There’s an essay by Diego Gracia called “Palliative Care and the Historical Background” that I frequently use in classes about Care ethics, and there’s a passage in it that always gets a fascinating reaction from students.  In this passage, Gracia claims that

the true goal of medicine has always been curing, rather than taking care of the patient. Caring has never been the goal of medicine.

In fact, in the context of palliative care, he takes this one step further:

Thus, if the type of care specific to medicine is curing, then palliative care has nothing to do with medicine…

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Reproduced from the PEA Soup blog:

We are very pleased to announce a new partnership between PEA Soup and the distinguished journal, Ethics.  In addition to our regular postings, PEA Soup’s editors will select one article from each issue of Ethics to be the focus of a featured discussion on our blog.  Ethics, in turn, will make an on-line copy of the featured article available to our readers for free (for three months).  At the time of the article’s publication, we will post a link to the open-access copy, and then a week later an open discussion of it will be introduced with a critical précis by an invited discussant.

We expect that this partnership will give rise to a series of lively and productive conversations.  Stay tuned for details on the first featured article, which will be selected from the next issue of Ethics (Volume 120, Number 1).

Special thanks to everyone at Ethics, especially its Editor, Henry S. Richardson, and Managing Editor, Catherine Galko Campbell, for their help and participation.

Nice idea!

This looks like it could be interesting…

Department of Philosophy, University of Bristol

This is an informal workshop on topics in the philosophy of medicine.

Everyone is welcome.

•09.45–11.00 Kevin Brosnan (Cambridge) “Does nothing in medicine make sense except in light of evolution?”
•11.15–12.30 Jeremy Howick (UCL) “Defining a role for mechanistic reasoning in EBM”
•13.30–14.45 Havi Carel (UWE) “Phenomenology and its application in clinical medicine”
•15.00–16.15 Alex Broadbent (Cambridge) “Inferring causation in epidemiology: mechanisms, black boxes, and contrasts”

The workshop will take place in the Common Room, Ground Floor, Department of Philosophy, 9 Woodland Road.

There is no need to register—it will be fine if you just turn up on the day. (If you do know that you are coming, it may be helpful to let us know, to ensure that we have a large enough room.) If you have any questions, please contact Alexander.Bird {AT} bristol.ac.uk.

At least the Trolley Problem has been solved.  (Hat-tip to Brian Leiter for the pointer.)

I’m going a bit off-topic with this, I think, but John Coggon’s reply to today’s earlier post has got me thinking.  His reply pointed out that

[i]t might be worth noting that Article 9 of the European Convention on Human Rights (presumably the key right under issue) states:

“Everyone has the right to freedom of thought, conscience and religion; this right includes freedom to change his religion or belief, and freedom, either alone or in community with others and in public or private, to manifest his religion or belief, in worship, teaching, practice and observance.”

This has got me thinking about the nature of that supposed right. more…

“I’m surprised,” said the German philosopher whose name I’ve forgotten but next to whom I was walking towards the ice-cream parlour, “how little argument there is here.”

I have to admit it - had he chosen his parallel sessions unluckily, he could easily have been left with the notion that the ESPMH is an argument-free zone: I, too, was struck by that.  And anyone who thought or dared hope that principlism might one day fade would have been disappointed, too - it seems to be alive and well.  I agreed with the claim of one paper that I heard that we ought to move away from B&C - but not with the suggestion that we ought to move towards another principlist system.

But enough carping - every conference has papers that don’t impress, and contributors that don’t impress either; but every confernce also has papers that are interesting, challenging, and provocative.  The same applies here.  more…

I’ve recently been reading some work on health incentives - the kind of incentive that may be used to encourage people to pursue ostensibly desirable courses of action in return for some kind of reward (frequently monetary).  Some schemes are aimed at promoting a vague healthy lifestyle, as when people are rewarded for losing weight or smoking less; others are directed at ensuring that people stick to a course of medication.

This has got me thinking about a debate in metaethics between internalists and externalists. more…

Dan Sulmasy has a piece on Bioethics Forum at the moment in which he considers the next 40 years of bioethics.  It’s a curious piece, making six main claims or predictions about the future, to which I’ll return in a minute: but before that, I think it’s worth looking at his scene-setting:

I suggest that bioethics has evolved through three phases: a religious phase in the 1950s and ’60s, a philosophical phase in the ’70s and ’80s, and a political-empirical phase from the ’90s to the present. Much as been written and said about the first two phases, but little about more recent history.

By the late 1980s, just as I was starting serious study in the field, philosophical bioethics had created a standard canon and had begun to rest on its achievements. Physicians, who found the language of philosophers alien but had been taking courses in bioethics, began re-engaging the field (or, in some cases, reclaiming it as their own). 

The general public, policymakers, and many of the new young students entering the field of bioethics by this time also began to complain that philosophy did not supply enough concrete answers to their pressing questions. They wanted solutions to social policy problems such as the distribution of health care resources, cost-containment, and physician-assisted suicide.

I’m interested to know whether this natural history of bioethics is accurate.  On the face of it, I’m not sure.  It - perhaps - describes the genesis of bioethics in the US, but I’m not sure that the subject has followed the same route in Europe, where there simply has not been a religious or political phase.  Bioethics has grown out of a renewed interest in applied ethics, which has grown out of good, old-fashioned, seminar-room ethics.  To the extent that claims are made about what should be done, and what the law should say, bioethics is “political” - but it isn’t political in the strong sense that I think Sulmasy uses the term; it isn’t about activism on behalf of this or that group (and it shouldn’t be, either).  And I’ve already articulated my suspicions of the supposed “empirical turn” in the subject; empirical studies may feed ethical debate, but they oughtn’t to be treated as a substitute.

But back to the six points, which I’ve edited down here.

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I can stop, you know.  Any time.  Honest.

Perhaps as something of a counterbalance to the generally pro-decriminalisation stuff I’ve been posting for the past couple of months, it’s worth pointing to Alexandre Erler’s piece on the issue on the Practical Ethics blog.  The tone of the post is thoughtful and more sympathetic to the current state of affairs than the kind of thing I’ve been citing so far, admitting that

there might be something to the idea that decriminalizing the use of cannabis (and other drugs) would send the wrong message: presumably, we wouldn’t want a substance to be made freely available if its only possible use was to allow those who purchased it to kill themselves. And there is some scientific evidence that cannabis is actually more harmful than tobacco. Suppose this evidence were conclusive: it might then be argued that a state’s commitment to liberal principles cannot justify its endorsing the use of just any substance by its citizens, no matter how harmful it might be. A limit must be placed somewhere, and one might argue that cannabis (and “tougher” drugs), but not tobacco, goes beyond that limit. This line of argument might be the best way of developing idea that decriminalizing cannabis “would send the wrong message”. But even if it is, its proponents need to clearly present it in an open debate, and they might also need further scientific evidence to back up their claims about the harmfulness of cannabis use. The term “drug” is not a magic word that can justify prohibiting the use of any substance it is properly applied to.

There’s a lot that’s right about this - especially about the (mis)use of the word “drugs” and the way it gets used in a morally (and moralistically) loaded manner.  Just as there is no such thing as a bad food, there is no such thing as a bad drug - it’s what you do with it that makes the difference.  (The Greeks knew that: their word “pharmakon” was wonderfully equivocal.  A poison is just a drug you can’t handle.)

I’m not so sure about the safety restriction, though.  I can think of plenty of people who’d insist that there is no limit to the idiocy that people should be allowed to commit, as long as it’s an “authentic” action on their part, and noone else - or, at least, noone who hasn’t consented - is hurt.  Often, these people cite R v Brown as a paradigm example of the law getting things wrong (or protesting a wee bit too much): it should, they say, have been much more permissive.  Though I’m not much of a fan of Mill, I have to admit that something like the Harm Principle is, at least pragmatically, attractive: the Brown ruling does seem to me to hit the wrong note.  This being the case, it’d be harder to accept the assumption about the free availability of deadly substances; and, mutatis mutandis, the same would apply to drug policy.

The real question concerns the unconsented harm to others that may be caused, and how to balance that with the demands of liberty.  On this, it would seem that there is an argument of at least some sort against cannabis use: but even there, it’s only limited.  We’d have to say, I think, that public cannabis use ought to be restricted for just the same reason that public smoking or drink-driving ought to be - but that’s really no big deal, and concerns the circumstances of cannabis use more than cannabis use in itself (or harder drug use, for that matter), which would remain something of which we might disapprove, but not something that we’d be entitled to ban outright.

So the end point would seem to be that we ought to be careful about these things.  It’s remarkably trivial.

Here’s a poser: imagine that your patient comes to you reporting the canonical symptoms of a condition that is untreatable.  You agree that this patient is suffering from something, and that the reported symptoms tally with those that are reported by other sufferers.  However, the reason that the disease is untreatable is that - frankly - there’s no such thing.

Or, rather, there is a medical condition associated with these reported symptoms, but there’s no evidence for it being anything other than psychosomatic.  Frankly, anyone suffering from this “disease” is delusional.  And yet “sufferers” are well-organised, and by no means stupid; they are convinced not only that they’re ill, but that at least parts of the medical establishment are being (at best) pig-headed in ignoring their plight.  Welcome to the world of Morgellons.  (According to some, it’s very close to the world of Chronic Fatigue Syndrome.  Both conditions are medically controversial, both lead to undeniable suffering, both boast active lay activists, and so on.)

Being told that they are not deserving of medical attention risks alienating sufferers and will not make them abandon their false beliefs; and, besides, it would miss the point.  Noone denies that putative Morgellons patients are suffering from something debilitating: it’s the identity of that something that’s open to doubt.  Besides: there is something medicine can do.  It can provide placebos, for example.  Or it can provide anti-psychotics.  Of course, a patient who’s convinced that there is something organically amiss won’t take kindly to being given anti-psychotics - so you’d have to lie and say that they were something else.  Result: patient gets better, but the disease “diagnosis” gains some gravitas: if people can suffer from it, and it can be treated, then it looks like a proper illness.

So there’s a pragmatic worry, with an ethical dimension, that we may associate with this course of action.  But there’s also a couple of more direct ethical worries.  In the first place, in prescribing antipsychotics, you’d be prescribing a powerful drug that would be unnecessary.  Well - hang on: would it be unnecessary?  if it shifts a debilitating condition, and is the most immediately effective way of doing so, what’s the criterion of necessity here?  (Granted, psychotherapy of some sort might get the same results, but that’d depend on the patient accepting that psychotherapy was in order, and turning up to the appointment.)  But it would be prescribed under false pretences - as would a placebo - and this raises questions about truth-telling.  (Martin Robbins has more on this.)

It seems that we might be getting into noble lie territory here: the idea that doctors may distort the truth in order to achieve results that all would agree are desirable.  Note that “noble lie” is a translation of gennaion pseudos, and the verb pseudesthai means originally not to lie, but to twist.  Twisting is what would be going on here: medics would be treating a real problem - just not quite the one that the patients think they have, and not in the way that they think it’s being treated.  Still, implicit in going for medical help is the expectation that you’ll be made better, and if a little twisting is necessary for that, then what’s the problem?  Anyone - doctor or patient - who wills the end of health presumably infallibly wills also the means necessary thereto.

The point is this: it’s very easy to get carried away by the need for truthfulness - but claims made about the importance of truthfulness may potentially come a cropper when people have a strong belief in an illness’ existence and effects on them.  The notion of valid consent, which requires truth, seems to demand that the patients have something like a truth-tracking lebenswelt.  If that’s not the case, then many bets seem to be off.  In such cases, when claims about the nature of an illness are (as far as anyone can tell) systematically erroneous, then there may be a case for ditching truth in favour of something more like truthiness - the quality by which one’s statements have the emotionally satisfying ring of plausibility without actually having all that much to do with reality.  The occasional noble lie might have a place in decent medical practice.

Oh - incidentally: if you’re an ME or Morgellons sufferer and you want to post an angry response, please note that I’m going to be away for a week, so I won’t be able to get back to you too quickly.  And if you’re going to complain about my Greek - well, you wouldn’t be the first.  It’s terrible.