Barbara Maier

Enlightened Versus Normative Management: Ethics versus Morals

We generally think of management as an independent, self-contained subject. Everybody in the working process is managing something. Responsibility for medical acting gets increasingly shifted from the patient-physician relationship so that management increasingly “performs medicine.” The decisions have been made in advance, yet the responsibility for the negative result falls on the individual physician. Every time a doctor or healthcare worker is at fault, management and administration are also. The standard practice of requiring excessive overwork is bad ethics, bad medicine, bad science, and bad management. Medical professionals are among the most highly stressed occupational groups. Most stress is due to management and organizational factors. The blame for burnout is falsely ascribed to the individual burnt out physician or nurse, not to the system. Thus individualization of responsibility covers again the responsibility of perverse management.

A Critique of Evidence-Based Medicine (EBM): Evidence-Based Medicine and Philosophy-Based Medicine

The critique of EBM is not meant to discard EBM in general, rather to challenge its shortcomings and to support its positive intentions by introducing a philosophy of evidence, and providing a constructive critique of the concept, methods, and its findings. The EBM research studies are based largely on complex mathematical and statistical data and data analysis. Statistics do not give clinical results, but only statistical results. When we quantify we typically remove all of the qualities from the individual. Evidence answers the question of how we know something. We need philosophical analysis to determine what evidence is. This is philosophical evidence-based medicine. The problem of placebo in EBM is not resolved yet. Placebo is defined in this chapter as the positive assessments and emotions one has, and these do have a bodily effect.

Emotion In Medicine

On the Cognitive Theory of Emotion an emotion is a cognition (assessment or evaluation), which causes bodily feeling. Emotion can be changed by changing the cognition. Negative emotions such as anger, revenge are due to faulty assessments such as failure to accept reality, failure to understand that we can only do that, which is within our power and a misuse of value terms. Emotion is not at all the sort of mentalistic thing that can be “released.” It is on the basis of the cognitive theory of emotion that we may regard negative emotions as philosophy of language fallacies. Assessments are enculturated and so are emotions and in need of an ethical critique, especially in the area of medicine, for healthcare-workers as well as their patients.

Lying in Medicine

A theory of lying is presented. A lie is to believe one thing and to express another. The liar must be aware that the belief and statement are different. On this new definition: A lie is not the same as making a false statement. A lie is not the same as not telling the objective truth. A lie in itself is neither good nor bad, but just a contradiction between belief and statement. There are consequences of lying: We gain faulty information on which to base decisions. We fail to understand what or how the liar really thinks and feels which is especially important in medicine. Communication is undermined as well as relationships, which are based on communication. Trust is undermined. Lying promotes more lying and encourages others to lie. A lie (or truth) may benefit all in the short run, but not in the long run, or vice versa. We may not realize or be able to know in advance the harmful consequences that even the smallest lie may have.

Metaphor in Medicine: The Metaphorical Method

What is to be shown in this chapter is that and how metaphor may be used as a scientific method of analysis and how it functions in medical statements. The metaphorical method is used to gain insights into the philosophy of medicine and bioethics. Philosophy of medicine is metaphors about medicine. The meanings of medicine are generated by a constant stream of metaphors. Types of metaphors are presented and examples are given how to work with them (A healthcare worker (H) – patient (P) metaphoric: H/P modeling in medicine). Metaphorical methods are useful for analysis of and writing research papers (a guideline how to do that is presented). The Metaphorical Method is used throughout this book to critically examine medicine and bioethics, practice and theory and establish a philosophy of medicine relevant to its practical tasks.

The Philosophy of Prevention

We use the word “prevention” as if its meaning is fully before us, self contained and as if we know what it means. Prevention of what? In the first place, prevention presupposes something to be prevented. If prevention has the goal to eliminate or lessen disease, then what prevention means depends on the definition of disease. If disease is thought of only as a physical dysfunction, then prevention only involves avoidance of that physical dysfunction. If disease is defined as whatever blocks one’s total physical, emotional and cognitive well-being and improvement of health, then prevention involves helping people change their lifestyle to move toward a balance of physical, emotional, social, spiritual, and intellectual health. Prevention has the insight to anticipate rather than wait for disaster to happen. Prevention is an active process, prevention is a kind of practical as well as philosophical intervention.

Care: A Critique of the Ethics and Emotion of Care

This chapter aims at the clarification of the notion of care on the basis of the cognitive-emotive theory of caring. Care theories are presented and critiqued. Bonding is analyzed. Empathy, sympathy and helper’s syndrome are examined. A philosophy of caring is presented rather than only morals of caring. An analysis of caring is seen to require an analysis of ethics, the self, causes of action, motivation, and emotion. It is also shown how caring may be redefined and based on a naturalistic, humanistic theory of ethics. Philosophy and ethics of personality involve the emotion of care towards the humanistic concept of rational care.

Ethics Counseling: Philosophy of Medicine Counseling Instead of Medical Ethics Counseling

The philosophy of medicine is a critique of the concepts and methods of medicine. Ethics Committee often only represent the enculturated views of its members, often only reflect the morals of a society. Who would qualify to be on such a committee and what should be the requirements? This is not at all clear, not even dealt with. Medical ethics counseling is not enough when only dealing with certain bioethics directions like principlism, Kantian deontology, situational ethics, case method, etc. Philosophy of medicine counseling is asked for when dealing in depth with the theory and practice of medicine and bioethics.

Philosophy and Ethics of the Body

The medical system as part of culture is based on culture and morals, and so are the concepts of the body. Man has a body and is his/her body at the same time. Plessner called it the “excentricity of man,” the double aspect of one’s existence as body and as “Leib.” The latter is being one’s body in all dimensions conceivable, living to the full, stressing social relations, communication and exchange. Body language is expressing the body, implies language, is “leibhaftig”, language embodied. It is narrative medicine of bodies. One can speak of the personally understood body in relationships, as one’s own body, as the body of a beloved person, a person you care for (as a mother for her child, a physician for his patient, etc.), the body of every human person.

Egoism and Altruism in Medicine

The definitions of altruism and egoism are shown to be vague and ambiguous and so is our language. A clarification of altruism and egoism requires an analysis of ethics, the self, causes of action, motivation, and emotion. The problem of altruism versus egoism is seen to be a pseudo problem. So altruism and egoism have to be redefined and based on a naturalistic, humanistic theory of ethics in order to make sense in contexts of medicine as well as in our whole lives. A rational, humanistic altruism based on a naturalistic theory of ethics welcomes positive altruism and positive egoism in terms of positive consequences. Schweitzer wrote, “According to the responsibility in me, I have to decide what I have to give away from my life, my possessions, my quietness, and what I may keep.” A physician must decide that.