Debates over health care have focused for so long on economics that the proper goals for medicine seem to be taken for granted; yet problems in health care stem as much from a lack of agreement about the goals and priorities of medicine as from the way systems function. This book asks basic questions about the purposes and ends of medicine and shows that the answers have practical implications for future health care delivery, medical research, (...) and the education of medical students. The Hastings Center coordinated teams of physicians, nurses, public health experts, philosophers, theologians, politicians, health care administrators, social workers, and lawyers in fourteen countries to explore these issues. In this volume, they articulate four basic goals of medicine — prevention of disease, relief of suffering, care of the ill, and avoidance of premature death — and examine them in light of the cultural, political, and economic pressures under which medicine functions. In reporting these findings, the contributors touch on a wide range of diverse issues such as genetic technology, Chinese medicine, care of the elderly, and prevention and public health. The Goals of Medicine clearly demonstrates the importance of clarifying the purposes of medicine before attempting to change the economic and organizational systems. It warns that without such examination, any reform efforts may be fruitless. (shrink)

The purpose of this article is to present a normative theory of the goals of medicine (a theory that tells us in what respects medicine should benefit the patient) that is both comprehensive and unified. A review of the relevant literature suggests that there are at least seven plausible goals that are irreducible to each other, namely to promote functioning, to maintain or restore normal structure and function, to promote quality of life, to save and prolong (...) life, to help the patient to cope well with her condition, to improve the external conditions under which people live, and to promote the growth and development of children. However, it seems that all these goals need to be qualified in different ways, e.g. it does not seem reasonable to improve physiological function or functional ability unless this is expected to have positive effects on quality of life and/or length of life, or to improve the quality of life in any respect, or by any means. These qualifications all suggest that the proposed goals are, as goals, conceptually, and not just causally, related to one another, and that they should therefore not be regarded in isolation. Instead, we should think of the medical enterprise as having a multidimensional goal structure rather than a single goal. In order to depict clearly how the different goals are related to one another, a multidimensional model is constructed. (shrink)

Different kinds of medical technologies and biotechnologies have all been developed for “therapeutic purposes,” but the possible uses of these technologies are not restricted to therapy. These possibilities give rise to a number of questions. This chapter discusses whether mood enhancement is a legitimate goal of medicine when medical resources are limited and the medical enterprise is publicly funded. It focusses on the case of mood enhancement through so‐called cosmetic psychopharmaceuticals. It suggests that we should give absolute priority to (...) those who suffer most; we should give equal weight to all improvements in well‐being, regardless of where on the scale they occur; the better a person feels, the less is the value of a certain improvement; once a certain level of subjective well‐being is achieved, further improvement is worth nothing from a medical perspective, and an improvement beyond normal mood still has value, but it is worth less. (shrink)

In this paper, we argue that promoting patient values is a legitimate goal of medicine. Our view offers a justification for certain current practices, including birth control and living organ donation, that are widely accepted but do not fit neatly within the most common extant accounts of the goals of medicine. Moreover, we argue that recognising value promotion as a goal of medicine will expand the scope of medical practice by including some procedures that are sometimes (...) rejected as being outside the scope of acceptable medical practice, such as certain forms of physician-assisted death. We then rebut some common and possible objections to this view. Our aim is not to argue that other accounts are mistaken—except when they argue for a single goal that does not include patient values—but rather to show that value promotion should play a more central role in discussions about the goals of medicine. (shrink)

Taking as its starting point a recent statement of the Goals of Medicine published by the Hastings Centre, this paper argues against the dualistic distinction between pain and suffering. It uses an Aristotelian conception of the person to suggest that malady, pain, and disablement are objective forms of suffering not dependent upon any state of consciousness of the victim. As a result, medicine effectively relieves suffering when it cures malady and relieves pain. There is no medical mission (...) to confront the spiritual condition of the patient. (shrink)

Taking as its starting point a recent statement of the Goals of Medicine published by the Hastings Centre, this paper argues against the dualistic distinction between pain and suffering. It uses an Aristotelian conception of the person to suggest that malady, pain, and disablement are objective forms of suffering not dependent upon any state of consciousness of the victim. As a result, medicine effectively relieves suffering when it cures malady and relieves pain. There is no medical mission (...) to confront the spiritual condition of the patient. (shrink)

Bengt Brülde in his article ``The Goals of Medicine. Towards a Unified Theory'' has proposed a normative theory of the goals of medicine within which the concept of quality of life plays a crucial role. In Brülde's analysis, however, the very concept of medicine is deliberately left quite vague and it is therefore difficult to see how the goals of medicine are related to the goals of closely allied enterprises such as health (...) promotion and social welfare. In this reply I therefore propose an analysis of these related conceptual areas. I do this mainly in two respects. Following the nomenclature in a previously published article I propose a systematic conceptual framework for all varieties of health enhancement and distinguish different notions of medicine within this framework. A consequence of this analysis is, for instance, that the means and also the immediate goals of medicine in its broadest sense are more diversified than the means and immediate goals of medicine in its narrowest sense. From this position I expand the topic further by comparing medicine and health enhancement with social welfare and try to trace the basic features between – as well as the common properties of – these different enterprises. (shrink)

This article reviews the development of a new set of practices within modern medicine that can generally be called “cosmetic medicine,” practices that include cosmetic surgery, cosmetic dermatology, and cosmetic gynecology. I argue that the development of such fields indicates a fundamental change in the practice of medicine. After reviewing the possible explanations proposed for such developments, in order to indicate the social and cultural origin of the driving forces, I discuss the implications of these revolutionary changes (...) for the perceived goal of medicine. Of particular importance is the development of beauty as the main goal in cosmetic medicine. The development of the new fields supports the idea that... (shrink)

Aristotle’s ethical system was guided by his vision of human flourishing (also, but potentially misleadingly, translated as happiness). For Aristotle, human flourishing was a rich holistic concept about a life lived well until its ending. Both living a long life and dying well were integral to the Aristotelian ideal of human flourishing. Using Aristotle’s concept of human flourishing to inform the goals of medicine has the potential to provide guidance to clinical decision-makers regarding the provision of burdensome treatments, (...) such as intensive care treatment, where pursuing a chance of survival must be balanced against the risk of exposing patients to a negative dying experience. By conceptually uniting potentially competing goals of medicine, such as prolonging life and the promotion of peaceful deaths, Aristotle’s understanding of human flourishing creates an argument for the integration of palliative care considerations into intensive care decision-making and for advanced care planning with healthy patients. (shrink)

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)

Biomedical innovations are making possible the enhancement of human capabilities. There are two philosophical stances on the role that medicine should play in this respect. On the one hand, naturalism rejects every medical intervention that goes beyond preventing and treating disease. On the other hand, welfarism advocates enhancements that foster subjective well-being. We will show that both positions have considerable shortcomings. Consequently, we will introduce a third characterization in which therapies and enhancements can be reconciled with the legitimate objectives (...) of medicine inasmuch as they improve the capabilities that enable the freedom to pursue personal well-being. (shrink)

It is plausible that what possible courses of action patients may legitimately expect their physicians to take is ultimately determined by what medicine as a profession is supposed to do and, consequently, that we can determine the moral acceptability of voluntary euthanasia and physician-assisted suicide on the basis of identifying the proper goals of medicine. This article examines the main ways of defining the proper goals of medicine found in the recent bioethics literature and argues (...) that they cannot provide a clear answer to the question of whether or not voluntary euthanasia and physician-assisted suicide are morally acceptable. It is suggested that to find a plausible answer to this question and to complete the task of defining the proper goals of medicine, we must determine what is the best philosophical theory about the nature of prudential value. (shrink)

ABSTRACT In a recent issue of this journal, David Silver and Gerald Dworkin discuss the physicians' role in execution by lethal injection. Dworkin concludes that discussion by stating that, at that point, he is unable to think of an acceptable set of moral principles to support the view that it is illegitimate for physicians to participate in execution by lethal injection that would not rule out certain other plausible moral judgements, namely that euthanasia is under certain conditions legitimate and that (...) organ‐donation surgery is sometimes permissible. This article draws attention to some problems in the views of Silver and Dworkin and suggests moral principles which support the three moral views just mentioned. (shrink)

Recent years have witnessed a growing concern that terminally illpatients are needlessly suffering in the dying process. This has ledto demands that physicians become more attentive in the assessment ofsuffering and that they treat their patients as `whole persons.'' Forthe most part, these demands have not fallen on deaf ears. It is nowwidely accepted that the relief of suffering is one of the fundamentalgoals of medicine. Without question this is a positive development.However, while the importance of treating suffering has (...) generally beenacknowledged, insufficient attention has been paid to the question ofwhether different types of terminal suffering require differnt responsesfrom health care professionals. In this paper we introduce a distinctionbetween two types of suffering likely to be present at the end of life,and we argue that physicians must distinguish between these types if theyare to respond appropriately to the suffering of their terminally illpatients. After introducing this distinction and explaining its basis,we further argue that the distinction informs a (novel) principle ofproportionality, one that should guide physicians in balancing theircompeting obligations in responding to terminal suffering. As weexplain, this principle is justified by reference to the intereststerminally ill patients have in restoration, as well as in therelief of suffering, at the end of life. (shrink)

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.

While other parts of medicine and health care seems traditionally to be primarily directed at preventing losses of bodily functions, repairing said functions in the case of such losses, or at least to provide ailment for unpleasant symptoms, sports medicine has allready from the beginning been involved with the project of enhancing bodily functions with regard to sports performance. First, when sports medicine involve itself in the traditional health care activity of prevention, therapy and ailment, the aim (...) is often very different from ordinary medical activities in that it tries to secure bodily functions far beyond what is required to reach what would normally be seen as a non-pathological state of a person. Second, sports medicine actively involves itself in the project of extending and enhancing human performance capacities through medical knowledge and technology. This raises several issues both with regard to medical ethics and the ethics of sports. For example, how should the goals of sports medicine be viewed from the perspective of rationing scarce health care resources? Should sports medicine be restricted by rules from the sports community as to which performance enhancing activities are tolerated in that sector? Or should sports medicine rather direct what is to be accepted within the world of sports? Both lines of reasoning are to be found in debates about, e.g., doping, controversial training methods and the potential use of gene technology in sports. The paper will address these issues and analyse them from a philosophical point of view. (shrink)

To practice medicine and ethics, physicians need wisdom and integrity to integrate scientific knowledge, patient preferences, their own moral commitments, and society's expectations. This work of integration requires a physician to pursue certain goals of care, determine moral priorities, and understand that conscience or integrity require harmony among a person's beliefs, values, reasoning, actions, and identity. But the moral and religious pluralism of contemporary society makes this integration challenging and uncertain. How physicians treat patients will depend on the (...) particular beliefs and values they and other health professionals bring to each instance of shared decision making. This book offers a framework for practical wisdom in medicine that addresses the need for integrity in the life of each health professional. In doing so, it acknowledges the challenge of moral pluralism and the need for moral dialogue and humility as professionals fulfil their obligations to patients, themselves, and society. (shrink)

Clinical decision making is a challenging task that requires practical wisdom—the practised ability to help patients choose wisely among available diagnostic and treatment options. But practical wisdom is not a concept one typically hears mentioned in medical training and practice. Instead, emphasis is placed on clinical judgement. The author draws from Aristotle and Aquinas to describe the virtue of practical wisdom and compare it with clinical judgement. From this comparison, the author suggests that a more complete understanding of clinical judgement (...) requires its explicit integration with goals of care and ethical values. Although clinicians may be justified in assuming that goals of care and ethical values are implicit in routine decision making, it remains important for training purposes to encourage habits of clinical judgement that are consciously goal-directed and ethically informed. By connecting clinical judgement to patients' goals and values, clinical decisions are more likely to stay focused on the particular interests of individual patients. To cultivate wise clinical judgement among trainees, educational efforts should aim at the integration of clinical judgement, communication with patients about goals of care, and ethical reasoning. But ultimately, training in wise clinical judgement will take years of practice in the company of experienced clinicians who are able to demonstrate practical wisdom by example. By helping trainees develop clinical judgement that incorporates patients' goals of care and ethical reasoning, we may help lessen the risk that ‘clinical judgement’ will merely express ‘the clinician's judgement.’. (shrink)

Health-related quality of life is the ultimate general goal for medicine, health care and public health, including health promotion and health education. The other important general goal is health-related welfare. The aim of the paper is to explain what this means and what the consequences of these assumptions are for health work. This involves defining the central terms “health”, “quality of life” and “welfare” and showing what their conceptual relations are. Health-related quality of life has two central meanings: health-related (...) well-being, which constitutes quality of life, and health as ability, which contributes causally to quality of life. Four meanings of health-related welfare are put forward: general well-being, health as ability, other inner properties of the individual, and external factors. States and processes covered by these categories contribute causally to health-related quality of life. Finally, using these distinctions, some more specific goals for medicine and health care, on the one hand, and for public health and health promotion, on the other, are outlined. In the former fields work is primarily directed towards changing the health-related quality of life of the individual through direct measures, “manipulating” the individual, whereas public health work and health promotion primarily use indirect measures and further health through various sorts of health-related welfare changes, e.g. through changing the environment. (shrink)

In previous literature, ethicists mention several goals of Clinical Ethics Support (CES). It is unknown what key persons in healthcare institutions see as main–—and sub-goals of CES. This article presents the goals of CES as perceived by board members and members of ethics support staff. This is part of a Dutch national research using a mixed methods design with questionnaires, focus groups and interviews. Quantitative and qualitative data were analyzed and combined in an iterative process. Four main (...) clusters of goals were found: 1) encouraging an ethical climate, 2) fostering an accountable and transparent organization, 3) developing professionalism and a final goal, overarching the previous three, 4) good care. Most important sub-goals of CES were: attention for ethical issues, raising awareness of ethical issues, fostering ethical reflection and supporting employees. The article ends with a discussion on the desirability to further operationalize the general goal of good care, the context-boundedness of our findings and the need to relate goals of CES to the features of organizational cultures to further improve the integration of CES in healthcare institutions. (shrink)

In this commentary on the article by Arthur L. Caplan [1] the philosophy of medicine is viewed from a medical perspective. Philosophical studies have a long tradition in medicine, especially during periods of paradigmatic unrest, and they serve the same goal as other medical activities: the prevention and treatment of disease. The medical profession needs the help of professional philosophers in much the same way as it needs the cooperation of basic scientists. Philosophy of medicine may not (...) deserve the status of a philosophical subspecialty or field, but it so closely linked to the main trends of contemporary medical thinking that it must be regarded as an emerging (or reemerging) medical subdiscipline. (shrink)

On an initial read, neither A.A. Milne's Winnie the Pooh Adventures or Hugh Lofting's The Story of Dr. Dolittle come across as literature written about trauma, and yet both stories derived from authors who were at the front lines of World War I and who put their war experiences into their stories. Evoking nostalgia and drawing on simple lore, both of these works continue to touch the human psyche. Both writers reinvented the way we see trauma and pain, whilst advocating (...) for broader access to holistic healthcare. This, in turn, has impacted our relationship with trauma texts and healthcare forever. (shrink)

It seems impossible to completely cover the field indicated by the title of this report because of the many contributions of individual physicians and non-physicians to problems of the philosophy of medicine in Austria, and to their solution. The main trends are rooted in historic developments and in the current problems of medicine and health care, which are similar world-wide. In Austria famous names like empress Maria Theresia or the physician Ignaz Semmelweis have to be mentioned in connection (...) with the development of the ideas of a philosophy of medicine. In recent times again influential and well-known persons in related fields of medicine and health care are Austrians. However, the main line of new developments goes mostly unseen by the public: activities in medical ethics with the goal to humanize health care, carried on by groups of young physicians, biomedical engineers and students. (shrink)

Definitions of health and disease are of more than theoretical interest. Understanding what it means to be healthy has implications for choices in medical treatment, for ethically sound informed consent, and for accurate assessment of policies or programs. This deeper understanding can help us create more effective public policy for health and medicine. It is notable that such contentious legal initiatives as the Americans with Disability Act and the Patients' Bill of Rights fail to define adequately the medical terms (...) on which their effectiveness depends. In Ethics and the Metaphysics of Medicine, Kenneth Richman develops an "embedded instrumentalist" theory of health and applies it to practical problems in health care and medicine, addressing topics that range from the philosophy of science to knee surgery."Embedded instrumentalist" theories hold that health is a match between one's goals and one's ability to reach those goals, and that the relevant goals may vary from individual to individual. This captures the normative implications of the term health while avoiding problematic relativism. Richman's embedded instrumentalism differs from other theories of health in drawing a distinction between the health of individuals as biological organisms and the health of individuals as moral agents. This distinction illuminates many difficulties in patient-provider communication and helps us understand conflicts between promoting health and promoting ethically permissible behavior. After exploring, expanding, and defending this theory in the first part of the book, Richman examines its ethical implications, discussing such concerns as the connection between medical beneficence and respect for autonomy, patient-provider communication, living wills, and clinical education. (shrink)

The focus of this special issue is on moral psychology and the goals of moral education. My focus will be considerably narrower in addressing the following question: In light of the situationist movement in psychology and philosophy, what should be the goal(s) of character education? The main conclusion will be that the central goal of character education should be modified in a certain way to make it more empirically informed. But not to worry, as this modification should be amenable (...) to most contemporary supporters of character education. (shrink)

A basic question of medical ethics is whether the norms governing medical practice should be understood as the application of principles and rules of the common morality to medicine or whether some of these norms are internal or proper to medicine. In this article we describe and defend an evolutionary perspective on the internal morality of medicine that is defined in terms of the goals of clinical medicine and a set of duties that constrain medical (...) practice in pursuit of these goals. This perspective is developed by means of a critical examination of the essentialist conception of the internal morality of medicine advocated by Edmund Pellegrino and the critique of internal morality approaches by Robert Veatch and Tom Beauchamp. (shrink)

Some ethical issues facing contemporary medicine cannot be fully understood without addressing medicine's internal morality. Medicine as a profession is characterized by certain moral goals and morally acceptable means for achieving those goals. The list of appropriate goals and means allows some medical actions to be classified as clear violations of the internal morality, and others as borderline or controversial cases. Replies are available for common objections, including the superfluity of internal morality for ethical (...) analysis, the argument that internal morality is merely an apology for medicine's traditional power and authority, and the claim that there is no single, "core" internal morality. The value of addressing the internal morality of medicine may be illustrated by a detailed investigation of ethical issues posed by managed care. Managed care poses some fundamental challenges for medicine's internal morality, but also calls for thoughtful reflection and reconsideration of some traditionally held moral views on patient fidelity in particular. (shrink)

Edmund D. Pellegrino has played a central role in shaping the fields of bioethics and the philosophy of medicine. His writings encompass original explorations of the healing relationship, the need to place humanism in the medical curriculum, the nature of the patient’s good, and the importance of a virtue-based normative ethics for health care. In this anthology, H. Tristram Engelhardt, Jr., and Fabrice Jotterand have created a rich presentation of Pellegrino’s thought and its development. Pellegrino’s work has been dedicated (...) to showing that bioethics must be understood in the context of medical humanities, and that medical humanities, in turn, must be understood in the context of the philosophy of medicine. Arguing that bioethics should not be restricted to topics such as abortion, third-party-assisted reproduction, physician-assisted suicide, or cloning, Pellegrino has instead stressed that such issues are shaped by foundational views regarding the nature of the physician-patient relationship and the goals of medicine, which are the proper focus of the philosophy of medicine. This volume includes a preface by Dr. Pellegrino and a comprehensive Introduction by the editors. Of interest to medical ethicists as well as students, scholars, and physicians, _The Philosophy of Medicine Reborn_ offers fascinating insights into the emergence of a field and the work of one of its pioneers. “After a long period of dormancy, philosophy of medicine has blossomed with new life. The single most important physician-philosopher in that rebirth has been Edmund Pellegrino. His contributions to virtue theory, the concept of beneficence, the dispute over the internal and external sources of a morality for medicine, and the role of the Hippocratic tradition are all critical. The essays collected in this volume have changed the history of the philosophy of medicine. He shows that philosophy of medicine can be done with both passion and compassion.” —_Robert M. Veatch, Kennedy Institute of Ethics, Georgetown University_ “Edmund Pellegrino's words have helped medical students, faculty, scholars and patients address the challenges they encounter in medicine and medical practice. His personal support has also been critical for many of us in developing programs in medical ethics and philosophy of medicine in our universities. Dr. Pellegrino combines the wisdom of a great physician with those of a great philosopher to produce a body of writing that will continue to inspire us all. This volume contains some of his best and most influential work.” —_Loretta Kopelman, The Brody School of Medicine, East Carolina University_ _ _ “Edmund Pellegrino has been a leading light in the philosophy of medicine for a generation. He was instrumental in the birth of bioethics, founded one of the leading journals, and provided able leadership in organizing early activities of the profession. He has served as department chairman, dean, and university president. Most recently, he chairs the President’s Council on Bioethics. In all this, first and foremost, he has been a physician. Those who are ill and suffering make a claim upon him. To respond to this claim, Pellegrino creatively brings together the worlds of science and of the humanities. For him, that is what medicine is about, making it the most scientific of the humanities and the most humane of the sciences. Fortunately for us, Pellegrino brings these worlds together in thought, as well as in practice. In this selection from his writings, Engelhardt and Jotterand have captured the heart of Pellegrino’s project, both in depth and breadth, so we can also hear that claim of the ill and so we can see what worlds must come together if we are to respond in the appropriate way.” —_George Khushf, University of South Carolina_ “Pellegrino’s work is both a treasure and important for understanding bioethics. His work in philosophy of medicine addresses the crucial questions that are so important to understanding the practice of medicine and the ethics of health care.” —_Kevin Wildes, President, Loyola University_ _ _. (shrink)