After describing the disorder of psychopathy, I examine the theories and the evidence concerning the psychopaths’ deficient moral capacities. I first examine whether or not psychopaths can pass tests of moral knowledge. Most of the evidence suggests that they can. If there is a lack of moral understanding, then it has to be due to an incapacity that affects not their declarative knowledge of moral norms, but their deeper understanding of them. I then examine two suggestions: it is their deficient (...) practical reason or their stunted emotions that are at fault. The evidence supports both explanations. I conclude with an overview of the debate concerning whether they are morally or legally responsible for their actions. (shrink)

Since the founding of the University of Limburg (1974), in The Netherlands, an innovative medical curriculum has been guided by educational principles of problem-orientation, continuous assessment, student initiative and attitude development. The teaching of medical ethics was built into the preclinical curriculum from the start. However, the clinical years remained largely unaffected, and only recently has an effort been made to extend the educational philosophy to this more or less traditional part of medical education. Within this context, an experiment of (...) clinical ethics teaching was introduced in the Obstetrics and Gynaecology (Ob/Gyn) clerkships. The objectives, methods and results of this experimental programme are described in this paper. The success of the teaching is based on three features of the programme: 1) its student-centred approach; 2) the programme is designed in a way similar to regular patient conferences; 3) the programme is taught by a team consisting of both clinician and ethicist. Before starting a longitudinal programme of ethics teaching during the clinical years, it proved very helpful to experiment with a well designed and evaluated pilot programme. (shrink)

Cartesian dualism has been viewed by medical theorists to be oneof the chief causes of a reductionist/mechanistic treatment ofthe patient. Although I aver that Cartesian dualism is one culprit for the misapprehension of the genuine treatment of patients in termsof both mind and body, I argue that interactive dualism whichstresses the interaction of mind and body is essential to treatpatients with dignity and compassion. Thus, adequate medical carethat is humanistic in nature is difficult (if not impossible)to achieve without physicians adhering (...) to a dualistic frameworkin which the body and person is treated during illness. (shrink)

Contemporary art can be a powerful pedagogical tool in the health humanities. Students in an undergraduate course in the health humanities explore the subjective experience of illness and develop their empathy by studying three artists in the context of the AIDS epidemic: Keith Haring, Felix Gonzalez-Torres, and Wolfgang Tillmans. Using assignments based in narrative pedagogy, students expand their empathic response to pain and suffering. The role of visual art in health humanities pedagogy is discussed.

Medical professionals are a community of highly educated individuals with a commitment to a core set of ideals and principles. This community provides both technical and ethical socialization. The ideal physician is confident, empathic, forthright, respectful, and thorough. These ideals allow us to define broadly "the excellence" of being a physician. At the core of these ideals is the ability to be empathic. Empathy exhibits itself in attributes of an individual's moral character and also in actions that actualize and support (...) communal life. Empathy, however, can be diminished or even lost and must be nurtured on an ongoing basis. The development of ethical physicians is strongly linked to experiences in the training period. Moral traits are situation-sensitive psychological and behavioral dispositions. The clinical environment of medical training programs can be so intense as to lead to conditions that may actually deprofessionalize trainees. Creating a clinical environment that is ethically nurturing and sustaining is an indispensable component of practicing medicine. (shrink)

This paper argues that we have wrongly and not for the patient’s benefit made a form of stark autonomy our highest value which allows physicians to slip out from under their basic duty which has always been to pursue a particular patient’s good. In general – I shall argue – it is the patient’s right to select his or her own goals and the physician’s duty to inform the patient of the feasibility of that goal and of the means needed (...) to attain it. If the goal is not one that is possible, the patient, with the physician and family, must select a feasible goal and then discuss the costs/benefits of various approaches. The physician should take a leading role in helping the patient select the goal. I argue that to simply present a laundry list of means and insist that patients choose for themselves is not only abandoning patients to their autonomy but is, in fact, a crass form of violating the patient’s autonomy. Freely choosing not to choose is a choice a patient with decisional capacity is entitled to make and one that needs to be respected. (shrink)

Encounters with illness, impairment, and aging can disrupt one’s experiential relationship with self, body, others, and world. “Healing” takes place when the individual is able to re-integrate his or her world, even if the condition is not medically curable. Drawing on work in the phenomenology of the body, this article examines a series of eight “healing strategies” individuals employ, each representing a different way of orienting toward the painful or impaired body. One may lean into freeing oneself from the body, (...) through strategies of “refusing,” “ignoring,” “objectifying,” or “transcending” its problems. Conversely, one may choose to embrace the body, through strategies such as “accepting,” “listening,” “befriending,” or “witnessing.” It can be beneficial to have a good number of such coping strategies at one’s disposal, enhancing flexible response to chronic challenges. They also are often used in synergistic or complementary combinations. (shrink)

The lived body has structures of ability built up over time through habit. Serious illness, injury, and incapacity can disrupt these capacities, and thereby, one’s relationship to the body, and to time itself. This paper focuses attention on a series of healing strategies individuals then employ on the “chessboard” of possibilities intrinsic to lived embodiment. This can include restoring past abilities (pointing to the future to recreate the past); and/or transforming one’s bodily structure or use-patterns, or the external environment, to (...) compensate. With many conditions, including progressive aging, no full rehabilitation is possible. Nevertheless, one can also seek consolation, richness, or hope by remembering the past; anticipating the future; or presencing, that is, living fully in the now. Insofar as past, present, and future are interwoven in one’s life experience, many also meet adversity by a life-story revision, constructing a new narrative to render events meaningful. Some also access a sense of transpersonal timelessness, whether through anticipation of an afterlife, or a sense of the eternal present. There is a literature on the adaptive coping mechanism used by the chronically ill, but with its diverse patient populations, methodologies, and categories, it has proved difficult to systematize. This article suggests that the structures of lived embodiment, as explored by phenomenology, provide a way to understand the modes of wholeness individuals access over time, and in relation to time—what is here termed chronic healing. (shrink)

This report explores the relationship between philosophy and medicine in the U.K. We note that medical training involves very little formal instruction in philosophy and ethics, and that, with few exceptions, philosophers in the U.K. do not contribute to the instruction of physicians or the philosophy of medicine. However, reviewing the problems arising out of recent developments within scientific medicine we find a pressing need for future philosophical analysis in the following areas: psychiatry, organ transplantation, abortion, euthanasia, experiments on living (...) subjects, consent, confidentiality, the relationship between medicine and political authority, and the provisions for social justice in medicine. (shrink)

Summary Care and cure have been described as different kinds of ethical approaches to clinical situations. Female concerns in nursing care have been contrasted with masculine, cure orientated physician's attitudes. Ethics in such different voices may have sociologic determinants, but they do not represent intrinsic distinctions. Medicine has shown a divergent development, on the one hand stressing cure in a deterministic and instrumental way, on the other hand being aware that disease is as much a pathographic as a biographic, care‐requiring (...) existential situation. Disease is a breakdown of the living organism, to be cured by therapeutic efforts, but it is also the distressing failure of the lived body, requiring concern and care. Based on Lévinas’ ethics of encounter, it is suggested that any interpersonal relatedness is based on concern for the other, being grounded on an essentially ethical interaction. The clinical encounter is a paradigm of such ethics‐based relationships, which necessarily builds on awareness of the other qua other, and is concerned with fulfilling the therapeutic mandate. Caring for the other means doing one's best to help her/him, so that care and cure are inextricably interwoven, although care is the more fundamental form of human relatedness. Thus, neither gender nor professional tasks can allow for a caring attitude to develop without curing concerns, just as trying to cure without caring is unthinkable. (shrink)

Germund Hesslow has argued that concepts of health and disease serve no important scientific, clinical, or ethical function. However, this conclusion depends upon the particular concept of disease he espouses; namely, on Boorse's functional notion. The fact/value split embodied in the functional notion of disease leads to a sharp split between the science of medicine and bioethics, making the philosophy of medicine irrelevant for both. By placing this disease concept in the broader context of medical history, I shall show that (...) it does capture an essential part of modern medical ideology. However, it is also a self-contradictory notion. By making explicit the value desiderata of medical nosologies, a reconfiguration of the relation between medicine, bioethics, and the philosophy of medicine is initiated. This, in turn, will involve a recovery of the caring dimensions of medicine, and thus a more humane practice. (shrink)

What clinicians, biomedical scientists, and other health care professionals know as individuals or as groups and how they come to know and use knowledge are central concerns of medical epistemology. Activities associated with knowledge production and use are called epistemic practices. Such practices are considered in biomedical and clinical literatures, social sciences of medicine, philosophy of science and philosophy of medicine, and also in other nonmedical literatures. A host of different kinds of knowledge claims have been identified, each with different (...) uses and logics of justification. A general framework is needed to situate these diverse contributions in medical epistemology, so we can see how they fit together. But developing such a framework turns out to be quite tricky. In this survey, three possible frameworks are considered along with the difficulties associated with each of them. The essay concludes with a fourth framework, which considers any epistemology as part of a practice that is oriented toward overcoming errors that emerge in antecedently given practices where knowledge is developed and used. As medicine indirectly advances health by directly mitigating disease, so epistemology indirectly advances knowledge by directly mitigating error. (shrink)

Use of humanities content in American medical education has been debated for well over 60 years. While many respected scholars and medical educators have purported the value of humanities content in medical training, its inclusion remains unstandardized, and the undergraduate medical curriculum continues to be focused on scientific and technical content. Cited barriers to the integration of humanities include time and space in an already overburdened curriculum, and a lack of consensus on the exact content, pedagogy and instruction. Edmund Pellegrino, (...) physician and scholar of the latter twentieth century, spent much of his professional life promoting the value and importance of the humanities in medical education, seeking the best way to incorporate and teach this content in clinically relevant ways. His efforts included the founding of multiple enterprises starting in the 1960s and 1970s to promote human values in medical education, including the Society for Health and Human Values and its Institute on Human Values in Medicine. Regardless of his efforts and those of many others into the current century, the medical humanities remains a curricular orphan, unable to find a lasting home in medical education and training. (shrink)

Modern medicine faces fundamental challenges that various approaches to the philosophy of medicine have tried to address. One of these approaches is based on the ancient concept of phronesis. This paper investigates whether this concept can be used as a moral basis for the challenges facing modern medicine and, in particular, analyses phronesis as it is applied in the works of Pellegrino and Thomasma. It scrutinises some difficulties with a phronesis-based theory, specifically, how it presupposes a moral community of professionals. (...) It is argued that Pellegrino and Thomasma's concept of phronesis corresponds to a Hippocratic concept of t�chn�, and that this latter concept seems to address many of the challenging issues Pellegrino and Thomasma also address. Thus, if modern medicine is to find its philosophical model in ancient concepts, it appears that the Hippocratic t�chn� is closer to the ancient concept of medicine than the Aristotelian phronesis, and that it might avoid many of the pitfalls of a phronesis-based approach. (shrink)

Many physicians assert that new cost-control mechanisms inappropriately interfere with clinical decision-making. They claim that high costs arise from poorly practiced medicine, and argue that effective utilization of resources is best promoted by advancing the scientific and ethical ideals of medicine. However, the claim is not warranted by empirical evidence. In this essay, I show how it rests upon aesthetic considerations associated with diagnostic elegance. I first consider scientific rationality generally. After a review of analytical empiricist and socio-historical approaches in (...) the philosophy of science, a form of Kant's aesthetic is used to explain how scientific discovery and justification are linked, and to show how meta-theoretical considerations associated with the goals and method of science work together with exemplars of practice. This analysis enables us to understand how the ideals of medicine as a science guide the initial patient history and physical exam in such a way that a parsimonious use of tests is indicated. Aesthetic considerations unite the basic scientific and ethical commitments of the modern medical paradigm and are central for rightly understanding clinical judgment. (shrink)

In professional medical ethics, the physician traditionally is obliged to fulfil specific duties as well as to embody a responsible and trustworthy personality. In the public discussion, different concepts are suggested to describe the desired underlying attitude of physicians. In this article, one of them—empathy—is presented in an interpretation that is meant to depicture (together with the two additional concepts compassion and care) this attitude. Therefore empathy in the clinical context is defined as the adequate understanding of the inner processes (...) of the patient concerning his health-related problems. Adequacy is scrutinized on behalf of the emotional and subjective involvement of he physician, and on the necessary dependence on medical—moral—goals. In the present interpretation, empathy alone is no guarantee of the right moral attitude, but a necessary instrumental skill in order to perceive and treat a patient as an individual person. The concepts of compassion and care that will be discussed in two forthcoming articles are necessary parts to describe the desired moral attitude of the physician more completely. (shrink)

In professional medical ethics, the physician traditionally is obliged to fulfil specific duties as well as to embody a responsible and trustworthy personality. In the public discussion, different concepts are suggested to describe the desired moral attitude of physicians. In a series of three articles, three of the discussed concepts are presented in an interpretation that is meant to characterise the morally emotional part of this attitude: “empathy”, “compassion” and “care”. In the first article of the series, “empathy” has been (...) developed as a mainly cognitive and morally neutral capacity of understanding. In the second article, the emotional and virtuous core of the desired professional attitude—compassion—has been presented. Compassion as a professional attitude has been distinguished from a spontaneous feeling of compassion, and has been related to a general idea of man as vulnerable and solidary being. Thus, the dignity of the patient is safeguarded in spite of the asymmetry of compassion. In this article, the third concept of the triad—“care”—is presented. Care is conceived as an attitude as well as an activity which can be directed to different objects: if it is directed to another sentient being, it is regarded as intrinsically morally valuable; implying (1) the acceptance of being addressed, (2) a benevolent inclination to help and to foster, and (3) activity to realize this. There are different forms of benevolence that can underlie caring. With regard to the professional physician’s ethos, the attitude of empathic compassion as developed in the two previous articles is proposed to be the adequate underlying attitude of care which demands the right balance between closeness and professionalism and the right form of attention to the person of the patient. ‘Empathic compassionate care’ does not, however, describe the whole of the desired attitude of a physician, but focuses on the morally-emotive aspects. In order to get also the cognitive and practical aspects of biomedicine into the picture, ‘empathic compassionate care’ has to be combined with an attitude of responsibility that is more directed to decision-making and outcome than a caring attitude alone can be. The reconstruction of the desired professional attitude in terms of “empathic compassionate care” and “responsibility” is certainly not the only possible description, but it is a detailed proposal in order to give an impulse for the discussion about the inner tacit values and the meaning of medicine and clinical healthcare professions. (shrink)

This paper begins by examining the claim that the practice of medicine is essentially a moral endeavor. According to this view, all clinical practice has moral content, and each clinical situation has a moral dimension. I suggest that in order to recognize this moral dimension, clinicians must engage in an interpretive process, and that they must be able to interpret clinical data in ethical terms. However, clinicians often lack the ‘moral perception’ required to appreciate this moral dimension. I will argue (...) that physicians lack moral perception when the clinical data they are given do not offer sufficient opportunity for interpretation. This paper draws on the work of Merleau-Ponty to suggest that this loss of interpretation is, paradoxically, the result of the way that patients experience illness. This thesis may be productive, first, because it suggests opportunities to explore the process of moral perception. This thesis also suggests ways for ethicists and educators to enhance clinicians' perception of the ethical dimensions of clinical practice. Finally, the concept of moral perception, when grounded in the patient's experience of illness, creates a fruitful area of inquiry that warrants inclusion in what may someday be the philosophy of medicine's canon. (shrink)

The conception of the doctor–patient relationship under Australian law has followed British common law tradition whereby the relationship is founded in a contractual exchange. By contrast, this article presents a rationale and framework for an alternative model—a “Trust Model”—for implementation into law to more accurately reflect the contemporary therapeutic dynamic. The framework has four elements: an assumption that professional conflicts with patient safety, motivated by financial or personal interests, should be avoided; an onus on doctors to disclose these conflicts; a (...) proposed mechanism to contend with instances where doctors choose not to disclose; and sanctions for non-compliance with the regime. (shrink)

Informed consent, decision-making styles and the role of patient–physician relationships are imperative aspects of clinical medicine worldwide. We present the case of a 74-year-old woman afflicted with advanced liver cancer whose attending physician, per request of the family, did not inform her of her true diagnosis. In our analysis, we explore the differences in informed-consent styles between patients who hold an “independent” and “interdependent” construal of the self and then highlight the possible implications maintained by this position in the context (...) of international clinical ethics. Finally, we discuss the need to reassess informed-consent styles suitable to the needs of each patient regardless of whether he or she resides in the United States or in Japan. (shrink)

This thesis is about the content and concerns of each of four disciplines pertaining to the field of bioethics: medicine, philosophy, religion and law. Emphasis is put on the human values each reflects in patients' lives. A last chapter is dedicated to patients' narrative in order to bring a practical perspective to the discussions of the previous chapters. The four essential human values interconnecting among the four disciplines are: the patients' need for authority, the need for protection, the existential questioning (...) about the meaning of life, and the fear of death. (shrink)

The increasing impact of technology on health care has raised some important questions. This study is undertaken to examine how the predominance of a scientific approach to medicine and health care undermines other crucial aspects of the relationship between patients and care givers.