abstracts

ABSTRACTS





[1] THE DOCTOR AND THE LITERARY TEXT - pitfalls and potentials

Rolf Ahlzén (Sweden)



It is often taken for granted that an acquaintance with literature - novels, poetry, drama - is enriching for

the medical practitioner. The assumption is made that a deepened understanding of ill people will result

from meeting with illness in literature and that this should serve the purpose of improving the clinical

encounter. In accordance with such conjectures, many medical schools are now introducing courses in

literature, and anthologies are produced with the aim of offering suitable reading for medical students.

It is, however, not at all certain that literature will do the work that is expected of it. Surprisingly little is

said about the conditions under which literary texts can affect the reader in the way that is hoped for. A

number of complications appear: Reading is perhaps not seldom a flight from reality rather than a bold

facing up to it; illness narratives from "real life" must in all reasonable ways be better material than

fiction for expanding one‟s experience of clinical realities; literary taste is so varied that whatever texts

are chosen there will always be a number of readers for whom form conceals the content that might carry

the important experiences.

These possible objections must be faced if a theory about the uses of literary texts in medical education

and in clinical settings is to be developed. If they can be met in a convincing way the task remains of

showing what literature might possibly do, that is what potential it carries, and how we can go about

practically to use this potential.

One of the few philosophers who has been wrestling with these issues concerning the nature of literary

texts in connection to professional knowledge is Martha Nussbaum. Leaning on Aristotle‟s ethics and

using some of the novels of the western canon, she has offered an eloquent plea for the potential of

literature.

The paper thus discusses ways of overcoming the objections to the claims about literature and medicine,

and also outlines the potential of literature as a way of knowledge for the clinician or clinician to be. I

will draw in part on Nussbaums‟ writings but it will also try to outline possible ways of studying em-

pirically the relation between medicine and literature.







[2] EUTHANASIA - THE CONCEPTUAL REVIEW

Anna Alichniewicz (Poland)



Among the most characteristic features of modern medicine are its technical possibilities of interfering

in the process of dying. Alas, it too often means the unreasonable attempt at postponing death, which

resulted in prolonging the terminal phase or even agony and causing an increasing amount of the pa-

tient's suffering. These phenomena are at least partly responsible for the growing interest in euthanasia,

recently observed in modern societies. Nevertheless, the discussion about the problem of euthanasia - in

the public as well as in the bioethical milieus has been affected by the ambiguity of the terms applied. It

seems that the problem of defining the main concepts referring to the end of life issues (voluntary,

non-voluntary, involuntary/ active, passive euthanasia: ordinary and extraordinary means; the double

effect) is of fundamental significance, since the susceptibility of various interpretations of the terms

involved in the debate of the end of life medical treatment causes not only theoretical, but also practical

consequences. The terms occurring in public opinion surveys are often differently understood in various

studies, which makes their comparability and value problematic, both from the theoretical and practical

points of view. The goal of my paper is to do the analytical review of the concepts mentioned above. My

special attention is devoted to the two questions: first, the relation between often confusedly used

concepts of passive euthanasia and withholding/withdrawal of extraordinary means, which I discussed

on the basis of the problem of the moral difference between acts and omissions (killing and letting die)

and the problem of agent-causation and responsibility; secondly, the question of active euthanasia and



5

the theory of double effect, where the problem of conceptualizing of the act and intention seems to be

crucial.







[3] IS “DIGNITY” A BIOETHICAL PRINCIPLE?

Roberto Andorno (Germany)



Principlism in biomedical ethics, especially as developed by authors like Beauchamp and Childress, has

been severely criticized, for example, for the difficulty to harmonize the various principles. Neverthe-

less, it continues to play an important role in bioethical discussions. In this context, we may ask if the

notion of "dignity» can really be considered as a principle of biomedical ethics, next to others, as it has

been proposed by Peter Kemp. The notion of "dignity" has had and continues to have great significance

in ethical reflection. In the current context of bioethics, it is usually used to indicate an unconditional

and untouchable nucleus of human personality which should be preserved from some irreversible

technological interventions. The UNESCO Universal Declaration on Human Genome and Human

Rights is a good example of the increasing relevance of this notion. Our intention is to defend the idea

that “dignity” is more than a principle among others, but that it provides a very broad framework that

gives sense to medicine as a whole and, in general, to all social and juridical institutions, even if,

paradoxically, it is extremely difficult to determine its meaning and content with great precision.





[4] THE MORAL CHALLENGE OF DECODE GENETICS IN ICELAND

Vilhjámur Árnason (Iceland)



In this paper I will describe the complicated project of setting up a centralized database with health care

information and genealogical data about the entire population of Iceland. I will critically analyze the

public discussion that took place and the regulations that have been established. i will try to sort out the

main ethical considerations that are related to this project. These can be divided into three main issues.

First, the issue of privacy, where the focus is on the question whether data of this sort are unidentifiable

and also whether a strong emphasis on privacy can cause other ethical complications. Secondly, the

issue of patient-professional relationship. Can the technological emphasis on privacy replace the trust

and confidentiality between doctor and a patient? The third and most complex and morally interesting

issue is the question of consent. Here we are faced with a cluster of questions: Does the requirement of

informed consent apply in this case? If not, what is the alternative? Is it possible to obtain a societal

informed consent? What is the status of minors, the incompetent and the deceased? What kind of in-

formed consent should be required if health-care data and genealogical data are to be connected with

genetic information? I will discuss these questions and put forth ideas as to how we can best deal with

them.







[5] ANIMALS IN MEDICAL SCIENCES: THE EMERGENCE OF A HUMANE

PERSPECTIVE

David Badcott (United Kingdom)



The use of animals in medical research stems from two basic assumptions: one moral, the other epis-

temological:

a) that it is morally justifiable to subject non-human animals to experimental investigations of potential

benefit to human beings or other animals

b) that the results of such testing can be extrapolated to human beings or other animal species

But the basis of these assertions is by no means universally accepted and there is a tendency to "see-saw"

from moral arguments to epistemological ones or vice versa in a way that fails to fully satisfy either

advocates or their critics. With these reservations in mind, it is worth considering whether the "usual"





6

arguments exhaust the issues and we might with advantage look more closely at the significance of what

could be considered to be the "extra dimension", that human nature which separates mankind from all

other species.

Human beings share with all living creatures both plants and animals the fundamental "building blocks"

of life. There are just 20 amino acids throughout the whole of nature and all living things employ the

same four-letter code to carry genetic information. A small percentage difference in such material

separates mankind from the higher apes and rather more from mice, and we are only distantly related, in

genetic terms, to plant species. Yet these crucial variances account for both the emergence of human

rationality and our moral perspective. We posses both the ability to seek by experimental means in-

formation of potential value in preventing or alleviating human suffering, and at the same time, an

aptitude for reflection on the moral validity of the means by which this is achieved.

Arthur Koestler wrote of deep level conflicts which impinge on "... the very essence of the human

predicament", which he attributed to the split between intellectually ruled reason and emotion-

ally-governed belief. Indeed, it is perhaps just this uneasy disjunction stemming from our emergent

human nature which underpins the tensions often revealed in discussion of the acceptability of the use of

animals in medical sciences. But to this circumstance, we might also add the pivotal role of analogy

which we employ both to support extrapolation of physiological data from animal to man, and in

transposing our moral (anthropomorphic) sentiments in the reverse direction. The paper will explore

these and related issues, drawing on the work of contemporary philosophers such as Holmes Rolston,

but as much with the intention of contributing toward explanation of the impasse, rather than providing

a means of resolving the seemingly insoluble conflict.







[6] MEDICINE AND SOCIETY IN THE NEW MILLENNIUM: A historical lesson about

the role of medicine in social change and cultural reforms

Y. Michael Barilan, Moshe Weintraub (Israel)



Medicine is often called upon to play a pioneering role in social reform and progress. On the other hand,

many people harbor fears of physicians who might abuse or misuse medicine. Medicophobia has per-

vades the public lóre since times immemorial.

This presentation looks into the witch craze of early modern Europe and into European anti-Semitism.

In order to derive lessons for contemporary understandings of medicophobia and how to secure trust in

biomedicine.

Some historians are perplexed by the fact that physicians, surgeons, apothecaries and midwives were

hardly accused of witchcraft, even though they were reasonable suspects when someone died or took ill.

We find it even more puzzling since Jewish doctors who were believed to be very skilled physicians,

were often accused of malicious abuse of their healing powers. The Capetengian Kings, for example,

employed Jews as their private physicians, but those very same doctors were later accused of poisoning

their kingly patients.

It is widely held that the Hippocratic Oath, by binding practitioners to etiquette of a closed professional

guild, strives to secure confidence in them. We wish to highlight the integrative, rather than the seclu-

sive, vector of the oath. Medical practice must be well woven into the values and occurrences of the

society in which it strives to establish its practice. Renaissance practitioners were honed of the better

part of society: hence their pledged commitment to moral values provided them with strong immunity

against suspicion even at times of fanatic persecutions. Jewish practitioners were always foreigners and

their morality was never trusted, even at times of relative tolerance.

The extremes of medieval society seem outlandish for academicians who are frequent travellers of

cyberspace. We, nevertheless, believe that the inner workings of public opinion and social cohesion

have not changed much, and that trust and cooperation with the medical establishment is as haphazard as

it has always been. Physicians are prone to be biased by their education and high socio-economic status

and to become insensitive to their own society and culture. The too low rates of donations of organs for

transplantation, and the work of Ivan Illich about modern "iatrogenesis” are the tips of an iceberg of

heartless and precarious confidence in physicians, in healthcare institutions, in the pharmaceutical

industry and in academic or lay biomedicine.



7

The lesson for Medicine in the third millennium is that physicians should be more sensitive to the values

of their society. Physicians, who try to harness medicine to an ideological cart that would lead society

ahead of its mainstream convictions, risk the loss of public trust. Our culture is currently struggling to

shape its moral and legal policies about issues such as physician assisted suicide, abortion, genetic

engineering, control of recreational drugs etc. We suggest that healthcare providers refrain from taking

the lead in those matters so as to remain close to the heart of the ever-suspicious public.





[7] FACING SOCIO-ECONOMIC REALITY AND SOME CHALLENGES IN CON-

TEMPORARY GENETIC RESEARCH AND THERAPY

Jeffrey H. Barker (USA)



In this essay, I focus on the realities and ethical challenges involved in the creation and use of large-scale

genetic databases and in the application of genetic research in clinical trials of gene therapy. Issues

addressed include individual and collective informed consent, privacy, democratic decision-processes in

the setting of social priorities, and the interplay of privately-funded research and government regulation.

One current and controversial example will be discussed as a case study, that of the recently-halted gene

therapy trials at the University of Pennsylvania's Institute for Human Gene Therapy, where a young man

died in 1999 as a result of one of the trials.







[8] HEALTH CARE IN THE NEW MILLENNIUM

Robert J. Barnet (USA)



This presentation will review the developments in health care that have taken place in the twentieth cen-

tury and reflect on what changes might occur in the twenty first century. Attitudes, scientific knowledge

and beliefs that were present at the beginning and end of the twentieth century will be identified. This

will serve as a reference point for looking at health care in the twenty first century.

The presentation will explore the concept of health, of wellness as the appropriate goal of medicine and

what priority these ideas should be given. Relevant questions will be posed and reflected on. These

questions include the following: Whether there is a crisis in both the philosophy and delivery of health

care? Whether our concerns have been manipulated? What impact the expansion of the current system

will have and whether it will worsen the situation by entrapping more and miring down many others? Is

there a scarcity of health resources or is there an illusion of scarcity because of expanding medicaliza-

tion.

There are implications that greater access to professional health care, more technology and greater

expertise are necessary. In almost every area of the world, access to the more sophisticated and expen-

sive treatment provided by the complex entities and professionals who control and provide health care is

seen, especially by health professionals themselves, as necessary, or at least desirable. The expectations

and priorities are often influenced by those sectors of society, the wealthy, the well educated and the

politically powerful, that have a vested interest. While there are concerns about high and ever increasing

costs, many of those in the greatest need are often excluded. It is this dilemma, involving what is per-

ceived as unmet needs in the presence of limited resources, that creates what is characterized by many as

a health care crisis. At the same time, other basic human needs, including adequate housing, education,

sanitation, and efforts directed at the elimination of violence, are often given lower priorities than so-

phisticated medical technology. The related topics of medicalization, iatrogenesis and insitutional-

ization will be reviewed. The issues of how, or whether, compassion and caring will be part of health

care as well as societal attitudes on pain, suffering and death in the new millennium will be explored.

Will the profession of medicine, in this next millennium, continue as a profession, a moral endeavor? Or

will it become primarily a technological or commercial enterprise? Is it possible to provide greater

availability of professionalized health care and maintain (or restore) the integrity and traditions of the

medical profession? Is that even desirable? Will the prevention of heart disease and the elimination of

cancer and AIDS make the degenerative diseases more prevalent, or as the spread of AIDS demon-

strates, will fundamentally different challenges develop?



8

There is wisdom in traditional societies and effective modalities in alternative medicine. Will some fun-

damental knowledge emerge from those sources that will shatter our contemporary paradigm? Changes

in health care are undoubtedly needed but it is only one facet. Alternatives to market driven society,

such as a recognition of the importance of vernacular values and the concept of a convivial society, will

be discussed.

This paper will seek to establish a fresh perspective, which reaffirms the freedom and dignity of the

human person as central, is sensitive to fundamental human needs, recognizes mortality and the limits of

science and technology. This will be presented as the critical challenge to health care and society as we

enter the new century and the new millennium.







[9] SOCIAL-POLITICAL TRANSFORMATION IN RUSSIA AND NEW TRENDS IN

HEALTHCARE

Valentin A. Bazhanov, Ludmila I. Kopytova (Russia)



1. Social-political transformation in Russia since early 1990's has serious impact on the Russia's

population. Mortality has risen on 1/4 while the birth rate has fallen on 1/3. Though the trend for the

diminishing of birth rate and increase of mortality take place since the late 1960's when the USSR was a

super-power, the above mentioned facts evaluated now by communists and their supporters as a geno-

cide of Russians.

2. Soviet society promoted ''community'' type of human relationship. It means that the collective mo-

rality was dominant along with the definite conduct and standards of life. The decay of communism in

the USSR, the crash of Soviet regime and drastic weakening of communist ideology in (new) Russia

lead to notable strengthening of individual morality and conduct. To put it in metaphorically, if during

Soviet era the social reality have had been constructing the person, then today the person predominantly

constructs the reality he/she have been living. Quite obvious that novel social values and morality

emerged and developing along with radical decline of GNP, overt unemployment and the rest of phe-

nomena natural for the transition period, has unfavorable impact on prosperity and the health of many

citizens. Russian healthcare system challenges the task it never seen for past decades. What response is

possible to meet this challenge to the healthcare?

3. Response seems to be bivalent: on the one hand a decade ago unavailable medicines may be found at

any pharmacy. On the other, they may be purchased only by few people for their high prices, precision

medical instruments are installed in hospitals but one must pay a lot to undergone the medical tests, and

only pretty wealthy persons could offer such tests. The society split into well-to-do and poor people.

Consequently split the healthcare. Non-institutional, so to speak, aspect of the quest for optimal re-

sponse closely related to the engendering of the new medical ideology, which regulates the relationship

of physician and patient, new image of rule and pathology, new approaches to the therapy.

4. This ideology may be called holistic. The men considered here as being in the co-evolution with

him/herself and nature. The therapy presupposes involvement of all set of medical directions and means

applied to the body, reason and soul of person. One's body - not merely the system in homeostasis, but

the hierarchy of structures, the sustainability and dynamic equilibrium of which is secured by

self-organization. The healing means self-healing for the doctor stimulates the transition of the body

from one state into another through activating predominantly positive feedback launched by tiny im-

pacts both of physical and non-physical character. The physician offers patient knowledge, heart and

assistance in order to promote the patient's revival of slumbering internal forces, renew his/her health

due to the merge of their energies and wills and thus provide the self-healing of patient who constructs

the reality where lives. Thereby the unconformity of social-political climate and personal moral settings

are likely to overcome.









[10] THE CREATIVE IN-BETWEEN. Emmanuel Levinas and the consultation in general

practice



9

Eli Berg (Norway)



After more than 20 years as a general practitioner I felt so unpleasant as a doctor that I must ask myself

What am I and my profession doing with all the people seeking our help? So many of my patients were

on my list year after year, and I and the rest of the health care system could not help them. Now and then

I also felt that my investigations and my therapy made the patients feel further bad. Something must be

wrong.

My first experiment was to invite a psychologist into my practice. Our common consultations with some

of my most suffering patients made great surprise. Many of the patients stopped their medications for

complaints from both body and soul, they made important decisions for their lives, and they did not need

me as much as before. These patients were among my so-called difficult ones.

The next step in my seeking for help as a medical doctor was to invite myself to have a journey together

with one of the patients with suffering from the whole alphabet. We walked around on his childhood

island for five days. By the way a life story grew visible for his inner eye, a story that shocked both

himself and me as his doctor. And many of his complaints attacked him abruptly and unexpected when

he stayed in the village. Today he has control of most of his complaints, and he has taken place in his

own life for the first time.

My consultations changed after these experiences. Every patient was met with some variation of

"Please, tell me!" Then I shut my mouth and was active listening, trying to give them support for re-

flection and further telling. Many patients ended their speech by saying something like "this is not a

medical problem. Now I can see it." Others needed further medical investigation, but perhaps in another

way than both of us had thought in advance.

I wonder if my experiences can be lightened up by parts of the philosophy of Emmanuel Levinas. I am

fascinated by his thoughts about human meetings in general, the meeting with the face of the Other, the

naked and vulnerable one. My position as a helper is that beneath the other, only by the fact that we are

meeting each other, not by my decision to take that position.

Another theme in the philosophy of Levinas is about how we as human beings in western philosophy try

to make everything to something known from earlier, not opening up for what we cannot know anything

about. Perhaps the basis for our medical understanding need to be changed? Perhaps our diagnostic

thinking, our objectivating act, is a sort of putting everything together in boxes with known limits or

walls (diagnosis)? Perhaps we by this obstruct the possibility to follow the patients in their unique life, in

their unique context, different from our own and different from what the medical profession has taken

for granted?







[11] PERSONALISM VERSUS PRINCIPLISM IN BIOETHICS

Tadeusz Biesaga (Poland)



Taking into account the personalistic view the author criticizes the bioethics of the four principles,

which was once put forward by Tom L. Beauchamp and James F. Childress and named as principlism

by its opponents. It occurs that one cannot find justification for the above mentioned four basic

principles (autonomy, nonmaleficence, beneficence and justice), which would give them moral

character and constitute their adequate content. Such a justification – according to the author of the

article – can be provided by the following personalistic norm: persona est affirmanda propter se

ipsam. This norm is basic to these principles, which are subsidiary.

Without referring to the affirmation of dignity of the human person for himself, i.e. without defining that

bioethics is concerned about the human person and his real good, the proposed principles cannot be

applied since they do not have any content, and no wonder, being in mutual conflict they contradict one

another. The roulette in the form of mutually conflicting principles, where one principle eliminates the

other, for example beneficence eliminates autonomy, and the other way round, shows that we deal with

bioethics of „principles without principles‟, i.e. without a principle which would give these efforts a

moral character and which would allow us to find what is the good in the beneficence.

One cannot avoid the question about the value of human life to which a given personalistic norm refers

directly. One cannot avoid referring to philosophical anthropology, which defines a concept of person



10

and real, objective good for person. In doing so numerous bioethicists deal for example with the problem

of personal status of a human embryo or with problems related to the possibility of interfering and

changing the genetic structure of man.

The author opposes the narrow, functional concept of person presented by such bioethicists as H. T. Eng-

elhardt or P. Singer who regard it as a basis of many wrong moral choices in their bioethics.







[12] MORAL CONFLICTS IN THE CONTEXT OF LIVING KIDNEY DONATION - the

recipients' perspective at follow-up



Nikola Biller-Andorno, Alexander Wopfner, Henning Schauenburg (Germany)



Patients' moral expertise is still rarely used as a resource in medical ethics literature. We address this

lack in a study involving patients who have received a kidney from a living donor at Goettingen Uni-

versity Hospital. In Germany, like in many other countries world-wide, organ donation is being advo-

cated increasingly as an alternative to scarce postmortal transplants. It is therefore of particular impor-

tance to take the patients' perspective into account, not only with regard to potential therapeutic impli-

cations for the individual patient, but also as part of a continued effort to further improve the quality of

medical care.

The sample of the study consists of 26 patients (60% male), between 20 and 68 years of age. Trans-

plantation had been performed between 1995 and 1999, with most organs (73%) donated by the patient's

mother, wife or sister, and only 23% provided by brother, father or husband. Patients are asked to fill out

questionnaires concerning their physical and psychosocial well-being during one of their follow-up

visits at the hospital. A consecutive 60minute interview explores the recipient's perception of the do-

nation process: How did the issue of living organ donation arise? Whose initiative was it? What was the

role of medical advice'? Who was involved in the decision of accepting the offer and how did the moral

conflict present itself to the prospective recipient? We then address changes in the family structure and

the role of the donor and recipient. Finally, we ask for the criteria of a suitable donor and explore pa-

tients' preferences given the hypothetical choice between postmortal donation. Living organ donation

(from whom?) and xenotransplantation. Interviewing is followed by transcription and computer-aided

analysis.

The paper will summarize the central moral conflicts perceived by the organ recipients and their

judgements regarding potential therapeutic alternatives. Findings will be discussed in the light of:

- selection of suitable recipient-donor pairs by transplant programs

- the influence of medical advice in initiating or deciding on a living organ donation - the potential

development of xenotransplantation as a therapeutic option

Conclusion: The patient's perspective is still an underestimated and largely untapped source for ethical

reflection and analysis in medicine. It certainly cannot give normative answers to the many ethical

questions that continue to arise in the context of living organ donation. Nevertheless, it can provide a

valuable contribution on how to work towards a humane health care, even - or especially - in a

"high-tech" field like organ transplantation.







[13] THE IMAGE OF DEATH AND DYING IN HOSPITALS - an analysis of terms

Thomas Bohrer (Germany)



One of the most important images, but less recognised in medicine at present is the problem of death and

dying in the hospital.

Traditionally the human being has a special relationship to both. It is postulated by this paper that the

necessity exists of an interdisciplinary approach to the subject. The matter possesses high urgency, as

most people die today in elderly homes and hospitals away from their home, against their original will to

die at home. The terms which are used to characterise death and dying in hospitals are of main interest

for this analysis. These terms applied by different groups, health care professionals, family members and



11

patients are explored. The following general problems are discussed: What means death and dying under

stationary circumstances, what is the meaning of these terms, what is thought, when these terms are

applied and what are the advantages to use them like that ?

It is part of the ethical and ontological field of thanatology to find out the meaning of death and dying

and to compare it with the present status. In the present public opinion the images of death and dying are

totally different from historical views: Death seems menacing, deficitory, pathological; it seems to be a

catastrophe which no longer belongs to life itself. This paper wants to point out that reasons for that are

mainly sociological and strongly influenced by the dislike to discuss the matter. An example for that is

the actual situation in hospitals with the following specific questions to be posed: Is death in hospitals a

side effect of modern medicine and can health care professionals ignore the fact of dying?

Three theses in general are postulated: First, there is a special concept of death and dying under hospital

circumstances which does not fit to our natural terms. The terms are highly classificatory. They imply

alternative decisions, are orientated empirically and comparatively to existing conditions and based on

objectively metric findings by health care professionals. Second, the terms of death and dying in hos-

pitals are strongly connected to a special social role for those who die there, e.g. the role of an outcast of

society. Third, a new concept of death and dying cannot be founded solely on a medical-natural scien-

tific base. This has great effects on bioethics, as it has to deal with these terms itself.

In conclusion: we have to find the necessary conditions for death and dying in autonomy. Future per-

spectives are shown to point out the significance of humanising health care images and efforts con-

cerning death and dying in hospitals.







[14] ETHICAL ASPECTS OF USING TRANSGENETICAL ANIMALS IN

XENOTRANSPLANTS

Paweł Bortkiewicz (Poland)



The main objective of this paper is to consider the issue of ethical (and possibly legal) boundaries of

xenotransplantation (transplantation across species). It seems that transplanting animal organs to human

beings has become a significant alternative to traditional transplantation. Such transplants appear to

eliminate the contentious ethical issues related, in the first place, to transplantation of single organs. On

the other hand it raises new and challenging questions linked to the transgeneticity of animals, the limits

of experiments on animals as well as dignity of a human beings.

The paper consists of three parts.

Part one present a description of how transgenetic animals are used for xenotransplants. The use of such

organisms results from practical problems faced by traditional transplantology (limited availability of

human organs, ethical and legal issues regarding the pronouncement of death and the permission to

remove from the body and transplant organs and the problems of selecting the recipient in case of a

limited number of organs and many patients waiting for the operation). In this context, xenotransplan-

tation seems to be unaffected by the above-mentioned issues. Briefly mentioned is also the method of

creating and cloning of transgenetical animals and the essence of the across-species transplant itself.

Part two offers an insight into two dominant models of bioethics - a utilitarian and a personalistic one.

Both of them imply certain attitudes and applications of ethical norms in concrete issues (here: the

problem of genetically modified animals in the treatment of humans.

Utilitarian attitudes (given the diversity of this trend) stress the necessity of weighing the pros and cons

in the evaluation of prospective consequences. Personalist ethics, characteristic of the fundamental

streams of Catholic thought, maintains that the only criterion of all the medical incursions into the

human organism is the dignity of a human being and the good of the patient.

The last part discusses some detailed issues and is an attempt to elucidate them from the point of view of

the above-mentioned ethical models. One of these issues is the boundary of risk to be taken in dealing

with animal and human nature. The other question to be pointed out is the case of human dignity - that of

the patient. Another problem can be described as the influence of the received organ on the mentality of

the patient and, at the same time, on his or her consciousness and identity as a person. Still another issue

is the problem of ethical evaluation of the transplant's costs - especially in terms of justification of such





12

operations with the scope of basic medical services - given the lack of funds to cover such medical

expenses.

The last issue is the question about ethical admissibility of these procedures towards animals.

This paper is meant to be an overview of the existing situation in the discussed problem are and is not

meant to formulate ready and explicit conclusions.







[15] SHALL PARENTS DECIDE? A grounded theory study of patents' participation in

life-and-death decisions concerning their premature children.

Berit S. Brinchmann (Norway)



The aim of this project is to generate knowledge about parents' participation in life and-death decisions

concerning their very premature and/or critically ill infants in hospitals neonatal units. What are health

personnel's and parents' attitudes towards parents‟ involvement in such decision making? Do parents

and health personnel agree? If not; how do their views differ? This project is the third phase of a larger

study entitled "Ethical decisions in neonatal units, in whose best interest?" The focus of the study's first

phase was on how nurses and physicians experience these difficult ethical decisions. The second phase

of the study focused on how parents, having been part of such ethical decision-making, experience life

with a severely disabled child.

A descriptive study design has been chosen using field observations and in-depth interviews. 22 inter-

views and 120 hours of observations of nurses' and physicians' work in a neonatal unit was conducted in

1995/96. During 1997/99, 19-qualitative interviews with 34 parents of 29 children have been made. 12

of the infants have died, 17 were alive at the time of the interview. The qualitative, comparative method

(Grounded theory) has been used in the analysis of the data. The analysis was carried out continuously

and in parallel with data collection.

The findings seem to indicate that both health personnel and parents agree that parents should not have

the final word in decisions concerning their infants‟ future life or death. Such a responsibility is likely to

make parents feel guilty, and puts too heavy burdens on parents who lack the medical knowledge and the

professional experience needed to make such a decision. These decisions are seen as both medical and

ethical, and the physician is legally and medically responsible. However, these decisions should be

discussed with other physicians and nurses involved in the treatment of the infant, and parents should be

informed and listened to during the whole decision-making process. The parents concern is how nurses

and physicians communicate with parents who are experiencing a crisis, and how this serious informa-

tion is presented. Some examples deal with problems of physicians acting too paternalistic.

In the paper these findings will be discussed against previous research and ethical principals of

"autonomy" and "best interest".







[16] AN ETHICAL EVALUATION OF SURGERY TRIALS WITH A SHAM SURGERY

CONTROL GROUP

Baruch A. Brody (USA)



The debate about the ethical acceptability and humanness of sham surgery trials has recently heightened

with the publication of two conflicting assessments in the New England Journal of Medicine. Those

assessments focused on one such trial, the trial of fetal tissue transplants for Parkinson's disease, where

the sham surgery was quite invasive and involved a general anesthetic. This presentation will describe a

different sham surgery trial for which I served as the chair of the DSMB, a trial evaluating arthroscopic

surgery for osteoarthritis of the knee. In that trial, the sham surgery involved only a minimal superficial

incision and no general anesthetic. I shall argue that the relevant ethical standards as far as risks and

benefits are concerned are whether the risks have been minimized and whether the resulting risks are

justified by the benefits of maintaining the blind. I will further argue that both of those standards were

met in this trial. It has been suggested that such trials must be flawed ethically because no subjects

would give informed consent to being randomized into such a trial. I will present the technique we



13

employed to maximize the likelihood that consent to participation was informed in our trial and data

about enrolment which support that claim. Finally, I will consider questions of justice associated with

this trial. My conclusion will be that not all sham surgery trials are the same, and that some may clearly

be both humane and ethically justifiable, even if others are not.







[17] LUDWIK FLECK’S REAPPRAISAL OF THE HISTORY OF GERM-THEORIES.

Historiographical and epistemological considerations

Stig Brorson (Denmark)



This paper deals with the concept of proto-ideas introduced in the 1930's by the Polish microbiologist

and medical philosopher Ludwik Fleck (1896-1961). According to Fleck, many established scientific

facts are, in their development, linked to prescientific proto-ideas. While such ideas have been present

continuously in history, their interpretations exhibit no continuity. Fleck suggested to perceive modern

knowledge of infection as a strictly timebound interpretation of an ancient proto-idea regarding disease

as caused by animalia minuta. In this paper I address several interrelated historiographical and epis-

temological problems implied by Fleck's thesis.

After having introduced the concept of proto-ideas I shall discuss:

a) to what extent a philosophical thesis can be supported by history,

b) what kind of historical support that counts as support,

c) if Fleck succeed in combining an anachronical and a diachronical perspective on science,

d) what role the notion of continuity can play within a non-realist theory of science,

e) whether it makes sense to ascribe no truth-content to proto-ideas, and

f) to what degree Fleck can maintain the non-neutrality of the analyst's viewpoint.

Of course, these complex matters cannot be discussed thoroughly within the presentation but I will

attempt to demonstrate some of the problems raised by my work with Fleck's thesis in the context of

historical germ-theories.

On the one hand, I am sceptical about a couple of Fleck's philosophical assumptions. On the other hand,

I conclude that Fleck's concept of proto-ideas provides a fruitful frame for understanding the precondi-

tions for modern knowledge of infection.







[18] HEALTH CONCEPTIONS, ETHICS AND NURSING PRACTICE

Maria Bettina Camargo Bub (Brazil)



The practice of nursing in Brazil has been strongly influenced by two conceptions of health. In some

ways, by the medical model, which is totally focussed in the disease itself, and in other way, by a

number of nursing theories (most of them from the USA) in which the focus is set on the human being.

Whether, according to Nordenfelt (1995), in the biomedical model (or biostatistical to Boorse), health is

handled through an analytic perspective, our opinion is that in nursing theories health is handled as what

the same author describes as a holistic perspective. In the first one, the issues in focus are the organs‟ and

body systems‟ structural and functional abnormalities, while, in the second it is the human being as a

whole.

In the first, the concepts are linked to the disease process. In this context, the diseases are classified and

characterized due to etiologic factors, structural alterations and/or functional manifestations (signs and

symptoms), while in the theoretical models used by nurses, the central concepts are: the human being,

disease/health, environment and nursing. What we have observed, is that depending on the dominant

health conception, the practice of nursing is influenced positively or negatively, for we are led to act in

very different ways. So, our concerning in this work, is to reflect about the ways by which the different

conceptions of health reflect themselves in our concrete practic, more specific on the relationship be-

tween nurse/patient and the caring process (assessment, nursing diagnosis, interventions and evalua-

tion). From the ethical point of view, we can easily imagine that a relationship nurse/patient based on an

analytic perspective tends to be more prescriptive, for the focus is on the disease, and the actions aim at



14

the control of signs and symptoms, denying the patient his or her own humanity, for the meanings

attributed to the events related with his/her health, his/her desires and intentions are not considered. On

the other hand, a relationship nurse/patient in a holistic perspective can only be mediated through the

dialogue between equals, where the base of the caring process turns to be the health problems experience

and their consequences to people's lives as a whole. For, beyond the ethical implications we can verify

that in the caring process, the nature of nursing diagnosis is modified according to the dominant health

perspective in a certain caring context.







[19] PREDICT ANY RISK IN MEDICINE? About a clinical-biological research activity of

prediction about child's diabetes.

Bruno Cadoré, Pierre Boitte, Claude Deschamps (France)



From the introduction of the context in which the problem has been studied, quite a few questions are

worth being asked. How can be distinguished a screening activity and a prediction activity? is it a

clinical activity or a research activity? What kind of link can exist between prediction and prevention?

These questions lead to precise epistemological limits of such a practice (the relevance of the biological

reductionism, the mutations of clinical approach in the predicitve medicine) and to wonder about the

normative ethic which is implicit in this clinical practice.

The notion of risk then seems essential in the questioning.

After such a reflection, we can come back to the questioning of what such a practice will lead to. It will

be then possible to point out the main points we have to be careful to carry on this activity, or to decide

to spot this activity.







[20] GENETIC INFORMATION, HEALTH INSURANCE, AND HUMANITY

Robert F. Card (USA)



Philosophical questions arising from the human genome project are not completely new: they raise

traditional issues in social and political philosophy as well as pressing questions in medical ethics, since

properly addressing these questions is central to building a just society. This paper explores the most

humane way to use genetic information in risk classification for health insurance purposes. Some argue

that there should be full disclosure of information from genetic testing to insurers, since individuals who

have had genetic tests performed could use this private information to engage in "adverse selection,"

thereby exploiting insurance companies. Others argue that information from genetic testing should not

be used at all in setting insurance premiums, since the model of actuarial fairness is not appropriate for

such decisions.

I contend that both of these positions are mistaken. While I agree that the model of actuarial fairness is

limited in application, the latter position is untenable since the phenomena of "adverse selection" sug-

gests that genetic information may properly be used by insurers in some cases. The former position,

which supports full disclosure, is unreasonable since individuals who have been genetically tested may

not have knowledge of all results of genetic tests. For instance, a person with a family history of

Huntington's disease may order a genetic test for herself, or for her fetus via amniocentesis, only out of

an interest in this disease. Even if we suppose that the test is negative, a genetic test may reveal other

unfortunate aspects of one's genetic inheritance, so that full disclosure of genetic test information to

insurance companies may lead to increased premiums for other reasons. If only the information re-

garding the gene for Huntington's is revealed by the genetic counselor, it is unjust to increase this in-

dividual's insurance premiums, since only those troubling aspects of one's genetic inheritance which one

knows about can be used to engage in adverse selection.

This paper adopts a broadly Rawlsian approach on which the social purpose of insurance is seen as

intimately linked to the fact that health is a natural primary good--adequate health is essential for ful-

filling every person's conception of the good. Rawls' Original Position may be taken to suggest that







15

since persons' genetic makeup is not within their control, any society which puts additional economic

burdens upon those with unfavorable genetic prospects is unjust.

While this "Control Principle" is significant, the strong conclusion above is unwarranted, since in the

actual world knowledge of genetic risks can wrongly be used by individuals to their advantage. The

most humane position balances insurers' and individuals' concerns, since a society which adopts this

approach is best able to both respect the individual's rights while also safeguarding the primary good of

health for other policyholders. The paper concludes by developing and responding to objections to its

thesis.



References:

- American Council of Life Insurance and Health Insurance Association of America, from Report of the ALCI-HIAA Task

Force on Genetic Testing (ACLI-HIAA, 1991); Reprinted in Levine, C. (ed.) 1999. Taking Sides: Clashing Views on

Controversial Bioethical Issues. Eight Edition, pp. 210-214. (Guilford: Dushkin/McGraw-Hill)

- Thomas H. Murray, from "Genetics and the Moral Mission of Health Insurance," Hastings Center Report.

(Nov/Dec.. 1992) Reprinted in Levine, C. (ed.) 1999. Taking Sides: Clashing Views on Controversial Bio-

ethical Issues. Eight Edition, pp. 215-220. (Guilford: Dushkin/McGraw-Hill)

- -Rawls, J. 1973. A Theory of Justice. (Cambridge: Belknap Press).









[21] THE CONCEPT OF DEATH AND THE PRACTICE OF TRANSPLANTATION

Asta Cekanauskaite (Lithuania)



1. The main goals of this report are, firstly, to present that organ donation is acceptable to Christian

doctrine but its practice is rather complicate in Catholic societies and, secondly, to reveal one of the

reasons of this phenomenon - coexistence of different concepts of death.

2. According to statistical data transplantation in Lithuania like in other European countries commonly

do not even start because relatives of the dead person do not consent to sacrifice his or her organs for

donation. Lithuania is a Catholic country where value of life is predominant. Public debates and public

opinion polls on euthanasia or artificial fertilisation clearly illustrate this fact. Usually it is argued that

life is given by God and so people should not interfere in life and death affairs. Euthanasia and artificial

fertilisation are really not acceptable to Christian doctrine. However the Church doesn't reject organ

donation, on the contrary, it induces such practice. Organ donation is interpreted as the highest expres-

sion of Christian love for another human being. Thus transplantation is more than acceptable for the

Christian way of thinking. Reality shows very different view, though. Why?

3. Transplantation becomes possible only because of a special concept of death - "brain death". Such

understanding of death is legally established in most countries including Lithuania. Although statistical

data, showing that the main factors constraining the practice of transplantation are not medical, indi-

rectly reveal the fact that the concept of "brain death" isn't quite accepted neither by the general public,

nor by physicians.

4. If we try to examine carefully the transplantation procedure itself and various problems related with it,

we will notice at least two different (although coexisting) concepts of death. One may be called tradi-

tional or natural, the other - medical, or, as have been mentioned above, "brain death".

From the common (unprofessional) point of view "brain death" is just a scientific abstraction. In that

case an unquestionable proof of vitality is breathing and heart beating. Despite the fact that the proce-

dures and criteria for death determination are legally established even the professionals usually try to

avoid turning-off the ventilator for a person who is considered to be dead according to medical criteria

(for whom "brain death" is diagnosed). Instead of "pushing the button" they prefer a "moderate" way of

life ending for a man which in fact is already dead - they little by little reduce the amount of oxygen.

Such a ritualisation of life ending shows the collision of professional (scientific) and traditional (natural)

attitudes towards death.









[22] COMPASSIONATE HEALTHCARE IN A CAPITALISTIC ECONOMY



16

Karolin Cheboski (USA)



Are the values of compassionate healthcare systems consistent with the values of a capitalistic econ-

omy? Where are the discrepancies between these two value systems, and are they mutually supportable

by a social philosophy of healthcare delivery?

Healthcare systems in the United States have undergone dramatic evolution in the past twenty years,

trying to quantify and qualify the delivery of healthcare services, while financially supporting a system

which was becoming increasingly complex. Prepayment of healthcare services through insurance sys-

tems had difficulty anticipating increased costs based on new technologies in medical care. Little at-

tention was paid to the necessary transformation of healthcare values, which was needed to accompany

the change to prepayment healthcare delivery systems.

In addition, the shift to a healthcare system functioning with limited resources, and financial account-

ability, required that healthcare practitioners develop a large group of new skills to deal with the value

system conflict that was inherent in prepaid healthcare delivery systems. The ability to deal effectively

with patient expectations when coverage was limited, negotiate stages of patient care, and reengineer

medical practices to accommodate the new variability in healthcare delivery was not offered and was not

pursued by healthcare providers.

Capitalistic economies reward financial gain, measure the distribution of available services, and make

choices about which services are financially viable. Compassionate healthcare proponents see the

limitation of access to services, based on the inability to provide payment, as morally unacceptable.

This paper will explore this conflict, and will offer recommendations for the development of humane

healthcare systems that are also accountable financially, and function for the overall good of the society.









[23] HEALTHY WAY OF LIFE OF YOUTH IN BULGARIA

L. Cherkezova (Bulgaria)



The natural desire of the people to learn, to understand and to manage their health and life today have a

new meaning and has become the main value in their life. The question for the preparation of the young

generation to have a healthy lifestyle has become very critical, since together with the scientific and

technological achievements, the modern civilization hides also a lot of risks for the health.

Modern youth are endangered by various diseases and fatal incidents, caused by the factors of the nature

and social environment as well as by specific unhealthy models of behavior, which are shaped during the

childhood and teenage years. Young people don't accept the health as a main value and have a tendency

to overlook the healthy lifestyle. With their young sureness in life and with the solving of the main life

problems they often underestimate even the most basic norms for maintaining the relatively healthy

level of life.

The current research will answer the necessity for having a clear idea of the conditions, stimulus and

barriers for the healthy life style of the young people in Bulgaria.







[24] PHILOSOPHY OF THE WEAK AND THE STRONG INTERACTION IN WESTERN

(EUROPEAN) AND ORIENTAL (CHINESE) MEDICINE

Yu P. Chukova (Russia)



European (Western) and Chinese (Oriental) medicine exist independently of one another throughout the

millenia. In Western medicine allopaty and homoeopathy co-exist as parallel branches. In our country

the homoeopathy was prohibited for a long time and the separate practise medicines were in semilegal

existence. All of these branches of medicine have the same object of study - person. So different





17

methods of influence on a person have been seemed strange up to the rising of the thermodynamic

theory of electromagnatic interaction with living systems.

This theory presents the fundamental laws of the electromagnetic energy conversion efficiency into

Helmholz free energy. One makes it possible to understand so strong difference between Western and

Oriental medicine, allopathy and homoeopathy, and contemporary methods of treatment.

The living systems are open systems in the thermodynamic sense. This system exchanges both mass

(reactants and products) and energy (electromagnetic energy and thermal one) with the environment. It

is very important for living systems existing under day/night change to take account of electromagnetic

radiation. This day-night change of the light intensity is about 20 orders of magnitude of light intensity.

This wide range of energy intensity means that this interaction is a very important although it is very

habitual and usual.

The normal conditions of people existence are isothermal ones. This is a very rigid condition: the

temperature range for man is small (10 degrees). For the efficiency of isothermal processes the ther-

modynamics of irreversible processes presents the following. By weak action the isothermal process

efficiency and the power absorbed have the logarithmic relationship, then the efficiency shows the

maximum or plateau to be followed by decrease up to zero.

The subsequent increase of absorbed power makes it possible to heat of the living system and cause the

thermal process. The efficiency of thermal process and absorbed power is the linear function. It means

that the isothermal and thermal processes are subject to various laws and these functions are differen-

tiated easily by experiment. It stands for the same result will be able to obtain by different methods.

These two effect ranges are the basis of the existence of two kinds of medicine: Western and Oriental,

allopathy and homoeapathy.

The Western medicine and allopathy are related to only the thermal processes, and Oriental one and

homoeapathy are related to the isothermal process.

The action division into the thermal and isothermal processes (weak and strong actions) takes place in

both physical and chemical processes. The outcome (two interaction ranges) holds true for both elec-

tromagnetic field and chemical agents.

This thermodynamic theory holds for both objective sensory physiology and subjective sensory physi-

ology. The Weber-Fechner law is the experimental form of the thermodynamic theory laws. It shows

that the thermodynavic theory is valid for consciousness.



References:

1. Chukova Yu.P. - Russian Journal of Physical Chemistry, 1990, v. 64, p. 16-19

2. Chukova Yu.P. - Dokl. Biological Sciences.Proceedings of the Academy of Sciences of the USSR, 1988, v. 300, p. 306-308;

1990, v.311, p. 237-239

3. Chukova Yu.P. - Vol. of abstracts 10-th International congress of logic, methodology and philosophy of sciences, 1995,

Florence, p. 509

4. Chukova Yu.P. - Biophysics, 1989,v. 34, No 5; 1992, v. 37, No 5, p. 889-893

5. Chukova Yu.P. Vol. of abstracts, 11-th International congress of logic, methodology and philosophy of sciences, 1999,

Krakow, p. 334

6. Chukova Yu.P. - Bioelectrochemistry and bioenergetics, 1999, v. 48, p. 349-353









[25] CLONING AND THE IDENTITY OF THE PERSON

Barbara Chyrowicz (Poland)



The argument frequently raised by the opponents of cloning holds that cloning should be rejected on the

grounds that it violates the identity of the clone. This objection seems to be rather paradoxical, since,

according to the common understanding, the ultimate purpose of the technology of cloning consists

precisely in exact replication, that is in making identical copies of the humans who are to be cloned. In

my article I attempt to explain what we understand by the identity of the person and then argue that

cloning as such does not violate the person‟s numerical or metaphysical identity, or the identity of the

person as belonging to a species. Yet it significantly affects something that could be referred to as the

individuality of the person. By individuality I understand the collective traits of a given individual which

result in his or her way of behaviour, thinking or expression, as well as in the person‟s life story and the

so-called “recipe of life,” unique and hence unrepeatable among other individuals. The fact that the



18

numerical individuality of persons, as well as their uniqueness resulting from personal expression, is

discernible, indicates that all the attempts to impose anything on the person are doomed to failure,

regardless of whether they are attempts on the part of individuals or systems, and no matter whether the

system in question is of political or eugenic nature or what ideas it reflects. In a certain respect the

project of cloning humans is not a novel idea. The desire to replicate oneself or others does not neces-

sarily result from the successful experiments with the cloning of a sheep, a mouse or other animals,

although the context provided by the technological success with cloning certainly gives a new face to the

idea of replication and enhances new prospects for it.







[26] SOCIOLOGICAL ISSUES OF MEDICAL PREFESSIONAL AUTONOMY IN

REFERENCE TO THE MEDICAL MALPRACTICE PROBLEMS

Bardhyl Çipi (Albania)



Medical malpractice actually constitutes an important problem in Western countries. It presents also a

particular importance in Albania. In medical malpractice, usually, it is possible to pursue one of three

strategies, or any combination of them.

First, there is individualistic regulation through the law: the patient suing the doctor if the service is

inadequate.

Second, there is collective regulation through the profession and society. In this case, the medical pro-

fession must ensure that its members are competent and that patients are protected.

Third, there is a mixed system, where this regulation is shared between society and profession. As a

matter of fact, in these different systems, the question of the presence or not of the medical professional

autonomy plays a big part.

From the sociological view-points, there are two main attitudes: the first suggests a diminution of

medical professional autonomy. After Oppenheimer (1973) and Marie Haug (1973), the medical pro-

fession is losing significant degrees of power either through processes of what has been called 'depro-

fessionalisation', of through 'proletarianization' and this process will be major future trend. The second

attitude underlines that the profession of medicine is going through a period of change and serious

challenge, but that it will be able to maintain status and high degrees of autonomy in significant areas of

professional work. To my opinion the arguments of the authors of this second attitude: Weber, Parson,

Freidson etc., are scientifically more exact: 'The autonomy is the central characteristic of a profession.

An important role in this autonomy plays the state and the medical education, the organisation of work,

the control process found in work setting, etc.' For this reason, it is necessary to reinforce in general the

medical self-regulation. As far as the Albania is concerned, this collective regulation has been lacking,

because the Order of doctors is not helped as much as it is needed to carry out the duty of control of the

moral aspects of the physician's activity and their breaches. Therefore, I think that self-regulation must

play a greater role in the conditions of the medical malpractice crisis.







[27] STRESS AS A RISK FACTOR IN POPULATION OF YOUNG HEALTHY MEN

Maria Cisek, Tomasz Brzostek, Ewa Wilczek-Rużyczka (Poland)



The World Health Organization defines `health' not as merely the absence of a disease but as a state of

physical, mental and social well-being. Medical and social sciences try to find the ways of defining the

positive concept of health. The multifactoral model of disease indicates the importance of socio-cultural

and psychological factors having an influence on health. Each individual has to cope with a variety of

factors causing stress. If they are considerably strong, an individual can easily be deprived of satisfac-

tion with life and is not able to enjoy life fully. There have been a lot of studies proving a negative

influence of stressful events on the individual's well-being and their role in aetiology of somatic dis-

eases, as well as their other harmful effects on health with regard to social environment.

Cardiovascular diseases develop as a result of interaction of the complex of factors involved in a

cause-effect chain. The main risk factors are of biophysiological, social and/or psychological nature.



19

The aim of this study is presentation of the incidence of stress as a risk factor of ischaemic heart disease

in men below 50 years of age.

In the assessment of stressful factors Social Readjustment Rating Scale was used. According to the

standard scale of stressful events; the score below 80 means an average level of stress, 80-150 means ton

heavy stress - the risk of heart infarct exceeds 50 per cent, and over 300 - extremely high risk of heart

infarct. Apart from this, Personality Pattern A (Friedman and Rosenman), evaluation of physical

symptoms of stress and professional stress (Trauer) were incorporated.

The study group included 64 young healthy men working in the state offices. The mean age was 40

years.

The results of our investigation show that stressful events occur in as many as 80% of the examined

men, nut of which 40% has got 150 score, and another 40% - 300. The score ranged between 25 and 399,

the mean was 209. Over 60 % of the men studied showed Personality Pattern A. In the group studied,

65% of men assess their work as very stressful. Physical symptoms of stress were reported by 90%, nut

of which 60% presented four somatic symptoms.

Various types of stress are connected and related to each other. The results of the studies indicate the

beneficial effect of the training of stress management in difficult situations by healthy people, as well as

providing social and emotional support, which is the scope of health promotion.





[28] THE MATRIX: AN ETHICAL PERSPECTIVE FOR HUMAN GENETIC MEDICINE

Marilyn E. Coors (USA)



The Human Genome Project is producing vast amounts of information that promises tremendous benefit

for humankind and, in turn, generates profound ethical questions. In response to the challenges that

genetic technology raises, this paper proposes a value-based approach to ethical analysis in the field of

human genetic medicine. A philosophical inquiry was conducted which resulted in the Human Genome

Matrix, an analytic tool to differentiate those procedures, policies, and research in human genetics that

are ethical from those that are unethical. The Matrix applies the ethical language at human dignity to the

scientific issues of health and disease. The foci of the Matrix are current applications of genetic medi-

cine and future somatic cell and germ-line gene alterations.

The purpose of the Matrix is to facilitate the deliberations of genetic professionals, ethicists, and review

boards who are considering complex ethical issues in human medical genetics.

Theory

Evidence suggests that any ethical theory, in itself, is insufficient to address the

complex and far-reaching decisions required by the advances of human molecular genetics (Hanson

1997). Decisions of these proportions require an alignment of diverse disciplines and ethical theories in

order to assess the unique implications of the genetic revolution. In order to accomplish this task, the

works of four philosophers were examined to identify values, obligations, and virtues germane to an

ethical perspective on human genetic medicine. The outcome is presented in the Human Genome Ma-

trix.

Results

The Human Genome Matrix is comprised of a scientific axis representing aspects of human genetic

medicine and an ethical axis consisting of seven questions summarizing the values, virtues, and duties

ascertained by philosophical inquiry. The analysis of the ethics of virtue, as interpreted by physician and

ethicist Edmund Pellegrino, establishes the virtues of justice, integrity, and wisdom as important com-

ponents of an ethical perspective for genetic technology (Edmund Pellegrino 1995). Philosopher Hans

Jonas emphasizes the responsibility involved in ethical duty (Jonas 1984). The particularizing ethic of

Emmanuel Levinas represents the contribution of postmodern philosophy and culminates in the inclu-

sion of the values of difference and informed consent in the Human Genome Matrix (1969). Utilitarian

ethicist John Stuart Mill provides the calculation of benefit versus harm as a factor to be addressed in

ethical assessment of human genetics (Mill 1957). The ensuing Matrix is proposed as a vehicle to rep-

resent an ethical perspective having the capacity to address the unique temporal and ethcal dilemmas

that genetic medicine poses.

[29] THE PATIENT PROTECTIVE ORGANISATION INTITUTIONS AND THEIR

POSSIBLE NETWORK, CO-OPERATION AND WORK DISTRIBUTION



20

Zsuzsa Csató, Klara Laszlo (Hungary)



In Hungary the associations and among them the patient self-help organisations were legally “permit-

ted” 11 years ago. During this period about 60 nation-wide patient organisations and around 800 in-

formal groups and special patient serving foundations were established. There basic aims are the interest

protection - from individual advising to lobbying for legal changes - they offer special services, first of

all information and education, and nearly all of them offers community for people with similar prob-

lems.

The first public conference about patient rights was organised by the patient movement in 1992. On the

other hand, there were enthusiastic experts on patient rights since about 12 years. This was a small group

of lawyers, advocates and some professional working and so knowing well the European rights. They

offered information, education and some legal practice in the field. These professionals established the

TASZ, the Society for Freedom, in psychiatric field, the “Szószóló” Foundation for Patient Rights in

1996. Since this they start pilot projects on patient advocate field, they offer free advocacy, information

leaflets, posters etc.

In 1997 December the new Law on Health Care had a special chapter on patient rights offering detailed

description on them at an international level and ordering local patent advocates for human rights pro-

tection.

In this way we have three different systems for patient protection. Recently the question is, how the

governmental ombudsman like system, the professional free protection and the self-help movement can

and will work together effectively.





[30] ETHICAL ASPECTS OF SHAM SURGERY IN PATIENTS WITH PARKINSON

DISEASE

Wim J. M. Dekkers (The Netherlands)



Since a few decades the availability of human body parts is increasingly of importance for the treatment

of patients and biomedical research. One of the promising areas in this field is embryonic and foetal

tissue transplantation (EFTT). One of the diseases which nowadays are treated with EFTT is Parkinson

Disease (PD). Worldwide about 300 patients with PD have been treated with intracerebral transplanta-

tion of foetal tissue (containing embryonic dopaminergic neurons). The results have been variable, but

several centers have observed consistent and clinically meaningful benefits in open label trials. In order

to determine the safety and efficacy of this new medical technique, recently a double blind, placebo

controlled study has been started. This method would be the only way to exclude the possibility that the

benefits of EFTT are due to a placebo effect or investigator bias. In this study 24 patients undergo EFTT

and 12 patients only so-called sham surgery. Each placebo procedure includes, among other things, the

placement of a stereotactic frame, target localization on magnetic resonance imaging, general anesthe-

sia, and a skin incision with a partial burr hole, that does not penetrate the inner cortex of the skull. There

is no needle penetration into the brain and no fetal tissue is implanted.

In my paper I will address the question whether it is morally allowed to perform sham surgery in an

experimental study in patients with PD in order to assess the safety and efficacy of intracerebral trans-

plantation of foetal tissue. In my critical comments I will emphasize the differences (1) between two

kinds of moral questions related to new medical technologies (questions of application which arise and

remain within the framework of the technology and fundamental questions which concern the tech-

nology itself), (2) between sham surgery and "real" placebo surgery, and (3) between pharmaceutical

studies, "traditional" surgery, and cellular-based therapies. The most difficult question to answer is

whether there is a "reasonable" balance between the clinical and scientific value of a particular study on

the one hand, and the burden (risks and inconveniences) it causes to the research subjects on the other

hand. Crucial is whether there is an alternative research design that does not involve sham surgery and

that will pose a lower risk of harm to the subjects in the control group. I will concentrate on the notion of

integrity of the human body and on the relation between the risks of a protocol on the one hand and the

informed consent of research subjects on the other hand.

[31] THE CONCEPTS OF HEALTH AND DISEASE IN PREDICTIVE MEDICINE AND

THE INFLUENCE OF RECENT GENETIC RESEARCH.



21

Kris Dierickx (Belgium)





Predictive medicine has come in the spotlight again due to the recent developments in the domain of

medical genetics. The developments in this area will lead to the fact that more and more people at an

earlier stage will know if they have an (increased) risk for a certain affection. But the rise of the genetics

related predictive medicine forms a part of a much broader development, wherein thinking in terms of

health risks is going to determine the perspective on health. As being at risk, the people concerned fall

between two stools: because they are neither ill, they cannot play the role of the ill person; because the

are nor completely considered healthy (as a result of the predictions), they are excluded of the provisions

that exist for healthy persons. Formulating health care issues in terms of risks has consequences for the

way people are looking at themselves, their body, their fellow people, and for the relations between

doctors and their -potential- patients. The expansion of non-symptoms related predictive medicine

(genetics, health education, medical examination in the context of employment or insurance) necessi-

tates a reconsideration of normative questions that are at stake in politics, ethics, courts, movies, books,

theatre etc. The expansion of the non-symptoms related medicine not only leads to new medical prac-

tices and social interventions, but also changes the concepts of health and disease. In conditional pre-

dictions the idea of risk creates a continuum between health and disease; it introduces a relation between

the acts and circumstances of healthy people now, and (the risk for) a later disease. In our paper we will

discuss this change in the concepts of health and disease in the light of a specific form of non-symptoms

related predictive medicine, i.e. genetic medicine.

Since two decades the main aim in medical genetics is no longer an investigation into the genetic

structure of mankind, but one tries to make a relation between genetic research and diseases. Molecular

biology became molecular genetics and introduced the concepts of `genetic disease' and 'genetic health':

results could be used for diagnosis, treatment and prevention of affections. This implicates that genetic

research is developing further within the framework of health and disease. Some authors (e.g. E. Fox

Keller) claim that predictive genetic research confers more weight to the biological meanings of health,

in comparison with other meanings of health. By using the genome as the norm for the health of people,

cultural and social aspects of health are made subordinate to the biological aspects of mankind. In our

paper we try to examine this thesis. Therefore we examine the concepts of genetic health and disease as

well in a conceptual as a societal perspective.









[32] PATIENTS’ RIGHTS - PRESENT STATUS IN BULGARIA

Svetlana Dimitrova (Bulgaria)



Many changes in the structure of both hospital and primary health care in Bulgaria have started to take

place in the last few years. Patients‟ expectations and demands have been becoming different as well.

The process of structural and attitudinal changes in the context of new social and economical conditions

influences the status of patients‟ rights. The main medico-ethical conflict of our society is rational use of

insufficient health care resources. That is why the development of primary health care has been a na-

tional strategic goal. Patients‟ rights are raised in the National strategy for development of primary

health care as the first problem of the present status of this basic health care. In this article an analysis

has been made based on four rights shown as most important in the Strategy: right to free choice of

personal doctor, right to information, right to continuous health care with good quality and right to

confidentiality of medical information. Some results of author‟s own investigations made during the

period 1993-1996 concerning those rights are discussed as well.







[33] MEDICINE IN THE PHILOSOPHY OF TIBETAN BUDDHISM

Elvira Djaltchinova-Malec (Poland)





22

In my paper I would like to present one of the oldest traditional healthcare systems and the answers

which it gives us on the main problems of modern man. The most important texts of Tibetan medicine

show that the goal of medicine and philosophy in the Tibetan tradition is the same. Tibetan medicine

arose from the basic principles of Buddhism. According to Buddhism the main purpose of all living

beings is liberation from disease and other forms of suffering. Medicine aspires to this same liberation

too.

As a part of the Buddhist philosophical system, Tibetan medicine in opposite to modern Western

medicine, and treats human health as a harmony of many important elements like the state of con-

sciousness and mind, diet, life style, weather, environment etc. Disease is a disruption between the

Universe (the macrocosm) and man (the microcosm). Mind is the Lord of all suffering and happiness.

Tibetan medicine emphasizes the use of herbs, behaviors and diet which restore man to his “true nature".







[34] NURSES' PROFESSIONAL ETHICS. Deontological code and the autonomy of decisions

Beata Dobrowolska (Poland)



The essence of nurses' work lies in the protection of the most precious for man values - his health and

life. The duty comprehended in such a way is the essence of nursing deontology. The code of profes-

sional ethics is to be the guarantee for fulfilling this duty, and by being the set of logically ordered norms

appropriate for the nurses' work, it should be the basis for decision making.

However can we speak about the autonomy/independence of nurse's decision that is guided in her work

only by automatically accepted norms incorporated in the deontological code?

In such a case - according to the author - we can speak about the independence of decision making.

Decisions based only on the code are not definite nurse's decisions analysed in her inner world. But they

are abstract decisions taken by those who designed the code.

Therefore it should be emphasised that we can speak about the autonomy of decision-making only when

the norms of deontological code are the subject of individual evaluation and they are confronted with the

presented by nurse hierarchy of values. It changes to a great extent the character of responsibility for the

undertaken tasks by nurse. We deal here with individual responsibility and this - according to the author

- has some influence on the quality of care.







[35] DOCTORS' MOTIVATIONS

Jan Doroszewski (Poland)



The claim that the quality and effectiveness of work depend on the type and intensity of motivation is a

well known truth. In the present paper I will consider this connection from the viewpoint of medicine.

When a person chooses medical studies and practices the medical profession, he or she aims at gaining

and realizing values which concern either other people (externally-directed, altruistic values) or himself

or herself (subjectively-centered, egocentric values). Health and life of individual people and human

populations - or the ideal of health - are the basic medical values; motivation directed at this aim belongs

to the first group. The opposite class of subjectively-centered values may be divided into two kinds,

namely - on the one hand - possession of material goods, and - on the other hand - various types of

satisfaction connected with a moral merit, acquisition of and expertise in a certain field of knowledge,

performance of certain manual and mental operations, some kind of contact with other people etc. The

above motivations are morally non-negative; of course, they are not exclusive, whereas satisfaction

from having authority over patients is an example of a morally negative motivation.

Probably most of those morally non-negative motivations (if not all of them) apply to a varying degree

to all medical students and doctors. Owing to the fact that care for the health of people is a fundamental

social task of every medical doctor and constitutes its differentia specifica among other professions, the

altruistic motivation (in the above sense) is a necessary component of the psychic equipment of a doctor.

High quality and effectiveness of medical services require also the presence of subjective-centered



23

motivations, especially satisfaction from professional expertise and activity, as well as from contacts

and communication with people. Financial motivation of a doctor may be advantageous from the

viewpoint of quality and effectiveness of his or her work, on condition, however, that it is linked with

commercial honesty (“good payment, for a good product"); connection with the principle “the quality of

a product is proportional to its price" would be deleterious. As regards all morally non-negative moti-

vations, an important factor is their appropriate intensity.

In every modern society numerous aspects of medicine are rapidly changing; if, however, medicine is to

remain a health-caring activity, the self-centered motivations should continue to be complementary to

the externally-directed ones.







[36] MODERN MEDICAL COGNITION

Jan Doroszewski (Poland)



The present paper presents the view that progress in medical sciences, technology and organizational

structures promotes the development of the humane aspects of medicine.

The medical practical cognition is an intellectual basis for decisions which the doctor takes together - as

far as possible - with his or her patient. The greater are possibilities of altering the state of human or-

ganism and psyche, the deeper, more complex and versatile must be the physician‟s cognition of the

patient.

Several scores of years from now, practical medicine was based on the observation and reasoning em-

bracing a restricted number of rather precisely defined symptoms, clinical entities and therapeutic

methods; it was possible to exert an intended influence on relatively simple (i.e. only superficially

known) phenomena by means of comparatively unsofisticated actions with fairly predictable results.

Difficult clinical problems resembled intricate puzzles, but the aims of therapy, or good of the patient,

was mostly quite evident. At present in almost all more complex cases there appear a great number of

diagnostic and therapeutic actions which the physician should take into consideration and among whom

he or she should select those that in a given situation are the best from a purely medical viewpoint as

well as the most conformable with the patient's attitude. The problems that arise in these situations are

frequently extremely complex not only in theory but also in practice; they may be formulated and solved

due to the great richness of various branches of modern medical knowledge. The concepts of diseases,

symptoms and signs, medical interventions etc. are no more rigid schemes that play the role of bricks in

a building; now their meaning is composed of chains and sets of phenomena interrelated by variously

formulated general statements which constitute manifold elements of the diagnosis and therapeutic

design. Aiming at making the understanding of the human organism deeper, more adequate and more

flexible according to different needs, we drive away from the traditional “complex clockwork" notion of

organism. In this way the cognition of the patient may be not only much more complete (i.e. more

detailed and more integrating in the same time), more certain and better adapted to technical possibili-

ties, but also more individualized, better reflecting the psychic sphere and more useful for fulfilling the

patient's choices and attitudes. As a price, however, the physician's reasoning becomes more and more

complex, difficult and requiring abilities of solving non-standard open problems.





[37] ACCORDING TO NEED AND NEED ALONE

Andrew Edgar (United Kingdom)



It is the avowed intention of the UK National Health Service that services should be provided purely on

the criterion of 'need and need alone'. This paper will ask if such a demand can be the basis of a coherent

and workable approach to health care allocation, given the continuing scarcity of resources, and there-

fore the necessity of prioritising claims upon the health care service.

It will be argued that there is a systematic ambiguity in the concept of 'need' in this context. On the one

hand, the appeal to 'need' may express a fundamental public commitment to the NHS. On this inter-

pretation, 'need' expresses the desire that no one who has a legitimate claim should be excluded from the

health care system; and crucially that no one should be excluded because of properties of the treatment



24

that they require (such as cost). This interpretation of 'need' entails that the NHS rejects any explicit

appeal to rationing principles, or to the establishment of a list of NHS funded core services. On the other

hand, 'need' may refer to 'clinical need'. According to this interpretation, prioritisation of needs claims

does take place, but prioritisation will be purely in terms of objective medical criteria.

It will be argued that the ambiguity within the concept of 'need' serves to obscure the necessity of es-

tablishing the moral values that must inform the allocation of scarce health care resources, both insofar

as clinical need appears to reduce prioritisation to a problem of objective medical judgement, and need

as public solidarity is laudable but inarticulate.

It will be suggested that the refusal to confront the moral issues of prioritisation and rationing leaves the

UKNHS in a continual state of moral (as well as financial) crisis. This crisis could be resolved through

the introduction of a finite and fundable list of core service, but only at the expense of the inclusive

solidarity that continues to characterise the service. The paper will therefore argue that the public

commitment to the service must be analysed anew. It will be argued that the continuing moral crisis is

fruitful, if it is understood in terms of the continuing involvement of the public in a debate over the

service. The NHS is not to be organised according to pre-existing communal values (as for example was

attempted in Oregon). Rather, debate over the health care system, and most importantly public response

to particular cases or crisis events, serves to allow for the development and articulation of values. In

effect, it may be argued that moral determination of the NHS proceeds in a manner akin to casuistry.

The paper will conclude by analysing some of the weaknesses of this moral debate (and not least its

vulnerability to sensationalism and prejudice), as well as its strengths and the implications that it has for

the moral grounding of other health care systems.







[38] EVOLUTIONARY PSYCHIATRY AND NOSOLOGY

Luc Faucher (USA)



In the early nineties, Nesse and Williams (1991) announced that we were to witness the dawn of Dar-

winian medicine. According to them, in a near future this approach of illness would revolutionized

traditional medicine. In their "Why We Get Sick?", they showed how the injection of evolutionary

thinking in medicine could radically change our way of conceiving illnesses: for instance, they draw

attention to the distinction between symptoms of illness and adaptive way of the body to fight illness

that are like symptoms in their unpleasantness. As they explained, it is important not to get rid of the

second since in doing so we would deprive ourselves of important defense mechanisms. As they

demonstrated, in many cases the confusion between the two had result in poor treatment of illness.

It didn't took long for psychiatrists to see the possibilities of the new program for their field. The last few

years have seen an explosion of evolutionary explanations of mental illnesses. Though, despite the

enthusiasm, it seems that the used of evolutionary thinking had not been as radical as promised - being

limited, as it was, to the explanation of already known mental illnesses (schizophrenia, drug abuse,

depression, etc.). The result is that, with a few exceptions, psychiatrists stayed inside the boundary of

classical approaches to the classification of mental illness (such as those offered by the DSM, for in-

stance). However, these classifications, as I will show, have been under attack and many critics are

asking for a revision of them that would not only bear more on science than the actual ones, but that

would also facilitate the establishment of relations between diverse scientific disciplines (genetics,

cognitive sciences, neurosciences, and, to some extent, human sciences).

My aim in this talk will be to describe a way in which evolutionary thinking could bring a radical change

of view in the domain of the taxonomy of mental illness. I contend that this change would meet the

demands of the critics of the classical model of taxonomy. I intend to demonstrate this through the

analysis of two of the best philosophical reflections on that topic nowadays: Jerome Wakefield's con-

ceptual analysis of the concept of "mental illness" and Dominic Murphy and Steven Stich's work on

taxonomy. In brief, I will show that Wakefield's conceptual analysis leads to some counter-intuitive

results (not capturing what seems perfectly good examples of illness) and is anyway of a limited interest,

given that our intuitive concepts are relative to our culture (I will illustrate the later point by the use of

data from developmental psychology). I will also criticize the narrow conception of the social and

cultural influences on illness. Because of those shortcomings, I intend to take side with Murphy and



25

Stich who are not preoccupied by conceptual analysis but by a more scientific definition of mental

illness. I will describe how they used evolutionary thinking to identify some new taxonomic

meta-categories. I'll illustrate how these categories not only allow to reconfigure in a more accurate way

the domain of mental illnesses, but also how they can be used as heuristics for the discovery of new

ones. I'll illustrate this point with a few psychopathologies like post-partum depression, autism and

sociopathy. I'll conclude by showing how this account of taxonomy might clash with diagnostic prac-

tices because both use different concepts of "function". That should remind evolutionary psychiatrists to

stay modest and to leave the door open to other non-evolutionary explanations of mental illness.







[39] THE TRAGEDY OF MODERN MEDICINE

Stale Fredriksen (Norway)







The permanent crisis of western health care systems can be interpreted as a Greek tragedy. As for the

heroes of the tragedies, the problems of modern medicine can bee seen as a consequence not of the bad

things that medicine do, but as a consequence of the good things. And the best thing about modern

medicine is its capability to document the effect of its interventions, separating what is effective, from

what is useless and even dangerous.

Like Oedipus, modern medicine is on a honourable quest for truth. And as for Oedipus, it is precisely

this quest that leads to ruin. The reason being that there is an inescapable conflict between the certainty

of medical knowledge, and the possibility to understand the same knowledge. This is because the sci-

entific methods needed to reach valid results, at the same time renders the results incomprehensive. To

defend this claim, I will use Jürgen Habermas theory of understanding. According to Habermas, to

understand something, you have to be able to relate it to the rest of your life - to your life-world. Now, to

relate specialised knowledge to everyday life is no easy matter.

Therefore, medicine is in trouble not despite of, but because of its best efforts. Giving up objectification,

documentation and natural science would be as irresponsible as it is impossible. Continuing like today

will imply falling with grace.







[40] HOSPITAL ETHICS COMMITTEES IN LITHUANIA: Challenges of the transition

society

Eugenijus Gefenas, Vilma Navickiene, Asta Cekanauskaite (Lithuania)



There is a strong tendency to institutionalise biomedical research ethics all over the world. Research

ethics committees (REC) have been established in many developing countries not to mention so-called

"research intensive" societies where RECs have been functioning for a few decades. The process of

institutionalising other areas of health care ethics is, however, much more controversial. The role and

usefulness of hospital ethics committees (HEC) remain rather debated issues.

In contrast to many European countries this kind of committees exists mainly in the United States. HEC

in both Western and Central-Eastern European (CEE) countries could be regarded as a rather recent and

not very much spread phenomenon. What is no less important, however, even USA authors are con-

cerned about the developments of HEC and talk about HEC "failure to thrive" syndrome. Such a failure

is characterised as (1) unawareness of many members of the hospital staff about the existence of the

ethics committee in their institution; (2) problematic attendance at the committee meetings - "absen-

teeism"; (3) uncertainty felt even by the committed committee members about usefulness and relevant

functions of the committee.

The establishment and functioning of HEC in the context of Central and Eastern European countries

seems to be no less controversial process as compared with Western societies. On the one hand, many

CEE countries are trying to introduce HEC into their health care systems. In some countries the estab-

lishment of HEC is even legally binding. On the other hand, however, the understanding of what are the



26

functions of HEC is very often quite different from Western ones. In particular, there is a strong ten-

dency in many post-communist societies to assign ethics committees the role of "moral police" , to use it

as a substitute for legal or administrative regulations. The problem is, however, that the attempts to

"implement" such an interpretation of medical ethics using such institutions as HEC could give coun-

terproductive results such as discrediting the topic itself.

Is it reasonable to stimulate the process of establishing HEC in the context of "legalistic" understanding

of health care ethics? What are the functions to be assigned to HEC? Are they different from those

regarded as central ones in Western societies? The paper highlights these peculiarities of building HEC

system in Lithuania, which probably also reflects the controversies faced by other transition societies

following the developments of Western health care ethics.









[41] EVIDENCE BASED MEDICINE - THE NEW CLINICAL PARADIGM

Petra Gelhaus (Germany)



During the last years medical research has spread a new trend in hospitals: evidence-based medicine.

The standards of clinical research for new drugs - prospective, randomized, double blind, pla-

cebo-controlled studies (according to the “Good Clinical Practice” - Guidelines) are also becoming the

measure of established therapies and methods. Big databases like “Medline" and internet access allow

each physician to get current news from all over the world fitting to his actual question. He is able to

collect facts independently of antiquated textbooks, superiors or refresher courses. All in all medical

knowledge has got a new scientific “gold standard".

Of course, better evidence is a very good thing, not only according to an ethic of science but also ac-

cording to medical ethics. But is the speaking of a new kind of medicine, an evidence-based medicine

appropriate? First of all, clinical studies present statistical evidence - the physician has to deal with a

single patient. Probabilistic knowledge easy help them, but it does not override the individual deci-

sion-making. For methodological as well as economical reasons epidemiology has its problems with

rare or even unique situations, but the doctor is obliged to treat the (unique) patient even if there is no

trustworthy evidence. So obviously evidence-based medicine cannot be the only medical paradigm.

Secondly, the published studies need a great effort of analysis and interpretation. If a physician wanted

to evaluate adequately all the relevant evidence he had no time left for his patients. Therefore, he de-

pends on good and apposite reviews on the subject (e.g. by the Cochrane Collaboration). To examine

these reviews overcharges the time and capacities of most physicians - their new authority is no longer

their teacher or their professional society but the (anonymous) review panel.

Thirdly, the advocates of evidence-based medicine hold that medicine is just the applied medical science

- if you have got the evidence by the internet you only need to apply it. Thinking of some results of the

theory of action or of some detailed analysis of clinical decision-making (e.g. by Peter Hucklenbroich)

this assumption appears to be by far too simple.

We can summerize that evidence-based medicine surely is a systematic and by the possibilities of the

internet more (or less) applicable epidemiologic tool for the physician, but there is no hint for it to be a

completely new paradigm. The overemphasis may only be due to the enthusiasm for the internet's

possibilities, but it also implicates same severe consequences for the image of the physician and the

medical system as a whole: by strengthening the anonymous review authorities, the local responsibility

diminishes. The decision of the single physician out of the individual patient-doctor-relationship seems

less important - science tends to dictate the right treatment. Where is the room for humanness, under-

standing and ethical decision-making in a merely evidence based medicine? Admitting the necessity of

current knowledge in medicine, the author holds that there is much more urge to improve the ethical and

psychological than the biostatistical education of physicians.







[42] ULTRASOUND IN PREGNANCY: THE IMPACT OF DIAGNOSTIC UNCERTAINTY

Linn Getz, Kjell Å. Salvesen, Reynir T. Geirsson, Anne Luise Kirkengen (Iceland/Norway)



27

Clinical setting and background facts: Due to advancing imaging technology in obstetric ultrasound, a

clinical scenario of diagnostic uncertainty has become more common in relation to "routine" ultrasound

screening in the 18-19th gestational weeks. This also relates to the 10-14 week scan, which has been

introduced in the last years. The examiner identifies subtle anatomical abnormalities, so called "soft

signs" or "markers" in the fetus that create diagnostic dilemmas. Soft signs are associated with an in-

creased risk of the fetus being afflicted by a genetical syndrome, such as trisomy 21 (Down syndrome).

The magnitude of the risk is small, usually less than 1/100, depending on the type and number of

markers present; about 11 anatomical markers have been identified by now. In such situations of di-

agnostic uncertainty the clinician meets the challenge of finding a follow-up strategy. He/she might not

explicitly communicate the subtlest findings to the expecting parents but still may not be able to prevent

a covert communication of discomfort created by a finding. He/she might, alternatively, offer invasive

investigations that may rule out a genetic defect. If such pathology is confirmed, one possible option

arising is to terminate the pregnancy. The clinician may also inform the parents and advocate expec-

tancy. The frequency of diagnostic uncertainty is at present about 2-5% in a screening situation, de-

pending on the technology and method used and the skills of the examiner. Experts performing ultra-

sound screening in pregnancy at specialised centres report that such complex cases cause anxiety in both

personnel and expecting parents.

Aspects of philosophy and ethics: Research on how diagnostic uncertainty related to diagnostic ultra-

sound in pregnancy is experienced, is very scarce. The existing literature, however, indicates that the

experience of uncertainty seems to he extremely strainful for the expectant mother and difficult to cope

with. We are not aware of any investigation into how this uncertainty affects the father, the couple or the

examiner. Consequently, the paper will briefly review the current literature on uncertainty related to

ultrasound screening in pregnancy, with emphasis on the impact on the pregnant woman. It will further

discuss why this particular uncertainty seems less tolerable and more demanding to face than any other

diagnostic uncertainty with a comparable risk of 1/100 or even less. The first author (a physician) has

begun to investigate how diagnostic uncertainty in obstetric ultrasound is communicated experienced

and coped with by the persons involved in such a medical enterprise. The ethical implications of such

encounters with medical technology will be discussed. Likewise, the ethical framework of a research

setting will be problematized, within which every medical finding does create moral dilemmas for the

persons involved. Finally, the topics of the value-neutral medical knowledge and of the detached

medical expert will be addressed.







[43] BIOETHICS IN SLOVAKIA 1990 - 2000

Jozef Glasa, Ján Bielik, Mária Glasová, Ján Ďačok, Mária Mojzešová, Ján Porubský (Slovakia)



In Slovakia, bioethics was developed as a discipline after the „Velvet Revolution‟ of November 19891.

It started as an initiative of self-educated physicians, theologians, philosophers, and members of other

disciplines, that survived and grew up scientifically and morally in the underground or in privacy. It

embodied in its protagonists different traditions of the medical ethical thought inherited from the past

and was enriched by the intellectual input of the western traditional and modern (and ‟postmodern‟)

philosophical thought. Since 1990 „institutions‟ of Slovak bioethics were created in a step-wise manner:

Central Ethics Committee of the Ministry of Health (1990), Chair of Medical Ethics of the Postgraduate

Medical School (PMS) in Bratislava (1991) - later on developed into the Institute of Medical Ethics and

Bioethics (IMEB) of PMS and the Faculty of Medicine of the Comenius University in Bratislava (1992).

Research ethics committees were set up in the research institutions and major hospitals in the country,

according to the guidelines issued by the Ministry of Health (1992) 2. Medical Ethics & Bioethics (an

international journal, quarterly, bilingual (Slovak-English) was started (1994). Texts on medical ethics

for university students (1993) and on nursing ethics (1998) in Slovak language were published. Post-

graduate (since 1991) and regular undergraduate education (1992) of health care professionals (doctors

and nurses) was established. Medical ethics (or bioethics) is taught, as a compulsory discipline at the

faculties of medicine in Slovakia, as well as nursing ethics is a compulsory subject at the nursing schools

throughout the country. Scientific societies of the Slovak Medical Association, as well as the SMA



28

itself, and also Slovak Medical Chamber establish the ethics committees. „Committee for Bioethics‟ has

been established also by the Slovak Catholic Bishops' Conference (1995).Several international con-

gresses, conferences and postgraduate courses were held. Multiple international contacts, exchange and

collaboration were developed simultaneously, including the participation of Slovak experts in various

international ethics commissions (e.g. CDBI in Strasbourg, etc.). Slovak bioethics, developing gradually

its educational and research institutions (e.g. Institute of Medical Ethics and Bioethics in Bratislava); its

own and shared communication channels (e.g. journal Medical Ethics & Bioethics; growing input into

the professional and general media information space); and also „working institutions‟ (i.e. ethics

committees) - has established a non-negligible position within the contemporary transformation proc-

esses of the Slovak medicine and health care system.



References:

1

Glasa, J. et al.: Bioethics in the Period of Transition. Medical Ethics & Bioethics, 6, 1999; 4 – 8.

2

Glasa, J. et al.: Ethics Committees and Achievement of Good Clinical Practice. Thérapie, 51, 1996; 369 – 372.









[44] ETHICS COMMITTEES IN POST-TOTALITARIAN SOCIETY: PROBLEM OF

CONSENSUS

Jozef Glasa, Ján Bielik, Ján Ďačok, Mária Glasová, Ján Porubský (Slovakia)



Ethics committees are usually expected to reach and frame their decisions by consensus. In a post

totalitarian society1 the conception of consensus might somewhat differ from the one present in societies

with a long-term, un-interrupted tradition of democratic development. In 1990s, post totalitarian socie-

ties of Central and East Europe have been walking difficult paths from the situation, when matters of

public interest had been decided almost solely within the structures of a totalitarian power (usually a

„communist‟ party and by the party dominated governmental or municipal structures) and the political

decisions implemented by more or less coercive exercise of that power (while requiring the broadest

community attainment – „imposed consensus‟); toward societies deciding their fate and matters of

public interest via institutions of a modern, pluralistic, parliamentary democracy (subscribing implicitly

or even explicitly to consensus, perceived mostly as „overlapping‟ or „procedural‟).

Paper gives an outline of evolution of the notion of consensus in the post totalitarian Slovakia, as seen

within the frame of the first decade of establishment and work of ethics committees in the institutions of

biomedical research and health care2. The developments have been neither straightforward, nor simple.

The „lessons learned‟, however, may be used to foster a future progress, avoiding as much as possible

the repetition of past mistakes and „blind alleys‟. If consensus and its achievement are not to descent to

mere hypocrisy or manipulation, both society and the ethics committee, as the former‟s „miniaturized‟

sample, should (re-)learn and use methods of fair, dialogic discourse to define the common ground of

moral understanding. It would enable an expansion of shared space of moral reasoning and foster

genuine consensual decision making. Ethics committees should not abandon this courageous task,

especially when facing „relativistic deviation‟ of moral pluralism., which threats to undermine their „true

moral performance‟. Examples of present challenges for ethics committees‟ consensual decision making

will be outlined in the paper.



Referencies:

1

Glasa, J: Bioethics and the challenges of a society in transition. Birth and development of bioethics in the post

totalitarian Slovakia (1990 – 2000). J. Kennedy Institute of Ethics (2000, in press).

2

Glasa, J, Bielk, J, Glasová, M., Ďačok, J, Porubský, J.: Ethics committees (HECs and IRBs) and health care

reform. HEC Forum (2000, in press).









[45] ILLNESS AND TREATMENT. Essay on the borderline of philosophical anthropology

and axiology





29

Maria Gołaszewska (Poland)



At the start of our considerations we assume that human's life is the highest value in the anthroposphere.

Biological life and health are the necessary conditions of existence and development of the

pro-axiological attitude. However, many axiological systems appreciate better human abilities for

creating and discovering higher, over-vital values, than the mere fact of biological life.

In the physician's milieu, the traditional principle put forward by Hypocrites is obligatory. Thus, in the

medical practice moral codes are more significant and obligatory than the legal code, which acts only in

drastic (extreme) cases. Responsibility for errors in medical art includes both the physician committing

the mistake, his teachers and his working conditions.

It often happens that the responsibility for the patient and his health is transferred for to high-tech de-

vices used in diagnosis and treatment.

The relation patient - doctor is complex: the ill is concentrated on his own person, as unique and unre-

peatable, and he demands a similar attitude from his doctor - whereas the latter treats his patient in an

impersonal way, almost as a number in his registration card.

A doctor is in the position to make constant appreciations, evaluations, choice between lesser or bigger

evil. Hierarchization and ordering of values according to the accepted criteria is a common attitude in

this matter.

Patient's evaluation concerns doctors - the most appreciated are those, who evoke maximum confidence.

The world of values evoked most often by ill people contains the highest values, apart from the vital

ones (e.g. truth, goodness, beauty). The ill ask questions like: why do I suffer? Is my illness something

accidental or it is a punishment for some guilt. Should it be treated as an occasion for meditation over

oneself, over the world, Summum Bonum (God, highest values)? Is it a mistakes of nature?.

In most cases doctors are non-believers and support rationalist thinking - but in the name of tolerance

they are ready to respect fideistic inclinations of their patients - considering these inclinations as one

more placebo according to their conviction that hope issuing from faith fortifies vital forces.







[46] THE SEARCH FOR THE FOUNTAIN OF YOUTH. An ethical analysis of new devel-

opments in biogerontology

Bert Gordijn (The Netherlands)



For a long time, a variety of interventions have been practised that could delay the onset of age-related

declines or improve matters for those who are getting older. Man has always been fascinated to discover

the extent to which the ageing process is subject to human control. Nowadays, the idea of a fountain of

youth seems to have a bigger appeal than ever. Recent developments in biogerontology, one of the most

exciting fields of contemporary biomedical research, bear the promise that molecular controls that

regulate the ageing process itself may be discovered. The understanding of the ageing process has

immensely advanced and gained by the new ability to dissect ageing at its most fundamental cellular and

molecular levels. This presentation will examine the issues that arise in relation to biogerontological

attempts to understand, delay or prevent ageing from a molecular perspective.

I shall begin by examining ageing and its causes as understood from a biogerontological perspective.

There does not seem to be one unified theory about ageing. Instead, there are different theories about

molecular processes that seem to play an important role in the process of ageing. Thereupon, I will focus

on methods to prevent or delay ageing, for example, lifestyle interventions, pharmacological interven-

tions, biological interventions or molecular-genetic interventions. I will especially try to outline dif-

ferent potential methods of controlling ageing that are inspired by the modern biogerontological theo-

ries, for example, gene therapy involving genes for antioxidant enzymes, like superoxide dismutase or

catalase or genes for natural proteins such as leptin, which suppresses appetite.

Finally, I will proceed to discuss the ethical and philosophical anthropological dimensions of the de-

velopment and use of these molecular interventions. It seems to be very likely that molecular medicine

will continue to enable us to learn more and more about the fundamental aspects of the ageing process.

This will probably inspire new efforts to increase both the quantity and the quality of our lifespan. What





30

are the main ethical problems that are generated the new molecular approaches to human ageing? What

will be the repercussions of our efforts to control ageing on our attitudes towards and response to age-

ing? How, finally, will these molecular approaches and interventions influence our view on what it is to

be a human being?







[47] CONCEPT OF SUFFERING

Joanna Hańderek (Poland)



What is suffering? How can this unclear concept be defined? Unclear - because it accommodates various

meanings that have been assigned to it, or modified, in the history of human thought. A problem of

definition is made all the more complicated by the fact that the concept of suffering is common for such

diverse disciplines as philosophy and medicine. Also literature devotes much attention to suffering. This

article will be an attempt to put into order the selected meanings of this concept, and to examine the

meaning of suffering from a point of view of philosophy.

Suffering can be defined as a state, situation, event, or sensation. Scheler focused on distinction between

suffering and pain. Pain is a sensation of physical processes taking place in our body. Yet in order for

such sensation to occur, consciousness is needed. Consciousness detects pain just as it reveals the

process of ageing, which is one of the most acute sensations of pain. Suffering is state, state of our

feelings, a feeling derived from a sensation of pain.

Emmanuel Levinas developed an interesting concept of suffering. For Levinas, suffering is an event

whereby our existence is fulfilled. Physical suffering is a human being's involvement in life, and it is a

situation where a human being can escape from neither himself nor his existence. Thus understood,

suffering links us with life, concurrently revealing death.

For Albert Camus, suffering is a state of existence whereby we discover the absurd of our being, in-

comprehensibility and irrationality of what happens to us, and what surrounds us.

Simon Weil perceives suffering as a trial to which life and distant God submit us, a trial that conditions

our existence and self-realisation. In her austere philosophy, suffering features in life as an important

element of self-creation and self-restraint.

Apart from the above philosophers, a task of comprehension and definition of suffering was undertaken

by Schopenhauer, Shestov, Unamuno, Nietzsche, Kierkegaard and many others. In my paper, I will

focus on those philosophers who defmed the concept of suffering in opposition to the concept of pain, or

who made a distinction between physical and moral or mental suffering (e.g. Levinas).

Suffering is related to death, loneliness and time (as shown by Levinas). Therefore, in order to propose a

precise definition of suffering, relations between suffering and loneliness, death and time have to be

examined.

Suffering makes us aware of relations we are involved in. It makes us realise our own and others exis-

tence. Irrespective whether it means loneliness or openness to others, it is a state, an event or a relation

that changes our perception of the world. It is an important event in our life and its role calls for com-

prehension.









[48] GENE TECHNIQUES OR WHY A VIRGIN BLUSHED

Jan Hartman (Poland)



There are strong noises around several gene techniques, like cloning or genetic modifying of food. The

easiest way to be right and taken seriously is to underline threads and dangers connected to them.

However being a campaigner "against", ascribed into the course of progressive actions, as such un-

dergoes a thread: of becoming reactionary or at least ambiguous. The presentation aims at considering

this ambiguity and proposes an introductory account of the level and scale of the moral challenge witch

the new techniques impose upon us.

Certainly, the authority of a scientist, who has the best reasons not to mythologize what is a question of



31

pure technique and reason, should not be undermined, and I would say even more: this authority must be

protected against populistic hysteria and unjustified political claims to the power of control and as-

sessment. However, we must not forget the limits to scientific competence and get overwhelmed by

light-minded scientism, shifting moral challenges of all kinds into the guardianship of religion and

public moral supervision, whoever‟s responsibility that might be.

The question of imagination - not scientific anticipation, not fantasy, but just imagination - of possible

material consequences of the development of genetic techniques is not the only one which must be

carefully taken into account. This is only a challenge for our imaginative skills: let us present to our

minds what may really happen when the human genotype becomes to any significant extent manipu-

lable. How much more serious is the consequent challenge to our moral condition! For what we must

now face is the question of how to develop our moral concepts and skills in order to meet the coming

future technical reality with responsibility. We must take the risk of imagining what may be unavoidable

in the next century - the eugenic society…









[49] ANTENATAL SCREAMING – ETHICAL DILEMMAS OF A GENETIC

COUNSELLOR

Homa Syeda Hasan (Norway)



Maternal serum screening for Down's syndrome and neural tube defects has been an established form of

screening for over a decade. Screening for these conditions has become widely accepted as a result of

consumer demand and public health programmes even though this activity falls under dubious criteria of

„negative‟ eugenics (to rid society of undesirable individuals). This paper is an outline of the ethical

dilemmas posed in clinical situations when screening antenatally for Down's syndrome and neural tube

defects. It will highlight the human face of screening from both the counsellor and a patient‟s perspec-

tive. This includes misinformation, decision making process (theoretical verses reality) and external

pressures affecting patient autonomy. It will also expand on the dichotomy that arises when viewing

public health policy goals and the expectation of the individual approaching the screening programme as

well as the moral dilemmas of the counsellor working within public health system with the patient‟s best

interest as a primary duty.

The cost of screening will be discussed in relation to the disvaluement of Down's syndrome fetuses and

the loss of normal fetuses as a result of diagnostic tests. The less apparent cost of screening, which takes

the form of maternal-fetal bonding, will also be discussed.

An alternative suggestion will be proposed as an evolution to the advancement of medical technology in

this field. A suggestion that will serve the purposes of patient autonomy, public health goals and also the

rights of the future person with Down's syndrome.

As a follow-on to Judith Lee Kissels‟s paper, the issue of informed consent will be elaborated in relation

to given scenarios that arise in clinical practice.









[50] ETHICAL ISSUES IN PALLIATIVE CARE

Henk ten Have (The Netherlands)



This presentation will focus on the ethical aspects of palliative care. The European Commission supports

an international project in palliative care ethics (PALLIUM). Research teams (ethicists and palliative care

professionals) from the Netherlands, Belgium, Sweden, UK, Italy, Spain, Germany cooperate. The

objectives of the project are: (1) examine the organisation of palliative care in various countries, (2)

analyse the concept(s) of palliative care, (3) explain the relationship between concept and organisation, (4)

study the ethical aspects of palliative care. This presentation will focus on the latter objective.



32

It is argued that the concept of palliative care has at least three dimensions: 1. philosophy of care; 2. set of

expert clinical practices; 3. set of expert counselling practices.

Also historical analysis does not reveal a uniform concept. There are at least two histories of palliation; the

verb "palliare" is related to two meanings: to cloak or to shield. The concept has therefore different

interpretations, as well as pejorative vs. positive associations.

Palliative care has nonetheless specific characteristics. It is argued that four characteristics are

fundamental: specific goal; attitude of restraint; integral care; active participation of patient and family.

The ethical dimensions have been explored with the use of a survey among 2,174 delegates to the EAPC

conference in Geneva in September 1999. The returned questionnaires represent a response rate of 35.3%.

Explicit items in the questionnaire have focused on values and moral questions in palliative care. The data

of the survey will be discussed, in order to identify the ethical dimensions of palliative care.









[51] ABORTION BASED ON DISABILITY - A RIGHT OR A WRONG?

Matti Häyry (Finland)



Is it a woman's inalienable right to terminate her pregnancy, if it is predicted that the child would be

physically or mentally disabled? In a recent contribution, Rosamond Rhodes seems to argue for this

position by maintaining that all rights, including the rights of the unborn, depend on the choices made by

other people. Fetuses have a right to life only insofar as pregnant women grant them this right by as-

senting to continue the pregnancy to term. One possible implication of this view is that when women

find out that their potential children could be disabled, they can opt out from their original choice to bear

the child, and choose to abort.

This view is not unusual in medical practice in affluent Western countries. In most European countries

and in the United States fetal defects are seen, in the eyes of the law, as good grounds for abortion. But

the arguments for this practice can easily seem false. Rosamond Rhodes's views, which resemble partly

the arguments put forward by Helga Kuhse and Peter Singer in their controversial book Should the Baby

Live? are no exception. Why would it be acceptable to abort disabled fetuses, when healthy fetuses are

protected by legal and moral rights, and when discrimination against the disabled is banned once they

have been born?

Simo Vehmas has recently argued that views which condone abortion on the grounds of intellectual

disabilities are based on two discriminative assumptions, the assumptions of "intelligism" and "perfec-

tionism". His own solution is to say that the right to life is founded on our nature as social beings, and as

persons with disabilities are social beings, their right to life is as firm as the right to life of those who do

not have disabilities.

In this presentation, I will explore the views of Rhodes, Kuhse, Singer and Vehmas, and argue that they

all have their problems. All attempts to justify abortions by appeals to fetal defects, as individual

shortcomings in the unborn human beings are suspicious. But it is not evident that these problems could

be overcome by assuming more "social" definitions of "personhood" and rights, either.









[52] VIRTUE ETHICS IN THE NOVEL THE PLAGUE BY ALBERT CAMUS

Ute Heinrich (Germany)



Center of attention in the novel The Plague is a physician: Doctor Bernard Rieux. He and a group of men

fight against an epidemic in a French-Algerian town in the middle of the last century. There are also two

other doctors involved in that frustrating fight without antibiotics.

The novel is a parable. Camus calls it even a lampoon although he never tells his view explicitly and

avoids using philosophical or ethical terminology. The emphasis lies on the behaviour and the character

of the people concerned. Their aim is to fight against death where death is always present, but the author

aims at writing a plain chronicle, adding some documents that allegedly are written by some of them. At



33

the end of the novel the reader learns that the author of the chronicle is himself part of the plot: Doctor

Bernard Rieux. He is the central figure and the narrative writer at the same time. This method - to hide

the own ideas behind different persons is a stylistic means reminding of Kierkegaard. At the same time,

the novel appears to be authentic.

Formally, The Plague is a novel but it may be read as a narrative ethic as well. The reader is invited to

take sides. If this is true virtue ethics seems to be a suitable tool to make explicit the moral idea Camus

has embodied in the persons of his novel. Accordingly, we shall interpret them in terms of virtue ethics

and try to answer the following questions: Why does Camus attribute the role of the chronicler to a

physician? Does he mean that physicians are persons of high moral standing or does he simply need a

person who is professionally committed with epidemics? Why does he take just an epidemic as an

example of existential threat?







[53] CULTIVATED ILLNESS HELPS PATIENTS TO MANAGE THEIR LIFE, AND

DOCTORS TO MANAGE THEIR PATIENTS

Olle Hellström (Sweden)



The aim of the paper is to illuminate how doctors and patients unintentionally co-operate in medical

practice and how this may result in the growth of modern illnesses. The paper is part of a project fo-

cusing on the concepts of meaning and dialogue in the light of the doctor-patient relationship, and

delineating a dialogic model for encountering patients as persons. The illnesses that are referred to are

especially fibromyalgia and chronic fatigue syndrome.

Two seemingly conflicting action-perspectives are presented and discussed and a third one, based on

long practical experience from family medicine, is sketched. The first perspective is biomedical, the

second psycho-somatic and the third dialogic. The three display a progression from seeing pure bodily

mechanisms, via viewing the body influenced by a psyche, to meeting a person's embodied meaning.

Whereas the two first perspectives lean on cause-effect mechanisms, the third recognizes a human

intentional and future directed mode of living. Dialogically thinking doctors ask for the meaning of

imaginable intentional bodily and verbal actions.

The theoretical discourse of the paper is backed up by findings from two empirical phenomenological

psychological studies, the first elucidating how doctors structure their meaning of fibromyalgia. It is

found that doctors appear to have more difficulty in encountering fibromyalgia patients than many other

patients and try to manage this by keeping to strictly biomedical notions and measures.

A corresponding investigation of patients' experience of living with fibromyalgia indicates that they see

the illness as unpredictable, invisible and giving rise to enfeebling symptoms. Also the search for causes

and explanations of the suffering are important traits, as are the patients' efforts to cope with the threat of

failure and repressing thoughts about the future.

The two fibromyalgia studies point to a relation between medical actions and the tendency of patients to

attribute biomedical meaning to their experienced bodily manifestations. Meaning and dialogue are

concepts of great importance regarding the understanding of, and the attitude to, the experience of being

ill.

The introduction of the concept of cultivated illness is intended to help focusing on the illness, i.e.

experiences of disease, as the patient's means to communicate what is not directly presentable in spoken

words. In their search for meaning patients may use disease language for expressing something about a

non-linguistic and opaque body. Reduced to a biomedical thing the body can be operated on and

x-rayed, but the personal living body as a whole can not be looked through. Sometimes it is exploited by

the sufferer as a bearer of some defects that legitimise his failure to manage his feeling of not being the

one whom he aims to be.

Cultivated illness is meant to be defended by patients as something real and used by doctors to avoid

reconsidering their deeply rooted biomedical knowledge.









34

[54] GUIDELINES FOR WITHHOLDING OR WITHDRAWAL OF TREATMENT IN

NEONATAL CARE: Deficits - benefits - acceptance

Eckhard Herych (Germany)



In the care for critically ill or severely impaired neonates situations arise, where further treatment may

be considered futile. Nonetheless it can be observed that physicians are reluctant in these situations to

discontinue, withhold or withdraw treatment. At the same time those involved in care feel uneasy about

situations which - in their own words - can best be described as prolongation of suffering or of dying. In

the past, one of the reasons for this problem has been the lack of a legally valid instrument to justify the

change of therapeutic goals, or to terminate treatment. But even if such an instrument existed, the pro-

fessional involved must have knowledge of the code, be able to interpret it correctly and put its spirit

into practice.

In late 1998 the German Board of Physicians (Bundesarztekammer) issued a recommendation on

“physicians` care for the dying". Furthermore it is noteworthy that during the last ten years, numerous

codes and guidelines on the prerequisites for the termination of treatment have been issued on national

and international scales.

It will be the task of this paper to present a comparative analysis of these guidelines, based on a recent

case study. In a first step, the case of a pair of twins, suffering from an intrauterine parabolic syndrome

will be presented and analyzed. In the process of this case serious complications emerged for both

neonates, ranging from intraventricular hemorrhage to hypoperfusion of the lower extremities which

made amputation unavoidable. Despite the fact that a recommendation on the discontinuation of therapy

existed, the professionals in charge took recourse on medical data only. In the second part of the paper a

step-by-step analysis of the case will be performed, in order to determine which course of action may be

chosen in such situations. In a third part, exemplary codes and guidelines from other European countries

will be applied to the case, in order to open up an international perspective.







[55] FACETS OF VIRTUE

Friedrich Heubel (Germany)



“Virtue ethics" is seen by some as merely self-referential and, as such, not built on firm ground. The

German term “Tugend" sounds old-fashioned. Where definitions of virtue are given they differ. But the

subject-matter, if understood in a very broad sense as “moral excellence", seems to be by no means

outdated. Therefore, I shall explore the different facets, associations and contents of this famous term,

mainly dealing with the Aristotelian, the medieval and the Kantian concepts. I shall try to clarify some

misunderstandings, to look for common ground and to identify strong points as well as pitfalls.







[56] ON THE ASYMMETRY BETWEEN THE CONCEPTS OF HEALTH AND DISEASE

Bjorn Hofmann (Norway)



There is a basic discussion on the relation between the concepts of health and disease. It has been

maintained that the concept of health is primary or constitutive to the concept of disease, or that they are

equivalent concepts. This paper will argue that there is an inherent asymmetry between the concepts of

health and disease, and that „disease‟ is the primary concept. Logically, there seems to be a primacy to

the concept of health. „Dis-ease‟, „un-pleasentness‟, „dis-comfort‟, „dys-function‟, „dis-ability‟ all are

negatively defined.

In ethics, however, it seems that negative notions are more primitive than positive ones. It is easier to

explain what is unpleasant than what is pleasant, define suffering than happiness, what is bad than what

is good. Accordingly, the concept of disease is prior to the concept of health.

There are basic differences between the concepts of health and disease. The extension of „disease‟

comprises many disease entities whereas the extension of health does not. Diseases are classified,

whereas there is no classification of health. Diseases are said to be caused, health is not. Health varies



35

along a continuum, whereas disease appears in discrete entities. It has been argued that disease is a

particular phenomenon, whereas health is a “general margin” in life: While health is a disposition,

disease is an occurring event. Disease is temporal, whereas health is not. We can date when we became

ill and when we became well again. We have to experience disease to experience health.

Furthermore, it has been argued that in medicine knowledge of disease precedes knowledge of health;

pathology is basic to physiology. This can be related to the ethical appeal in medicine: The sick person‟s

plea for help is prior to the search for knowledge of bodily functioning. Within this framework it will be

argued that there is an asymmetry between health and disease, and that there seems to be a primacy to

the concept of disease.







[57] DOES CHAOS THEORY HAVE MAJOR IMPLICATIONS FOR PHILOSOPHY OF

MEDICINE?

Sǿren Holm (United Kingdom/Norway)



In the literature it is sometimes claimed that chaos theory, non-linear dynamics, and the theory of

fractals have major implications for philosophy of medicine, especially for our analysis of the concept of

disease and the concept of causation.

This paper gives a brief introduction to the mathematics underlying chaos theory and non-linear dy-

namics.

It is then shown that chaos theory has only very minimal implications for the analysis of the concept of

disease and the concept of causation, mainly because the mathematics of chaotic processes entail that

these processes are fully deterministic. The practical unpredictability of chaotic processes, caused by

their extreme sensitivity to initial conditions, may raise practical problems in diagnosis, prognosis and

treatment, but it raises no major theoretical problems.

The fact that a chaotic condition may be healthy, and a more regular process unhealthy, as seem to be the

case with regard to the heart beat, is only superficially paradoxical. On reflection it can be easily en-

compassed even within the most reductionistic disease models. Chaos theory may thus be very impor-

tant for our understanding of physiological processes, and specific disease entities, without having any

major implications for philosophy of medicine.







[58] FROM COMPETITION TO COLLABORATION. Toward independence in Polish

nursing education

Kari Hovland Aasen (Norway), Paula Hancock (UK)



Aim: In order to realise Polish health care reforms to improve the quality of Polish health care and in

preparation for Poland‟s accession to the European Economic Community, there was a need to

strengthen the role and improve the quality of the health care professionals, including nursing and

midwifery.

In collaboration with the Polish Nursing leaders and the Nursing Association of Norway, a new national

nursing curriculum was developed. Funded by (Norway here!) the Polish Ministry of Health and the

British Council, experienced teachers from Norway, England and Scotland, were invited to work with

Polish teachers and students to implement the new curriculum.

The visiting teachers came from different countries with different cultures and met with different

schools in Poland. They all knew best and were the best when it came to defining the quality of nursing.

Competition was in the air in spite of their common aim: to collaborate for better nursing care in Poland.

Question: How to implement the Curriculum so that leaders, teachers and students develop toward the

intention of the curriculum in their personal view and own culture.

Method: The methods used in developing and evaluating the program are mainly based on the con-

structivistic theory. The aims and general strategy for the project was formed in a Workshop in Krakow

1996. The Norwegian, English, Scottish and Polish teachers met with the representatives from The

Ministry of Health, and the Warsaw Centre for Medical Education at annual workshops. The workshops



36

enabled all those involved with implementing the new curriculum to get to know each other, to identify

the individual needs of the nursing schools and their students and to monitor and evaluate progress.

Exchanges of teachers and students to our countries from our representatives visiting the Polish schools

several times each years was important part of the program. The purpose of such exchange visits was to

introduce the new concepts of independent student centred learning by working with the Polish teachers

and their students.

Results: The process of professional democratising and development takes time, especially in a culture

ruled by a central political and professional policy and dominated by medical rather than nursing

thinking.

The schools were different and therefore also their development and achievements.

There is evidence of increased trust and between the schools (two schools want to join in a common

college). The use of independent methods of studying and use of professional nursing thinking increased

and the end of the project is marked by enthusiasm and a genuine wish to develop independent nursing.







[59] COMMUNITY EMPOWERMENT IN COPING WITH HEALTH CARE ETHICAL

PROBLEMS IN LITHUANIA

Irayda Jakušovaité (Lithuania)



The WHO document “Health XXI” emphasizes the role of ethical evaluations of health problems. One of

the tasks of European health policy is to create the mechanisms allowing to strengthen the significance of

ethical considerations in decisions making processes concerning health care of individuals, groups of in-

dividuals, health professionals and health care in general. Modern health policy ethics has already reached

the level where traditional concepts in medicine (doctor-patient relations) are not sufficient to solve them. It

is necessary to reflect the new structure of ethics in health care including not only micro level (doc-

tor-patient relations), but macro level (community ethics, health care management ethics, ethics of health

policy) as well.

One of the biggest changes in modern health care and medicine is shift from the disease treatment towards

health promotion and disease prevention, the shift from the hospital towards community. New public health

policy context presents evident shifts from the treatment of patients towards the continuous health care in

the community. People are encouraged to take care of their own health. They are involved into the process

of making health care decisions. Similar situation in the strategy of the process of dealing with ethical

questions is observed. There is a move from the institution-oriented health care towards commu-

nity-orientated one. It is well documented that the balance of interests between people and organizations in

the modern society is lot. This is especially true for the communities which just had broken with autocratic

political, social and economic systems, like Lithuania. That‟s why community involvement into decision

making process is important in order to have health care system in Lithuania more humanistic.

The study on the empowerment of community in copying ethical problems in health care in Lithuania

performed in Kaunas county by scientists of Kaunas University of Medicine showed that the conflicts may

be explained from two different perspectives:

- the sociological perspective in which the focus is on professional-bureaucratic conflicts in roles;

- an ethical perspective in which the focus is on conflict of obligation.

The relationship between these two perspectives is the relationship between roles and obligations. In

other words, it is very important to understand that conflicts may be seen as occurring not between or

among roles, but rather between or among the duties, obligations or responsibilities generated by these

roles.

The study showed that a major health policy task in Lithuania is to manage a gap between demand and

supply of health care and between the affordable and possible. In the context of health financing crisis it

is obvious that only rationing and prioritising will have an increasingly important role in coping ethical

problems in Lithuania‟s health care reform.









37

[60] DISTRIBUTIVE JUSTICE AND HEALTH CARE: Different theoretical approaches

Sigita Jakutyté (Lithuania)



Regarding justice in modern medicine we face the problem of resource allocation. Citizens get angry at

inadequate medical care and physicians are worried about drying financial resources for treatment. Such

statement is not anything like castle in the air. It is grounded on statistics and daily collisions with

medical practise. If the state can't guarantee any realistic legal basis for satisfying all citizens we can ask

about moral basis.

Keeping away from more detailed macro and micro allocation we analize different determinations of the

principle of distributive justice. We cast a glance at three modern philosophical theories to reveal

egalitarian, libertarian, and utilitarian point of view. Despite the solidity of arguments every theory deals

with the same fault while regarding its applicability in health care. We find that any reduction of justice

to separate moral quality can't be sufficient basis for its application.

These theoretical approaches and our conclusions are verified by the facts of health care situation in

Lithuania. The process of verification is done meaning two-tier model of modern health care system.

Egalitarian approach to distributive justice identifies justice with equality. Theorists hold that principles

of justice include obligations to structure institutions to reduce barriers that prevent fair opportunity and

benefit to worst off.

Such argumentation faces two problems. It is not clear about the agents of resource allocation in health

care. Who establishes an appropriate level of care: representatives of government, population or any

agents of medical profession?

Latter question deals with more fundamental one about the right to health care. Does equality of

treatment is the same as principle of equal consideration of interests?

Utilitarian approach is meshed by theories of economic development. According to this point justice

demands actions and policies that maximize well-being. The principle of utility is substituted for justice.

The hot disputes here turn upon the recipients of treatment. If we neglect an incommensurable value on

life and argue that there is something of greater importance than saving a life we are seeking for

common well-being and effectivness. Neverthless everybody feels that justice is something else than the

effectivness of results.

Contrary to egalitarians and utilitarians, libertarians reject an appropriate normative ideal for distrib-

uting health care. They declare abstract human rights to liberty. Accordingly justice does not demand

optimal results but rather places constraints on acts and policies. In other words justice is advanced as

demandation not to restrict on free trade. The main dispute turns upon requesters for treatment. If no-

body has welfare rights may we dream about a right to health care? If we loss natural and social lottery

and seem to be unfortunate may we hope for any free treatment? If the principle of social justice choices

justifies justice so Aristotelian conception of social justice as equality is being collapsed by wilful

arrangements.







[61] PLACENTAL BLOOD TRANSFUSION - HISTORICAL AND ETHICAL ASPECTS

Piotr Jankowski, Krzysztof Marczewski (Poland)



Recently, a greater interest is observed concerning the taking of placental blood in order to use it in

future. The study pays attention to some ethical aspects like the ownership of the placenta or the possible

commercial problems. We reminded the very first study on placental blood transfusion, which took

place before the World War II and also other abandoned methods used in transfusiology in the past.







[62] CONCEPT OR CONCEPTS OF PALLIATIVE CARE?

Rien Janssens (The Netherlands)



The concept of palliative care is ambiguous. Although on a very general level, there is agreement that



38

the total person of the patient together with his/her loved ones are at the centre of care, disagreement

exists on a variety of themes. For instance, whereas some state that palliative care can already begin at

the time of diagnosis, or even before that time, others limit palliative care to the terminal phase. Dis-

agreement exists furthermore on the organizational context most suitable to provide palliative care in.

Whereas some plea for the establishment of more in-patient, independent hospices, others argue that

palliative care should be developed inside the formal health care system. Another controversial issue is

whether the intentional hastening of death (which is explicitly excluded from palliative care in the

definition of palliative care of the World Health Organization) can be part of palliative care. Some

people who exclude such kinds of acts explicitly state that the quality and the creativity of palliative

modalities become damaged once the door is open for euthanasia. Others, who do not exclude eutha-

nasia, state that the best of palliative care can never prevent or take away all euthanasia requests. In other

words, what is at stake in this argument are different conceptions of the quality of palliative care.

Meanwhile, a lot remains unclear with regard to the supposed quality of palliative care due to a lack of

empirical evidence. This makes a part of the debate on the concept of palliative care somewhat ideo-

logical. I will argue that the most heavily debated issues on the concept of palliative care (especially the

supposed interrelation between the quality of palliative care and the permission of euthanasia) are based

on insufficient empirical evidence and therefore subject to ideological use. Perhaps, when the ideo-

logical arguments in the debates will be filtered out, there may appear to be a bigger consensus on what

palliative care is than might be the case on first sight.









[63] BIOETHICAL THREAT - EUGENICS

Małgorzata Jantos (Poland)



For thousands of years the following rule has been the cornerstone of medicine: above all, to help pa-

tients. Works of Hippocrates have long been a reference point for the European philosophy with respect

to the physician's activities and responsibilities. Even today, the Hippocratic oath translated into many

languages is taken as an oath of ethical professional behaviour by newly qualified doctors on their

graduation.

The Hippocratic tradition with its focus on moral issues, however, has been changing owing to high-tech

advances in medicine. These advances and molecular medicine achievements in particular seem to

provide boundless possibilities of interference in life. Prenatal diagnosis has become remarkably suc-

cessful over the last decade. Embryos can undergo surgical intervention before being implanted into the

womb and genetic interference has become a reality.

As a matter of fact, the drive to improve the species - eugenics - is not, by any means a recent devel-

opment. Between the years 1920-1930 alcoholics and mentally retarded were sterilized on a massive

scale in numerous states in the USA. A number of Noble-prize winners within the scope of medicine and

biology were in favour of planned selection instead of natural one. At the same time, opposition against

the eugenic science was rising among medicine philosophers and moral science representatives.

Despite the division of eugenics into the positive (helping to design and create genetically "corrected"

children) and negative (preventing crippled children from being born - apprehension about development

of eugenics is justified. Irresponsibility of the medical laboratories staff can bring about startling results.

Nevertheless, medical research leading to eliminating genetic diseases should not be banned.

Rather than prohibiting, medical research should be brought under control and carefully organized, as

hypocrisy of scientists claiming that they observe the law might be a real threat. Molecular genetics may

become a menace to humanity. This will happen when medicine will change its basic rule of helping

people and start manipulating them instead.









[64] THROUGH DOCTORS' GLASSES: The story of one article of the law on organ trans-

plantation or how could closed eyelids of the deceased person conceal our sins



39

Givi Javashvili, Guram Kiknadze (Georgia)



Ethical aspects of human organ transplantation remain to be among the most crucial issues of bioethics.

Despite of the fact, that transplantation is relatively young branch of medicine, the above issue seems to

be already "worn out". The different models of organ procurement (express donation, presumed dona-

tion, routine removal etc.), ethical problems related to each of these models, issues of scarcity in the

supply of organs and methods of their allocation etc. has been extensively studied.

Many countries are still on their way toward defining, what system of organ retrieval they should adopt.

Choosing the most appropriate model for the certain country or region depends on various factors.

Current presentation (article) aims at accentuating one of the above-mentioned factors, particularly,

attitude of health care professionals toward the problem of organ transfer.

On 24 December 2000, Georgian Parliament adopted the "Law on Removal and Usage of Human Or-

gans, Tissues and Organ parts" by three reading. This brought to end the tree year "marathon race" of

debates on the transplantation law. The only reason for such delay was an article related to the removal

of organs from unsupervised cadavers (cadavers, whose relatives is not possible to identify during the

certain time-frame). Generally the law provides for the expressed donation (opting in) system of organ

retrieval from cadavers. The subject of disagreement was the issue, whether this principle should also be

spread on unsupervised cadavers as well.

One group of the MPs argued that organs should be removed from the non-heart-beating cadaver,

without taking into account the fact that nothing is known about the wishes of the deceased. It should be

emphasised that considerations of these MPs were based on the arguments of health care professionals,

mainly transplantologists and didn't reflect the opinion of the general society.

The above mentioned case shows that considerable part of health care professionals doesn't know the

fundamental principle of modern medical ethics and patients' rights - principle of autonomy, respect for

the individual and for self-determination. This is reality, which has been demonstrated by the relatively

small sociological survey (100 respondents) carried our by the Georgian Health Law and Bioethics

Society in 1999. According to the results of the survey, more than 50% of health care professionals don't

acknowledge the principles related to patient's autonomy (informed consent, privacy etc).

Conclusions:

a. Health care professionals‟ arguments should be avoided to be the only source for decision making

process in health policy, when problem is related to human rights in the field of health care.

b. An important strategy in promoting patients‟ individual rights might be rising awareness of health

care professionals in the issues of modern medical ethics, which might constitute the obligatory part of

their professional training.







[65] THE MORAL STANDING OF ALZHEIMER'S PATIENTS: Theory and policy

Agnieszka Jaworska, (USA)





Contemporaneous preferences of a person afflicted with Alzheimer‟s disease often come into conflict

with the attitudes and values the person held when he or she was still healthy. This gives rise to a di-

lemma: should conscientious caregivers, in their efforts to best respect a patient with dementia, give

priority to the preferences and attitudes this person held before becoming demented, or should they

follow the person‟s present preferences?

There are two dominant theoretical perspectives on resolving such dilemmas. According to Rebecca

Dresser, decisions affecting a demented person at a given time must speak to the person‟s point of view

as current at that time. By contrast, on Ronald Dworkin‟s view, we fail to take seriously both the

autonomy and the well-being of a demented patient, unless we follow the patient‟s earlier wishes,

wishes originated when she was still capable of acting autonomously and still able to judge what was

required for her overall well-being.

This paper develops a third alternative. Like Dresser, I take seriously the current interests of demented

patients, but for very different reasons: I argue that many such patients are still capable of autonomy to a

significant degree and that they still have authority concerning their well-being. However, I emphasise



40

very different aspects of both autonomy and well-being than Dworkin. I argue that the capacity to value

is not completely lost in dementia, and insofar as it is not, respect for the immediate interests of a de-

mented person compromises neither her well-being nor the respect for her autonomy. I trace the im-

plications of this approach for policies affecting decision-making on behalf of demented patients.







[66] THE EPISTEMOLOGY AND ETHICS OF HUMANISTIC MEDICAL PRACTICE

AND MENTORING - a neo-Polanyian medical philosophy

Stephanie R. Jha (USA)



The purpose of this paper is to introduce a philosophical frame for humane healthcare practice and

training of physicians. It sketches an approach to clinical practice, which aims to resolve the dilemma of

choosing between a mechanistic and a phenomenological model. It also speaks to priorities set by the

International Project of the Hastings Center on `The Goals of Medicine:' "any strong vision of the goals

of medicine must incorporate the art of human judgement in the face of uncertainty, a core of humanistic

and moral values, and the findings of careful science." (The Hastings Center Report V.26, #6, 1996) The

doctor-patient relation needs to encompass both the 'curing' (the scientific) and the 'caring' (the exis-

tential) functions. Of the two, the scientific aspect, with its higher degree of certainty of outcome has

been emphasized The Hastings Center Report has found the existential aspect, the humanistic approach,

generally wanting both in medical education and in practice. Its recommendation for good medical

education is to "foster an ability to move back and forth between a narrowly focused scientific approach

and a wide-angle lens perception of the human and social context of illness and disease."

This essay argues that Polanyi's epistemology can be explored and adapted for a scientific-humanistic

clinical medicine. Michael Polanyi was a physician, chemist and philosopher af science. His philosophy

of tacit knowing was to counteract mechanistic approaches. A modified form of his philosophy com-

bined with an ethics based partly on his epistemology and partly on his informal notion of duty, will

provide a philosophy of 'nature and nurture' in clinical medicine. I labelled this neo-Polanyian, recon-

ciling 'hard science' with 'phenomenological attitudes' in the clinical situation, yet not compromising the

science. To show the structure and function of tacit knowing, I analyzed it into a series of 'models' and

showed the dynamic connection (called 'intellectual passion') among these 'models,' the better to un-

derstand the mind-body relation. The neo-Polanyian proposal is a formal structure going beyond Po-

lanyi, to accommodate 'indirect knowledge,' the doctor's interpretation of the patient's experience from

physiological data. 'Direct knowledge' is, of course, the doctor's knowledge of the physiological data.

The proposal has positive implications for clinical practice, especially in the mentoring of novices,

because it lays out the structural and functional components of insight and understanding The ethics of

mentoring is schematized using a 'two poles of knowledge' form of tacit knowledge epistemology, here

analyzed into its vectorial components, the better to show the mentor's function in the emergence of the

ethical being of the novice physician. This proposal sketches the use of the relation between tacit and

explicit knowing, giving an ontological, epistemological and ethical framework for clinical medicine

which coincides with goals in the Hastings Report as it applies to the mind body relation, the doc-

tor-patient relation and the medical education issue. Neo-Polanyian philosophy of medicine neither

looses sight of the need for medical science to be objective, nor does it loose sight of the humane ele-

ment in the doctor-patient relationship.







[67] INFORMED CONSENT IN DENTAL MEDICINE IN CROATIA

Zvonimir Kaić (Croatia)



International Principles of Ethics for dental Profession should be considered as guidelines for every

Dentist according to the rules of the Fédération Dentaire International (FDI). Moreover, six ethical

principles must be applied by the dentist when performing everyday, routine work with the patient: a)

autonomy of the patient - right to self-determination; b) nonmaleficence - duty to do no harm, duty to

prevent harm to others; duty to remove harm from others; c) beneficence - obligation to do good on



41

behalf of others; d) justice - obligation to treat others fairly, not to discriminate, and to distribute re-

sources equitably; e) veracity - duty to tell the truth; f) fidelity - obligation to keep promises.

Currently, dentists in the Republic of Croatia are obliged to follow these principles issued in 1996 by the

Croatian Dentist Chamber Principles of Ethics and Code of Professional Conduct. The regulated rela-

tionship between dentist and patient is found in the chapter V. (from articles 26 to 41). Furthermore,

FDI's 1988 health history form is a very useful tool for recording the general health of the dental patient

before starting any treatment. An informed consent form for the proposed treatment in dental medicine

follows the previous form. According to the Croatian Law of the Health Protection (NN 1/97, article

26th, point 5th and point 11th) the patient has to be informed about the proposed treatment and its

possible risks.

The process of informed consent remains the primary mechanism for protecting patient autonomy in

treatment decisions. Lack of a written permission for the proposed treatment can be legally inappro-

priate according to the Croatian Penalty Law. Today in Croatia there are eight dental medicine speci-

alities: family dentistry, prosthodontics, orthodontics, pedodontics, dental pathology and endodontics,

oral medicine, periodontology and oral surgery (NN 33/94).

Each discipline has own specific procedure or treats a definite kind of a patient (for instance a child).

This means that informed consent has to be tailored and adapted to special needs. The price of a

prosthodontics device will be very important. However, the patient has to be given precise information

before starting with treatment. Moreover for decades, dentists in Croatia have been giving their patients

short maintenance guidelines for prosthodontic or orthodontic devices, oral hygiene, and post oral

surgery, to name a few and similar.







[68] POLISH PHYSICIANS' PHILOSOPHICAL REFLECTION UPON HEALTH

Ewa Kałamacka (Poland)



What is the meaning of health for man? This question has been asked by nearly all the philosophers in the

history of mankind who tackled the issue of lifestyles. The various answers they proposed set the course of

the history of human thought, and also the history of medicine, as it is medicine that people have always

turned to for adequate means of health protection. While illness was seen as a special situation which called

for intervention, health remained inconspicuous and was up to philosophers to 'discover'. The reflection of

many generations of physicians grappling with those elusive problems gave rise to health instruction, which

was a response of the medical profession to social thought. Physicians have been teaching the principles of

hygiene and disseminating medical knowledge for ages. This is an all-important function, shaping the

attitudes towards health and promoting the desired forms of behaviour. It could thus be expected that

physicians' views on health and a healthy lifestyle are generally known. Alas, this in not the case. People are

more interested in the history of disease and in spectacular successes of therapeutic medicine, whereas the

history of health philosophy and its practical implementation - instruction - remain overlooked.

"God always forgives; man sometimes forgives; Nature never forgives - if someone defies Nature, it strikes

back and takes its revenge." And people have indeed defied Nature for ages through unhealthy and often

passive lifestyles which brought on various ailments and diseases. The fundamental truth that, no matter

what kind of activity one pursues, exercise is always necessary as it allows one to stay fit (and the lack of

exercise breeds disease) has been repeatedly pointed out by physicians in Poland since the 16th century.

The human organism is genetically programmed to live an active life. Its main functions and the basic

life-sustaining activities take the form of incessant movement. Therefore, exercise is good for one's health.

Modern science has confirmed what physicians have long known and sought to communicate to others -

sometimes in a naive way, but always to the point. Their popular belief and in-depth reflection alike

associated health with motor activity, although, it needs to be stressed the strength and postulated

mechanism of this association varied. Generally, physicians intended to promote health and build up in

their patients an immunity to physical and mental ailments, so that they would become masters of their

bodies without the need to think of their health at all times. Initially, it was believed that the desired forms of

behaviour could be instilled in people through health education conducted by means of the printed word. A

great many books, leaflets and periodicals were published. Basically, the authors advocated an

individualised regimen to ensure good health, improve one's physical and mental abilities and increase life



42

expectancy. The reasons behind health-awareness were not purely egoistic: an individual's utility to society

was also emphasised in this context. However, it turned out in practice that education alone, if not supported

with other measures, was no guarantee of the final success. It was only in the 19th century that the first

institutions emerged oriented towards the active promotion of health. An important role was played in this

field by gymnastic societies.

It follows that - contrary to popular belief - the interest in matters of health and the tremendous activity of

health-promoters observed in Poland today are hardly a new development. In fact, they stem from the work

of the luminaries of Polish medicine throughout the ages, such as W. Oczko, S. Petrycy, L. Lafontaine, L.

Bierkowski, H. Jordan or E. Piasecki.







[69] AUTONOMY OF THE PATIENT – AUTONOMY OF THE PHYSICIAN – IN

OPPOSITION OR COMPLEMENTARY TO ANOTHER

Józef Kałuża (Poland)



Autonomy of the patient has gained in recent times on meaning and its role in the formation of relation

between the patient and physician can only hardly be overestimated. However if autonomy of the patient

is accepted as an achievement of unique importance for the sick and community we are witnessing the

ignorance of autonomy of the physician. Physician's activity in many discussions is marked by pater-

nalism as the main cause of deprivation of patient's will and freedom of choice. Autonomy as its at-

tributes has opportunity to choose. According to this “we analyse autonomous action in terms of normal

choosers who act 1. intentionally, 2. with understanding and 3. without controlling influences that

determine their actions”. (Beauchamp and Childress, 1994). If we take into account the aforementioned

criteria according to which autonomy is evaluated, it can be assumed that autonomy of the physician is

under steady limitation because of influence of the following factors: the introduction of standards,

economical conditions as defined by insurance institution‟s, the richness of the community members,

and by the efficiency of organisational structures of health care services and administration. Each of the

aforementioned factors may contribute to disturbances of balance between autonomy of the patient and

autonomy of the physicians.







[70] HERMENEUTICS AND DIALOGUE IN HEALTHCARE

Peter Kampits (Austria)



Traditionally the human being in healthcare is regarded as patient. Disease is seen as an organic or

biological dysfunction that can be repaired by intervention of the doctor. Psychical or spiritual factors

are either neglected or seen as a complementary factor. Even the discussion of pa-

tient-doctor-relationship between autonomy and paternalism is based on this perspective. Holistic

medicines are very often seen as an alternative.

A hermeneutical approach to the human being could overtake these reductions. It opens a perspective of

'reading' the human being and its conditions of health and diseases. Furthermore, a hermeneutical ap-

proach can help to establish the patient-doctor-relationship as a permanent dialogue.









[71] SOCIAL AND CULTURAL ASPECTS OF PSYCHOPHARMACOLOGY

DEVELOPMENT

Andrzej Kapusta (Poland)



European psychiatry witnesses a great influence and interest in contemporary trends of American

psychiatry. It is important to reconstruct evolution and transformations of American psychiatry from the

psychosocial vision of mental illness to the biological approach to psychiatry. Today, reductionism



43

dominates the institutions of psychiatric and psychological research and practice; therefore it will be

useful to see how culture and commerce infiltrate and what is often presented as purely scientific tri-

umphs. The phenomenon of biologic psychiatry is in itself a symptom or acting of larger underlying

cultural process. In my presentation I would like to examine the influence of psychopharmacology on

social reality, social reception of human nature and hopes and dangers connected with production of

new drugs.

Psychiatrists play a particular role in cultural and individual fantasies. In present-day psychiatry new

generation of drugs effectively relieve many symptoms that previously defied therapy. The practical

efficacy of these drugs can now be explained through our rapidly mounting knowledge of biologic and

genetic mechanisms involved in pathogenesis of mental disorder. But treatment procedures have be-

come simplistic and reductionistic. Psychiatrists must be aware of the complexity of psychiatric diag-

nosis and social consequences of biologic psychiatry. A person with his or her individual history and his

or her body and social circumstance, exists as a mixed product of nature and nurture, and this kind of

person can be helped to change. New physiological research and new drugs provoke series of questions

about nature of the self and our "cultural psyche".









[72] INTER-ETHICS: DEVELOPING NORMS FOR A NEW PARADIGM OF

HEALTHCARE

George Khushf (USA)



Traditional norms of medicine presuppose an individually practiced, individually oriented form of

healthcare, in which 'medically necessary' care is a function of science, and values come in as a second

step and concern the use and abuse of the individually oriented, scientifically based care. It also pre-

supposes that social and policy issues can be addressed independent of decisions about 'standard of care'

and the norms of scientific practice. The macro-ethical policy issues are thus separated from the mi-

cro-ethics of the physician-patient relation; ethics generally is separated from the science.

Based on these assumptions, the traditional approach to promoting a more humane healthcare takes two

forms, reflecting the micro/macro distinction. First, there is an attempt to redirect the physician/s focus

from a narrow disease orientation so that s/he may be attentive to the broader disrupted life world of the

patient. Second, there is an attempt to establish health policy that assures social solidarity, providing

access to healthcare services and protection against the harm to livelihood that attends illness.

This traditional approach is misguided because it is not sufficiently attentive to the institutionally based,

community oriented character of care - even in countries that provided universal coverage and are

attentive to social solidarity. An insufficient distinction has been made between community and society,

and this has broad implications for healthcare. The public/private distinction presupposed by current

forms of micro- and macro-ethics needs to be reassessed, and this, in turn, entails a reassessment of the

relation between medical science and ethics. Today healthcare is practiced by institutions, not just by

individuals; it is team-based, and community oriented, involving multiple professionals, not just medi-

cine. The scientific base extends well beyond the so-called 'basic sciences', including not just sociology

and psychology (as advocated in the biopsychosocial model), but also economics and administrative

knowledge associated with quality assurance. Ethics is no longer neatly separate from the science. In

this context, ethical considerations play a role in the formation of the institutional context that, in turn,

frames the standard of care. To promote a more humane form of health care and properly address the

ethical issues found in the new health care settings, we need an organizational inter-ethic; namely, an

ethic for the middle level institutions that make many of the most significant decisions regarding care.

Such an ethic must involve a more positive appraisal of the role that institutions and administrators now

play in configuring clinical care.









[73] PRINCIPLES OF MODERN MEDICAL ETHICS AND HEALTH CARE



44

PROFESSIONALS. Relation between health law and education: from declaration to im-

plementation (Georgian experience)

Guram Kiknadze, Givi Javashvili, Akaki Barkalaia (Georgia)



Georgia, like other countries of post-communist space, is on its way of building open, civil society and

elaborating appropriate health legislation for this kind of society. Health legislation currently being in

force in Georgia touches upon all basic issues of modern medical ethics, like informed consent, confi-

dentiality, end of life decisions, euthanasia etc. The above-mentioned legislation is generally harmo-

nised with the one of the western world, with the recommendations and declarations of the international

organisations (e.g. "A Declaration on the Promotion of Patients' Rights in Europe").

However, there is considerable discrepancy between the principles provided by law and the imple-

mentation of these principles in the health care system of Georgia. One of the most important reasons of

the above-mentioned discrepancy is lack of knowledge concerning the main principles of modern

medical ethics and negative attitude of the medical personnel towards some of them. This especially

concerns the item of patient‟s participation in the decision making process. The contemporary under-

standing of such items as "autonomy of the patient" and the respect of his/her dignity are mainly un-

known to health care professionals. This type of (paternalistic) attitude has its own objective grounds. It

should be taken into consideration that the generations of medical personnel were brought up in the

conditions of totalitarian ideology.

The way out from the situation currently existed in Georgia is persistent education of health care pro-

viders and patients to change their mentality. All the legal provisions aiming at changing physi-

cian-patient relationship and promoting of patients' rights will remain to be futile declarations, unless

awareness of the society will increase. Only awareness can help patients to "survive" and safeguard their

rights like the visitors of ancient Thebe, who could escape the deadly Sphinx of Thebe only by giving

correct answer to her question.









[74] VICTIMS OF ABUSE - REVICTIMIZED IN MEDICAL CONTEXTS

Anne Luise Kirkengen (Norway)



A phenomenological study of the embodiment of sexual violations in childhood will be presented. The

impact of socially silenced boundary assaults has been explored among adult incest survivors. Strategies

of adaptation to incompatible but simultaneously existing realities and universes of meaning have been

studied.

Silenced boundary violation result in the unmaking of objects that have been part of the abusive acts.

Any aspect of the objective world may change its meaning by afflicted pain, abuse, and humiliation. As

parts of such experiences, these aspects are re-designed. Likewise may any part of the body that the

abused person has dissociated during abuse, change meaning in a certain sense. This may result in an

altered perceptibility, and in reactivations of pain or horror in the past by particular sensations in certain

body parts at present. The unmaking of objects, and the unmaking of bodies by abuse causes very

special problems when abused people attend medical services for health problems that are long-term

effects of afflicted pain and humiliation there-and-then, though unrecognized as origins of the pain or

panic they suffer from here-and-now.

Violation puts meaning at risk. Persons presenting symptoms or behaviour in accordance with silenced,

hidden universes of meaning will appear and be treated as sick or unsane. The long-term health impact

of silenced abuse holds characteristics that do not meet the most central of preconditions for correct

biomedical interpretation. Consequently, malinterpretation will generate maltreatment with a high

degree of probability. While asking for help, victims of abuse risk to become revictimized by medical

measures.







45

[75] ESTABLISHING A NATIONAL PATIENT'S RIGHT OFFICE IN HUNGARY

Eszter Kismödi (Hungary)



Since 1997 I have been a member of the Szoszolo - Spokesperson Foundation for the Protection of

Patients Rights in Hungary. The foundation was started in 1997; it organized an experimental program

supported by the Soros Foundation. This initiative is working to establish the institution of patients

rights advocates in hospitals, according to the new Hungarian Patients Rights Law. I worked in two of

them as a patients advocate.(The new Health Law was enacted in December 1999, the patients rights

advocate chapter came into force in 2000). The aim of the program is to develop mechanisms which

ensure the prevalence of human rights, patients rights in the health care system. The proposals generated

by this program offered useful guidance for the legislators, patients, health providers, potential repre-

sentatives. Since last year I have been researching the Israeli Patients Rights Law, and Patients advocacy

system were very similar to the Hungarian system. In Israel, I have been conducting an academic re-

search project observing the patients rights advocacy system in Israel, visiting 23 hospitals.

As a result of my experiences and ideas the "Szoszolo Foundation" will establish a National Patient's

Rights Office in Hungary in May under my direction. The paper will discuss my experiences in the

patient's advocacy field in Israel, will report about the first 3 months experiences and future expectations

of the new Patient's Rights Office in Hungary.









[76] ABRACADABRA! INFORMED CONSENT

Judith Lee Kissel (USA)



Contemporary medicine confronts us with problems that, more and more, are being addressed with

'procedural solutions' flowing from the principle of autonomy, such as that of informed consent. These

procedures may take the form of regulations, as in the United States, or that of guidelines, as in many

parts of Europe. Such solutions are desirable, especially in pluralistic societies, due to their seeming

value-neutrality. Procedural solutions appear to act as depolarizing agents - formalities - that neutralize

certain moral issues.

However, informed consent, or some version of it, has effects deleterious to medical ethics and to the

solidarity of communities within which medicine is a social practice. It substitutes sterile procedures for

profound, substantive reflection on the nature of the human being, of the person, on how we respect the

human and on the intrinsic morality of the practice of medicine. In this paper I examine informed

consent and its cognates in relation to several examples in which procedural solutions appear to 'depo-

larize' morally problematic situations:

First, informed consent, as used in regard to body-as-property cases in the United States, manages a

two-fold transformation. On the one hand, the procedure converts the status of body-parts from that of

vehicles of personhood to that of property and resources to be mined and exploited as genetic and

pharmaceutical products and commodities. On one and the same form, and sometimes even as a con-

dition of medical treatment, current consent documents routinely ask permission not only for the in-

tervention but for use of materials taken in the course of the intervention. On the other hand, the pro-

cedure recasts itself from one meant to reverse the abuses of subjects by researchers and clinicians,

familiar to us from well-documented cases in Europe and the United States, to one that safeguards

profits to medical entrepreneurs. Moreover, in the body case, informed consent substitutes for profound

reflection on the meaning of the human and of personhood.

Second, in cases of assisted suicide the consent of the patient supposedly changes the nature of 'killing'.

Moreover, consent procedures exonerate clinicians from considerations about medicine's essential

morality, not to mention liberating them from being concerned about, and having profound respect for,

their patients. Once the patient has decided he wants to die - now - the clinician need no longer worry





46

about her moral responsibility for, say, prescribing a lethal dose of medication. Once the patient has

determined he wants to continue futile treatment, the clinician need no longer need involve herself about

the fruitful use, or waste, of scarce resources.

Third, take the case of research in which physician-researchers experimenting with gene therapy own or

invest in the company whose product they are studying. Informing the patient, according to some,

presumably not only frees these clinicians from apprehensions about conflict of interest but eliminates

the very conflict itself.

Fourth, non-directive counselling apparently changes public policies of pre-natal screening, with their

very real eugenic consequences, into cases of individual decision-making involving only individual sets

of would-be parents and their would-be offspring. We take this stand even though epidemiological data

indicates the near total elimination of certain deformities and conditions due to such prenatal screening.

Moreover, once the patient makes the decision, the clinician no longer need be concerned about what

screening says about respect for 'less than perfect' persons.

Finally, value-neutrality on the part of the clinician promises respect for the beliefs of pluralistic so-

cieties, but such a promise is deceiving. The impartiality toward the 'good life' thus promised comes

with historical background, social nuance, concept of self, and a set of values. Procedural solutions in

general, and informed consent in particular, are part of a context that underlies the social and political

phenomenon of atomism and laissez faire capitalism.









[77] SOLIDARITY AND HEALTH CARE IN ANCIENT GREEK TRAGEDIES

Theano D. Kontopoulou, Spyros G. Marketos (Greece)



The ancient Greek tragedies of Aeschylus, Sophocles and Euripides are a rich source of information

about the health care of the fifth century B. C. in Greece. The healing art is supposed to be granted to the

humans by Prometheus - an inferior God - thanks to his solidarity to their miseries because of diseases.

In many tragedies health care is provided by healer Gods, who take compassion on sufferers. Zeus

releases Io from her illness, touching her with his hand, as he can no longer bear seeing her tortured by

Hera. Apollo saves Orestes from his mental disease feeling sympathy for his obedient follower. Beyond

these magicoreligious ways of healing art, the human health care presented in ancient Greek tragedies is

based on social solidarity. Ill people, who can' t serve themselves, are accompanied in all their activities

and attentively nursed by members of their family or by close friends. Orestes, enjoys the ministrations

of his-sister, Electra and of his friend, Pylades. Handicapped members of the society, such as blind

people, are always guided and supported by somebody, who doesn't necessarily belong to their family or

friendly environment. The blind old man Oedipus, banished from his town, is guided to Kolonos by his

daughter Antigone. The blind prophet Tiresias however comes to Oedipus' palace guided by a young

boy, who is no relative of him. It seems probable, that the social health care undertakes to provide help to

disabled people, who can't afford such help by themselves. The most sensitive age groups, the children

and the aged, are under special care. The children are fed, and brought up by nurses. Orestes' nurse

brings him up with real self - denial and breaks down, as soon as she hears that he is dead. With the care

of aged are charged their descendants; usually their children, but sometimes also their grandchildren. It

is noteworthy, that Ajax wants to assure the care of his old parents, before he commits suicide. He gets

so far as to name his substitute for this task, that is his son Telamus. There are two cases however in

which no solidarity is shown towards the sufferers. The first one is that of Ajax, who has a mental

disease. The social environment wishes his death and denies providing him health care. The second case

is that of Philoctetes, who is chased away and lives alone on the uninhabited island of Lemnos, because

of an infectious ulcer of his leg. These aforementioned exceptions reveal the fear of mental and infec-

tious diseases, due to the deficiency of knowledge and experience in their treatment. In conclusion, the

health care of the fifth century B. C. in Greece, which is outlined in the ancient Greek tragedies, is based

on social and personal solidarity towards the suffering individuals of the society.









47

[78] PSYCHOTROPIC DRUG USE IN CHILDREN: are these drugs free from long-term

adverse effects?

Sotiris Kotsopoulos (Canada)



The discovery and use of drugs to treat mental illness are, no doubt, the greatest achievements of psy-

chopharmacology and psychiatry of our days. The effects and side effects of these drugs are usually

studied adequately and the informed psychiatrist may use them effectively and with confidence. This

however may not apply if these drugs are considered for administration to children.

Children are referred to child psychiatrists by parents, schools and social services in large numbers with

the request and the anticipation that disordered behaviour and emotions may be corrected with the

administration of psychotropic drugs. The pharmacokinetics of these drugs, however, on children, are

not well known. For example the effects and side-effects of the most frequently prescribed drug in child

psychiatry, methylphenidate (Ritalin), have been studied for a continuous use of 14 months only. Yet

methylphenidate is administered to many children who are diagnosed with attention defi-

cit/hyperactivity disorder for long periods of time (years) and often in doses far exceeding those rec-

ommended.

Concerns arise about the potential effects of psychotropic drugs on the developing brain of the child.

Unlike the adult whose brain is fully developed the child's brain is still developing. The processes of

development of neurotransmitter systems and pathways (e.g. serotonin, dopamine) have yet to be

completed. How the process of development and maturation of the neurotransmitter systems occur is not

known. However it is speculated that, as in other biological systems, development depends on feedback

mechanisms which take place probably in the synapses.

Psychotropic drugs work in the synapses restoring balance in a neurotransmitter system. The clinical

effects of a restored neurotransmitter balance are often impressive, normalizing behaviour and emotions

in children. A question is now raised: Since the child's brain is in a stage of development does long-term

administration of psychotropic drugs interfere with feedback mechanisms in the synapses and conse-

quently impede normal development and maturation? If this question/hypothesis cannot be refuted by

knowledge currently available, then, the physician faces a serious ethical problem when he/she con-

siders the administration of a psychotropic drug to children for a long period of time. Are short-term

gains, no matter how impressive these may be, sufficient to disregard concerns about possible long-term

side-effects? In the opinion of this author, physicians should exercise extreme care in the use of psy-

chotropic drugs in children until more knowledge is gained on their long-term effects on the developing

brain.







[79] EUGENIC GENETIC ENGINEERING AS A MANIFESTATION OF CULTURE OF

DEATH IN HUMAN GENETICS

Tomasz Kraj (Poland)



In his Encyclical Letter Evangelium vitae John Paul II confirms the great value and inviolability of

human life. However, in the present world there is an alarming attitude which devalues human life

especially in its most vulnerable moments: conception, birth, illness and its terminal phase. The Pope

defines it as the culture of death. Its most expressive signs are the killing of the innocent person by

means of abortion and euthanasia. However, the culture of death is a complex reality, i.e. it does not

exist only in its extreme manifestation. That is why the Encyclical Letter also describes its foundation in

exuberant subjectivism and the pretensions of an unrestricted freedom of the individual and its roots

in the concession to the logic of evil and in the indifference towards God and his ultimate rejection.

This paper aims at the presentation of how the culture of death manifests itself within human genetics.

Among numerous genetic achievements and proposals recognized by the teaching of the Church as

morally good or neutral there is the kind of intervention which may never be accepted. This is the at-

tempt to create people with pre-established qualities, also known as eugenic genetic engineering which

could be realized as human cloning and so called eugenic germ-line engineering.





48

The eugenic proposals are based on the anthropology which rejects the concept of the human person as a

spiritual and corporeal unity: as if the essence of man were only his spiritual subjectivity. His body is

recognized as a raw material which can be modelled according to the projects chosen in freedom and

total independence from any philosophical assumption or ethical norm previously established. Eugenic

genetic engineering does not explicitly reject inconvenient human life (although it would in practice

involve the killing of human embryos as a result of laboratory procedures or mishaps) but it aims posi-

tively at producing or making individuals who are wanted or seen as having value.

In this position there is no place for God and for life as a free gift from God, a gift which should be

accepted with love. There is no recognized identity of the human person which should be respected, but

only a complex of biological and social functions which may be manipulated at will. Not only is this a

view in which the good of the human person (especially in its embryonic stage) is depreciated, but it also

contains many excuses to justify the proposed interference with man which have their foundation in

exuberant subjectivism and the pretensions of an unrestricted freedom of the one who has at his

disposal technical abilities to carry out certain projects. These elements are recognized by John Paul

II as significant features of the culture of death.









[80] THE IMPOSSIBILITY OF UNDERSTANDING ANOTHER. K. Jaspers' phenomenol-

ogical point of view on schizophrenia

Thomas Krause (Germany)





K. Jaspers' phenomenological psychiatry is positioned in the same scientific and psychiatric period like

E. Kraepelin and E. Bleuler. But Jaspers' phenomenology has put into words the idea understanding

("Verstehen") the psychiatric patient. However the phenomenology is a scientific method as a phi-

losophy as well as an ethical basic attitude. Therefore it moulds the meeting by psychiatrist and patient

and this one isn't deficient, invalid by itself, it is first of all a human being. Because the phenomenologist

is besides a method also a tool in the phenomenology, now it should be discussed whether phenome-

nology referring to schizophrenia is insufficient or contradictory. After describing essential propositions

of K. Jaspers' phenomenological psychiatry it should be investigated, whether it is possible at all to

understand schizophrenia or to set up a communication with it, since phenomenological psychiatry has

the propositions, that schizophrenia has the characteristics of unempathy ("Uneinfiihlbarkeit"), incom-

prehensibility ("Unbegreifbarkeit") and inunderstandability ("Unverstehbarkeit"). Therefore schizo-

phrenia and phenomenology use different languages and schizophrenia is mutes to phenomenological

propositions. Since phenomenology is a philosophy as well as a way of encounter, there are two con-

sequences for schizophrenia. First schizophrenia is a disease as well as a malady and therefore a con-

stitution of human being and consequently most human, what is more creative and productive. But since

schizophrenia isn't the way of truth, but of madness, schizophrenia appears to be a misspent of life; the

so called life as the liberty to create and translate into action the own will.

The untruthfulness and inunderstanability in the phenomenological point of view on schizophrenia is the

sign, that phenomenological psychiatry fail the will to understand the psychiatric patient just on

schizophrenia.

This contradiction is the only philosophical problem of phenomenological psychiatry.







[81] ETHICAL PROBLEMS OF ARTIFICIAL INSEMINATION: the views of Lithuanian

students

Tamara Kuntelija, Vija Praneviciute, Eugenijus Gefenas (Lithuania)



The paper deals with ethical and legal problems related with artificial insemination. It is based on the

results of an anonymous questionnaire distributed among Vilnius University students. The question-

naire was formulated after examining the data from different European countries in the period of



49

1990-1998 on the issues of artificial insemination.

The questionnaire examines such topics as gamete or genetic material donation, commercial aspects of

artificial insemination, the problem of surrogate motherhood, embryo status as well as the problem of

further destiny of unused embryos.

The results of the questionnaire will be present and dominant tendencies will be analyzed. For example,

the majority of students justify artificial insemination in vitro with donor sperm, they are disposed to

approve altruistic gamete donation. They think that the embryo has the same right to life as the new-

borns; they also think that the children commenced by the way of artificial insemination have the right to

get information about their biological parents. These opinions will be interpreted in our socio-cultural

and legal context. The attempts will also be made to examine the differences between medical and

non-medical students on the ethical issues related with artificial insemination mentioned above.







[82] “HEALING ATTEMPTS" ON TERMINALLY ILL PATIENTS. A casuistic investiga-

tion

Dorothee Lange, Nina Schmahl-Menges (Germany)



“Healing attempt" is defined as the clinical use of a drug that has not been tested completely with the

goal of healing a patient.

The patient‟s lack of interest or his/her refusal, further therapies already successfully standardized, or an

inadequate relation of risk and benefit (utility and futility) hinder the use of this medicine. There have

been very few publications on the ethical aspects of these healing attempts in German medical literature.

According to § 41 of the German law governing the manufacture and prescription of drugs

(Arzneimittelgesetz) healing attempts have to be approved by ethical committees, but, as to our

knowledge, the ethical aspects of such healing attempts have not been dealt with sufficiently.

The project “Ethical Issues in the Aid of Dying”1, funded by the Deutsche Forschungsgemeinschaft,

realized in Freiburg and Munich is a first step towards a systematic view of these ethical aspects.

For the first time case-related documentation of clinical decisions on therapy restrictions, including

decisions on healing attempts, are recorded in detail and analysed ethically.

In the course of this project the case of a 32-year-old patient was included in the clinical documentation.

This patient suffered from AML and after chemotherapy, developed an extensive fungus infection

during the expected period of infection (cytopenia). As all the therapies applied so far to fight this life

threatening infection had not been successful, the use of a healing attempt, i.e. of a not fully testified

anti-fungus medicament was discussed.

In an extensive presentation of this case the following views of all the individuals involved and groups

are given and discussed under ethical aspects. The fully-informed patient, who is in a very bad general

condition, at first refuses any further therapy and wishes to die at home with the help of sufficient pain

medication. Urged by his wife, who demanded maximum therapy and the healing attempt for the pa-

tient, he changed his attitude towards therapy and agreed to the measures planned.

In this context there is the question of patient autonomy. The doctors disagreed in their views con-

cerning further procedure. A majority saw the necessity of the healing attempt because of the young age

of the patient and the fact that the AML was treated for the first time. Some of the doctors, however, had

objections: they weighed the very small chances of survival against the patient‟s original wish to die at

home. In addition, nursing staff and a psycho-oncologist took part in the decision finding.

The different views on the ethical justification of the healing attempt in this case and on the ethical

problems of such healing attempts in general are presented and analysed.



References:

1

“Rahmenbedingungen passiver Sterbehilfe" funded by the German Research Council (DFG). Project leaders:

Prof. Dr. W. Hiddemann, University Hospital Munich-Grosshadern and PD Dr. Stella Reiter-Theil, University

Hospital Freiburg









50

[83] CARE FOR THE DYING: An empirical study of ethical and psychological problems

Dorothee Lange, Alexander Wunsch, Wolfgang Hiddemann, Stella Reiter-Theil (Germany)



Objective:

Physicians have to apply not only medical knowledge, but also ethical and psychosocial competence in

the care for the dying. Dying people are faced with the threat of prolonged suffer which may result from

advanced high technology medicine. Physicians are challenged with the decision to withhold or apply

this type of treatment. This decision is often difficult and lacks objective criteria. So far, studies in this

area have been restricted mostly to reports about experiences, case reports and theoretical papers. There

is a lack of empirical data in German-speaking literature about these issues. Therefore, the approach of

this study is empirical, namely to explore and analyze problems in this domain.

Methods:

A questionnaire with 30 items was developed to evaluate ethical problems in the care for the dying, the

education for this task, and physicians' psychological problems. The questionnaire was sent to hospital

physicians and general practitioners of various kinds of disciplines and different levels of experience.

468 returned questionnaires from a complete inquiry in the region of South-Wurttemberg were statis-

tically and qualitatively analyzed.

Results:

When asked about ethical problems, a large majority of physicians, leaving their clinical field aside,

reported problems concerning (1) withdrawal of treatment and (2) the care for the relatives of the dying.

The qualitative analysis showed that lack of time is a very important problem. Almost half of the phy-

sicians said that they feel insecure in taking care for the dying. Thereby, physicians reported mostly an

emotion of helplessness. In the qualitative analysis mourn for the patient who died was reported by most

doctors. The professional experience and years of practice of a physician is an important factor in coping

with the difficult task of palliative care. The qualitative analysis showed that a majority of physicians

find some support from their family, friends or colleagues. Besides, a lack of specific ethical and psy-

chological training for the care of the dying was reported.

Conclusions:

The analysis of the data allows the following conclusions. Ethical reflection and an impact on psycho-

logical research can improve the situation of the care of the dying. As a result suggestions for specific

training in ethical and psychosocial competence will be made, particularly for young and inexperienced

physicians.







[84] THE COUNCIL OF EUROPE AND THE MEMBER STATES toward the problem of

protection of human rights and dignity of the human being in the context of the applica-

tion of biology and medicine

Kazimierz Lankosz (Poland)



The article focuses on two fundamental issues: the freedom of academic research and lack of restraints

in conducting scientific experiments as well as the potential danger to human rights, man‟s fundamental

freedoms as well as the basic question when human life really begins.

For centuries, the freedom of learning and academic research has constituted the chief postulate of both

scholars and scientists in their struggle for the right to independent research. In our century, science has

accomplished spectacular achievements, among others in the sphere of biology and medicine. There

appeared new perspectives and possibilities, but also considerable dangers and threats to the entire

mankind. There is no consensus in the international debate as to the question of what research and

experiments on the human being may be permitted and what should be banned and whether some form

of international regulations should at all be introduced concerning these issues. The legislative systems

of individual countries differ in this respect.

The system of protection of the human rights and fundamental freedoms is based on the European

Convention of 1950. It is the most advanced international system of human rights protection in the

contemporary world. Some of the rights, which are being protected by the Convention, may be threat-



51

ened by the recent developments and advances in scientific research and the unrestrained freedom of

conducting scientific experiments. In its numerous documents, the Council of Europe has become a

pioneer in formulating the principles of bioethics on the international arena as well as in the drawing up

of various legal instruments marking out the boundaries of the freedom of scientific research and ex-

periments, particularly in the sphere of medicine, biology and in the applications of genetic engineering.

In this context, special attention should be drawn to the preparatory work and debate connected with the

signing under the auspices of the Council of Europe of the Convention for the Protection of Human

Rights and Dignity of the Human Being with Regard to the Application of Biology and Medicine (the

convention was opened for signing in 1997) and the auxiliary protocol concerning among others, the

issue of legal protection of the human embryo. An analysis of the main resolution of the convention may

also be useful during the debate on the respective regulations in the Polish law.









[85] CONCEPTION OF HEALTH AND ILLNESS ON THE VERGE OF THE 21ST

CENTURY

Anna Latawiec (Poland)



The beginning of the 21st century brings both positive and negative effects of intensive progress of

civilisation. Not only ecological conditions of human being's life are destroyed but also norms deter-

mining his health, that have been in force so far. Interference into environment by means of genetic

engineering, techniques of modem civilisation, promotion of healthy lifestyle affects biological and

psychological state of health. The thing is to weaken immunity system and loosen interpersonal rela-

tionships. As a consequence existing illness processes increase and new ones occur on the social and

biological background.

This study is aimed at discussing the essence of health and illness in the context of historical draft as

well as attempt to find the slight limit dividing both states of the organism in the aspect not only closely

connected with the way and quality of life under changing conditions but also in comparison with

analysis of human being's place in a surrounding biological and social environment.







[86] THE TRANSITION FROM PREMODERN TO MODERN ETHICS IN MEDICINE.

The analysis of the patients’ points of view

Zita Liubarskiené (Lithuania)



On the basis of conventionally accepted systematisation of ethics in medicine and orientating towards

the perspective of humane healthcare, a sociological study of in-hospital patients was performed. In the

report the results of the study are analysed and a discussion on ethical situation in the area of personal

healthcare in Lithuania is presented.

According to how physician-patient relationships are formed, two different ethical systems in medicine

can be distinguished: the premodern and the modern ones. The premodern system reflects paternalistic

relationships, the dominance of the physician‟s decisions, and the patient‟s compliance. The modern

system that accepts the role of the informed and active patient, the physician-patient relationships that

are based on partnership, and that stresses the respect for patient‟s autonomy, is more consistent with the

humanistic level of medical ethics. The modern ethical relationships are best reflected by the principles

of the patient‟s informativeness and autonomy. On the international level these principles are consoli-

dated in the Patients‟ Rights declaration of Lisbon (1981) issued by World Physicians‟ Association, also

in the Convention of Human Rights and Biomedicine issued by European countries (1997). In Lithuania

the implementation of these principles is regulated by the law on “Patients‟ rights and indemnity for

damage to health” (1996).

Irrespectively of their age, education, and sex, the patients who participated in the study expressed their

will to be fully informed (100% of men and 90% of women). The patients were given a questionnaire

containing 16 questions that should reveal to what extent the patients in healthcare institutions are



52

autonomous, how much their right to choose is respected and how actively they can participate in the

treatment plan.

While comparing the data on female patients, it was noticed that the women at the age where the ability

to work is best were most interested in the course of treatment. Also high correlation between the pa-

tients‟ education level and their interest in their healthcare was found – the more educated the patients

were the more violations of the principles of informativeness and autonomy they indicated. About ¼ of

women and almost ½ of men did not even know if they should be considered informed or not.

If patients do not have the possibility to actively participate in the treatment program designed by the

physician, to what level the ethical situation in medicine should be ascribed? If patients do not even

know if they are informed or not, can we talk about patients who know their rights?

The analysis of this social study is directed not only towards gaining knowledge but also towards im-

proving the organisation of healthcare. The report is illustrated with tables, so it can well be a poster

report.







[87] SPIRITUALITY-CARE ETHICS AND THE RESPONSIBILITY OF THE PHYSICIAN

TO ALLEVIATE SUFFERING IN A SECULARISTIC TIME

Elena Lugo (Puerto Rico)



In the Hastings Center report on The Goals Of Medicine one reads: "But some suffering, particularly

when connected with a chronic or terminal condition, can raise for patients questions about the meaning

of life itself, of good and evil, of personal fate and destiny - questions commonly thought of as spiritual

or philosophical, not medical, in nature" (Nov-Dec. 1996)

While medicine ought to recognize its own boundaries and finite possibilities to address the human

condition, the healing function of medicine entails, in my view, at least the effort to respond to the

person as a whole and to stress care and not limit itself to cure. Though care demands clinical-technical

excellence, it also implies concern, empathy and personal response to the deeper levels of the experience

of suffering. The physician is thus called to respond to the spiritual dimension of his patient. But in order

to do so effectively, the physician ought to cultivate a spiritual dimension as a clinical resource. But, on

the one hand, contemporary secularism as such permeates many schools of medicine and encourages

either apathy toward the spiritual or regards it as mere sentimentality unworthy of a professional. On the

other hand, some trends toward spirituality in medicine underestimate the scientific-technical strength

of contemporary medicine. I intend to argue that both a radical form of secularism and a spiritualistic

reaction against it in their respective denial of the transcendental feature of the person undermines its

inherent dignity, ignores the complexity of the suffering patient, and endangers the physician/patient

relationship in the order of care particularly before the experience of suffering, as integral to the human

condition. I will revise critically the concept of spirituality as actually connected to medicine in some

clinical ethics settings in USA, within and without a religious context, and argue that this must be

disengaged from some "New Age" ingredients so as to become, not only integral, but also fundamental

to an ethics of care faced with suffering as ultimately a mystery open to understanding if not to expla-

nation.

My presentation consists of four segments: first, an appraisal of radical secularism and how it has in-

fluenced medical education and practice particularly in relation to the diverse meanings of suffering as

experienced by chronic and terminal patients. Second, an exposition of spirituality as the human need

and capacity for relationship to whatever or whoever gives meaning, purpose, and direction to our lives.

If not properly understood, spirituality can challenge and misinterpret scientific and technical excel-

lence. But if understood to engage our capacities for self-transcendence and meaning-making within the

complementary interplay of reason and faith, it can strengthen an ethics of care. Third, an attempt to

argue how care ethics must be rooted in virtues while virtues receive a cognitive and affective founda-

tion in religious ecumenical spirituality without excluding a purely humanistic spiritual dimension in the

person as such. Fourth, recommendations on how to integrate spirituality into a clinical ethics of care as

guidance to an effective scientific-technically sophisticated response to the chronic/terminal patients

who are at present under-treated or over-treated but seldom adequately treated.





53

[88] DOES LITHUANIAN LAW ON THE RIGHTS OF PATIENTS CONTRIBUTE TO

HUMANE HEALTHCARE?

Kristina Lukauskaité (United Kingdom)





In order to secure health law contribution to humane healthcare, the rights of patients have to be granted

by law. The right of a patient not to undergo any kind of treatment or even be touched by a health care

professional unless the patient (or, in the case of his/her incompetence to provide such consent – his/her

proxy or legal guardian) has provided informed consent to his/her treatment is one of the most important

patients' rights. For the patients to be able to enjoy this right it must be enforced - there must be a legal

mechanism dealing with their complaints and enabling them to receive compensation for the damage

done by violating this right.

In Lithuania, the Law on the Rights of Patients and Compensation of the Damage to Their Health

entirely came into force on 1 January 1999. 1n comparison with the international guidelines and regu-

lations (Principles of the Rights of Patients in Europe, Council of Europe Convention on Human Rights

and Biomedicine, the Declaration of Helsinki), the Lithuanian law grants all basic patients' rights,

including the right not to be treated unless informed consent is given, The concept of damage inflicted

upon patients, however, in this law encompasses only "material" damage (e.g., the one which has re-

sulted from malfunctioning of the medical equipment or due to infection or inflammation in connection

with the examination or treatment or patients). Failure of the health care professional to obtain informed

consent from a patient, however, causes mostly "moral" damage to the patient, which is not mentioned

in the law. Moreover, the law grants compensation only for "damage inflicted upon a patient's health

through the legitimate actions of a physician or nursing staff member". The damage suffered by patients

as a result of the culpable actions of a health care professional may be compensated in accordance with

the procedure established by the Civil Code. However, failure of a health professional to obtain the

patient's or his/her legal guardian's informed consent before starting treatment or examination (except in

cases of emergency and therapeutic benefit) is nowhere mentioned as a culpable action. Therefore a

patient whose (or whose guardian's) informed consent has not been obtained has no possibility to re-

ceive compensation. Firstly, because the damage he/she has suffered is not a "material" one (and

therefore not covered by the law), and secondly, because compensation procedure of the Civil Code

does apply only to culpable actions.

Regarding the right not to be treated or examined without having given informed consent, the law is

merely declarative: it grants the right without providing any means for its implementation.

The study analyses the shortcomings of the Lithuanian Law on the Rights of Patients as well as exam-

ines their reasons. In order to find out the reasons, the shorthand report of the parliamentary session in

which the law was adopted is analysed. The reasons will also be identified during semi-structured

interviews conducted with the drafters of the law. Amendments of the law are suggested.









[89] RESEARCH ON COGNITIVELY IMPAIRED PERSONS - a precondition for humane

healthcare or a threat to humanity?

Giovanni Maio (Germany)



Medical progress is an ambivalent phenomenon. It can create problems which endanger humane

healthcare, while it is incontrovertible that growth of medical knowledge may also be prerequisite for a

more humane medicine in the future. If we assume an inherent value of research, the ethical conflict

arises that we must perform research in the interest of future patients, but that this may occasionally

injure the interests of present patients. For precisely in the case of cognitively impaired persons the

question arises whether it is compatible with humane healthcare, not only to treat, but also to use these



54

patients for research purposes.

In this contribution it will be examined whether it is possible to resolve this conflict in recourse to the

principle of justice. Some bioethicists and theologians have formulated a general duty of solidarity also

pertaining to cognitively impaired persons as a justification for research on these persons. If one ex-

amines this thesis from the theory of justice according to John Rawls it is revealed that such a duty of

solidarity cannot necessarily be extrapolated from Rawls` conception of justice. This is at least true of

Rawls difference principle according to which social and economic inequalities are to be arranged so to

be of maximum benefit to the least well of. If one assumes that research on cognitively impaired persons

could be viewed as putting these persons in a poorer position, then Rawls` difference principle would

offer no basis of argument for the performance of research on cognitively impaired persons in the in-

terest of future patients, because according to the difference principle only those measures are justifiable

which serve the interest of the respective least well of. Those measures which would engender addi-

tional injury for the least well of could not be balanced by any utility according to Rawls.

However, the difference principle in John Rawls is subordinate to the first principle, according to which

each person has an equal right to the most extensive basic liberty compatible with the same liberty for

others. These "primary goods" are determined by the freedom and integrity of the person. Precisely this

integrity of decionnaly impaired persons would be endangered if one would abstain from research and

thus relinquish the increase in knowledge related to their disease. Thus one could conclude, at least from

Rawls` first principle that society must take on a duty to guarantee the degrees of freedom for cogni-

tively impaired persons and thus also support the efforts for their healing.

It cannot be clearly elucidated from Rawls` first principle what form these efforts may take. To conclude

from John Rawls the exclusive demand for intensification of research, would be a foreshortened adop-

tion of a certain ontological preconception of healthcare. Thus from Rawls` justice as fairness, by no

means follows a social duty of research or a duty of solidarity pertaining to cognitively impaired per-

sons. This principle, however, makes clear how problematic the retreat from research is, and, that the

renounciation of research must be legitimated as much as its undertaking.







[90] TOWARD A PHENOMENOLOGICAL PHILOSOPHY OF MEDICINE

Pierre Mallia (Malta)



The four principles of biomedical ethics are obvious and yet so indeterminate in resolving moral prob-

lems. With post-modern ideas lingering around the sociology of medicine it is important to form a

philosophy of medicine which continues to respect the ethos that has always centred around the good of

the patient. I propose to do this through the phenomenology of medicine and in particular through

Heideggerian methodology.

Whilst Dasein is defined by Heidegger as concern and there being both a positive and negative concern;

being can thus be defined as `care'. In health care this `care' is centred around the care of the patient and

it can only be a positive care - that of doing good; of curing or aiding healing. Thus Beneficence become

the `phenomenon' of the physician patient relationship - a phenomenon being descńbed as that which

defines itself in itself.

It can be argued that nonmaleficence is not a phenomenon but a direct result - a manifestation - of

beneficence. There would be no need to describe nonmaleficence if there were not a priori the attempt to

do good (even though the maxim goes 'primum non nocere'). In a similar manner there would not be a

need to describe `respect for autonomy' if there were not an a priori attempt to do good. Therefore

although autonomy is a phenomenon of libertarian philosophy, starting from Kant through the modern

theories, within the realm of the ontology of the physician-patient relation it is as well a manifestation of

the original phenomenon of beneficence.

Justice is somewhat more complicated because it relates the wishes of the patient or the demands of the

cure to social justice and to scarce resources. Thus this principle depends at large on a more social

encounter. Thus there is a duality of justice - that of society and that within the relationship. If we were

to start through being-with-one-another and the answer to difficult questions may find ground in the

phenomenological approach. Thus an antibiotic will not be prescribed if it does more harm to society at

large, even if it helps the patient in the short term.



55

Questions of justice are difficult to discern because they are a phenomenon of being-with-one-another

and can have numerous interpretations. There are mainly to extremes of argumentation. One (Engel-

hardt) favours a totalitarian libertarian approach whereby two moral agents may decide between

themselves what moral path to follow. This has inherent flaws leading to arguments of reductio ad

absurdum. Moreover it takes us backwards along the evolution of moral ideas to the times of the duel.

The other extreme favours a `traditional' (MacIntyre) approach which argues that traditions have sur-

vived contrasting moral ideas and that therefore traditional modes of justice have a basis to them which

ought not to be ignored. Philosophers like Sissela Bok argue that one should be optimistic that we are

able to find common pathways for justice; and hence `being-with-one-another'.

Now one may argue that some may not have beneficence in mind when doing medicine but fame or

money. Indeed these are not bad in themselves and have been described as goods external to the tradi-

tion of medicine. Yet the goods internal remain that of beneficence and joy in giving. Those who seek

only goods external are being parasitic to the tradition which has traditionally based itself on the goods

internal.

The phenomenological approach of being-with allows argumentation for a caring approach to health

care and protects itself from the many post-modern ideas emerging. Not that post-modern ideas are all

wrong; but surely because many are dangerous and can be solely self-centred. Although medicine is at

the service of humanity; it is not the possessed servant. One may decide to have a chapel in one's home,

but that does not give him the right to dictate religion to the priest serving in the chapel. With modern

medicine becoming more and more centred around insurance and profit-making organisations, and with

litigation orienting many towards defensive medicine it is well to have this ideal at the heart of a phi-

losophy of medicine.





[91] ON THE ILLNESS AND ITS MODES OF EXISTENCE FROM A CULTURALIST'S

APPROACH

Krzysztof Marczewski, Mariola Kuszyk-Bytniewska, Andrzej Kapusta (Poland)



The article discusses the concept of illness and its modes of existence. The authors concentrate on

Florian Znaniecki's theory of the concrete reality". This theory allows treating the illness as a part of

human world. What we call the illness depends on specific experience of different human subjects (a

physician, a patient, and medical institutions). The authors concentrate also on some aspects of

Znaniecki's theory, which affect the contemporary medicine.







[92] THE EVOLUTION OF THE IMAGE OF THE PHYSICIAN THROUGH THREE

THOUSAND YEARS: From the priest, through Guardian Angel to Mephistopheles.

Krzysztof Marczewski, Sabina Magierska, Mariola Kuszyk-Bytniewska, Piotr Jankowski

(Poland)



The progress of the medical knowledge and social changes changed totally the psychological and phi-

losophical relationship between the physician and the patient. Since this time there is still the almost

total monopoly of medicine, which means that in order to recover somebody‟s heath, it is mandatory for

him to ask a physician for help. There is an analogy to the part of the church in obtainment of salvation.

Surprisingly, all attempts of breaking the monopoly in treatment of diseases remind the history of her-

esy.

Since a very long time to almost nowadays, a doctor appeared as a priest in patient's mind. So a doctor as

a priest was able to order a patient to do something or forbid him; to do something else (for example

same dietary restrictions).

In medicine of the 20th century a partnership and patient's rights started to exist, and the doctor became

aware as a Guardian Angel. He gives us suggestions, pieces of advice, and information (sometimes they

are quite selected). But this is a patient, who is responsible for the final decision.

Nowadays a physician is a scientist, who looks for diseases before a patient notices the symptoms

(diabetes, hypertension, and osteoporosis). A physician proposes new and excellent methods of treat-



56

ment, of improving the quality of life, diminishing a pain, and even shortening of human life. In modern

societies almost all people become clients (the new word for “patient") of health service system. The

system alone is changing into health industry.

The gene therapy, “in vitro" fertilisation, cell cultures, storage and reproduction of tissues, cloning, and

also euthanasia will be possible in a very clone future. It will probably create a different image of a

physician. We have to consider if the smiling and nice doctor, who promises, for example, the regain of

the youth, won‟t be a Faust's Mephistopheles? And he will demand not only his material reward for him,

but also...







[93] ETHICAL PROBLEMS OF INVOLUNTARY TREATMENT

Jovan Marić, Danijela Tiosavljević (Yugoslavia)



The question of ability of patient to decide himself what is the best for him is very discussible. In theory

two opposite attitudes are met: the attitude of individualism (mostly in so called western societies),

which absolutizes individual rights with the idea: the will of patient is the utmost law ("voluntas aegroti

suprema lex"); and the collective attitude (mostly in eastern societies), which stresses general interests

with the idea: health ("good") of patient is the topic law ("sanus aegroti suprema lex"). We prefer this

other case. The thesis is that human life, besides individual, has also social values. The predominant

thesis is: the health of individual is general good, and because of that the society (in this case medicine

and doctor) intrudes in estimation what is the best for patient. Ethical justification of limitation of will of

patient in various situations is many time approved (prevention of suicide, negated euthanasia, public

health interest - legal institution of compulsory or involuntary treatment).

[94] BULGARIAN WOMEN'S DECISION ON ABORTION - IS IT PERSONAL?

Juliana Marinova, Stanka Markova, Katya Peeva (Bulgaria)



Background. In Bulgaria induced legal abortion is often used as a method of birth control. Abortion rates

are high (48.1% of women aged 15-49 in 1996) and abortion is mainly considered as a serious problem

of women's reproductive health. The aim of this report is to describe some aspects of women's decision

on abortion as a responsible moral dilemma: whether and how it is influenced by their close relation-

ships.

Objective. 398 women who had already decided to terminate their pregnancies were inquired by self-

-administered questionnaire. Their voluntary consent for participation in this study was taken. They

represent 95% of all women undergone an induced abortion in abortion clinics in Stara Zagora for the

period of three months. The problem was considered by women's basic demographic and social char-

acteristics (as age, marriage, parity, education).

Results. Majority of women had discussed the situation of their present pregnancy only with their

partner (78.1 %). They expressed the view that they were not been able to decide on abortion without

sharing the responsibility about it with their partner. They had a right to decide by themselves but they

did not apply this right. More than a half of women inquired (57.6%) considered that the main cause for

this decision was connected with their close relationships - care for children and family.

Conclusions. The most of women faced to the real problem to decide an abortion did not make the

decision as a freely obtainable option. Their decision on abortion was not personal. Women preferred to

share the responsibility about it with their partners. In reality they applied ethics of care of a conse-

quentialist.







[95] THE PROBLEM OF TRUTH IN APPLIED ETHICS

Barbara Maroszyńska-Jeżowska (Poland)



In this paper I would like to analyse why a moral discourse is much more complex than the term “ap-

plied ethics” might suggest. It is so because bioethics is of an interdisciplinary nature. On the other hand,

like every well-established moral discipline, bioethics has to collect a substantial knowledge of moral



57

facts, be able to justify this knowledge using the appropriate tools, and be open for searching alternate

solutions to moral dilemmas.

A permanent presence of moral dilemmas is an indispensable facet of human life. As such, it forces a

human being to undertake intellectual efforts in order to draw moral conclusions and to make moral

choices. It is unavoidable that during these activities one has to analyse a package of descriptive, con-

ceptual and normative statements, and, at the same time, evaluate premises and obligations underlying

them. Moral and philosophical theories are only a part of a larger body of knowledge that is involved in

bioethical enterprise. There are also medical and health sciences, nursing sciences, law and social sci-

ences that play an important role in bioethics.

Two approaches to the problem of truth will be taken into account: realistic and constructivistic. The

analysis will be limited to the meta-ethical dimension, i.e., to the problem of justification and truth.









[96] THE FIRST CRITERION

Manuel Barroso Silvério Marques (Portugal)



Epistemological problems have caused outbursts of controversy since the beginning of Western science.

For some medical writers, only what was manifest was reliable; for others, even the generalities (the

KOINOTETES of the Methodists) were visible indicators of the proper treatment and known by direct

acquaintance. I propose that inherent in the epistemic virtues of the clinician lies the ancient concept of

METRON as a measure for internal properties, a feeling of rightness, a 'gut' feeling.

AISTHESIS was the foundation of one (ancient) criterion for (fast) decisions under uncertainty; pro-

viding a forgotten bridge between the whole and the part, the general and the particular, and resolving

the paradox of the faculty of judgment.

Developing the study of the foundations of the clinical practice, I shall approach the issue of precision in

the medical act (AKRIBEIA), following previous work. The basis of modern medical decision-making

will be related to the Galenic axiomatic tradition and compared to Hellenistic Medicine, mainly to the

Methodist' concept of PHAINOMENON KOINOTETES. It will be proposed that presentation

(GNOSIS) of a clinical picture, the Gestalt qualities of clinical accidents and properties, legitimates

generalisations (a possible meaning of KOINOTETES} about the various, equivocal and heterogeneous

manifestations of diseases. The debate so generated turned around the criteria (CANON) and the just

measure (METRON). It will be argued that, for the Ancients, the proper metric, described by the Hip-

pocratic writer as SOMATOS TOU AISTHESIS (the body feeling), must convene with intersubjective

and objective standards. 'Gut' feeling was the first criterion for resolving clinical dilemmas.









[97] THE ETHICS COMMITTEES - THE PORTUGUESE CASE

Jorge Melo, Pereira de Almeida (Portugal)



The present paper aims at explaining the history, legal attributions and composition of ethics committees

in Portugal. It also explains the work they develop and the limitations their members are confronted

with, once by law they have functions of independent review board and ethics committee altogether.

Coming from nowhere, in a country of recent habits of open discussion of tough and touchy questions

their role is not easy. Deep and not always open-minded presence of the church that for centuries im-

pregnated the social tissue and the work of new faiths with strong public positions, do not easy the work

or the efficacy of the committees either on the working place nor at the community. Their impact is

small and far from the desirable level.

The countrywide dissemination of the committees which must exist in every healthcare unit, public or

private alike, could make one think of an educational program for their members given before they

assume work and of a systematic review of the results and interventions. None exist or is even men-

tioned in the law. This could be even more expected because although mainly consultative in their



58

functions, they spend the vast majority of their work analysing the clinical trials, an activity for which

they can be sued, should anything go wrong.

The example of the ethics committee's work of one institution in Lisbon- the Portuguese Institute of

Oncology - will finish the paper: showing the wide possibilities and difficulties the members face on

everyday practice - an effort that is not possible to anticipate from the reading of the law.







[98] INTEGRATIVE MEDICINE? The scope of Thure von Uexküll's model of psychoso-

matics

Daniela Mergenthaler (Germany)



Psychosomatics, grossly speaking, deals with interrelationships between organic, mental and social

functions in the diseased organism. Thus, psychosomatics can be considered as a binding discipline

conjoining different approaches to human diseases. But so far psychosomatics lacks a unifying concept.

Its label conjoins a multitude of approaches and attitudes. This is not surprising from a philosophical

point of view, since psychosomatics is inevitably confronted with one of the most fundamental problems

of philosophy, the so-called mind-body problem.

In Germany, psychosomatics has been deeply influenced by the concepts of Thure von Uexküll. Di-

agnosing that contemporary biomedicine still relies on overcome epistemological and anthropological

traditions provided by philosophers and physicians in the 17th century Uexküll claims for an integrative

view onto human being in medicine. He forms its theoretical framework means by the following phi-

losophical, biological and psychological concepts:

- General systems theory interprets the human body as a living system consisting of a hierarchy of

different levels of organisation. Each level has got its own, irreducible or emergent qualities. The

connections between different levels are realized as procedures of translation.

- Semiotics considers all functions of life, e.g. cellular communication, perception or even physi-

cian-patient interactions, as sign-processes. They are three-relational and entail a significate, a sign and

an interpretant. The latter affects their inherent subjectivity and circularity.

- Freud's psychoanalysis and Piaget's developmental psychology stress the historical dimensions of

human being.

- The functional cycle developed by Jakob von Uexküll explains on the basis of a dynamical feedback

circuit how organisms construct their realities as subjective environments by perception and meaningful

utilisation of signs.

Within this background Uexküll elaborates the situational cycle that shows how human beings construct

their subjective realities via different sign-processes. It is a feedback cycle enlarged by elements of

fantasy and creativity. The situational cycle forms the conceptual basis of a psychosomatic medicine.

Diseases are no objective facts, but matters of subjective interpretations and as such parts of subjective

environments. The patient produces different symptoms, which refer to underlying (disease) conditions

and which are interpreted by him as well as by the physician. Uexküll reformulates the target of the

physician-patient relationship as a construction of a common reality. His model is very promising for

medicine and especially psychosomatics, as it allows an integrative approach and combines different

levels and ways of interpretation for human phenomena. On the other hand, it has been criticized to be

mystifying; in so far his concept of emergence does not provide a coherent fusion of physiological,

physiological and sociological perspectives, but only an addition of different ways of description. So it

would seem only as utterance of the persisting ignorance concerning the relationship of mind and body.

In this presentation, my aim is to discuss the implications and limitations of the situational cycle for a

psychosomatic medicine. It is questionable that it suffices for an all-encompassing model for medical

activities, since there are obviously structures or facts beyond semiotic interpretation in medicine. But

nevertheless, Uexküll's concept seems to be worthwhile to be pursued and established as alternative to

common mechanistic, rigid views.









59

[99] EUROPEAN STANDARDS: JUDGMENTS OF EUROPEAN COURT OF HUMAN

RIGHTS AND CHANGES IN POLISH HEALTHCARE SYSTEM

Anna Mokrzycka (Poland)





For almost half a century healthcare in Poland was closely related to the ideas of the socialist system and

consequently ruled by norms of such system of law, which belonged to the first one. Based on the

general rule that everyone has the right to the same kind of medical treatment and no one can be ex-

cluded from the healthcare system, the system in fact was not able to provide such forms of healthcare

that would be satisfying for both sides: patients and people working in this system.

In a period of radical changes in healthcare system, changes being a straight, but not a simple, conse-

quence of the whole economic and political process which Poland undergoes are maybe the most im-

portant. Having in mind an old sentence one could paraphrase it: “healthy community in well healthcare

system".

An elementary requirement for achievement this situation is adjusting the standard of healthcare in

Poland with those in Europe, which may be done by law, through the process of harmonisation of

internal law. Under the notion of standards I understand not only the values related to healthcare in

particular but also those connected with legal procedures protecting patients; measures given by internal

law and also guaranteed by international norms. One of them is the right to protect own personal data,

which certainly constitutes a part of much wider right to privacy constituted in international law in such

basic act like the European Convention on Human Rights and protected by European Commission and

European Court of Human Rights. Following the text of this Convention one can easily see that only in

cases when there are essential reasons this right can be limited, namely: in cases being in accordance

with the law and necessary in democratic society, for reasons of national security as well as public

safety, then because of economic well-being of the country, the prevention of disorder or crime, and the

last but not least: the protection of health or morals and the protection of the rights and freedoms of

others (Article 8 of the Convention).

In this paper I would like to analyse briefly some of the judgements and decisions of the European Court

of Human Rights related to protection of personal data with regard to the medical record.

I want to suggest that the study of this judgements gives much wider scope of European standards in this

field and may be helpful in the process of harmonization of polish internal law, which I understand as

seeking for new solutions on one hand but profiting from those well regarded on the other. I believe that

it is possible to avoid some problems of a great importance and that it is always the better way com-

paring with necessity of bearing the consequences.









[100] INDIVIDUALISED 'EVIDENCE-BASED' DECISION SUPPORT: Myth and reality of

patient autonomy

Bert C. Molewijk, Wilma Otten, Anne Stiggelbout, Dupuis Heelen, Job Kievit, (The Nether-

lands)



According to Sackett et al. (1996), evidence-based medicine is the conscientious, explicit, and judicious

use of current best evidence in making decisions about the care of individual patients. Besides that

evidence-based medicine aims at optimizing the treatment outcomes for patients in terms of

life-expectancy (corrected for the quality of life), it also introduces a new form of patient education in

the pursuit of `evidence-informed patient choice', based on the principle of patient autonomy (Entwistle

et al., 1998). In our empirical-ethics research, we studied the relationship between individualised `evi-

dence-based' decision support and patient autonomy in a prospective multi-center randomised trial. In

this paper we present the results from a normative analysis of the qualitative data (interviews, observa-

tion notes, audio-taped consultations between surgeons and patients).

A Markov decision analytic model has been developed for the treatment of abdominal asymptomatic

artery aneurysm (AAAA) in which the use of patient characteristics and risk factors allows for the



60

individualisation of expected outcomes. An AAAA is a localized dilatation of an artery which in case of

a rupture can cause immediate death. The decision model calculates patient-specific mortality and

life-expectancy for three treatment options: surgery, watchful waiting, and doing nothing. After having

given informed consent for participation in the present study, aneurysm patients received either (1) a

brief brochure with general risk information only; or (2) in addition an extensive brochure with indi-

vidualised risk information for each treatment option.

The results from the normative analysis of the qualitative data show that the decision. support changed

the patients' and surgeons' perceptions of the medical problem consideredly. Moreover, it also trans-

formed the traditional roles of the patient and surgeon in the decision making process. Some remarkable

and paradoxical examples with their normative consequences will be discussed; such as `auton-

omy-paternalism' and the increased awareness of the complexity of the decision and its inherent un-

certainties. In the discussion, the central focus will be the (im)possibilities of patient autonomy with this

kind of decision support. Additionally, the importance of empirical ethics will be discussed in revealing

the often implicit moral dimensions of (decision support in) daily practice.



References:

Sackett, D.L., W.S. Richardson, W. Rosenberg, R.B. Haynes, 1996. `Evidence Based Medicine'. How to practice

and teach EBM? Churchill Livingstone, New York.

Entwistle, V.A., T.A. Sheldon, A. Sowden, LS. Watt, 1998. Evidence-informed patient choice: Practical issues

involving patients in decisions about health care technologies. In: International Journal of Technology Assessment

in Health Care 1998 14: 212-25.



[101] THE EXISTENTIALIST PROJECT AND THE HEALTHCARE SYSTEM

Piotr Mróz (Poland)



This short paper is intended to concentrate on the notion of insanity rife in various types of human

society. Some of the presented ideas resort directly to existentialist doctrine of man‟s projects. By and

large, insanity is not a fully conscious way of making choices, constituting values and realizing such

projects as e.g. works of art. Thus we want to bring into focus the “disastrous” adventures of such

mavericks as Baudlaire, Genet, Cezanne or Flaubert. It stands to reason that the idea of vivid, oft dra-

matic strife and everlasting conflict between an “ailing”, ill individual and the sane, “righteous” and

law–abiding society is profusely discussed here. Generally speaking, insanity may be said to perform a

kind of a response – on the part of an individual – to his/her existential predicament. As a free, tran-

scendent force human consciousness is nothing else but a state of unhampered and dynamic force. The

latter is equated with, by the existentialists, our freedom we are all condemned to. Thus all our projects

and choices are not to be separated from the responsibility we must take for them. This specific, hor-

rifying truth is a basic, primordial source of our being ill–at–ease in the world: the absurd, contingent

and totally unjustified mass of the being–in–itself. To same extent art and philosophy seem to be a kind

of partial recuperation and a way of the existential salvation. But the idea of overcoming the essential

absurdity and original “fall” is wholly deprived of any theistic and religious overtones treated – in this

concept of insanity – as acute forms of “false faith” and “the spirit of seriousness.”







[102] ASPECTS OF "HUMANE HEALTH-CARE": What is the patient talking about?

Gerald Neitzke (Germany)



Medicine and health care systems are changing profoundly. The extensive debate on patient autonomy

resulted in the fact, that medicine does no longer provide the single or objective answer to health

problems. Individual patients increasingly demand for different diagnostic and therapeutic strategies.

On the other hand there is a health care system, which does no longer automatically pay for all medically

indicated measures. How can humanity be saved in this changing, pluralistic system? First the indi-

vidual requirements for health care have to be met. They are not any longer identical with a maximum

medical supply. Physicians and patients do not have to look for the optimum medical answer to a health

problem, but for the adequate solution in a unique situation, regarding individual needs and values. How





61

can individual needs and requirements be analysed within a medical setting?

This paper provides two helpful tools from psychology. The well-established theory of communication

by Schulz von Thun will be adopted to conflicts and problems of the physician-patient-interaction and

medical ethics. The first tool is designed to make health-care providers more sensitive to what the

patient is really talking about: What other messages hide behind the "factual statement"? According to

Schulz von Thun a physician also has to analyse the patient's self-revelation, his or her appeal, and the

statements about the relationship. Examples from everyday practice will prove the relevance of this

psychological tool within a medical context. The second tool deals with conflicts of differing

value-systems. Applied to medicine, Schulz von Thun's theory discloses that varying attitudes and

convictions will invariably cause distorted patterns of communication. This leads to severe misunder-

standings and, as a consequence, to questionable medical decisions. Examples from daily routine on the

ward will be given, e.g. attitudes towards life and death, the degree of willingness for activity/action vs.

acceptance of the situation, and matters of risk-management. These techniques can be used on the ward,

when analysing moral conflicts, and teaching students at medical schools.

A better comprehension among physicians and patients could support patient-centred care. This enables

more specific and individual therapeutic decisions. Understanding of the physician-patient-interaction

therefore is a prerequisite of a "humane medicine". The psychological tools connect the medically

feasible (and indicated) to the individually desirable and preferred. A health-care-system based on

individual values and choices rather than a predetermined system of objective medical necessities is a

system aimed at. A physician-patient-interaction as drafted above is crucial for these changes: The

effects on health care costs have still to be figured out. It is a moral demand not to cut down on

healthcare before having established the real, actual requirements of every diseased.

[103] PHILOSOPHICAL ANTHROPOLOGY AS A METHODOLOGICAL STARTING

POINT FOR COGNITION

Maria Nemčekova, Katarina Ziakova, Jan Kudlicka (Slovak Republic)



In the point of view of western civilization pain becomes to be one of the most serious problems in the

sphere of health care. Since about 90% of patients suffers from pain of various origins. Most of them

persist chronically often with no obvious organic damage. The authors present some outcomes of re-

search project entitled "Philosophical - ethical aspects of life quality of patients suffering from chronic

pain". Compendium of scientific project was: to share in clarifying a disease from human point of view

or according to personal stage of patient by use of philosophical thinking and exact science methods. On

foundation of theoretical analysis and results of empirical research to look for the possibilities of health

care humanization and life quality improvement of people suffering from chronic pain.

The purpose of this paper is to show how philosophy illuminates and in some measure hepls solving

some of important problems troubling chronically ill patients (without patients with cancer). The

guiding aim has been to make their suffering more understandable by holistic approach to man.

Method: Set of 6 questionnaires were used to obtained data ( Pain and meaning of life. What do you do if

you suffer? What cause your suffering better or worse? Do you know some methods which relieved your

pain? Is your life influenced by pain and how? Pain and religion.) Questionnaire was anonymous and

voluntary. The study took place from March to October 1999 in the following hospitals: Research

Department of Rheumatic Diseases in Piestany, SR and Clinic of Neurosurgery in Martin Faculty

Hospital in Martin, SR. The answers of 265 respondents at the time their hospitalization were statistical

evaluated. Many important emotional and spiritual influences on pain experience were found out.









[104] ARE THERE BIOMEDICAL LAWS?

László Nemes (Hungary)



The philosophy of medicine and the philosophy of biology are in some important sense very similar

subdisciplines but at different stages of development. For the philosophers of medicine this fact provides

good reason for appealing to philosophy of biology for methodological, conceptual and theoretical

models. Furthermore some insights from the philosophy of biology should be integrated immediately



62

into our area, the philosophy of medicine.

One of the central issues of philosophy of biology is the so-called species problem. How can we identify

a biological species? What makes two individuals members of the same species? Even though these

questions seem prima facie to be trivial careful philosophical analysis reveals some fundamental

problems in the definition of species. The traditional conceptions of species (in the line of Aristotelian

and Linnean thinking) regard species as essentially defined entities - or with a more modern term as

natural kinds. Unfortunately these conceptions met with serious difficulties both practically and theo-

retically. The Darwinian view of evolution has inevitable consequences for concepts and taxonomies of

biological species. Currently the most plausible concept of species is probably that considers a bio-

logical species to be an individual entity. On this view a species is a historically defined entity with

determinate space-time limits rather than an essentially defined universal natural kind.

This new conception of biological species has important consequences concerning the question of the

very existence of biological laws. Indeed, this is one of the central problems in current philosophy of

science and particularly in philosophy of biology. In order to be universal a natural law should not

contain individuals and space-time limitations but only natural kinds without such limits. In the light of

the individuality thesis concerning biological species proposed and propagated by M. T. Ghiselin and D.

L. Hull from the 1970's we couldn't warrant the status of natural laws for generalizations in biology at

least in cases where that comprise a concrete species name. Consequently biological sciences become

more similar to some social or historical sciences than physics where genuine natural laws are funda-

mental. I hasten to add that this characteristic does not devalue the sciences of this kind in any sense.

Provided that we accept the Hull-Ghiselin thesis on species and the consequences implicated by this to

the philosophical nature of this science, we can ponder whether there are biomedical laws at all. Because

generalizations of medicine apply to determinate species (mainly Homo sapiens but of course other

animals too in veterinary science in the one hand and e.g. bacterial causes of their diseases on the other)

these biomedical generalizations are not laws. In addition to its theoretical (metaphysical) significance it

has very important implications to the practical side of healthcare. Although the essentialistic definitions

of diseases could be useful in some respect there are various problems of their own even at the level of

daily practice. The ultimate point of my proposal is that conceptual questions of medicine (the phi-

losophy of medicine in general) can throw some light on practical issues in medical education and

praxis.







[105] THE PRINCIPLE OF AUTONOMY: The physician’s authority and the patient’s obe-

dience.

Lesław Niebrój (Poland)



Although respect for autonomy of the patient is still considered as an ethical standard, in recent years

there has been an increasing critique of nature and some consequences of (traditionally understood) the

principle of autonomy. It seems be necessary to reconsider this principle. This article seeks to make a

contribution to this debate by using notions of authority and obedience to indicate the possibility of

rebuild the patient-physician relationship into the relay alliance of two autonomous subjects. Concep-

tions of: “charismatic authority”, which is based on the personal authority of the physician, and “virtue

of obedience” are recalled. The physician wisdom, knowledge, morality and etiquette are examined as

sources of the personal authority. The “charismatic authority” of doctor is than analysed according to the

distinction between the “epistemological” and the “deontological” authority. The conclusion will be

reached that the discursive richness of this notions of authority and obedience can provide important

insights to establish correct understanding of the principle of autonomy in medical practice.







[106] TOWARDS A BASIS FOR THE INTERNATIONAL CLASSIFICATION OF

FUNCTIONING AND DISABILITY

Lennart Nordenfelt (Sweden)





63

In 1980 the World Health Organization (WHO) published the International Classification of Impair-

ments, Disabilities and Handicaps (ICIDH). This publication is important and interesting for a number

of reasons. It contains the first comprehensive classification and nomenclature in the field of disability.

But it also constitutes a first attempt at a philosophy of disability, in part by introducing a set of elaborate

definitions of the concepts of impairment, disability and handicap, the core concepts of disability. The

conceptual structure of the ICIDH has been the focus of intense critical discussion for nearly two dec-

ades among professionals in rehabilitative medicine and social scientists, but also - although to a lesser

extent - among philosophers. This is unfortunate since these concepts are of great philosophical sig-

nificance.

The WHO has now released its beta-2 draft of the review ICIDH-2, called the International Classifi-

cation of Functioning and Disability. This product of an elaborate discussion and international collo-

bration, the ICIDH-2 is a thoroughly revised disability classificatory. The beta-2 draft has been sub-

mitted for substantial test all over the world. There is now a great general support for applying this

classification in the rehabilitative sector of medicine. This means that the ICIDH-2 will have a far

greater impact on the institutions of health care and their practices than the original ICIDH had. There is,

therefore, a clear need to subject the classification, and its underlying conceptual model, to philoso-

phical scrutiny. Indeed, WHO welcomes this input into the revision process.

In my On Disabilities and Their Classification (1983/1997) I analysed the conceptual foundations of the

initial version of the ICIDH. I discerned a number of conceptual problems in the proposed taxonomy.

These concerned the basic conceptual underpinning of the classification as well as the relations and

boundaries between the main categories: impairment, disability and handicap. In the present paper I

wish to make a similar scrutiny of the Beta 2 Draft and consider what improvements have been made

and what deficiencies still remain.









[107] EVOLUTION AND ANIMAL EXPERIMENTATION

Anders Nordgren (Sweden)



James Rachels uses the theory of evolution in an argument against animal experimentation which in-

flicts pain on animals that are subject to "biographical lives". He argues that this theory undermines the

idea of a special human dignity and supports moral individualism, i.e., the view that individuals should

be treated on the basis of their own particular characteristics, not on the basis of their belonging to a

group, for instance, a species. With respect to animal experimentation, this implies that if it is wrong to

use humans in experiments, then it is also wrong to use animals, unless there are relevant differences

between them that justify a difference in treatment. Rachels finds no such differences with regard to

those animals that are commonly used. To the extent that these animals feel pain, the experiments should

not be carried out.

However, it seems equally possible to use the theory of evolution in an argument in favour of at least

some experimentation involving animal pain. Michael Ruse provides the starting point for such a use of

the theory, although he does not develop the argument explicitly. Ruse maintains that humans, in fact,

have stronger moral feelings toward relatives than strangers, and he explains these feelings as a result of

evolution by the process of kin selection. On the basis of this descriptive and explanatory account, he

proposes that in order to be biopsychologically realistic we should adopt the normative view that we

have stronger obligations to relatives than strangers. If we extend Ruse's argument to animals, we can

assert that we have stronger moral feelings toward humans than animals, and explain this by reference to

an even lesser degree of genetic kinship between human and animals than between relatives and

strangers. On this basis, we can argue that in order to be biopsychologically realistic we should adopt the

normative view that we have stronger obligations to human beings than to individuals of other species.

We have moral obligations to animals but when there is a conflict between our obligations to humans

and our obligations to animals, the former outweigh the latter. In this way, at least some experimentation

which inflicts pain on animals can be justified.

In conclusion, it seems possible to use the theory of evolution in arguments in favour of as well as

against animal experimentation. This suggests that the theory cannot in itself give any specific guidance



64

regarding our obligations to animals used in scientific research. It has to be supplemented with certain

other considerations. However, these other considerations have to be judged on their own merits.







[108] THE ROLE OF POSITIVE EVIDENCE IN MEDICAL TECHNOLOGY

Ingemar Nordin (Sweden)



The problem of induction remains in technology. But there are some interesting differences between

proving the truth of an explanatory, scientific theory and proving the functionality of a technique. These

differences make it possible to explain the role of positive evidence in medical technology, and why it is

more rational to prefer a therapy corroborated by empirical evidence to those that are not. Positive

evidence also has a role to play for the distinction between quackery and genuine medicine. On the other

hand, such evidence gives no reason to rely on the preferred choice of action. It gives no guarantees for

the future. This has consequences for the rationality of practical decision-making.



The full paper on-line: http: / / www.tema.liu.se/ people/ ingno/ text.htm



[109] ETHICAL DECISION-MAKING IN NEONATAL UNITS. The normative significance of

vitality

Per Nordtvet, Berit S. Brinchmann (Norway)



This paper will be concerned with the phenomenon of vitality, which appeared to be one of the main

findings in a larger grounded theory study about life and death decisions in hospitals' neonatal units

(Brinchmann 1998, 1999a, 1999b, 2000). Decisions about withholding or withdrawing medical treat-

ment are essentially ambivalent and uncertain due to prognostic uncertainties. One study showed that

perceptions of the infant's vitality were important in deciding whether to continue or terminate active

treatment of very premature and critically ill children (Brinchmann, 2000). Professional knowledge and

experience, together with definite signs of the child's energy and vigour contributed to decisions about

further treatment or not. These decisions proved to be very much based on healthcare personnel's sub-

jective experiences and embedded in judgements about the particular and concrete situation.

The paper will discuss the normative legitimacy of vitality as an ethical appeal. To what extent does

vitality as a sign perceived by nurses and doctors have moral content? How can these intuitions strongly

held by nurses and doctors be understood as ethical? More important: To what extent can the subjective

experiences of doctors and nurses ground ethical decision making in cases where the child's life is at

stake? Signs of vitality as experienced by physicians and nurses might be vulnerable to accusations of

being too subjective and unreliable as basis for moral judgements in these cases.

The paper will argue that still, ambivalence and uncertainty are distinctive features of ethical deci-

sion-making in these contexts. In fact uncertainty represents a general epistemological problem in

ethics. However, there are several ways of dealing with this kind of capriciousness in ethical deci-

sion-making about these actual cases. Besides voicing the need for interdisciplinary informa-

tion-gathering and discussions into particular cases, a more fully understanding of the moral phe-

nomenology of signs of vitality might contribute to more qualified decision-making.

In this regard certain aspects of an ethics of proximity and some versions of moral realism might throw

light on the normative basis for these difficult decisions.



References:

Brinchmann, BS. "We did what we could; he was such a `nice' baby". How do nurses and doctors make ethical

decisions in the neonatal unit? (in Norwegian). Vard i Norden, Nursing Science and Research in the Nordic

Countries, 1998 (2): 16 - 21.

Brinchmann, BS. Ethical Decisions about Neonates in Norway (abstract). Image. Journal of Nursing Scholarship,

1999: 31:3, 276-7 (a).

Brinchmann, BS. Vitality as a criterion of the prognosis of premature infants? (in Norwegian). Tidsskr Nor Lae-

geforen. The Journal of the Norwegian Medical Association, 1999; 119: 2993 - 5 (b).

Brinchmann, BS. They have to show that they can make it - vitality as a criterion for the prognoses of premature

infants. Nursing Ethics, 2000 7(2): 141 - 147 (in press).





65

[110] KALMYK TRADITIONAL MEDICINE: History and modern time

Ellara Omakaeva (Russia)



Nowadays the growing interest in the traditional medicine has made me turn to a careful study of

Kalmyk sources. I have found some interesting notes concerning the methods of treatment in the col-

lections of Oirat manuscripts in Sanct-Petersburg and Elista.

The Kalmyk Medicine is based on Indo-Tibetan, Chinese and European science of curing people. Ti-

betan medicine first came to the Kalmyks in the 17th century, when Buddhism began to spread in this

region. Kalmyk doctors "emchi" and "otochi" masterfully applied and developed Tibetan medicine in

Kalmyk conditions. They had a good knowledge of medicinal herbs that grew in Kalmykia. The prin-

cipal handbook for them was the famous treatise "Dzhud-shi" translated into Oirat by a prominent

scholar and religious leader Zaya-Pandita Namkai-Dzhamtso (1599-1662). This tremendous work is

well-known under the title "Arasani jureken nayiman uyetu nigouca ubadisiyin undusun" including four

volumes with 154 chapters.

This work deals with the principles of treatment. Original works of Kalmyk physicians appeared in the

19th century as a logical result of the development of national medicine. Bembeev, a well-educated

person, wrote his fundamental work "Popular methods of curing the Kalmyks" which have been pre-

served in Russian National Library in St. Petersburg. The evidence of the Chinese influence is a treatise

on blood-letting and acupuncture which was translated from Chinese to Oirat in the past and recently

published in Russia in Latin transliteration with Russian translation. The book "Axarxan surgali" whose

author is a Russian physician I. Kamenetskij was translated from Russian into Kalmyk in the early 19th

century.

So the traditional Kalmyk medicine has three main methods of treatment: 1) medicinal therapy; 2)

non-drug therapy (that is massage, bloodletting, and acupuncture); 3) diet. The Kalmyk emchis believed

that the human organism is composed by 5 proto-elements: fire, water, tree, iron and earth. The patron of

medicine is the Buddha of medicine (Otchi burxn).

The Buddhist medicine was developed in the monasteries and temples by lamas-emchis. They used

astrology and lunar calendar in their work. Later in the 1930s when xuruls were closed and monks

arrested and even killed, the traditional medicine began gradually to pass away.Till 1990s some lamas

(Namka Kichikov and others) were curing people illegally. Legal practice of traditional medicine was

restored in Kalmykia in the 1990s. It is worth mentioning that apart from emchi there are the so-called

medlegchi whose function is also to cure people. They used prayers and mantras and performed special

rites. This method is known as "domnlgn". All these methods are now widely used in Kalmykia signi-

fying a revival of traditional medicine.







[111] PHILOSOPHIZATION AS A THREAT TO MODERN MEDICINE, IN PARTICULAR

TO CONTEMPORARY PSYCHIATRY

Yaman Örs (Turkey)



In any academic setting or on any serious occasion in which a philosophical presentation is made,

particularly, and relevantly here, as regards another activity, one must have in mind the question,

“Which philosophy?” One should relevantly ask, further, whether the philosophical approach in ques-

tion would allow us to see the conceptual issues involved in the universe of discourse in a different light;

or if, conversely, this approach might have an implicit “function” of replacing the methodological

framework of that activity, with its basic assumptions, specific approaches, semantics, techniques, and

similar general points. If, in short, the “philosophy” of any academic activity cannot be kept in a safe

distance from the activity itself, and is allowed, so to speak, to be incorporated into its theory and

practice, one might safely say, then, that the activity is apparently under the threat of philosophization

within the conceptual limits of the universe of discourse in question. Basic sciences from physics to

sociology, and applied fields with a basic science approach as their necessary condition, such as the



66

clinical branches of medicine for instance, may be said to constitute the foremost domain in our time

which is under threat in this respect.

Seen in the light of such a critically methodological perspective, medicine today, psychiatry in par-

ticular, appears to be undergoing philosophization as an academic and professional field. This is due, in

my view, to a methodological misunderstanding of the function of the philosophy of medicine and

psychiatry (and, of course, of philosophy in general), irrespective of whether or not one consciously

works within the limits of the interdisciplinary field of philosophy and psychiatry (and the philosophy of

medicine). One of the essential points missed by the interested psychiatrists and philosophers alike

seems to be the following. There are, and have always been, philosophies rather than just one phi-

losophical activity insofar as there exist widely differing schools or currents in philosophy. And with

their ever widening differences the subsets of traditional and/or traditionally oriented philosophy as its

extensions in our time, such as British empiricism, Neo-Kantianism, critical rationalism, existentialism,

or phenomenology, or even the Marxist philosophy, for instance, would possibly bring the eternally

unsolvable problems of their overall field to psychiatry. This we observe, for example, in the case of the

so-called hermeneutics allegedly as a way of understanding the patient and the scientific issues involved

in the clinic, or the concept of „the other‟ replacing that of empathy vis-à-vis the patient.

A true understanding of the methodological status and academic function of the philosophy of psy-

chiatry would become possible only if we could see philosophical activity in general in its true place,

that is, essentially as a meta-activity at the conceptual level. Closely related to this methodological

requirement is an ethical responsibility on the part of the philosopher and the psychiatrist interested in

this domain. And if a philosopher could speak, possibly not unjustifiably, of “the ethics of changing

other people‟s minds” in psychiatry (see AAPP Newsletter 7 (1): 2-3, 1999), one could also use the

expression, apparently equally justifiably I think, “the ethics of changing the minds of professional

people through philosophizing”.









[112] ON INSTITUTIONAL PATERNALISM

Valdar Parve (Estonia)



A standard bioethical committee acts towards the applicant of the permission for human experimenta-

tion and the test person of that research in accordance with the model of non-informative paternalism.

Towards the applicant the committee-paternalism is a soft one; towards the test person of that research it

is rather a hard one.

Soft committee-paternalism (towards the performer of human experimentation)

The decision made by the bioethical committee to give (or not to give) to the applicant the permission to

perform a human experimentation implicitly refers to the rules, which have already been manifested as

the corner stones of the decision-making. Even if a bioethical committee decided to prohibit the project

without specifying the motives and the arguments against the experimentation in that issue, every ap-

plicant can deduce the motives the committee had via comparative analysis of the rejected application of

research and the rules of the committee behaviour.

Hard committee-paternalism (towards the test person)

A decision, especially the refusal, of a project of human research may cut of the admission of a number

of diseased persons to the medicine they are in urgent need and which they cannot get in any other way.

In many cases the only chance to get very costly medicine the person needs is to participate in a clinical

testing of the medicine as a test person in a relatively poor country.

Characteristics of a relatively poor country

Mental and physical environment is more morbific as in established countries. There is a relatively high

rate of diseases not curable in that particular country due to the limited resources of medicine, but which

probably are curable in rich countries. (For the citizen of the poor country the real cost of a medication is

about five times higher because the income level in average is sevenfold lower in comparison with the

same one in rich countries.) Poor society alone cannot provide with treatment and medicine a number of

its citizens, except to treat them as the test persons. (A profit-seeking pharmaceutical company pays for

clinical trials.) Poor society is also incapable for the betterment of the environment as fast as the state of



67

health of the morbid people actually needs to avoid its obvious decline.

The bioethical committee, which follows the same rules and standards the committee in established

country follows, sometimes blocks the only way, how a person could get the necessary medicine in poor

country.

The justification of the paternalist deeds of a bioethical committee towards the persons the committee

cannot inform and ask their opinion concerning their experimental medication is the issue.







[113] BIOETHICAL REFLECTIONS ON RECENT DEVELOPMENTS REGARDING

ANIMALS IN EXPERIMENTATION: Cloning, transgenics, and xenotransplantation

Renzo Pegoraro (Italy)



Presently, cloning of animals in Italy is forbidden due to the Resolution of the European Parliament

B4-209/97 and to the Ordinance of March 5th, 1997 signed by the Ministry of Health.

Transgenics and cloning open new scientific horizons, in the fields of zoology, pharmacology, medi-

cine, and most importantly biotechnology: in fact, the production of tissues and organs, for use, for

example, in xenotransplantation, is one of the objectives of applied research in this sector. The results

obtained are therefore considered very important and promising with respect to the scientific knowledge

acquired thus far in the area of molecular biology and the many positive verifications involving public

health.

Overall, the production of organisms with identical genetic heritage could pose insurmountable prob-

lems involving the risk of reducing animal biodiversity, with consequential limits to genetic selection

and species-specific adaptation, as well as to the effects on the "web of life" in the area of which man

and other animals have the need to establish a complex relationship of equilibrium.

In order to proceed to an ethical evaluation of the various prospective outcomes of the development of

transgenic technology and of the new procedure of cloning, and the meaning of xenotransplantation, it is

therefore indispensable to recognize the interdisciplinary character of each phase concerning experi-

mentation, formulating contextually, a prospective and orientative judgement that asserts the legitimacy

or illegitimacy of each of these.

In Padova, in January 200, a research project has begun concerning, on the one hand, transgenic animals

and xenotransplantation (from a pig to a monkey) and on the other hand, reflections by an interdisci-

plinary group on the bioethical issues which this research raises.







[114] THE PROBLEM INTERPRETING THE CONCEPT OF HEALTH AS ETHICAL

VALUE

Eimantas Peicius (Lithuania)



The essential idea of the current paper is the analysis of the concept of „health‟ in the bioethical context.

Usually taken as a value itself, or something absolutely positive and very precious for all human beings,

the concept seems to have no specific significance and democratic plurality of the interpretations of its

meaning leads to some unclearity in nowadays. There are not many positive philosophical arguments to

prove it as ethical value, except denying anti-values (suffering) or accepting it a priori. So the meaning

of this concept remains multiple and it does not help for comprehensive intercourse. Besides this, on the

top is a question: What is meant by operating the term „health‟, particularly in Lithuanian health care

environment?

The traditional definition of health (as absence of disease) leads to dualistic interpretation. The law (for

example, Lithuanian) or Conventions concerning health and medicine emphasize its social aspects,

while a particular physician mostly cares about welfare of individual (patient). There is no aim to

overcome such duality of concept of health, but rather to realize what is less idealistic as a value.

Firstly, is health just an object, is it able to identify or to be taken as measure, o rather more subjective

thing: a great idea, the result of mind, the intimate inner state of body. Secondly, the analysis of suffering

vs. health again leads to problems of individual such as placebo, special characteristics of organism and



68

so on. The analysis of this term might lead us to the result that it is more like a value of freedom, or some

kind of happiness, i. e. impossible to fix it, because of too much factors to exert influence on it. Thirdly,

the question of priority of values let us to find out that interpretation of health consequently depends on

the understanding what is human being (religious, secular; technocratic, humanistic). The interpretation

of this concept might seem to be too narrow: interrelationships of health and industry, health and

commercial world, health and ideology...; either too broad: as if the goals of health care are focused on

the very particular aspects of reality and are not valid for all of them.

Concluding this, pluralistic conceptions of the concept of health lead to the different presuppositions

concerning the ethical dilemmas, and naturally, it results in different decisions. Hence, health as a value

is a reasonable, but at the same time, a dangerous and not reliable background for resolving global

questions as well as individual. The issue of the problem of interpretation opens some conclusions about

values as ambivalent, complex and required for more consensus.









[115] THE ETHICAL CODE OF THE HUNGARIAN MEDICAL ASSOCIATION

Ivan Peley, Bela Blasszauer (Hungary)



After the collapse of Communism, it became urgent and timely to create ethical guidelines for physi-

cians. An Act in 1994 has given the right to the recently formed Hungarian Medical Association to

regulate and control the behaviour of its members. This license applied to all Hungarian physicians,

since membership in the Association was mandatory. The Medical Association has established national

and local network of ethics committees whose task was to oversee the conduct of physicians, and if

necessary, to exercise sanctions or protect the falsely accused member. However, in order to make such

decisions, there was a need for a guideline, a need for an ethical code that made clear what behaviour

was moral and what was not. Therefore, a comprehensive ethical code of conduct was needed. The

Association has set up a committee, called Ethical College, whose first job was to compose their opinion

on certain issue, for example, on euthanasia. Later on, these opinions were translated into the Ethical

Code of the Hungarian Medical Association, published in 1998. Every member of the Association could

receive a free copy of it.

The Code was created by members of the Ethical College, who were elected through democratic process

within the medical profession. Before general acceptance of the ethical guideline, it had to go through

various forums and the final approval had to come from the general assembly meeting. The ethical code

is based on the Hippocratic principles and international human right declarations. The constant changes

and spectacular progress of medicine demand a periodical review and alteration of the code.

The two years long experience with the practical usefulness and short comings of the ethical code should

be critically reviewed, and the lesson could be utilized for the future role of ethical codes in pa-

tient-physician relationship.









[116] HUMANE HEALTHCARE AS A THEME FOR SOCIAL ETHICS

Martien A. M. Pijnenburg (The Netherlands)



The endeavor to humane healthcare has necessarily a strong social-ethical dimension. To stress this is

important first because of the very concept of 'humane healthcare'. In contrast to for instance the quali-

fication 'just healthcare', the concept of 'humane', which can be understood as 'man-loving', contains the

risk of approaching health care as a mainly personal enterprise of a caregiver, where by 'personal' is

explained in terms of attitude and altruistic virtues, and put in opposition to his / her technical knowl-

edge and skills. For all clarity: attitude and virtues are important qualifications for a caregiver and useful

counterweights against or corrections of merely pragmatic and technical views on helping people. But a

one-sided highlighting of these aspects neglects the fact that a doctor or a nurse are not only individual





69

persons, standing in personal relations to their patients, but always and also functionaries within a

existing system. This system itself is strongly oriented on rational, technical, pragmatic and economical

dimensions. These characteristics of the system 'health care' have a strong normative and formative

influence on the persons working within the system; they shape their attitudes. Analyzing the human-

izing or dehumanizing aspects of health care therefore asks for a critical analysis of the internal morality

of the system.

The second reason for a social-ethical approach of health care is 'humane' as a criterion for qualifying

health care. It seems to refer to a fixed and clear standard, which for instance enables to distinguish

between humane, inhumane or less humane health care. Such a standard is based on a certain view of

man. But one of the features of modern western cultures is the lack of consensus in views of man.

Religious, philosophical and cultural pluralism results in a multitude of private convictions. According

to one conviction one could interpret humane as 'respecting every patient as an autonomous and

self-determining person'. According however to an other conviction one could hold, that 'humane' stands

for respecting the finitude of human life and the acknowledgement of tragic and suffering in the human

existence. In our time both convictions can claim equality in worth - because they are defended as

personal beliefs and personal beliefs should be respected - so none of them gives us a kind of golden

standard for humanness. This finding has an analogy with the insight that in general it is very hard to

define in positive terms concepts like humane, health, and happiness. It is much easier to define their

opposites of inhumane, unhealthy or unhappiness. Also health care itself, although the name suggests

otherwise, finds it starting point not in health, but in the lack or disturbance of health: in illness, diseases,

or handicaps. Ethics reflects the same procedure: the ethical search starts in the experience of contrast,

dissensus or doubts and in emotions of indignation, anger of confusion; it starts, because the humanum

is threatened, violated or darkened. These kinds of experiences ask for analysis of their causes and

backgrounds. Such an analysis can not be restricted to health care as an interpersonal enterprise, but

must be broadened to the social and cultural context. This last point can be illustrated on the perception

of dementia in our culture.









[117] INFORMED CONSENT IN POLAND

Jerzy Pobocha (Poland)



Subsequent revisions of the Polish Code of Medical Ethics passed between 1966 and 1993 have ad-

dressed the principle of informed consent by the patient. This principle complies with the provisions of

law: art. 82 and 945 of the Civil Code, as well as art. 31 and 32 of the Physician‟s Profession Act from 26

March 1997. However, the paternalistic tradition in Polish medical practice has in reality reduced this

principle to consent “in blanco”, giving the doctor a free hand in selecting the method and procedure and

leaving the patient without thorough information as to the objectives, scope, risks and benefits of

therapy. It happens that consent is limited to the patient‟s signature in the hospital admission card.

Patients tend to assume that the doctor “knows better” and thus is more apt to decide on the “best method

of treatment”.

The doctrine of informed consent in Poland has been confronted with serious problems, partly because

the term “informed” has been translated into Polish as “conscious”, making it correspond with the usage

in the Civil Code, whereby a declaration of will is contingent upon the subject being “conscious”, in

other words possessing the capacity and competency to perform as declared. According to my study,

doctors tend to understand “conscious” literally, as opposed to “unconscious”. The analysis of 115 civil

lawsuits revealed that the term “conscious” of the Civil Code (art. 82 and 945) is also misinterpreted in

the ruling of testamentary competency. Consequently, “conscious” should be abandoned in favor of

“informed” or “competent” appropriately translated into Polish. Further implementation of the doctrine

of informed consent in Poland would require:

1. Proper understanding of the notion that, according to L. Beauchamp and J.F. Childress, encom-

passes 1. competency in understanding and decision-making; 2. voluntary decision; 3. release of

relevant information; 4. therapeutic recommendations (care planning); 5. ascertainment that items





70

3 and 4 have been well understood; 6. decision (selection of therapy); 7. consent and disclosure of

decision;

2. Limitation of paternalistic practices with the help of mass media and by informing patients as to

their right to make autonomous decisions concerning treatment;

3. More extensive use of questionnaires in the process of informed consent;

4. Implementation of tests examining the competency of patients than can be used by ordinary phy-

sicians and not only by psychiatrists.

As it appears from the literature, similar problems with informed consent have emerged in other coun-

tries, among them Japan. The possibility of therapeutic privilege (withholding of information) is pro-

vided for by art. 17 of the Code of Medical Ethics, as well as art. 31 item 4 of the Physician‟s Profession

Act. Recourse to this possibility is limited by the provision that “upon demand of the patient the phy-

sician is obliged to provide the relevant information”.





[118] EDUCATIONAL NEURO-ETHICS: Respect for children's neuro-developmental phases

vs. teaching experiments of unknown consequences

Anneliese A. Pontius (USA)



The innate nature of neuro-developmental phases had largely been ignored by behaviorists' belief in the

unlimited effects of environmental nurture. Three experiments were perpetrated on unwitting young

children without neurological knowledge about potential consequences:

First, the most striking of an obviously doomed attempt was made by persistent 'walking' exercises of

four newborns (Science 1972). This was based on the neurologically uninformed authors' conviction

that it was only a "belief in the invariance of the motor system" and the "subtle forces in society" which

deprives the one-week olds and "erodes the self-rewarding activities underlying the infant's curiosity".

The presence of the Babinski reflex was reported, unwittingly revealing the natural immaturity of

pyramical tract myelination required for walking (at ca 8 months) in contrast to the early "stepping

reflex".

Second, "new math" was attempted to be taught from kindergarden on. It emphasizes deduction over

induction and requires various late maturing frontal lobe system functions (not before puberty), e.g.

flexible selection of logical operations, sequential ordering, serially constructed arithmetical operations

and switching of the principle of ongoing action. The resulting confusion of the young children was

soon observable and such teaching was aborted.

Thirdly, the "whole word" or "sight reading" method of literacy instruction expected beginners to "read"

(like experts) an entire word without first using their natural neuro-developmental ability of perceiving

parts, analyzing them and then synthesizing them into a whole. The whole word approach in the young

children overemphasizes a processing habit required for an entire picture at the expense of sequential

processing necessary for the letters of a word. These two different processes tap different brain systems.

Thus, it cannot be ruled out that the "whole word" literacy instruction of beginners may have contributed

over the years to 26 million North-American "functional illiterates", a status not prevalent when pho-

netic reading was taught even in one-room, one-class school houses.

Potentially insidious consequences cannot be known aforehand when new, neurologically uninformed

teaching experiments are perpetrated on millions of unwitting school children. This suggests Educa-

tional Neuro-Ethics as an additional branch of bioethics for optimal cognitive fitness.









[119] PUBLICITY PRINCIPLE AND RESTRUCTURING OF THE HEALTH CARE

SYSTEM

Sashka Popova (Bulgaria)



My concern in this paper has been to argue for the importance of publicity principle in the process of

restructuring of the health care system (changes in legislation, structural changes, changes in health care





71

financing system in countries in transition). The national efforts ought to be informed by the key lessons

from the experience during the last ten years on the way to democracy, such as:

- inability to get inflation properly under control and severe financial constraints;

- substitution of public style with closely party style of management;

- inability to transform political conceptions into practical programs for management;

- use of high-handed methods, use of covert or tacit methods of making decisions without public debate

of alternatives;

- partial institutional mechanisms existed for public participation that look like a form of social control

rather than a democratic opportunity;

- inability to stabilise and benefit from the resources of emerging civil society.

I advance arguments in support of citizen deliberation and decision-making in articulating fair health

care rationing. The growth of civil societies which are independent of official institutions can be very

creative for drawing attention to health issues they consider important. There is a need to stimulate their

development and support the establishment of mechanisms for creating and sustaining a dialogue and

co-operation with policy- and decision-makers. It is argued all these need a methodology, a style of

reflection, a clear map of the way forward to be adopted with regard to the realities.







[120] RESPONSIBILITY FOR THE OTHER - CAN THERE BE A LEVINASIAN

BIOETHICS? (Levinas, Z. Bauman)

Zsuzsa Porczi (Hungary)



The lecture examines the possibility of introducing the phenomenological analysis of the I and the Other

in the works of French philosopher Emmanuel Levinas into philosophical bioethics. While trying to

acknowledge the scarce but significant contributions of several bioethists regarding the topic the lecture

will present important levinasian terms and show their relevance to bioethics (responsibility, the

“face-to-face”, suffering, vulnerability). The essential assumption the author prevails deals with a hiatus

that can be sensed in the present developments of bioethics despite the fact that interpretations abound.

Levinas claims that the major ethical theories of deontology or consequentialism fail to respond to the

call of the Other, which he identifies as the core of ethical inquiry. What he is describing is an ele-

mentary ethics on the ground of which all our moral insights originate. The author conveys that while

the examination of critical issues of modern medicine remains to be the central task of bioethics there

should be a profound analysis of the closeness of human beings in healing situations. Such an attempt

might have fruitful contributions to medical education, mediating the relevance of ethics, and raising

moral awareness of those choosing a healing profession. Another aspect the lecture intends to highlight

is how a framework worked out by sociologist Zygmunt Bauman regarding the morals of modernity

might justify contemporary attacks of the legalization tendencies in our field as he is looking for ways of

approaching our fellow human beings bearing in mind the „beyond‟ that is manifested in the Other of

radical difference as opposed to the Citizen of equal rights and responsibilities.









[121] THE SIGNIFICANCE OF EXPERIENCE OF ILLNESS FOR PROVIDER-PATIENT

RELATIONSHIP IN REHABILITATION MEDICINE AND FOR BIOETHICS

Alicja Przyłuska-Fiszer (Poland)



The main topic of my presentation is the significance of experience of illness, especially the experience

of disability, for professional-patient relationship in rehabilitation medicine. It is well known that dis-

ability has a great influence for patient‟s experience of the body and for his/her social relations with

others. For the healthy person the body is an inseparably part of what he is, it grounds all his interactions

with the environment. Its body is the instrument through which the person is interacting with the world.

For the ill person the body becomes something alien, something being out of control. The purpose of my

paper is to discuss the ethical implications of the feeling of isolation from our own bodies and loses of



72

existential identity. I intend to analyse that problem from two points of view: 1) in the context of dif-

ferent models of rehabilitation relationships; and 2) in the light of the main principles of biomedical

ethics, specially the moral principle of respect for individual autonomy.







[122] LANGUAGE AS A MEDIUM FOR THE NEGATION OR AFFIRMATION OF

SUFFERING IN THE ART OF TREATMENT

Zygmunt Pucko (Poland)



Language in the entirety that is the art of treatment plays an obviously active and often even determining

role. Being, among other things, a medium for the negation or affirmation of suffering. Equally this

aspect of verbal communication, between the doctor and patients, is the fundamental criterion for the

quality of the therapeutic relation and ethical questions. It may become a form of code designating the

field of concepts and experiences, through the help of which the patient becomes aware of, and under-

stands the sense or absurdity of the world.

It appears as a type of a double meaning code in, among others, political correctness, the notion popular

at present. The paper is an attempt to give examples of words and phrases that are politically and socially

acceptable as well as regarded as offensive, the removal of which is strongly advocated. It is crucial

when dealing with discrimination of and prejudice against patients with, for instance, disabilities, pa-

tients of different cultures etc. The problem has its own specificity in post-communist countries. The

main aim is to help medical staffs to be aware of making the extremely difficult choices they are con-

fronted with when using language; also as far as political correctness is concerned, as well as the fact

that their ethical and social attitudes will be described and judged by the patients and their families.









[123] IS THERE A NEED FOR CLINICAL ETHICS SUPPORT SERVICES?

Conclusions from an empirical-analytical research program

Stella Reiter-Theil, Wolfgang Hiddemann (Germany)



Is there a need for clinical ethics support services? This question would not easily have been heard in

Europe only a few years ago, when there was much doubt about the possibility to couple clinical practice

and ethical study. It has been only recently that clinical ethics has begun to spread over German Euro-

pean countries in different shapes: hospital ethics committees, ethics rounds or teams, and ethics case

consultation. It seems, thus, that the opening question is answered increasingly by “yes". But it remains

rather unclear on which grounds this affirmative answer should be based.

In the broad realm of pressing ethical challenges and severe conflicts in daily patient care, issues of

end-of-life-decision making as well as of end-of-life-care are prevailing. Therefore, the authors have

initiated an interdisciplinary research program focusing on clinical and ethical aspects arising at the turn

from curative to palliative care. On the background of a systematic approach of more than 100 structured

case-by-case analyses, empirical evaluation is undertaken to identify patterns of difficulties in making,

justifying, and carrying through end-of-life-decisions.

Results of this problem analysis will be presented referring to internal oncology as well as to internal

intensive care. Conclusions will be formulated in the light of the results of a need analysis performed

after interview studies with health professionals from the connecting clinical fields. Coming back to the

recent development of clinical ethics in Germany and other European countries and the different forms

of support services, it will be discussed which kind of approach would be fitting with which type of

problem or need found in pre-terminal patient care.



References:

1. Reiter-Theil S (1998) Therapiebegrenzung und Sterben im Gesprach zwischen Arzt und Patient. Ein

integrativęs Modell fur ein vernachlassigtes Problem. Ethik Med 10: 74-90

2. Reiter-Theil S (1999) Ethik in der Klinik - Theorie tiir die Praxis: Ziele, Aufgaben und Mtiglichkeiten des



73

Ethik-Konsils. Ethik Med 11, 4: 222-232

3. Reiter-Theil S (1999) Bericht uber das Experten-Kolloquium “Ethik-Beratung in der Medizin", Akademie der

Wissenschaften und der Literatur, Mainz. Jahrbuch, Franz Steiner, Stuttgart, S. 205-209

4. Reiter-Theil S (2000/in press) Ethics Consultation on Demand. Concepts, Experiences and a Case Study.

Journal of Medical Ethics. June

5. Reiter-Theil S, Hiddemann W (1999) Ethik in der Medizin. Bedarf und Formen. Der Internist 40: 246-254

6. Reiter-Theil S, Lenz G (1999) Probleme der Behandlungsbegrenzung im Kontext einer internistischen

Intensivstation. Ein kasuistischer Beitrag mit pflegeethischer Perspektive. Zeitschrift ftir Medizinische Ethik









[124] PROMOTING PALLIATIVE CARE IN ORDER TO PRESERVE HUMANE

MEDICINE. The German medical council's guidelines on terminal medical care

Stephan W. Sahm (Germany)



End-of-life issues have been discussed with increasing intensity in many countries for years. In 1998 the

German Medical Council published new principles concerning terminal medical care. This document

has not sufficiently been paid attention to in an international context as yet. Hence, this paper will

carefully scrutinise the peculiarities of the new guidelines.

The document exhibits several characteristics. First, it does not refer to notions commonly used with

regard to end-of-life issues, such as "passive euthanasia" and "indirect euthanasia". Instead it speaks of

"change of the treatment objective". In doing so it avoids much of the semantic confusion that often

blurs the discussion. Up to now great quarrel exists in bioethical literature on how to make a distinction

between ending specific life-sustaining treatment and acts of euthanasia. Implicitly, the principles

delineate that the moral quality of acts do not solely depend on the mode of action, i.e. active or passive

(as is often claimed in the literature). Hence, they can consistently reject active euthanasia as well as

physician assisted suicide.

The most important feature of the principles is their promotion of palliative care. A duty to offer basic

care is hold to be unconditional and specified explicitly. Basic care is directed to palliation, not to

prolonging life. It signifies the point where the goal of treatment has changed, where prolonging life is

no longer the objective, i.e., life-sustaining treatment is to be stopped. By that reasonable decision

making at the end of life is facilitated. Weighing to limit life-sustaining treatment is thought to be the

routine in clinical medicine rather than the exception.

Artificial feeding is not considered as basic care. Concerning patients near death, the principles state that

there is an obligation to "still hunger and thirst". The latter wording makes sense in that it shifts the

obligation to provide nutrition and hydration to a subjective level. Stilling hunger and thirst does not

necessarily mean, but not exclude artificial feeding. Yet, concerning patients with life threatening

conditions who are not near death (e.g. persistent vegetative state) the guidelines appear to be a weak

compromise because of public quarrels which accompanied the preparation of the document. Stopping

artificial feeding based on patient‟s previous expressed will is not mentioned explicitly here. That is why

the permission to do so can at best indirectly delineated from the wording. Yet, it is said that physicians

should consider the omission of other life-preserving measures if patient‟s condition is worsening.

Additionally, the principles were welcomed by many because they emphasise patient‟s autonomy as

they regard advance directives as evidence of the presumed wishes of patients who are not able to

consent. Physicians are obliged to scrutinise such documents carefully and to check whether they are

applicable to the current condition.







[125] THE PROBLEM OF 'THOUGHT-STYLES' IN CONTEMPORARY MEDICINE

Jarosław J. Sak (Poland)



The contemporary philosophical reflection on development and present condition of medicine faces the





74

significant problem of inadequacy and insufficiency of its applied conceptions. Medicine at the end of

the twentieth century seems to be the meeting point of theoretical explicitness of biological, chemical,

and physical facts and obscurity of medical practice. In this sphere it is possible to observe similar

relations and references to those which exist between science and art. Within philosophical-medical

analysis the widespread notion of paradigm reveals considerable degree of incompleteness and un-

peculiarity.

In search of suitable categories, which would enable to describe evolution of scientific fact in medicine

more adequately, it seems difficult not to notice epistemology of L. Fleck: the concept of `thought-style'

became one of the basic category. In accordance with the concept of that Polish bacteriologist and

philosopher every new cognitive activity depends on previous state of cognition, because inheritance of

that known, changes internal and external conditions of new cognition. "Thought-style' manifests itself

in directed perception.

I am going to apply the category of `thought-style' in philosophical reflection focused on explanation of

formation and evolution of medical Fact. In my opinion, it will also enable to describe specific inner

structure of contemporary medical thinking and also to distinguish its certain subtypes (i. g, bacterio-

logical, genetic, and pharmacological). Birth of new styles in contemporary medicine may not enable

holistic view of human nature and its explanation. Explanation of rules governing the medical thinking

may enable to understand and perhaps also to predict diagnostic and therapeutic tendencies in con-

temporary medicine.







[126] INFORMATION DISCLOSURE VS. PRIVACY PROTECTION. Issue posed by the

nation's first legal organ transplant from a brain dead donor in Japan

Aiko Sawada (Japan)



It was 1968 when the nation's first heart transplant was performed by Prof. Wada of the Sapporo

Medical College in Japan. In this heart transplant various problems were revealed later and other doctors

accused him for these problems. He destroyed the evidence and got off without being indicted. This

vague settlement led to the public scepticism of medicine, which caused delay in the development of

organ transplantation in Japan.

With reflection on such a case, the Organ Transplant Law enacted in 1997 includes unprecedentedly

strict regulations on transplants, some of which are requirements for organ donation that ask for both

documents of donor's determination written while alive and an approval of the donor's family.

However, for sixteen months after the law's enactment, any legal organ transplants from the brain dead

were not performed because learning from Prof. Wada's case, the Ministry of Health and Welfare be-

came cautious. Then the first legal organ transplant from a brain dead donor was performed in February

in 1999 and another issue never discussed before arose: how to balance the conflicting needs of dis-

closing information and protecting privacy.

Having got information of the emergence of the nation's first brain dead organ donor, mass media started

large-scale coverage before the legal judgement of brain death was conducted, which created a sensation

in society. At the point the media reported the process of the legal judgement of brain death on TV, the

donor's enraged family made a strong protest to the hospital and media. Receiving this protest, the

Ministry of Health and Welfare and the hospital immediately stopped releasing the information. As a

result, process of this critical event was almost hid from the public eye.

Some-who pursued transparency in medicine argued, "We shouldn't repeat the same mistake that was

made in Prof. Wada's transplant." Others who valued the privacy protection more objected to the ar-

gument. The nation's four organ transplants from the brain dead performed in 1999 posed an issue over

information disclosure and privacy protection.

In this presentation, the presenter would like to consider this issue according to the following four

points.

1. Timing to disclose the information: As for the information about the organ transplants from the brain

dead, which is better, a real-time disclosure or an ex post facto disclosure '? The presenter thinks a

real-time disclosure after the completion of the legal, judgement of brain death is better.

2. Range of information to be disclosed: All the information necessary for medical and ethical verifi-



75

cation should be disclosed but the specifics of the individual should not be.

3. Who discloses the information to whom: The medical institutes involved should be responsible for

releasing all the information and should disclose all the information, except that which specifies the

individual, to all competent persons older than 15 years old, if they ask.

4. Ethics of Journalism: Reporters should weigh public benefits against human rights.







[127] ETHICS AND MEDICAL TECHNOLOGIES

Lieke van der Scheer (The Netherlands)



It is a fact that new developments in medical technology are giving rise to new questions in medical

ethics. It is another fact that medical ethics has great difficulties in facing those new questions. In this

paper I shall argue that the problem has its origins in a number of traditional philosophical presupposi-

tions regarding the question of `meaning'. Moreover, I want to propose an alternative approach which

makes it possible for ethics to make a contribution to the search for the good life.

My paper starts from two observations:

1. Traditional definitions which are also operative in ethics start from a distinction between different

sorts of entities. They have their origin in a dualistic conception of reality, which not only translates

itself in, for instance, the distinction between body en mind, nature and culture, woman and man, animal

and man, man and machine, individual and environment, but which infers from such terminological

distinction the doctrine that these terms refer to self-subsisting substances which are strictly separated

from each other. In the light of bio-technical developments, for instance, fetal surgery, the increasing

symbiotic relationship between man and machine (think of the relationship between machine and a

patient suffering from kidney insufficiency), the transplantation of pig valves in human beings, etc. this

belief in fixed boundaries between different species is increasingly being challenged.

2. The traditional ontological substance approach of reality is also challenged by today's scientific

practice which shows that (1) properties, far from belonging to things are in fact always interrelational,

and moreover, that (2) properties that used to be considered `essential' can in fact now be manipulated.

This raises the question concerning the consequences of such fluidity of properties for the question of

meaning. Meanings can no longer be considered to be `in truth', isolated, fixed and absolute, but they

appear to be defined in terms of specific points of view, contexts and relations.

Statement of the problem

These two observations have led me to the hypothesis that terms must be understood as references to

(scientific) objects which are the results of research rather than being references to things or objects to

be studied by scientific research, which supposedly must reveal their true nature. The meaning of a term

can be defined or can be actual only in its usage which cannot be dissociated from historical circum-

stances, which is always particular rather than general, not fixed but subject to change. Meanings of

terms issue from their context, and are therefore relational. There are no general, a-temporal criteria

which enable us to define their true meaning.

Thus, biotechnology is leading to new meanings and practices. It forces us to see that the meaning of

`meaning' has changed. This hypothesis that the meaning of `meaning' has changed, appears first of all

to be a condition for a re-examination of the role of terms which enter into a reflection upon

bio-technology, such as those mentioned above: body and mind, nature and culture, woman and man,

animal and man, man and machine, individual and environment. This finding also has consequences for

the normativity of ethical theories. So, also the terms functioning in traditional ethical theories, such as

`value', `norm', `law', `duty', `means and ends', and especially `moral experience', must be re-examined

in the light of the consequences of the proposed insights regarding meaning. The question ought to be

raised whether or not it is possible to take seriously the consequences of the change in the meaning of

`meaning' on the one hand, and to formulate a non-relativistic theory which does not relapse into ab-

solutism on the other.







[128] THE PHYSICIAN-PATIENT RELATIONSHIP: MEDICINE OR MAGIC?



76

Edvin Schei (Norway)



To what extent are scientific rationality and medical technology intertwined with magical thinking in

modern society? Do symbols, subjective interpretations and culturally influenced meaning influence

disease and healing processes? And how would an irrational belief in rationality influence the roles of

doctor and patient, respectively?

In this paper I tentatively use concepts and insights from the study of religion to shed light on the

workings of the physician-patient-relationship in the secularised Western culture, where issues of health

and medicine receive much public and private attention.

Medicine and natural science has replaced the church in a number of ways, but this does not mean that

religious modes of thinking and acting have ceased to exist, they may simply have changed location,

vocabulary and appearance. In the past, when religion was strong and science weak, people mistakenly

believed magic to be medicine. Now, when science is strong and religion weak, people mistakenly

believe medicine to be magic." This aphorism by Thomas Szasz underestimates the symbolic function

of medicine. A functional sociological definition of religion highlights "the providing of meaning and

belonging to individuals and groups". Recent textbooks in the sociology of religion devote large sec-

tions to the discussion of modern health care systems, pointing to the existential importance of medical

arenas in people's lives. This exposes a contrast between medicine's self-understanding as a purely

technical enterprise, and its symbolic function as provider of meaning and belonging in modern society.

The notions of "physician role" and "patient role" hint at the symbolic significance of the ritual be-

haviour that constitutes medical encounters. In the optimal therapeutic relationship, biomedical meas-

ures combine with liturgical elements to release and support the self-healing potentials of the patient,

helping the patient to fight disease or to find the strength necessary to cope with disability, approaching

death, sorrow and suffering. Conversely, negative encounters with physicians and healthcare systems

have the power to aggravate patients' health status and deepen suffering. The relative importance of the

biotechnical and symbolic functions of medicine varies on a continuum from intensive care to psy-

chotherapy. It is, however, an important task for any physician to structure and develop the dialogue, the

context and the sequence of encounters in ways which optimise the symbolic function, or magic, of the

physician-patient relationship.







[129] THE DEBATE BETWEEN NATURALISTS AND NORMATIVISTS ON THE

CONCEPT OF MENTAL ILLNESS AND DISEASE

Thomas Schramme (Germany)



I want to defend the concept of mental illness against threats from a sceptical side. Sceptics like Thomas

Szasz assert that the concept of mental illness cannot be used in a reasonable way, i.e. in analogy to the

concept of somatic illness. In the sceptics' view "mental illness" is not a proper medical term, contrary to

the "scientific" one in somatic medicine, hence mental illness does not exist. The intellectual challenge

of this sceptical assault on the integrity of Psychiatry was met in two fundamentally different ways:

Normativism and Naturalism.

Normativists usually defend the concept of mental illness by questioning one premise of the sceptical

argument, namely that the terms "health" and "illness" in somatic medicine are value-free. They propose

the general value-ladenness of both the concepts of somatic and mental illness, hence save the analogy.

Naturalists reject the sceptic conclusion that mental illness does not exist by defending a value free

theory of mental disease, that is, they doubt another premise of the sceptics" argument, namely that such

a theory is impossible in Psychiatry. Many theorists are convinced that Naturalism failed and the recent

debate in Philosophy of Medicine somewhat changed to a merely internal discussion on what sort of

Normativism (e.g. by Nordenfelt, Culver/Gert, Fulford or Wakefield) is adequate.

Nevertheless I want to defend a naturalistic account of the concept of mental disease which is based on

the theory of Christopher Boorse. I will concede to the alternative normativistic account that there is a

different, namely, an evaluative view about the phenomena concerned, which stresses that mental illness

is a disvalued condition. I will argue that both perspectives are compatible - since they concern different

concepts, namely, mental disease and mental illness, but that there is a conceptual priority of the natu-



77

ralistic view, i.e. mental disease is the necessary condition of mental illness (the extension of the concept

"mental disease" covers the extension of the concept "mental illness"), while not every mental disease is

a mental illness, since it may not be subjectively disvalued (the extension of "mental disease" may be

broader than "mental illness").







[130] END-OF-LIFE DECISIONS IN NEONATES IN HUNGARY. An international com-

parative study

Karoly Schultz (Hungary)



Modern medical technology enables infants, who have severe and irreversible handicaps or extreme low

birthweight, to survive. The recognition of the newborn who may benefit from aggressive support

remains a significant problem for neonatologists. Hungarian paediatricians in the past preferred not to

discuss these issues publicly and in Hungary all seriously and irreversibly defective newborns were

supposed to be treated, no matter what the cost of the treatment was and what the decisions of the parents

were. But recently the Hungarian paediatricians‟ attitude to discuss these issues more openly appears to

be changing. To evaluate the current practice of end-of -life decisions in neonates 76 paediatricians

working at neonatal or perinatal intensive care units were interviewed. Of all interviewed paediatricians

84 had withdrawn or withheld treatment because of no survival chance or poor quality of later life.

Parents were involved in the decision in 43%, colleagues were consulted in 88%; but Hungarian doctors

were unwilling to consult nurses (only 13% did so). Hungarian paediatricians were clearly against active

euthanasia, (only two doctors said active euthanasia may be morally acceptable in certain circumstances

e.g. anencephaly). The majority of paediatricians were of the opinion that all cases of forgoing treatment

should be reviewed by independent experts (neonatalogist, paediatric surgeon, ethicist) or the hospital

ethics committee. The results of our study were compared to similar studies done in Poland, Canada,

Australia and The Netherlands.









[131] DEVELOPING OF SENSITIVITY ABOUT NEEDS AND SUFFERING OF ILL MEN

BY MEDICAL STUDENT

Siemińska Maria J., Szymańska Maria (Poland)



Doctor and patient get together in the circle of feelings assigned by suffering. Sensitivity about suf-

fering is the axle setting the character of meeting between the doctor and the patient, The patient's illness

experience are individual, private, often very difficult to describe. But possibility of understanding

another man's suffering ensues that suffering is a universal feeling.

The method - we propose medical students to entry into the world of patient's experience and to write a

letter to the doctor.

The analysis of the utterance of 82 students allows to establish the most important factors which are

formatting the spectrum of sensitivity to suffering of ill man; far example;

- information about illness - human treatment

- skills in communication

- cult of knowledge, professionalism, reliance.







[132] THEORIES OF JUSTICE AND QUESTION OF THEIR APPLICATION IN HEALTH

CARE REFORMS IN CENTRAL AND EASTERN EUROPE

Jiří Šimek, Vladimír Špalek (Czech Republic)









78

After ten years of experiences with post-communist freedom we start to realise, that to became full

members of developed Euro-Atlantic society we must do more than to establish democratic institutions

- build civic society and learn really democratic way of thinking and negotiating. We should accept

western philosophical foundations; but because of different political and sociological situation we must

use them in our specific way. One example of this necessity can be problem of justice

Justice is a difficult theme in contemporary philosophy. In a society where is no generally accepted set

of values, different social, political and worldview perspectives lead to different understandings of

essence of justice. When there is no agreement on issues, American philosophers elaborated procedural

rules, which would lead to just solutions. To resume we can mention only briefly a cornerstone of

modern theories of justice - John Rawls‟ theory of justice, extreme liberal position of R. Nozick and

communitarian objections directed mainly against widely accepted liberal philosophy of man.

In applying modern theories of justice on contemporary health care systems we can come to some

conclusions. The way in which a health care system is organised is deeply influenced by prevailing set

of values of the society. As societies do differ in shared values health care systems in various countries

must be to some extent different. There are various groups of interest in every state; negotiation between

representatives of these different groups is necessary to keep justice in health care. There must exist

some advocates for those groups of people whose voice is too weak to be heard. Only such system that

gives an adequate use of health services to the most disadvantaged we can consider to be just. Two tier

health care system is unacceptable because health belongs to basic rights; health is essential condition

for realisation any notion of good.

There are some obstacles in post-communist countries, which make application of theories of justice in

health care systems more difficult. Well-known “iron curtain” between east and west prevented ex-

change of ideas and information. While in western countries justice became more and more prominent

and openly discussed problem, in communist area whatever did leading party was just and beyond any

discussion. Therefore people from post-communist countries believe that justice is something what

results from a good social order and do not understand the role of public negotiation. Public debate was

stopped and now we must learn how to conduct it. Different concepts of justice are too polarised to

extreme liberal and egalitarian positions and therefore wider agreement is very difficult. Western con-

ception of justice and equity in health care is too costly for post-communist countries. Rationing of

health services is necessity of everyday life. Health care providers are used to keep back information

about lack of resources for scarce diagnostic and therapeutic measures; public control of use of scarce

services does not exist. Thanks to grey economics richer people have better access to some health

services. There is no simple solution. Physicians hesitate to disclose the situation. The only result of

such disclosure for many people would be that they realise that there exists therapy for their illness,

which could save their health, but that they never will receive it. If it is not possible to give some therapy

to everybody, we can withhold it at all. But is it really just not to give life saving treatment to anybody?







[133] THE STRENGTH OF PHILOSOPHICAL ARGUMENTS FOR ADVANCE DIREC-

TIVES

Juan Carlos Siurana (Spain)



In the literature about advance directives, we can find philosophical arguments for and against them.

Some philosophical arguments for advance directives are the following ones: 1) Platonism: the in-

competent dying person survives as real person in the memory of the other people. 2) Kantianism: They

respect the fundamental value of human life and make the patient free from her guilty incapacity. 3)

Liberalism: They respect the people that do not execute them, then they are a right, but not a duty. 4)

Socialism: They contribute to develop a participative democracy. 5) Utilitarianism: They reduce the

feeling of blame and the stress in the healthcare practitioners and the family. 6) Hermeneutics: They

show the way of being of the human being that lives planning the future. 7) Discourse ethics: They

reduce the asymmetries between the doctor and patient, and are grounded in the consensus between the

affected.

Some philosophical arguments against advance directives are the following ones: 1) Humanism: These

documents force the patient to reject his incapacities, undervaluing so his life. 2) Personalism: They



79

impede the relationship of proximity between the doctor and patient. 3) Comunitarianism: They suport

individualism. 4) Relativism: In some cultures they are understood as an offence to the doctor. 5)

Scepticism: They do not solve the problem of the patients that do not want to discuss about this question.

In my presentation I am not going to defend a particular school against others. I will just show that

behind the arguments for and against advance directives there is a different conception of what these

documents are: 1) Arguments for them consider that advance directives are grounded in the principle

that says that the values of a person should direct the decisions that affect her. 2) Arguments against

them consider that the now existing documents do not have as a result that the values of a person direct

the decisions that affect her.

The important philosophical question is not if the now existing documents, or the now existing way of

practicing them, let the people reach this goal. The important philosophical question is that the goal is to

be reached. The strength of philosophical arguments for advance directives lies in the fact that they show

how the world should be “in the long run”. So, arguments for them will persist in the future, arguments

against them will disappear in the future, when the progress be realized.









[134] BECOMING A 'SUBJECT' IN BIOMEDICAL RESEARCH: Exploring the zone of

embodiment between Leib and Körper

Stuart F. Spicker (U.S.A.)



The extant philosophical - particularly the phenomenological - literature is replete with publications that

reflect the distinction between the “lived body” (Leib) and the “objective” or “thing-like” body”

(Korper), the human body construed as merely another spatio-temporal thing, a limiting case being the

newly-dead human corpse. The “zone of embodiment between Leib and Korper” - experienced as a

two-directional process or transformation from Leib to Korper and Korper to Leib (what I shall refer to

as “lived body-thing” or Leibkorper) - however, has generally been neglected in the extant literature.

But it is one‟s lived body (I avoid employing the misleading Cartesian term „mind‟) that has the capacity

to transform into or to become the subject of (say) a physician‟s gaze, and at least temporarily, to

“absent” oneself from one‟s fully lived-embodiment in order to allow the physician to examine one‟s

body “objectively,” i.e., to permit one‟s lived body to become more like a mere thing, though not

completely so, not yet a corpse (Korper). Indeed, “Cartesian dualism,” though it has shown itself to be a

mistaken account of the mind-body relation, is perhaps a useful model if understood as a description of

one‟s condition during serious illness: the body “I had” is no longer the body “I am” - it has become

foreign; it may even be the enemy.

Healthy as well as sick persons may, moreover, not only become patients, they frequently agree to

become or to serve as research “subjects” - to participate in biomedical and behavioral protocols or-

ganized by principal investigators who are intent upon the study of the efficacy and safety of new sub-

stances - potential pharmaceuticals - as well as new, implantable devices - e.g., an Automatic Im-

plantable Cardioverter Defibrillator (AICD). These biomedical researchers “test an hypothesis, permit

conclusions to be drawn, and thereby ...develop or contribute to generalizable knowledge....”

[OPRR/NIH, Protecting Human Research Subjects: Institutional Review Board Guidebook, U.S. Gov-

ernment Printing Office, Washington, D.C., 1993, p. xxi.] They are usually physicians by training: this

distinction Stephen Toulmin cryptically described some years ago, when he remarked that whereas

physicians are (or ought to be) concerned with “MY liver,” researchers are primarily concerned with

“THE liver.”

Persons in the role of research subjects have frequently employed the “guinea pig” simile as a

self-description of their experience during their participation in clinical trials, especially when they hear

“it‟s an experiment” and they truly believe their participation will be of no direct benefit to themselves.

I shall explore (by including a few case reports and personal accounts by research subjects) some

descriptions of the zone of embodiment between Leib and Korper heretofore neglected in the extant

philosophical literature. The outcome of this exploration has, I shall argue, important ethical implica-

tions for researchers who enroll persons to serve as research subjects. That is, there is more to the

NIH/FDA regulations that address the multi-faceted concept of informed consent than simply that an



80

adult person (i) be adequately informed of and (ii) understand (demonstrate adequate mental capacity to

comprehend the full nature of) the experimental protocol and its bearing on his/her health, and in the end

(iii) decide voluntarily, without coercion, to participate (at least initially) in the study.

A potential subject‟s autonomous decision to participate in a research protocol (even in cases where he

or she is the sole patient/subject) has typically been framed in the language of voluntary deci-

sion-making, as acts of free will and choice, rather than framed in terms of a person‟s capacity tempo-

rarily to suspend his/her lived-body experiential unity as an active body-in-the-world to become more

like a mere thing-body undergoing interventions by researchers in their quest to acquire new, gener-

alizable biomedical knowledge.







[135] HOSPITAL ETHICS COMMITTEES - SAFEGUARDS OF "HUMANE HEALTH

CARE" IN HEALTH CARE INSTITUTIONS? A Dutch-German experience.

Norbert Steinkamp (The Netherlands)



Radical changes in medicine as well as in moral attitudes cannot be adequately understood in terms of

individual ethics alone. They must be seen as changes on an institutional level. On the other hand, moral

sensitivity of the professional as a human being is a necessary prerequisite of patient-centered, humane

health care. In this situation, Health Care Ethics Committees (HECs) are both seen as a safeguard of

patient autonomy and a body of support for doctors, nurses etc. in the context of institutions.

This paper provides insights from an internal perspective of an ongoing process: the development of

moral deliberation and HECs in two European countries as different as Germany and the Netherlands. In

the Netherlands, more than 200 committees had been established by 1988. The National Hospital In-

stitute has brought forward a concept of ethics committees as a tool of reflection on morals and values on

a management level. Responsibilities of the committees are described as developing guidelines and

protocols, health policy advice, consultation, consideration of fundamental ethical questions, and edu-

cation.

In Germany, Health Care Ethics Committees have become an emerging issue during the 1990s. At first,

a few committees were established as bodies which consider difficult cases of treatment or contribute to

the formation of ethical guidelines for hospitals. By the year 2000, numerous projects are being worked

on, potential committee members are being trained, and a discourse, both academic and non-academic,

has come to life about the role, tasks, and membership of HECs. As a recommendation or model statute

on the federal level does not exist, the development of HECs is mostly initiated by hospitals, hospital

foundations, churches, etc. throughout the country.

In this context, the question of medical ethics expertise has been vividly discussed by both the German

and the Dutch public for several years. Can ethical expertise be developed `bottom up' via participation

and representation of professionals and citizens on HECs or does it have to be institutionally imple-

mented by the management? Held against recent philosophical discourse, consensus building has to be

built on moral theory while theory needs to be reconciled with inductive inferences based on the ex-

perience of participants of moral debates(1). As one expert, Prof. Ludger Honnefelder of Bonn, holds:

combining both `top down' and `bottom up' ways of thinking and acting may bring forth a Gestalt of

HECs specific for a certain national context that at the same time is apt to contribute to an ongoing

international discussion.



Reference:

David J. Casarett, Frona Daskal, and John Lantos. "The Authority of the Clinical Ethicist." Hastings Center Report

28, no. 6 (1998): pp. 6-11.









[136] PLATO AND HOLISTIC MEDICINE

William E. Stempsey (USA)







81

I would not want to live in Plato‟s Republic. However, Plato had some provocative things to say about

health and doctors in his ideal society. Looking at them anew might challenge us and bring us to a deeper

appreciation of what is most dear to us in medicine. Plato‟s views on medicine cannot be fully under-

stood except in the context of his ethics and his philosophy in general. Ethics, for Plato, is broadly

construed to include not only a theory of choice and action about appropriate interpersonal relationships

(as in most modern theories), but also a theory of human goods. This is what Moravcsik (1992, pp.

94-98) calls an “ideal ethics.”

Health is a human good. For Plato, health is something quite similar to our present conception of holistic

health (Naso and Woollen, 1989). In Plato‟s account, the human being is composed of body and soul.

Medicine treats the body; however, the reason to treat the body is not for its own sake but for the sake of

the whole human being, body and soul. Gymnastics is meant to maintain the present health of the body;

when it does its job, medicine is not needed. Gymnastics is preventative medicine, in a way. Plato also

makes it clear in chapter 3 of the Republic that undertaking gymnastics is a means to health of the soul

and not just the body. Ordinary athletes treat diet and gymnastics only as a means to build muscle. The

lover of wisdom, however, sees beyond this, and uses gymnastics as a means to arouse the spirited part

of human nature (410b-c). It is clear, then, that Plato is opposed to the type of scientism or materialism

that sees health solely in terms of the biological.

Medicine is the techné, or craft, that aims at bringing about this health. Theory and activity are in-

separable in the techné. Health is a good. However, one is not necessarily a good doctor just because one

produces health in one‟s patients. In the Charmides, Plato says that if you take away knowledge of good

and evil, the practice of medicine will still produce health, but it will not be well or beneficially done

(174c). It is knowledge of the good that will bring about morally good action. Medical practice may

bring about physical health, but such practice is not virtuous medical practice. Medicine, in the context

of Platonic ethics, demands a holistic approach that combines knowledge of the good and virtuous

action.



References:

Moravcsik, Julius, 1992: Plato and Platonism: Plato’s Conception of Appearance and Reality in Ontology,

Epistemology, and Ethics, and its Modern Echoes, Blackwell, Oxford.

Naso, William B., and Woollen, Thomas H., 1989: “Holistic Medicine in Ancient Greece: The Medical Model of

Alcmaeon and Plato,” Pharos 52, 26-30.









[137] A PHENOMENOLOGICAL ANALYSIS OF THE CONCEPTS OF HANDICAP AND

CHRONIC ILLNESS

Fredrik Svenaeus (Sweden)



In this paper an attempt will be made to draw distinctions between the phenomena of handicap and

chronic illness from a phenomenological point of view. In opposition to a biostatistical theory of health

the handicapped most often do not consider themselves to be unhealthy despite their functional defects.

As a consequence of this, "disability" has often been preferred to the term "handicap", and this change in

terminology seems to point towards a theory of health and illness that is rather focused on the subject as

an individual inhabiting a world through her actions than on biological functions. Since disability itself

has been developed as the key concept of ill-health in action-oriented theories of health, such as the one

of Lennart Nordenfelt(1), however, the notion of "disabled" as a substitute for "handicapped" is prob-

lematic if one wants to maintain that the handicapped are not ill, but nevertheless different from the

normal.

Drawing on my own previous attempts to develop a phenomenological theory of health and illness(2), I

would instead try to found the distinction between handicap and illness working in the framework of

Martin Heidegger's existential "being-in-the-world". Is the being-in-the-world of the handicapped dif-

ferent in any important sense from that of the chronically ill, with whom they seem to share many

predicaments? The governing idea of this analysis will be that the being-in-the-world of the handi-

capped can be understood as a homelike, although different being-in-the-world than the standard one.





82

References:

(1) Nordenfelt, Lennart (1987, rev. ed. 1995) On the Nature of Health: An Action-Theoretic Approach, Dordrecht:

Reidel Publishing.

(2) Svenaeus, Fredrik (1999) The Hermeneutics of Medicine and the Phenomenology of Health: Steps towards a

Philosophy of Medical Practice, Linkoping Studies in Arts and Science.









[138] THE PRINCIPLE OF SOLIDARITY AND HEALTH CARE REFORM IN POLAND

Zbigniew Szawarski (Poland)





The principle of solidarity is a moral foundation of many modern European health care systems. It

originates from the Biblical parable of Good Samaritan and imposes upon us a moral obligation to help

those who are in need. It is assumed that all people have an equal right to health care and, ideally, health

care resources should be distributed to each according to his needs. The principle of solidarity is

strongly connected with the principle of equality. There is of course a lot of debates concerning the idea

of health care needs, rationing, prioritisation, the cost and efficiency of the system based on the principle

of solidarity, however it is difficult to deny its internal justice. Poland, like many other post-soviet

Central and Eastern European countries has decided to reform its health care system. However, the first

results of the reform are more than controversial. The emerging health care system is far from just health

care. One can blame of course organisational failures but that would be only a part of the explanation. It

seems to me that the present mood in Poland (as well as in other Central and Eastern European

countries) is strongly in favour of liberal theories of health policy. I am trying to offer and discuss

several hypotheses explaining why in the clash of egalitarian and liberal health care policies the Polish

political élite tends to favour Polish style liberal approach. I assume that my conclusions are to some

extent valid in regard to other Central and Eastern European countries.









[139] BST AND ITS CRITICS

Anna Szczęsna (Poland)



The purpose of the paper is to examine critically the arguments against so-called 'biostatistical theory'

(BST) summarized in the recent Christopher Boorse's essay 'Defining Disease' (in: 'What is Disease', ed. by

J.M. Humber and R F. Almeder, Humana Press 1997).

I argue that

1 both the concept of 'disease' and of 'illness' are value-laden; however we should distinguish two

different kinds of 'value-ladeness', what is connected with the two-fold nature of medicine as (a) a

science (b) a clinical practice and its pursued goals: (a) cognitive (b) non-cognitive ones. The concept

of disease should be regarded as cognitively value-laden and non-cognitively value-free;

2 a definition of 'disease' should be formulated on the basis of clinical practice; its meaning resting on

the concepts of biological function and statistical normality provides only a general framework for a

more substantial definition.

In the context I intend to examine whether and to which extent the debate between naturalists and norma-

tivists in the philosophy of medicine could be regarded as a mirror of the more general discussions in the

philosophy of science.









83

[140] THE CONCEPT OF 'PERSON' AND ITS CHANGE IN ITS HISTORICAL AND

SOCIAL CONTEXT. How does it recognize our real existence?

Akihisa Takahata (Japan)



Every individual possesses ones own body as a person in nowadays-legal meaning. This is one of the

principal right of the modern society. But this right has an important contradiction.

On the one hand human beings are individuals with being their individual subjects. Therefore human

beings cannot transfer themselves as their own subject. On the other hand they can transfer any pieces of

themselves as persons on their rights.

These two matters make one contradiction in this case. Because human beings cannot have their own

absolute rights with being divided between some pieces by using their own rights. Today human beings

are faced with this contradiction on various cases as the so-called 'Brain-Death' case. Therefor the

'Brain-Death' problem cleared what is the person in legal meaning today. And that is one of the real

results of main conflicts in our modern capitalist society. In this context individuals became to have dual

meanings, person and an unorganized thing. With these momentum the inner-contradictions of our

existence as human beings are said to be worked out. However the most basic foundation of this con-

tradiction as a real existence is not the relationship between person and the unorganized thing mentioned

above, but just 'work', because those matters are the products of 'work', which is the only origin of all

social matters including them.

This second relationship between person and her/his working subjectivity brings our concern, how we

find out the relation of our existence in modern society and our person in the historical and social con-

text, up onto another stage, which opens the new perspective to a new system in our society. Because we

cannot cut our working forces off from our natural existences, our bodies even in this society. So

modern human being is a sort of 'subject' made of its person, its social existence and its natural exis-

tence, body itself. And people must be said to be making their certain relationship in the social context

and in our everyday lives.

In modern society this connection and linkage brings us up onto the new perspective to a new system in

this society. In the system, we are guaranteed for our social existences and our living rights, therefore we

have the 'persons' on the foundation of our existence of our natural and original way of human living.

It must be today's task to find out the new function of the modern person which cannot be maintained in

its form. So this is the first object for all the people to rehabilitate their own 'subjectiveness'. As the

working subjects we can never give up any possibility in our human lives, even when we cannot work.

Or we must not be abandoned as unorganized things, even if our situations are very hard.

Therefore we must find out, accept and recognize our rights to live from the viewpoint of our present

situations, or our nowadays 'existences', even if we are embryos, physically handicapped beings or

advanced ages, and so on. It will be one of the most important missions in his modern society.







[141] WHAT IS ’A NATURAL HUMAN BEING’?

Tuija Takala (Finland)



The developments of the past decades in medical science have led us to reconsider the concept of

‟natural‟. Especially the new gene technologies seem to challenge our conventional conception of ‟a

natural human being‟. Does tampering with the genes pose a threat to the natural man?

Ever since its beginning, medical science has challenged the concept of ‟natural‟. Blood transfusions,

organ transplants and artificial methods of reproduction are among the many treatment practices whose

naturalness (in accordance with the nature) can be questioned. Nevertheless, it has been argued that the

new gene technologies are a different, and a more serious kind of a threat to the natural human being.

In this paper the author examines whether the above statement is plausible. The analysis begins with the

definition of the adjective ‟natural‟ and more specifically, of the ‟natural human being‟. Is there a

definition of ‟a natural human being‟ that is in contradiction with the gene technologies but that can, at

the same time, be seen to condone most of the other practices currently used in modern medicine? What

is the crucial difference between genes and other living tissue?



84

If it were argued that tampering with human genes is unnatural, poses a threat to the natural human being

and should thus be condemned, would it also follow that we are, in the end, our genes? It seems that this

is a conclusion difficult to avoid, but the possibilities of doing so will be studied carefully. A promising

approach might be to think gene technologies as a threat to the natural human being in general, even if

not to the particular individual being treated.

The concept of a natural human being is of great importance to the ethics of medicine and healthcare. It

is, however, a matter of dispute what this concept entails. When the concept is challenged, as with the

new technologies, do we reformulate the concept to fit the ethical conclusions we wish to come up with,

or is there a ‟natural‟ concept of ‟a natural human being‟ that could guide us through the ethical di-

lemmas brought to the fore by the technologies.







[142] OUGHT WE TO SENTENCE PEOPLE TO PSYCHIATRIC TREATMENT?

Torbjörn Tännsjö (Sweden)



In principle, there seem to be three main ways, in which society can react, when people commit crimes

under influence of mental illness.

1. The excuse model. We excuse them. If they are dangerous, they are detained in the interest of the

safety of the rest of the citizens.

2. The mixed model. We hold them responsible for their criminal offence, we convict them, but we do

not sentence them to jail. Instead we sentence them to psychiatric treatment.

3. The full responsibility model. We sentence them to jail, but offer them (voluntary) psychiatric

treatment.

The advantages of the full responsibility model are obvious. We get a clear delineation of roles. We

allow the psychiatrist to be just a doctor, not a warden. We liberate psychiatry of the objective of de-

ciding whether people who were mentally ill when they committed criminal offences 'could have acted

otherwise' - a hopeless task. We allow that psychiatrists live up to their professional ethical code (the

Hawaii Declaration). We treat psychically ill persons as 'normal', we allow them to repent their crimes,

which renders easier their recovery.

However, three objections to the full responsibility model come to mind. First of all, is it not unfair to

sentence people who could not help doing what they did to jail? And, secondly, the question of fairness

set to one side, is it not inhumane to sentence mentally ill persons themselves, and does it not mean that

they will be a burden to other prisoners? Finally, when the people sentenced to prison have served their

time, they must eventually be released. But what if, because of their mental disorder, they are still

dangerous to others?

In my paper, which is based on my recent book, Coercive care: the ethics of choice in health and

medicine (London and New York: Routledge, 1999), I show that, if our system of criminal punishment

takes a civilised form, neither of these objections carries any weight.







[143] MORAL ARGUMENTS AGAINST HUMAN GERM-LINE THERAPY

Felix Thiele (Germany)



It is claimed that the incorporation of human or non-human genes in the Germline of Humans (known as

Human Germline Therapy, HGT) might be a major contribution to medicine: it is hoped that HGT helps

to decrease both the occurrence of hereditary diseases as well as of other severe diseases with a he-

reditary component (e.g. cardiovascular diseases or cancer).

HGT has stimulated an intense debate about its moral status, though it is far from being available as a

routine medical procedure and is legally prohibited in many countries. Opponents to HGT argue that it is

„unnatural‟, „inhumane‟, or „immoral‟ and demand that HGT is banned for moral reasons. But it seems

important to re-examine the moral arguments against HGT closely, since the potential medical benefit of

HGT should not be abandoned without very good reasons.





85

The paper will refute a slippery slope type argument against HGT; this argument predicts that HGT will

result in the „horrible result‟ of a „new eugenics‟ if is not banned.

First, the argument will be reconstructed by clarifying the structure and content of the involved type of

slippery slope argument. It will be argued that proponents of slippery slope arguments often assume that

an allegedly immoral initial action is (in a law-like manner) followed by a „horrible result‟. It will be

argued that this assumption unjustifiably neglects the possibility of a planned norm-design regulating

the potential consequences of the initial action.

Second, the concept of eugenics will be examined. It will be differentiated between a „top-down

eugenics‟ and a „bottom-up eugenics‟. It will be argued that i) the „top-down eugenics‟ is morally un-

acceptable, and ii) that „bottom-up eugenics‟ can be morally acceptable - depending on the aims for

which it is applied. The second claim - i.e. that the result of HGT is not necessarily a „horrible‟ one - will

be defended by carefully exploring possible and morally acceptable aims of HGT.

Finally, the paper will make use of a concept of R.M. Hare concerning the time-orientation of prefer-

ences. In Moral Thinking Hare distinguished between „now-now‟, „now-then‟, and „then-then‟ prefer-

ences. This differentiation can help to understand why some possible results of HGT seem to be in-

compatible with some widely distributed moral intuitions, but actually are morally acceptable from the

perspective of moral philosophy.

Moral intuitions - i.e. moral preferences - play an important part in motivating moral debates. But moral

intuitions are changing and time-bound; they are, therefore, not a suitable guide in the assessment of the

moral status of technical advance in medicine. By focusing on the detailed study of the case of HGT, the

paper wants to contribute both to the theory of bioethics and to the timely debate on HGT.





[144] SEARCHING ANEW FOR THE PHILOSOPHICAL FOUNDATIONS OF HEALTH

CARE

David C. Thomasma (USA)



The search for philosophical foundations for health care is frustrated in our time by the movements of

postmodernism, anti-foundationalism, and cultural relativism, to name just three. My approach to trying

to resolve this impass will be:

1. Acknowledge the value of postmodernism in clearing away presumed verities that simply did not

exist.

2. Underscore the importance of vigilance about certain foundations proposed in the past that neglected

the roles of interpreters, gender, cultures, and the like, in formulating a desired scientific neutrality.

3. Attempt to acknowledge yet transcend the problem of cultural relativism.

4. This attempt will appeal to both objective and subjective a prioris. I will discuss three possible a

prioris, or foundational conditions for health care:

a. The existential: human finitude and commonalities of illness and healing.

b. This historical/cultural: the experiences of Western culture that can form a kind of cultural con-

science about good and evils, especially demeaning tendencies in health care that diminish the per-

sonhood of the patient.

c. The foundational relationships: among which is the relation of healer and healed found in all cultures.

The foundational relationships are essential to human survival in community, and are transhistorical and

cross-cultural.

These reflections will then be used to anchor proposals for empowerment as the healing aim of health

care for the 21st Century.







[145] ETHICAL PROBLEMS OF ABORTION

Danijela Tiosavljević (Yugoslavia)



In Yugoslavia the attitude towards abortion (artificial break of pregnancy) is very clear and in front of

medical doctors are not posed ethical dilemmas. In Yugoslavian Constitution is said that "every woman





86

has inalienable right to decide independently about the order and number of birth of children". In ac-

cordance with that principle is adopted the attitude that fetus could not be outside of mother's intestines

in the first months of pregnancy, regarding that it is the part of woman and she has right to decide about

its destiny.

New regulations (1995) much more liberally deal with the whole problem, including the regulations

about contraception, sterilization and artificial insemination. The implications about all forms of con-

traception give right to woman, mature and mentally capable, to, according to new regulations, up to 10

weeks of pregnancy freely decide about artificial aborts. Only after 10 weeks of pregnancy, if the

woman further on wishes the artificial break, she is obliged to refer to board. To youngsters below 16

years besides request for break of pregnancy is needed the approval of parents or guardians. The regu-

lations say that woman can chose the institutions in which she wants to break the pregnancy and ster-

ilization could be performed according to the law only in persons above 35 years of age (of course with

their request).

According to regulations, the indications for artificial break of pregnancy which is older than 20 weeks

are: ethical, eugenical and medical. The agreement for break of pregnancy older than 10 weeks ac-

cording to these indications give first step and second step boards in appropriate medical institutions.

The tendencies for further liberalization of abortion in Yugoslavia are noticeable and new regulations in

Yugoslavia represent the step forward in right of man to freely decide about the way of organizing your

personal life.







[146] GENOMICS: ON CONTINGENCY OF GENESIS

Pavel D. Tishchenko (Russia)



The Human Genome Project (HGP) gives enormous power to control genesis of future human beings.

And if "the Lord" had a clear knowledge in whose image and after whose likeness to create people,

biomedical professionals, "playing God", are very uncertain on this principle issue. In spite of years of

intense debates we are still faced with three principle questions that Hans Jonas had formulated in the

beginning of 70s as basic for ethical evaluation of the genetic control of future people: "Who will be the

image makers, by what standards, and on the basis of what knowledge?" In my presentation I would like

to propose an interpretation of genetic genesis of human beings using a model of "contingent identity".

Critical evaluation of Jurgen Habermas and Richard Rorty ideas on the same topic will provide the

necessary theoretical basis. Contingency of the standard normative image of "normal human beings",

complex social construction of the "image-maker", and contingent relations of truth oriented scientific

knowledge with metaphoric discourses of modern public sphere will be discussed.









[147] “IN MUCH WISDOM IS MUCH SADNESS...”: Dualism vs. monism in a medieval phi-

losophical discourse on disease

Larissa Trembovler (Israel)



The study of historical approaches to disease allows us to understand the unique role of disease as a

touchstone and an encounter of different philosophical traditions. Disease, from the one side, initiates a

free “interdisciplinary” discourse (by physicians, philosophers, and theologians); from the other side, it

reveals internal tensions between the concepts underlying the different fields of thought. In this paper I

will focus upon the connection between disease and intellectual activity as discussed in medieval Ara-

bic* medical and philosophical writings as an example of the interaction of ideas.

According to some medieval commentaries (like that of R. Saadia Gaon) to Ecclesiastes 1.18 “For in

much wisdom is much sadness, and multiplying knowledge is multiplying sorrow”, intellectual de-

velopment and achievement of wisdom are connected to physical suffering caused by the body‟s natural

resistance to the soul‟s perfection. There is a resemblance in this statement to a well-known description



87

of psychological causes of melancholy, accepted by the Galenic medicine of the period. According to

the consensus of all medical authorities beginning from Rufus of Ephesus and Galen which includes also

al-Razi (Razes), Ishaq ibn Imran and Ibn Sina (Avicenna), melancholy frequently occurs because of too

hard and too prolonged intellectual activity. However, concerning the treatment of the disease we find

here two opposite types of recommendations. The first way of treatment includes in addition to dietetic

and other regimen prescriptions also restriction of intellectual activity, that is the mind of a sick person is

supposed to rest. Characteristic recommendations of this type are found in al-Razi‟s writings.

On the other hand, Moses Maimonides in his medical treatise “Regimen of Health”, though recom-

mending dietetic prescriptions and other traditional medical devices, notes that the only true and really

efficient way to overcome the disease is through study (that is, the study of the religious law and other

religious aspects).

To our opinion, these two opposite ways of treatment correlate to different points of view of human

nature. According to the monistic approach to human nature, its origin being related basically to ancient

Stoic philosophy, the man is “one unity”, that is, there is no essential opposition between soul and body.

Melancholy results from the disturbance of the unity of the parts and the lack of harmony due to too hard

and prolonged study; rest, thus, restores the harmony and, consequently, the health. According to the

dualistic approach, it consists of two opposites, the soul and the body being in a constant struggle.

Development of the soul through intellectual activity causes resistance of the body, which leads to the

disease. The recommended way of treatment, accordingly, is the strengthening of the soul (by additional

study}, thus helping it to overcome the body‟s resistance.



*Arabic here indicates the language of the sources whereas most of them had been written not by Arabs but by

Jews, Persians, Turks et al.









[148] AGENCY, ILLNESS & FUNCTION

Stephen Tyreman (United Kingdom)



Despite the scientific emphasis on Evidence Based Medicine, the view that health care practice is more

than applied science is still widely accepted, even in medical education. (Coles, 2000; Maudsley &

Strivens, 2000). What „more‟ refers to is unclear but entails value-judgements of some kind. The ways

in which values feature in practice can broadly be divided into (a) the view that evaluative judgements,

such as ethical considerations, supplement scientific ones (which remain foundational) and (b) the more

radical view that values are implicit in the knowledge base – specifically concepts of health, illness and

disease – that underpins all health care endeavours. (Fulford, 1989; Nordenfelt, 1995)

This paper, while not underestimating the contribution that scientific knowledge and methodology

makes to health practice, argues that what prompts a patient to seek health care is loss, actual or per-

ceived, of agency. It argues that the concept of (lost) agency defines illness and that the role of a prac-

titioner is to restore or enhance agency, where agency is defined as a person‟s „taken-for-granted ability

to engage with the world‟. The process of enhancing agency is informed but not determined by science.

This argument is further strengthened by the claim that the concept of function, i.e., the way in which

certain biological properties are selected as of special significance to biology and medicine, depends on

intuitions of human agency. On this view the claim that the function of the heart is to pump blood

(rather than, say, to occupy space) comes from the belief that pumping blood enhances, or in this case is

a necessary requirement for, human agency. This means that the concept of function, which forms the

basis of physiology, is evaluative and rests on an understanding of human agency. Because intuitions of

what human agency is are subject to social and cultural influences, debate about what agency (and hence

what a „good‟ human being) is needs to be rehearsed, and possible revised, with every generation in

order to come to a consensus about what good health care is. Medicine and society‟s uncritical

over-reliance on scientific judgements has led to the erroneous belief that issues associated with health

and illness are known or knowable without such a debate and this, perhaps, is responsible for the per-

ceived lack of humanity in technological health care.





88

References:

- Coles, C. (2000). Teaching the teachers. Med. Educ., 34(2), 84-85.

- Fulford, K. W. M. (1989). Moral Theory and Medical Practice. Cambridge: Cambridge University Press.

- Maudsley, G., & Strivens, J. (2000). 'Science', 'critical thinking' and 'competence' for Tomorrow's Doctors. A

review of terms and concepts. Med Educ, 34(1), 53-60.

- Nordenfelt, L. (1995). On the Nature of Health: An Action-Theoretic Approach. (2nd ed.). (Vol. 26). Dordrecht:

D.Reidel Publishing Co.





[149] HEALTH - AS A CENTRAL ONTOLOGICAL PROBLEM

Veber Victor R., Khroutski Konstantin S. (Russia)



We define the problem of individual health of man as a central ontological problem. Here exist two

macro-approaches to solve this mega-problem: the Metaphysical and the Dialectical one. The Meta-

physical - actually existing - approach defines (WHO, 1946) health as a "state of complete physical,

mental, and social well-being”. We oppose to it the Dialectical approach which considers the process of

Earth's Living Organization evolution as a universal, whole and emergent process in its substance. Here

man is established as the central unit of this cosmic evolutionary process, responsible for its continua-

tion and reasonable transcendent organization of a future new higher level of Earth's integrity. Earth's

Living Organization evolutionary process is a single whole - that is the incontestable fact of natural

sciences. The latter is well known at least since the discovery of DNA by Watson and Crick, "which

proves the unity of all kinds of life and the genetic transmission of psychic characters by these mole-

cules" (Rensch, 1971). Consequently, scientific knowledge in Human, Social and Life sciences must be

universal as well.

On the basis of this truth - of the wholeness of Earth's life - we have:

1) the principles of universal integration and of universal evolutionism rule the actual world: every

living subject is an Integrated Subject (including the Living Earth herself); and every living subject

exists in a single order: he/she successfully evolves by integrating himself/herself into the ascending -

of complexity - whole levels of biological, regional or whole Earth's living ecological (social) integrity:

of a molecule, organelle, cell, tissue, organ, organism, ecosystem (biocenos, biosphere), human being,

family, community, society; the next integrity inevitably should be the whole humanity;

2) since the appearance of man - biological species homo sapience – we have the qualitatively distinct

stage of the world evolutionary process: that is the emergence of conscious reasonable constructive

interference of man into world evolutionary processes that determine the general process of Earth's

Living Evolution on the whole;

3) Earth's human being still does not possess the Cosmic consciousness - of his/her integrity with and

responsibility for the continuation of the common cosmic evolutionary process;

4) Individual's health is a natural attribute of any Subject to participate in the common whole cosmic

process of Earth's Living Evolution: to be healthy - that is constantly to participate in the natural Earth's

cosmic evolutionary process;

5) We must discern the 'natural, causal' diseases which result from the influences of existing harmful

environmental factors - from the 'artificial' ones, which are caused - ultimately - by the ontological and

epistemological incompetence of modern philosophy, science and man;

6) To solve the problem of modern "civilization diseases" etiopathogenesis, - we need to consider

contemporary man from the cosmic ontological level - as a naturally predertermined person to fulfil his

specific functional mission on the erection of a new higher evolutionary level of Earth's living integrity.

7) Current Russian biomedical reality presents a lot of examples to ascertain the above stated theses.









[150] ETHICAL CONTRADICTIONS OF PREVENTIVE MEDICINE: Case study of influ-

enza vaccination

Marija Veniute, Laima Adomelyte (Lithuania)







89

Vaccination is a method of preventive medicine which aims to decrease the morbidity of people from

infectious diseases. Recently the campaign of commercial influenza vaccination has been started in

Lithuania. We may distinguish 3 groups of interests in this area (pharmaceutical companies, individual,

healthcare providers, governmental institutions responsible for public health).

Each of these groups expects different benefit from vaccination. Often their interests clash and the needs

of single individual are being sacrificed for the benefit of the community. Most probably here the

solidarity is violated: the risk group people (elderly over 60, pregnant, those who suffer from chronic

diseases, those with an immunodeficiency syndrome, alcohol addicts, asocial and poor) are not vacci-

nated because of financial problems and lack of information. Particularly the attention should be paid to

inhabitants in small towns because the vaccination programs are provided for big city population

mostly. It seems therefore that such a situation doesn‟t meet the principle of solidarity and justice in

healthcare.

In addition in this area healthcare providers face such ethical problem as preventive paradox: the benefit

of vaccination could be evaluated on the community level and may not necessarily offer any use to a

particular participating individual.

Besides, the advertisement of influenza vaccination through information media has been widely spread

in Lithuania as well: on TV, radio, booklets; it also derives from GP etc. Sometimes the flow of in-

formation is biased and aims to influence a person‟s decision to be vaccinated. The data about influenza

vaccine provided to the patients don‟t correspond to the facts about the immunity forming duration,

efficiency of the vaccine etc.

Analyzing the case of influenza vaccination in Lithuania we‟ll present the critical study of the vacci-

nation advertisements (comparing them with the data from official bodies on their safety & efficiency)

as well as the results of the questionnaire on patients‟ understanding the information concerning vac-

cination. The paper also deals with the ethical issues of informed consent to the vaccination procedures

as well as the preventive paradox in the transition society.









[151] ETHICS OF HUMAN EXPERIMENTATION IN AEROSPACE AND MILITARY

MEDICINE: Principles and real

Vasiliy Vlassov (Russia)



Vulnerability of military personnel as subjects of study is well recognized. This means that consent by

military servicemen may de biased due to their special position in the service. Unfortunately the nature

of research in aerospace industry as well as other military research makes impossible use of random

subjects from population. The only reasonable approach in defense of military servicemen as study

subjects is to compensate their vulnerability as decision-makers by thorough risk/benefit ratio evalua-

tion in course of preparation of research proposals and in the review of these proposals. The concept that

free consent means that subject accept prospective risks is of a limited validity.

Whenever possible biomedical experiments must be done not on military personnel exclusively. It is

reasonable to include civil subjects and subjects not belonging to the special military or research

community. If possible, experiments have to be done on the groups of personnel who may benefit from

the results of the study. There are the straightforward, but difficult way to keep evaluation of risk/benefit

ratio as close as possible to the acceptable in the society values. Deception in the research involving

military personnel or other vulnerable subjects must be limited because it leads to further impairment of

their decision making in the course of giving consent.









[152] CHANCES AND LIMITS OF INFORMED CONSENT IN PSYCHIATRY

Jochen Vollmann (Germany)



During the last three decades the doctrine of informed consent has become a legal and ethical standard in

medicine. However, ethical and practical problems arise if patients or research subjects have lost the



90

capacity or competence to give valid informed consent due to their medical conditions. This situation

occurs frequently in paediatrics, emergency medicine and in mental health. In particular in the field of

psychiatry the assessment of competence to give informed consent to medical treatment and to par-

ticipation in clinical trials is a controversial issue in Europe.

I will present in this paper new empirical data on the assessment of competence in patient with different

mental disorders from the U.S. as well as from our ongoing research project at the Department of

Psychiatry of the Free University of Berlin (funded by the Deutsche Forschungsgemeinschaft). I will

present different standards for assessing patients capacities to make treatment decisions and demon-

strate how the choice of standards for determining competence affect the identity and proportion of

patients classified as impaired. Therefore the selection of these standards has to be discussed critically

under medical and ethical issues and formal policies relating to the characterisation of persons as in-

competent must be fashioned with caution.

Therefore we have to re-examine our concept of competence and autonomy in psychiatry and must

discuss its role in relation to other ethical principals and within the given cultural context. Later I would

like to discuss in particular with colleagues form East- and South Europe.









[153] IS THERE A CONCEPT OF DISEASE IN PALLIATIVE MEDICINE?

Joachim Widder (Austria)



Usually, palliative treatment is understood as treatment not intending to cure a disease, but to make

symptoms disappear (or to prevent certain symptoms from appearing). It can be defined as treatment of

a chronic condition that does not aim at making the condition disappear; the condition will at last lead to

death; the choice of treatment is decisively influenced by the consideration of how it will affect the way

of dying of the patient. The concept of palliative treatment presupposes that 1) the disease must either be

incurable (the attempt to cure will fail with an unacceptably high probability); or 2) curative treatment

would involve an unacceptable burden or risk (the attempt to cure is not the preferred way of action).

These two presuppositions have quite different standings. If a disease is incurable (e.g., stage IV lung

cancer), any meaningful treatment cannot just aim at the disease. The problem is, to clearly define the

objective of therapy. If a disease is curable, but the attempt to cure is not preferred it is again crucial to

define the objective of therapy. It seems that the distinction between curative and palliative treatment

does not refer to the causal / symptomatic distinction, but to the goals of therapy.

The goals of therapy do not depend on the usual concept of disease. If, however, the goals of therapy are

chosen entirely independently of a concept of disease or illness, medicine becomes pure

bio-(psycho-social) engineering. Alternatively, to maintain a more classical conception of medicine (the

human endeavour having to do with disease) necessitates an adaptation of the concept of disease.









[154] EVIL MEDICINE

Åge Wifstad (Norway)



The method used in the industrialised mass murder of Jews was developed and tested within German

psychiatry, where as many as 200.000 were murdered under the direction of the ”Euthanasia Pro-

gramme”. The doctors‟ enthusiasm for this programme, coupled with their distanced contemplation of

”life unworthy of life”, can be understood as the legitimisation of certain rules of speech, which helped

them to ”forget” that they were dealing with people.

In her Eichmann study Hannah Arendt launches the expression ”the banality of evil” to describe the fact

that Adolf Eichmann was no monster, but an extremely ordinary person. More than anything else it was

his remoteness from reality and his thoughtlessness that caused him to send hundreds of thousands of

people off to certain death, according to Arendt.





91

In this paper I will argue that Arendt‟s conceptual model is not wholly adequate in explicating what

happened in the medical holocaust. The ”Euthanasia Programme” was not only an administrative

measure within a bureaucracy, but professionaly motivated. Perhaps it hurts even more to accept this,

than it does to accept that thoughtless remoteness from reality can be the motivating power behind the

worst imaginable acts.







[155] EMPATHY IN INTERPERSONAL CONTACTS

Ewa Wilczek-Rużyczka (Poland)



The interpretation of empathy as interpersonal communication and pro-social activity does not exclude

the importance of intrapersonal processes undergoing in both partners of the interaction. The research

workers studying the phenomenon of empathy have not yet elaborated a univocal approach towards the

questions connected with this phenomenon. They agree, however, as to one thing: empathy has a con-

structive influence on the formation of interpersonal relations. It is of practical importance in carrying

out such professions as nurse, psychologist, teacher, and doctor.

The quality of interpersonal contacts marks out both communicative and task-oriented dimensions of

empathy. It seems that also its intrapsychic function that accompanies empathy is of certain signifi-

cance. The emotional and cognitive contact of a person and the object of empathy can be gratifying in

itself for both sides. Frequently people who are weak, unwell and unhappy and even those experiencing

joy, feel the need of contact with other people who would be able to share their present sensual ex-

perience. Also, highly empathic people are oriented at this kind of reactions of their potential objects.

The feeling of closeness in the similarity of experiences is a value in itself and fulfils specific needs of

both partners. It is also connected with the fact that not every object expects help and that providing help

is sometimes purposeless or impossible in certain situations of suffering. The ability of insight and

interpretation of one‟s own experiences required in the process of mature empathy provides an indi-

vidual with new sensual experiences, at the same time making them more sensitive to others‟ emotional

reactions.

The purpose of the present paper is an attempt to show the importance of empathy in interpersonal

contacts with special emphasis on relations connected with providing help.







[156] LOGIC AND INTERPRETATION OF RANDOMISED CLINICAL TRIALS

Henrik R. Wulff (Denmark)



According to Popper the scientific process ought to be one of hypothetico-deductive reasoning. The

gifted scientist generates bold hypotheses which he then endeavours to falsify experimentally. Popper‟s

philosophy is very popular among medical scientists, and it is not surprising that attempts have been

made to interpret the logic of the randomised clinical trial (RCT) within a Popperian framework of

thinking. These attempts have failed. The hypotheses which are tested in RCTs are usually far from

bold, and the hypothesis which the statistician attempts to reject by his analysis is not the initial hy-

pothesis, but the null hypothesis.

The history of the controlled therapeutic trial from the days of Jules Gavaret in the 1840s reveals that it

is best described as a typical example of inductive research. The researcher makes a series of singular

observations and, relying on „the law of large numbers‟, he then formulates a general „therapeutic law‟

(Gavaret‟s expression). The „law‟ may state that treatment A cures, say, 20% more patients than

treatment B or just that treatment A is more efficient than treatment B. The research methods have now

been refined by the introduction of randomisation and statistical calculations, but basically the logic of

this type of research remains unchanged. The statistical analysis takes the form of hy-

pothetico-deductive thought experiments (calculation of confidence limits or P-values), but these cal-

culations only play an ancillary role They serve to assess the precision of the „therapeutic law‟ which

were reached by inductive inference.





92

The use of the results of RCTs in everyday clinical practice (evidence-based medicine) also illustrates

the empiricist tradition of clinical medicine. The general „therapeutic laws‟ generated by RCTs are used

to predict what will happen in the individual case. If the RCT has shown that the probability of cure is

20% higher using treatment A than treatment B, it is tempting to infer that in the individual case the

probability of cure will also be 20% higher, if we prefer treatment A. However, this inference requires a

analysis of the probability concept. In the RCT the probability is a frequency, whereas in the individual

case it may be regarded as a measure of subjective belief. Radical empiricists do not appreciate this

distinction as from their point of view predictions must always be based on series of observations.

Medical practitioners, however, also base their subjective beliefs on deductions from theoretical

knowledge and on the characteristics of the individual patient. Popper‟s realist interpretation of indi-

vidual probabilities may also be considered.







[157] ETHICAL REVIEW OF EXPERIMENTS WITH HUMAN BEINGS AS AN INDUSTRY

Boris G. Yudin (Russia)



Nuremberg Code was based at the presumption that any experiment with human subjects was to be

perceived as something inherently linked with possibility of serious damages for involved participants

and, consequently, admissible only in some exclusive cases, as a last resort. Now perception and

meaning of human experimentation are drastically changed. Such experiments become essential and

even necessary part of development and the very existence of biomedical sciences in their present-day

forms. Yet the problem: whether such experiments are first of all risks or benefits for participants, still

exists. More than that, now the scope of the risks becomes even bigger than previously due to risks

associated with disclosure of confident information about participants (as in epidemiological studies, for

instance).

Along with that we can speak about one more tendency, related with previous one. Human experi-

mentation now is minutely elaborated in cognitive-methodological as well as in social terms field of

activity. It takes more and more and more massive scale. H. Jonas (1969) ones told about industry of

scientific research; today we can speak not only about such industry (or industry of scientific experi-

ments) - human experimentation becomes a kind of industry as well. Rapidly growing demand on it goes

not only from science but also from different rather powerful economic and social powers.

Concerns about possible risks for participants of such experiments in general are effectively blocked by

existing (and minutely elaborated as well) system of ethical review of these experiments. Such super-

structure of ethical review is not just a newly emerging social institution for protection of participants of

experiments. It also tends to be - in terms of its social organization - a kind of industry, development of

which is influenced by general laws and rules of industrial development.

Along with other things it means that the institution of ethical review becomes one of factors involved in

competitive race in the field of biomedicine. After all, it takes some money to have proper organized

system of ethical review and to carry out a research project through such system. So, this system which

is intended for ethical assessment of research on humans plays also another role of controlling access to

markets of biomedical goods and services. Such countries as, for instance, Russia, have rather essential

scientific potential and have no superstructure of ethical review. And lack of such superstructure pro-

duces serious competitive disadvantage in the field of biomedical technologies.







[158] WHAT MAY IT MEAN “HUMANE” IN “HUMANE HEALTH CARE”

Zbigniew Zalewski (Poland)



Humanness of a caregiver is one of the most important features expect in a health care context. This

expectation is deeply rooted in a conviction that every human being should be treated with the respect

adequate to his/her dignity. As such, it is a cornerstone and a hallmark of what is called “humane health

care”.





93

However, the adjective “humane” seems to be not absolutely resistant to ambiguity. If taken into ac-

count as an opposite to its antonym – the adjective “inhumane”, it reveals certain semantic opacity. It is

not beyond the scope of common imagination that one can do in a humane way something, which is per

se wrong, for example, one can kill a dog “humanely”, i.e. in a “humane” way. This means that one does

it with human feelings, and not “inhumanely” – brutally, sadistically or mechanically.

A similar sense may be attached to one‟s attitude toward a human being. Being influenced by deeply

human feelings like compassion or mercy, one can, for instance, cause someone‟s death to shorten

his/her hopeless and inalleviatable suffering. Moreover, one can do it respecting someone‟s autonomous

wish or request. This kind of situation poses some substantial doubts regarding the sense of “humanity”

or “humanness”. It seems that these concepts need a certain additional determination in order to make

the phrase “humane health care” fully meaningful and unambiguous. Yet, subdued to such a semantic

procedure they are prone to lose their original, appealing sense and acquire a kind of a dangerously

ideological semantic “surplus”.





[159] ETHICS OF CLINICAL RESEARCH IN ONCOLOGY: Informed consent, cultural and

economic differences, and free choice

Matjaž Zwitter (Slovenia)



Patient‟s informed consent has been in the focus of all discussions of ethics of clinical research. Our

three surveys on the practice of informed consent among physicians involved in randomised clinical

trials (RCTs) for lung and breast cancer revealed the following findings:

1) a substantial proportion of patients participating in RCTs are incompletely informed about the

diagnosis, prognosis, and random choice of treatment;

2) the level of informed consent is higher in trials of lesser importance for the patient (such as RCTs of

antiemetics or other forms of supportive care) and lower in trials of specific anti-cancer treatment

(such as RCTs of mastectomy vs. breast-preserving treatment for breast cancer);

3) marked geographical differences in the pattern of informed consent are seen between North-

ern-Western (N-W) Europe and South-East (S-E) of the continent;

4) physicians in N-W Europe spend significantly more time than their colleagues in S-E Europe for

explanation of a trial and obtaining informed consent;

5) in spite of a greater effort of their physicians, a high proportion of N-W patients and only few from

S-E countries decline participation in a trial.

How to explain the differences between different parts of Europe? The classical explanation is, in one

word, culture. Culture as a broad understanding of values in life, culture linked to the predominant

religion, culture as a reflection of recent history of respecting or ignoring human rights, culture as an

indispensable ingredient of relations between a patient and her physician, and culture which determines

our understanding of the proper balance between respect of patient's autonomy and medical paternalism.

In addition to culture, health economics and organisation of the health care play an important role in

shaping the communication process. It is much easier to speak openly to a patient if all proven methods

of diagnostics and treatment are available and if the health care is based on social solidarity. On the other

hand, the task is much more difficult if there are long waiting lists and shortage of equipment, of drugs,

of hospital beds, and if the patient or her family has to contribute towards the costs of treatment. In such

circumstances, participation in a clinical trial may be the only option for a decent treatment. This lack of

alternatives may be an explanation for our observation that few patients from South and East Europe

refuse to join a clinical trial.









94