I should note at the outset that an early version of this book was published several years ago in Mandarin.¹ The reason for this is that a good friend, Chen-yun Tsai, a Professor of Philosophy at the National Chengchi University in Taipei, asked me if I would write a book that would lay out the principal topics and themes of my several decades of work in medical humanities and clinical ethics. He was also concerned that at that time, only two of my books of clinical ethics narratives had been published over there, and he was concerned that persons in that still-developing field in Taiwan should know of my philosophical views on those themes. His invitation came at the conclusion of a seven-lecture tour of universities in Taiwan in 2004, and it was with that prominently in mind that I agreed with Professor Tsai’s suggestion, but only after he had agreed to undertake the book’s translation into complex Chinese Mandarin, used among professionals in colleges and universities. Working with him and the editor of his university’s Press, Chu-po Chen, the book was in due course completed and the translation begun. But given the complexities of the language and those of translation, especially from my own not always Standard English usages, this took several years to complete.

When I decided to try and publish the book in English, however, it was clear to me that it had to be thoroughly rewritten. I am hopeful that the result, presented here, will be found to be helpful to readers.

I had already come to appreciate, as I noted in one of my early books, the act of writing and publishing a book seems an audacious act. That’s true, in its way; but how much more audacious, then, is writing the following book, one which takes up the major parts of a lifetime of writing and attempts to put it all together in a single place? Indeed. Yet, that is what I’ve done here, and what I intended to do some years ago when I was approached by Professor Tsai to write the book focused on my most developed work about medicine and health care. When I considered having it published here, one reader stated that it did little more than repeat what I’d been writing over the last decade of my active career. That, along with my conviction that much had to be done to bring the study up to more appropriate standards led me to engage in this extensive analysis.

That criticism I now regard as simply wrong-headed; there is much that is quite new here. More than that, this is the only place where these ideas can be found connected together, where they are able to knock up against as well as complement each other. So, I do not hesitate at all at this time in my life, to try and share these ideas with others, to give them a kind of public presence, available to one and all. So, I am happy to engage the challenge of yet another book, exploring themes that have long a close part of my life as a philosopher making my way in the world of clinical and research medicine.

For a number of years² most of my efforts were focused, in Husserl’s apt terms (Husserl 1960, p. 7), on immersing myself within the world of clinical practice and biomedical research. My aim was straightforward: to understand the clinical encounter,³ from within, as an actual participant with appertaining accountabilities and responsibilities as stringent as those that any other clinician must assume.

Before coming to Vanderbilt University Medical Center in 1981, I had already become fascinated with the complex phenomenon of clinical practice, but did not yet have the occasion to become an actual participant in clinical encounters. Like most others in this then-burgeoning field—bioethics or the medical humanities—I had been content to observe clinical situations from time to time, to think about one or another so-called ‘problem’ as it was presented to me, mostly by physicians, or which otherwise caught my interest, sharing my reflections mainly with colleagues in philosophy and others of the humanities and social sciences. The idea that a philosopher might actually have a legitimate place in clinical encounters, discussions and decisions had not occurred to me in any serious way until conversations with several physician friends posed the challenge—and colleagues at Vanderbilt presented the opportunity.

What it’s really like to be involved as an actual participant in these therapeutic settings—especially to be and to be held accountable for whatever is said and done—only gradually became clear (Zaner 1994, 1995). So impressive were these encounters that I eventually decided to share what I could of the experience in several collections of narratives stemming from my clinical experiences (Zaner 1993, 2004). In the present study, however, my aim is quite different: while presenting the core of what I have learned in my more than three decades in this field, I hope as well to engage in a number of philosophical reflections within and about the world of medicine (which could well eventually lead into a philosophy of, and philosophical concerns within, clinical medicine and biomedical research).

With the exception of Scott Buchanan’s seminal effort (Buchanan 1938/1991), philosophers traditionally paid surprisingly little attention to the phenomenon of medicine—neither to theoretical issues (some of which Buchanan addressed), nor to the nature of clinical practice (which he pretty much ignored), nor to issues ingredient to medical and biomedical research (which lay largely in the future). In any case, and unfortunately, his work went largely unnoticed when it was first published and has even remained oddly obscure since its re-issue in 1991, thanks to Edmund D. Pellegrino’s urging. Since the late 1960s, to be sure, an increasing number of philosophers have addressed some of the issues posed by medicine (although most have been restricted to ethics). Prior to Buchanan’s study, philosophy and medicine have with only rare exceptions been out of touch with one another—exceptions include Galen’s seminal attempt in the second century to synthesize the insights of Plato and Aristotle with Hippocratic medicine, and Descartes’ more than casual encounters with the medicine of his time (Zaner 1982, 1988/2002).

As becomes quite evident from even a modest reading in the history of medicine, Descartes’ involvements with medicine were exceptional (Lindeboom 1978). Discovering his early and enduring fascination with anatomy, physiology, and clinical therapeutics, has made a lasting impression on my reading of the history of philosophy, where one finds little if any mention of his concerns.

Why this reciprocal ignorance should have occurred, I cannot rightly say. Working within clinical and research medicine has in any case convinced me that it is intolerable, and that both medicine and philosophy are much the worse for it. There are few philosophical themes or problems whose pursuit would not greatly benefit from a serious study of medicine—especially the philosophy of science, philosophical anthropology, and epistemology, not only ethics. Similarly, most clinical or research settings within medicine would clearly benefit enormously from even modest understanding of philosophical, not to mention ethical, analysis and sensitivity.

For instance, from its inception, as several have noted, (Edelstein 1967; Leder 1992) medicine’s history is rich in examples of rigorously developed funds of empirical knowledge—including a variety of methods, rules, checks, tests, theories, and other recognized features of empirical scientific endeavors, careful attention to which would be revealing and rewarding. Certainly for me, medicine has provided a wonderfully complex and fertile terrain to pursue many fundamental questions about human life: self, person, body and embodiment, sexuality, interpersonal and social relations, perception and emotion, to mention but several.⁴

Ethics, of course, has captured the attention of most people alert to the involvement in health care of persons concerned with values, especially with those embedded in policy questions. Thanks to a number of developments in medicine and research since the 1960s, when ethical issues began to engage more and more philosophers and theologians, ethics has entered what seems to be a veritable renaissance. Stephen Toulmin perceptively noted some years ago that it may well be that medicine, in fact, “saved the life of ethics.” (Toulmin 1982). I am fully convinced that the same could be said of many other philosophical issues, were other aspects of medical thinking and practice to attract attention to the same degree as ethics, for they offer a remarkably rich tapestry of phenomena for the philosopher, in particular for those of us who work within the philosophical discipline of phenomenology.

At the same time, physicians, now and for the foreseeable future, have begun to realize the serious need for philosophical reflection within medicine led by the efforts of Dr. Pellegrino (1970, 1974, 1979, 1983) and Dr. Pellegrino and Thomasma (1981), not only regarding the recognized ethical facets of medicine but more especially the nature of medicine itself. Other physicians, especially Eric Cassell (1976, 1984, 1991, 1997), have also for some years been grappling with these more bracing issues, resulting in a growing body of literature beginning to redress this need (Kleinman 1988; White 1988; Hunter 1991; Leder 1990; Bishop and Scudder 1990). It is clear from these writings, and from the wider medical literature, that there are numerous systematic and historical issues far beyond and in a sense even more fundamental than the more well-known involvement with ethics—issues which invite, indeed require, philosophical reflection, and that have by now received much-needed attention.

These wider issues have been at the center of my concerns from the day I first started in this field—thanks to Pellegrino’s very persuasive invitation that I become ‘involved,’ in the common terms of the times, in 1971, as the first Director of the Division of Social Sciences and Humanities in Medicine at the new medical center of the State University of New York at Stony Brook. I quickly learned, however, that writing about what I eventually came to term the clinical encounter would have to be postponed in order to acquire experience in and understanding of clinical work. No sooner would some insight occur than, typically, it would have to be quickly revised. Little did I realize, however, that the postponement would last well over 15 years after that first, very tentative beginning.

Gradually, some ideas about clinical encounters and medicine began to be evident—thanks to what I came to call the “practical distantiation” or “circumstantial understanding” that gradually seemed to me characteristic of the philosopher’s clinical involvement (Zaner 1988/2002, pp. 40, 242–48, 267–82; Charon 2006)—resulting in a number of preliminary attempts over the past several decades to articulate and probe various aspects of this complex phenomenon (Zaner 1983, 1984). Some of these ideas were worked into a later and more sustained analysis. That study, I must add, was never intended to be more than an initial exploration, and left many themes merely suggested, some poorly addressed, and others even completely unexplored. Since then, I have been self-consciously working to redress its flaws, both clinical and philosophical, and especially to begin the arduous but quite essential process of phenomenological explication (Zaner 1990, 1995, 2004).

For reasons as puzzling to me as it might for others, my essays in this field (like my earlier philosophical ones) have only rarely been published in the same place. Often as not, they appeared in publications that rarely attract wide notice (for instance, in collections of essays on special topics), especially from colleagues in philosophy. There thus seemed good reason to put these many reflections together as a sustained study, even if only some of the many topics can be addressed here.

Hopefully, this study will be of some interest to all my colleagues; more importantly, I hope that the problems analyzed will provoke others as well to turn to them. There are few enterprises in our society for which careful study has become so exigent as medicine and health care more generally. My aim in publishing these explorations is that it will contribute to this pressing need.

More broadly, and without undue pretension, I intend this study to advance the vision Pellegrino first enunciated years ago—of a “new Paideia” to which philosophy and medicine must in our times be the principal contributors, just as they jointly produced that stunning and embracing vision in ancient Greece.

At the beginning of any disciplined study of the activities of clinical ethics consultation, concerns about methodology inevitably arise. This is all the more important as I became immersed as a philosopher in the sphere of clinical work. One concept underlying the practice of clinical ethics as I have conceived it is the idea that moral issues cannot be sufficiently understood in abstraction from the situations in which these issues arise in the first place, as will be probed further in Chap. 6. What is important, in practice, is to pay close attention to the actual circumstances, the ways in which what is perceived as a “problem” has come about, and how the specific circumstances are understood by those whose situation it is. Otherwise, precisely those features of the situation, which both present problems and suggest possible resolutions, could well be missed (Chap. 3).

Another component of the method has its basis in an agreement with Alasdair MacIntyre on the relation of “virtue” and “practice.” In his words, “A virtue is an acquired human quality the possession and exercise of which tends to enable us to achieve those goods which are internal to practices and the lack of which effectively prevents us from achieving any such goods” (MacIntyre 1981). This suggests that, to engage in practical reasoning about moral issues in clinical situations, is in the first instance to subject one’s own attitudes, choices, preferences, and tastes to the standards that currently, albeit only partially, define the practice. One can attain that understanding only by actually engaging in and subsequent reflection on the practice itself. Expressed a bit differently, self-reflection is ingredient to these reflections on medicine.