Writing about phenomenology and medicine some years ago, I emphasized a point that I believed to be fundamental to understanding medicine. “Medicine’s central theme is clear: the clinical event governs” (Zaner 1997, p. 446).

I came to the same view in other writings, (Zaner 1994a, b, c, 2005) where I urged that not only ethical issues but more broadly phenomenological matters closely related to the clinical event are similarly fundamental to understanding medicine: the interpretation of symptoms, (Zaner 1988/2002) clinical judgment, (Zaner 1994a, b, c) the social structure of clinical encounters, (Zaner 2006) the multiple forms of responsibility and uncertainty, (Zaner 1996) and others. The focus on the clinical event suggests that the core phenomenological theme is the health care professional-patient relationship, and thus the central epistemological theme of medicine follows directly from its practical, clinical orientation: medical knowledge is ordained to the goal of helping afflicted and compromised persons; such knowledge, in this sense, has its root in practice. In this, we come across another dimension of the pragmatic character of my study.

A survey of the main issues in both public and professional settings since the early 1960s, suggests that almost every one of them takes its point from its relation to, or implications from, that special relationship between professional and patient: the clinical encounter. This is as true for solid organ transplantation as it is for in utero surgery, as true for prevention as it is for prognosis, as true for dying persons as it is for embryos. It is also true even for the more exotic topics occasioned by the continuous outpouring of procedures, drugs and equipment from medicine’s expanding bounty, whether diagnostic or therapeutic.

Hans Jonas had persuasively argued that “practical use is no accident but is integral to [modern science]… science is technological by is very nature” (Jonas 1966). The very same characteristic seems true of medicine as well—not only in view of its acceptance of this science as the major feature of medicine, but even more, as suggested, its central commitment to providing understanding (in the form of a diagnosis) and treatment for individual persons.

It is in any event clear that the primary issues of interest to philosophers and ethicists more generally have been the practical, ethical, and epistemological facets of medicine: clinical judgment in diagnoses (what is wrong?), therapeutics (what can be done about it?), and decision-making (what should be done?). In the same way, there has been serious interest in determining the nature of clinical judgment, (Pellegrino 1979a, b) the structure of clinical encounters, (Cassell 1979/1985, 1985) and the illness experience (Frank 2001, p. 241; Kleinman 1988).

Although this focus on the clinical event brought out a number of serious moral issues, for the last five or six decades of the involvement of philosophers and others in the humanities in health care, the questions that captivated both public attention and professional study had to do mainly with what may be called issues at the end of life. Popular and professional publications alike, as well as government agencies, became absorbed with such questions as aid in dying (by physicians or others), euthanasia, brain death and, along with these, advanced directives (living wills, durable power of attorney for health care). When the Nancy Cruzan case reached the U. S. Supreme Court in 1990,¹ not only did the right to sign an advance directive become securely established, but the case motivated Congress to pass, in 1991, a law requiring all health care institutions duly to inform all incoming patients and their significant others of this right to refuse treatments when terminally ill. The only remaining questions were about public and professional education—which proved substantial indeed.

Other difficult, even harsh, questions had, of course, already occasioned heated disputes: abortion, treatment for severely premature babies, ensuring informed consent and privacy, allocation of scarce resources, and still others. Some became part of our public iconography: a liver transplant for the 3-year-old child living in poverty; choosing who should get renal dialysis when there are not enough machines; what to do about exotic, novel alternative forms of pregnancy (surrogate mothers, artificial insemination, in vitro fertilization and embryo transfer, stem cell research, human cloning, etc.); whether family planning should include sex pre-determination; and many others. Dramatic, highly sophisticated types of diagnostic imaging technology brought on still more issues: ultrasound (US), computer-assisted tomography (CAT), positron emission tomography (PET), magnetic resonance imaging (MRI), and so on. Others arrived in the wake of breathtaking forms of treatment: multi-drug chemotherapy, cellular transfusion, mind-altering drugs, and the like. Still others came on the heels of sensational forms of surgical intervention: intrauterine surgery, solid organ transplantation, neural cell implantation, stem cell infusion, etc. And some came about simply because the health care system came to the point of near-collapse from mal-distribution of resources; or from too many non- and under-insured people; or other sources stemming from the broader society’s inability to confront and resolve grievous social problems such as the increasing numbers of children living in poverty, ghettos, damage from violent weather patterns, and wide-spread hunger. Perhaps the most compelling irony of the latter half of the twentieth century in the United States is the existence of a society whose wealth and power exceeded those of other nations yet could not properly feed, clothe, house, educate or employ many of its own citizens—and thus recently wound up far below other nations in such matters as infant mortality, care for difficult pregnancies and others.

Beyond these concerns, questions of social justice (equality, diversity, distribution, violence, disability, etc.) continue to plague most nations in the new millennium. Nevertheless, a number of other issues have become prominent and, doubtless, will complicate social and political discourse even more. Whether questions of social justice are addressed in fruitful ways or not, these other, already conspicuous matters seem especially compelling.

Unlike the preoccupying questions of the past five decades (withdrawal and withholding life supports, do-not-resuscitate orders, living wills, death and dying, right to die, aid-in-dying, and other end of life issues), those that have already begun to enthrall and even obsess so many people and institutions concern the opposite end of the life-spectrum: life before birth—from the impact of molecular biology and genetics on medical theory and clinical practice, to questions of the legitimate use of genetic information, cellular manipulations, embryo research, to pre-natal diagnosis and fetal interventions more broadly.²

The implications especially of the genome project have clearly stretched our moral imagination well beyond traditional limits. If a central, governing thought in the late twentieth century was the “what-is-to-come” (the future: Zukunft)—that is, death, believed to be determinative for the being and life of humans—the twenty-first century is already noticeably turning the other direction in search of religious, moral and ontological guidance. Birth, not death, seems definitive; genetics, not geriatrics, is seen as the basic medical and biomedical discipline; not end-of-life, but life-before-birth has become focal. With that critical shift, questions invariably emerge about the relationships between medicine’s practices (clinical encounters) and its pervasive commitment to being a science, or dependent on the biomedical sciences. Indeed, with the latter’s full emergence since the end of World War II, the sense of ‘clinical’ has begun to fade, although by no means has it disappeared; better expressed, ‘clinical’ has increasingly become transformed, now being more and more regarded as a matter of ‘science,’ as in the emergence of so-called ‘evidence-based’ medicine (See Henry et al. 2007).

If we would thus seek to explicate the phenomenon of medicine phenomenologically, especially in its more recent transformation through innovative developments in biomedical science, we have no choice but to attempt precisely what Edmund Husserl demanded in the first pages of his great work, Cartesian Meditations. There, he presented the required project bluntly: asking how the idea of science with its goals and methods can be “uncovered and apprehended,” he answered unequivocally that “there is nothing to keep us from ‘immersing ourselves’ in the scientific striving and doing that pertain to them.” That is, we can and must ask ourselves in the most rigorous manner what it is that the ‘scientist’ is truly attempting to do in that intellectual labor called ‘science;’ what are scientists after and how will they know when they have arrived? We must do this rigorous kind of reflective thinking, Husserl insists, “in order to see clearly and distinctly what is really being aimed at” (Husserl 1960, p. 9). Precisely this act must be attempted if we would similarly disclose the inner sense of medicine and its methods. And this kind of work is essential, I believe, to the work of clinical ethics and, more broadly, the medical humanities.

Following that effort is what leads to the disclosure of the phenomena noted above: the sense of ‘symptoms’ and the variety of possible ‘interpretations,’ the explication of diagnosis and clinical judgment as well as the illness experience, the modes of givenness specific to the moral dimensions of clinical encounters, and the place of uncertainty and error, as well as the phenomena of trust and responsibility (see Chap. 4), and still others. Explicating these, furthermore, requires careful attention to their temporality structures, as well as the subjective (noetic) and objective (noematic) aspects, the ego dimensions and belief character appertaining to the way in which these are experienced in times of illness and of healing. For instance, not only is illness concretely experienced as a disruption in the flow of daily life, but at the same time it discloses an often unnoticed dimension of gratitude and the promise of being healed and returning to normal life—that helps make prominent, too, the multiple forms of inner time awareness specific to illness: the struggle with ‘feeling bad’ through the temporal modes of ‘waiting to heal’ or for scars to form.

Now that fundamental changes are occurring at the very heart of the new union of medicine with biomedical science, however, it is imperative to undertake with renewed energy those very efforts again: to immerse ourselves in the newly emerging currents of medicine that are only now becoming clear enough to permit that immersion and explication. That such phenomenological explication from within medicine itself must take nothing for granted goes, hopefully, without saying. That the course of the analysis must demand clear evidence for each judgment about each new prominence as it appears is also obviously true. What is occurring, it must be emphasized, is so fundamental—and is happening with such amazing speed within medicine, arguably among the most significant of human endeavors—that extraordinary caution and discipline must take precedence. As Hans Jonas once urged in a related context, “Since no less than the very nature and image of man are at issue, prudence becomes itself our first ethical duty, and hypothetical reasoning our first responsibility” (Jonas 1984, p. 141). This statement I would qualify only modestly, emphasizing not so much “prudence,” which stems ultimately from Aristotle and has its place in this work, but accentuating instead another Greek notion key to the history of medicine and philosophy: self-restraint (sophrōsyne) as fundamental to clinical and, as will hopefully become clear as we proceed, phenomenological responsibility.

Matters are made all the more complicated by the fact, as I see it, that not very much about the discipline of ethics in medicine is well understood—by the general public, medical personnel, well-meaning academic colleagues, and even by some of the medical humanities’ more dedicated practitioners. This is even truer when the new developments in the world of medicine and biomedical research are taken into consideration—as they must be, in order to make sense of the ethical issues these novel developments bring about. Indeed, the more serious are the latter, the more are they the occasion for many of the persistent questions, the intractable conflicts, and unending disputes integral to the new genetics and biomedicine.

Put this over against the amazing growth and popularity of the field of bioethics—from meager beginnings in the early 1960s to the world-wide status it enjoyed only a decade later—and we face one of the most intriguing questions about this field: What can account for this striking popularity of an endeavor still so poorly explained, especially in what may seem such central and important questions about human life and death? Equally perplexing, it remains unclear just what the at times raucous concern is all about (Zaner 2003, 2013).³ And that, to be candid, is complicated by the further fact, as I’ll point out later on, that few of its practitioners and advocates agree on what ‘it’ really is! Bioethics, like ethics more broadly, remains seriously problematic (MacIntyre 1981; Toulmin 1982).

Even after I had been involved for more than a decade, it was very common to face the question—it seemed at the time more accusation than query—“what the hell is that philosopher doing in our hospital?” (Zaner 1994a, b, c). Or, as I have often had to wonder: “Is ‘ethicist’ anything to call a philosopher?”—a question that seemed imperative to state openly. This, too, appeared to be more an ill-mannered indictment from colleagues in the humanities than a question seeking serious response.

I must also acknowledge that I am fully cognizant that there are some who apparently have a firmer grip than I on the what this field is all about; nor do they seem nearly as puzzled as I. Robert Veatch, for one, published a book a long time ago with what still seems to me an audacious title, A Theory of Medical Ethics, (Veatch 1981) an imprudent undertaking, I have thought, simply because, as subsequent events have made plain, it was far too early for anyone to have the necessary understanding of everything about this field, even whether this was in any sense a ‘field’. Tom Beauchamp and James Childress put out another, very popular, if also, as I think, premature book, Principles of Medical Ethics (Beauchamp and Childress 1983/2012). A bit more modestly, H. Tristram Englehardt, Jr. waited for a few years before publishing his own version of such grand and unreserved visions; (Englehardt 1986) and there are others, (Katz 1984; Pellegrino and Thomasma 1987) no one of which could be ‘the correct’ version, as each most often disagreed more or less seriously with the others—a phenomenon not in the least uncommon in our times, as another commentator noted early on as well.

Nor should I forget to mention the vast number of conferences, professional meetings, symposia and the like, along with their resulting published collections of essays (to which, I confess, I have also contributed now and then), not to mention the many other anthologies and book series, which appeared over this span of time, and continue to appear. Bioethics, or the medical humanities, has been a prolific growth industry, not only in the United States, but worldwide. Not to press the point too much, most of this vast literature exhibits a marvelous confidence about the field, its so-called main problems, methods, and even what theories or principles are thought to be appropriate for dealing with those issues.

I confess to having been as perplexed by this striking production as I have been at its popularity. What’s more, I still remain somewhat at a loss; at times I am convinced that I have neither the wits nor the patience to appreciate, or even keep up with, all these books, essays, articles, speeches, conferences, presentations, and the rest, despite the fact that I have myself been seriously involved since 1971, have participated in quite a few of these goings-on, and before and after my retirement in 2002 taught undergraduate, graduate, medical, nursing, law, religious studies, and other courses and seminars for many years—all of them at least related to this arena of themes and questions. I have even sponsored a few conferences, special lectures and the like; I have not, in fine, shown exactly awe-inspiring modesty in my own record of publications and involvements. Not to mention my palpable audacity in initially accepting and then remaining in a very prestigious position at Vanderbilt University Medical Center from 1981 until my retirement in 2002.

Given all this, it must seem odd to others, as it surely does to me, that I would say what I just said about being at times at sea, at others bemused, about this still burgeoning arena.

As I’ve said before, too, I would like very much to help any readers I might have to be just as perplexed as I, for I find myself still astonished at how so many could possibly be so confident about what the field is all about, much less how one actually goes about doing whatever it is that one does as one of its practitioners—I think in particular of becoming seriously involved, as a philosopher, in clinical work. I need to explain why that is, why this venture (and, for some, adventure) remains still so strange, albeit deeply fascinating. It will shortly become clear that my concern centers in particular on what has become known as ‘clinical ethics,’ although only a very few of its practitioners are actually involved in clinical encounters in the way I and most of my students and colleagues at Vanderbilt were for many years.

Wonder therefore seems to me the proper mood for anyone who chances to look into these matters. But first, along with wonder, a bit of history may be helpful.

What was behind the initial idea, over 40 years ago, of asking philosophers and others⁴ in the so-called humanities to come into medical centers (at first, only medical and, a bit later, nursing schools and, much later, into hospitals) in order to participate in medical education and, in some instances, even in clinical situations?

To understand this question is to understand as well a great deal about the subsequent development of bio- (or bio-medical) ethics. It seemed to physicians and medical educators fairly straightforward: considerable help on so-called values and cultural matters was deemed important and it was hoped that the help would come from persons trained in philosophy, ethics in particular.

With the astonishing new technologies and medical knowledge already at hand in the early 1960s, and even more remarkable prospects on the immediate horizon, (Taylor 1968) physicians had good reason to be troubled (see Chap. 9).⁵ Furthermore, new diagnostic tools and techniques promised more accurate, and ever earlier, detection of diseases and anomalies hitherto not available of both present and possible damage—a trend that has continued unabated. Coupled with these were emerging new surgical techniques and instrumentalities, pharmacological interventions, (Farber and Wilson 1961) new types of anesthesia, and all manner of new treatments for conditions not previously treatable as well as for those previously not very effectively treated. Resuscitative techniques along with associated technologies and new medical understanding showed that different body-systems function and cease to function in different ways and paces, and that some could be artificially re-started and supported, thereby allowing needed time for medications to work properly, or healing to take place.

These raised quite awesome, and in some cases wholly new, issues, and gave to many perennial issues a new force and content Gorovitz et al. (1976). Not only was it increasingly possible to maintain patients who only a few years before would have died, often very painfully (as with end-stage renal disease), but also the horizons of life’s beginnings and endings were becoming ever more well understood, and though not widely realized at the time they were also being perforce re-defined (Eccles 1970; Penfield 1975; Burnett 1978).

Not that there were no problems; to the contrary. Some perceptive physicians and researchers were already agonizing over the value and moral issues implicit to these developments (Beecher 1959a, b). Recognizing their lack of the training and knowledge to grapple with such issues, they quite naturally turned to others whose credentials at least seemed to bespeak competence, if not expertise (Liddle 1967). Many of these physicians, too, were haunted by the horrors of the Nazi concentration camps, especially the many medical experiments carried on in them, and seemed anxious to realize in practice what was asserted in the Medical Trials at Nuremberg (Howard-Jones 1982; Annas and Grodin 1982; Curran 1982) and by the United Nations Charter, affirming the existence of inalienable human rights, especially for those who are sick, maimed, and vulnerable.⁶

The lingo of the times is suggestive: physicians and others in the so-called health care system expressed (and continue to express) serious dismay over, even while precious little energy has been expended to rectify perceived flaws in, the bureaucratic organization of the modern health science centers and health care more generally, as well as the way new technologies tend, as was often said, “to dehumanize” people. Most health care professionals exhibited genuine concern over the increasing specialization in health care after World War II, which seemed to ‘fragment’ the ‘whole person,’ promoting more focus on diseases and organ systems than on people (even while every one of them recognizes the remarkable advances achieved precisely by such specialization) (Pellegrino 1979a, b). While many tried earnestly to stay abreast of the ever-growing cornucopia of new developments, substances, sub-specialties and the like, this often meant that physicians were obliged to be and remain technically proficient, and thus that they did not always have the time or inclination to be alert to moral issues, religious values, sensitive caring and other such concerns.

The ‘new physician,’ avidly discussed as the major part of the agenda for medicine in the 1970s and beyond, it was thought, needed to be ‘humanized.’ But, as has been pointed out numerous times, it was not in the least clear what this would require nor, in the end, why it was thought to be so important. Such ‘humanists,’ after all, were hardly the talk of the commons, nor had they made notable or recognized contributions to the common weal, much less to health care. Moreover, to use phrases such as ‘medical humanities’ seemed only to confuse and bewilder.

One practicing physician, Samuel Martin, lamented publicly in 1972 that it was not at all clear about who was responsible for training that new physician. For many educators, medicine needed to call on humanists—so-called ‘experts in human values’—and a new name was quickly concocted for the new breed: ethicist, an occupation as unlikely⁷ as the name was awkwardly sibilant. Martin and others were dubious about the entire venture. In poignant, if inelegant terms, Martin worried whether so-called humanists “are trying to outscience our scientists. At some time we must deal not only with what makes a humanist, but also with how we can facilitate the transmission of his art” (Martin 1972).

Which could hardly be more to the point: what indeed “makes a humanist,” how transmit that “art,” and what, in the end, are the “humanities” actually all about? To be sure, Martin perhaps should have worried not only about those trying to “outscience” the scientists, but just as much about those at work cultivating ever sharper and deeper divisions between what C. P. Snow had earlier termed the two cultures. In any event, neither scientists nor physicians, ever more reliant on the biomedical sciences, nor the humanist pretenders to the crown of knowledge were likely to worry about Martin’s appeal. Indeed, an appeal to supposed experts in values was not only quite implausible at the time, but for the most part highly improbable given that most so-called humanists were rarely interested in, much less competent to make recommendations about, such matters as were posed daily in the process of creating the new medicine and its supposed new healers: what is death and how ought a person’s last days be managed, much less how ought such persons be cared for? For that matter, is a person whose breathing occurs solely because of a ventilator’s mournful chug still alive or in some halfway condition never seen before? When does a fetus become a person? Is a comatose individual still a person? The questions only proliferated and, too often, left ‘humanists’ quite as bewildered as anyone else. Help, in short, seemed ever more distant and unlikely as regards the intense issues faced by health care professionals on the wards, in the nursing homes, or other places where our society tends to house the sick, maim, and elderly.

At first, in the 1960s, only a few, rather venturesome people responded in any way to the appeal in the early 1970s from physicians such as Dr. Martin. Others began to join in within a few years, however.⁸ Those who did respond found the world of clinical medicine decidedly eerie, if also compelling. The existential cut of Martin’s jibe about what makes a humanist—more to the point, what is a philosopher, what is that art, and how can it be transmitted?—was a keenly felt, daily reality. Separated from comfortable home base in a Department of Philosophy, truth be told, we were utter naifs in this strange new world, literal aliens listening in on a esoteric Babel of technical noise and abbreviated, highly technical language.

When in deference to our lack of understanding about how the noise might be (it wasn’t always) translated into English (“What does ‘PTA’ mean?” “Oh, that’s ‘prior to admission’!”), our ignorance only became all the more plainly pathetic, as we were sometimes stunned into silence (“PDA?” “Oh, that’s ‘patent ductus arteriosis,’ which if we can’t do anything about it, means certain death for this baby!”). When we were nonetheless encouraged to talk or offer some opinion (“…whether a child born with developing hydrocephalus secondary to myelomeningocele should have a shunt instituted…”), we found ourselves babbling in an equally alien tongue about moral agents, persons and potential persons who could in all likelihood never become persons, but who yet perhaps should, that is, might be treated as if they were persons or as if they still had or might be said to now possess some kind of moral status… . Not particularly helpful in the press of the circumstances which occasioned the request in the first place.

Many philosophers recoiled in shock and dismay: this simply is no place for a philosopher: our education, training and disposition includes nothing that could in any way prepare us for rendering such judgments, much less making definitive moral declarations on the spur of such critical care moments. Indeed, even if one could, per impossible, begin to untangle some of the densely packed moral themes and issues presented in what were termed ‘clinical cases,’ we could only lament that we had neither the time to do so properly nor the appropriately prepared audience to listen to and hear the discourse, much less participate in subsequent indispensable philosophical discussion.

Nor did gradual familiarity with clinical settings, specific types of conditions, situations and patients, technical jargon, exotic technologies, and the rest help to ease the razor-sharp sense many of us felt: that the philosopher remains an interloper, a stranger in a strange land, a theorist in the land of therapists. The philosopher’s stock-in-trade, I was reminded more than once (by colleagues as much as by physicians), is principles and norms (remember Hume, Mill, or Kant!), and neither therapy nor guidance counseling. The philosopher’s business is foundations, ideas, concepts, and logic, not, as often seemed to be the real agenda, sensitizing health professionals to value phenomena, nor engaging in acts of persuasion to try and convince them to act more humanely. The mind is to be studied, not expanded, by our labors! Even so, the movement got quickly underway, and already showed remarkable growth during the 1970s and early 1980s (Pellegrino and McElhiney 1981).⁹

What rapidly developed, especially during the latter period, is readily understandable, even if, as I’ll suggest, somewhat dubious. The new arena of concerns (and, truth be told, of employment¹⁰) began to be viewed simply as a different place to conduct the usual sort of business of philosophers: writing scholarly tracts, talking with each other, and teaching courses (with appropriate modifications to accommodate the intensely practice, problem-oriented, and professionally motivated students of medicine).

Not only did this turn to accustomed pedagogy tend to dull the knife-edged issues occasioned by clinical situations; it was also widely urged that such encounters were quite unnecessary and possibly even obstacles to the conduct of sound philosophy. Thus, many agreed with the notions that the philosopher is simply out of place in clinical settings, and that physicians are seriously misled if they look to philosophers for solutions to the questions of human conduct and decision faced by physicians (only rarely were patients and families, much less nurses or other health professionals mentioned in these contexts). While medicine was seen as presenting fascinating and even demanding social and moral issues, it was generally assumed that philosophers could properly address them solely in philosophy’s usual ways (Shaffer 1975).

Ethics, for all its traditional emphasis on practical reason, was typically regarded by almost everyone as a theoretical, not a practical, much less therapeutic discipline. Medicine was thus quickly, and with noticeable relief, interpreted as merely one among many of the ‘fields’ to which philosophy was to be ‘applied,’ through its familiar advocacy of one or another set of ethical principles, analysis, and argumentation. Not surprisingly, biomedical ethics swiftly became known as ‘applied ethics’—not unlike the engineer who ‘applies,’ say, the rules and notions of structural engineering and, more basically, of physics—a view that has to my knowledge rarely been seriously questioned. The ethical analyst’s task was to study such knotty words as ‘good,’ ‘evil,’ ‘right,’ ‘wrong,’ ‘decision,’ ‘responsibility,’ ‘action,’ and suchlike; nothing more. In a rare moment of candor, R. M. Hare openly declared:

Philosophy is a training in the study of such tricky words and their logical properties, in order to establish canons of valid argument or reasoning, and so enable people who have mastered it to avoid errors in reasoning, and so answer their moral questioning with their eyes open. It is my belief that, once the issues are thoroughly clarified in this way, the problems will not seem so perplexing as they did at first… . (Hare 1977)

Only gold members can continue reading. Log In or Register to continue

Share this:

• Click to share on Twitter (Opens in new window)
• Click to share on Facebook (Opens in new window)

Related

Related posts:

Openings into Clinical Ethics Introduction Voices and Time Responsibility in Clinical Ethics Consultation At the Beginning and End of Life: A Meditation on the Subtle Hoax of Matter Visions and Re-visions: Life and the Accident of Birth

Stay updated, free articles. Join our Telegram channel

Join