Here is a thoroughly updated edition of a classic in palliative medicine. Two new chapters have been added to the 1991 edition, along with a new preface summarizing where progress has been made and where it has not in the area of pain management. This book addresses the timely issue of doctor-patient relationships arguing that the patient, not the disease, should be the central focus of medicine. Included are a number of compelling patient narratives. Praise for the first edition "Well (...) written. . .should be read by everyone in medical practice or considering a career in medicine."---JAMA. "Memorable passages, important ideas, and critical analysis. This is a book that clinicians and educators should read."---New England Journal of Medicine. (shrink)

" Dr. Cassell discusses the world of the sick, the healing connection and healer's battle, the role of omnipotence in the healer's art, illness and disease, and ...

Medicine and ethics alike must learn properly to attend to suffering. We can never truly experience another's distress. We can, however, learn to recognize the particular purposes, values, and aesthetic responses that shape the sense of self whose integrity is threatened by pain, disease, and the mischances of life.

Like the broom in “The Sorcerer's Apprentice,” technologies take on a life of their own. To bring them under control, doctors must learn to tolerate ambiguity, resist the lure of the immediate, cease fearing uncertainty, and rechannel their response to wonder.

The goals of medicine -- A story about a patient with aortic stenosis -- What are facts in medicine? -- Clarify the chain of events that led to the present state : the case as a narrative -- The case of Myra Manner -- Examine your presuppositions and preconceptions -- Separate and examine the values at issue -- A question of judgment -- The patient, the doctor, and the relationship -- Observation, prognosis, and prognosticating -- Thinking in medicine -- Accepting (...) the challenge. (shrink)

Although written primarily for medical research, the Belmont principles have permeated clinical medicine as well. In fact, they are part of a broad cultural shift that has dramatically reworked the relationship between doctor and patient. In the early 1950s, medicine was about making the patient better and maintaining optimism when the patient could not get better. By the 1990s, medicine was about the treatment of specific physiological systems, as directed by the patient, but as limited by the society's concern for (...) justice. (shrink)

Healers: Extraordinary Clinicians at Work, by David Schenck and Larry R. Churchill, and What Patients Teach: The Everyday Ethics of Health Care, by Churchill, Joseph B. Fanning, and Schenck are both important and thought‐inspiring books. For the first, Schenck and Churchill recruited fifty practitioners, mostly physicians but some clinicians who practice alternative therapies, “identified by their peers as excellent healers,” and interviewed them to find out what they did to establish a good relationship with their patients. The results of their (...) interviews and how they wrote their book makes this the best and most concrete understanding of a necessary step to healing that I have read. What Patients Teach examines the patients’ perspective about forming relationships with their clinicians. The patients’ clinicians were asked to nominate patients to be interviewed to help answer the question. This volume, while important, is less extraordinary than the first because we hear less what the patients want to say and more what the authors want to tell us. That aside, taken together, these two books are a major advance in the literature of healing. (shrink)

Book reviewed in this article: Thinking Clearly About Death. By Jay F. Rosenberg.

In lieu of an abstract, here is a brief excerpt of the content:Philosophy, Psychiatry, & Psychology 10.3 (2003) 225-226 [Access article in PDF] Travelers in the Land of Sickness Eric J. Cassell THE PROBLEM OF knowing another person and the world in which that person lives, particularly someone with major mental illness, is addressed in this interesting and rich essay. The number of different metaphors and concepts Potter employs to describe the task of crossing into and then understanding (...) the thoughts, emotions, symptoms, constraints, context, and perspectives of another testifies to the difficulties involved.Yet, as I read the essay, it was not clear what the clinician world traveler, moral tourist, empathizer (and other categories) is supposed to do on the journey to another person. Why do we reach out to the sick person? What is it that we want to know or do that makes this trip necessary? Potter is primarily concerned with mental illness—the examples she cites are patients with schizophrenia—while my experience has in the main been with persons with physical illness, but for the moment, the differences are less important than the central lesson. The illness that the patient presents—the experience of the symptoms, the impairments, disability, and disruptions of the emotional and social existence that happen because of the disease result from an amalgam of the disease process with the specific nature of the sick person. There is no disease in pure form; there is no disease in abstract for clinicians. There is only this sick person. She correctly quotes me, because of all this, as pointing out the importance of integrating knowledge of this particular patient with the abstract knowledge of disease to understand the illness as it is expressed in this person. All to form a basis for the treatment of the patient and especially to help relieve suffering because suffering is always personal, particular, and individual. (It is important in thinking about this topic to remember that most serious diseases, psychiatric and otherwise, are chronic and take place over significant lived time. The acute schizophrenic symptoms or the acute infectious diseases, as dramatic as they are, distract attention from the importance of the place of the sick person.)In physical disease, our long (and continuing) history of separating human beings from nature and the body, and the importance medicine places on objectivity and the objective, have made the inevitable personalization of the disease and symptoms virtually invisible. After ages of explaining psychiatric diseases as the alienation of the person, and a long psychoanalytic period of finding their origins in the person, in the last 30 years these diseases have become increasingly objectified. The place of the person has been diminished as psychiatry has entered the DSM, neurotransmitter, and effective psychotropic drug era. For both physical and mental disease, however, and whatever the current ideology, the nature of person is crucial in determining the onset, diagnosis, course, treatment, and outcome of each illness. It is in order to have an impact on these crucial aspects of sickness that clinicians must come to know their patients to the degree possible. [End Page 225]But there is something more. Nancy Potter quotes a woman with schizophrenia as saying, "All that was my former self has crumbled and fallen together and a creature has emerged of whom I know nothing. She is a stranger to me... She is not real—she is not I... She is I—and because I still have myself on my hands, even if I am a maniac, I must deal with me somehow." (Potter, 2003, p. 215)Must she deal with this crazy self alone? Is that not what her doctors and caregivers are for? But how can they take care of her, protect her, keep what is left intact, and sustain her until she is (hopefully) better without knowing who she is? She makes clear in those few phrases that inside her there is a person with a past, a family, a world, a culture, a role(s) in life, relationships, a body, dreams for the future, things she does, and all the other things that make up a person. It is in... (shrink)

To the Editor: Daniel Callahan is correct when, in “Rationing: Theory, Politics, and Passions”, he tells us that the combination of ever-rising medical costs and ever-increasing demand for expensive resources by physicians and their patients will—in the absence of any workable, generally acceptable mode of official rationing—lead to covert rationing. Or, more precisely, it will encourage us to extend the covert rationing that already exists, where those with more get more. As things stand now, this is unavoidable. However..

Book reviewed in this article: Talking with Patients. By Eric J. Cassell.

Book reviewed in this article: Suffering and the Beneficent Community: Beyond Libertarianism. By Erich H. Loewy. The Nature of Suffering and the Goals of Medicine. By Eric J. Cassell.

The theory and practice of history and its relevance to the modern world, by Britains greatest radical historian.

Game of Thrones is a popular, award-winning television series with an eight-season run on Home Box Office, based on the Song of Fire and Ice series of books by George R.R. Martin. It depicts a morally complex political situation in a fantasy environment that has some similarities to medieval Europe. In the midst of this setting, the series advocates a cynical attitude towards politics, social structures, and religion. Most notably, the series suggests that there is no such thing as political (...) legitimacy. This chapter identifies a pattern of cynicism throughout Game of Thrones but points towards the thoughts of John Locke and Thomas Aquinas as possible alternatives to the story’s cynicism. (shrink)

The fundamental problems of a philosophy of science emerge as a set of antinomies: relativism-Absolutism, Subjectivity-Objectivity, And theory-Practice. Each one of these antinomies is overcome in dialectical philosophy. Science is a dialectical process and requires a dialectical philosophy. But unlike the hegelian dialectic which is initiated by only internal limitations, The dialectic of science is also generated by the external intervention of nature. Science is then necessarily a historical process. Therefore, A scientist is true to science and acts ethically "as (...) a scientist" only if he acts to secure the historical possibility of science in the future. Science is ethically complete when it creates only itself. (shrink)

Phagocytosis is the process of recognition and engulfment of microorganisms or tissue debris that accumulate during infection, inflammation or wound repair. This ingestion, which is performed most efficiently by migrating, bone marrow‐derived cells called ‘professional phagocytes’, is essential for successful host defense. Ingestion results when an invading microorganism is recognized by specific receptors on the phagocyte surface and requires multiple, successive interactions between the phagocyte and the target. Each of these interactions results in a signal transduction event, which is confined (...) to the membrane and cytoskeleton around the ligated receptor and which is required for successful phagocytosis. Many molecules found at sites of inflammation or infection stimulate phagocytosis, so that efficient ingestion is confined to the site of infection or inflammation, which in turn limits the proinflammatory and tissue‐destructive processes that accompany phagocytosis. This review summarizes current understanding of this critical component of host defense and of its regulation. (shrink)

Extracorporeal membrane oxygenation (ECMO) is currently reserved predominantly for bridging patients to a different destination therapy, but the use of ECMO as a destination therapy itself (ECMO-DT...

To the student of the recent history of theological ideas in the West, it sometimes seems as though, of all the ‘new’ subjects that have been intro duced into theological discussion during the last hundred or so years, only two have proved to be of permanent significance. One is, of course, biblical criticism, and the other, the subject which in my University is still called ‘comparative religion’—the dispassionate study of the religions of the world as phenomena in their own right.

The legal and ethical asymmetry between honoring positive claims of conscience versus negative claims of conscience was recently analyzed by several articles in this journal. The first author of this article (ALB) identified unique but defeasible reasons against honoring positive claims of conscience, such as the greater threat they post to institutional values and institutional resources than negative claims of conscience. However, ALB wrote, when these reasons can be overcome, positive claims of conscience should enjoy the same ethical and legal (...) respect as negative claims of conscience. This article argues that the prescription of birth control by non-Roman Catholic physicians in Roman Catholic institutions is an example of a positive claim of conscience that can overcome concerns of institutional values and resources, and therefore ought to receive the same ethical respect and legal protection as negative claims of conscience. In making this argument, this article also responds to several of the thoughtful comments raised by Alberto Giubilini and Dominic Wilkinson. (shrink)