Theory

1
Theory Ethics in MedicineARTH02055, 2 CP

• Andres Soosaar
• Department of Public Health
• http//biomedicum.ut.ee/andress

2
General goals of the course 1

• 1.Overview of theoretical basis of medicine
  Medicine as science, practice, and art. The
  evidence-based medicine.
• 2. Basic issues of human nature and general
  worldview.
• 3. Philosophical questions of scientific
  knowledge in biology and medicine.

3
A very general goal

• To put medicine into broader context and
  philosophical context is actually broad enough.

4
General approach

• Philosophical and/or interdisciplinary approach.
• Level of account is rather introductory and
  offering contexts, not transmission of final
  truths.

5
What is philosophy?

• Gr philosophia Love of Wisdom
• By Jenicek ja Hitchcock (2005) philosphy is the
  study of fundamental questions, that is,
  questions about concepts and principles.
• Main branches of philosophy are metaphysics and
  ontology (being and reality) epistemology
  (knowledge) logic (inference) and ethics
  (values).

6
What is science?

• 3 a knowledge or a system of knowledge covering
  general truths or the operation of general laws
  especially as obtained and tested through
  scientific method b such knowledge or such a
  system of knowledge concerned with the physical
  world and its phenomena NATURAL
  SCIENCEMerriam-Webster Online Dictionary
• The issue of knowledge is important in both
  science and philosophy. A measure of quality of
  knowledge is truth.

7
Truth

• There are several ways to understand truth, but
  the most popular approach is probably the
  correspondence theory of truth which means that
  proposition is true in case when it corresponds
  to the reality.
• Absolute and relative truths. Science seems to
  move toward absolute truth, because theories are
  becoming more and more exact and fitting better
  with reality during scientific research.

8
Aristotle (384322 bc) on truth

• To say of what is that it is not, or of what is
  not that it is, is false, while to say of what is
  that it is, and of what is not that it is not, is
  true
• (Metaphysics 1011b25)

9
Philosophy and Science

• Until Modern Times philosophy and science were
  focused almost on the same issues. It was
  tenacious hope to understand general principles
  of world only with reason without empirical
  support. Immanuel Kant gave an influential
  criticism of so called pure reason.
• Nowadays they are rather different but still
  overlapping fields, e.g. philosophy of physics
  and theoretical physics.
• Empirical approach is in sciences much more
  important as this in philosophy. In sciences is
  the format to get or produce new knowledge
  clearly more collective as it happens in
  philosophy.

10
Philosophy and Science

• By John Searle (1999) philosophy has 3 different
  features
• Philosophy is in large part concerned with
  questions that we have not found a satisfactory
  and systematic way to answer
• Philosophical questions tend to be what I
  (Searle) will call framework questions.
• Philosophical questions are ofted questions
  about our concepts and relationship between our
  concepts and the world they represent.

11
Some features of modern philosophy

• There is more applied philosophies, i.e.
  philosophies which are focused on certain field
  of science, e.g. Philosophy of physics, biology
  or medicine.
• Philosophy seems to take over the central
  cognitive format of sciences the peer-reviewed
  publication.
• 2 first items together are showing that
  philosophy is more and more socially driven.
• Philosophical writings have usually 1 author and
  its commentators, in sciences there usually
  dominates collective authorship. At the same time
  philosophical schools and traditions are still
  very influential. One possible role of philosophy
  is to offer for human environment potential but
  still coherent set of ideas.

12
System of sciences

• There are several divisions on different basis
• Popular division is natural and social sciences
  and humanities, also fundamental and applied
  sciences.
• The basis for different sciences comes from their
  object and research methods.
• Nowadays the is a tendency to combine sciences in
  several ways, we are speaking about
  interdisciplinarity, e.g. Neurosciences.

13
Philosophy of medicine

• H. Tristram Engelhardt Jr defines the issue in
  Routledge Encyclopedia of Philosophy as follows
• The philosophy of medicine can be generally
  defined as encompassing those issues in
  epistemology, axiology, logic, methodology and
  metaphysics generated by or related to medicine

14
Interpretations (4) of the philosophy of medicine

• Speculative medicine as the attempt to discover
  the basic philosophical principles that lie
  behind the practice of medicine.
• Logic of medicine brings togeteher attempts to
  clarify the character of scientific reasoning in
  medicine.
• Philosophy of medicine as a subspeciality of
  philosophy of science.
• Other explorations of philosophical issues that
  have special salience in medicine, e.g. bioethics
  stands in this division
• Tr Engelhardt JR, KWM Wildes. Encyclopedia of
  Bioethics, 3rd ed, 3 vol. Pp. 1738-9.

15
What is medicine?

• There are different opinions on that issue
• Scientific medicine and alternative medicine
• The central situation in medicine is the
  physician-patient relationship or therapeutic
  relationship which goals in improvement of
  patient condition.

16

• medicine
• Online Medical Dictionary http//cancerweb.ncl.ac.
  uk/
• A scientifically-based discipline dedicated to
  the prevention and treatment of disease and
  injury.
• MedlinePlus Medical Dictionary
• http//www.nlm.nih.gov/medlineplus/mplusdictionary
  .html
• 2 a the science and art dealing with the
  maintenance of health and the prevention,
  alleviation, or cure of disease

17
Central concepts of medicine

• Health-disease distinction.
• Basic principles are (i) existence of some norms
  and (ii) possibility to modify abnormal
  situations. Here is a lot of issues from natural
  sciences and psychology.
• The therapeutic relationship.
• Ideal situation would be that human relations are
  symmetrical but disease makes them clearly
  asymmetrical. Here is a lot of issues from
  psychology and social sciences.

18

• Health a state of optimal physical, mental, and
  social wellbeing, and not merely the absence of
  disease and infirmity
• Dorlands Illustrated Medical Dictionary, 28th
  ed., p. 736

19

• disease any deviation from or interruption of
  the normal structure or functions of any part,
  organ, or system (or combination of thereof) of
  the body that is manifested by a characteristic
  set of symptoms and signs and whose etiology,
  pathology, and prognosis may be known or unknown.
• Dorlands Illustrated Medical Dictionary, 28th
  ed., p. 478.

20
Health-disease distinction

• The central goal of medicine is to support
  wellbeing (sic! Rather moral or psychological
  concept) of human beings.
• Health and disease are qualitatively different
  conditions.
• There are 1 health and many diseases
• Health-disease distinction needs certain norm(s)
• Health-disease distinction is complex but seem to
  be reduced on psychological (emotional) status of
  wellbeing indeed (or subjectivity).

21
Connections between health and disease

• It doesnt seem to be a law constant amount of
  health and disease

Health
Disease
?
?
22
Connections between health and disease

• Is this like a jump from one zone to another?

Disease
Disease
23
Development of the concept of disease

• The concept of disease has been varied during
  history, but the central questions of the issue
  have been the cause and nature of disease.
• Human nature has biological, psychological, and
  social dimension and therefore there is no wonder
  that there are biological, anthropological,
  sociological, philosophical etc explanations of
  diseases.
• In medical practice is the key issue the process
  of disease, its nature, signs and possibilities
  for correction (therapy) and prevention.

24
Scientific and alternative medicine

• The scientific (conventional) medicine is
  grounded on scientific knowledge and methods. The
  health care systems in the developed countries
  are build up on the basis of the scientific
  medicine and it is accepted and cultivated in
  medical faculties.
• Alternative medicine is a vague term which covers
  numerous isolated practicies, e.g. Homeopathy,
  anthroposophical medicine, yoga etc.
• NB! Our course is about scientific medicine.

25

• Alternative medicine broadly describes methods
  and practices used in place of, or in addition
  to, conventional medical treatments. The precise
  scope of alternative medicine is a matter of some
  debate and depends to a great extent on the
  definition of "conventional medicine." Positions
  on the distinction between the two include those
  who reject the safety and efficacy of the other,
  and a number of positions in between.
• The debate on alternative medicine is complicated
  further by the diversity of treatments that are
  categorized as "alternative." These include
  practices that incorporate spiritual,
  metaphysical, or religious underpinnings
  non-European medical traditions newly developed
  approaches to healing and a number of others.
  Proponents of one class of alternative medicine
  may reject others.
• http//en.wikipedia.org/wiki/Alternative_medicine

26

• The National Center for Complementary and
  Alternative Medicine defines complementary and
  alternative medicine as "a group of diverse
  medical and health care systems, practices, and
  products that are not presently considered to be
  part of conventional medicine". One distinction
  that the NCCAM makes is that complementary
  medicine is used in conjunction with conventional
  medicine whereas alternative medicine is used in
  place of conventional medicine. The NCCAM also
  defines integrative medicine as the combination
  of "mainstream medical therapies and CAM
  therapies for which there is some high-quality
  scientific evidence of safety and effectiveness".
• http//en.wikipedia.org/wiki/Alternative_medicine

27
A conference on general issues of medicine

• Eesti Arstide Liit, Tartu Ülikooli Kliinikumi
  Eetikakomitee, Tartu Ülikooli Eetikakeskus ja
  Eesti Bioeetika Nõukogu tähistavad rahvusvahelist
  arstieetikapäeva konverentsigaKas
  alternatiivmeditsiin pakub tõenduspõhisele ravile
  konkurentsi?
• Has alternative medicine any chance to compete
  with evidence-based medicine?
• 16.septembril 2005. a. algusega kell 11 Tartu
  Ülikooli raamatukogus

28
Birth of medicine as field and profession

• Since very old times an ill person has needed
  help of others both to survive that condition and
  get some treatment or therapy to reject that
  disease. This basic situation has had long
  history and interesting course of development,
  see the course on history of medicine.
• An important aspect of that development was
  increased ability of some members of community to
  help ill person in that difficult condition.

29
The physician-patient relationship
30

• human being and human being
• therapeutic relationship
• Doctor and Patient
• Medical man and Patient
• Medical men and Patient
• Service provider and client

31

• The doctor-patient relationship has medical,
  psychological, social, legal, moral and other
  aspects, therefore it is possible to study this
  relationship within different sciences and
  methods.
• A big problem with such approach is a problem
  that people mainly deal with the specific aspect
  of their interest and they may loose human being
  as whole.

32
SOCIETY

• Patient Healer

diagnostics
therapy
Self Family Doctor with medical staff
Witch computer or robot time
NATURE
33
4 types of the professional-patient relationship
(Entralgo, 2003)

• Spontaneus or instinctive relationship
• Empirical relationship
• Magico-religious realtionship
• Scientific relationship
• All types are presented almost at all times. The
  professional-patient relationship has both
  diagnostic and curative aspect or side.

34
Main features of the scientific
professional-patient relationship

• Continuous secularization
• 2 main aspects ethical one (comes still very
  much from Christianity)and technical one (comes
  biological sciences, currently evidence-based
  medicine).
• Permanent dilemma Patient as person (ethics)
  versus patient as a set of tissues and organs.
• Modern scientific medicine is very powerful, it
  is able penetrate deeply into many aspects of
  human existence.
• Resources for medicine are limited in every
  society and it raises the issue of justice in
  allocation of them.

35
People in medicine as professionals

• Medical professionals have obtained accept and
  authorization for their professional activities
  from society, they also have got responsibility
  for those activities.
• Those people necessarily got better access to
  medical information and it started to cumulate
  into their hands.

36
Features of a profession (Greenwood, 1957)

• Systematic body of theory
• Authority to define problems and their treatment
• Community sanctions to admit and train its
  members
• Ethical codes that stress an ideal of service of
  others
• A culture that includes the institutions
  necessary to carry out all of its functions.
• NB! Nowadays society has intrude into several
  activities above.

37
Medicine as a teamwork

• Permanent deepening of specialization adds new
  specialities into medical environment which
  necessarily increases the number of specialists
  which have their own role in treatment of every
  case.
• If activities in team are badly coordinated, it
  produces confusions and negative emotions in
  patient mind.
• Medical institutions have traditionally had
  strong hierarchical organization.

38
Medical terminology

• An important tool in medicine both to communicate
  with each other and to do research is medical
  terminology and system of terms.
• The ability to know and use that terminology is
  absolutely necessary for every doctor but is at
  the same time a big source of confusions outside
  of professional circle.

39
Medical terminology

• Big number of basic medical terms comes from old
  Greek and Latin languages.
• New terminology comes mostly from English and is
  often directly taken into different languages.
• Countries have special boards which task is to
  develop medical terminology.

40
Online sources of medical terminology

• Online Medical Dictionary http//cancerweb.ncl.ac.
  uk/
• MedlinePlus Medical Dictionary
• http//www.nlm.nih.gov/medlineplus/mplusdictionary
  .html

41
ICD-10

• World Health Organization (WHO) has released the
  10th version of International Classification of
  Diseases (ICD) in 1992. http//www.who.int/classif
  ications/icd/en/
• ICD is an extremely important agreement in
  medicine

42
General philosophical worldview concepts which
matter in medicine

• Realism
• Mind-Body Problem
• Causality
• Norm and normativity
• Life and death

43
References

• Jenicek M, Hitchcock DL. Evidence-based practice
  logic and critical thinking in medicine. AMA
  Press, 2005.
• Searle JR. The future of philosophy. Phil.
  Trans.R.Soc.Lond. B, 1999, 354,2069-2080.
• Several articels from Encyclopedia of Bioethics,
  3rd ed, 2003.

44

• Prof Dietrich von Engelhardt (Lübeck University)
  will give the lecture Principles and Values in
  Medical Humanities on Tuesday, September at
  16.00 in Linkberg lecture hall (Hospital main
  building, 8 Puusepa St).