Michael H. Kottow

The Vulnerable and the Susceptible

Human beings are essentially vulnerable in the view that their existence qua humans is not given but constructed. This vulnerability received basic protection from the State, expressed in the form of the universal rights all citizens are meant to enjoy. In addition, many individuals fall prey to destitution and deprivation, requiring social action aimed at recognising the specific harms they suffer and providing remedial assistance to palliate or remove their plights. Citizens receive protection against their biologic vulnerability by means of an in rem right to health [care], which is more an attitude of protection than a specific programme. When individuals become susceptible, that is, biologically weak or diseased, they also increase their predisposition to additional harm, and require social actions to treat their demeaned condition. Such assistance takes the form of positive healthcare rights. Research on human beings has been slow to observe that the subjects recruited are susceptible, especially so if research is done in less developed countries. By mislabelling them as vulnerable--a characteristic they share with all humans--sponsors avoid registering the deprivation these people suffer, and the ethical obligation to offer them remedial help. The distinction between vulnerability and susceptibility also marks the difference between being intact but fragile--vulnerable--and being injured and predisposed to compound additional harm--susceptible. Awareness of this difference should give additional force to the rejection of double standards in research ethics.

Classical medicine v alternative medical practices.

Classical medicine operates in a climate of rational discourse, scientific knowledge accretion and the acceptance of ethical standards that regulate its activities. Criticism has centred on the excessive technological emphasis of modern medicine and on its social strategy aimed at defending exclusiveness and the privileges of professional status. Alternative therapeutic approaches have taken advantage of the eroded public image of medicine, offering treatments based on holistic philosophies that stress the non-rational, non-technical and non-scientific approach to the unwell, disregarding traditional diagnostic categories and concentrating on enhancing subjective comfort and well-being, but remaining oblivious to the organic substrate of disease. This leads to questionable ethics in terms of false hopes and lost opportunities for effective therapy.

Theoretical aids in teaching medical ethics

Medical ethics could be better understood if some basic theoretical aspects of practices in health care are analysed. By discussing the underlying ethical principles that govern medical practice, the student should also become familiar with the notion that medical ethics is much more than the external application of socially accepted moral standards. Professions in general and medicine in particular have internal values that command their moral virtuosity at the same time as their technical excellence. Three examples where clinical practice can be clearly shown to require an ethical analysis are given: medical praxiology illustrates the motives, means and aims of physicians and patients; clinical decision-making as a practical syllogism that reaches prescriptive conclusions based on medical knowledge and the patients wishes/intentions. Finally, diagnostics as an ethical bayesian approach is discussed, where the patient informedly decides the benefits and risks of further testing.

In defence of medical ethics.

A number of recent publications by the philosopher David Seedhouse are discussed. Although medicine is an eminently ethical enterprise, the technical and ethical aspects of health care practices can be distinguished, therefore justifying the existence of medical ethics and its teaching as a specific part of every medical curriculum. The goal of teaching medical ethics is to make health care practitioners aware of the essential ethical aspects of their work. Furthermore, the contention that rational bioethics is a fruitless enterprise because it analyses non-rational social events seems neither theoretically tenable nor to be borne out by actual practice. Medical ethics in particular and bioethics in general, constitute a field of expertise that must make itself understandable and convincing to relevant audiences in health care.

Letter from Germany.

Medical ethics in the Federal Republic of Germany is characterized by two recurrent themes: a deontological emphasis on the physicians duty; and a conception of the patient as needy and help seeking, morally and biologically inferior to the physician. The philosophical and historical underpinnings of contemporary German attitudes toward euthanasia and the physician-patient relationship are discussed. Medico-ethical thought in Germany is described as conservative and unsophisticated, its development hampered by bitter antagonism between the defenders of existing institutions and practices, which include academically well situated physicians, theologians, and right-wing politicians, and the iconoclasts, represented by sociologists, journalists, lay people, and younger physicians in training.

Letter to the editor: a commentary on M. K. Wynia's "consequentialism and harsh interrogations"

At least till the beginning of the present century, public health has been the stepchild of applied ethics. The American Journal of Bioethics is therefore to be commended for having initiated a regular feature on “Public Health and Bioethics,” which hopefully will evolve to a more symbiotic “Bioethics in Public Health.” Nevertheless the first contribution, M.K. Wynia’s “Consequentialism and Harsh Interrogations,” (Wynia 2005) is disquieting for it falls in line with two highly controversial conceptions:

In-vitro Fertilisation — ein Umstrittenes Experiment

These proceedings of a conference on genome analysis and gene therapy (Bochum, FRG, 1989) represent an impressive array of analytical papers that thoroughly cover the field in its technical, legal and bioethical aspects. The material is necessarily of uneven quality, at times repetitious and not always original, but most positions are solidly argued and adequately referenced. Genome analysis is presented as reasonably acceptable, but information gained can obviously be used in controversial ways: Can defective embryos be aborted? Will genetic predispositions lead to discrimination in the job market or in contracting insurance coverage? Will genetically determined potential disease unleash social demands that such individuals assume an extra share of self-protection? Could public interest make genome analysis mandatory? In posing these questions, the different authors make it clear that the ethics of genome analysis are to be separated from the far more encompassing problems of how to dispose of the knowledge thus gained. A strong and optimistic argument tries to dissect fear of knowledge from distrust about its applications. Genome mapping is not nourished by some malignant or controversial desire to change the genetic endowment of human beings. Eugenics have been misused in a monstruous fashion, but nothing of this kind is implicit in contemporary genetic research. Fears considered unreasonable are jeopardising the possibility of learning how to avoid such maiming conditions as sickle-cell disease. Research is not to be restricted, but political control of its applications should be flexible and efficient. It is understandable that researchorientated and therapeutically-sensitive interests should view political control of genetic research as paralysing and unfair to potential beneficiaries. But, as other contributors in this volume state, regulation of research projects may be ignored or circumvented by privately funded laboratories and, furthermore, there is no convincing historic precedent to show that knowledge, once secured, will lie dormant because dire consequences must be expected from its application. All contributors agree that gene technology is to be restricted to the control of disease, avoiding so-called enhancement genetic engineering, which, incidentally, is practised in some countries and approved ofby a substantial number of doctors and ethicists for the purpose of sex determination. Most arguments in this area are of a utilitarian kind and therefore inconclusive, but deontological stances carry the day on one issue only: it is agreed that eventual approval of gene therapy must remain restricted to somatic cell genes, definitely excluding germ-line cell manipulation, on the basis of H Jonass concern about irreversible, illegitimate and unauthorised interference with future generations. In sum, this collection of essays competently represents current views on the controversial issues of gene technology and, although not offering new insights, it should serve as a comprehensive and timely review of current thoughts on the matter.

Medical ethics: who decides what?

The FME symposium on teaching medical ethics takes up the issue of competence and responsibility in matters concerning bioethics (1). Foreseeably, the medical participants argue that physicians are prepared, or can be easily prepared, to handle all relevant aspects of medical ethics. The contrary position is sustained by the philosophically trained participants, who believe that physicians do not, in fact cannot, sufficiently manage medico-ethical problems. This paper sees a role for both parties. Medical ethicists should properly be involved in medical education and in analytical and systematic study of medical ethics. They should not generally be involved in clinical medico-moral decision-making, which is properly the realm of patient and (ethically competent) doctor.