Literature Review
Happy New Year!
I apologize for the interval between Literature Reviews, so here is the first of 2007.
Today's Review will collate abstracts, if available (and titles and authors, if not), from the following journals:
Medical Humanities Vol. 32, no. 2 (2006):
Narratives of psychiatric malingering in works of fiction
Correspondence to:
Victor Kuperman
Einsteinstraat 81, 6533 NH Nijmegen, Netherlands; rkuperman@yahoo.com
This paper argues that the representation of psychiatric malingering in literary and cinematographic narratives informs societal stereotypes, and thus influences the clinical phenomenology of malingering. The study aims to identify sociocultural models of malingering in contemporary Western society based on the narrative analysis of about 60 fictional and non-fiction texts. Two behavioural patterns derived from the Foucauldian categories folly and madness are recognisable in naïve conceptualisations of fake insanity. Fabricated significations of deviation originate in grand societal narratives rather than in medical discourse, and construct characters such as animal like underdeveloped simpletons or detached, irrational, violent madmen. Each pattern stems from its own archaic conceptual basis and dictates a distinct framework for strategies of malingering. The semiotic structure of artistic narratives of malingering is discussed in comparison with the symptomatology of existing psychiatric models.
ORIGINAL ARTICLE
Envying Cinderella and the future of medical enhancements
Correspondence to:
A Volandes
Center for Bioethics, Brigham and Women’s Hospital, 75 Francis Street, Boston, MA 02144, USA; avolandes@post.harvard.edu
The medical profession is increasingly absorbing technologies that offer medical care that is more luxury than need. From foot sculpting surgeries to breast and pectoral implants, physicians are increasingly putting patients under the knife to improve on the normal, to make better than well. Medicine’s enthusiasm for absorbing such technologies may corrode the moral priority that it has traditionally held as a profession. Medicine’s moral status declines when it both provides medical luxuries and meets medical needs. Patients without health care will increasingly envy patients who receive healthcare luxuries. Instead, however, of doing away with such luxuries, medicine can institute a pay scheme whereby medical luxuries help subsidise care for those without health care. In this fashion, any feelings of envy are pre-empted and the profession retains its moral status.
Enhancement: are ethicists excessively influenced by baseless speculations?
Correspondence to:
D G Jones
Department of Anatomy and Structural Biology, University of Otago, PO Box 913, Dunedin, New Zealand; gareth.jones@stonebow.otago.ac.nz
Most commentators draw a sharp distinction between therapy and enhancement, applauding therapy and rejecting enhancement. Not only is this distinction unclear but enhancement is often seen in grandiose terms in which human beings are radically transformed. Such far-reaching visions are then used to reject current procedures such as pre-implantation genetic diagnosis. To overcome this highly problematic impasse, enhancement has been divided into three categories, ranging from the health-related enhancement of category 1, through the non-health-related enhancement of category 2, to the transhumanism or posthumanism of category 3. Arguably, most enhancements are of the category 1 variety, and hence closely related to treatment. Also, we are already enhanced, when compared with our forebears. It is only when we accept this and dispense with baseless speculation will we be in a position to conduct ethical discussions within a realistic framework.
The novel Arrowsmith, Paul de Kruif (1890–1971) and Jacques Loeb (1859–1924): a literary portrait of "medical science"
Institute for the History of Medicine, Heinrich-Heine-University Duesseldorf, Duesseldorf, Germany
Correspondence to:
H M Fangerau
Institute for the History of Medicine, Heinrich-Heine-University Duesseldorf, Universitaetsstrasse 1, 40225 Duesseldorf, Germany; heiner.fangerau@uni-duesseldorf.de
Shortly after bacteriologist Paul de Kruif had been dismissed from a research position at the Rockefeller Institute for Medical Research, he started contributing to a novel in collaboration with the future Nobel laureate Sinclair Lewis. The novel, Arrowsmith, would become one of the most famous satires on medicine and science. Using de Kruif’s correspondence with his idol Jacques Loeb, this paper describes the many ways in which medical science is depicted in Arrowsmith. This article compares the novel with de Kruif’s and Loeb’s biographies, and (1) focuses on the struggles of the main character, Martin Arrowsmith, as an allegory of the institutionalisation of medical research in the US, (2) shows that (influenced by de Kruif) Sinclair’s purpose is to caricaturise scientific work in modern medical research institutions anywhere and (3) shows that the novel depicts a reductionist philosophy of research that seems to contradict the "messiness" of medical practice.
The missing future tense in medical narrative
1 School of Medical Practice and Public Health, University of Newcastle, Newcastle, UK
2 Weill Medical College in Qatar, Cornell University, Doha, Qatar
Correspondence to:
Dr L G Olson
148 Chemin de la Planche Brulée, 01210 Ferney-Voltaire, France; les.olson@wanadoo.fr
Medical narrative is normally assumed to be a past tense narrative. Patients’ and students’ past tense narratives should be supplemented by future tense narratives, and in particular by what we call hypothetical narratives—narratives such as those offered by a medical student in response to the instruction "Tell me a story about when you are a doctor". These narratives are suggested to be especially useful in clinical and educational contexts because they offer greater insight into the narrator’s hopes and expectations than past tense narratives, which can be helpful in planning management and teaching. The narrator’s ethical principles are also exposed more clearly than when using the past tense narrative. Some ethical concerns raised by analysing narratives offered by patients or students, as if they were literary narratives, are avoided by hypothetical narratives. This suggestion is based on Ricoeur’s account of the ethical importance of veracity in narrative, or "attestation of what has occurred". The patient/doctor or student/teacher relationship is found to have an implicit concern for the narrator’s intention that makes the assumptions underlying literary analysis untenable.
Need humanities be so useless? Justifying the place and role of humanities as a critical resource for performance and practice
1 School of English, Communication and Philosophy, Cardiff University, Cardiff, Wales, UK
2 School of Religious and Theological Studies, Cardiff University, Cardiff, Wales, UK
Correspondence to:
S Pattison
Cardiff University, Humanities Building, Colum Drive, Cardiff CF10 3EU, Wales, UK; PattisonS@cardiff.ac.uk
Justifying the existence, position, and relevance of academic humanities scholarship may be difficult in the face of chronic practical needs in health care. Such scholarship may seem parasitic on human activity and performance that directly contributes to human wellbeing and health care. Here, a possible and partial justification for the importance of scholarship in the humanities as a critical resource for practice and performance is undertaken by two humanities scholars. Human identity and emotion are reflected and defined by performances, both in the traditional disciplines of the humanities, such as art and literature, and in the sciences and medicine. The critical attitude that such performances might inadvertently undermine is sustained by the humanities. The humanities disciplines ask the question: "What is it to be human?" Uncritical emotion and expression, arising, for example, from understanding developments in medicine and science, which might exclude or corrupt much that is of value in the healthcare sector and other areas of practical performance, can be constrained by this.
Discourse ethics in practical medicine
Medical Faculty, University of Ulm, Germany
Correspondence to:
Dr F Keller
Dvision of Nephrology, Medical Faculty, University Hospital, Robert Koch Strasse 8, D-89070 Ulm, Germany; frieder.keller@uni-ulm.de
Problems emerge in practical medicine because the binary ethics of the classic patient/doctor relationship has been replaced by multiagent interaction between those engaged in the process of diagnosis and treatment. New methods are required to deal with complex problems in every patient. Where and why the current practice can fail is illustrated with an example of an unspectacular routine case of cancer. The failure may result from basing the procedure on mechanistic methods or from the deficit and difficulty in communication. Whether rule based algorithms could have improved the treatment in the patient with cancer is discussed. How discourse ethics may fit better with the course of the case is described. Clinical Medicine follows a similar logic to that modelled by discursive ethics, ethics thinking should essentially contribute to the procedural logic of medical practice. Discourse ethics can be used as a procedural model that copes with the complexity and temporality of practical medicine. Applied discourse ethics can turn out to be both instrumental in mediating inherent conflicts and constitutive for value based problem solving in modern medical practice.
Nietzsche’s morality: a genealogy of medical malpractice
Correspondence to:
T J Papadimos
Departments of Anesthesiology, Medicine, and Medical Microbiology and Immunology, Medical University of Ohio, 3000 Arlington Avenue, Toledo, Ohio 43614, USA; tpapadimos@meduohio.edu
Medical malpractice is of increasing concern and 60 billion dollars are added annually to healthcare costs. The practice of defensive medicine, decreased availability of doctors, and increased health insurance premiums are all results of medical malpractice. An argument is made from the perspective of Friedrich Nietzsche’s On the Genealogy of Morals that a primal cause of the litigiousness of the public against doctors results from resentment or "ressentiment". The relationship of promises, responsibility, and guilt between doctors and patients is explored, as well as what may be necessary to reduce the public’s ressentiment. Modern malpractice in the US is covered by Nietzsche’s line of reasoning in On the Genealogy of Morals, although his reasoning is condemned by most Western philosophers. Doctors may be able to better manage their interactions with patients and limit their exposure to litigation by understanding and exploring alternative philosophical and historical origins—or aetiologies—of patient/doctor conflict.
Autopathography and humane medicine: The diving bell and the butterfly—an interpretation
Mercy University Hospital, Cork, UK
Correspondence to:
P J Kearney
Paediatrics and Child Health, University College Cork, Cork, Republic of Ireland; p.kearney@ucc.ie
Autopathographies are an expanding genre of books and articles that are a potential resource for students interested in the medical humanities. New curricula emphasise the need to familiarise medical students with the patient’s point of view. Different specialities compete for the student’s attention and the medical humanities are not an exception. Some form of assessment is necessary to reflect the importance of the patient’s perspective. One way may be to request students analyse their chosen autopathography. The article presents an example based on one of the better know accounts. The identified themes reflect the sudden disruption in the author’s biography. The topics are connected to the medical disorder and illustrated by quotations. The different categories of autopathography can be helpful in understanding the author’s perspective. In this instance the author was a full time editor before his stroke. The style of the book employs professional distance from the narrative. This is more compatible with the description of metapathography rather than the original classification of autopathogrphies as religious, angry or alternative.
A silly expression: Consultants’ implicit and explicit understanding of Medical Humanities. A qualitative analysis
Correspondence to:
Lynn V Knight
Peninsula Medical School, Universities of Exeter and Plymouth, Portland Square, Drake Circus, Plymouth PL4 8AA, UK; lynn.knight@pms.ac.uk
The term Medical Humanities has still not been established in the wider medical, educational and academic communities. This qualitative study, conducted across three acute care trusts, is an exploration of whether clinicians were familiar with the term Medical Humanities, and if so, what the term meant to them and whether they considered the associated concepts relevant to medical practice and education. Reactions to the term Medical Humanities were varied: many clinicians had not heard of the term before, some were unsure what it meant, others displayed mistrust or contempt for it. Explicit definitions that were elicited were categorised (inductively) according to three main approaches to the understanding of Medical Humanities: Humanistic-holistic, Humanities-medicine seperate and Intellectual exercise. Findings indicate that the lack of clarity about the term Medical Humanities among experienced healthcare professionals, contrasts with their sophisticated implicit knowledge of key issues frequently associated with Medical Humanities. Thus, while some clinicians could not define Medical Humanities and some definitions separated humanities from medicine, all clinicians implicitly acknowledged the importance of Medical Humanities issues within their clinical and teaching practices during conversations prior to any mention of the term. It appears that clinicians as role models for medical students can inadvertently convey an ambivalent position towards the Medical Humanities that encompass the very values and attitudes they are trying to inculcate, sending out mixed messages to the novices.
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Medical Anthropology Vol 25, no. 4 (2006)
Risk, Citizenship, and Public Discourse: Coeval Dialogues on War and Health in Vancouver's Downtown Eastside1
LESLIE A. ROBERTSON A1
A1 Department of Sociology and Anthropology, University of Windsor, Ontario. 401 Sunset Ave., Windsor, Ontario, N9B 3P4, 519 253 3000 (3977)
Abstract:
This article is about September 11, 2001, and its narrated effects on the lives of nine street-involved women in Vancouver's Downtown Eastside. I outline the locations from which they spoke about war and health: as consumers and economic agents whose bodies are linked to transnational economic processes; as residents in a local community of shared knowledge and practices; and as marginalized citizens of a nation-state. I hope to emphasize the value of engaging research subjects in coeval dialogues that work against essentializing, state-sanctioned discourses narrated in the context of armed conflict and a public health crisis. To women drug users in Vancouver's Downtown Eastside, the “War against Terror” evokes particular sites of knowledge: the body, the local community, and transnational processes. Their repertoires of war stimulate questions about citizenship and perceptions of risk, challenging dominating medical and political discourses that tend to temporally and spatially localize their engagement with the world.
Body and Illness: Considering Visayan Filipino Children's Perspectives within Local and Global Relationships of Inequality
LISA M. MITCHELL
Abstract:
Despite a plethora of studies counting, examining, assessing, and diagnosing Filipino children living in poverty, children's own perceptions and concerns about their health and security are rarely elicited. This article draws from fieldwork in an urban neighbourhood in the Visayan Philippines among children who, every day, face a complex and precarious landscape dominated by multigenerational poverty, social marginalization, recurring hunger, and the hazards of living and playing amidst mounting garbage and effluent. I discuss children's perspectives on body and illness in this challenging environment and examine their ideas within the larger context of adult-child, hierarchical relationships, and colonial and contemporary government discourses on children, health, and citizenship. I also examine children's sense of place, agency, and vulnerability, and I discuss the view held by many adults in this community: their children's ideas hold little value.
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Journal of Medicine & Philosophy Vol. 31, No. 6 (2006)
Bioethics and the Philosophy of Medicine: A Thirty-Year Perspective
H. TRISTRAM ENGELHARDT JR. A1, JEREMY R. GARRETT A1, FABRICE JOTTERAND A2
A1 Rice University, Houston, Texas, USA
A2 University of Texas at Dallas, Dallas, Texas, USA
Bioethics and Politics: “Doing Ethics” in the Public Square
EDMUND D. PELLEGRINO A1
A1 President's Council on Bioethics, Washington, DC, USA
ROBERT M. VEATCH A1
A1 The Kennedy Institute of Ethics, Georgetown University, Washington, DC, USA
Abstract:
The celebration of thirty years of publication of The Journal of Medicine and Philosophy provides an opportunity to reflect on how medical ethics has evolved over that period. The reshaping of the field has occurred in no small part because of the impact of branches of philosophy other than ethics. These have included influences from Kantian theory of respect for persons, personal identity theory, philosophy of biology, linguistic analysis of the concepts of health and disease, personhood theory, epistemology, and political philosophy. More critically, medicine itself has begun to be reshaped. The most fundamental restructuring of medicine is currently occurring—stemming, in part, from the application of contemporary philosophy of science to the medical field. There is no journal more central to these critical events of the past three decades than The Journal of Medicine and Philosophy.
Bioethics as a Second-Order Discipline: Who Is Not a Bioethicist?
LORETTA M. KOPELMAN A1
A1 Brody School of Medicine, Greenville, North Carolina, USA
Abstract:
A dispute exists about whether bioethics should become a new discipline with its own methods, competency standards, duties, honored texts, and core curriculum. Unique expertise is a necessary condition for disciplines. Using the current literature, different views about the sort of expertise that might be unique to bioethicists are critically examined to determine if there is an expertise that might meet this requirement. Candidates include analyses of expertise based in “philosophical ethics,” “casuistry,” “atheoretical or situation ethics,” “conventionalist relativism,” “institutional guidance,” “regulatory guidance and compliance,” “political advocacy,” “functionalism,” and “principlism.” None succeed in identifying a unique area of expertise for successful bioethicists that could serve as a basis for making it a new discipline. Rather expertise in bioethics is rooted in many professions, disciplines and fields and best understood as a second-order discipline.
Look Who's Talking: The Interdisciplinarity of Bioethics and the Implications for Bioethics Education
ANA S. ILTIS A1
A1 Saint Louis University, St. Louis, Missouri, USA
Abstract:
There are competing accounts of the birth of bioethics. Despite the differences among them, these accounts share the claim that bioethics was not born in a single disciplinary home or in a single social space, but in numerous, including hospitals, doctors' offices, research laboratories, courtrooms, medical schools, churches and synagogues, and philosophy classrooms. This essay considers the interdisciplinarity of bioethics and the contribution of new disciplines to bioethics. It also explores the implications of interdisciplinarity for bioethics education. As bioethics develops, it will be helpful to identify essential elements in the education of bioethicists and to distinguish between members of other disciplines who make important contributions to bioethics and bioethicists.
The Right to Die as the Triumph of Autonomy
TOM L. BEAUCHAMP A1
A1 Georgetown University, Washington, DC, USA
On Evoking Clinical Meaning1
RICHARD M. ZANER A1
A1 Vanderbilt University Medical Center, Nashville, Tennessee, USA
Abstract:
It was in the course of one particular clinical encounter that I came to realize the power of narrative, especially for expressing clinically presented ethical matters. In Husserlian terms, the mode of evidence proper to the unique and the singular is the very indirection that is the genius of story-telling. Moreover, the clinical consultant is unavoidably changed by his or her clinical involvement. The individuals whose situation is at issue have their own stories that need telling. Clinical ethics is in this sense a way of helping patients, families, and, yes, health providers to discover and give voice to those stories. In this way, clinical ethics is an evoking of meaning. Kierkegaard understood this well: Indirect communication is the language for the unique and the otherwise inexpressible.
Life is Short, Medicine is Long”: Reflections on a Bioethical Insight
ALBERT R. JONSEN A1
A1 California Pacific Medical Center, San Francisco, California, USA
Abstract:
The famous first aphorism of Hippocrates, “Life is short, the art is long” was long considered a perfect summary of medical ethics. Modern physicians find the words impossible to understand. But it can be interpreted as a fundamental insight into the ethical problems of modern medicine. The technology of modern scientific medicine can sustain life, even when life is losing its vitality. How should decisions be made about the use of technology and by whom? This is the incessant question of modern medical ethics.
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