The current main source of transplantable organs is from heart-beating donors. These are patients who have suffered a catastrophic brain injury, been ventilated, declared dead by neurological criteria, and had their vital functions maintained mechanically until the point of transplantation. But the demand for organs far outstrips the supply, and these patients are not the only potential donors. The idea behind non-heart-beating transplantation is to expand the donor pool by including in it patients who are in hopeless conditions but who (...) are not dying because of brain injury and hence will not suffer the neurological death necessary to become heart-beating donors. As long as we continue to hold the so-called dead donor rule, according to which dying donors cannot have their organs taken before they are dead, this requires that death be able to be declared by alternative criteria, specifically by cardiopulmonary criteria. The challenge is to find such criteria that will identify a state that the public will readily recognize as death and that will facilitate non-heart-beating transplantation. a. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:The Institute of Medicine’s Report on Non-Heart-Beating Organ TransplantationRoger Herdman (bio), Tom L. Beauchamp (bio), and John T. Potts Jr. (bio)In December 1997, the Institute of Medicine (IOM) released a report on medical and ethical issues in the procurement of non-heart-beating organ donors. This report had been requested in May 1997 by the Department of Health and Human Services (DHHS). We will here describe the (...) genesis of the IOM report, the medical and moral concerns that led the DHHS to sponsor it, the process of producing it, and its conclusions. The analyses, findings, and recommendations of the report are also reviewed, in particular the central issues that led to suggestions for policy changes.Transplantation BackgroundAs a first step, some background in the relevant aspects of organ transplantation will prove useful. For the purposes of this analysis, “transplantation” involves the transfer of cells, tissues, or solid organs from one human to another to replace the structure or function of comparable body components that, through injury or disease, are defective or of inadequate function. The IOM report deals with solid organs, primarily kidneys and livers, whose blood supply is reconnected in the organ recipient, in contrast to cells, like bone marrow, and tissues, like corneas. A variety of donor types exists for organ transplantation, each with particular medical and scientific conditions.Living donors are healthy (and usually genetically related) individuals who volunteer to provide either a whole, paired organ such as a kidney or a section of an organ such as a liver. Cadaver donors are individuals who have died and from whom a full array of organs can be taken. “Heart-beating” cadaver donors are individuals who have suffered “brain death,” that is, irreversible cessation of function of the whole brain including the brain stem; and “non-heart-beating” donors (NHBDs) are individuals who are ill or injured, but not “brain dead,” and who have suffered cardiopulmonary death, that is, irreversible cessation of cardiac and respiratory function. NHBDs can be “controlled,” which means that [End Page 83] they can be sustained by artificial life support systems until a medical and family decision is made to terminate futile life support. This can be done at a scheduled time and in a controlled manner, and organs can then be recovered for transplantation. NHBDs can also be “uncontrolled,” which means that their hearts and breathing have stopped through disease or injury at an unexpected time or in an uncontrolled manner, and they cannot be resuscitated; the organs of some individuals of this description can be recovered for transplantation. The IOM report focused on both controlled and uncontrolled NHBDs and on problems specific to them.The questions that were asked and addressed in the IOM report became current and salient beginning in 1992 with the establishment of the University of Pittsburgh “Policy for the Management of Terminally Ill Patients Who May Become Organ Donors After Death.” This policy addressed controlled NHBDs and the ethical questions raised by their use; much of the discussion was reported in the June 1993 special issue of the Kennedy Institute of Ethics Journal. Public notice and anxiety about some of these concerns were sharpened and refocused by national and local media allegations of improper treatment of donors at the Cleveland Clinic in 1997, specifically premature—i.e., antemortem—recovery of organs and administration of drugs that allegedly might hasten donor death.The DHHS Request for StudyIt is not surprising that several federal actions would be taken in response to these events. Some, such as the results of a transplantation task force, remain largely internal to DHHS at this writing. Others are public, such as the IOM study of the NHBD situation. In May 1997, the DHHS initiated contacts with the IOM with the goal of exploring federal concerns about the medical and ethical treatment of NHBDs, in particular the allegations directed at the Cleveland Clinic.The DHHS response should be understood in at least three contexts. First, living donors and uncontrolled NHBDs were essentially the only donor types in the early days of transplantation in the United States. The technologies, ethics, and social acceptance of controlling and terminating life support for... (shrink)

In lieu of an abstract, here is a brief excerpt of the content:The Institute of MedicineRuth Ellen Bulger (bio)IN 1863 the National Academy of Sciences (NAS) was established by federal charter to advise the government on scientific matters. Almost 100 years later, in 1971, the Academy created the Institute of Medicine within the NAS to focus on health-related problems and issues. Today the IOM has a program budget of about $13 million, which includes both private and government (...) funds, and is regarded as a leading center for health policy research.After briefly explaining the structure and general goals of IOM, this article describes several new or anticipated projects as well as some recently completed reports that have a strong ethical component.The IOMThe IOM's distinguished membership is made up of health care professionals of all sorts, scientists working in health-related disciplines, and lawyers, economists, and others knowledgeable in and involved with policies and activities associated with health issues. It is organized around eight working groups or divisions: Health Sciences Policy; Health Care Services; Health Promotion and Disease Prevention, including AIDS activities; International Health; Biobehavioral Sciences and Mental Disorders; the Food and Nutrition Board; the Medical Follow-up Agency; and the Health Policy Fellowship Programs. Each of these divisions is assisted by an oversight board that provides advice on its activities.It is important to know at the outset that IOM has decided that each of the divisions will include consideration of human values and ethical issues in their activities. Therefore, no separate locus was established within the IOM to deal with these matters. I am director of the Division of Health Sciences Policy, which is the only division that has made ethics a priority in its work, and it is the focus of this article.We have addressed questions of ethics, human values, social values, decision making, and priority setting in many of the division's reports. In fact, most of our reports at least raise ethical questions. In addition, a portion of the interest from endowment funds given to IOM by the Howard Hughes Medical Institute has been devoted to work in this area. [End Page 73]The division's advisory board, headed by Claude Bennett, chairman of the Department of Medicine, University of Alabama at Birmingham School of Medicine, has decided on two major priorities for the division: (1) foster an environment conducive to productive research, and (2) anticipate the impact of scientific—especially biomedical—advances on society, monitoring and considering the social and ethical factors that accompany basic scientific and technological progress. These two priorities are interdependent because the fostering of a good environment for research presupposes that the results of this research will produce beneficial effects for the society that supports the research.Upcoming StudiesSociety has been unable to establish a mechanism for discussing in a meaningful way—and possibly resolving—a number of pressing national issues with social, ethical, legal, and scientific ramifications. The President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research considered several such issues and produced important reports about them. However, the commission was funded only until 1983. The Congressional Biomedical Ethics Advisory Committee was authorized in 1985 to address these contentious issues, but it was caught in the crossfire of congressional abortion politics and subsequently died. A new model is needed to attempt to develop national consensus on these complex, contentious issues.The Board on Health Sciences Policy has wrestled with this idea. Recently, it approved a proposal to establish a study committee charged with developing effective alternative methodologies for anticipating and addressing the social, legal, and ethical issues that may accompany rapid advances in biomedical science and technology. This multidisciplinary committee will be given a series of tasks: (1) to explore past experiences with some of these varying methodologies (i.e., town meetings, consensus conferences, forums, commissions, etc.); (2) to develop an agenda of issues likely to arise in the future; (3) to define and test a variety of alternative methodological approaches to these questions; (4) to evaluate strengths, weaknesses, and impact of the various approaches; and (5) to make recommendations on the process and structure by which this fact-finding, analytical, and decision-making function could be... (shrink)

Most donated organs in the United States come from brain dead donors, while a small percentage come from patients who die in “controlled,” or expected, circumstances, typically after the family or surrogate makes a decision to withdraw life support. The number of organs available for transplant could be substantially if donations were permitted in “uncontrolled” circumstances–that is, from people who die unexpectedly, often outside the hospital. According to projections from the Institute of Medicine, establishing programs permitting “uncontrolled donation (...) after circulatory determination of death,” or uDCDD, throughout the United States has the potential to provide 22,000 more donation opportunities annually. In contrast, U.S. controlled donation after circulatory determination of death, or cDCDD, cases have increased progressively over the past decade from 87 to 848 donors, but currently account for only 10.6 percent of all deceased donors. Following the IOM recommendations, several projects exploring the feasibility of uDCDD were funded by the federal government, including a grant from the Health Resources and Services Administration that supported a pilot project in New York City in which the authors of this article participated.A key feature of our protocol, and indeed of many uDCDD protocols, is the initiation of preservation methods such as chest compressions and extracorporeal membrane oxygenation shortly after death in order to perfuse and preserve the donor's organs. Critics of uDCDD argue that the means of determining death deviates from generally ascribed principles. They assert that reinstituting circulation in order to preserve organs has the effect of “undoing” the prior determination of death. The result is that cDCDD is widely accepted and practiced routinely even though it only marginally increases the number of organs available for transplantation, and uDCDD is widely considered unacceptable despite being ethically embraced and proven to significantly increase organ donation opportunities in other countries. This article explores the evolution of this counterintuitive state of affairs and calls for a policy that, in line with the IOM report, allows for both cDCDD and uDCDD protocols. (shrink)

We argue that the recommendations made by the Institute of Medicine’s 2011 report, Chimpanzees in Biomedical and Behavioral Research : Assessing the Necessity, are methodologically and ethically confused. We argue that a proper understanding of evolution and complexity theory in terms of the science and ethics of using chimpanzees in biomedical research would have had led the committee to recommend not merely limiting but eliminating the use of chimpanzees in biomedical research. Specifically, we argue that a proper understanding (...) of the difference between the gross level of examination of species and examinations on finer levels can shed light on important methodological and ethical inconsistencies leading to ignorance of potentially unethical practices and policies regarding the use of animals in scientific research. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Women and Health Research:A Report from the Institute of MedicineAnna C. Mastroianni (bio), Ruth Faden (bio), and Daniel Federman (bio)In recent years, claims have been made by segments of the research community and by women's health advocacy groups that clinical research practices and policies have not benefitted women's health to the same extent as men's health. Central to these claims has been an assertion that women have been (...) inadequately represented as subjects of clinical studies and that as a result neither health conditions unique to women—e.g., menopause—nor women's manifestations of health problems affecting both sexes—e.g., heart disease—have been investigated sufficiently.The scientific community, including federal agencies that sponsor and regulate clinical studies, is increasingly responsive to these claims and is taking steps to raise the level of women's participation in clinical studies. Controversy and concern have surrounded these actions, however. Two of the claims that have been made are: (1) that women are more difficult to study than men because of their cyclical hormonal changes; and (2) that conducting gender-specific subgroup analyses would increase the size of study populations, raise the cost of studies, and thereby reduce the number of studies that could be performed with the limited resources available. In addition, controversy over the inclusion of women of childbearing potential and pregnant women has been particularly salient. Concerns have been expressed about avoiding potential harm to existing or potential fetuses and about the possible legal and financial ramifications of such harm. A further concern involves the perceived difficulties in enrolling women in studies and retaining them for the duration of the studies.Against this backdrop, the Office of Research on Women's Health at the National Institutes of Health (NIH) asked the Institute of Medicine (IOM) in October 1992 to establish the Committee on the Ethical and Legal Issues Relating to the Inclusion of Women in Clinical Studies. The Committee's charge was to: (1) consider the ethical and legal implications of including women, particularly pregnant women and women of childbearing potential, in clinical studies; (2) examine known instances of litigation regarding injuries to research subjects [End Page 55] and describe existing legal liabilities and protections; and (3) provide practical advice on these issues for consideration by NIH, institutional review boards (IRBs), and clinical investigators.The 16 Committee members came from diverse backgrounds: bioethics, law, epidemiology and biostatistics, public health policy, obstetrics and gynecology, clinical research, pharmaceutical development, social and behavioral sciences, and clinical evaluative sciences.1 Chaired by two of the authors of this article, Ruth Faden and Daniel Federman, and coordinated by the third, IOM Study Director Anna Mastroianni, the Committee met five times over a fourteen-month period, convened a one-and-one-half day invitational workshop, and commissioned several background papers. The Committee's deliberations were complicated by the announcement of new federal policies late in its term. Specifically, the Food and Drug Administration (FDA) issued guidelines (FDA 1993) to replace its 1977 guidelines, which prohibited the inclusion of women of childbearing potential in early phases of most clinical drug trials. In addition, Congress passed the NIH Revitalization Act of 1993 (P.L. 103-43), which contains provisions mandating the inclusion of women and racial and ethnic minorities in NIH-sponsored clinical research. In February 1994, the IOM Committee publicly issued its final report and recommendations, Women and Health Research: Ethical and Legal Issues of Including Women in Clinical Studies, publishing the workshop presentations and commissioned papers in a separate volume.Deliberations of the CommitteeA number of issues arose at the outset as the Committee considered its charge. A few members initially believed that verification of the underrepresentation of women relative to men in clinical studies as a whole was a prerequisite to providing policy recommendations. Others believed that such an examination would be an important contribution to the knowledge base, but that it was not necessary for addressing the Committee's charge. As summarized in the Committee's report, the Committee's research indicated that firm conclusions about the relative underrepresentation of women could not be drawn from the available data because of the lack of systematic information... (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Convention for Protection of Human Rights and Dignity of the Human Being with Regard to the Application of Biology and Biomedicine: Convention on Human Rights and BiomedicineCouncil of EuropePreambleThe Member States of the Council of Europe, the other States and the European Community signatories hereto,Bearing in mind the Universal Declaration of Human Rights proclaimed by the General Assembly of the United Nations on 10 December 1948;Bearing in mind the (...) Convention for the Protection of Human Rights and Fundamental Freedoms of 4 November 1950;Bearing in mind the European Social Charter of 18 October 1961;Bearing in mind the International Covenant on Civil and Political Rights and the International Covenant on Economic, Social and Cultural Rights of 16 December 1966;Bearing in mind the Convention for the Protection of Individuals with Regard to Automatic Processing of Personal Data of 28 January 1981;Bearing also in mind the Convention on the Rights of the Child of 20 November 1989;Considering that the aim of the Council of Europe is the achievement of a greater unity between its members and that one of the methods by which that aim is to be pursued is the maintenance and further realisation of human rights and fundamental freedoms;Conscious of the accelerating developments in biology and medicine;Convinced of the need to respect the human being both as an individual and as a member of the human species and recognising the importance of ensuring the dignity of the human being; [End Page 277]Conscious that the misuse of biology and medicine may lead to acts endangering human dignity;Affirming that progress in biology and medicine should be used for the benefit of present and future generations;Stressing the need for international co-operation so that all humanity may enjoy the benefits of biology and medicine;Recognising the importance of promoting a public debate on the questions posed by the application of biology and medicine and the responses to be given thereto;Wishing to remind all members of society of their rights and responsibilities;Taking account of the work of the Parliamentary Assembly in this field, including Recommendation 1160 (1991) on the preparation of a Convention on bioethics;Resolving to take such measures as are necessary to safeguard human dignity and the fundamental rights and freedoms of the individual with regard to the application of biology and medicine;Have agreed as follows:Chapter IGeneral provisionsArticle 1. (Purpose and object)Parties to this Convention shall protect the dignity and identity of all human beings and guarantee everyone, without discrimination, respect for their integrity and other rights and fundamental freedoms with regard to the application of biology and medicine.Each Party shall take in its internal law the necessary measures to give effect to the provisions of this Convention.Article 2. (Primacy of the human being)The interests and welfare of the human being shall prevail over the sole interest of society or science.Article 3. (Equitable access to health care)Parties, taking into account health needs and available resources, shall take appropriate measures with a view to providing, within their jurisdiction, equitable access to health care of appropriate quality. [End Page 278]Article 4. (Professional standards)Any intervention in the health field, including research, must be carried out in accordance with relevant professional obligations and standards.Chapter IIConsentArticle 5. (General rule)An intervention in the health field may only be carried out after the person concerned has given free and informed consent to it.This person shall beforehand be given appropriate information as to the purpose and nature of the intervention as well as on its consequences and risks.The person concerned may freely withdraw consent at any time.Article 6. (Protection of persons not able to consent)1. Subject to Articles 17 and 20 below, an intervention may only be carried out on a person who does not have the capacity to consent, for his or her direct benefit.2. Where, according to law, a minor does not have the capacity to consent to an intervention, the intervention may only be carried out with the authorisation of his or her representative or an authority or a person or... (shrink)

Since ancient times, tattoos were a form of expressing spiritual trends or a life style. Our country does not have a very complex culture regarding tattoos or persons who practice this kind of art and thus for their bearers the majority of existing tattoos lack a special meaning. In forensic science, by conducting physical, traumatic expertise or by postponing the punishment, we find, a lot of times, persons in detention for different criminal acts, and the examination of these is necessary. (...) According to this retrospective study, we noticed an increased frequency of biblical tattoos in the case of convicts from the prisons that belong to Forensic Institute of Medicine from Cluj. We will try to find explanations in the forensic literature for the marks they have and if these have a special meaning for them, and also for the circumstances in which these were made. We will also present the church’s point of view regarding these practices. (shrink)

Traditionally, organ retrieval from cadavers has taken place only in cases where the declaration of death has occurred using “brain death” criteria. Under these criteria, specific tests are performed to demonstrate directly a lack of brain activity. Recently, as a result of efforts to increase organ procurement, attention has been directed at the use of so-called “non-heart-beating” donors : individuals who are declared dead not as a result of direct measurements of brain function, but rather as a result of the (...) cessation of heart and respiratory functions. Attempts to obtain organs from such individuals have recently resulted in substantial negative publicity. Claims were made that the deaths of patients were being accelerated in order to get organs, and that sometimes organs were being removed from patients who were not yet dead. (shrink)

Traditionally, organ retrieval from cadavers has taken place only in cases where the declaration of death has occurred using “brain death” criteria. Under these criteria, specific tests are performed to demonstrate directly a lack of brain activity. Recently, as a result of efforts to increase organ procurement, attention has been directed at the use of so-called “non-heart-beating” donors : individuals who are declared dead not as a result of direct measurements of brain function, but rather as a result of the (...) cessation of heart and respiratory functions. Attempts to obtain organs from such individuals have recently resulted in substantial negative publicity. Claims were made that the deaths of patients were being accelerated in order to get organs, and that sometimes organs were being removed from patients who were not yet dead. (shrink)

This symposium explores the boldest recommendation of the Institute of Medicine’s Committee on Increasing Rates of Organ Donation, namely, the recommendation that the U.S. consider a new population of potential donors. In its 2006 report, Organ Donation: Opportunities for Action, the committee recommended pilot programs in socalled “uncontrolled” donation after a circulatory determination of death. Potential uDCD donors have died from an unexpected loss of circulation, either due to sudden cardiac arrest or excessive blood loss following traumatic injury. (...) Because circulation is lost before death is determined and long before organ procurement could begin, potentially transplantable organs will die from oxygen starvation unless they are quickly preserved by cooling or other means. (shrink)

This symposium explores the boldest recommendation of the Institute of Medicine’s Committee on Increasing Rates of Organ Donation, namely, the recommendation that the U.S. consider a new population of potential donors. In its 2006 report, Organ Donation: Opportunities for Action, the committee recommended pilot programs in socalled “uncontrolled” donation after a circulatory determination of death. Potential uDCD donors have died from an unexpected loss of circulation, either due to sudden cardiac arrest or excessive blood loss following traumatic injury. (...) Because circulation is lost before death is determined and long before organ procurement could begin, potentially transplantable organs will die from oxygen starvation unless they are quickly preserved by cooling or other means. (shrink)

The consideration of racial differences in the biology of disease and treatment options is a hallmark of modern medicine. However, this time-honored medical tradition has no scientific basis, and the premise itself, that is, the existence of biological differences between the commonly known races, is false inasmuch as races are only sociocultural constructions. It is time to rid medical research of the highly damaging exercise of searching for supposed racial differences in the biological manifestations of disease. The practice not (...) only condoned but required by the National Institutes of Health of utilizing racial identification as a demographic characteristic with assumed biological implications is at best badly flawed, and at worst unintentionally contributes to perpetuating the fallacy of natural differences between persons of different skin color, which has been used in the past to advance the cause of racial discrimination. (shrink)

Papers presented at a symposium on philosophy and medicine at the Institute for the Medical Humanities at the University of Texas Medical Branch in 1974 were published in the inaugural volume of this series.

Today's medicine is spiritually deflated and morally adrift; this book explains why and offers an ethical framework to renew and guide practitioners in fulfilling their profession to heal. What is medicine and what is it for? What does it mean to be a good doctor? Answers to these questions are essential both to the practice of medicine and to understanding the moral norms that shape that practice. The Way of Medicine articulates and defends an account of (...) medicine and medical ethics meant to challenge the reigning provider of services model, in which clinicians eschew any claim to know what is good for a patient and instead offer an array of "health care services" for the sake of the patient's subjective well-being. Against this trend, Farr Curlin and Christopher Tollefsen call for practitioners to recover what they call the Way of Medicine, which offers physicians both a path out of the provider of services model and also the moral resources necessary to resist the various political, institutional, and cultural forces that constantly push practitioners and patients into thinking of their relationship in terms of economic exchange. Curlin and Tollefsen offer an accessible account of the ancient ethical tradition from which contemporary medicine and bioethics has departed. Their investigation, drawing on the scholarship of Leon Kass, Alasdair MacIntyre, and John Finnis, leads them to explore the nature of medicine as a practice, health as the end of medicine, the doctor-patient relationship, the rule of double effect in medical practice, and a number of clinical ethical issues from the beginning of life to its end. In the final chapter, the authors take up debates about conscience in medicine, arguing that rather than pretending to not know what is good for patients, physicians should contend conscientiously for the patient's health and, in so doing, contend conscientiously for good medicine. The Way of Medicine is an intellectually serious yet accessible exploration of medical practice written for medical students, health care professionals, and students and scholars of bioethics and medical ethics. (shrink)

This response to Kevin WildesÕs article in the previous issue of the Kennedy Institute of Ethics Journal addresses several major points of disagreement between Pellegrino and Wildes regarding the nature and scope of a philosophy of medicine, in particular how it is derived and by what method of philosophical enquiry it is best pursued.

ArgumentRevising the diffusionist view of current scholarship on the Pasteur Institutes in China, this paper demonstrates the ways in which local networks and circumstances informed the circulation and construction of knowledge and practices relating to smallpox prophylaxis in the Southwest of China during the early twentieth century. I argue that the Pasteur Institute of Chengdu did not operate in a natural continuity with the preceding local French medical institutions, but rather presented an intentional break from them. This Institute, (...) as the first established by the French in China, strove for political and administrative independence both from the Chinese authority and from the Catholic Church. Yet, its operation realized political independence only partially. The founding of this Institute was also an attempt to satisfy the medical demand for local vaccine production. However, even though the Institute succeeded at producing the Jennerian vaccine locally, its production needed to accommodate local conditions pertaining to the climate, vaccine strains, and animals. Furthermore, vaccination had to conform to Chinese variolation, including its social and medical practices, in order to achieve the collaboration of local Chinese traditional practitioners with French colonial physicians, who were Pastorian-trained and worked at the Pasteur Institute of Chengdu. Thus the nature of the Pastorian work in Chengdu was not an imposition of foreign standards and practices, but rather a mutual compromise and collaboration between the French and the Chinese. (shrink)

The concept of moralisation of health behaviours was introduced in social psychology to describe the attribution of moral properties to habits and conditions like smoking or being a vegetarian. Moral properties are powerful motivators for people and institutions, as they may trigger blame, stigma, and appraisal, as well as the polarisation of interest and scientific hype. Here I extend the concept and illustrate how medicines and treatments can be seen as if they had moral properties, too, when they come to (...) be regarded as good or bad in the moral sense, and not just in the instrumental sense of benefiting or harming health. I propose the hydroxychloroquine (HCQ) controversy of 2020 as an example of moralisation of a medicine. HCQ and chloroquine are anti-malarial drugs, whose off-label use for Covid-19 was hotly discussed in the early months of the pandemic, both in the media and within the scientific community, and eventually dismissed when robust evidence came out. The point of the paper is to show that moralisation of health products and treatments may influence individual and institutional decisions in significant ways, and also affect research. For these reasons, it should be carefully monitored and critically assessed. (shrink)

Science and technology have vastly expanded the realm of medicine. The numbers of and knowledge about diseases has greatly increased, and we can help more people in many more ways than ever before. At the same time, the extensive expansion has also augmented harms, professional responsibility, and ethical concerns. While these challenges have been studied from a wide range of perspectives, the problems prevail. This article adds value to previous analyses by identifying how the moral imperative of medicine (...) has expanded in three ways: (1) from targeting experienced phenomena, such as pain and suffering, to non-experienced phenomena (paraclinical signs and indicators); (2) from addressing present pain to potential future suffering; and (3) from reducing negative wellbeing (pain and suffering) to promoting positive wellbeing. These expansions create and aggravate problems in medicine: medicalization, overdiagnosis, overtreatment, risk aversion, stigmatization, and healthism. Moreover, they threaten to infringe ethical principles, to distract attention and responsibility from other competent agents and institutions, to enhance the power and responsibility of professionals, and to change the professional-beneficiary relationship. In order to find ways to manage the moral expansion of medicine, four traditional ways of setting limits are analyzed and dismissed. However, basic asymmetries in ethics suggest that it is more justified to address people’s negative wellbeing (pain and suffering) than their positive wellbeing. Moreover, differences in epistemology, indicate that it is less uncertain to address present pain and suffering than future wellbeing and happiness. Based on these insights the article concludes that the moral imperative of medicine has a gradient from pain and suffering to wellbeing and happiness, and from the present to the future. Hence, in general present pain and suffering have normative priority over future positive wellbeing. (shrink)

With its rise in popularity, work in the phenomenology of medicine has also attracted its fair share of criticism. One such criticism maintains that, since the phenomenology of medicine does nothing but describe the experience of illness, it offers nothing one cannot obtain more easily by deploying simpler qualitative research methods. Fredrik Svenaeus has pushed back against this charge, insisting that the phenomenology of medicine not only describes but also _defines_ illness. Although I agree with Svenaeus’s claim (...) that the phenomenology of medicine does more than merely describe what it is like to be ill, once one acknowledges its more far-reaching theoretical aspirations, one sees that it faces an even more difficult set of objections. Taking a cue from recent work by Rebecca Kukla, Russell Powell, and Eric Scarffe, I argue that the phenomenology of medicine could answer these objections by developing an institutional definition of illness. This not only allows the phenomenology of medicine to answer its critics, but it does so in a way that preserves its major achievements and extends its reach within the philosophy of medicine. (shrink)

The thesis of this paper is that because the significance of Western medicine lies in its ability to enhance the health of persons within a society, the practice of medicine is foremost an ethic and only thereafter a science. In support of the priority of an ethical perspective in medical practice, the paper explores the socio-cultural nature of knowledge, upon which science itself is constructed. Next, it draws from Levinas' philosophy, which illumines the problem of ontological and epistemological (...) priority. Specifically, it examines Levinas' rendering of the human face and of language, as they found the case for the priority of justice, or ethics. Finally, the paper offers the practice of narrative discourse as one solution that elevates the status of ethics within the institution of medicine and that has the potential to counteract the tendency in medical practice to employ a universalizing methodology based in science's power to control the human Other. (shrink)