and crocheting. I was content and happy. I even postponed my plans to get registered as a doctor in the Western world.Before moving to this beautiful ethnic state in 2019, I previously worked as a government medical doctor in Yangon, the capital. As much as I loved working in those civilian hospitals, I could not support myself with a monthly pay of $100-$150 USD. It was a hard decision to leave the service because it meant I could not pursue the medical specialty that I had always longed for and had to leave like-minded supportive colleagues. In Myanmar, unless you are a civil servant, you cannot pursue further clinical specialties. However, after leaving the government’s service to work in humanitarian medical assistance in hard-to-reach areas of Burma, I learned that life is still beautiful outside my comfort zone, until February 2021 when the coup began. Democratically elected members of the country’s ruling party were overthrown by the military, which then bestowed power in a military junta.I expected the election prior to the coup in November 2020 to be an uphill battle for Burma, but nothing more. I was still in denial when I first heard the news from one of the town’s NGO staff. The person had to travel on a motorbike to inform everyone that the junta had staged the coup. No telephone or internet was working at that time. My colleagues and I cried in our office, saying, “We are so young, and the future is still ahead. I don’t think this is going to last long. Maybe it will be over in a few days or, at most, a few weeks.” Once the peaceful protests started nationwide, my friends and I provided medical cover for the protesters, initially for minor medical problems such as low sugar, low blood pressure, injuries from accidental minor slips and falls, etc. Never in my life had I imagined that I would be taking care of bullet wounds and people injured by live rounds. While learning about gunshot wounds in forensic medicine, I thought, “Oh, this is not going to be very useful because Burma is not America, and I am not going there.” Then suddenly, it became too real and more useful than I would’ve liked it to be.I always think back to one especially bloody day when many people in the town were shot with live rounds. We assisted many patients. Usually, we would go around with the protest groups until they were over in the late afternoon. The protesters were always peaceful. There were no riots, no harmful acts, or vandalism. Only when the protesters were cruelly dispersed with tear gas, high-pressure pumps, rubber bullets, and live rounds (to the head) did they decide to defend themselves while still making their voices heard. The only defenses people had to counteract the live rounds were things like metal covers, firecrackers, and slingshots.One afternoon in March 2021, my team and I took an early break for lunch—unaware that some people would lose their lives that afternoon. We followed the local protests through Facebook Live while having lunch and started to hear firecracker sounds. A few seconds later, we knew... (shrink)

This paper explores the consequences of the oft ignored fact that public health insurance must actually be supplied by the state. Depending how the state is modeled, different health insurance outcomes are expected. The benevolent model of the state does not account for many actual features of public health insurance systems. One alternative is to use a standard public choice model, where state action is determined by interaction between self-interested actors. Another alternative—related to a strand in public choice theory—is to (...) model the state as Leviathan. Interestingly, some proponents of public health insurance use an implicit Leviathan model, but not consistently. The Leviathan model of the state explains many features of public health insurance: its uncontrolled growth, its tendency toward monopoly, its capacity to buy trust and loyalty from the common people, its surveillance ability, its controlling nature, and even the persistence of its inefficiencies and waiting lines. (shrink)

One of the most pressing issues that confronts the Food and Drug Administration (FDA) is learning how to better address and assist in medical product development. FDA needs to prepare today so the agency can efficiently evaluate the technologies of tomorrow. Clearly, this is an area that impacts not only health care consumers but also our economies and financial markets. If the FDA can be a more aggressive part of the solution, they can help not only ease some of the (...) pressures that are driving up health care costs but also help all of us to maximize the value of medical innovations. The high cost of research and development is forcing many companies to make the short-term business decision to focus product development on those molecules that have a much higher potential to recoup expenditures. Unfortunately, this trumps attempts to develop potentially risky but breakthrough products for diseases affecting smaller populations, the orphan drugs. FDA's critical path initiative will enable innovative growth companies to better and more efficiently attack the steep hurdles facing them, allowing them to compete more effectively against the bigger, better-funded players in the market on a more level playing field. That means a real change in the risk/benefit equation for both the emerging growth companies and the public health. (shrink)