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•   CRITIQUE OF THE THE

I OM ED I C L

MO

El

The Th e clas clash h betw etween phys physic icia ian n and pati patie ent expe expect ctat atio ions ns

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By Jaime Fla Flamen menbau baum m July Ju ly 999

Thes Th esis is su subm bmit itte ted d ta th the e Fa Facu cult lty y   Gr Grad adua uate te St Stud udie ies s an and d Re Rese sear arch ch in pa part rtia iall ful fulfil fillme lment nt   th the e re requ quir irem emen ents ts of the de degr gree ee   Master of Scie Sciences nces Bioe Bioethic thics s Spe Specia cializ lizati ation on

Bi Biom omed edic ical al Ethi Ethics cs Un Unit it Division   Expe Experime rimenta ntall Med Medici icine ne Department   Medicine McGi Mc GiII II Uni Univers versity ity Montreal Quebec Canada

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Flamen enba baum um 99 999 9 © Jaime Flam

 

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  B TR CT Biom Biomed edic icin ine e evo vollve ved d from ar artt to sci cie enc nce. e. Based on the scie scienc nce, e, bi biom omed edic icin ine e buil bu iltt its cu cullture re.. The scie scient ntif ific ic bi biom omed edic ical al cu cult ltur ure e ca cann nnot ot cape wi with th in indi divi vidu dual al ne need eds s exp xprressed durin ring a consultation. Th The e doct cto or-p r-patient rel relationship, more than a simp simplle en enc cou oun nter where bi biom ome edi dic cin ine e ca can n flex its mu musc scle les s ag agai ains nstt a di dise seas ase e, is th the e exp xpec ecte ted d mo mom men entt where the patient s iIIness will be al alllev eviiat ate ed. The sci cie ent ntiific construct const ruct Id Idis isea ease se ha has s no corr correl elat atio ion n with th the e soci social al con constr struct uct iIIness • Doctor Doctor an and d  

 

 l

pati pa tien entt are, the here reffore re,, no nott in cp cppo posi sing ng fie ield lds s bu butt in di diff ffer eren entt un univ iver erse ses. s.

It is tim ime e for a para rad digm shift.

•

 ÉSU É

La biomédecine a évolué de l art vers l a science. Axée s ur la science, la bio bioméd édec eciine a co cons nsttru ruiit sa propre cu cullture qui n es estt pas ca capa pabl ble e de faire face au aux x beso be soin ins s ind ndiv ivid idue uells ex expo posé sés s pa parr le pa pati tien entt pe pend ndan antt une co cons nsul ulta tati tion on.. La rel relat atiion médeci méd ecin-p n-pati atient ent,, plus qu un re renc ncon ontr tre e don t la mé méde deci cine ne s ex exer erci cite te po pour ur co cont ntre rerr la maladie, es estt le mom omen entt attendu par le patient pour le so soul ulag agem emen entt de son mal al.. Or, le cons constru truit it sci scienti entifiq fique ue II IIma mala ladi die e nia  

w

~ u n e

relation av avec ec le co cont ntru ruit it so soc cial ma l .

Ainsi, médecin et pat atiient ne so son nt pas dans des camps amps op oppo posé sés s mais plutôt dans dans des un univ iver ers s dist distin inct cts. s. l  est temp temps s dl un cha change ngemen mentt

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  e paradigme.

 

 

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KNOWLEDGMENT

1am a storyteller a an nd mos ostt if no nott ail my tale ales are are inspired by   yobservations of the the world 1 liv ive e an and d pe peop oplle 1 met. T h is paper is one more o f   ytales. Th This is time time it is not a fa ble o r a metaphor; it is a descriptio n o

y be beli lief efs s an and d tr trut uths hs..

This Th is mo mono nogr grap aph h is the result o mo more re than twen twenty ty years of me medi dica call prac practi tice ce

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in inten ens sive ca care re unit and instructor. In addition

 n

HIV AIDS care centers as a physician and as an

iitt is the result o al alm mos ostt fifty years of living with very

inte intere rest stin ing g peo peopl ple. e. He Here re 1 wa want nt to ac ackn know owte tedg dge e ail ail th them em:: Rela Relati tive ves s and st stra rang nger ers s fri rie end nds s an and d foes pr prof ofes esso sors rs and st stud uden ents ts au auth thor ors s and rea reade ders rs pa pattient ients s an and d doct do ctor ors s ea each ch an and d ev ever ery y on one e o th them em co coll llab abor orat atin ing g with an ines inesti tima mabl ble e part. Th This is would be a ra radi dica callly di difffere ren nt pa pape perr if on one e si sin ngle gle perso rson was no nott met. Than Th ank k you ail.

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• To R T U and V with with love love

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1wish to ex expr pres ess s my gr grat atit itud ude e to so sorn rne e o the many pe pers rsan ans s tha hatt in a way o r another anoth er he help lped ed m wi with th the pr prep epar arat atio ion n o th this is mo mono nogr grap aph: h: th the e sta staff ff an and d libr librar aria ians ns o th the e McGiII Iibr brar ariies in sp spec ecia iall Ms D Dia iane ne Phil hilip of the Mc McLe Lenn nnan an Library M Ms s

Mary ary Si Simo mon n and Mr Wa Wayn yne e L3Bei of the Os Osie ierr Library o the Hi Hist story ory of Me Medi dici cine ne eii r a ss is tan ce in my researc rch h; an and d my supe superv rvis isor or or t h e

Pr Prof of

Ed Edwa ward rd W

Keys Ke yser erli ling ngk k fo forr pu puttti ting ng me on th the e ri righ ghtt tr trac ack k an and d tea eac ching hing m how to exp xpre ress ss my idea ideas s mo more re c early  

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INDEX  

S T R

C T

ACKNOWLEDGMENT

3

INDEX

5

INTRODUCTION

6

Chapte Cha pterr One: AB ABOU OUT T ON E AN D MA MANY NY PROF PROFESSIO ESSIONALS NALS Sectio Sec tion n 1 Histo Historical rical Back Backgrou ground nd Sect Se ctio ion n Il Sc Scie ienc nce e and th the e De Defi fini niti tion on   Biomedical Constructs Sect Se ctio ion n III The Biom Biomed edic ical al Cu Cult ltur ure e Sect Se ctio ion n IV Opp Opposi ositio tions ns Sect Se ctio ion n V In Intro trodu ducin cing g Bioe Bioeth thic ics s Transition

9   2

38 45 52 58

Chapter Two Two:: EN ENCO COUN UNTE TERS RS AN D DIS ENCOUNTERS Sectio Sec tion n 1 Th The e Sce Scena nario rio Sect Se ctio ion n Il Th The e Pr Proc oces ess s   the Clin Clinic ical al En Enco coun unte terr Sect Se ctio ion n III One IIl IIlust ustrat rative ive Case Secti Se ction on IV Afte Afterm rmat ath h Transition

6 62 69 79

Chapter Th Chapter Three ree:: NE NEGO GOTI TIAT ATIN ING G TH E UNNEGOTIABLE Sect Se ctio ion n 1 Th The e Th Theo eory ry   the Prac Practi tice ce   Biom Biomedici edicine ne an and d Bioethics Sect Se ctio ion n Il   Beli Believe eve You You Belie Believe ve   Th They ey Be Belie lieve ve

92

III

Section   Bioe Bioeth thic ics s as a Cu Cush shio ion n Transition

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N D R ~ S U M ~

8

9

93

96   2   2

Chapte Cha pterr Fou Four: r: O NE NE A M ON ON G MA MANY NY FUT FUTURE URES S Section Sect ion 1 Mod Models els Sect Se ctio ion n Il Pa Para radi digm gms s and Tr Tren ends ds

  4   7  23

CONCLUSION

 3

REFERENCES

 35

 

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INTRO U TION

Dur uriing my pr prof ofes essi sian anal alli life fe as a ph phys ysic icia ian n an and d du duri ring ng th the e elab elabor orat atio ion n of this di diss sser erta tati tion on 1h 1ha ad the op oppo port rtun unit ity y to me meet et rrea ead d an and d st stud udy y man many y diss dissen enti ting ng vai vaices ces abou ab outt the the curr curren entt st stat atus us of bi biom omed edic icin ine e So Sorn rne e disa disagr gree ee with the biom biomed edic ical al mo mode dell other ers s wit ith h the way re rese sear arch ch is de desi sign gned ed and pe perf rfor orm med So Sorn rne e au auth thor ors s co com mplai plain n abou ab outt the the way the pro roffessi sio onaliza zattion process developed Many ob objjec ectt to the mann ma nner er by which pr prof ofes essi sion onal al po pow wer is ex exer ertted Ev Even en if biom biomed edie iein ine e bran brandi dish shes es its re res sults in it its s defense s sor orne ne arg rgue ue th that at such re resu sullts ma may y be qu ques esti tion oned ed as suc uch h or may be credited to ot othe herr domains De Desp spiite

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many man y crit critie ies s bio biome medi dici cine ne is st stiill

evo vollving in the same way tha hatt it has been for decades if no nott centuries with the same model met methads hads phil philosop osophy hy cult culture ure iideo deolog logy y pol politi ities es a and nd aims Th The e bi biom omed edie ieal al syst system em is sa power erfful th that at it abso absorb rbs s

 il

criti criticis cisms ms wit withou houtt dev deviat iatin ing g from from

its its pa path th T h i s monograph demonstrates the need for structural reforms biomedici biom edicine ne My crit critici icism sm wi willll

 e

in

supported  y n an anal alys ysis is of th the e roles mod model els s and

mutual mut ual use of bi bioe oeth thic ics s an and d bi biam amed edie iein ine e F Fur urth ther ermo more re th the e bioet bioethi hics cs inst instru rume ment nt which was designed ta be a regulatory tool will be ex exam amin ined ed

in

terms of its

vali valida dati tion on of the the bi biom omed edic ical al mo moda dall This Thi s pa pape perr is al also so abo about ut op oppo posi siti tion ons s The These se op oppo posi siti tion ons s are are ge gene nera rate ted d by th the e manicheistic maniche istic eha eharact racter er of health rel ela ated is issu sue es and res result in a sh shae aek k of values and idea ideas s For ex exam ampl ple e Thom Thomasm asma a an and d Pe Pell lleg egri rino no no note ted d eigh eighte teen en year years s ago that mas mastt of the ar arti ticl cles es on me medi dici cine ne and and et eth hic ics s de deal altt on only ly with spec speciifi fie e issu issues es of bioe bioeth thiics and

 

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that that fo foun unda dati tion onal al issue issues s wer ere e ra rare rely ly ex exam amin ined ed.. The They y argu argued ed tha thatt med medicin icine e prom promot otes es health whil ile e Wh Whit itb bec eck, k, in the same year, 1981 a , said that that this health promo mottion ion was a mi misc scon once cept ptio ion. n. If th the e doctor-patient relationship could be reduced to the crudeness

 

West We stem em Cartesian science, this pap aper er wo woul uld d hav ave e no reason ta exist, ist, bu butt a do doct ctor or and a patient do ne t fünction as a clûsed system düring a cûnsültation. The doct docto o -

patient relationship is al also so th the e product of ex exte tern rnal al proc proces ess ses es,, sinc since e a do doct ctor or and a patient mu must st frequently interact with the external environment to complete the cons co nsult ultati ation on or trea treatm tmen ent. t.   The flow o f information and ethical issues such as cons co nse ent, nt, dis iscl clos osur ure, e, truth telling, and au auto tono nomy my ea easi sily ly fit fit into into the the mo mode dell of an op ope en

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system. An ideal pr prof ofes essi sion onal al be beha havi vior or ca can n al also so be draw drawn n into into this this co cont ntex ext, t, ba base sed d on th the e most va vaiu iuab able le pr prec ecep epts ts or be beli lie efs   th the e mo mome men nt or of the author.  

have to cit cite here Ivan Illich and Th Thom omas as Szasz, in my opinion two of the

most mo st im impo port rtan antt su sup ppo port rter ers s of individual re resp spon onsi sibi bili lity ty and pe pers rson onal al freedom in heal he alth th prom promot otio ion n an and d ma main inte tena nanc nce. e. Th They ey arg argue ue that that orga organi nize zed d med medic icine ine inhi inhibi bits ts the the in indi divi vidu dual al ab abil ilit ity y fo forr se self lf-c -car arin ing. g. In their view, the patient should have absolute autonomy. My po poin ints ts of ag agre reem emen entt an and d di disa sagr gree eeme ment nt with ith the their ir po posi siti tion ons s nee eed d no nott to be dis iscu cus sse sed d he herre since they advocate a ne new w vision of the the cu curr rren entt biomedical parad pa radigm igm and 1 su supp ppor ortt th the e need for a ne new w pa para rad digm igm alto altog gethe ether. r. Likewise se,, sorne rne criti tic cisms ab abou outt the met eth hod odo olo log gy of scie ien nce ce,, such as those developed by Paul

If this relationship were a closed one, we could exp expect ect a pr prog ogre ress ssiv ive e de deca cay y on th the e amo amount unt of  Morowi wittz, 1978 1978 ; however, what occurs is th energy  information informatio n exchanged  Moro the e oppo opposi site te:: a gain in information. 1.

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Feyerabend

do not require furt rth her analysis in this paper

s i n c e b io me d ic a l

meth me thod odol olog ogy y is here here only only re rele leva vant nt fo forr it its s cons conseq eque uenc nce es net net for its its desig sign. ln this paper a shor shortt over overvi view ew of th the e hi hist ster ery y of bio biomed medici icine ne will be foll follow owed ed by a de scr iption of some cultural as p e c ts char ch arac acte terr of heal health th re rela latted issue issues s will

 

of

biom biomed edic icin ine. e. Then Then the the dial dialec ecti tic c

expl ex plor ored ed as a tool to intr introd oduc uce e bi bioe oeth thic ics. s.

The c inic inical al encoun encounter ter bet ,, Jeen a healer healer th the e phys physic icia ian n and and

th

help he lp seeker seeker the the

patient will also also be anal analyz yzed ed.. A si simp mple le and and shor shortt hypot ypothe heti tica call case case will be offe offere red d as an il illu lust stra rati tion on fo forr the conc concep epts ts th that at are in intr trod oduc uced ed in this this pape paper. r. Afte Afterr exam examin inin ing g th the e cons conseq eque uenc nces es of the c1inical encoun encounter ter 1will pres presen entt a short disc discus ussi sion on abou aboutt beli be lief efs. s. Bioethics Bioethics will be re rein intr trod oduc uced ed but th this is time time as a para parame medi dica call pro profess fessiion. on.

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Consid Con sideri ering ng bioethic bioethics s as such the discussion wil will be conseque consequently ntly centra centraliz lized ed in cl clin inic ical al bi bioe oeth thic ics. s. Fin ina all lly y th the e curr curren entt bi biom omed edic ical al mode modell will be discuss discussed ed and and sorn sorne e conc conclu lusi sion ons s strongly strongly influ influenc enced ed by Khun Khun will be draw drawn. n.

 

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Chapte Cha pterr One B O U T O NE

ND

 

NY

PROFESSION LS

Our bo bodi dies es are si sile lent nt.. No Norm rmal ally ly we do not feel the ph phys ysio iolo logi gica call fu func ncti tion ons s th that at n :)r  :)r a\ J takin ••

 

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them.. Eve them Everyb rybody ody,, in a certain moment of hi his s or he herr Iife, will fe feel el some somethin thing g dif differ ferent ent.. It ma may y be a fas aste terr heartbeat, bowel so soun unds ds or mo move vem men ents ts,, trem tremor ors, s, cram cramps ps,, pa pain ins, s, and an d su sure rely ly,, th this is will ca caus use e di disc scom omffor ortt. Ho Howe weve ver, r, pe peo ople reac reactt ta disc discom omfo fort rts s ve very ry diff differ eren entl tly, y, wh whil ile e so sorn rne e ig igno nore re them, othe others rs ma y de desp spai air. r. Wh When en abn abnorm ormal al fe feel elin ings gs

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abo bout ut ou ourr bodies reach a threshold, we lo look ok fo forr help. We want ou ourr bod odie ies s ta return to th that at si sile lent nt ex exis iste tenc nce e to which we ar are e acc accust ustome omed. d. Sorne Sor ne id ideas eas Ii Iink nked ed to ou ourr bio iolo logi gica call worfd can on onlly be de defi fine ned d wh when en in pairs. This Th is is pa part rtiicu cullarl arly true when we try to un unde ders rsta tand nd notions such as co comf mfor ortt an and d di disc scom omfo fort rt,, no norm rmal alcy cy and abnormalcy, heal health th and disease, or Ii Iiffe and death. To brid bridge ge the the ga gap p be bettwee een n the opposites we ha have ve reco recou urse rse to religion, ph phiilos osop ophy hy,, an and d science. We ne nee ed an explanation to he help lp us ca cape pe with the reality of our finitud ude e. W e sometim some times es nee need d help.2

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:. Help, in Can Canad ada, a, means means the Health Care Syst System em.. Th The e gatekeeper ta the se serv rvic ices es it provides is the Iicensed phys physic icia ian n or dact dactor or who prac practic tices es biomedicine. biomedicine. While biomedicine is not the only healing system available, it is the anly one that that is re reco cogn gniz ized ed for insurance coverage purposes. This means th that at if someone wants ta be tr trea eate ted d by mea eans ns of homeopathy, for for example, he or she will have ta seek a heale ealerr that that is nat graced by offici official al lilice cens nsin ing, g, and pay tor tor the the se serv rvic ices es.. Since biomedicine is the only recognized system, ei eith ther er it sho shoul uld d fulf ulfill our needs an and d expectations or we should adapt ta what it can real realisti isticall callyoff yoffer. er. Neither Neither happens, and this monograph tries to understand why not.

 

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Mrs. liA was sick, ick, and biom biomed edic icin ine e cu cure red d her er.. When When

liB bec become omes s sick sick,,

 

it is reasonable to expect that biomedicine will also cure him. This imprecise inductive reasoning is common and unchallenged among

lay-people. It

pr pres esup uppo pose ses s a gen gener eriic enti ntity disease tha that is fully known and controlled by a powe po werf rful ul bio biomed medici icine. ne. Accord According ing to this his reas reason onin ing, g, bot both Mrs. A and Mr uB react whelher or no nott it is the sa same me.. Last (1981) wonders how how man any y equaJ equ aJlly te a disease, whe people care ta know ab abou outt thei theirr own medical cu cult ltur ure, e, and how how mu much ch a pr prac acti titi tion oner er nee ne eds ta know know ta prac practi tice ce biom biomed edic icin ine e. Biom Biomed edic icin ine e appe appear ars s ta be a sc scie ienc nce. e. As a sc scie ienc nce, e, it ex expl plai ains ns clea clearr causal relat elatio ions nshi hips ps be betw twee een n pathol olo ogical ag agen entt and di dise seas ase, e, bet betwe ween en ther therap apeu euti tic c inte interv rven enti tion ons s an and d cur cure, and betw betwee een n resea esearrch and

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pr prac acti tica call res esu ult lts s. As a co coun unte terp rpoi oint nt to the cert certai aint ntie ies s of scie scient ntif ific ic no norm rmal alit ity y ling linger ers s unce un cert rtai aint nty y re rega gard rdin ing g the the su subj bjec ecti tivi vity ty of the prac practi tice ce (Ste (Stein in and Apprey, 1985). This Th is pa pape perr is ab abou outt bioe bioeth thic ics s and biom biomed edic icin ine, e, doct doctor ors s and and pati patien ents ts,, scienc science e and bel eliief efs, s, obje object ctiv ivis ism m an and d su subj bjec ecti tivi vism sm,, and expe expect ctat atio ions ns and re real alit itie ies. s. Each of these thes e terr terrns ns can be unde derrstoo ood d eith either er as an insi inside derr or an outsider. For example, a pati pa tien entt is an ou outs tsid ider er to biom biomed edic icin ine e sc sciien ence ce whi hile le being an insider in the

of

beli be lief efs s and ex expe pect ctat atio ions ns that that rela relate tes s to biom biomed edic icin ine. e. Conv Conver erse sely ly,, th the e phys physic icia ian n is an in insi side derr to the sci scien enti tiffic world, but is an outsider ta the patien patients ts re real alit itie ies. s. This This nonno n-en enco coun unte terr prov provid ides es a refe refere renc nce e fr fram ame e for the observ observati ation on

of

the doctor-pat doctor-patient ient

re rela lati tion onsh ship ip.. The obje object ctiv ive e of this this chap chaptp tprr is ta prepar are e the basis fo forr an an anal alys ysis is of the issue of the cult cultur ure e

of

both physic sicians and pa pattie ient nts s. To do

5

surve vey y th the e 1 will sur

deve de velo lopm pmen entt of biom biomed edic icin ine e in orde orderr to gain in insi sigh ghtt int nto o th the e scien cienttif ific ic,, soci ocial al,, and

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cultur cul tural al context context in whic hich do doct ctor ors s an and d pa pati tien ents ts coexist. Since th this is coex coexis iste tenc nce e is to a cer erta taiin ext exten entt moni monito tore red d by bio bioethi ethic cs, it will also lso be introduced.

Sect Se ctio ion n

HIS HISTO TORI RICAL CAL BAC BACKGR KGROUN OUND D

Biom Biomed edic icin ine e is just just on one e healin aling g syst system em or medical tr trad adit itio ion n (Young, 1995) amon am ong g many many others dev eve elop loped by humankind. It is the curr curren entt Wes esttern medical paradi par adigm gm or norm normal al sci scienc ence. e. Someti Sometimes mes,, bio biomed medici icine ne is also also ca calllled ed   bigmedicine (S (Sch chwa wart rtz, z, 1988). Th The e hist histor ory y of biom biomed edic icin ine e is always Iinked in th the e backgr backgroun ound d with ec econ onom omic ics, s, po poli liti tics cs,, and so soci ciet ety. y. No Nott ail the the link links s will be exp explor lored ed equ equall ally y in this simple sim ple over overvi view ew.. •

Bio me dici ne s historical roots ma y be easily traced b ack to th the e anci ancien entt Greek Gr eeks s (Nut (Nutto ton, n, 1995 1995). ).  

thos those e no nott fami famili liar ar with th the e historicaJ disc discus ussi sion on,, it may may

appea ap pearr th that at bi biom omed edic icin ine e ev evol olve ved d in a hist histor oric ical al co cont ntin inuu uum, m, gath gather erin ing g info inform rmat atio ion n and an d know knowlledge edge,, and and de deve velo lopi ping ng ne

techn hno olog ogiies and tools. One of th the e modem

re resu sult lts s of thi this tech techno nolo logi gica caff ev evol olut utio ion n is the the su subs bsti titu tuti tion on of huma humani nita tari rian an ca care re fo forr the enterp ent erpris rise e of biomed biomedici icine. ne. Acc Accord ording ing to this this mo mode dem m naive ive fa fant ntas asy, y, symp sympat athe heti tic c and know kn owle ledg dgea eabl ble e phys physic icia ians ns wit with qu quas asii-sa sace cerd rdot otal al mi miss ssio ions ns were were rep epla lace ced d by co  d speci cia alists whose only apparent interest is the disease, and nat the diseased. Indee deed, bi biom omed edic iciine is a tech techno nola lagi gica call en ende dea a ;j( with only hist histar aric ical al ties with the fo form rmer er Western medi medica call tr trad adit itio ions ns that that are are iden identi tifi fied ed with th the e af affe fect ctio iona nate te fi figu gure re of th the e cari caring ng phys physic icia ian. n.

•  

 

•

The Th e do domi mina nant nt ideas about how our bod odiies worked and resp respon onde ded d to stim timuli uli evol ev olve ved d ov over er time. Th They ey were first related,

in

prim primit itiv ive e so soci ciet etie ies, s, to ex exttern ernal and

supe su pema matu tura rall ca caus uses es.. An individual was su subj bjec ectted to th the e will and po powe werr of un unkn know own n force orces. s. Th The e di dise seas ase e or suffering was interp rprret ete ed as the result of the baffling and unco un cont ntro roll llab able le ac acti tion on of forc rce es, such as go god ds, spiri piritts, witches, an and d evil eyes. The û nl nl y wa y to face this kind of threat was

ta

plac placat ate e the temp mper er of th the e su supe pern rnat atur urai ai

for orce ces s th thro roug ugh h sa sacr crif ific ices es or spells Ac Acke kerk rkne nech cht, t, 1992; Contenau, 1938; Leca, 1971 19 71;; Pa Pare rent ntii and Fi Fior oren enzo zola la,, 19 1968 68;; Pr Prec ecop ope, e, 195 954 4). Pr Prot otec ecti tive ve am amul ulet ets s be beca came me a

forn

prevent prev entive ive med medic icine ine.. ln an anci cien entt Gre ree ece ce,, the the Hi Hipp ppoc ocra rati tic c ph phys ysic icia ian n was co comp mpel elle led d ta ob obse serv rve e the

•

patient with the ut utmo most st ac accu cura racy cy and ta ex exam amin ine e th the e ob objject ctiive symp sympto toms ms.. He had vi virt rtua uall lly y no te tech chno nollog ogiica call help,

 

trust

in

one sirlgle symptom cou Id lead ta

erroneous erron eous con conclu clusio sions ns Wi Witt ttem em,, 1995). Wi Witth no ot othe herr diagn gno ostic tool but the five natu na tura rall sen senses ses an and d ph phil ilos osop ophi hica call re reas ason onin ing, g, the ob obse serv rvat atio ion n of inte interna rnaii phen phenome omena na thro throug ugh h the their ir ex exte tern rnal al ma mani nife fest stat atio ions ns tra transf nsform ormed ed me medi dici cine ne into into a scho scholar larly ly sys system tem,, where ere the the pr proc oces ess s of un unde ders rsta tand ndin ing g dis diseas ease e was pe perf rfor orme med d by loca locali lizi zing ng it insi inside de the body. According to this reasoning, the body could suffer from component unba un ballan ance ces s th that at we were re the ul ulttimat ate e ca caus use e of di dise seas ase. e. The he hea aling ing syst system ems s sha hare red d phil ph ilos osop ophi hica call con concep cepts ts with as astr tron onom omy, y, as astr trol olog ogy, y, ma math them emat atic ics, s, gram gramma mar, r, an and d logi logic c of the pericd. It was not a domain in itself. It was one more branch of the Whole. Even Ev en if sorn sorne e th theo eore reti tica call cont contra radi dict ctio ions ns ap appe pear ared ed,, th the e fu fusi sion on of Ar Aris isto totl tle e an and d Ga Gale len ns ideas ide as we were re the the do domi minan nantt pa para radi digm gm

in

West We ster ern n me medi dici cine ne for ce cent ntur urie ies s in the form

of a broa broadl dly y de defi fine ned d scho schola larl rly y med ediica call tr trad adit itio ion. n.

•  

 

•

Basi Ba sica call lly, y, four el elem emen ents ts---ea eart rth, h, tire tire,, wate waterr and ai airr--a -and nd fo four ur qual qualit itie iess--d -dry ry,, cold, h ot and

moist w

cons co nsti titu tute ted d the the esse essenc nce e

r

co cons nsid ider ered ed ever-p ever-pres resent ent

of

the universe McVaugh, 1969). Living beings were

in

dif ifte tere ren nt amou amount nts s and

c o m po s e d of f our humours--blood, bl ack bile, yel low bile and phlegm. The balan ba lancin cing g or, or,

in

a m ode r n way of saying il, t he he fine tuning and equilibrium o f the

elements and humûurs resulted in health, in a macroc rocosmic and mic icro roc cosmic se sens nse. e. Di Dise seas ase e coul could d be the the co cons nseq eque uenc nce e of nonnon-na natu tura ral, l, co cont ntra ra-n -natu atura rall

or

natural

reasons. As such, th the e pati patien entt was viewed glo loba ball lly, y, si sin nce th the e ul ulti tim mate meas measur ures es th that at caused imb imbala lan nces and and dise diseas ase e were air, food food and and dri rin nk, exe exercis rcise e and and rest, sl slee eep p and walking, fa fas stin ing g and and fu full lln ness, ss, and af affe fect ctio ions ns of th the e min ind d; each of th thes ese e requ requir ire ed

•

an appropria iate te quantity tity,, quality, function and or ord der Johannitu tus s, 1974). Al Almo most st w /e /erything concerned with normal human life and its relations was potentially harmful

or

bene be nefi fici cial al.. This in intr tric icat ate e web of el elem emen ents ts,, qual qualit itie ies s and humo humors rs,, woul would d

render a particular complexio ion n the symme ymmetr try y of which, according ta Avicenna  193  19 30), if ri ris ske ked d, co coul uld d be life life-t -thr hrea eate teni ning ng Camp Campor ores esi, i, 1994 1994). ). The Th e scho schola larl rly y medi medica call syst system em was on only ly one one am amon ong g many many at var ario ious us points ints in

his isto torry. At diffe iffere ren nt pla lac ces and momen ts ts o f history, many different healing

traditions had a c l ai m t o being the only heali ng practice able ta alleviate the suff suffer erin ing; g; each each became became the domin dominant ant tr tren end d at one or anoth the er

mom nt

in

one spec specif ifie ie heale healer-p r-pati atien entt encounte encounterr

of history tory and pl plac ace e of th the e wor d. It seem eems unli lik kely th that at

peo pe opl ple e su subm bmit itte ted d ta di diff ffer eren entt so sort rts s of treat treatme ment nts s wi with thou outt argu arguin ing g abou aboutt th the e resu result lts. s. The Th e sh shee eerr numb number er of type types s of healin ling syst system ems s in the the West Wester ern n hi hist sto ory of medi medici cine ne alone shows th the e dispo isposi siti tio on to choose wh what at could uld be seen by each persan as the

 

•  

•

bestt he bes heal alin ing g me meth thod od.. The othe otherr cat catego egorie ries s

 

heale alers, rs, su such ch as wise ise wo wom men en,, blo blood

letters , barbers, and quacks, were as fashionable and available as theïr cont co ntem empor poran aneou eous s scho schola larly rly p ysi us

  r

d oc t or up to the nineteenth century

(Sawyer, 1995). A t any rate, there was a c ommo n aim among ail practices: the reg regai ain ning of th the e ba bala lanc nce e th that at me mean antt re rest stor orat atio ion n of the orga organi nism sm s wellell-be bein ing. g. No matt atter the aim

  rthe

method, the the pa pati tien entt had the po yv r ta chûûs€: no nott

only on ly the the heale aler, but al also so the the he hea ali ling ng syst system em;; fre requ quen entl tly, y, he heal aler ers s prac practi tice ced d mor more e tha han n one on e system. Healers were at service of th the e pa pattients or th thei eirr co comm mmun unit itie ies s an and d ac acte ted d acco ac cord rdin ingl gly y (Park, 19 1985 85). ). Go Gove vern rnme ment nt of offi fici ciai ais, s, pat atiien entts, and so soci ciet ety y in ge gene nera rall coul co uld d co con ntrol the pa paym ymen entt of hea ealler ers s, ob obey ey   rigno ignore re thei theirr rec recom omme menda ndati tions ons,, an and d

•

choo choose se the the he heal alin ing g scho school ol,, tre rend nd or syst system em the they y were go goin ing g ta em empl ploy oy (M (McC cCul ullo loug ugh, h, 1999). Scholarly med edic icin ine e amasse sed d a form ormida dab ble wealth of knowledge derived most mo stly ly fram ph phil ilos osop ophi hica call sp spec ecul ulat atio ion n an and d so sorn rne e ca care refu full an and d ac accu cura rate te ob obse serv rvat atio ion n  

patients. This syste m did not have different tools

  r

treatments

tr

its

con co ntem tempo pora rari ries es to pr prop opos ose, e, bu butt was po powe werf rful ul du due e to it its s ex expl plan anat ator ory y co cont nten ent. t. Also Also,, sinc since e it relied on the the written co com mmu muni nica cati tion on of knowledge, it became, in a soc ociiet ety y of illiterates, a pro rofe fess ssio ion n on onlly available to the uppe perr strat ratum of the society, or fo forr thos those e aspiring to join join thi his s stra stratu tum, m, ma main inly ly be beca caus use e th thes ese e prac practi titi tion oner ers s ap appe pear ared ed to be kn know owlledg dge eab ablle, an and d to know mea ean nt, sinc since e an anci cien entt Greees, a gain in status (S (Sat ate es, 1995; Lloyd oyd, 19 1996 96). ). Its written tr trad adit itio ion n mad ade e scho schola larl rly y me medi dici cine ne gain, fo forr good

  r

for worse, a certain aristocratie flair and identification with the other

recognized scie scienc nces es an and d arts, su suc ch as ma math them emat atic ics s an and d logi logic. c. Ta ga gain in th the e resp respec ectt

 

•  

•

of the ruling classes was the aim and accomplished goal of scholarly medicine (Rawcl (Ra wcliff iff,, 199 1995). 5). The Th e ma main in prof profes essi sion onal al ob obje ject ctiv ive e of the the scho schola larl rly y ph phys ysic icia ian n wa nott l th the e cu cure re wass no make his   pa patie tient nt reg ega ain th the e in the modem sense of the term. The p ysi us tried ta make lost lost eq equ uil iliibr briu ium m by co corr rrec ecti ting ng the the disease, or the the un unba bala lanc nce e betwee een n el elem emen ents ts and humours in the pa pati tien entt s co cons nsti titu tuti tion on (Siraisi, 1990). His di dia agn gnos osti tic c to tool ols s were a comp co mpre rehe hens nsiv ive e inte interr rrog ogat ator ory y ob obse serv rvat atio ion n of vi visi sibl ble e si sign gns, s, the ev eval alua uati tion on of pulse, sinc si nce e the the ph phys ysic icia ian n was on only ly allo allowe wed d to touc touch h his pa pati tien entt s wr wris ist( t(Mc McVa Vaug ugh, h, 1969), ur urin inos osco copy py (C (Can anto ton n and Ca Cast stel ella lano no,, 1988), an and d th the e ho horo rosc scop ope e (Fre (Frenc nch, h, 19 1994 94). ). Th The e rest restor orat ativ ive e pr proc oced edur ures es we were re co comp mpos osed ed of die dietar tary y me meas asur ures es,, bl bloo oodl dlet etti ting ng,, co comp mple lex x

•

remed ediies co comp mpo ose sed d so some meti time mes s of more than thirty ingredients, so sorn rne e rare and bizarre. and also advice on personal or social behavior, which would enter into minu mi nute te de deta tail ils s of the the pa pati tien entt s Iife, incl includ udin ing g se sexu xual al fr freq eque uenc ncy y (Sir ira aisi, 1990) 90). The Th e ther therap ape eut utic ic foun found dat atio ion n of sc scho hola larl rly y me medi dici cine ne was was based on a the heo ory of the contraries.

If something caused the ailment, the opposite could cure it;

si simi mila larl rly, y, if a sy symp mpto tom m ap appe pear ared ed.. the prov provoc ocat atio ion n of its op oppo posi site te wo wou uld di dimi mini nish sh th the e sy symp mpto tom m s ca caus use e (Van (Vanni nier er,, 1945 45)). Th The e usual se sequ quen ence ce   inter interventi ventions ons pre prescr scribe ibed d by Galen and reiterated by his followers start arted with an alteration of th the e diet and usual attitudes o f the patient to promote health; later. i f the case showed no impr im prov ovem emen ent, t, they they pres prescr crib ibed ed me medi dica cati tion ons. s. Bloo Bloodl dlet etti ting ng an and d su surg rger ery y cou could ld al also so be used us ed if ne nece cess ssar ary. y.

Male gender is used used here because only in rare instances were women all allowed owed to achieve the status of Iicensed p ysi us in the scholarly medical tradition.  

 

•

 6

•

Phys ysic icia ian ns we were re me memb mber ers s of a libera rall prof profes essi sion on that requ requir ired ed a un univ iver ersi sity ty education and were expected to be gen enttle leme men n. Physicians were secon ond ded by surg su rgeo eons ns and ap apot othe heca cari ries es,, th thei eirr regular as assi sist stan ants ts in the mo more re do down wn-t -too-ea eart rth h ac acti tivi viti ties es (Porter, 19 1992 92). ). Th The e ph phys ysic icia ian n s ta task sk was to diag diagno nose se,, pro provid vide e att attend endanc ance e and to advise. Wh When en a pr pre escr scrip ipti tio on of rem emed edie ies s wa wass indi indica cate ted, d, the prep prepar arat atio ion n of wass only one the potion by the apothecary wa on e part of the art. ln orde orderr ta tr tran ansf sfer er ta the pres prescr crip ipti tion on the ma macr croc ocos osmi mic c qu qual alit itie ies s that the pa pati tien entt needed, a ho horo rosc scop ope e was done. It was not a forecast as in the modern sense. This horoscope would give inst instru ruct ctio ions ns ab abou outt the be best st mom momen entt to prepare the concoction, blee leed the the pa pati tien entt ou outt of his excess of a plethora, done by a barber or a surgeon, or even the best mome mo ment nt to consume a restorative meal, sin inc ce man many y herbs, pla plants nts, and even foods

•

had as astr tral al co conn nnec ecti tion ons s (P (Paz azzi zini ni an and d Pirani. 19 1980 80). ). He Heal alth th wa wass then then un unde ders rstoo tood d in a cosmi mic c sense; the the aim wa wass to re rees esta tabl blis ish h the dy dyna nami mic c eq equi uili libr briu ium m am amon ong g ail the the constituents of the body and soul (Canton an and d Castellano, 1988). Health was a st stat ate e on only ly ac achi hiev eved ed by th the e in indi divi vidu dual al as a wh whol ole. e. Whether Whet her hea healin ling g wa wass considered an art, as for for the scho schola larl rly y physician,4 or a craf craftt or te hné as fo forr ot othe herr healers, lay peop oplle had no acce ccess ta co comp mple lete te heali lin ng know edge They had to rely on th the e as assum sumpti ptions ons,, inte interp rpre reta tati tion ons, s, an and d aff affir irmat matio ions ns

of the healer, blindly obeying their prescriptions and advice (Conrad, 1995). Contrary to how they are now viewed, people then thought that these non bi biom omed edic icin ine e he heal alin ing g sys system tems s us usua ualllly y wo work rked ed.. They we were re ritua ritualis listi tic c an and d trad tradit itio iona nal, l,

The scho schola larl rly y tr trad adit itio ion n wa was s th the e on only ly medi medica call syst system em  

 

rece receiv ive e the the epith epithet et llart.

• 17

•

had visib iblle effects, were based on universal beliefs, and tried ta mimi imic what the body bo dy nat natura urally lly woul would d do to balan balance ce itself itself.. The peri period od be betw twee een n la late te ei eigh ghte teen enth th cent centur ury y an and d eart earty y ni nine nete teen enth th is wh whe en the para pa radi digm gm sh shif iftt leadin ing g to bi biom omed edic icin ine e occ occurre urred d Bern Berna ard rd,, Le Lema mair ire e and Larcan, 1995). It was then that a purely descriptive domain acquired an experimental di dime mens nsio ion. n. Enii Eniigh ghte tenm nmen entt phys physic icia ians ns io ioo oked fo forr si simpie mpie and gene genera raii ia iaws ws tO expiain li livi vin ng beings in health and si sic ckn knes ess s Risse, 1995). Bio iom medi dic cin ine e developed as a result of the use of a different methodological approach to the human body, characterized by a shift

tr

reasoning and spec specul ulat atio ion n to expe experi rime men ntati tation on,,

primarily in Pa Pari ris s hosp hospit ital als s from from th the e Fren rench revo revolu luti tion on onwar nward d Wa Wadd ddig igto ton, n, 1973). This Th is par ara adig igm m shif shiftt wa wass un una avoid voida abl ble e due to the progr rogre essive ive possibil iliity of direct

•

observ serva ati tion on of th the e human body, in incl clu udin ing g the the use of tech techno nolo logi gica call tools such such as the mi c r o s c o p e

Porter, 1995). The former medical tradition, based on logical

reasoning, could not deal with the accumulation of experimental data that contr co ntrad adic icte ted d its philos philosoph ophica icall ass assump umptio tions, ns, as with the the exa examp mple le of the the de desc scri ript ptio ion n o f the circulation of the blood by Harvey. However, the rise of biomedicine, ove ov erp rpo oweri werin ng th the e norm normat ativ ive e role of sc scho hola larl rly y medi medici cine ne was slow. Othe Otherr meth method ods s lingered in one form or anothe anotherr in th the e la last st century5  Ack Ackerk erknec necht, ht, 19 1948 48;; Cang Canguille uillem, m, 1988) and remain even now now in th the e form of the al alte tern rnat ativ ive e me med dical ical syst system em.. Toda To day, y, when when we thi think nk ab abou outt medi medici cine ne,, we are are re refe ferr rrin ing g to bi biom omed edic icin ine, e, with it its s sc scie ient ntifi ific c meth method odol olog ogy y and stati statisti stica cally lly prov proven en resu result lts. s.

 

have a clear idea of

There are many examples. Just ta cite one published in the first irst issue of u-rhe Ne New w England Journal of Medicine, bloodletting was cited as bei being used used as adj adjuva uvant nt treat treatme ment nt by Angina Pector Pec toris is Warren Warren,, 1812 .  

 

•  

•

it its s objective: the cu curre of disea eas ses, or at le leas astt the alleviati ation of suffering from the sy symp mpto toms ms of di dise seas ase. e. Fu Furt rthe herm rmor ore, e, the de defi fini nitio tions ns to term terms s su such ch as dise disease, ase, cu cure re,, alleviation, treatment, and results have been accepted as within the realm of biomedicine, which has acquired a le legi gittim imat ate e monopoly to define the conc nce epts  Arnold, 1993 . This is the same implicit right that allows othe herr professionals to defi de fine ne thei theirr term terms, s, co conc ncep epts ts an and d jarg jargon ons. s. Hi Hist sto oric rical allly, th the e pa pati tien entt appe pear ared ed to ha have ve more po powe werr th an the the he heal aler er.. As already stated, the patient could choose no nott only the professional, but also the healing practice and system. Only recently did the healing power come into the hands of the biomedical practitioner Light and Levine, 1988 and did pa pati tien ents ts surrender their power in exchange for the relief suggested by the magical

•

omnipotence ves estted by biome med dicine Stein and Apprey, 198 985 5 . As a resu result lt of many in infflu lue enc nces es,, on only ly biome med dica call phy hys sic icia ians ns were empowered by the stat tate to legally exercise professional health activities

Stevens, 1998 .  The biomedical

professional is th thus us the legal ag agen entt of bi biom omed edic ical al acts and func functi tion ons s. When we ret eter er ta physic iciians and an d the their ir pr prac acti tice ce toda today, y, we als lso o rete reterr t J the pr pro ofess fessiion on.. Dur uriing its ea earl rly y hi hist sto ory ry,, me medi dici cine ne could be prac practi tice ced d by any anyone one with eno noug ugh h kno nowt wted edge ge of il. il. A Iice Iicens nsin ing g pr proc oces ess s ev evol olve ved d in ti time me,, and the kn know owlled edg ge of

According Accord ing to  rodyand Fl Flet etch cher er 1993 1993 , th ther ere e are thre three e types of po powe wer: r: 1 ow owne ned d po powe werr -- the po powe werr is ac ackn know owle ledg dged ed as po poss sses esse sed d by so some meon one, e, 2 shar shared ed po powe werr - the the po powe werr is divi divide ded d with othe otherr pa part rtie ies s in th the e re rela lati tion onsh ship ip.. an and d 3 ai aim med po powe werr - wh wher ere e po powe werr is ex exer erte ted d spec specif ific ical ally ly towar to ward d a ta targ rget et..  he tirst irst,, ow owne ned d po power wer is the the on one e ob obta tain ined ed by biom biomedi edicin cine e in it its s his histo tori rica call pr proc oces ess, s, as weil as the on one e on once ce po poss sses esse sed d by the pat patient ient;; the seco second nd,, is the powe powerr in a rela relati tion onsh ship ip of eq equa uals ls;; the la last st is a trus trustt re rela lati tion on with with the the em empo powe were red, d, one be beli liev eves es that that the the ha hand nded ed po powe werr will ill not be mi misu suse sed. d. Auth Author orit ity y is a so sour urce ce of powe powerr Ro Roy, y, 19 1980 80 p.15 a and nd pr prof ofes essi sion onal al author authority ity is a sourc source e of prof profes essi sion onal al power power.. On Once ce obt obtain ained ed,, po powe werr is auto automa mati tica cally lly exer exerte ted, d, but but if ab abuse used d it is trans transfo form rmed ed in into to pate patern rnali alism sm,, the the dic dictat tator orshi ship p of hum human an rela relation tionship ships. s. 6

 

• 19

the art had to

 

proved. Th The e process

of

Iicensing a physi us which va vari ried ed

•

th thro roug ugho hout ut Eu Euro rope pe,, al allo lowe wed d fo forr th the e control of prof profes essi sion onal al stan standa dard rds s and gran grante ted d scho schola larf rfy y me medi dici cine ne,, an and d its he heir ir bi biom omed edic icin ine, e, th the e stat status us of an offi offici cial al me medi dica call syst system em  S  Sttarr, 1982). Neverth the ele les ss, Iicensing did no nott mean universal recognition and acceptance

of

mediclnes

our da day y is an exa xam mple of thls. At an any y rate, as an ans nsw wer to the public

 

th the e healing system, The widespread use

of

alte altern rnat ativ ive e or soft soft  

pres pressu sure re fo forr th the e offic officialli iallicens censing ing and ce cert rtif ific icat atio ion n of he heal alth th prof profes essi sion onal als, s, deg degree ree-granting schools of me med dicin icine e proliferated in the last one hundred years Shorti, 1983). Ucens nsiing di divi vide ded d the the he hea alth lth care world in two:   1) the insi inside de world, the on one e of th the e Iicensed he heal aler ers, s, the pr prof ofes essi sion onal al ph phys ysic icia ians ns,, an and d   2) the the ou outs tsid ide e world, the the one on e of the pa pati tie ent nts s an and d the heiir social network.

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ln the lat late nin inet ete een entth ce cen ntu tury ry and the beginning of the the twentieth, ma main inly ly in North America, biomedicine determined how the healing practice should be es esta tabl blis ishe hed. d. Ph Phys ysic icia ians ns to took ok co cont ntro roll ov over er th the e ad admi miss ssio ion n proc proces ess s into into the the pro profes fessio sion n and

of

the th ther era apeu euti tic c relation with the pa pati tien entt Moskop, 1980), Biomedicine

mana ma nage ged d ta con consol solida idate te

pr prof ofes essi sion onal al mo mono nopo poly ly as the the so sole le prov provid ider er of he hea alth lth

ca care re exp xper erti tise se,, al alie iena nati ting ng or re rest stri rict ctin ing g dr dram amat atic ical ally ly the the wo work rk of other pro profess fession ionals, als, succeeding in controlling ail facets of its organization and practice, and gua uara rant ntee eein ing g th that at ail co cont ntra rais is of qu qual alit ity y and qua quanti ntity ty would uld be inte intern rnai ai Bo Bozz zzin inii an and d Contandriapoulos,   n ; Clar Clarke ke,, 1990). Wi With thc c  .:t any external force rce to im impe pede de it, biomed bio medici icine ne und unduly uly ex exte tend nded ed th the e ju juri risd sdic icti tion on

of

its expertise, bu butt did not fulfill its

expl ex plic icit it et eth hica ical an and d so soci cial al pr prom omis ises es Fr Frei eids dson on,, 19 1988 88). ).

 

•  

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From art to scie scienc nce, e, co conc ncep eptu tual ally ly,, me medi dici cine ne has tr trav ave eled led a long long dist distan ance ce..  he

scien enttif ific ic method and the prafessionalization pracess that fra rame med d tod today s

biome biomedic dical al prac practi tice ce de defi fine ned d no noti tion ons s su such ch as cure cure,, no norm rmal alcy cy,, effi effici cien ency cy,, and effi effica cacy cy.. T h e s e terms have no sim iiar meaning

 

history and are cruciai ta the

unde un ders rsta tand ndin ing g of ho how w biom biomed edic icin ine e se sees es itse itself lf and how it

 s practiced.

It was not on only ly

the the monopoly of the health care system that biamedicine conquered, it was the exclusive exclusi ve jur jurisd isdict iction ion o th the e de defi fini niti tion on of di dise seas ase e and, the here reffor ore, e, the the be beha havi vior or pe peop ople le shauld sha uld ha have ve   order to be co cons nsid ider ered ed sick sick.. Biom Biomed edic icin ine e ga gain ine ed the the ex excl clus usiv ive e ri righ ghtt ta de desi sign gn an off officia iciall sick sick-r -rol ole e Frei Freids dson on,, 1988, p20S).

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Di Dise seas ase e fo follllow ows s hu human manity ity in its its hi hist stor oric ical al  

o u m ~ y

if we cannat avoid it, let us

try try to expl pla ain il il.. Egyptia tian and and Me Meso sopo pota tami mian an heale alers rs,, am amon ong g othe others rs,, plac placed ed dise diseas ase e in a sup upe erna rnatura turall realm, while ile Gr Gree eeks ks and the heir ir dire direct ct heir, the the scho schola larl rly y me medi dic cal tradition, tri

ta exp xpla lain in dise diseas ase e with ith a mo more re na natu tura rali list stic ic ap appr proa oach ch.. Ea Each ch me medi dica call

syst system em explains dise diseas ase e in its co cont ntem empo pora rary ry con onttex extt. For ex exam ampl ple, e, in simp simpli list stic ic term terms, s, the the medieval Cat ath holic lic Church cansidered disea isease se as a divin ivine e v i s i ta ti o n moti mo tiva vate ted d by the sins of th the e per person son-to -to su suff ffer er me mean antt to redeem Tuney, 1935, p.31 p.31). ).  u r

way of understanding dise diseas ase e is by placing its ulti ultima mate te or orig igin ins s in the mo mole lecu cula larr

con ons sti tittue uent nts s of the body. No ma matt tter er the the explanation used, we still are are left with the suffering.

 

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Section Il   SCIENCE  N

THE DEFINITION O F BIOMEDIC L

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CONSTRUCTS

Underfying the exercise of biomedicine are the construed concepts of norrmatity, disease, with th no the e desc descri ript ptio ion n of each mo morb rbid id st stat ate, e, outc outcom ome, e, and and he heal alth th among many others. These concepts are the foundation of the biomedical know kn owle ledg dge, e, pr prac acti tice ce,, an and d scie scienc nce, e, and will th ther eref efor ore e be brief briefly ly revi review ewed ed he here re.. Acco Ac corrdi din ng ta Ti Ting ng (c (cit ited ed in Gr Greg egor ory, y, 19 1992 92,, p. p.82 82)) sc scie ienc nce e is one of the few areas o f human life where the majority does not rule.

Greg Gr egor ory y fu furt rthe herr ad adds ds,,

l Science is characterized by th the e pr prog ogre ress ssiv ive e ex expa pans nsio ion n of our ab abil ilit ity y to pred predic ictt the

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beha be havi vior or of the the ph phys ysic ical al wo worl rld. d. Not with withou outt so sorn rne e iron irony, y, Di Dick ckso son n de defi fine nes s scie scienc nce e as in its its br broa oade dest st sense sense

 

the ac acti tivi vity ty of tho hose se who de defi fine ne th them emse selv lves es as resea esearc rch h

scie scient ntis ists ts (1988, p.19). Thes These e as asse sert rtio ions ns can be li link nked ed and in inte terp rpre rete ted d in many ways wa ys.. My re read adin ing g is that a mi mino norrit ity y of pe peop ople le ex exer ertt sorn sorne e so sort rt of di disc scre reti tion onal al po powe werr to design the in intterp rprreta tattion of the be beh hav avio iorr of natu nature re,, or in other wo word rds, s, to dictate sorne kind of scie ien nti tiffic truth. Accor cordi din ng to Hesse (1970), what we really d o in science is cons constr truc uctt mod models els that that will des descr cribe ibe phenom phenomena ena;; sci scienc ence e is no nott a proc proces ess s o f unveiling universal truths. The problem here is that Gregory and Ting are scientists and Hesse is a ph phililos osop ophe herr and, as Ga Gauth uthier ier st stat ates es,, the there re is a di dich chot otom omy y between theory eory and pr prac acti tice ce in ail le leve vells of th the e sc scie ient ntif ific ic di disc scou ours rse e (1995, p. p.7) 7).. At any rate, the goal of science is to generate understanding (Pickett, Kolasa and Jones, 1991). This dichotomy between theory and practice will dictate the perception of science by people at large. Science, which derives trom the root

 

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Itscire

lita know

Gove, 1976, p. p.2 203 032) 2),, is a proc oces ess s of si simp mpli lifi fica cati tion on.. Sc Scie ienc nce e

is not   be beca caus use e it is faulty in this his isto torrical mo mome ment nt,, but be beca caus use e it is its func functi tion on..

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Scienc Sci ence e prov provid ides es us with the the ele leme ment nts s ne nec ces ess sary fo forr understa tan nding ing and eval ev alua uati ting ng na natu turre and it its s ph phen enom omen ena. a. Ev Eval alua uati tion on repr repres esen ents ts the the prac practi tice ce,, wh whil ile e unde un ders rsta tand ndin ing g re repr pres esen ents ts the the sc scie ienc nce. e. On One e ca can n un unde ders rsta tand nd so some meth thin ing g for for it its s own value alue:: a ratio ationa nall proc proces ess s de depe pend nds s on oth other er no noti tion ons s on only ly in relation to its com comple plexit xity, y,  

the the more co com mple lex x the notion to be understood, the more preliminary are the

noti no tion ons s re requ quir ired ed.. To ev eval alua uate te is to do a mechanical comparison th tha at can be done automatically. An evaluation is a comparison of entities, which means that one eval ev alua uate tes s so some meth thin ing g havin ing g an anot othe herr no noti tion on as a stand tanda ard rd.. Th The e st stan anda dard rd of care, used to define pro proced cedure ures s and treatments in bi biom omed edic icin ine, e, be belo long ngs s to thi this s ca cate tego gory ry..

•

Science has three aspects:  1

technology,  2

knowl nowled edg ge, and  3

methodolog metho dology y Ki King ng,, 1982). In bi biom omed edic icin ine, e, the these se asp aspect ects s ar are e inter intertwi twined ned in such a way that that tech techno nolo logy gy offe offers rs the tool tools s ta obtain mo morre kno nowt wted edg ge an and d va vali lida date te it, while at the sam e time depends on the other two to be furt furthe herr de deve velo lope ped. d. A sc scie ient ntif ific ic in inst strrum umen ent, t, as derived from a theory, can be seen as the the ma mate teri rial aliz izat atio ion n of that that theory theo ry Gau Gauthi thier, er, 1995).7 The Th e biomedical system is scientific in the sense o f being a body of knowledge. Biomedicine obeys the criteria for theory construction: clarity, cohe co here renc nce, e, co comp mplet leten enes ess s an and d comp compreh rehensi ensiven veness, ess, simp simplici licity, ty, exp explana lanator tory y po powe wer, r,

Knowledge ma mayy assume many roles:  1 economic, as a commodity,  2 politic. as an e/ement of power, and  3 foreign polîcy, as an element of influence and imperia imperialistic listic dominati domination on  Dick Dickso son, n, 19 1988 88). ). The main source of knowl knowledge edge today today is science. Applied sciences ar are e the de demon monstr strati ation on of their their validi validity. ty. Biome Biomedic dicine ine is also an ins instru trume ment nt of social social and political domination and ideolog ideological ical colonization; colonization; health care distribution is a form of political and social control  Arnold. 1993, Trennert. 1998 . 7

 

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outp ou tput ut power, and practicability. Once biomedicine is believed ta be a sci cien enti tifi fic c

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endeavor, we have to accept its predictive power. This explanatory c ontent re repr pres esen ente ted d by th the e pr pred edic icti tive ve powe powerr is fo forr public heal health th,, insu insura ranc nce e co comp mpan anie ies, s, and and the lay public in general, the most most important sc sciien enttifi ific aspe aspec ct of bi bio omedicinesc scie ienc nce, e, wi witth co conc ncom omita itant nt major major impa impact cts s on the eco econom nomy. y. The Th e ma majo jorr goal of med edic icin ine e appears to be th the e cure ure (Y (Yos oshi hida da,, 199 995) 5).. To achi ac hiev eve e this goal, the no noti tio on of a required efficacy em emer erge ges. s. The The ca capa paci city ty th that at th the e phys ph ysic icia ian, n, a tec techn hniq ique ue,, a proced edu ure, a drug regimen, or even a medi dic cal sy syst stem em ha has s ta be ef effi fica caci ciou ous s is its ef effi fici cien ency cy (Sha hah h, 1994). A cure cure is defi define ned d wit ithi hin n impo import rtan antt cons co nstr trai aint nts. s. The bi biom omed edic ical al cu cure re is in inte terp rprret eted ed as ei eith ther er the di disa sapp ppea eara ranc nce e of th the e di dise seas ase e and th the e res esttit itut utio ion n of phy physical functions to th thei eirr ante anterrio iorr state, as if that

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di dise seas ase e has ne neve verr stru ruc ck, or th the e control of the di dise seas ase e by min iniimiz iziing it its s im impa pact cts s on the organism. To achieve this goal, the physician will use his or her body of knowledge. For Murp Murphy hy,, bi biome omedic dicine ine is based on fa fac cts (199 (1997, 7, p. p.1 192 92)). The The ac acce cept ptan ance ce of what constitutes a biomedical fa fact ct is di difffe ferrent from what what may cons consti titu tute te a fa fact ct in othe otherr milieu. To qualify knowledge as scientific, it mu must st first be admitted by the sc scie ient ntif ific ic co comm mmun unit ity y as such ch.. To Toda day y s science de dema mand nds s some ome form of validation befo be fore re its its ad admi miss ssio ion n into into th the e do doma main in (Suppe,   993 99 3 p. p.16 161) 1).. Th The e proc proces ess s of vali valida dati tion on is di dict ctat ated ed by the the me meth thod odol olog ogy. y. Each scie cience nce has a meth method odol olog ogy; y; th this is meth method odol olog ogy y is a link link betw betwee een n co conc ncep epts ts an and d re real alit itie ies s and thus it must must remain rel elat ativ ivel ely y st stat atio iona nary ry ta be used as a framework. The reference framework nature

 

  r its

 

modern science is not

arder, as it was in the past, but the a r d e r of reason. Only wh at is

• rational can be scientific and true--even if Godel (1931) proved that rational constructs

impreci ecisi sion on ho  d impr

with within in them-therefore in the ar ard der of reasan there is no

•

cert ce rtai aint nty. y. Th The e ar arde derr

of

construc cons tructt hypoth hypothese eses s

theori ories es   nd the

Data

in

reasan departs from a reference framework in order ta (Gr (Graci acia a 19 1992 92). ).

soci so cial al sciences are sub ubjjecti tiv ve

sClent sCl entifi ific c approac approach h

is

reflected

in

in

nature. The objectivity of the

a me meth thod odol olog ogy y with a te tend nden ency cy to see wholes as

unique abjects where general laws can obse ob serv rvat atio ion n of thei theirr behav ehavio iorr as wh whol oles es..

be

discovered or formulated af afte terr the

biomed edic icin ine, e,  n biom

which which

is

a soci ocial sc scie ienc nce e

according to Sigerist (1936), wh what at is grouped together as mani anifestations of the whol wh ole e ar are e di diff ffer eren entt com omp plex exe es of ev even ents ts aff affec ecti ting ng di diss ssim imil ilar ar in indi divi vidu dual als, s, even even if th they ey are beli believ eved ed to be related

•

to

each ea ch othe otherr in a simi simila larr manner manner (Hayek, 1979).

As Tyles states, l the problem with the descent to pure physiological m e c h a n i s m s is that it leaves t h e qualitative difference between normal and path pa thol olog ogic ical al at the the leve vell of iII IIus uso ory ap appe pear aran ance ce (1993, p735 p735). ). The key concep conceptt he here re is the di disp spar arit ity y between qual qualit itat ativ ive e and quantitative di diff ffer eren ence ces. s. A quan quanti tittat ativ ive e difference diffe rence re refe fers rs

to

the pop opu ulati ation, since since it is the re resu sult lt ob obta tain ined ed by the bi biom omed edic ical al

scienc sci ence e st stud udie ies, s, white the qual qualit itat ativ ive e reter ters

to

the in ind divid ividua ual, l, since nce it

is

wha wh at th the e

physic phy sician ian sees in his or her offi office ce.. Sorn So rne e as aspe pect cts s of biom biomed edic icin ine e are are

rooted in

the nat natur ura al scie scienc nces es,, whi hille ot othe herr

aspe as pect cts s der eriive fram the human scie scienc nces es.. Biom Biomed edic icin inee-sc scie ienc nce e ob obttai ain ns mast mast of it its s foundat foun dation ional al con concept cepts s

tro m th e

natu atural ral sciences. However, it al also so deri derive ves s pa part rt of its

meth me thod odol olog ogy y from the the human sc scie ienc nces es.. Biom Biomed ediical cal clin clinic ical al pr prac acti tice ce is as ge gene neri ric c as statistical data allow, since i t is constrained by its basic, indivisible unit o f

 

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meas me asur ure e of the the single single pati patien entt Sc Schr hrëd ëdin inge ger, r, 1994). In oth other er wor ords ds,, na natu tura rall scie scienc nces es

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give th the e physician pr prec ecis ise e da data ta th that at los lose pre rec cision when tr tran ansl slat ated ed into into the body of a patie patient nt.. The Th e explanation of an any y biological function presupposes a description of normality. The explanation of the function does not explain the presupposed norma ormali litty, yet no norm rmal alit ity y is so some meho how w Iink inked to the co cont ntra rast st between fun function ion and malf ma lfun unct ctio ion n Wa Wachb chbro roit, it, 19 1994 94). ). Biome Biomedic dical al scie scienc nce e is basa sad d on the no noti tio on tha that the there is a certa rtain range

 

phys ph ysio iolo logi giea eall func functi tion ons s which ich gr gran antt the or orga gani nism sm as a who hole le

its be best st pe perf rfor orma manc nce. e. Th This is ra rang nge e ca can n be ge gene neri rica call lly y ca call lled ed no norm rmaL aL Alte Altern rnat ativ ivel ely, y, when a no nonn-op opti tima mall pe perf rfor orma manc nce e is to tou und nd,, it is due to an ab abno norm rmal alcy cy tha hatt can be rooted in, or be the cause of, a disease. The basic principle behind applied

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biomedicine is th that at on once ce the abn bno orm rmal alit ity y or its cause is remo remove ved, d, the the orga rganis nism will tend to return to its op opti tima mall pe perf rfor orma manc nce. e. Biomedicine assumes the existence of the absolute normal value as a mea me asu sure reme ment nt scal scale e again ins st whieh everybody can be equally measured. This stand tanda ard is im impe pers rson onal al and stat statis isti tica call lly y obtained; it is ba basi sic c to the exercise of the the pro profess fessio ion n. A ce cert rtai ain n no norm rm or no norm rmal ality ity is co cons nstr truc ucte ted d tr

broad broa d gene generaliz ralization ations. s.

Some So me of the these ge gene nera rali liza zati tion ons, s, sp spec ecif ific ical ally ly those that that are are relate ted d ta certain ma male le fe feat atur ures es,, val alue ues, s, bod bodies ies an and d ex expe peri rien ence ces s ar are e cri riti tici ciz zed as co cons nsti titu tuti ting ng the the ove vera rall ll huma hu man n norm Lit Littl tle e, 1996).8 Simi Simila larl rly, y, we can argue that that the the ce cert rtai ain n protot totypica ical

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The image used in man many y medica medicall schools and textbooks when referring to the  normal weighi ghing ng sevent seventyy kilograms. and one meter and individual is a young adult male Caucasian. wei the idea deall se seve vent nty y ce cent ntime imete ters rs tall. tall. This This statis statistic ticall ally-o y-obta btaine ined d normal indiv individua iduall repres represent ents s the physical patient. which rev reveal eals s import important ant cu cultu ltura rall and ideological bi bias ases es that that are are deeply rooted in biomed medici icine. ne. This prejud prejudice ice is. furthermore pervasive to ail the biomedical and embodied by bio field.

 

 

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pati pa tien entt that that is used fo forr most clinica nicall tr tria ialls does no nott in fact act exist. Th The e no norrms obt obtain ained ed in c1inical trials ha harrdl dly y correspond ta what the physician face ces s in pr prac acti tice ce.. Th The e

physician is tr trai aine ned d ta react to de devi viat atiion ons s of the norm that is ob obse serv rved ed in the the ac actu tual al patient. The norm or a normative ca case se should be the evaluation tool that co coul uld d be used us ed me mech chan anic ical ally ly or au auto tom mat atic ical ally ly.. However, as the Harvard La Law w states, un unde derr the mo most st rigorously controlled conditions of pressure, temperature, volume, hum umiidity, and other variables, the organism will do as it damn weil pleases Thomasma, 1984, p.34). Since there is no standard basis for a satisfactory scie scient ntif ific ic ev eval alua uati tion on,, the ph phys ysic icia ian n mus mustt re reso sort rt to scie scient ntif ific ic un unde ders rsta tand ndin ing g thro throug ugh h modeling in orde orderr to deal with the pa pattie ient nt.. Acc ccor ord ding to Canguilhem  1982), what is normal ca cann nnot ot be defined

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and d pa obj ective1y; furt furthe her, r, th the e di diff ffer eren ence ces s be betw twee een n nor normal mal an path thol olog ogic ical al st stat ates es can cannot not and d normaHty are inte be ex expr pres esse sed d in qua quanti ntitat tative ive te term rms. s. He Healt alth h an interc rcha hang ngea eabl ble e in th the e

cl clin inic ical al co cont ntex extt Boo oorrse se,, 1975). Eve ven n if Nor orde denf nfel eltt  1993) equates health and a statist stat istical ical no norm rmal al pa patt tter ern n to the ab abse senc nce e of ail diseases, one should ho how wev ever er be awar aw are e th that at hea eallth an and d no norm rmal alit ity y   no nott de desc scrribe the sam ame e st stat ate, e, and tha hatt  

~

cure

refers to the process of regaining normality Tyles, 1993, p. p.74 741) 1),, but does not necessarily

 t

to health. For a physician, normal is a very fluid concept that

efiinit nitions ions of disease ofte often n goes go es beyond the level of mo mole lecu cula larr descriptions.   Def incl includ ude e st stat ates es of ab abno norrma mallity ity Ll Llo oyd, 954). This use, abuse, and misuse of the terms terms norm ormal and abnormal are cu cush shiion oned ed for the prac practtice ice of biom biomed ediicine cine by param arame etrical values, since normal becomes respectful when it incorporates An example of th the e precis precision ion problem in biamedicine is that which arises tram the acceptable ranges in labaratory results. For a graphi graphical cal view, see Laposata  1992 .

 

 

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stat statis isti tics cs Tyles, 1993, p. p.73 736) 6).. As a re resu sullt, an ac acce cept ptab able le de degr gree ee of im impr prec ecis isio ion n

or

in ince cert rtit itud ude e is no norm rmal aliize zed d in the general clinical de deci cisi sion on-m -mak akin ing g proc proces ess. s. As a

result, the ph phys ysic iciian pl play ays s with od odds ds ev ever ery y da day y and in ev ever ery y ca case se.. Th This is ince incert rtit itud ude e of bio biomed medici icinene-cli clinic nical al pra practi ctice ce re reve veal als s th the e fundam fundament entall ally y inte interp rpret retiv ive, e, an and d ther therefo efore re subj subjec ecti tive, ve, rol role th that at th the e phys physic icia ian n pe perf rfor orms ms..

Disease is no nott ea easi sily ly un unde ders rsto tood od,, no nott even by physicians, even if seen as a cl clea earl rly y def efiine ned d pa path thol olog ogiical cal entity, with a beginning ng,, ev evo olut utiion on,, and end. Wh What at is described by scie scienc nce e and wh what at is seen in th the e consul consultat tation ion room room requ requir ire e expl explan anat atio ion. n. One e ffort was made by Alexander n.d., p.44) , who formulated disease as a func functi tion on of  a hered hereditar itary y const constitut itution, ion,  b bi birt rth h tra trauma umas, s,  c org organi anic c dis diseas eases es in the infancy,  d

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nature and quality of care during infancy,  e

traum tra umat atic ic ph phys ysic ical al

experi exp erienc ences es du duri ring ng in infa fancy ncy,,  f tr trau auma mati tic c em emot otio iona nall ex expe peri rien ence ces s dur durin ing g infa infanc ncy, y, an and d so on, adding ail events of ail ph phas ase es of life. In ot othe herr wo word rds, s, he redu redund ndan anttly st stat ated ed thatt di tha disea sease se

 

is a fun unct ctiion of th the e sum of innu innume mera rabl ble e fact ctor ors. s. This ex exp pressi ssion

th thus us lend nds s an ex exa act and sc scie ient ntif ifiic fla laiir ta a set set of unk nkno now wn circ circum umst stan ance ces. s. Another attempt to explain the individual patient was made by Meador  1965). He de desc scri rib bed ed,, def efiine ned, d, and clas assi siffied the non dise diseas ase e en enttity or simpl mply y ll llno nond ndis isea ease se,, st stat atiing th that at he heal altth or no nond ndis isea ease se coul could d not be seen seen as an un unsp spec ecif ific ic entity. For Meador, the fun unct ctiion of the phy hys sici cian an was to be best stow ow a dia diagn gno osis sis, eit eithe herr di dise seas ase e A or nondisease A, the la latt tter er sugger;ting th that at the pa pati tien entt is sp spec ecif ific ical ally ly healthy: he or she does no nott have disease A. Th Thiis so solv lves es an im impo port rtan antt pro problem blem in

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general practice: when patients are symptomatic without any diagnosable path pa thol olog ogy, y, they they ma may y be cl clas assi siffie ied d ac acco cord rdiing to the pa path thol olog ogy y th they ey do no nott have ve.. Th The e

 

•

physician still try to understand why patients do not behave the way sc ience predicts.

Death shou ould ld be the result of a series

of

noti no tice ceab able le even events ts,, yet sorn sorne e pa patie tient nts s

di die e sudd dde enly and with ithout a previous dise sea ase. In the the cases whe here re de deat ath h ov over erco come mes s an ap appa pare rent ntly ly no norm rmal al su subj bjec ect, t, a ph phys ysic icia ian n tr trie ies s to find a s sci cien enti tifi fic c ex expl plan anat atio ion n of the event. If he or she cannat, a flaw will remain in the explan plana atory tory po pow wer of bi biom omed edic icin inee-sc scie ienc nces es.. So Sorn rne e of the ex expl plan anat atio ions ns in the these ma marg rgin inal al ev even ents ts are are qui quite te naiv na ive. e. Pr Prui uitt tt in 19 1974 74 just justif ifie ied d su sudd dden en de deat ath h as an ex expr pres essi sion on of func functi tion onal al dise diseas ase. e. e

mustt reme mus rememb mber er he here re that that func functi tion onal al in in biom biomed edic ical al jarg jargon on is the the op oppo posi site te

 o rg a n i c,

of

which means that a functional disease does not have an anatomo-

path pa thol olog ogic ical al sub substr strate ate or ca caus use. e.

•

Medi Me dici cine ne is a valu valuee-Ia Iaad aded ed sc scie ienc nce. e.

 a

make mak e Judgments ins inside ide this this con contex textt

is to sustain these values. The main jud judgmen entt practiced in biomedieine is the di diag agno nosi sis; s; to car carry ry the the me meta taph phor or furt furthe her, r, the the tre treatm atment ent is the the sen sentenc tence e to wh whic ich h the pati pa tien entt is con onde demn mned ed.. Th The e diagnosis is not wha whatt the the patie tient ne neee eess ssar aril ily y wants nts, but but si sinc nce e he or sh she e wan ants ts a trea treatr trn nen ent, t, ace ceo ordin rding g ta mo mode dem m We West ster ern n so soci ciet ety, y, trea treatm tmen entt ea ean n only be pro provid vided ed aft after er a diag diagno nost stic ic proc proced edur ure. e. Ne Neve vert rthe hele less ss,, many  r oblivious

ta t he

t

t

t hat the knowledge of disease as a philosophieal canstruct is

mean me anin ingl gles ess s He Hess ssla law, w, 19 1993 93). ). Ho How wev eve er, wi with th the the kn know owle ledg dge e of a sp spec ecif ifie ie pa path thol olog ogie ie process thq t appears to be prec precis ise e scien scientif tific ic know knowle ledg dge, e, ther there e is an expe expect ctat atio ion n tha thatt the treatment will be as pre rec cise ise as the na name me of the the disease. Na Nami ming ng is our way of

•

unde un ders rsta tand ndin ing g dise diseas ases es,, but it does not foll follow ow that that the dise diseas ase es will be tre treated.   with th the the in inte tern rns s at the neurology ward by saying that uring my internship we used ta joke wi they used ta make precise anatomical diagnosis in each each pati patien entt only ta presc prescribe ribe barbit barbitura urates tes 1

 

29

•

Even th thou ough gh the the diag diagno nos sjs is central to the practice of medicine, it still does not chan ch ange ge the fact tha that the diagn iagnos osiis repr repres esen ents ts a choiee among a seri serie es of cla las sses. Thes Th ese e classes are grouped when a similarity between two or more elements is

found

King, 1982, p.90). However, many

these classes are construed by

sc scie ient ntis ists ts pr prim imar aril ily y for for thei theirr sc scie ient ntif ific ic us use. e. Bath ph phys ysic icia ians ns an and d pati patien ents ts are mere mere spee sp eeta tato tors rs or inc inciden identtai users

 

the ciassification system. The motion of the

system sys tems s an and d not thei theirr an anat atom omy y fr freq eque uent ntly ly de defi fine nes s a di diso sord rder er

Fraz Frazie ier, r, 1987 1987,, p vii);

the dia diagno gnosis sis is the the proc proces ess s where the the phys physic icia ian n tr trie ies s to de defi fine ne or dete determ rmin ine e what what is th the e di dise seas ase e af afffecti ectin ng the pa pattient ient.. Du Duri ring ng the the di diag agno nost stic ic pr proc oces ess, s, the doct doctor or tr trie ies s to ev eval alua uate te the patient, but no nott to und nder erst sta and him or her. F o r Murphy, disease is a definite construct, while the diagnosis of the

•

Jisease m y n o t be 1981, p.289). The fact is that disease is one of the many sc scie ient ntif ific ic conv conven enti tion ons s that that ha have ve been been de devi vise sed d fo forr pr prac acti tica call purp purpos oses es Mu Murp rphy hy,, 19 1981 81,, p.289). The The at atte temp mptt ta disc discov over er the the dise diseas ase e th that at af affl flic icts ts a pa pati tien entt is the di diag agno nost stic ic pr proc oces ess. s. The cl clin inic ical al reas reason onin ing g in the the clin clinic ical al en enco coun unte terr fl flo ows tr tram am ef effe fect ct to cause. It is rea reason soning ing bac backwa kwards rds from wh what at it is ob obse serv rve ed to what ha had d ca caus used ed it. The The ru rullin ing g outt of cr ou crit iter eria ia and the the ge gene nera rati tion on of diff differ eren enti tial al di diag agno nosi sis s re repr pres esen ents ts the de dedu duct ctiv ive e part o the the di diag agno nosi sis. s. It requires ex expe peri rien ence ce and in info form rmat atio ion. n. Cl Clin inic ical al casu casuis istr try y is esse es sent ntia iall to di diag agno nosi sis. s. Biom Biomed edic icin ine e as aspi pire res s to be a science through gaining precision, just as in the past it aspired to b e an art by acq acquir uiring ing co cohe here renc nce. e. According to Eistein 1978), th the e real diag diagno nost stic ic pro roce cess ss can be char charac acte teri rize zed d as a

•

hypothetic-deductive aCtivity a reit reiter erat ativ ive e ge gene nera rati tion on,, and va valilida dati tion on of hypo hypoth thes eses es,,

and com comple plex x B vitam vitamins ins ta ail of them alike.

 

 

•

wit ith h fo four ur sta tage ges: s:  a fi firs rstt impr impres essi sion ons, s, th that at are very ery shor short; t;  b ea earl rly y gene genera rati tion on of diagnos diag nostic tic hypoth hypothes esis; is;  c oriented collection of new new data data and its its in intterpr rpretati tatio on under the Iight of the generated: and  d evaluation of the hypothe thesis. is. Both the the

pati pa tien entt and th the e phys physic icia ian n expe expect ct a dia iag gnosis sis. Ho How wever ever,, a pre preci cise se id iden enti tifi fica cati tion on of a disease is not always obtained. Moreover, Wh Whit itbe beck ck 1981) contends tha that di diag agno nosi sis s do does es not not have have a purpo urpos se in itself. The si simp mple le dete determ rmtn tnat atio ion n of the the natu nature re o f a disease only contributes to the general goals o f clinical medicine. The diag diagno nosi sis s is impo import rtan antt fo forr th the e pati patien entt in th the e valid validati ation on

 

the sic sick-ro k-role. le.

How Ho w a phys hysicia ician n rea reaches a dia iag gnosis is still till un unde derr debate. The reasoning unde un dert rtyi ying ng th the e decisi decision on-ma -makin king g proc proces ess s need eeds, for for the sake of bi biom omed edic icin inee-sc scien ience ce,, a bett better er expl explan anat atio ion, n, sinc since e it appe appear ars s to b e par parado adoxic xicall ally, y, the the wea weakes kestt and the the mo most st t

•

crucial part of th the e bio iome medi dic cal health care process. It is crucia iall becdu cduse it is based on the diagnostic label furnished by the physician tha that the system will act; it is weakest because i t is a subjective decision triggering objective measures.  Prob  Pr obab abililis isti tic c re reas ason onin ing g reli relies es on th the e stat statis isti tica call rel relati ation ons s betw betwee een n c1inical variables and is fr freq eque uent ntly ly used used in fo form rma ai calc calcu ula lati tion ons s of di dise seas ase e li lik kel elih iha aods. ods. Pro roba bab bil ilis isti tic c re reas ason onin ing g is espe especi cial ally ly usef useful ul in evok evokin ing g di diag agno nost stic ic hy hypo poth thes eses es an and d in asse assess ssin ing g the sig ign niti tic cance of clinieal findings and test results. Causal reasoning builds a physiologie model and assesses a patienfs findings for coherence and comp co mple lete tene ness ss ag agai ains nstt the mode model; l; it fu func ncti tion ons s es espe peei eial ally ly effec effectiv tively ely in ver verific ificati ation on of di diag agno nos stic tic hy hypo poth thes eses es.. Dete Determ rmin inis isti tie e reasoning co consi nsists sts of se sets ts of co comp mpil iled ed rule rules s gene ge nera rate ted d fr fra am ro rout utin ine, e, we wellll-d -def efin ined ed prac practi tice ces s Kassi Kassire rer, r, 19 1989 89,, 89 893) 3).. The physic physician ian

 

• •

 

constructs a diagnostic hypothesis that he or she will try to prove

 

disprove

throug thr ough h diagno diagnosti stic c pr proc oced edur ures es.. Sinc Since e theoretical concepts such as health and disease are so frequently

used in bi bio omed medic icin ine e, on one e ma may y co conc nclu lude de tha thatt th the ey are impo import rtan antt fo forr th the e bi biom omed edic ical al deci de cisi sion on-m -mak akin ing g pr pro oces cess as weil. Accor cordi din ng to Hessl slo ow (1993), th that at is not true. Thes Th ese e theo theore reti tica call noti notion ons s ar are e ir irre rele leva vant nt when when de deci cisi sion ons s su such ch as tre treatm atment ent are are to be made. Th Thes ese e no noti tion ons s ma may y be useful in generic terms, but only as a reference to a class of elements. The decision-making process of a physician is based upon differ dif ferent ent co conc ncep epts ts th than an th thos ose e

 

the patient. To make a diagnosis is to engage in

a her erm meneu neutic process, where interpretation skills are integral in associating scie scienc nce e with the the pa pati tien entt s st stor ory y (Bowman, 19 1992 92). ). The ph phys ysic icia ian n s subj subjec ecti tivi vity ty pl play ays s

•

a majo majorr raie in this this compara comparativ tive e and ev eval alua uati tive ve proc proces ess. s. Accor Accordin ding g to Ridd Riddere erekh khof offf (1993), the diagnostic process follows Baconian Uinduction by enum enumer erat atio ion n re reas ason onin ing: g: de depa part rtin ing g tr trom om co conj njec ectu ture res, s, one pr proc ocee eeds ds ta gath gather er empi empiri rica call ev evid iden ence ces s to su p po rt or dismiss the initial conjectures. This process is implied by the ir irre repr prod oduc ucib ibil ilit ity y and specul ula ative nature of the stra trate tegy gy when used or applied in bi biom omed edic icin ine. e. At the sam same e ti time me,, thi his s re reas ason onin ing g al allo low ws gre great ater er tle tlexib xibili ility ty in answ answer erin ing g patients needs. The ob obje ject ctiv ives es of the diagnostic ar are e ta cl clas assi sify fy,, measur measure, e, un unde ders rsta tand nd an and d eval ev alua uate te.. To reach a di diag agno nosi sis, s, a phys physic icia ian n mu must st acqu acquir ire e

t

ts

selectively select ively and and in a

certa certain in seq sequen uence. ce. In addition, this mu must st be done in a cert certai ain n ti time me fram frame e (Murphy,

•

1997). No matt matter er what hat th the e pr pro oce cess ss of me medi dica call reasoning is, it is al alwa ways ys val alu ue-Ia e-Iade den n

 

 

•

(Pe Pellle legr grin ino o an and d Th Thom omas asma ma,, 1981). Me Medi dica call rea eas son onin ing g is the theref refore ore infl flue uenc nced ed by exte ex tema mall fact factor ors s si sinc nce e va valu lues es ar are e ac acqu quir ired ed.. At the the en end d of the clinical en enco coun unte terr and, hope peffully, afte afterr a diag diagno nosi sis s is made,

treatment follows. The treatment is a process during which physicians match patients to av avai aila labl ble e tr trea eatm tmen ents ts.. Ster Stern n and Tr Traj ajte tenb nber erg g (1998) recognized two patt pa tter erns ns of tre treatm atment ent be betw twee een n  1) ph phys ysic icia ians ns with a sm smal alll po port rtfo foli lio o of eho hoiice ces s, and (2) those with ma many ny ehoices. Doctors with a larg arger portfolio were more sensible abou ab outt their pa pati tien ents ts needs. At any rate, the eff ffic icie ien ncy of the matching process depends on the sk skil illl an and d kn know owle ledg dge e

 

each ea ch par partic ticul ular ar ph phys ysic icia ian. n. Wh When en ch choo oosi sing ng

a druQ, ph phys ysic icia ians ns te tend nd to eo eons nsid ider er th the e cura curati tive ve effe effect ct as the the on only ly crit criter erio ion n of choi choiee ee (Lilja, 1987). It mu must st be noted tha hatt th thiis cur urin ing g effe effect ct is defi fin ned ins inside ide biomedicine,

•

with onl nly y in ind direc irectt linKs to the patient, the ultimate user, or beneficiary, of the treatment. One of the the be beha havi vior ors s lin linked ta th the e ph phys ysic icia ian n is the the ther therap apeu euti tic c be beha havi vior or.. This This in incl clud udes es gi givi ving ng ad advi vice ce,, ex expl plai aini ning ng,, disc discus ussi sing ng,, an and d lilist sten enin ing. g. Ho Howe weve ver, r, on one e mus mustt be awar aw are e tha hatt ph phys ysic icia ians ns are trained in scienc nce es, bu butt no nott in li list sten enin ing g (Fur (Furst st,, 1998, p.235). Parsons (1964) states that the physician centers his or her raie on the lIres Irespo pons nsiibi biii iity ty for th the e we welf lfar are e of th the e patien patientt in the the se sens nse e of faci facili lita tati ting ng his rec recov over ery y fram iIIness to the best of the physician s ability (p.447). This almast idyllic desc de scri ript ptio ion n leads us ta the term  i11ness. The ha harrdd-e eor ore e science, added ta th the e un unce cert rtai aint ntie ies s of the the prac practi tice ce,, ha has s ta be

•

contrasted with th the e meta tap pho horric la lang ngua uage ge of the pa pati tien entt. Th The e sp spee eech ch of the patien ient is metaphorical, as is any speech. This metaphor is thought ta be analyzed

 

•

 

obj bje ectively by biomedicine through propaedeutics. The results of th the e clinical examinatio exami nation n add added ed to the quan quanti tita tati tive ve and qu qual alit itat ativ ive e tests tests become become more imp impor ortan tantt th an an any y ot othe herr com ompl plai ain nt or obse observ rvat atio ion n made made by the pat patie ien nt. For ex exam ampl ple e so sorrne

intten in ens siv ive e ca care re un unit it pat atiient ents di die e de desp spit ite e havi having ng ex exh hib ibit ited ed no norm rmal al la labo bora rato tory ry ex exa ams. ms. The objective result obtained m a y or may not coincide with th the e sub subje ject ctiv ive e comp co mpla lain ints ts of the patient; ne neve vert rthe hele less ss it is th the e obje object ctiv ive e resu result lt th that at will ill defi define ne the presence

 

absence of disease and it is this disease that will be treated. The

physic sician tr trea eats ts the disease th that at he or she fin inds ds   nd no nott th the e one the pati patien entt ac actu tual ally ly has.  n othe otherr words tth he tr trea eattme ment nt is directed at the di dise seas ase e that is found ound by the physician; it is no nott directed at th the e iIIness the pati patien entt has. St Stil illl it is im impo port rtan antt to note note th at the physician alone c hoos es what is or is not important in th the e pat atiien entt s

•

di disc scou ours rse. e. Th This is simu simult ltan aneo eous usly ly ob obje ject ctiv ive e an and d su subj bjec ecti tive ve choi choice ce af affe fect cts s the deci decisi sion on maki ma king ng process. Language ac acts ts as th the e sol sole medi mediat ator or be betw twee een n natu nature re an and d sc scie ienc nce. e. ln a pr prot otot otyp ypic ical al co cons nsul ulta tati tion on in info form rmat atio ion n flows fi firs rstt from the pati patien entt to the physician an.. Th The e la lattte terr processes th this is in info form rmat atio ion n and ch chan anne nels ls it back to th the e pati patien entt the e form of a proposed tr trea eatm tme ent nt.. The The information received by th the e physician in th cons co nsis ists ts of a se sett of obj bjec ecttive ive data data re rela lati ting ng to th the e di dise seas ase/ e/il illn lnes ess/ s/si sick ckne ness ss mixe mixed d with a set of sign signif ifie iers rs co con nve veyi yin ng   il the em emot otio iona nall load   nd ex expe pect ctat atio ions ns tha thatt the pati patien entt might mig ht ha hav ve. Th The e ph phys ysic icia ian n g gene eneral rally ly uni unilat latera erally lly cho choose oses s whic which h inf informa ormation tion upon whic wh ich h to ba base se his or her de deci cisi sion on ma maki king ng proc oce ess. Usua Usuall lly y the in info form rmat atio ion n th that at is re rega gard rded ed as re rele leva vant nt to the clin clinic ical al situ situat atio ion n is ac acce cept pted ed and th the e rema remain inde derr is si simp mply ly

•

di scarded

no matter the impor tanc e i t may have to the patient. Wh at is

subsequently subsequentl y pr proc oces esse sed d in bi biom omed edic icin ine e is thus not the se self lf of the pat atiient bu but   n

 

•

ima mag ge of th the e patient s body. 1 Th The e co cons nseq eque uent nt info inforrma mati tion on that that will be se sent nt ba bac ck ta the pa pati tien entt--t -the he trea treatm tmen entt--a -alr lrea eady dy stri stripp pped ed of the orig origin inal al sign signif ifie iers rs,, rega regard rde ed as variables, is furth further er depers depersonaliz onalized ed by th the e sta statist tistiica call as assu sump mpti tion ons s of the the biom biomed edic ical al

m ethodol ogy that presuppose a tight control on ail variables. Therefore, the di diag agno nosi sis s and tr trea eatm tmen entt ar are e ai aime med d at a se sellfle fless patie atient nt.. For Nor Norden dentelt telt,,

 

say sa y that that one has a disease is to say something differ ferent

and m ore specifie th a an n ta sa y that one is iII

p.282) 2).. Th The e ma main in dist distin inct ctio ion n 1993, p.28

betw be twee een n dise diseas ase e an and d iII iIIne nes ss in bi biom omed edic icin ine e is tha that dise diseas ase e is a ma malf lfun unct ctio ioni ning ng of th the e biological appara aratus whereas iIIness is a reaction at the human level ta this disease dis ease Kl Klei einm nman an,, Ei Eise senb nber erg g an and d Goo ood, d, 1978). Dis Diseas ease e is sh shap aped ed biom biomed edic ical ally ly where rea as iIIness is shaped culturally. The different levels of specificity cited by

•

Nordenfelt, th that at is by one dise isease se---a specifie patho-physiological entity--ma may y th ther eref efor ore e give rise to di diff ffe ere rent nt illnesses. Disease refers to abnormalities in the st stru ruct ctur ure e an and/ d/or or fun unct ctio ion n of or orga gans ns and organ sys systems tems.. The path atholo ology indica dicattes whet wh ethe herr or no nott the hey y ar are e cu cult ltur ural ally ly re reco cogn gniz ized ed,, which is the the are arena of the biom biomed edic ical al mod mo del. el. IIIness, conversely, refers to a person s perception and experiences

 

certain socially disvalued states that include, but are not Iimited ta, disease. Sic ickn kne ess is a bl bla ank nket et term used ta label events involving disease an and d/or /or iIIness   Young Young,, 19 1982 82). ). The Th e cultu turral me mean anin ings gs of di dise seas ase e and iIIness are are also diff differ eren entt Kleinma inman n, 1988). A disease m a y o r m a y n ot correspond ta an iIIness and vice-versa. A

•

Biomedicine Biomedic ine str strugg uggles les wi with th th the e incorporation of a self into a pa patie tient nt s body. Mind-body dualism is fundamental in the Cart Cartesia esian n thought thought from which bio biomed medicin icine e derived derived its methodology. To all allow ow the simul simultan taneo eous us expres expressio sion n of mi mind nd an and d body is ta add uncontrollable variables into the clinical clinic al equatio equation. n. Part of th this is problem is discussed in Kleinman  1986).  l

 

35

•

di dise sea ase ma may y exist wi with thou outt a co corr rres esp pon ondi ding ng illness; ss; an and d illne llness ss ma may y ex exiist withou outt a dise diseas ase. e. Pa Pattie ient nts s id iden enti tify fy th them emse selv lves es as ill on only ly if the dise diseas ase e is se seri riou ous s enou ough gh to somehow in incap capaci acitat tate e th them em by  1 beco becoming ming und undesi esirab rable, le,  2 en enti titl tlin ing g to spec specia iall

tr treat eatme ment nt,, or  3 be becom comin ing g a valid ex excu cuse se fo forr a crit critic iciz izab able le be beha havi vior or (B (Boo oors rse, e, 19 1975 75). ). Diseases and iIInesses are employed as metaphors and used within meta me taph phor oric ic language. Metaphors, which include metap apho hori ric cal language, are ex expl plan anat ator ory y too oolls (H (Hes esse se,, 1970). We must be aware are tha thatt dise diseas ase e an and d iIIness are are no nott entities   r s

th they ey ar are e ex expl plan anat ator ory y mod models els12 mi mirro rrori ring ng mu mult ltililev evel el rel relat atio ions ns be betw twee een n

a separa separate te comp comple lex, x, fl flui uid, d, tot otal al phe phenom nomeno enon: n: sick sickne ness ss (Kl (Klein einman man,, Eisen Eisenber berg g an and d Good Go od,, 197 978 8 p.252). Th They ey answer ob obje ject ctiv ive e and su subj bjec ecti tive ve qu ques esti tion ons s ab abou outt why, how an and d when the ep epis isod ode e occurred. The ex expl plan anat ator ory y mo mode dell is, in ot other her words ords,, ho how w

•

each of the people who intervene in the iIIness proc oce ess, live and understand the sic si ckne ness ss.. Whil ile e the physician s explanatory model is based on the disease, the pati pa tien entt s is centered in th the e iIIness (B (Bal alle lest ster er and Pe Perd rdig igue uero ro,, 19 1992 92). ). Fo Forr the pa pati tien ent, t, ther there e is no such thing as a specifie di dis sea ease se,, there is on only ly his or he herr pers ersona nall illnes lness s. The Th e di diag agno nosi sis s is on onlly important in its raie as a tool for eliminating iIIness. Both mode mo dels ls are are eulturally eonditioned and of offfer the ne nece cess ssar ary y tools for evaluating commun com munica icati tion on str strate ategi gies es and soci social al ro role les. s. The Th e stat state e of iIIness is seen as a co comp mpllex co cont ntex extt th that at inc nclu lude des, s, as asiide trom th the e intri rins nsiically patho-physiological pheno

 

s ~

one s personal emotional

comp comple lexi xion on,, soci social al ne netw twor ork, k, and ph phil ilos osop ophi hica call issu issues es.. Ho Howe weve ver, r, fe feel elin ing g ab abno norm rmal al

•

Explanatory models are th the e notions tha thatt patien patients, ts, fami famililies es and practitioners ha have ve abo about ut a specifie iIIness episode (Klein man, 1988, p.121).  2

 

 

36

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does not make someone a sick person automatically. This abnormality m u s t reach a thre thresh shol old d be beyo yond nd whi hich ch the the per ers son will se seek ek relief. At this moment, th the e person is tran transf sfor orme med d int nto o a pa pati tien entt in the the cons consul ulta tati tion on or clin clinic ical al en enco coun unte ter. r. Bi Biom omed edic icin ine e is a de dete term rmin inis isttic scie scienc nce. e. 13 This means that sorne cause

determ det ermine ines s sorn sorne e effe effect ct in a dir direct ect re rela lati tion onsh ship ip.. Th Ther ere e is no op opti tion on or fre freedo edom m in the path pa thoo-ph phys ysio iolo logi gica call pr proc oces ess: s: on once ce a ca caus use e is in place, a mo morb rbid id ph phen enom omen enon on will succ succee eed. d. Ph Phys ysic icia ians ns ar are e tr trai aine ned d to thi think this this way. Biom Biomed ediical cal scie scient ntis ists ts de desi sign gn th thei eirr expe peri rim ments nts this way. The here re is no other option in the current biomedical norm. Bi Biom omed edic ical al scie scienc nce e mov moves es fro rom m ob obse serv rvat atio ion n an and d disc discov over ery y to ne new w ob obse serva rvati tion ons s an and d discov dis coverie eries s th thro roug ugh h evid evidence ence an and d stat statis isti tical cal man manipu ipulat lation ion o da data ta (Jo (Jons nsen en,, 1993, s2). Wi With thou outt co comp mple lete te kn know owle ledg dge e of the en enti tire re do doma main in,, the prac practi tice ce of biom biomed edic icin ine e •

m u s t fi fill in the blanks. As Gelfand indicates, the di dise seas ase e is far far tr

s t a

t

~

of scie scient ntif ific ic kno knowl wledg edge e about

pert pe rtec ectt and will pr prob obab ablly re rema main in so fo forr ce cent ntur urie ies, s, an and d wh whil ile e this his

is the ca case se no sto stone ca can n be left eft un unttum ume ed wh wher ere e the pat atiients health is co conc nce erne rned, ev even en if the the no nons nsci cien enti tifi fic c me meth thod od is a thorn in the the fl fles esh h of th the e scie scient ntif ific ic doct doctor or (196 (1968, 8, p. 46). In other wo word rds, s, in a sc-e sc-eal alle led d de dema mand ndin ing g an and d inno innova vati tive ve sci scient entif ific ic en ende deavo avorr thatt is do tha dom min inat ate ed by the rigors of the scie scient ntif ific ic met etho hod d, phy hysi sici cian ans s are are frequ requen entl tly y unscientific. Causality is on e o f the comerstones o f modern medicine (Rizzi and Pede ders rsen en 19 1992 92). ). Th The e tr trad adit itio iona nall ca cau usa sall ev evol olut utio ion n of eve vent nts s is:  1 mani manifest festati ation on of di dise seas ase e thro hroug ugh h si sign gns s an and d symp sympto toms ms,, ca caus used ed by  2 the dise diseas ase e it itse self lf,, ca caus used ed by

•

Determinis Determ inism m mean means s that suff sufficien icientt infor informat mation ion  l t allo ws pred predic icti tion on of a spec specif ifie ie re resu sult lt at a o allows latterr time latte time t - Ca Caus usal alit ity y me mean ans s that that a spec specif ifie ie prec preced edin ing g ev even entt (or cau ause se ) fo forr ev ever ery y ef effe fect ct o (Cushing. 1989 p 10  3

 

 

•

path thog ogeni enic c me mech chan anis ism m c cau ause sed d by  4 an etiology. Rizzi and Pe Pede ders rsen en add  3 a pa therapeutics to this model

which almost reverses the events: the more it

appr ap proa oach ches es etiology the more it is thought to be causal and the grea eatter the

know kn owled ledge ge ab abou outt the di dise seas ase. e. However as Rizzi and Pedersen in indi dica catte multi factoria fact oriall dise diseases ases are com common monly ly re reco cogn gniz ized ed to toda day. y. Ne Never verth thele eless ss inve investig stigator ators s still still explo ex plore re a Iim imit ited ed nu numb mber er of et etio iolo logi gic c fact factor ors s si sinc nce e se seek ekin ing g a general ca caus use e an anddef effe fect ct relation would ge gen nerate in inn numer erab ablle variables. Which factors would be chos ch osen en re rema main ins s a per ers sonal and thus va valu lue e Iad ade en choiee. Biomedicine is a syst system em;; we have no now w defined sorne of the terms that that are used in the exercise of the profession. The university setting provides the •

des criptions o f a specifie pathology its signs and symptoms its relevance in the long term health of the patient or population its treatment and the ex expe pec cted outcome outc ome tro rom m th the e th ther erap apeu euti tic c pr proc oced edur ures es.. No Noti tions ons su such ch as effi effica cacy cy e eff ffic icie iene ney y cur cure e and health are part of a cultural vocabulary that pertains to biomedical pr prof ofes essi sion onal als. s. The evaluation or ju jud dgmen entt

of wha hatt constitutes no norm rmal alcy cy or

abnormalcy in the the ph phys ysio iolo logi gica call be beh hav avio iorr of a pa pattie ient nt is the le legi gittima matte ex exer erci cise se of the bi biom omed edic ical al pr pro ofes ess sio ion n. In sum tth hen th the e biomedical system defin efine es the st stan anda dard rd of ca care re tha hatt is going ta be u sed by bio biomed medica icall prof profes essi siona onals ls.. The stand standard ard of care is a biomedical cultural tool that is used ta eval uate the cul ulttures ures of the population in general; in ar arde derr ta know how ta use this this bi biom omed edic ical al cu cult ltur ural al tool tool o one ne

•

must mu st ac acqu quir ire e th the e bi biom omed edic ical al cu cult ltur ure e and be li lice cens nsed ed to prac acttic ice e bi biom omed edic icin ine. e.

 

 

•

Sect Se ctio ion n III

THE BI BIOM OMED EDIC IC

L CU CULT LTUR URE E

Professions are oc occu cupa pati tion ons, s, pro roc cess esses, es, and id ideo eolo logi gies es Clar Clarke ke,, 1990). Biom Biomed edic icin ine e is more. It is a culture and a society. Still, according to Clarke,

medi me dic cine ine in Canada dete determ rmin ines es it its s own standards rds for for educatio tion and tra training. Its pr prac acti tice ce in invo volv lves es legall legallic icens ensin ing; g; th this is lilice cens nsin ing g proc proce ess is ma mana nage ged d by the the memb member ers s of th the e medi medica call profe fes ssion. Fu Furt rthe herm rmor ore, e, th the e memb member ers s

the the medi medica call prof profes essi sion on

 

voic vo iced ed th them emse selv lves es stro strong ngly ly in th the e shap shapin ing g of th the e le legi gisl slat atio ion n affe affect ctin ing g the the prof profes essi sion on,, sa practi practitio tioner ners s are no now w rela relative tively ly free free tr

la lay y contr ontrol ol and and eval evalua uati tion on.. Clar Clarke ke ad add ds,

UPhysicians are self self-r -re egula gulati tin ng. This mean means s tha that thro throug ugh h thei theirr orga organi niza zati tion on they deci de cide de what constitutes good medical practice, dete determ rmin ine e the require irements for for

•

tr trai aini ning ng a phys physic icia ian, n, set stan standa dard rds s of pract ractic ice, e, and dis discip ciplin line e coll collea eagu gues es who depa depart rt fr from om th thes ese e sta tand nda ards rds

p.2 p.213 13). ). On the same issue, Murphy states that the

bi biom omed edic ical al pr prof ofes essi sion on claims claims ta be the most re reli liab able le auth author ority ity on the na natu ture re of the re real alit ity y it deal deals s with The bi biom omed edic ical al pro profe fes ssio ion n has the the ap app pro rov ved mono monopo poly ly of the right ta define health and illness and ta trea treatt iIIn iIInes ess s

1997, p S

The Th e power

biomedic biom edicine ine has has is polit itiical; it can contro trol the state tate to ma main inta tain in its pree preemi mine nenc nce. e. A ward of cauti aution on should be ad adde ded d here: bi biom omed edic icin ine e is not not the only self self-r -reg egul ulat atin ing g profession in Canada. Sorne parts of this monograph can be applied ta other pr prof ofes ess sio ions ns as weil. How However, er, a cri riti tic cal evalu lua atio ion n of the the bio iom medic edica al prof profe ess ssio ion, n, and not not of ot othe herr professions, is the objective of this paper.

•

Professional standard rds s generate specifie behaviors. The physician is expe ex pect cted ed ta beha behave ve in a spec specif ific ic cult ltu ural and social mann manner er,, which is lea leamed med from rom

 

•

 

peer s d u r i n g t he long hours aler ted,

of

studyin ing g and duty in university hospit ita als ls.. Platt

yo un g men trained in t h he e t ec h ni qu es

of

s c i e n c e ma y b e c o m e m o r e

in inte tere res ste ted d in the disease than han in the patient. This This is a part rtiicular dang danger er in whole ti time me pr pro ofe fess ssor oria iall units, part rtly ly beca becaus use e of th the eir pre reo occup cupati tio on with mech mechan anis isti tic c

scie scienc nce e and and partl tly y beca becaus use e th they ey are out out community (1963, p

of

touch with medic icin ine e as it exists in the

7). Th This is warn warnin ing g was written before fore modern bioet ioethi hics cs and

consum con sumer er moveme movements nts to took ok plac place, e, and and when when doub double le-b -blin lindd-ra rand ndom omiz ized ed-t -tri rial als s were were a novelty ty.. By then, physicia ician ns sti till ll we were re consid nsider ere ed tr tru ustf tfu ul. Brody and Fl Flet etc cher her state, liA un univ ive ersit rsity y hospital is not an egal egalit itar aria ian n st stru ruct ctur ure. e. The The peop eople at the uppe upperr end of th the e hiera ierarc rchy hy have more more contr ontrol ol than tho those  t the the lo lowe werr end (199 (1993, 3, p.30 p.30). ). This cont rol shapes the bi omedi cal culture. Physicians suffer a process o f

•

in indo doct ctri rina nati tion on th tha at ta tak kes th them em Students

 r

th the e comm common oner ers s wor world into the the hospit ita als ls..

ou t of

selected by theïr f uture paars in a selecti on process ruled by the

pr prof ofes essi sion on.. They They acqu acquir ire e th the e bi biom omed edic ical al cu cult ltur ure e in facu facult ltie ies s ru rule led d by the the prof profes essi sion on,, fr fro om a curr curric icul ulum um built with Iittl tle e

or

no help fr frcm cm outs outsid ider ers. s. St Stu udent dents s in inte tera ract ct with

pati pa tien ents ts only when th the e patien tients ts ar are e req require uired d as too tools for for the st stud uden ents ts ac acqu quis isiti ition on of ex expe perie rienc nce e and as prac practi tica call examp examples les an espri ritt e orp rps s in th the eir lon long hou hours

of

of

th the e effe effect cts s

of

treat tre atme ments nts.. Studen Students ts buil build d

work tha that sets them apart from the the rest

of

th the e societ society y (Goo (Good d, 1995). 95). G o o d demonstrates t h at bi omedi ci ne has a cul ture of its own, with its part pa rtic icu ular lar lan language, accepte ted d rituals, and respected ted hierarchy. Fur Furthe thermo rmore re,,

•

biome bio medi dici cine ne best bestow ows s ti titl tle es, insist insists s on co conf nfid iden enti tial alit ity y and and se secr crec ecy y of it its s re rela lati tion onsh ship ips, s, has its own own dr dra ass code, and, what what is more more im impo port rtan antt for this this paper, form formul ulat ates es the the

 

 

•

h u m a n b o dy

 n

disease

in

a culturally dist istinc ncttive ive fashion

 

p.65). Since

bi biom omed edic icin ine e is a We West ster ern n cu cultu ltura rall syst system em,, its its or orga gani niza zati tion on re refl flec ects ts the hier hierar arch chic ical al sy syst stem em of so soci ciet ety y Kahn, 19 1995 95). ). Whatt consti Wha stitut tutes a va vali lid d sc scie ient ntif ific ic ar argu gume ment ntat atio ion n insi inside de biome biomedi dica call scie scienc nce e

is also also cult ltu urall rally y bound. Biom Biomed edic ical al scie scienc nce e is a dist distin inct ct society ev even en among the othe otherr sci cie enc nces es.. Medical arti articl cles es cann cannot ot be read with the the sa same me lens lenses es used othe otherr sc scie ient ntif ific ic papers. The logi logica call de desi sign gn of bi biom omed edic ical al pa pap per ers s induct ind uctive ive de desi sign gn,,

in

is

of an informai and

on

mass ma ss me medi dia, a, Parenti nti 1989) sta stated ted

t hat somebody s competence was in part measured by the ability

•

 n

read

contrast with the formai and deductive design of the other

sc scie ienc nces es Ve Vela lano novi vitc tch, h, 199 1993). 3). Com Comment menting ing

some so meth thin ing g from

to

to

report

ideo ideolo logi gica call lly y ac acce cept ptab able le pe pers rspe pect ctiv ive. e. Fu Furt rthe herm rmor ore, e, on one es

pro opo port rtio iona nall to the the degree auto au tono nomy my is directl   pr

o

comp mplliance with the offici icial

perspective. This behavior is also warranted by an on-the-job ideological indo indoct ctrin rinat atio ion. n. Co Cons nseq eque uent ntly ly,, Pa Pare rent ntii ar argu gues es th that at jouma joumalist lists s ide ideolo ologic gically ally ref reflec lectt the the cons co nsol olid idat ated ed id ide eolo ology in the their ir repo porrtin ting. Wh Whil ile e Pa Parren enti ti does no nott refe referr to scie scient ntif ific ic publ pu blic icat atio ions ns or biom biomed edic icin ine, e, on one e ca cann nnot ot stop stop won onde deri ring ng if this ideo ideolo logi gic c pre pressur ssure e does do es no nott exist, which ma make kes s so some me su subj bjec ects ts more publishable than othe herrs and at leas leastt dete determi rmine nes s the acc accept eptabl able e fo form rmat at.. Biomedicine is inde indeed ed se self lf-c -con ondu duct cted ed.. Th Ther ere e is no me medi dica call pra practi ctice ce with withou outt a doct doctri rine ne:: it generates hypo hypoth thes eses es and prov provok okes es rese resear arch ch Boin oinet, et, 19 1911 11). ). If so sorn rne e defend the the idea that there is no nott

•

 n

offici off icial al doc doctri trine, ne,

 t

leas leastt it is indi indisp sput utab able le that that

there exis ists ts a body of pro rofe fess ssor ors s and re rese sear arch che ers that that re rece ceiv ive e a man manda date te fram the the st stat ate e to te teac ach h

 n

to

look look for be bett tter er ways to figh fightt dise diseas ase e  n ma main inta tain in pu publ blic ic hea health lth

 

4

•

(Col (C olli lin, n, 1935). Furthermore, research is l dominated by la larg rgee-s scal cale labor ora atory proje jec cts, often financed by govemmental agencies, private foundations an and d in indu dust stry ryJl Jl (Lindh (Lindhal, al,   992 p.97), which ma make kes s it cle lear ar th that at other in intter eres ests ts,, beyond thos those e of the the profe rofess ssiion onal al and the the client, are are pre rese sen nt. Scie Sc ient ntis ists ts maintain a highl ighly y eff effici icien entt informai network of co comm mmu uni nic cat atiion

(Cra (C rawf wfor ord, d, 19 1971 71). ). It would be na naïv ïve e ta pre pretend tend th that at th this is we web b doe oes s no nott id ideo eolo logi gica call lly y in infl flue uenc nce e the wh whol ole e fiel ield. Alt Althou hough gh no on one e st stat ates es th that at a fo form rmai ai le lead ader ersh ship ip exis existts in bi biom omed edic ical al scie scienc nce, e, the ex exis iste tenc nce e of op opin inio ion n le lead ader ers s is un unde deni niab able le as in any ot othe herr fi fiel eld d (Crane, 1972), esp spe ecial cially ly when we reme rememb mber er th that at mo most st pu publ blic icat atio ions ns in a certain field are rarely cited while only a few are frequently used as reference. Scienti Sci entists sts ar are e attr attrac acte ted d to an area where influential peers set the agenda, train

•

st stud uden ents ts,, an and d ma maiintai ntain n info inforrma maii co cont ntac acts ts,, wh whic ich h th thus us so soli lidi difi fies es th thei eirr in infl flue uenc nce. e. Thi his s is the the so-eafled invis visible co coll lleg ege e ; scie scient ntis ists ts ou outs tsid ide e th this is ci circ rcle le ha have ve gre great at di diff ffic icul ulty ty

publ pu blis ishi hing ng an and d ga gain inin ing g influ influenc ence e an and d imp import ortanc ance e in the fi fiel eld. d. Th Thes ese e op opin inio ion n le lead ader ers s mediate the transfer of information ta the public (Crane, 1972). Somehow, this in invi visi sibl ble e co coll lleg ege e is resp respon onsi sibl ble e for the po posi siti tivi vist stic ic ex expe pect ctat atio ions ns th that at are ge gene nera rate ted d by the the pu publ blic ic.. The bi biom omed edic ical al field is thus thus fram framed ed by th the e th theo eore reti tici cian ans s and pr prof ofes essi sion onal als s of biomedicine. They point t o what may o r may not pertain to the domain of bi biom omed edic ical al science. The de defi fini niti tion ons s pertaining to and delimiting the field of bi biom omed edic icin ine e ar are e obtai btain ned or elab elabor orat ated ed ba basa sad d on the th theo eore reti tica call pr prin inci cipl ples es on which

•

bi biom omed edic icin ine e is fou oun nde ded: d: sci scient entif ific ic me meth thod od an and d stat statis isti tica call in infe fere renc nce e an and d de dedu duct ctio ion. n. The use

 

purpose of this knowledge is also determined from the inside of

 

•

biom biomed edic icin ine e to the the out outsid side us use ers or, more more tech techni nica call lly y spe peak akin ing, g, the pati patien entt. One must mu st note here that that the patient is a passive ac acto torr in this whole process.   He

or

she

is used to obtain data, and is again used to apply techniques, procedures, o r reg egim ime ens ns.. Th The e fra rami ming ng,, the de defi fini niti tion on,, and the the us use e of biom biomed edic icin ine e are inde indepe pend nden entt of the the lay lay public. Th The e definition of the the standard

o

care, and and th the e decisio sion to allo alloca cate te

blom blomed edic icln lne e as the the offic fficiial he heal alin ing g syst system em was also also made made inde indepe pend nden entt of outsid outsiders ers  Freidson, 1988; Furst, 1998; Murphy, 1997). On One e mu must st note that hat the pati patien entt is only only a remo remote tely ly inte intere rest sted ed observer until the mome moment nt whe when he or she needs the serv servic ices es of the the syst system em Last, 1981). Ali t he knowledge used in clinical practice emanates

tr

biomedical

scie scienc nce; e; the the ph phys ysic icia ian n stru strugg ggle les s to ad adapt apt an idea ideali list stic ic st stan anda dard rd of care care obta obtain ined ed in

•

an ideal patient designed to reach an ideal ou outc tco ome in his

or

herr dow he down-t n-to-e o-eart arth h

ever ev eryd yday ay prac practi tice ce.. According to Froom and Froo Froom m, the prevalence, cour course se and prog progno nosi sis s of dise diseas ases es in pa pati tien ents ts referr ferred ed ta te tert rtia iary ry medi medica call cente enters rs fr freq eque uent ntly ly differ dif fer from from thos those e trea treate ted d in pr prim imar ary y ca carre sett settin ings gs.. Extr Extrap apol olat atio ion n of fi find ndin ings gs fr from om one popu po pula lati tion on ta an anot othe herr may may ther theref efor ore e be unwar unwarrante ranted d

1992, 1992, p. p.255 255). ). In th the e Unit United ed

State ates and Canada, referral canters are seen as the sole source of biomedical know kn owle ledg dge; e; ho howe weve ver, r, the gene genera rali liza zati tion on of this this kn know owle ledge dge to pr prim imar ary y care care settin settings gs crea create tes s se seri riou ous s disc discre repa panc ncie ies. s. Ac Acco cord rdin ing g ta Br Brod ody y 1992), this his prov oviides a so sour urce ce primar mary y care care is expected of tais taise e ce cert rtai aint nty y and is a fals false e scien cienc ce: the ph phys ysic icia ian n in pri ta apply the knowledge generated in referral centers, where certain tools o r

•

noted d however Patient is a techni technical cal term denating the diseased. Its etymolagy should be note sinc since e it its s ro roat at sugg sugges ests ts pass passiv ivit ity y when facing adv adversi ersity ty see Gave p.1655 .  · t

 

•

·B

meth me thod ods s are wors worshi hipp pped ed.. The kn know owle ledg dge e th tha at orig origin inat ates es in te tert rtia iary ry cent center ers s is calle called d the the st stan anda dard rd of care care.. Pati Pa tien ents ts lo look ok for ans answers wers that that biom biomed edic icin ine e does does no nott pro provi vid de (Wor (Worsl sley ey,, 1982), since sin ce bi biom omed edic ical al kn know owle ledg dge e pr prod oduc uctio tion n and cultur culture e are fo forr in inte tern rnai ai co cons nsum umpti ption on.. The exte extema mall publ public ic woul would d be id idea eally lly cons consti titu tute ted, d, as in Stims Stimson on s descrip description tion,,  y the

i d e a l p at i en t :

an obedient, passive, and unquesti oning recipient of medi cal

instr ins truc uctio tions ns (197 (1974 4, p. p.97 97). ). Any Any diverg divergen ence ce fr from om th this is mode modell would ould be ca cate tego gori rize zed, d, acco accord rdin ing g ta St Stim imso son, n, as ir irra rati tion onal al in the the Iig igh ht of medi medica call rati ration ona ali lity ty.. This This devia deviant nt pati pa tien entt is se seen en as such such,, from the the ph phys ysic icia ians ns pers perspe pect ctiv ive; e; also also this pers perspe pect ctiv ive e sees sees the the cu cure redl dl , the the norm normal al , the diff diffic icul ultt , the the beau beauti tifu full case 15 and   on. Physic Physician ians s write papers and describe t h es e patients, yet t hes e patients exist in medical •

literature only as carriers of a certain morbid state. T he patients voices still remain outs ou tsid ide e th the e medi medica call pape papers rs.. Biome Bio medic dicine ine,, Iike Iike ot othe herr te tech chni niqu ques es,, attem attempts pts to domi domina nate te th the e envir environ onme ment nt and orga organi nize ze it ac acco cord rdin ing g to human human va valu lues es (Can (Cangu guilh ilhem em,, 1982). Th Thes ese e valu values es ar are e cu cult ltur ural ally ly and so soci cial ally ly rooted. As demo demons nstr trat ated ed abov above, e, the root roots s of bi biom omed edic icin ine e are are in th the e Christian Weste terrn European society a nd nd culture, which later evolved in Chri Ch rist stia ian n North Ame America rica,, where it received its curr curre ent face. The The glo lob bali liz zati tio on of biomedi cal culture, beliefs, values, and met hods was not envisaged  y pro propone onent nts s th that at were were worried in solvin lving g thE

i ~ m e

i

t e

its

heal he alth th prob proble lem m o their

Chri Ch ris sti tia an Wes Wester tern patients. Bi Biom omed edic icin ine e was no t created ted, built, desi design gned ed,, or

•

A beauti beautiful ful case in biomedical jargon is a ty typi pical cal case. case. similar to the ones present in textbooks. usually of a rare or dif diffic ficult ult ta treat disease. In general it is a  bad case trom the patient patie nt s perspect perspective ive..  5

 

•

inte intend nded ed to be a mu mult ltii-c cul ultu turral sys syste tem. m. When dealin ling within its cultural conte ntext, bi biom omed edic icin ine e fa face ces s fe fewe werr valu lue e sh shoc ocks ks,, an and d th the e me meta taph phor oric ical al wo worl rld d ab abou outt the the bo body dy,, self se lf,, and rati tio ona nallity ity remainin ing g the sa same me fo forr both, ph phys ysic icia ians ns and patients. To be mult mu ltii-cu cult ltur ural al,, th the e or orig igin inal al de desi sign gn of bi biom omed edic icin ine e is plac placed ed un unde derr an anot othe herr stre stress ss.. With Wi th the glob global aliz izat atio ion n of trad trade, e, co comm mmun unic icat atio ion n and tran transp spor orta tati tion on ther there e is no long longer er,,

if there ever existed, an isolated nation o r people with its own public health conce con cems, ms, inde indepe pend nden entt of an exte terrnal world (R (Ray aymo mond nd,, 19 1998 98,, p.97). The world, ld, for for ail its di diff ffe eren entt cu cult ltur ure es and societies, is only one; the the tool used to define and face face disease, to interpret iIIness for the system, and to define, describe, obtain and main ma inta tain in and fram frame e no norm rmal alit ity y is th the e We West ster ern, n, Ch Chri rist stia ian n biom biomed edic icin ine. e. Anothe Ano therr majo majorr pr prob oble lem m in bi biom omed edic icin ine e is that that ther there e is a divo divorc rce e between

t

ts

and values (Tyles, 1993 p.731). We Wear ar indicates, Medicine is not only a science

•

and a te hné bu butt a fu fund ndam amen enta tall lly y val alu uee-Ia Iad den hu huma man n en ente terp rpri rise se.. In effec ffect, t, the the asse as sert rtio ion n tha thatt an any y pa part rtic icul ular ar in inte terv rven enti tion on is

~ m e d i

l l y

indicated indic ated mus mustt inco incorpor rporate ate

eval alua uati tio on as assu sump mpti tion on ab abou outt the wor orth thin ines ess s of the the goal of the proc proced edur ure. e. In any an ev given ca case se the ch cho oice ice of an any y par arti tic cul ula ar inte terrvention ion is a valu alue choice and this fact fact abou ab outt an any y me medi dica call ac actt is al alw ways pr pre esen sent, no mat matter ter how obvious obviously ly ap appr prop opri riat ate e the the prop propos osed ed in inte terv rven enttio ion n or ho how w ab abso solu lute te the co cons nsen ensu sus s am amon ong g the the pa part rtie ies s invo involv lved ed (1 (198 981, 1, p. p.27 27). ). Tho m ma as m ma a and Pellegrino (1981) point to three values as crucial to medicine:  1 th the e va valu lue e of th the e in indi divi vidu dual al pa pati tien ent, t,  2 the the va valu lue e

•

 

health, and (3) the the

val alue ue of alt ltrrui uism sm th that at me medi diat ates es the clas class s of pot oten enti tial al pa pati tien ents ts.. Sinc Since e the these are mo mora rall values,   would ad add d at le leas astt two two ot othe herr values:  1 the the se self lf-r -reg egul ulat atio ion n value, an and d  2

 

•

the ac acqu quis isit itio ion n of kn know owle ledg dge e va vallue ue.. Biom Biomed edic icin ine e ac acqu quir ired ed   n offi offici cial al mon monopo opoly ly to defi de fine ne hea eallth and dise diseas ase e and to tr trea eatt them (A (Arrno nolld, 1993, Trenn renner ert, t, 1998). This his mono mo nopo poly ly so some meho how w influenc nce ed the tr tra ans nsffor orm mati ation of a know owle ledg dge e do doma main in into a cult cu ltur ure e that that wa was s elit elitis ist, t, hier hierar arch chic ical al,,   nd ideological. The Th e ta tact ct is th that at clinical practice is th the e in inte terp rpre reta tati tion on of ph phy ysi sica call si sign gns s   nd sy symp mpto toms ms as de desc scri ribe bed d through the lenses

 

the patient and read through the

physicians physic ians ey eyes es.. Thi This s int inter erpr pret etati ation on is ho howe weve ver, r, no nott ob obje ject ctiv ive; e; its su subj bjec ecti tivi vity ty is in infl flue uenc nced ed by be belilief efs, s, kn know owfe fedg dge, e, cu cult ltur ure, e, inf inform ormati ation, on, so soci ciet ety, y, an and d sp spec ecif ifie ie fact factor ors s related ta the mo mom ment when the consultation occurs. Of course, the outcome d ire ct ly depends on the interpretation since an outcome is the result of the trea treatm tmen entt in indi dica catted by a diagno nos sis obtained from   n int interpr erpreta etation tion.. Bio Biomed medica icall cultur cul ture e in inte terp rpre rets ts pa pati tien ents ts cu cult ltur ures es   nd of offe fers rs them the cultural product of the

•

treatm tre atment ent.. Thi This s tre treatme atment nt is offered with ho hop pes of cure. Th The e ph phys ysic icia ian n will try to cure th the e di dise seas ase; e; the patient wants the iIIness ta be eliminated. Th The e result is a major change in the pa pattien entt s Iife; th the e physician is eit either her seen   s the be bene nevo vole lent nt,, be beni nign gn,,   rheroie

me medi diat ator or,, or th the e int ntru rude der, r, a malevolent, or malig aligna nant nt cau cause se of the the ch chan ange ge..

This Th is op oppo posi siti tion on of he heal alth th rela elate ted d issu issues es re requ quir ires es furt furthe herr ex expl plor orat atio ion. n.

Sect Se ctio ion n V

OPPO OPPOS S T ONS ONS

Bi Biom omed edic icin ine e de dea als with oppositions: Iif ife e and death, hea eallth and disease,

•

normal and abnormal, acute and chronic, and ultimately good and evi . This

 

•

mani ma nich chei eist stic ic set set is furt rth her di divi vide ded d according to two two views, that of the the pati patien entt and th t of the physic physicia ian. n.

It is undeniable that biomedicine is the result of a paradigm shift, and ac cording

to

Kuhn

1978 ,

one

p ar a di g m - - i n

our

ca s e

b i o m e di ci ne - - i s

incomm inc ommens ensura urable ble with the former normal science-sch science-scholarl olarly y medi medici cine ne.. If the heal healiing system we use today has evol evolve ved d and tr tran ansf sfor orm med into somet omethi hing ng very very dif differe rent nt

trom trom th thos ose e which existed in th e past, the pat patient has not. However, Kuhn did not refe referr to the observ serve ers outs outsid ide e th e paradigm or no norm rmal al scie scienc nce; e; they they did did not suffer, and an d will neve neverr suff suffer er one one spec specif ifie ie para parad dig igm m shif shift. t. For For the the unin uninit itia iate ted, d, the pr prin inci cipl ples es,, inte intern rnai ai cohe cohere ren nce, ce, or cont contra radi dict ctio ions ns of a spec specif ifie ie norm normal al sc scie ienc nce e do not matt matter er..  o suffer suf fer the shift, the internai cont contra radi dict ctio ions ns of th the e norm normal al sc scie ienc nce e must must be perc percei eive ved d o r ex exp perie rienced as such, and and one one can only perc rce eive them by being initiated.  y

•

b e i n g aware of neither th e n ee d nor the oc c u r r e nc e of a paradigm shift, and remaining in a def defunct unct norm normal al sc sciienc ence, the user user re rema main ins s in on one e para paradi digm gm,, whil while e the professional is in anot othe herr. The para paradi digm gms s are in incom comme mens nsura urabl ble, e, whic which h makes makes the commun com munica icatio tion n bet between ween user and pr prof ofes essi sion onal al pr prob oble lema mati tic. c. The dist distin inct ctio ion n betw betwee een n outs outsid ider er and in insi side derr is impo import rtan antt not not only to defi define ne th the e boun bounda dari ries es of the scie scienc nce e  s a rational enga engage gem ment, ent, but also also to def define, ine, in the   se o f bio iom medi edici cine ne,, its boun bounda dari ries es as a soci social al gath gather erin ing. g. The The re resu sullt o f the the dyad

outs ou tsid ider er/i /ins nsid ider er is that pati patien ents ts and doct octors re rem main in differe ren nt epi epistem stemol olog ogiical cal realit rea lities ies.. Howe Howeve ver, r, regar regardl dles ess s of any con contra rad diction, people expe expec ct sorn sorne e fo rm o f r esults from any kind of h u m a n endeavor. People expect s o me th in g

•

tr

bionledicine.

 

 t

•

The Th e pr prac acti tice ce of bi biom omed edic icin ine e star tarts with the the co cont ntra rast st of two actor ctors s: the the pa pati tien ent, t, client   ruser on on one e side, and th the e physician, do doct ctor or or he heal ale er on the other. Th Thes ese e two two ch char arac acter ters s meet an and d ex exch chan ange ge va valu lues es in a clin clinic ical al en enco coun unte terr or co cons nsul ulta tati tion on.. 16 According to Sril 197 1976), a co cons nsul ulta tati tion on can be se see en as a proc roces ess s of ex exc cha hang nge e of info inform rmat atio ion n and ad adv vic ice, e, which of ofte ten n in invo volv lve es a prof profes essi sion onal al or expert. Im Impl plie ied d by this exchange is the idea that to receive, one must also o

r

info inform rmat ation ion,, up upon on

which hich the the ex expe pert rt ad advi vice ce will be ba base sed. d. Wh Whilile e expe expert rtis ise e ma may y be ep epis iste temi mic c and bas based ed on wh what at th the e ex expe pert rt knows, that that is, the no noni ninv nvas asiv ive e prac practi tice ce of biom biomed edic icin ine, e,

 tma may y

also be perlormative and based on what the expert does, which is the invasive prac practi tice ce of biom biomed edic icin ine e We Wein inst stei ein, n, 199 993 3). Th Thes ese e two two do doma main ins s ma may y be conceptually and logi logica call lly y dist distin inct ct and, of course, the advice that that is given at the co cons nsul ulta tati tion on ma may y diff differ er when it is given by diffe iffere ren nt categories of experts. ts.

•

Three sets of oppositions have so far been canvassed:  1

scholarly

medi me dici cine nelb lbio iome medi dici cine ne,, or th the e pa para radi digm gm of fo form rmer er no norm rmal al scie scienc nce e co cont ntra rast sted ed with ith the the para pa radi digm gm of the the cu curr rren entt no norm rma al sc scie ienc nce; e;  2 the insi inside der/ r/ou outs tsid ider er,, or the the ph phys ysic icia ian n and the the pati tie ent; an and d  3 th the e ep epis istem temic/ ic/pe perfo rform rmat ative ive expe expert rts, s, wh whic ich h refe referr to the the no nonninv invasive and the invasive practices of clinical biomedicine. Two other majo ajor opposi opp ositio tions ns mus mustt be introduced now. The first is acute versus chronic care, the other oth er is biom biomed edic ical al scie scienc nce e ve vers rsus us bi biom omed edic ical al clin clinic ical al prac practi tice ce.. ln alma almast st every case, an acute disease is a Iimited event in the Iife of the patient. Most ailments or accidents leading to the the need of acute care are easily recognizable. if not diagnosed, by the patient or his/her social network. Th Thes ese e

•

mist stak ake e ta th thin ink k of these hese two characters as complete their ir social social It would be a mi completely ly isolated fram the network. Th the e heal health th syst system, em, a The e pati patien entt has family, friends, and culture. Th The e doct doctor or has th professional team and cul cultu ture. re.  6

 

•

in incl clud ude, e, bu butt ar are e no nott limit mited to the the sudden on onse sett of trauma, fever, and pai ain n. Both the phys ph ysic icia ian n an and d pa pati tien entt iden identi tity ty the the sa same me sign signif ifie iers rs in th the e com commun munica icaii iion on be betw twee een n the hem, m, an and d bo botth ex expe pec ct the sam same e thi thing from the the health pr prof ofes essi sion onal al s in inte terv rven enti tion on,, that is the the reli lie ef of symptoms an and d eli elimi mina nattion of threats. Litt ttlle or no confli conflict ct ar aris ises es in the the re rela lati tion onsh ship ip between the the ph phys ysic icia ian n and th the e pa pati tien entt in th thes ese e ci circ rcum umst stan ance ces. s. It sh shou ould ld be noted that that the tech techno nolo logi gica call de deve velo lopm pmen entt of pr proc oced edur ures es in acu acute te ca care re

is such th that at the margin of su succ cces ess s in acu acute te car care e in inter terve venti ntions ons is eve everr incre increasing asing.. Chronic care offers a different scenario. Usually the onset of chronic diseases is graduai and involves, in the early stages, little or no disabi ability. By offe offeri ring ng a va vast st array of un unsp spec ecif ific ic sy symp mpttom oms, s, the proc oce ess of diag agn nosis is di diff ffic icul ultt and an d freq freque uent ntly ly inv nvol olve ves s ma many ny au auxi xililiar ary y test tests s an and d in inte terr-co cons nsul ulta tati tion ons s with with spe specia cialis lists ts (Steward and Sullivan, 1982). A chronic condition affects many as asp pects cts of the

•

pati pa tien entt s li life fe,, in incl clud udin ing g the pat patien ientt s so soci cial al,, ec econ onom omic ic,, ps psyc ycho holo logi gica cal, l, an and d ph phys ysic ical al well-b wel l-bein eing g (C (Curt urtin in and Lubk bkiin, 19 1990 90). ). The ob obje ject ctiv ives es of th the e in inte terv rven enti tion on of the he heal alth th care pr prof ofes essi sion onal al are no longer clear for the patient, since there is rarely a sati sa tisf sfac acto tory ry trea treatm tmen entt or even diag diagno nosi sis. s. Th The e mu much ch de desi sire red d el elim imin inat atio ion n or re reli lief ef of symptoms

 

elim elimin inat atio ion n of thre threats ats is iIIusory in mo most st ca case ses s of ch chro roni nic c di dise seas ases es..

Faci Fa cing ng th the e di dise seas ase, e, the patient can respond to it with  1 action, an at atti titu tude de of se sellf helping or seeking for help;  2 inac inacti tion on,, wa wait it and se see, e, usu sual allly ca caus used ed by the vagu va guen enes ess s of the sy sym mpt ptom oms s; (3) rem emai aini ning ng in flux, a va vaci cill llat atio ion n bet betwe ween en th the e two al alre read ady y cited; and finally  4 counteraction, the denial of the symptoms, often

•

re reffer errred as an anti ti--illn illnes ess s beh ehav aviior. or. Th The e symp sympto tom m expe perrienc ence is recognized as not compatibie with one s perception of health and thus demands an ac acttio ion. n. The

 

 

•

chro ch roni nic c iIIness ma may y or m y not be perceived as such, which allows f o r other respon res ponses ses (Lub (Lubki kin, n, 19 1990 90). ). pattte tern rn of bi biom omed edic ical al in inte terv rven enti tion on ha has s diff differ eren entt me mean aning ings s for for the the pat patien ientt  h e pa  n

acut ac ute e or chronic care. In ac acut ute e care, the patien tientt is sick ick for for a limited period of time.

The Th e out outcom come e  n

 s

ei eith ther er reco recove very ry or de deat ath. h.

 n

th this is scen scenar ario io,, the the ph phys ysic icia ian n s ac acti tion on is,

gene ge nera ral, l, a ben enig ign n an and d ep ephe heme mera rall ev even entt in the the pa pati tien entt s Iife.

 n

chronic care, on the the

othe otherr han and d, the the di dise seas ase e ga gain ins s mo mom men entu tum m with time time and ev eve entua ntuall lly y affe affect cts s ail ail of the pati pa tien entt s activ ctivit itie ies. s. Th The e pa pati tien entt perce rceiv ives es a pr prog ogre ress ssiv ive e de deca cay y of his or he r health status, and in so some me ca case ses s be beco come mes s di disa sabl bled ed.. Th The e dise diseas ase e bec eco ome mes s the pa pati tien entt s perm pe rman anen entt co comp mpan anie ien; n; the the rol ole e of the the health ca care re prof profes essi sion onal al be beco come mes s blur blurre red d by slmult slm ultane aneous ously ly reli reliev evin ing g an and d no nott re reliliev evin ing g the patienfs su suff ffer erin ing. g. professional

•

 s

permanen perm anently tly pres present ent

 n

 n

chro chroni nic c ca care re,, the the

th the e pa pati tien entt s life, dict dicta ating ting and co cont ntro roll llin ing g

every mi minu nute te as aspe pect ct of his or her Iifest Iifestyle yle..  h e patie atient nt has to choos ose e the the less lesser er of two evils: to obey the ph phy ysi sic cia ian n and live with the the sp spec ecte terr of death with the dise diseas ase e unde un derr control, or to not ob obey ey th the e physician and live with the the sp spec ecte terr of de deat ath h with the the disea disease se un unco cont ntro roll lled ed.. Ano noth the er opposition appears in the semantic tics of biomedicine. Th The e word  medicine

s

a larg arge po port rtma mant ntea eau. u. Its me mean anin ing g ranges from a drug ob obta taiine ned d ov over er

the-co the -count unter er for the the relie ieff of an uns nspe pec cifi ific sy symp mpto tom, m, to the the stat state e su sup ppo porrted ted he heal alth th care sy syst stem em,, and, of cou ours rse e, passing by ev ever eryt ythi hing ng,, dire direct ctly ly or indi indire rect ctly ly,, rela relate ted d ta health and disease. Since the sa same me word is used ta na name me   ma many ny diff differ eren entt thi things ngs,,

•  

5

•

the meanings averlap. 7 We may reasonably expect that no on one e will co conf nfus use e a drug with the health care system; however, for lay people, baundaries between bi biom omed edic icin inee-sc scie ienc nce e and biom biomed edic icin inee-cl clin inic ical al pr prac acti tice ce are no nott cl clea earr and may, in fact, mean the sa same me thing. Tha hatt is why we must di diff ffer eren enti tiat ate e be betw twee een n the scie scienc nce e of bi biom omed edic icin ine e fram the clinicat prac practi tice ce of biom biomed edic icin ine; e; fu furt rthe herm rmor ore, e, ba bath th must be differentiated fram the health care system, which is also ge gene neri ric cal ally ly called

biomedicine, since one must remain aware that it is notoriously difficult to diffe dif feren rentia tiate te sat satisf isfact actori orily ly be betw twee een n ba basi sic c an and d ap appl plie ied d scie science nce (C (Cra rane ne,, 19 1972 72,, p 96). Wies Wi esin ing g and W e e (1998) state that scie ien nti tifi fic c knowledge and medical prac practi tice ce ar are e qu qual alit itat ativ ivel ely y dist distin inct ct.. Sc Scie ienc nce e pres presen ents ts fa fact ctua uall know knowle ledg dge e ab abou outt the general laws of a specifie phenomenon while practi tic ce deals with specifie and •

particular situations where the phenomena occur. In Fl Flec eck k s (1 (197 979 9, p.10) words,  th ther ere e is ho howe weve ver, r, a ve very ry im impo port rtan antt diff differ eren ence ce be betw twee een n exp experi erimen mentt an and d ex expe peri rien ence ce.. Whereas an experiment can be interpreted in terms of a simple question and ans nsw wer er,, ex expe perrien ience mu must st be un unde ders rsto tood od as a com comple plex x stat state e of in inte tell llec ectu tual al tr trai aini ning ng based upon the the inte intera ract ctio ion n inv involv olving ing the kn know ower er,, th that at wh whic ich h he al alre read ady y kno tJs and that that which he ha has s yet to leam leam.. Ex Expe peri rime ment nt an and d ex expe peri rien ence ce co coex exis istt in biomedicine. Expe Ex peri rime ment nt,, wh whic ich h refer fers to biom biomed edic icin inee-sc scie ienc nce, e, co comb mbin ines es with with ex expe peri rien ence ce,, or th the e

Not only Not only is the the simp simple le de defi fini niti tion on of biom biomed edic icin ine e prob proble lema mati tic. c. The The aims of this this tield ield are are also also diff diffic icul ultt to un unde ders rsta tand nd:: But But what what are are the the prof profes esse sed d go goal als s of me medi dici cine ne? ? This qu ques esti tion on is doubly doubly diff diffic icul ult. t. No Nott on only ly do does es medi medici cine ne suff suffer ers s tram tram a po pove vert rty y of ends ends,, but but it also is not not a monol onolit ithi hic c disc discip iplin line. e. Me Medic dicine ine em embr brace aces s ev ever eryt ythi hing ng trom trom pu publ blic ic heal health th sewa sewage ge treat treatmen mentt ta neur neuros osur urge gery ry,, tr ph phys ysic ical al therap therapy y to can cance cerr trea treatm tmen ent, t, from from me medi dica call techn technici ician ans s ta fami family ly prac practi tice ce..  h t is more, if the gene genera rall noti notio on of health lth is the goal of me medi dici cine ne,, then then few agre gree on its de defi fini niti tion on (Thoma (Th omasma sma,, 1990, 1990, p.2 p.245) 45).. 17

•  

51

•

b iome dicine -c lin ical practice, and th e combination yields the possibility for pred predic icti tion ons, s, prov provid ided ed cert certai ain n cond condit itio ions ns are re resp spec ecte ted d Tyle Tyles, s, 1993 1993,, p.73 p.731) 1).. Biom Biomed edic icin inee-cl clin inic ical al pr prac acti tice ce is not only only appl applie ied d biom biomed edic ical al sc scie ience nce.. It is also also t h e h u m a n e activity o f providing comfor t, help, and relief

Pellegrino and

Thom Th omas asma ma,, 1981). Thi This appl applie ied d scie scienc nce e beco become mes s a pr prof ofe essi ssion in a gove govern rnme ment ntal al s t r u c t u r e called th e health care sy stem. Th e three share not o nl y the epithet  biom biomed edic icin ine, e, but al also so a co conc ncep eptu tual al fr fram amew ewor ork k and and an episte epistemol mology ogy..

 h

contrast

betw be twee een n thes these e two two bi biom omed edic icin ines es is bett better er expl explai aine ned d by Fr Frei eids dson on 1988 1988,, p.16 p.168) 8)::  1 the m a j o r aim of the clinician is action, no t knowledge, as the scientist;  2 the prac practi titi tion oner er has has ta beli believ eve e in what what he or she is doi doing; but but doubt ubts and ques questtions ions are i mp o r ta n t tools for the scientist; 3) while clinicians are pr a gma tists and want  res  resul ults ts,, theo theory ry is one one of th the e conc concem ems s of sc scie ient ntis ists ts;;  4 with time time,, practi practitio tioner ners s tend tend

•

ta tr trus ustt th thei eirr accu accumu mula late ted d firs rstt hand experi perien enc ce, sc sciientists pref prefer er expe xperimental evidence; and 5) practitioners tend to emphasi asize the ideas of uncer certainty and inde indete term rmin inac acy, y, wher wherea eas s sc scie ient ntis ists ts lo look ok for re regu gula lari rity ty and lawf awful beha behavi vior or.. In other words, b i o me d i c i n e - s : i e n c e is a heuristic tool. It targets the o n to lo g y with a st stat atis isti tica call met etho hod. d. Biom Biomed edic icin inee-ap appl plie ied d scie scienc nce e or cli clinical ical pr prac acti tice ce is aime aimed d at a spec sp ecif ifie ie pati patien entt with a spec specif ifie ie comp compla lain int. t. It uses uses an indu induct ctiv ivee-de dedu duct ctiv ive e method, a n d its results are measured according to an absolute scale o f failure versus success. Human Hu manity ity has has a hi hist stor ory; y; more moreov over er,, each each cult cultur ural al gr gro oup, up, nati nation on,, pr prof ofes essi sion on,, and an d fami family ly can be seen een as havi aving a part partic icul ular ar histo story ry.. Thes These e hist histor orie ies s will will infl influe uenc nce e

•

e ac h person and will, to ge ther with o t h e r aspects, constitute the individual self.

 

 

•

Po w e r

a ls o

i nf l ue nc es

p e o p le ,

which

make s

t h em

a c c e p t,

s o me t im e s

unques unq uestioni tioningly ngly,, valu values es that  o not belong ta the initial set of that pers rsa a n . When some so meon one e is aff ffli lic cte ted d by di dise seas ase e and

in

need eed of care, the submission to power in

exch exchan ange ge for re reli lief ef may may  e co consi nside dered red a bless blessing ing.. Inde Indeed ed,,

in

so sorn rne e healing healing sy syst stem ems, s,

succ su cces essf sful ul heali ealin ng dema demand nded ed subm submis issi sion on ta super upern natu atural ral powers Keys Keyser erli ling ngk, k,

1998). He Hea alin ling may may mean th the e victory on th the e gre rea a te s t

of

ail oppo opposit sition ional al st stru rugg ggle les s

in healt h care: Iife versus death. Good versus evil are represented by many

meta me taph phor ors s and they are ail present

in

t he dail y work of a health c a re re provider.

Bioethics Bioet hics appear appeared ed on the sce scene in the hope hopes s that that it would offer fer the the much much-n -ne eeded eded guid gu idel elin ines es to th the e health care care syst system em

•

S e ct i o n V

 

INTRO INT RODU DU ING ING

on

dealing dea ling wit ith h di diffe ffere rent nt va valu lues es..

IOET IOETHI HI S

S i n c e there are int rinsi c relationships between medicine a nd values   Pellegri Pellegrino no and and Thom Thomas asma ma,, 1981). the oppo opposi siti tion ons s des descr crib ibed ed up ta this this poin intt,

in

addi ad diti tion on to th thos ose e left left unex unexam amin ined ed,, inev inevit itab ably ly gene genera rate te and and ag aggr grav avat ate e other co conf nflic licts ts of va valu lues es betw betwee een n th the e pr prof ofes essi sion onal al and th the e clie client nt.. Th The e pert pertin inen entt phil philos osop ophi hica call foru forum m to deal with confl flic ictts is ethics and,

in

the case case of healt lth h care, bio ioet ethi hics cs..

Hi Hist stor oric ical ally ly,, medic edical al et ethi hics cs deal dealtt mainly mainly with the re rela lati tion onsh ship ip care ca re pr Jfessional and his confidentiali confid entiality, ty, which which

w s

or

herr peers. Medic he ica al ethic ics s included:

of

the healt lth h

th

duty of

ai aime med d at main mainta tain inin ing g sorne pro roc cedure res s know known n only only to the

memb me mber ers s of th that at group; fee agre agreem emen ents ts,, in order order ta disc discou oura rage ge un unfa fair ir co comp mpet etiti ition on;; •

and permissible and forbidden procedures and practices, which defined a common

 

 

•

practi pra ctice ce that that di diff ffer eren enti tiat ated ed a pa part rtic icul ular ar heaJer grou group p from others. Init Initia iall lly, y, ethi ethics cs was n o t a b ou t the patient and his or her right5, as it is today; then, it was about the heal he aler er and hi his s

herr   rhe

pr prac acti tice ce (W (We ear ar,, Ge Geye yerr-Ko Kord rdes esch ch and Fren French ch,, 19 1993 93). ).

It was between the 1960 5 and 1970 5 with the rise of individual rights and fe femi mini nist st mo move veme ment nts s tha hatt biomedicine 5 do domi mina nant nt raie in the the dec deci5i i5ion on-ma -makin king g pr proc oces ess s st star arte ted d to be qu ques esti tion oned ed.. It Its s pa pate tern rnai aiis isti tic c de deci cisi sion on-m -mak akin ing g mo mode dell and the the sover so verei eignt gnty y of the pr prof ofes essi sion onal al in th the e do doct ctor or-p -pat atie ient nt rela relati tion onsh ship ip we were re the two two maj major or

concems. However, it is a mistake to single ou outt one factor as the main reason for th the e de deve velo lopm pmen entt of bioe bioeth thic ics. s. Th The e soc ocia iall dist distan anci cing ng be bettwe ween en do doct ctor or and pati patien ent, t, the the mode mo dern rn ho hosp spiita tall, and bio biome medi dica call research and tech techno nolo logy gy had eq equa uall lly y im impo port rtan antt roles in the the hi hist stor oric ical al pr proc oces ess. s. 8imi 8imila larl rly, y, th the e way biom biomed edic icin inee-sc scie iene nee e teeh teehno nolo logi gize zed d and an d pr prof ofes essi sion onal aliz ized ed he heal alin ing g pr prac acti tiee ee from th the e mi midd-tw twen enti tiet eth h ee eent ntur ury y on tend tended ed to

•

eclilips ec pse e bi biom omed edic ical al hu huma mani nism sm (Bar (Barna nard rd,, 19 1998 98). ). Pu Publ blic ic ex expe pect ctat atio ions ns we were re cl clos osel ely y ti tied ed to t h e authoritarian raie held by physicians. The power shift began with the rep epla lace ceme ment nt of the paternalistic model by th the e pati atien entt-au autton onom omy y mo mod del el.. A se sett of ethical and legal precepts evolved, mainly in North America, ta proteet the pr pres esum umab ably ly po powe werl rles ess s pa pati tien entt from a pr pres esum umab ably ly po powe werf rful ul ph phys ysic icia ian. n. By the 19705, cour co urts ts tended ta vi view ew th the e do doct ctor or-p -pat atie ien nt re rela lati tion onsh ship ip as a pa part rtne ners rshi hip, p, wi with th the fina nall word belonging to the patient. The fise of health care co cost sts s played a very ery im impo port rtan antt ra raie ie in the the pa pati tien entt righ ghtts mo move veme ment nt..   igh hea eallth care are cos ostts ge gene nerrated ated the the vi view ew that that health care was a mat ter

•

 

a right. With the Uright came the notion o f

best

inte intere rest st,, and the the inter erp pre rettat atiion of its meaning pa pass ssed ed in into to the ha hand nds s of the the pa pati tien ent. t. It be bec cam ame e understood th that at physicians may no nott be the be bes st ethical jud udge ges s of thei theirr

 

•

pati pa tien ents ts be best st in inte tere rest sts s and of the ap appr prop opri riat aten enes ess s of thera therape peut utic ic inte interv rven enti tion ons s tha thatt woul wo uld d be best st serv serve e the their ir pa pati tien ents ts ex expe peet etat atio ions ns (V (Vea each ch,, 19 1995 95). ). Ul Ulti tima mate tely ly,, this this doubt gave ga ve rise rise to th the e au auto tono nomy my debate. te. Ph Phys ysic icia ians ns are no now w ex expe pect cted ed to res espo pond nd to this new ne w cu cult ltur ural al vi vis sio ion. n. With With theï theïrr pa pati tien ents ts ex exer erci cisi sing ng their their ri righ ghts ts,, ph phys ysic icia ians ns beca became me aware of possible Iiability and malpractice; consequently, they developed a  defens  de fensive ive medicine medicine (M (Mar arsh sh and Ya Yarb rbor orou ough gh,, 19 1990 90). ).  

Just Ju st as biomedicine is a transformation of previous models of Western

medicine, bioethics also evolved from older professional ethics. If the forme merr appeared on the sce scene to ans nsw wer the specifie needs of the population and an d of the scie sc ient ntif ific ic com ommu mun nity ity, the latte atterr cam ame e as an ans answer to the the un unba bala lanc nced ed resu result lts s obtained by bio biome med dicin icine e. At this tim ime e, bioe bioeth thic ics s no long longer er de deal als s ex excl clus usiv ivel ely y with prof profes essi sion onal al rela relati tion onsh ship ips, s, as refl reflec ecte ted d by the the old old de deon ontol tologi ogica call

•

  o ~

s

and oa oath ths s.

Ins nste tead ad,, social responsibility and profession ional Iiability are the main concerns. However, as a legi legiti tima mate te child of the olde olderr de deon onto tolo logi gica call ethi thics, cs, the central figu figure re of bioe bioeth thic ics s   continues to be the ph phys ysic icia ian. n. Inde Indeed ed,, if pa para ra me mean ans s beside, pa para rallllel el and even even pa para rasi siti tic c (Gave, p.16 .1634 34), ), bi bioe oeth thic ics s seem seems s to be a pa para rame medi dica call ac acti tivi vity ty;; as sueh,

it

inherits, as do ail other paramedical activities, its methodology and

respectability tr

biom biomed edic icin ine. e. Sig Signif nifica icantl ntly, y, par paramed amedica icall pro profes fessio sions ns wo work rk unde underr

the the dire direct ctio ion n of ph phys ysic icia ians ns;; th thei eirr raie in the health care syst system em is legi legiti tima mate ted d by the the rela relati tien ensh ship ip th they ey main mainta tain in with th the e ph phys ysic icia ian n (F (Fre reid idso son, n, 1988, p.6 p.67). Coinciding with th the e be begi ginn nnin ing g of th the e bi bioe oeth thic ics s mo move veme ment nt in the the 19 1960 60s, s, so sorn rne e

•

clinicians in a moveme men nt called the cr criitical clinical schoel be beg gan to find the 1mustt st 1mus stre ress ss here here th that at from th this is point point on when 1refer to bi bioet oethi hics, cs, 1am targeting the applied or cli clini nical cal bioe bioeth thics ics..  l l

 

 

•

desc de scri ript ptio ion n of the the effe effect ct of drug drugs s inad inadeq equa uate te when ba base sed d on onlly on expe experime rimental ntal data, and an d began to perfo rform c1inical tria trials ls.. Th The e do doub uble le-b -bli lind nd ra rand ndom omiz ized ed trial bec became ame th the e ideal, and biostatistics gained a strong impulse as a methodological tool in biome bio medi dici cine ne-s -sci cien ence ce.. Th The e amo amount unt of rese esearc arch an and d th the e expe expens nses es in he heal alth th care care ha have ve multiplied in a few decades without any proportional effect on mo morb rbid idit ity y and mortality in the the de deve velo lope ped d world (W (Wul ulf, f, Pe Pede ders rsen en an and d Ro Rose sen nbe berg rg,, 198 986 6). Today, a popular version of bioethics is understood as founded in four pr prin inci cipl ples es:: au auto tono nomy my,, just justic ice, e, be bene nefi fice cenc nce, e, an and d no nonma nmale lefic ficenc ence e (Be (Beauc aucha hamp mp an and d

Childr Chi ldress ess,, 19 1983 83). ). In Can anad adia ian n so soci ciet ety, y, thes these e pr prin inci cipl ples es se seem em to be undisputed. In Inde deed ed,, th the e aut auton onomy omy and an d just justic ice e prin princi cipl ples es are are gr grou ound nded ed in th the e Ca Cana nadi dian an Charter  

Rights and in Quebec s Charter

 

Human Rights an and d Freedoms

while

Civilil Co Code de autonom auto nomy, y, Jen Jenefi eficen cence, ce, and non nonmale malefic ficence ence are ens enshri hrined ned in Quebec s Civ

•

and in the Me Medic dical al Co Code de

 

Ethics and the Nurses Code

 

Ethics. With ail this

appa ap para ratu tus, s, bioeth bioethics-a ics-a mino minorr form form of moral oral phi philos losop ophy hy pr prac acti tice ced d with within in med medici icine ne (Jons (J onsen en,, 19 1993 93,, s1 )-became a ph phililos osop ophy hy with pr prac acti tica call to tool ols s of ex exer erci cise se.. Bio Bioeth ethics ics attempts to be an ins instru trumen mentt of so socia ciall regu regula lati tion on (B (Bou ourg rgea eaul ult, t, 19 1992 92). ). an d McCullough (1984), only two models of moral Forr Bea Fo eauc ucha ham mp and

responsi resp onsibili bility ty exi exist: st:  1 the be bene nefi fice cenc nce e mode dell, an and d  2 th the e au auto tono nomy my mo mode del. l. Both ar are e co comp mpet etin ing g mo mode dels ls in bioethics. In the co cont ntex extt of cl clin inic ical al pr prac acti tice ce,, be bene nefi fice cenc nce e and nonmaleficence describe th the e same principle, since the application of one principle without the other would result in a contradiction (Gillon, 1986) and

•

contradictions in the practical world are translated into inaction. Marsh and

 

 

•

Yarb Ya rbor orou ough gh (1990) cl clea earl rly y diff differ eren enti tiat ate e be betw twee een n bene benefic ficenc ence e as a dec decis ision ion-m -maki aking ng mode mo dell and be bene nefi fice cenc nce e as a moral fo foun unda dati tion on tha hatt may gu guiide ph phys ysic icia ians ns.. Autonomy is a personls right to self-determination. Co nc ems about phys ph ysic icia ians ns au auton tonom omy y an and d po powe werr ar are e direc directl tly y linke inked d to th the e ex exer erci cise se of pa pate tern rnal alis ism m and the the im impa pact ct tha hatt thi his s pa pate tem mal alis ism m may hav ave e in he heal alth th care care,, bat ath h in te term rms s of po poli licy cy maki ma king ng an and d in terms of individual care. To balance the po powe werr in th the e rel relation onsh shiip, or at

leas leastt neu euttral ralize the the da dang nger ers s of biom biomed edic ical al pa pate tern rnal alis ism, m, th the e do doct ctri rine ne of info inform rmed ed

consent cons ent ap appe pear ared ed (D (Dan anie iels ls,, 1984 .19

Until the 19 1970 70 s s,, au auto tono nom my fo forr a pro roffes ess sion ona al grou group p me mean antt th the e fr free eedo dom m

tr

outsid out side e dire direct ctio ion n or t he freedom to perform one s work the w ay one wishes (F (Fre reid idso son, n, 19 1988 88,, p.36 p.368) 8).. The These se ac acti tion ons s an and d func functi tion ons s that cha charac racter terize ize pro profe fessi ssiona onall bi biom omed edic ical al work ork ar are e go goin ing g to be perform rme ed upon the pa pati tie ent nt,, who is expe expect cted ed to be

•

an inert or passive su subj bjec ectt. The de degr gree ee of power held by a prof rofessiona nall group can be tra race ced d to:  1 the sp spec ecia iali lize zed d kn know owle ledg dge e ne need eded ed to the prac practi tice ce,,  2 th the e soci social al distan dis tance ce be betw twee een n pr prof ofes essi sion onal al an and d cl clie ient nt,, an and d  3 th the e prof profes essi sion onal al grou group p grea greate terr homoge hom ogenei neity ty than than soci society ety in gen ener eral al (C (Cla lark rke, e, 1990, p. p.20 204) 4).. Ge Gelf lfan and d (1968) st stat ates es th that at the medical de degr gree ee warrants the ho hollde derr a certain se sens nse e of po powe werr over th the e lives of

l ).

•

his s or he sick sick people. Th The e relationship between the phys ysiician and hi herr patients According to Pola Poland nd (1 (199 997) 7),, the tirst irst ev ever er re reco cord rded ed use of th the e te term rm inf infor orrn rned ed consenr in law

was wa s in the Salgo case [Sa go v. Leland Stanford Jr Univ Universi ersity ty  o r d of Trustees 15 154 4 Cal. Cal. Ap App p. 2d 56 317 P. P.2 2d 170 170 (195 (1957) 7)]. ]. The The co cour urtt note noted d that that a phys hysic iciian vi viol olat ates es his duty duty to the pati patien entt if he with withho hold lds s any fact facts s nec necess essary ary to form the the basi basis s of an int intelli ellige gent nt co cons nsen entt by the pati patien entt ta the proposed propose d trea treatme tment. nt. Th e cour courtt als also no note ted d that that when when disc discus ussi sing ng risk risk,, th the e ph phys ysic icia ian n ha has s disc discre reti tion on  con consis sisten tentt with with the full ull dis disclo closur sure e of fact facts s nec necess essary ary ta an inf inform ormed ed cons consen ent. t. (P. (P.19 193) 3) Po Pola land nd also also ci cite tes s the Schl Schloe oend ndor orff ff case case as im impo port rtan antt in the the fram framin ing g of the doc doctr trine ine [Schloendorlf v. 125, 5, 10 105 5 N.E N.E. 92 (1 (191 914) 4)]] Eve Every ry hu huma man n be bein ing g of adult Society of New Yo York rk Hosp Hospit ital al 211 N.Y. 12 yea years and and sound mind has a right to dete determin rmine e what shaH be done with his own body; and a surg surgeo eon n who pe perf rfor orms ms an op oper erat atio ion n with withou outt his his pa pati tien entl tls s cons consen entt comm commit its s an as assa saul ult; t; fo forr whic which h he is li lia able in damages. (p.194)

 

 

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exhibits an in ineq equa uali lity ty of po pow wer ers. s. Howe Howeve ver, r, th the e do doct ctor or-p -pat atie ient nt rela relati tion onsh ship ip rema remain ins s reci recipr proc ocal al even in the face of this inequality since physicians cannot practice bi biom omed edic icin ine e without patients. Physicians as ass sume a do domi mina nant nt role due to their knowiedge; the pa pati tien entt is ex expe pect cted ed to be pa pass ssiv ive e (Ste (Stewa ward rd an and d Su Sulllliv ivan an,, 1982 . Katz (1984) described this situation as unbearable due to the dis isre rega gard rd for patients opin op inio ions ns,, vo vollit itio ion, n, an and d wi wish shes es.. Whe Whether ther th this is clai claim m refe refers rs to a gen genera eraliz lized ed si situ tuat atio ion n or is an exaggeration is beyond the scope of this monograph; nevertheless, the result of the societal ou outc tcry ry was a redefinition of the term au auto tono nomy my when used in the th e context of the hea ealt lth h care syst ste em. The foc ocu us of disc discus ussi sion on on the the is iss sue shif hifted ted

to the act ctiive pa part rtic icip ipat atio ion n of the pa pati tien entt in th the e pr proc oces ess s of rega regain inin ing g he heal alth th;; this this ac acti tive ve part pa rtici icipa patio tion n wa was s cal called led au auto tono nomy my.. Phys ysiici cian ans s mu must st re resp spec ectt pa pati tien ents ts au auto tono nomy my.. Th This is tru truism ism must be followed

•

today by doctors, j u s t as the aphorisms of Hippocrates were respected for centuries. The au auto tono nomy my of pa pati tien ents ts is co cons nsiide dere red d to be ab abso solu lute te when com omp pare ared to the power that physicians have to make decisions. Ultimately the choice of treatment treat ment be belo long ngs s to the patient, even if th ther ere e is no ch choi oic ce rega regard rdin ing g the diag diagno nosi sis s and expected outcome. When contrasted with theoretical ideals, a series of comp co mpro romi mise ses s and qu qual alif ifiica cati tion ons s hav ave e to be made to allo allow w the the do doct ctor or-p -pat atie ient nt relationship to function. Usually the patient still acquiesces to the physician s discret dis cretiona ionall po powe wer. r. Pati Pa tien ents ts au auto tono nomy my mu must st be qu qual alif ifie ied. d. Th Thom omas asma ma do does es il il,, when writing in

•

1983 that that au auto tono nomy my ma may y not ap appl ply y in so sorrne med edic ica al trea treatm tmen entt co cont ntex exts ts p. 3 and that that the im impa pact ct of di dise seas ase e on per person sonal al aut autono onomy my lim limits its self-d self-dete etermi rminat nation ion p. 4 .

 

5X

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Neve Ne vert rthe hele less ss,, he also lso indi indica cate tes s the prob proble lems ms th that at bioethics face: th the e au auto tono nomy my model as a model is also severely limited. It has been constructed in dialectical oppo op posi siti tion on to a pa pate tema mali list stic ic mod odel el.. But ne neit ithe herr pa pate tern rnal alis ism m nor autono autonomy my co corr rrec ectl tly y desc de scri ribe be the et ethi hica call no norm rms s go gove vern rnin ing g the doc doctor tor pa pati tien entt rel elat atio ion n (p (p.4 .4). ). Au Auton tonom omy y imp im pli lies es the the ri rig ght to dec eciide de,, in a rela relati tion onsh ship ip,, ac acco cord rdin ing g to per ers son onal al co conv nvic icti tion ons s and legacy. It also implies that the decision is going to be respected by the oth ther ers s in

involved in the relationship. If only one partner is being respected his o r her autton au ono omy an and d the other(s) is (are) not, th the e relati tio onship is un uneq equa uall and un uneth ethic ical al.. Power an and d au auto tono nomy my are no nott antit ntith heti etica cal. l. If au auto tono nomy my is understood as th the e ex exer erci cise se

of power, they they are the same thing. If power is interpreted as  the ab abil ilit ity y to form and eff effect on one e s will (McCullough, 1999, p.5), then it is th the e same thing as au auto tono nomy my..

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TR NS T ON

Acco Ac cord rdin ing g to certa ertain in med edic ical al trad tradit itio ions ns,, each pa pati tien entt is re rega gard rde ed as an end in h im or her hersel selt. t. The prof profes essi sion onal al aim is the pa pati tien ent; t; in other words the

his or

  r

p

~ i

n t

and

ailmen ailmentt are are inte interp rpre rete ted d on an indi indivi vidu dual al basis, no matter how long a

consul con sultat tation ion might las1 In oth other er he heal alin ing g trad tradit itio ions ns,, su such ch as the an anci cien entt Gre reek ek,, th the e diagnosis was a public process, someti tim mes involving public debates in which auto au tono nomy my an and d co conf nfid iden enti tial alit ity, y, whic Am Amer eric ican an so soci ciet ety y regards hi high ghly ly,, was ha hard rdly ly an is iss sue (A (Ack cker erkn knec echt ht,, 1992; Bates, 19 1995 95;; Co Conr nrad ad,, 19 1995 95). ). Wi With th th the e in intr trod oduc ucti tion on of

bi biom omed edic icin ine e and, later, biom ome edica ically lly ma mana nage ged d care, the aim of th the e cons consul ulta tattio ion n •

became t h e diagnosis of a disease. T h e time spent with each patient, o r the

 

 

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pr prod oduc ucti tivi vity ty,, plays an

important raie for th e physician, the health care

administration, and the health care policy makers. Thus, the medical practice migr mi grat ated ed from a Ugiving as asso soci ciat atio ion n with the the pa pati tien ent, t, to a ta taki king ng one (R (Rab abin inow owit itz, z, 198 19 80) 0).. Th The e he heal alth th ca care re syst system em no lon ong ger cares fo forr th the e individual and hi his s or he herr soul; instea tead, it treats the perso erson n s dis disease ta main aintai ain n a he heal alth thy y and pr prod oduc ucti tive ve soc ociiet ety. y. Physi sic cians expect to earn a living from th thei eirr profession; th thei eirr acts acts impact economically on a set o f paramedical professions and the b ud g et of the gove go vern rnme ment nt.. From the physician, one expects no nott only efficacy, which is a term usually usual ly re rela lated ted to the qu qua alit lity of the se serv rviice provided, bu butt also ef effi fici cien ency cy,, which is a

te term rm us usua ualllly y re rela late ted d to the amo moun untt of service provided. At the sa same me ti time me,, the vast majori maj ority ty of ail cases of illn illnes ess s are nev eve er se seen en by a ph phys ysic icia ian n (Sig (Siger eris ist, t, 19 1936 36). ). In US a third o f the people who are

•

 l

seek information online (Berst, 1999), which

demonstrate s that there is a changing pattern in the retrieval o f health care in info form rmat atio ion n by the the pa pattient ient an and/ d/or or the pa pati tien entt s so soci cial al ne netw twor ork. k. If th this is tr tren end d will reach Canada is st stil illl to be seen. With Wi th the patient trying to voice his or he herr will, and the ph phys ysic icia ian n entrenched in his or he herr biomedical judg judgme ment nt,, the co conf nfli lict ct th that at bioethics sh shou ould ld tr try y to mediate is cu cult ltur ural al.. However, bioe bioeth thic ics s uses the the sa same me to tool ols s as ph phys ysic icia ians ns to ev eval alua uate te and an d unde un ders rsta tand nd co conf nfllicts icts,, ther theref efor ore, e, bioe bioeth thic ics s has ga gain ined ed le legi giti tima macy cy in insi side de th the e health care ca re syst system em,, bu butt has ha s litt little le cred credib ibil ilit ity y as a cn cnti tic c

 

th the e syst system. em.

•  

 

•

Chapte Cha pterr Tw Two o ENCOU EN COUNT NTERS ERS AN AND D DI DIS S EN ENCO COUN UNTE TERS RS

Medical school gives people ople the the poss possib ibil ilit ity y of beco becomi ming ng memb member ers s of a type of ruli lin ng class May, 1997). To fully ully acquire ire this status. however. a st stu uden dent must acqu ac quire ire the the bi biom omed edic ical al cultu culture re.. Twen Twentie tiethth-ce cent ntury ury Westem Westem biom biomed edici icine ne can can be seen een as a cultu tura rall sys system tem. The org rga aniz nization tion of medi medici cine ne refl reflec ects ts the hier hierar arch chic ical al sys yste tem m of soci social al stra tratifi tific catio tion in the larger society, which allows physicians to use

bi biom omed edici icine ne to focu focus s on the the biol iologi ogical, ra rath ther er than the social, ori rig gins of the the pati patien entt s cond co nditi ition ons s Kah Kahn, 1995 1995). ). •

The doctor-patient relationship changed nût only because medical science chan ch ange ged, d, but but   l 

beca be caus use e soci societ ety y is n o longer the same. The physician is a

stran str ange gerr perfo rformin ming an act act or serv servic ice e on a

for for serv servic ice e bas basis. is. The The phys physic icia ian n is

 

expected to be trained in a univ univer ersi sity ty and and offe offerr curr curren entt pr prof ofes essi sion onal al serv servic ices es to his or her her patients. He

  rsh she e

expects to be paid for for the ser ervi vice ces s prov rovided. However,

th thes ese e servic rvice es impl imply y the the care are that that would be iden identi tifi fie ed by the the pati patien entt   s at one one time, grat gratui uito tou us. When he heal alth th and dise diseas ase e were Iinked to religio igion n, care was connected ted to compassion and was thus a religious or social duty. The healers of the past are romanticized   s always caring and compassionate, with a quasi-sacerdotal approach t mercantile •

the profession and the patient, unlike what today is seen   s a approach

commercialization

 

to

disease,

with

a

c ons e quen t

trivialization

  nd

the suffering. Contrary to what is com common monly ly beli believ eved ed,,

 

6

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moreov mor eover, er, advanc advances es in me medi dica call sc scie ienc nce e ha have ve not ma made de ph phys ysic icia ians ns be bett tter er healers (Wamer, 1995). Each co cons nsul ulttat atio ion n is packed with social, cultu turral, religious and scientific sig signi niffier iers. Each sign signif ifie ierr conv convey eys s a meas measure ure of va valu lue e dif differ feren entt fo forr ea each ch pa part rtic icip ipan ant. t. Unaware of this clash of values, the participants have disparate goals for the con co nsult sultat atio ion. n. Th The e ob obje ject ctiv ivit ity y of th the e bi biom omed edic ical al co cons nsul ulta tati tion on ma may y be co cont ntra rast sted ed with the subjectivity of the expectations of the patient; further, the object ectivity of the biomedical standard o f care may be contrasted, on the user s side, with the igno ignora ranc nce e of these these st stan anda dard rds s

The Th e exchange of information is basic to any consultation from either of its partic par ticipa ipant nt s poi points nts

 

view. How the pa pati tie ent emot emotio iona nall lly y perc erceiv ive es the docto torr is

direct dir ectly ly re rela late ted d ta th the e info inform rmat atio ionn-ex exch chan ange ge be beha havi vior ors. s. This This phys physic icia ian n s beha behavi vior or

•

directly influences the outcome by affecting satisfaction and compliance (Frederikson, 1992). Th The e physic iciian may pe perc rcei eive ve the pati patien entt as ea easy sy or dif iffi fic cul ultt the de degr gree ee of co coll lla abora borati tion on and de defe fere renc nce e he or sh she e rece receiv ives es.. An effective based on the comm co mmun unic icat atio ion n between both partn tne ers in the consu nsult ltat atio ion n is only possi ossibl ble e if they agree in a common cultural ground, where the exchange of information and emot em otio ions ns can be carr carrie ied d on (Balint, 1984). This is an ex exch chan ange ge of signif signifier iers s (Lac Lacan, an, 1985).

50ntag (1989) wants to Iib ibe era rate te il illn lnes ess s from its me meta taph phor oric ical al co con nte tent nt.. She bel elie ieve ves s that that the the me meta taph phor oric icaf af cont conten ents ts revea eveall prej prejud udic ices es rega regard rdin ing g the way way we see

•

disease and the diseased. If even eventu tual ally ly we are ail going to fall sick, iII or di disa sabl bled ed,, we should have an unprejudiced vision of the road ahead. Putting aside the

 

 

•

di disc scus ussi sion on as to whet whethe herr iIIness, in th the e br braa aad d sense should or should no t b e s e e en n or int inter erpre preted ted met metaph aphori orical cally, ly, diseas diseased ed people people do inde indeed ed us use e meta metaph phor ors s to ex expr pres ess s

themselves. Th e pr prob oble lem m re resi side des s in th the e us use e and inte interp rpre reta tati tion ons s of these meta metapha phars. rs. Curr Cu rren entl tly, y, the me a ir ir su suff ffe e rrii ng ng an d di sa sab ilility ty,, with th the e d ise isea as se ed mett aph aphors ors imply imply u n ffa persan requiring care an and d co comp mpas assi sion on,, co cons nseq eque uent ntly ly,, th thes ese e me meta taph phor ors s fe feed ed th e

unbala unb alance nce in th e doctor-patient rel relati ationsh onship. ip. To g a iin n a g rre e ate aterr u n nd de rrst sta a nd ndi ng ng of th e dyn dynami amic c re rela lati tion onsh ship ip that exists

betw be twee een n bi biom omed edic icin ine e an and d lay lay pe peop ople le,, we ha have ve to review ho w bio biomed medica icall knowledg knowledge e is used, p rrii ma ma rrii ly ly in th e clin clinical ical enco encounte unter. r.

•

Sect Se ctio ion n

SCENARIO

T

To pro provi vide de care fo r t h e n e e d y is a n e of society s most impo important rtant ro role les. s. Th e

h ea ea llth th ca care re sy syst ste em ap pp p ea ea rrs s to answer this need (M (Mus usta tard rd an and d Fr Fran ank, k, 19 1991 91). ). Th e pr proj ojec ecte ted d ai aim m of th e hea lt h c a arr e s y s t e m is t o supply se serv rvic ices es and and th ther ereb eby y impr improv ove e th e status of health of th the e popu popula lati tion on (Pin (Pinea eaul ult, t, Co Cont ntan andr drio iopo poul ulos os and and Less Lessar ard, d,

1985).   or th the e h ea ea lth lth care syste system, m,

he heal alth th is th e absence of diseases or injury

(Mus (M usta tarrd and Frank, 1991). As such ch,, health is an ab abso solu lute te sc scal ale e of va valu lues es.. St Stiill, ll, fo forr Mustard an d F rra ank, t h he e h e a l th c a arr e s y ys st e em m is re ac t iv e in n at ure. It uresponds to

p erc erce e iive ved d d ep ep a art rtu u rre e s fra fra m health th,, an d i de de n nti tify fyii ng ng th tho os se e de ep p art artu ures res in terms of concep con cepts ts an and d ca cate tego gori ries es de defi fine ned d by he heal alth th car care e pr prof ofes essi sion onal als s (p (p.? .?); ); in other wo word rds, s, •

t he he a b bs s o lu lu te te s c al al e is d efi efin ne ed d by bia biamed medica icall prof professi essional onals s at th e service of the th e

 

 

•

syste tem m, fo forr th the e use

of

the syst system em.. For Gelf Gelfan and d (1968), medic ica al ai aims ms are lin ink ked ta

restoration and m ai nt ena nc e of health. Si nce health, restoration and

th e

main ma inte ten nance ance ar are e defi fin ned within th the e syste ystem m, th this is cl clos oses es th the e cycl cycle e of self-s f-serving definitions. ln Quebec, there is a te ten n de den cy cy ta cali fo forr the participation management

of

of

society n  the

th the e health care care syste ystem m (L (Lem emie ieux ux et al, 1994), even if physicia ian ns

vo voic ices es are are stil stilll the majo majori rity ty.. Pine Pineau ault lt,, Cont Contan andr drio iopo poul ulos os and and Less Lessar ard d (1 (198 985) 5) co cont nten end d th

t

health care care policy icy should in inc clu lud de th the e determin ina atio ion n o f health care factors

outs ou tsid ide e the medi medica call system, and not not only only th e on ones es al alre read ady y cove covere red d by th the e medic ica al care care sys yste tem. m. Unde Underl rlyi ying ng th this is obse observ rvat atio ion n is th the e di dist stin inct ctio ion n betw betwee een n th the e heal health th ca care re

•

syste tem m and th the e medical care syst ystem, which is pr pres esen entt in th thei eirr paper, but but absent in Quebec, whe where th they ey made made th thei eirr stud study. y. T o d a y , w h i l e t he r e i s a l o ow w e r mortal it y rate d u e ta infections, there is

 n

inc incre reas ased ed pr prev eval alen ence ce of chr hron onic ic and and dege degene nera rati tive ve di dise seas ases es.. At th the e same same ti time me,, the i nc re ased f oc us on health i s s ue s

n 

t h e m e d i a gener at ed a c l i mat e of

 appr appreh ehen ensi sion on,, in ins securi curity ty,, and and al alar arm m about about di dise seas ase e (B (Ba arsk rsky, 1988 1988 p. p.4 414). The popu po pula larr belie lief is th that at quality lity of medi medici cine ne and level of health care ar are e th the e same same thing, and an d th tha at biom biomed edic icin ine e is a sour source ce for overa rall ll impr improv ovem emen ents ts n  he healt alth h (Lalan (Lalande de,, 1975 1975). ). Biom iomedic edicin ine e gain gains s a new new dim imen ensi sion on and is set set th the e ta tas sk of repairing th the e deca ecay of the huma hu man n body body

 u e

to increa increase sed d longev longevity ity..

Many Ma ny assum assume e th that at biom biomed edic icin ine e is th the e sole sole fa fact ctor or re resp spon onsi sib ble fo forr th the e in inc cre rea ase

•

in life span a n d the i mp mpr ovem ent detected in public health indexes. McKeown (1976) disa disagr gree ees s and proved beyo beyond nd any any re reas ason onab able le doub doubtt th that at publ public ic hea healt lth h and

 

•

medi me dica call pra ract ctiice ces s were no nott so sollely re res sponsible fo forr the dec eclline in mortality

 u

to

in infe fect ctio ious us di dise seas ases es in England and Wa Walles in th the e perio riod between 1838 and 197 970. 0. Social and ec econ onam amic ic improve vem ments of the po popu pula lati tion on ha had d a mu much ch more ore sign signif ific ican antt imp mpac actt. Al Alth thou ough gh Mc McKe Keow own n s co conc nclu lusi sion ons s ar are e crit critic iciz ized ed by so some me,, his work grea greatl tly y influenced hea ealt lth h policy in Can ana ada; fo forr ex exam ampl ple, e, th this is ha has s bee een n imp mpli lied ed by Mu Must star ard d and an d Frank rank (199 (1991) 1).. human an /ive /ives. s. Tech Te chno nola lagy gy simp simpli lifi fies es da dail ily y task tasks s and char chares es an and d inte interv rven enes es in hum Howev ever er,, no nott on only ly are we as individuals ap appl ply ying tec ech hno nollog ogy y at a growing pace, institution s ar e n o w doing the same. Th e s e institutionalized technological in inte terv rven enti tion ons s in in indi divid vidua uals ls ar are e cr crea eati ting ng ec ecol olog ogic ical al,, he heal alth th,, soci social al,, an and d psy psychol chologi ogical cal

•

cri ris ses (Trosko, 1989). The modern dream

of

science scienc e kno know-al w-all-c l-can-e an-every verythi thing ng

science, is bu butt a dr drea eam, m, pa part rtic icul ular arly ly when biomedicine is the science. Wh What at we are are dre ream amiing about is that the enormous accumulation of scientific knowledge did some so meth thin ing g ta insur insure e ce cert rtai aint nty y to biom biomed edic icin ine e clin clinic ical al-p -pra ract ctic ice e (W (Wie iesi sing ng and We e 199 998) 8).. Th The e fact fact is that that tod oda ay s the hera rape peu utics tics can still be su sum mma mari rize zed d by the fo foll llow owin ing g sce cen nar ariio: if th the e pa pati tien entt pre res sen entts a re reco cogn gniz izab able le dise diseas ase, e, sign sign,, symp sympto tom, m, or th thin ing, g, th the e physi ysician will re reac actt by pre resc scri ribi bing ng an an anti ti-t -thi hing ng.. Th This is is th the e Ga Gallen enic ic th theo eory ry of the the cont contra rari ries es wit with a scie scient ntif ific ic robe. Fu Furt rthe herm rmor ore, e, gov govem emmen mentt of offi fici ciai ais s an and d pa pati tien ents ts,, ac acco cord rdin ing g to Siegl Siegler er (1993), see eem m ta bel eliieve that that due ta te tech chno nolo logy gy,, ph phys ysic icia ians ns can can easi ea sily ly ma mane neuv uver er fra ram m sym sympt pto om ta diagno nos sis wit itho hout ut th the e need of interac raction with th the e patient.

•

The Th e ex exis iste tenc nce e

of

a calling was imp mpli lici citt in the early medical profession,

which mean antt th that at a physician owed a duty to a pa pati tien entt (P (Piica carrd, 19 198 81). Ac Acco cord rdiing to

 

 

•

Kodner Kod ner (1998 1998), ), phys physic icia ians ns are are no lon longer ger co conc ncem emed ed with buil buildi ding ng conn connec ecti tion ons s with th he e iirr patients. They are no longer willing to acce accep pt transference. Wi With thou outt  n emot em otio iona nall tie ie,, the ca care re-r -rol ole e is los ostt and and the the su supp ppos osed ed care care-g -giv iver er seems seems in indi diff ffer eren ent; t; in t h e case o f physicians, they are transformed into just an ot he r category of technicians in a world of technic nicians. A do doct ctor or los ose es his or her her in indi div vid idu ual face ace and, as Kodner states, tnere is no iong ionger er any any diff differ eren ence ce between a physi hysic cla lan n and  n institution. This progressive institutionalization of medicine also shrinks the physi ph ysici cian an s rai aie e (Pel (Pelle legr grin ino o an and d Th Thoma omasm sma, a, 19 1981 81); ); simult simultane aneous ously, ly, physic physician ians s see th thei eirr power over over the patients incr incre ease ase in thei theirr agen agency cy of la larg rgee-sc scal ale e health care inst instit itut utio ions ns that that orga organi nize ze and de deli live verr care care for soci societ ety y (McC (McCul ulio ioug ugh, h, 1999 1999,, p. p.1) 1).. This This

•

appare app arent nt cont contra radi dict ctio ion n se see ems to have a simple explanation. Physicians,  s indi indivi vidu dual als, s, ar are e losi losing ng pow ower er,, but when grouped in th the e in inst stit itut utio ion, n, they ov

r om

ail

re rece cent nt soci cie etal eff ffo orts to control them them.. Th The e in inst stiitu tuti tion on is th the e physicians physicians dom domain ain,, wher wh ere e pati patien ents ts are are ou outs tsid ider ers. s. Until the the las lastt cent centur ury, y, pa pati tien ents ts or thei theirr soci social al ne netw twor orks ks had had di dire rect ct econ econom omic ic exch ex chan ang ges with thei theirr health care prov proviider ders. Wit ith h the rise of th thiird part party y payers,  n idea ideali liza zati tion on of the the po poss ssib ibil ilit itie ies s and inf infal allib libil ility ity of te tech chno nolo logy gy ap appe pear ared ed wit ith h a sens sense e that th at hea healt lth h coul could d be offe offere red d on de dema mand nd.. Th This is was sh shar ared ed  y doc doctor tors s and and pati patien ents ts al alik ike e (Marsh and Ya Yarrbo boro roug ugh, h, 1990). The more more depe depend nden entt on technology we are, the le less ss se self lf-d -det eter ermi mine ned d we become; sinc since e ail te tec chnol hnolo ogi gic cal ef effo fort rts s come come with a prie iee e tag, the me meas asur ure e of the value of Iife ma may y be dang danger erou ousl sly y clos close e to its int ntri rins nsic ic

•

economic v l ue (T (Tho homa masma sma,, 1984). 4). Ph Phys ysic icia ians ns ar are e pr pres esse sed d to lower lower co cost sts s in health care. T o do

5

primary care physicians, the gate keepers,lt often delay the their

 

 

•

referrals

o

patients to specialized treatment. This trend exacerbates t he

dete de teri rior orat atio ion n of the do doct ctor or-p -pat atie ient nt rela relati tion onsh ship ip.. Th The e syst system em de decid cided ed th that at th the e cause for the the in incr crea ease se o hea eallth care are co cost sts s was th the e ph phy ysician, and in or orde derr ta control th the e exp xpen end dit itu ure re,, ph phys ysic icia ians ns had to be man anag age ed co cont ntro roll lled ed,, an and d re rest stri rict cted ed (K (Kod odne ner, r, 1

1998). Ali oth other er reas reason ons s for for the the incr increa easi sing ng hea eallth ca carre ex expe pens nses es,, which in inc clu lude des s the hi high gher er priee so soci ciet ety y has to pa pay y for for long longev evit ity y in chronic diseases, are placed in a seco se cond ndar ary y plane. Instead, physicians are held responsible for the results th they ey obtain. The maintenance of the health care system, its institutions, health care pro rofe fess ssiion onal als, s, an and d su supp ppor orti ting ng staf stafff requ requir ires es a si sign gnif ific ican antt ex expe pens nse e fo forr th the e Ca Cana nadi dian an

society. Bywater (1998) believes that, a t a certain moment, doctors became •

responsible for the ever-increasing health care costs and as a result, they should be man anag age ed, co cont ntro roll lled ed,, and rest restri rict cted ed.. Ne New w ma mana nage geri rial al tr tren ends ds app ppea earred to he help lp acqu ac quir ire e co cont ntro roll ove overr co cost sts s, which hich is ref efle lect cted ed by  manag  managed ed ca care re.. Managed ca carre is the cu curr rren entt ad admi mini nist stra rati tive ve ve vers rsio ion n of a he heal alth th car are e sy syst stem em,, where the pa pati tien entt receives the care need eded ed as ca calc lcul ulat ated ed by the av ave era rage ge   people affected by similar cond conditi itions. ons.  ln managed care, th the e pa pati tien ents ts c cas ases es are ma mana nage ged d that the services to be pro provided are seen as a pr prod oduc uctt that ge gene nera rattes in the sense that expenses, so th ther ere e is the need fo forr a man anag ager er that will control the costs and ma make ke the the sy syst stem em mo more re effi effici cien entt (Lebel, 199 996 6). Managed ca care re is view ewe ed by much of th the e biomed bio medica icalle lleade adersh rship ip as a ch chal alle leng nge e to the the moral id iden enti tity ty of th the e me medi dica call pr prof ofes essi sion. on.

•

A discussion on only on one e of the many pro probl blem ems s that that the adoption of this sys syste tem m bri brings ngs can be read in Bar Barsky sky and Borus  1995 . 2

 

 

•

They Th ey believe th that at th the e ph phy ysi sic cian sh shou ould ld na natt be co conc ncer erne ned d abo about ut th the e co cost sts s

o

health

c a re re and the tre a t me n t prescribed (Brady and Miller, 1998). Managed care is reco recogn gniz ized ed as

no t

only onl y Iimi Iimiti ting ng th the e ph phys ysic icia ians ns powe powerr an and d au auto tono nomy my,, bu butt also also tha thatt

of the the pa pati tien entts (S (Sie iegl gler er,, 1993 93). ). Li Limi miti ting ng the ma main inte tena nanc nce e prob proble lem m of to toda day y s me medi dica call system to cas t ma na g eme nt is thus n o ott only an ov over er-s -sim impl plif ific icat atio ion, n, bu butt also also th the e sour so urce ce of dif diffe feren rentt pr prob oble lems ms.. What Wh at is wo wors rse, e, there ar are e co comp mpla lain ints ts ab abou outt th the e qua quali lity ty of rela relati tion onsh ship ips s in ou ourr modern world. People seem ta relate in a more dist stan antt an and d superficial manner, mai aint ntai ain nin ing g a str strong ong at atta tach chme ment nt ta in indi divi vidu dual alit ity y and priv privac acy. y. Th This is de dehu huma mani niza zati tion on of re rellatio ations nshi hips ps af affe fects cts bath pr prof ofes essi sion onal al an and d pe pers rson onal al net networ works. ks. Thi This s proc proces ess s also also

•

affe affect cts s the do doct ctor or-p -pat atie ient nt re rela lati tion onsh ship ip.. Pa Pati tien ents ts and ph phys ysic icia ians ns ha have ve a diff differ eren entt vie view w o

the the co cont nten entt

o

a con consul sultat tation ion..  n ge gene nera ral, l, do doct ctor ors s spe spend nd on one e mi minu nute te ex expl plai aini ning ng

situations to the patient; while pa pati tien ents ts ar are e aw awar are e of this, do doct ctor ors s remain un unde derr th the e impression tha hatt th they ey spend muc much h mo more re ti time me in this tas task k (R (Rau auff ffen enba bart rt,, 19 1984 84). ). Lo Lock ck (1995) shows us tha hatt, at the sam same e tim time, phy hysi sici cian ans s are are be beco comi ming ng more ore dist distan antt from rom thei theirr patients as pe peo opl ple, e, yet cl clos oser er to th thei eirr patient nts s as disea diseases ses.. Sh She e de demo mons nstr trat ates es that bi biom omed edic ical al terms suc uch h as ud udis isea ease se,, Uhealth and even Upatient are are crea reated by bi biom omed edic icin ine e in a ce cert rtai ain n ca cant ntex ext, t, and are th ther eref efor ore e arbi arbitr trar ary. y. Th This is arbi arbitr trar arin ines ess s is, in the the bi biom omed edic ical al fi fiel eld, d, un unde ders rsto tood od as trut truth h an and d is tr tran ansf sforr orrne ned d into into au auth thor orit ity. y. Wh When en faced with the the pat atiien enttJs sub subje ject ctive ive trut truth, h, th this is ar arbi bitr trar arin ines ess s casts seno senous us do doub ubts ts up upor or,, th

•

authority of biomedicine, which in tu tum m forces the prac practtitio itione nerr to create more

unce un cert rtai aint nty y to imp impose ose upon th the e pa pati tien entt an and d so soci ciet ety. y.

 

 X

•

Peop Pe ople le seem wa wary ry o distr distrust ustin ing g ph phys ysic icia ians ns sinc since e po popu pula larr be beli lief efs s rega regard rdin ing g the po powe wers rs example

o

science are on a rise. The weekly tabloid  u

o

how ho w the med ediia tre rea ats biomedicine and

(P (Pot ottter) er) pro provid vides es an

  ow the

public Iikes ta see

bi biom omed edic icin ine e po port rtra raye yed. d. In it its s iss issue ue of De Decem cembe berr 8 19 1998 98,, the he head adli line ne read reads: s: ULatest Medi Me dica call Break Breakth throu rough ghs s New Mir Miracl acle e Cu Cures res and de desc scri ribe bes s the find inding ings abo about ut hea heart rt disea sease, se, canc cancer er,, Al Alzhe zheim imers ers dise diseas ase e and othe otherr dise diseas ases es.. Biom Biomed edic icin ine e and its livi living ng repres rep resent entati ative, ve, the ph physi ysici cian, an, bec become ome,, in th the e pro proce cess ss,, vict victiims of th thes ese e im imag ages es of in infa fall llib ibil ilit ity, y, om omni nipo pote tenc nce, e, an and d om omni nisc scie ience nce.. Th The e ph phys ysic icia ian n is vict victim imiz ized ed by his his

or

her

own be beli lief efs. s. He or she sh shar ares es an and d pro rom mote tes s the su supe peri rior orit ity y of biom iomed ediicine cine wh when en compare red d with other medical traditions. expectations

o

his hi s pat patien ients. ts.

However, he or she cannot fulfill the

•

Searc Se archin hing g for an emotionally satis satisfacto factory ry

~

u t i o n

ta the disc discom omfo fort rt tha hatt he

or she is experiencing, the the pati atien entt surrenders ta th the e physician's pow ower er (Balint, 1984 19 84). ). Patients bring thei theirr dise diseas ases es,, th thei eirr il illn lnes esse ses, s, and the their ir sick sickne ness sses es into into th thei eirr phys ph ysic icia ians ns'' offi office ces. s. Pa Pati tien ents ts ide identi ntify fy the the biom biomed edic ical al mod model el as capa capabl ble e complete c u r e or even

o

o

of offe feri ring ng a

miraculous salvation. They They assume that, once the

consultation is over, they will be cured. In mo me nts o f crisis, the imper fect biomed bio medica icall mode modell is re repl plac ace ed in the the pa pati tien ent' t's s mind by a prec precis ise e science, an almi almigh ghty ty ca n only ex biome bio medic dicine ine that can exis istt in an im imag agin inar ary y realm. Reali ality will be su sum mma mari rize zed d in a fi fift ftee een n minu minute tes s cons consul ulta tati tion on,, du duri ring ng wh whic ich h pa pati tien ents ts tell th their eir hist histor ory, y, dis disrob robe, e, are

ex exam amin ined ed,, get dressed, re rece ceiive sorn sorne e sort sort of pr prof ofes essi sion onal al orie orient ntat atio ion, n, an and d are are th then en

•

acknowl ackn owledg edged ed upo pon n ex exit it..

 

 

•

Section  

THE TH E PR PROC OCES ESS S  

THE TH E CL CLIN INIC IC L EN ENCO COUN UNTE TER R

Insi Inside ders rs and ou outs tsid ide ers, rs, sc scie ienc nce e and practi tic ce, expe expect ctat atio ions ns and rea realit itie ies s, doct do ctors ors and pa pati tien ents ts,, will finally meet and measure one against the other

in

a

clin clinic ica al encounter, the sta tag ge where upon which social roles related to healt lth h are played. According to Mechanic 1972), 75  

of

peop pe ople le have have,,

ail

spa pac ce of time, sympto tom ms th that at will fo forc rce e them to

an

in

acti ac tion on,, whet whethe herr it ran ranges fro from

self se lf-m -med edic icat atio ion n and re rest st to he help lp seek seekin ing. g. Thes These e pe peop ople le are are fo forc rced ed thei theirr percepti tio on about th the eir bodil ily y functio ion ns

is

a de dete term rmin inat ate e

to

act be beca caus use e

some so mewh what at diff ffe erent from prio iorr

experiences or trom ge gene nera rall know knowle ledg dge. e. The The re rela lati tion onsh ship ip be betw twee een n a pers person on and a

•

path pa tho ology logy star startt with th the e re real aliz izat atio ion n of sens sensat atio ions ns:: one fe feel els s he or she is sick sick due ta a di dise seas ase. e.

 n

il

and an d reco recogn gniz izes es th that at

other her words, a di dise seas ase e fo forr th the e di dis sease eased d is th the e

ana an atom tomic ical al and pat atho holo log gic ica al comp comple lex x th tha at man manif ife ests sts it itse self lf as

an

iIIness with it its s

some so meti time mes s characteri ris sti tic c signs and symptoms. A si sick ckne ness ss includes th the e social cont co nten entt surro urroun undi ding ng th the e pat atie ien nt, th the e supp suppor orti ting ng syste tem m, fa fami mily ly,, an and d socie society ty Yo Youn ung, g, 1982). It can be said that A pe pers rson on,,

in

an

iI iIIn Ines ess s star starts ts with th the e awar awaren enes ess s of an abnormality.

general, ta take kes s on ma many ny raies Barbe arberr and Kratz, 1980).

mono mo nogr grap aph h on only ly a fe few w w ilill

be

of impo import rtan ance ce.. To

be an

 n

this

acce ac cept ptab able le si sick ck persa rsan, one one

must mu st personity the sick-role: a set set of acceptable behaviors that will all llo ow the legi le giti timi miza zati tion on of devi deviat atio ions ns or no nonn-fu fulf lfil illm lmen entt of ot othe herr so soci cial al raie raies s Dento ton n, 1978) 978)..

•

It

is

this his pe pers rso oni nifi fica cati tion on th that at will giv ive e le leg git itim ima acy

ta

claims of suffering and help

 

 

•

seek se ekin ing, g, whil while e si simu mult ltan aneo eous usly ly ju just stif ifyi ying ng th the e assi assist stan ance ce and priv privil ileg eges es of bei being a pati pa tien ent, t, th the e so-ca so-call lled ed secon seconda dary ry gain gains s (Gol (Golds dste tein in,, 1961). (1964, 4, The Th e clas classi sic c def efiinition of the sick-r -ro ole was was given by Pars Parson ons s in 1951 (196 p. 439) and, nd, alth althou ough gh crit critic iciz ized ed,, it is still th the e clas classi sic c ref referen erence ce for for ail disc discus ussi sion ons s

abou ab outt the is issu sue. e. Pars Parson ons s mod model el is cons consti titu tute ted d by four four norma normati tive ve ex expe pect ctat atio ions ns::  1 th the e sick sick-r -rol ole e ju just stif ifie ies s in inca capa paci city ty and best bestow ows s the the rig right to its ex exer erci cise se,,  2 the sick sick rol role gives ives th the e righ rightt to ex exem emp pti tion on from ot othe herr soci social al role roles s resp respon onsi sibi bili liti ties es,,  3 ther there e is a duty duty to rec recogni ognize ze that iIIness is un unde desi sira rabl ble e and and ther theref efor ore e the

 l

perso pe rson n shou should ld

seek for help, and  4 the sick sick person has th the e duty to coopera ratte in the proce rocess ss of gettting weil. First, we have to clarify that Parson ge sons model is u biomedical model (8e9all, 1976) and, as such, its existence is bound to the biomedical paradigm.

•

Fur urttherm hermo ore, re, thi his s model appea ppears rs to better describe the acute patient. For the chroni chr onic c pati patien ent, t, th ther eref efor ore, e, Mecha Mechani nic c and Vo Volk lkar artt s now cl clas assi sic c desc descri ript ptio ion n of i1lness behavior seems more complete: the way in which sy symp mpto toms ms are perceived, evaluat ated ed and acted upon by a person who recog cognizes zes some some pain, disco iscom mfort, ort, or ether eth er si sign gn of er erga gani nic c malf malfun unct ctio ion. n. This beha behavi vior or trig riggers ers a fiv ive e st stag age e se set: t:  1 the symp sympto tom m expe experi rien ence ce st stag age, e,  2 as assu sum mpti tio on of the sick-r -ro ole,  3 me medi dica call care care contact,  4

depe de pend nden entt pati patien entt role, and when possible  5

rec recovery and

re reha habi bililita tati tion on (Mec (Mecha hani nic c and and Volkar Volkart, t, 1961). Thi This s is so-c so-cal alle led d iIIn iIInes ess s beha behavi vior or.. The The bigg biggest est cr crit itic icis ism m Pars Parson ons s had had to fa face ce wa wass abo about ut devi devian ancy cy;; howe howeve ver, r, he clari clarifi fied ed the the misc mi scon once cept ptio ion n by cle clear arlly sta tatting that hat iIIness was not a devi devian antt beha behavi vior or (1975).

•

Ar Arlu luke ke,, Kenn Kenned edy, y, and Kessl Kessler er (1979) re reeva evalu luat ated ed Pars Parson ons s model and and conclu concluded ded that that,, aven more more than twent wenty y years ears af aftter its formul rmulat atiion on,, it was still fairly rly accu accura ratte,

 

 

•

si sinc nce e there were only mi mino norr variations in thei theirr sa samp mple le s re res sul ultts. To summ summar ariz ize, e, th the en, th the e si sic ck pe pers rsan an is helpl lpless, and in need of help; is not responsible for his or her udev udevianf ianf condition; is not competent ta help him or hersel elff, thus, a han and dicap or disability is imposed upon him or herself; and, is un unab able le to functi tio on nor orma mall lly y in his or he herr Iife pat attter ern n. A ve very ry im impo port rtan antt point oint in this this di disc scus ussi sion on is th that at the sick sick-p -per erso son, n, as la layp ype ers rson on,, is unfi unfitt ta judg judge e the the tech techni nica call qual qualif ific icat atio ions ns of th the e heal health th pra ravi vid der. The sic ick k persan belongs to a minor inorit ity y group, the one expo xposed to soc socie iety ty as re. Di Dis sea ease sed d pe peop ople le must fu fullfi filll th thei eirr sick sick-r -rol oles es in arder abnorm abn ormal al and and in need of care. ta maintain a place in society despite the heir ir abnormality. Part of this expected behavior is he help lp see seeki king. ng. On the other hand, help mu must st be provided sa the cycle of legiti leg itimac macy y can can be closed. A new social role is now now pe peri rior orme med d by this person, sin since

•

s o ci e t y needs sick people to justify some

 

it its s st stru ruct ctur ures es..

 

If no tr trea eatm tmen entt is

available, or is perceived as unavailable b y sick people or society, the nonwill be followed by the comp co mple leti tion on of the the raie wil the exc exclu lusi sion on of the aff ffe ect cte ed persan from

th the e so soci ciet ety y Schwartz and Kart, 1978; Denton, 1978). Ta recapitulate, then, the natu na tura rall or ex expe pect cted ed cycl cycle e of dise diseas ase e is: un unwi willllin ingl gly y fa fallllin ing g ta a di dise seas ase, e, help seek seekin ing, g, trea treatm tmen ent, t, and fi fina nall lly y healing or deat eath. Th The e cy cycl cle e has has ta be com compl plete eted, d, or percei perceived ved as completed by the persan and his or her social network, in ar arde derr ta sati satis sfy the custom cus tomary ary so soci cial al be beha havi vior or faci facing ng sick sickne ness ss Ste Stewa ward rd and and Sull Sulliv ivan an,, 198 1982) 2).. IIIness tran transc scen ends ds the the st stat ate e of the pers persa an to be beco come me an instit institutiona utionalized lized ra raie ie.. and d ot This an othe herr raies lead ta the as asym ymm metri etric c str truc uctu ture re of the health care syst system em du due e

•

With the risk risk of being misinterpreted in mind an ex exampl ample e is the existence of poor people in India Ind ia legitimat legitimating ing the raie of Mothe Motherr Theresa Theresa of Ca Calc lcut utta ta.. If it were no nott for for them she woul would d be a benef ben efaet aetor or withou withoutt a cause 21

 

7

•

to its hi hier erar arch chiical cal co comp mpon onen ents ts of power, au auth thor orit ity, y, and and pre res stige. North Amer Americ ican an healt hea lth h car care e

is

the the prot protot otyp ypic ical al hier hierar arch chic ical al st stru ruct ctur ure. e. The asymme asymmetry try co coul uld d

upon up on the inst instit itut utio iona nall ce cert rtif ific icat atio ion n

 

be

based

the the ph phys ysic icia ian n as re res spo pons nsiibl ble e for heal healtth care care..

The health car care system has a pres presum umpt ptiv ive e co compe mpeten tence ce to de dea al with hea healt lth h issu issues es,, which compels the patient to look for it and ta close the cycle of roles (Parsons, 1975). At any rate, the mor morbid bid st stat ate e for the pa pati tien entt is simp simply ly an anoth other er norm norm

to

live live by

(Cangu (Ca nguilh ilhem, em, 1982 1982). ). A ph phys ysic iciian s se sellff-im imag age e is co cons nstr truc ucte ted d upon th the e answ answer ers s and expe expect ctat atio ions ns  

their the ir pa pati tien ents ts,, who who are, for for do doct ctor ors, s, the the mos mostt sign signif ific ican antt ot othe herr (M (Mal alms mshe heim imer er,,

1988, p.15). Ther Theref efor ore, e, ph phys ysic icia ians ns bec become ome what what th their eir pa pati tien ents ts expe expect ct th them em to be. This also explains why doctor and patient s raies are complementary. If for any re reas ason on thes these e role roles s are un unfu fulf lfil ille led d

  rare are

inte interp rpre rete ted d th thus us,, fr frus ustr trat atio ion n and re reje ject ctio ion n

•

will ill re resu sult lt (R (Ryn ynea ears rson on,, 1975 1975). ). Unco Un cons nsci ciou ous s me mecha chani nisms sms like like deni denial al,, dis disloc locati ation, on, cond conden ensa sati tion on,, projec projectio tion, n, and an d iden identi tifi fica cati tion on st star artt to take take plac place e diseas sease e, and wi with th the the st stru ruct ctur ure e

in

the rel relati ations onship hip

pers rson ons s   rpe

 

the pati patien entt with hi his s

  r her

that that will ac actt upon il. The The subc subcon onsc scio ious us,,

characterized by its symbolic language, equality of values for both int nte emal and extemal reality, or su supr prem emac acy y of the the int intern ernai, ai, pr pred edom omin inan ance ce of th the e pr priinciple of th the e pl plea eas sur ure, e, ab abs sen ence ce of chronology, and abs bsen ence ce of th the e con conce cep pt of contradiction, (Talla (Ta llafer ferro, ro, 1972), 1972), will ha have ve,, as in an any y othe ther human enc ncou ount nter er or action, a chie chieff ro role le in the doct doctor-p or-pati atient ent rel relati ations onshi hip. p.

•

The Th e do doct ctor or-p -pat atie ient nt rel relatio ations nshi hip p has been st stud udie ied d by many any authors like like Ey, Bema Be marrd, and Brisset, (1978), Freud (1912), an and d Gold Goldst stei ein n (1961), ju just st to cite cite thre three e publ pu blic icat atio ions ns tha thatt tr trea eatt the the ps psyc ycho holo logi gica call co cons nstr truc uctt ca call lled ed transf nsferenc ence. This This is a

 

73

•

basi ba sie e phe pheno nomen menon on that ru rule les s hu human man re rela latio tions nship hips s in ge gene nera rall and in pa part rtic icul ular ar,, when an ex exch chang ange e or de dele lega gati tion on of pow ower er oc oceu eurs rs (C (Can angu guil ilhe hem, m, 1982). Tran Transf sfer eren ence ce is  

repetition in the pre rese sent nt of an ol old d relationship. ip. It is an anachronis nism in the the se sen nse

that

t

feelings, defenses and impulses related to a person in the past are

tran transp spor orte ted d to so some meon one e el else se in the the pr pres esen entt (Freud, 1912). 2). Tran Transf sfer eren ence ce is the ac actt of shi hiffti ting ng so some meth thin ing g fram one form to ano noth the er. In the sense that is being used in this paper, it is the di dis spl pla ace ceme men nt of feelings and internai images from a patient s signif sig nifica icant nt ad adul ultt to the the he heal aler er (P (Per eres estr trel ello lo,, 1982). In the the tran transf sfer eren ence ce,, the pa pati tien entt proj projec ects ts his or he herr em emot otio iona nall co cont nten entt to tow war ard d th the e ph phys ysic icia ian. n. Th The e doc doctor tor is su susc scep epti tibl ble e to proj projec ecti ting ng his his or he herr im impr pres essi sion ons, s, se sens nsat atio ions ns,, or em emot otio ions ns towa toward rds s the the pa pati tien ent, t, whic wh ich h mo mobi bili lize zes s in inte tern rnai ai co conf nfli lict cts. s. Th This is is ca call lled ed co coun unte terr-tr tran ansf sfer eren ence ce (C (Cap apis isan ano, o, 1987 19 87). ). The ph phen enom omen enon on of co coun unte terr-tr tran ansf sfer eren ence ce co cons nsis ists ts of Uthoughts feelings, t

•

and ac acti tion ons s toward a patient tha that are ev evok oke ed by the the pa pati tien entt s behavio vior, bu butt that that the the physicia phys ician n exp experi erienc ences es to b e a part of or at le leas astt caused by the the pa pati tien entt (S (Ste tein in an and d Appr Ap prey ey,, 19 1985 85,, p 9) 9).. Sinc Since e bi biom omed edic icin ine e ev evol olve ves, s, a ge genu nuin ine e symp sympto tom m of an orga organi nic c dis diseas ease e ma may y or may not be validated in a ce cert rtai ain n mo mome ment nt;; the the legi legiti tima mati ting ng proc proces ess s is reci recipr proc ocal al even if wha hatt is signitied is di diffe ffere rent nt.. Th The e int intera eract ction ion be betw twee een n ph phys ysic icia ians ns an and d pa pati tien ents ts also shapes the changes in the manifestation of diseases. There is a sensible evo volu luti tio on of what could be a ge gen nuine symp mpto tom m of an orga organi nic c dis diseas ease e in time. Certain sym ymp pto toms ms may or may no nott be co cons nsid ider ered ed ac acce cept ptab able le to the the va valilida dati tion on of the the

•

si sick ck-r -rol ole e at a certain mo mome ment nt in time time (K (Kle lein inma man, n, 19 1986 86;; Sh Shor orte ter, r, 19 1992 92). ). Thi This s is the phen ph enom omen eno on th that at Bali lin nt (1984) refers to when stating ing tha that the patie atient nt use ses s his or

 

 

•

herr sy he sympt mptoms oms to build a tran transf sfer eren enti tial al re rela lati tion onsh ship ip with the ph phys ysic icia ian. n. The pa pati tien entt ada dap pts what he or she feels in or orde derr ta se sedu duce ce the he heal aler er.. Capi Ca pisa sano no argues th that at a do doct ctor or-p -pat atie ient nt rela relati tion onsh ship ip oc occu curs rs on t\vo t\vo leve levels ls::  1 th the e su supe perf rfic icia ial, l, where the the le leit itmo moti tiff is th the e di dise seas ase, e, and  2 the prof profou ound nd,, where ere the the le leit itmo moti tiff is th the e tr tran ansf sfer eren ence ce 1987 . At th the e su supe perf rfic icia iall level, issu issues es suc such h as po powe werrmay not be relevant; at the the pro protou tound leve level, l, howev eve er, autonomyauto nomy-patem patemaJis aJism m may   rmay th they ey ar are e not if th the e pat atie ien nt su surr rren ende ders rs ta a tra trans nsfe fere renti ntial al rela relati tion onsh ship ip all allowe owed d by a non countercoun ter-trans transferen ferential tial phys physicia ician. n. The Th e practice of biomedicine can be as generic as family practice, and as spec sp ecia iali lize zed d as hand surgery. Its pacing may be peaceful, as in plas plasti tic c surgery, or ch chao aoti tic, c, as in an intensive ca carre unit. The set etti ting ng ma may y be rural or in a un uniive vers rsit ity; y; the

•

physician, however, always has contact with his patient in the c1inicaf enc encoun ounter ter or 22

consultation.

The Th e clinical en enco coun unte terr is an any ythi hin ng but a sim impl ple e me meet etin ing. g. A patient

seek se eks s a physician, but bri rin ngs a comp mpllex se sett of personas with him

  r her,

which is

the mi micr cro o so soci ciet ety y that that the doc doctor tor will try to soothe, heal, or cure. On the the othe otherr side of the desk, the patient sees a person invested with many roles, who seems capable

 

exerting sorne sort of useful power upon him or her. T h e bilateral

distortion of reality is not usually perceived by bath sides and the consultation prog progre ress sses es as if no fu furt rthe herr ad adve vers rse e co cons nseq eque uenc nces es co coul uld d po poss ssibl ibly y ari arise. se. Un Unde derl rlyi ying ng th this is si simp mpli list stic ic view, a ne netw twor ork k of guilt, expe expect ctat atio ions ns,, an and d Wel Weltan tansch schauu auungs ngs prov provid ide e a fr frag agil ile e su supp ppor ortt fo forr each pa part rtic icip ipan ant. t.

•

Sorne biom biomedic edical al specia specialti lties es do not need a clinic clinical al encou encounte nterr proper, such uch as radiology, forensic, pathology, etc.; hawever, they receive the ne neces cessa sary ry inf inform ormat ation ion to per perfo form rm their their duties tram other physicia physicians ns who had a personal encounter wi witth the patients.  

 

75

separates two different worlds in a very unequal e xc h a n ge

of

mean eanings ngs; its pro roffess essor oriial role sign signai ais s to each ach side side the terr territ itor orie ies s and and the degre degree e

of

Th e desk

•

unevenness of ea each ch party. The The pl pla ace each one one occu occupi pies es

in

relation to the desk desk also also

sho sh ows where ere th the e power is and who holds it. However, the geography of the offi office ce only on ly exemplifies on one e of th the e many many si sign gns s th that at abou abound nd in this relationship that that hard hardly ly .......... L....e U

•• U ...... IIU e 

o .... U

d :...  

:I l· s e

+ l     lL

e LY ~

1

III  

+  e

 \ / 1 1l

\

al e

u +e +he U l U

II\ IV

 

unequal as it is unequal when anyo anyone ne seek seeks s for for advi advice ce

 

or

~Ui I\ l Ii i   V

U

f t-  o ue I It

 

iS

prof profes essi sion onal al help help in an any y

field. This i s a n unavoidable part and c haracteristic of the consultation. If part pa rtic icip ipan ants ts had had th the e same same le leve vell

of

know kn owle ledg dge e and and abil bility, ity, a cons consul ulta tati tion on woul would d be

unnecessary. The Th e cli clinica nicall enco encou unt nter er occu occurs rs in a moment moment of crisis •

in

the Iife of the pa pati tien entt.

Presumably, certain de fen se me c h a n i s ms such as psychologieal denial,

home

remedies, a nd friends advice, have already been consulted with no results. Impo Im pote tent nt and suffering, facing hi his s or her her own mort ortality, the the pati patien entt pu putts on the the sick sick-role and seeks eks a physician. Toget ogeth her with th the e dise diseas ase, e, the sick sick person go goes es to the the cons consul ulta tati tion on and and of offe fers rs hi his s or her her cult cultur ure, e, pers person onal alit ity, y, an and d Welt Weltan ansc scha hauu uung ng,, i e his or

herr self. he

Th e

patient s ee ks a cure, relief, care, and sympathy, though n o t

neces cessarily in this order. Thes These e needs put the pati atient ent in a receptive mood for for the inqu inquir ires es,, requ reques ests ts,, and and in inst stru ruct ctio ions ns of th the e phys physic icia ian. n. The The pati patien entt also also anti antici cipa pate tes s the the ex expl plan anat ator ory y power power of bi biom omed edic icin ine, e, whic which h is

rPfJu1 r ed

the physi hysici cia an re rece ceiv ive es th the e pati patien entt not not only only with his his raie off ffe ere red d by the egi egitimat ate e i n ve st i t ur e •

personal crisis,

or

of

to help cape. On the othe otherr side,

or

herr own self, but he but al50 with the the

a healer. T he physician is n ot in a

should not not le lett one one in intter erfe fere re wit with his his

or

her ex expe pect cted ed profes professio sional nal

 

 

•

role, an and d mu must st pro rov vide th the e help tha hatt is im impl plic icit it in th the e tr tran ansa sact ctio ion n Ry Rynea nearso rson, n, 19 1975 75). ). A co cons nsul ulta tati tion on is an ob obje ject ctiv ive e mee eetting with, in biom iomed ediicine cine,, a prec precis ise e tech chn niqu que e, deve de vellop opm men ent, t, and ai aims ms.. It is no nott de des sign gne ed, nor is th the e ph phys ysic icia ian n prep prepar ared ed.. to de deal al or merg me rge e co conf nfli lict ctin ing g ex expl plan anat ator ory y syst system ems. s. Si Sinc nce e co cons nsul ulta tati tion on,, diag diagno nosi sis, s, dise diseas ase, e, tr trea eatm tmen ent, t, and ou outc tcom ome e are def efiined by bi biom omed ediicin cine, the heiir me mean anin ings gs are are clea clearr for th e physician. The understanding o f these and other terms are part of the bi biom omed edic ical al cult cultur ure; e; to be a bi biom omed edic ical al pract practit itio ione nerr me mean ans s to acqu acquir ire e th this is cult cultur ure. e. For the patient the me mean anin ings gs ar are e fo forc rcef efu ull lly y di difffe fere rent nt;; if they hey were equal, the hey y would be shar sharin ing g the the same same cult cultur ure, e, wh whiich would me mean an th that at th the e pa pati tien entt was als also o a prac practi titi tion oner er.. Pro roffessi ssion onal al views ar are e alway ays s a reworking of cult cultur ural al views, and bo both th are are pe pers rson ona al

•

experi exp erienc ences es Kl Klei einm nman an,, 198 1987). 7).  n a br broa oade derr se sens nse, e, Klei Kleinm nman an st stat ates es th that at pa pati tien ents ts meta me taph phor ors s cann cannot ot be ea easi sily ly in inte terp rpre rete ted d  y

rigid c ystem like like th that at of biomedicine.

whic wh ich h le lead ads s to un unce cert rtai aint nty y in th the e pr prac acti tice ce of bi biom omed edic icin ine, e, in cont contra rast st to the ap appa pare rent nt

certa certain inty ty of bi biom omed edici icine ne scie scienc nce. e. ln th the e cl cliinical enco coun untter er,, both th the e ph phys ysic icia ian n and the pa pati tien entt play raies and buil bu ild d a rel relat atio ionsh nship ip.. Ge Gene nerR rRll lly, y, in a consu consult ltat atio ion n th ther ere e is a pa pattient nt,, inv nves este ted d with a si sickck-rol role, e, an and d exhi exhibi biti ting ng an iIIness be beh hav aviior or,, who suff suffer ers s th the e ef effe fect cts s of transference to a physician. T he d octor is invested with the healer-role, and exerts the prof profes essi sion onal al po powe werr conf confer erre red d to him or he herr by soci societ ety y throu hrough gh th the e Ii Iice cens nsin ing g pro proces cess. The Th e co comm mmun unic icat atio ion n is an exchange of styles of reasoning; the outcome of this cl cliinical en enco coun untter is int nter erpr pret eted ed by each of th the e part articip cipan antts un unde derr th the e Iigh ghtt of th thei eirr

•

own expecta ctations. Th This is uneven relationship finds its aim in the weil being of the pati pa tien ent. t. It is biome biomedi dicin cine e tha thatt de defi fine nes s we well ll-b -bei eing ng..

 

 

Biomedicine also has a very important role in de defi fini ning ng the hier hierar arch chic ical al

•

st stru ruct ctur ure e of sy symp mpto toma mato tolo logy gy,, which des esig ign ns the the stan standa dard rd of ca care re and sp spec ecif ifies ies the the mean me ans s to ac achi hiev eve e ce cert rtai ain n pred predet eter ermi mine ned d ou outc tcom omes es.. In othe otherr words, it de defi fine nes s the the prof profes essi sion onal al role in th the e clin clinic ica al enc nco oun untter er,, the exp xpe ecte cted results of the en enco coun unte ter, r, and fr fram ames es the the pa pati tien entt s pa part rtic icip ipat atio ion. n. Biome iomedi dica call po pow wer allows the de defi fini niti tion on of effi effici cien ency cy and effica icacy, the clinical definition of a disease, the tr trea eatm tmen entt of this di dise seas ase e according to the designed standards, and the definition of what is an accep ccepta tabl ble e outcome, and thus ind ndiirec ecttly defines health and disease. This se sett of exercises of power help to define biom biomed edic icin ine e as a disc discip ipli line ne and as a scie scienc nce. e. To diag agn nose and to treat are the two acts that define the biomedical profession; if

•

power has a major part in each of these constituents, it l as a major role in biom bi omed edic icin ine e an and d its its pr prac acti tice ce Furst urst,, 199 998) 8).. The pe perso rsonal nalize ized d tre treatme atment nt is crucial by be bein ing g soc social ially ly reco recogn gniz izab able le.. Without

a reco recogn gniz izab able le trea treatm tmen ent, t, the here re is no legi legiti tima macy cy of the sick-r -ro ole. If the dise diseas ased ed cann ca nnot ot fu fulf lfil illl th the e sick sick-r -rol ole, e, the social ial ne netw twor ork k ca cann nnot ot just justif ify y the accep ccepta tanc nce e of the diseas dis eased. ed. Con Conseq sequen uently tly,, the iI iIIn Iness ess is not validated an and d the the ab abno norm rmal alît îty y ca caus used ed by th the e di dise seas ase e be beco come mes s ap appa pare rent nt,, wh whic ich h je jeop opar ardi dize zes s the the so soci cial al stat status us of the the pe pers rson on.. This Th is frus frustr trat atio ion n is so co comm mmon on th that at We West ster ern n so soci ciet ety y cr crea eate ted d socia ociall stru struct ctur ures es to de deal al with it th the e so so-c -ca alled lled sp spec ecia iall inte intere rest st gro rou ups. Th The e do doct ctor or is also defeated in the proces ess s si sinc nce e his or he herr own role as a heal healer er or ca care re-g -giv iver er remains un unco comp mple lete ted. d. This cycle, for the biomedical professional, caUs for a series of acts, struc tructu ture res, s, se serv rvic ice es and al alli lied ed or pa para rapr prot otes essi sion onal als. s. Th The e tirs tirstt biome iomedi dic cal act is the the •

diagnosis; it is re reac ache hed d ba base sed d on a series of direct interventions Iike clinical

 

 

exami exa mina nati tion on and la labo bora rato tory ry pr pro ocedur ure es. Based on this this dia iag gnos nosis is,, a tr trea eatm tmen entt is

•

recommended or performed. 23 On e should note h e r e t h ha a t the availability of a spec specif ifie ie treat treatme ment nt and and comp compli lian ance ce to it are not th the e re resp spon onsi sibi bili lity ty of th the e phys physic icia ian. n. The Th e physi hysici cian an's 's responsib ibiilit ity y is the diagnosis and th e di disc sclo losu sure re of av avai aila labl ble e opti op tion ons s fo forr th that at spec specif ifie ie case case.. The effic ica acy of the tr trea eatm tmen ent, t, on the ot othe herr hand hand,, is the respon responsib sibilit ility y of

  i o m e d i c i n e

s c i e n c e ~ si sinc nce e

th the e re resu sult lts s of a ce cert rtai ain n pr proc ocedu edure re

or dr drug ug pres prescr crip ipti tion on are are defi define ned d by the the profession, ba base sed d on its its ow own n eva evalua luatio tions ns and and

standards.   Med Medic icin ine e is a habi habitt of cl clin inic ical al ju jud dgeme gement nt (Pelle (Pellegri grino no and Thomasma, Thomasma, 1981, 1981, p. 3). When When equa equati tin ng the the who whole medic edicin ine e to the cl clin inic ical al ju judg dgem emen ent, t, th the e auth author ors s take take

•

a stro strong ng id ideo eolo log gic ical al posit ositiion in relation to the scie scienc nce/ e/pr prac acti tice ce di dich chot otom omy y in th the e bi biom omed edic ical al doma domain in.. Ind Indeed, ed, as interpreted by Leeu Leeuwe wen n and Krismcl (1997), th the e pr prac acti tice ce of medi medici cine ne is in inde depe pend nden entt of con onc cepts su suc ch as di dise seas ase, e, an and d th the e physicia physician n does no t have have to unde unders rsta tand nd the mea meani ning ng of being il .

  he n s che mati zi ng the doctor-patient relationship, we can s a y i t is a

transaction of in info form rmat ation ion betw betwee een n two two di diff ffer eren entt symbol symbolic ic worl worlds ds,, whic which h re resu sult lts s in a s e t of ac acti tion ons s that that will fore foreve verr tran trans sfor form both part partic icip ipan ants ts (Nessa, 1996 1996). ).  h e pati pa tien entt br brin ings gs into the the cons consul ulta tati tion on a system of re reas aso oni ning ng th that at will be confro confronte nted d wit with th that at of t he physician. By the end of the consultati on, they will have built a sy synt nthe hesi size zed d sy syst stem em (Kle (Klein inma man, n, 198 1988). 8). The The pati patien entt desire desires s th this is modi modifi fica cati tion on;; in inde deed ed,, th that at is why why he subm submit its s hi him mself self to the consultation.  h e ph phys ysic icia ian, n, howe howeve ver, r, wi will ll

•

defe de fend nd him himsel selff agains againstt a deeper deeper emot emotio iona nall in invo volv lvem emen entt by acti acting ng defens defensivel ively y and The The ki kind nd of tre spec eciifie fie ca case se doe doess treatm atment ent,, surg surgie ieal al or clinical that is going ta be used in each sp not not ch chan ang ge th the e basic asics s of this study Z

 

 9

building inequ nequal alit itie ies s in into to the pr proc oces ess s Capi apisano sano,, 1987 . The The docto doctorr is pre prepare pared d to

•

of offe ferr his or her her patient ent onl only a product: a heal healtthier hier Iife, as defi efined and constrai rained by th the e capab capabil ilit itie ies s

 

bi biom omed edic icin ine e Abra Abramo movi vitc tch h and and Schw Schwar artz tz,, 1996 1996 . The The pati patien entt

wants much more: he

  r she

wants a healthier life as defined by his own values.

With Wi th the emer emerge genc nce e of thi his s conf confli lict ct of in inte tere rest sts. s. bi bioe oetthics hics gained mo mome ment ntum um.. The physic sician thinks he or she she

is

neut ne utra rall and deta detach ched ed when when eval evalua uati ting ng the the

patient. However, he or she she is tot otal allly  onne

te

with prec precon once cept ptio ions ns that that are are based based

on nothing other her than his or her her training. He or she is not a simple evaluator

  ra

neutral judge udge of the situation, he or she is an act active par artticipant ant of il.

•

Sect ection III

ONE ONE IL ILLU LUST STR R

TIV TIVE EC

SE SE

It is fr freq eque uent nt th that at the re rela lattio ions nshi hip p betw betwee een n doct doctor or and pati patien entt

is

tens tense e and and

unpleasan sant. The The number number of di dise seas ases es is Iimited, and the first irst qu ques esti tion on the pat patient ents

pose to them hemselv selves es and to the phy physi sic cian is wh whic ich h dise diseas ase e affl afflic icts ts them them.. The dise diseas ase e is pr pres esen entt befo before re th the e pr pres esen ence ce of th the e phys physic icia ian; n; once once orga organi niz zed, ed, it beco ecomes part part of th the e perso persona nali lity ty   the pati patien ent. t. This Th is pape paperr is no nott a casebook. However, at this momen omentt   am going to resort ta a hypo hypoth thet etiical cal case case to clar clarif ify y sorn sorne e poin pointts. The hypot hypothe heti tica call pati patient ent is a bl bla ack male male fort orty-f y-five ive years old, in good heal healtth until a coup couple le of week eeks before the consultation, when he started ta feel sporadic dizziness specially when changing decubitus. He decided to consult with his phys ph ysic iciian spec specif ific ical ally ly fo forr th these ese comp compla lain ints ts.. Hi His s neur neurol olog ogic ic,, acoust acoustic ic and and vesti vestibul bular ar •

examinations were normal, as were ail the rest

 

his phys physiica call and labor aborat ator ory y

 

 

evaluations, except fo forr hig igh h blood pr pres essu sure re.. Due to his age and fami family ly histo istorry, the the

•

phys ph ysic icia ian n de deci cide ded d to mor more e ag aggr gres essi sive vely ly trea treatt the the pa pati tient ent s hyp hypert erten ensio sion. n. Du Duri ring ng the course of his treatment, with the lowering of his blood pressure, the dizziness wors wo rsen ened ed.. Co Comp mpla lain inin ing g ag agai ain n ab abou outt it t

the physician, he was info inform rmed ed that the the

dizziness h d no appa apparent rent ph physi ysica call cor corres respon ponden dence, ce,  nd ta ease the symp mpttoms he shou sh ould ld avoid caffeine. Aiso he was told th that at the an anti ti--hy hyp perte ertens nsiv ive e trea treatm tme ent was nece ne cess ssar ary y to ma maiintain his health and th that at he would eve vent ntua uall lly y leam leam to live live with with ba bath th the the dizzi dizzine ness ss  nd the hyp hypert ertensi ension. on. The here re is a difference between the the disease seen by the physician and the iI iIIn Ines ess s felt felt by th the e pat patien ient. t.  s su such ch,, ther there e is a di diff ffer eren ence ce be betw twe een wh what at the the ph phys ysic icia ian n

•

is going to target and what the patients wants the physician to cure. Some

und nde esira sirabl ble e situ situa atio tions ns,, Iike th the e di dizz zzin ines ess s in thi this cas ase, e, are not de defi fine ned d as dise diseas ases es beca be caus use e th ther ere e is no specifie trea treatm tme ent fo forr them or becau aus se they they fall into into a ca cate tego gory ry th that at medical judg judgme ment nt dec ecla larres no nott to be a di dis sea eas se sinc since e the orga organi nic c beh eha avior ior is st stil illl wit ith hin normal ranges of variation. If there is no disease, there is no need to

cure. A cure can be understood  s a ch chan ange ge that that is as asse sess ssed ed,, faci facililita tate ted, d, me medi diat ated ed,, and an d mon monit itor ored ed by do doct ctor ors. s. Th The ere refo forre, the the ou outc tcom ome e de dete term rmin ined ed by a ch chan ange ge is no nott necessarily the one designed or desired before the intervention by the patient   Wrig Wright, ht, Wat Watson son,,  nd Be Bellll,, 19 1996 96). ). This Th is ca cas se is a good example of th the e ph phys ysic icia ian n s power to de defi fine ne a disease, whatt sh wha shou ould ld be treated, ho how w should it be treated, and ho how w to eva evalua luate te the the resu result lts s

•

in terms of its success or failure. The physician acted ethically and responsibly acco ac cord rdin ing g ta the cu curr rren entt pr pro oto toc col ols s. Th The e ef effe fect ctiv ive e co cont ntro roll of the the hy hype pert rten ensi sion on was

 

 

achi ac hiev eved ed and a pot oten enttial ri risk sk fo forr th the e pati patien entt wa was s elim elimin inat ated ed.. Th The e pa pati tien entt h how owev ever er

•

sti still feels si sick ck an and d fee eells be betr tray ayed ed.. His co conf nfid iden ence ce in th the e ph phys ysiician cian is shak aken en.. Th This is patien pat ientt s si situ tuat atio ion n co conf nfro ront nt th the e pr prob oble lem m wit ith h disp dispar arat ate e idea ideas s ab abou outt biom biomed edic icin ine es capabilities. Patien Pat ients ts sh shou ould ld be seen as a me mettap aph hori oric text bu butt the sci scientific metho hod d

provides only one tao to nor orma mali liz ze meta metaph pho ors. Phys hysic icia ian ns cann canne et read their pati pa tien ents ts pe perf rfec ecttly ly;; pa pattien entts ar are e mo more re aw awar are e of it no now w than in an any y ot othe herr mom omen entt of history.

Sect Se ctio ion n IV

•

FTER FTERM M TH

Biomedieine in general has Iimits. It is no nott alwa always ys ef effi fiea eaci ciou ous s or ef effi fici cien entt 50 th e cure may not always be achieved aceording to the p a t i e n f s viewpoint. Freq Freque uent ntly ly so sorn rne e type of re res sidua uall impa paiire red d fun unct ctiion rema remain ins s in th the e orga organi nism sm;; 50metim 50me times es the pr pric ice e to pay fo forr th the e re reco com mmen ende ded d proc proced edur ures es have a strong im impa pact ct

on the the qu qual alit ity y of li life fe of th the e pa pati tien entt ei eith ther er ec econ onom omic ical ally ly fu func ncti tion onal ally ly or both. Th The e contr con tras astt be betw twee een n wh what at is ex expe pect cted ed an and d what is ac ace eomplishe hed d has a ma majo jorr ef efffec ectt on how biom biomedic edicine ine an and d its pa para radi digm gmat atic ic pers persona-t ona-the he me medi dica call do doct ctor or or phy physic sician ian-are -are ju judg dged ed by th the e or ord dina nary ry per ers son society and the the law. Ot Othe herr med ediica call syst system ems s th that at attr attrib ibut ute e the ca caus uses es of iIIness to sup upem emat atu ura rall or extemal ag agen entts do no nott have have to fa face ce this his aS5 S5e essm sme ent si sin nce the di diff ffer eren ence ce between wh what at is of offe fere red d an and d wh what at is ob obta tain ined ed

•

is no nott 50 dramatie 24 as on one e ca can n ded edu uce from the ma many ny et ethn hno ograp graph hie ac acco coun unts ts of Since the eause of the disease is regarded as supernatural. the patient is the one to blame for the outcome by som someho ehow w meritin meriting g the dis disfav favor or of the supernatural pow power ers. s. For an exposition on different philoso philosophie phieal al sehools of medi medica call thought. see Manning  1973).

 

oth

•

r

medi me dica call tr trad adit itio ions ns.. 25 The contrast between a personal interpretation

o

phys ph ysic ical al fee feeli lin ngs an and d th the e ex expr pres essi sion on of th thei eirr va vallues an and d ho how w th they ey are are translated into into an impersonaJ scie scienc nce e bri rin ng th the e ma majo jorr co conf nfli lict ct be betw twee een n how th the e pa pati tien entt think hinks s an and d acts and what he or she ex expe pect cts s

tr

the worfd as an an answ swer er to th the e expressed and

unex un expr pres esse sed d ne need eds s and th the e sc scie ient ntif ific ic and and pr prof ofes essi sion onal al an answ swer er give given n by the he heal alth th care ca re syst system em an and d th the e he heal alth th ca care re pr prov ovid ider er.. On One e is a ge gene neri ric c qu quas asii plat platon onic ic qu ques estt the the othe otherr is a spec eciifie answer. Th The e an answ swer er do does es no nott mat atch ch the question. They are are in dif differ ferent ent ref refere erence nce fr fram amew ework orks. s. Aspe As pect cts s of hu huma man n comm commun unic icat atio ion n ar are e me meta taph phor oric ic as dise diseas ase e is metaphoric. A sen sa tio n o r emotion ca nno t be precisely described in words it must be translated

or

rationalized; during this process it ceases to be a sensation and

become bec omes s a symb symbol ol met etap apho horr or imag age. e. Si Simp mple le ex expl plan anat atio ions ns ma may y be and are •

used as tools to exert power o v e r the explicandum. T h e one th at explains creates the the im imag age e of wh what atev ever er is bei being ng ex expl plai ained ned.. Du Duri ring ng the clini clinical cal enc encoun ounter ter biome biomedi dicin cine e appr ap prop opri riat ates es the the im imag ages es to us use e th them em pr prac acti tica call lly y an and d rati ration onal ally ly.. The ph phys ysic icia ian n is the main ac acto torr in th the e cl clin inic ical al biom biomed edic ical al scen scenar ario io.. He or she

in inter terpre prets ts th the e bod body y and it its s fu func ncti tion ons s ma make kes s th the e ana anato tomi mical cal pa path thol ologi ogica call

c o r ~ e l

t i o n

and pre se nts the patient with a diagnosis. Th e physician also prescribes the treat tre atme ment nt an and d pe perf rfor orms ms any ne nece cess ssar ary y in inva vasi sive ve pro proce cedu dures res.. Ano Anothe therr resp respon onsi sibi bifi fity ty li link nked ed to the do doct ctor or is th the e cf cfin inic ical al re rese sear arch ch of new th thera erape peuti utic c me meas asur ures es.. In fact the physi phy sicia cianls nls ro role le is

 

inextricably linked to the the scie cience of biomedicine that the

succ succes esse ses s fai ailu lure res s and res respo pons nsib ibil ilit itie ies s of the lat latter ter are of ofte ten n conf confus used ed with tho those se

•

Ta cite ju just st one example. see Evans Pritchard  1976 . In this account. the medical system aims ta discover the the wi witc tch h who cause aused d the deat eath of the persan.  5

 

 

•

of

the phys physic icia ian n (Fre (Freid idso son, n, 1988 1988). ). The The patie patient' nt's s expe expect ctat atio ions ns rega regard rdin ing g the resu result lts s

of

the the treatm treatment ent ar are e thus thus in indi disc scri rimi mina nate tely ly leveled leveled

and an d biomedic biomedicine ine

 

 t

both the the phys physic icia ian n in part partic icul ular ar

general. But But the physicia ician n pl play ays s a doub double le role: (1) as care care-g -giv iver er

and (2) a s the researcher.

 h e

ethi ethica call profile profile

of

the the two two rela relati tion onsh ship ips s is di diff ffer eren ent: t:

while t he physician m u s t c ar e about a speci f i e patient, the r esear che r is more co conc ncem emed ed abou aboutt a fu futu ture re hy hypo poth thet etic ica a patie patient nt (Cat (Catto tori rini ni and phys ph ysie ieia ian n is caught caught betw betwee een n an im impe pers rson onal al c re

•

nd

science

~

~ c r d a c c i

1993). The

with a mand mandat ator ory y st stan anda dard rd of

a pati e en nt with personal concept i ons about health and d i s ea s e: what

a pp pp e ar ar s to be l os t is the out come. For Lynn

 nd

DeGrazia, what what matt matter ers s to the

pat atie ient nt.. and and shou should ld matte matterr to the the pra ract ctit itio ione ner, r,

 re

the patie patient nts' s' future future possi possibili bilitie ties. s.

Mor ore e spec specif ific ical ally ly,, what what is impo import rtan ant, t, is the the char charact acter er of the al alte tern rnat ativ ive e futu future res s that that the the patie atient nt could have have and and choo choosi sing ng amon among g poss po ssib ible le with th the e r a nk i n g

of

them

s o as t o a c h i e v e t h e

best

future

outc ou tcom omes es deter determin mined ed by the the pati patien ents ts pr pref efer eren ence ces s

(1991, p.3 .32 25). 5). Biom Biomed edic icin ine e ca cann nnot ot of offe ferr customcustom-fit fit outc outcom omes es,, even even if it reco recogn gniz izes es dise diseas ase e as a pers person onal al even eventt with a scie scient ntif ific ical ally ly kno known natura turall hi hist sto ory. ry.

Once On ce a diagn iagnos osis is is obtain taine ed, and co conf nfir irme med d by la lab bora rattory ev evid iden ence ces, s, the m e t h o d o l o g i c a l r e q u i r e m e n t s o f t h e p r o f e s s i o n a r e s at i s f i e d , t h e d i a g n o s i s conc co nclu lusi sion ons s prob robably ably confo onform rm to the re res searc rch h da data ta,, and the the pr prof ofes essi sion onal al aspec aspectt of th the e re rela lati tio onshi hip p cann cannot ot be crit riticiz icize ed on thes these e grou ground nds s because it is in conf confor ormi mity ty wit ith h th the e cu curr rren entt stan standa dard rds s of th the e profe fess ssio ion n. The physi hysic cia ian n has comp compli lied ed wi with th ail his or he r

•

lega legall and and scient scientific ific re resp spon onsib sibili ilitie ties. s.

  he

physician has the p owe owerr to ma ke ke

deci de cisi sion ons, s, to fu full lly y exe xert rt his pro rofe fess ssio ion n, fr fro om th the e sele select ctio ion n of rele releva van nt si sign gnif ifie iers rs in th the e inte interv rvie iew, w, to the the in inte terp rpre reta tati tion on of the the system system

of

re rea asonin ing g of th the e pati tie ent. It is based

 

on th thes ese e as assu sump mpti tion ons s that that the ph phys ysic icia ian n will offer a treatment. One One mu must st note here

•

t h a t while the diagnosis is in most cases an ob obje ject ctiv ive e co conc nclu lusi sion on ba base sed d on scientifically observable or measurable facts, the treatment may be a choice between  1 one or mo morre diff iffer ere ent procedures and  2 no trea treatm tmen ent. t. Often ften,, the profes pro fessio sional nal judgme judgment nt will be that that so some meon one e ne need eds s a tre treatme atmen nt, and the the pres prescr crip ipti tion on  

th ther erap apeu euti tic c pr proc oced edur ure e wo woul uld d be offe offere red d by a ph phys ysic icia ian n in a co cons nsui uita tati tion on,, sinc since e

with withou outt thi his s me medi dica call inte interv rven enti tion on pe peop ople le suf suffer fer a trip triple le de depr priv ivat atio ion: n: (1) their tro troub uble, le, treatm tmen ent, t, an and d (3) the pr proo ooff that that a dise iseas ased ed one do does es no nott really belong (2) the non trea ta so soci ciet ety y Mec ech hanic nic and Volka lkarrt, 1961 . This his is identified with med edic ica al care. The pati pa tien entt or th the e su supp ppor orti ting ng st stru ruct ctur ure e will look look for for the be best st ther therap apeu euti tic c op opti tion on.. Th This is is

•

th their eir pa part rt in the sick sick-r -rol ole. e. In mo most st ca cas ses es,, however, people will only find gen ene eric or symp sympto toma mati tic c tr trea eatm tmen ents ts.. Th The e exp xpe ecta ctation tion of a sl )ecific trea treatm tmen entt for a specifie diseas dis ease e af affl flic icti ting ng a sp spec ecif ifie ie pe pers rsan an,, i e a pe pers rson onal aliz ized ed trea treatmen tmentt is no nott fulfil lfille led. d. The Th e pa pati tien entt and the so soci cial al stru struct ctur ure, e, as a result, feel betrayed be beca caus use e biom biomed edic icin ine e app ap pea ears rs to have nothing ta offer. Also, patients want an ex expl plan anat atio ion n ab abou outt thei theirr il illlness. Th The e mo more re po powe werf rful ul the the ex expl plan anat atio ion, n, the the mo more re powerful the the scie scienc nce e and, in

tum, the more powerful the system, the medicine, and the healer. However, biomedic biom edicine ine of offe fers rs an ex expl plan anat atio ion n ab abou outt dise diseas ases es,, so som methi ethin ng alie alien n ta the the soc ociial needs of the patient. Wi With thou outt fulf fulfil illi ling ng su suc ch a ba bas sic need, biom biomed edic icin ine e plac places es itse itself lf in a fragi ragile le po posi sittion ion re rega garrdin ding the just justif ific icat atio ion n of its its so soci cial al po powe wer, r, its its se self lf-r -reg egul ulat atio ion, n, and an d it its s in infl flue uenc nce e in ma many ny as aspe pect cts s of co comm mmon on Iife. Biom Biomed edic ical al cul cultur ture e migr migrates ates tra tram m

•

an int nteg egra rate ted d pa parrt of the the so soci ciet ety y to a marg margin inal al and dist distur urbi bing ng po posi siti tion on.. Bi Biom omed edic icin ine e

 

 

is re requ quir ired ed by so soci ciet ety y as a whole, bu butt ac acco cord rdin ing g to th the e terms terms di dict ctat ated ed by tha thatt so socie ciety ty

•

and not thos those e of biom biomed edic icin ine. e. Ther Th eref efor ore, e, th the e res result ult of a clin linical enc nco ount nte er is a personal ep epiist ste emo mollog ogiica call clash.  

Beca Be caus use e he heal alth th is simu simult ltan aneou eousl sly y no norm rmat ativ ive e for th the e me medi dica call re rela lati tion onsh ship ip

and su subje bject ct to pe pers rson onal al an and d so soci cial al inte interp rpre reta tati tion on,, ex expe pert rt as assu sump mpti tion ons s ab abou outt th the e goa oall of me medi dici cine ne and pa pati tien entt as assu sump mpti tion ons s cias ciash. h. ï

s

ci cias ashe hes s ar are e mos of oftten th the e re resu sult lt

of diff iffering, non-explicit conceptions of health. Since the goal of medicine is ta restore health, this ta task sk mu mus st rest on dialogue to es esta tabl blis ish h th the e pa para rame mete ters rs and func functi tion ons s both oth do doct ctor or an and d pa pati tien entt will as assu sume me to reach th the e go goa al (Cas ass sel elll, 1991, P 50). Biom Biomed edic ical al scie scienc nce e do does es no nott ac acco comm mmod odat ate e pa pati tien ents ts'' de desi sire res s fo forr pe pers rson onal al an and d

•

personalized care that is aimed at their current needs and adapted to their expectations. In addition, an indi indivi vidu dual al pa pati tien ent' t's s cu cult ltur ure e and me meta tapho phori rical cal la lang ngua uage ge are ignored during the consultation. The physician's only instrument is the impersonal biomedical methodology; the results that he or she obtains are satisfacto satisfa ctory ry on only ly on a leg legal an and d sc scie ient ntif ific ic basis. He th thus us ca cann nnat at ful ulffil illl the pati patien ent' t's s re requ ques estt for pe pers rson onal aliz ized ed ca care re be beca caus use e ther there e is no provision in biomedicine-science

for for in ind div iviidu dua al care. Biom Biomed edic ical al cu cult ltur ure e do does es no nott re reco cogn gniz ize e a me meta taph phor oric ical al la lang ngua uage ge and an d re refu fuse ses s ta en ente terr into into a dial dialog ogue ue with ot othe herr cu cult ltur ures es re rega garrdi ding ng it its s pr prof ofes essi sion onal al domain. Both physicians and patients have expectations about the practice of bi biom omed edic icin ine. e. Also, do doct ctor ors s and pa pati tien ents ts ev eval alua uate te th the e me mean anin ing g of su succ cces ess s di diff ffer eren ently tly

•

Howan indivi individua duall cornes ta know, the theories on beliefs about knowledge, and the manner by wh whiich such pr prem emis ises es are int integra egrated ted in rational processes ar are e ex expl plai aine ned d by Hof ofer er and Pintrich  1997 as personal epistemology.  b

 

when it is applied to a therapeutic procedure Kleinman, Eisenberg and Good,

•

1978). When When asked about out th thei eirr sati tis sfa fac ctio ion n with the health care provided by the syst system em,, th the e pat atie ien nts re resp spon ons ses were grou rouped aro rou und four four ma majo jorr vari varia able les: s:  1 satisfaction wïth the outco outcome me,,  2 sa sati tisf sfac acti tion on wi with th the the care care prov provid ided ed,,  3 in relation wit ith h pati patien ents ts own expe expect ctat atio ions ns,, an and d  4 satisfaction with the the le leve vell of comm commun unic icat atio ion n between doct doctor or and pati tie ent Cook, 1988 p.9). If the patie ien nt is unsatis tisfie fied with the outc ou tcom ome e that that he or she cannot decide, if th the e ca care re provided is unsa unsati tisf sfac acto tory ry due to th the e impe impers rson onal al char charac acte terr of th the e syst system em,, if pati patien ents ts ex expe pect ctat atio ions ns are are pump pumped ed up by the medi a and the level of communication between physician and patient is beara rab bly reasonable, the least one can expect is that patients do not trust the

•

sy syst stem em,, th the e sc scie ienc nce e and th the e prac practi titi tion oner er anym anymor ore. e. As th the e fu fulf lfil illm lmen entt of an expec xpecta tati tion on,, sati satisf sfac acti tion on can only only

 

i n ~

r p r

t

on

pers pe rso onal nal gr grou ound nds, s, where in indi divi vidu dual al valu values es pl play ay the the majo majorr ro role le.. On One e cann cannot ot ig igno nore re the pa pati tien entt s expe expect ctat atio ions ns in a cons consul ulta tati tion on.. Heal Healin ing g sugg sugges ests ts a sens sensat atio ion n of well well-bein be ing, g, weal wealth th,, heal health th,, and and is a return to norm norma ali lity ty,, but no norm rmal alit ity y is an explanatory to tool ol.. The physi hysici cia an cann cannot ot be deaf to the patient s signifiers, since they are the

fr fra ames of his parti artic cul ula ar conc concep eptt of health th,, and they they ale lert rt the the ph phy ysici sician an ta the the level of fu func ncti tion onal alit ity y the pati tie ent want wants s to achi achiev eve. e. Acco Accord rdin ing g to Gelf Gelfan and d 1968 1968), ), the the fin final pro roo of of value to a medical episte istem mol olo ogy is the the allevia iattion of dise isease: the better ter it does, the better i t is. Scientifically. physicians compare their patients with st stat atis isti tic cal ally ly norma rmal standards, and exert th thei eirr pow owe er to align them them with ith that that norm orm by

•

interf int erferi ering ng dire directl ctly y in th the e patien patients ts body body.. Howe Howeve ver, r, pa pati tien ents ts cann cannat at be co comp mpar ared ed to sta tati tist stic ical ally ly normal standards, sin inc ce th they ey are not not a param rametric ric entry in a table.

 

 

Unfo Un fort rtun unat atel ely, y, th the e ph phys ysic icia ian n do does es no nott rece receiv ive e sci scien entif tific ic ins instru trume ments nts ta int interp erpre rett ea each ch

•

patie atient nt separately and ta ac actt ac acc cor ordi ding ngly ly.. Sinc ince ail biom biomed edic ical al da data ta is av avai aila labl ble e as a resu result lt of st stat atis isti tica call infe infere ren nce ce,, th the e pa pati tien entt be beco come mes s mo more re of a prob probab abil ilit ity y th an an individual. However, the human context contaminates the results of scientific obse ob serv rvat atio ion, n, wh whet ethe herr du due e to ge gend nder er Littl ittle e, 19 1996 96)) or so soci cioo-po poli liti tics cs Fr Fran anco co,, 19 1980 80). ). There ere is no neu eutr tral alit ity y

 

everla eve rlasti sting ng sta stabil bility ity in the value or concept of the norm,

even if a searc rch h fo forr ac accu cura rate te results lts

in

medi me dic cal sci scien ence ce is  n old old end endeav eavor or Ba Barl rlet ett, t,

1848 18 48;; Ca Caba bani nis, s, 18 1803 03). ). Kl Klei einm nman an.. Eise Eisenb nber erg, g, an and d Go Good od stat state, e, IICo IICont ntem empo pora rary ry me medi dica call pra pract ctice ice ha has s become bec ome incr increa easi sing ngly ly dis discor cordan dantt wi with th lay lay ex expe pect ctat atio ions ns.. Mo Mode dem m phy physici sicians ans diag diagnose nose

•

and an d trea treatt dise diseas ases es abn abnorm ormali alitie ties s

in

th the e stru struct ctur ure e and func functi tio on of bo bod dy or orga gans ns and

sy syst stem ems) s),, whe here reas as pa pati tien ents ts su suffe fferr illn illnes esse ses s ex expe peri rien ence ces s of disv disval alue ued d ch chan ange ges s stat st ates es of being and in social fun function; the human illn illne ess and disease. do no nott stand

in

a one one-too-o one rela relattion ion

 

in

defined,

19 197 78 p.251). The The ma maiin proo roof of the the worth of

a spe specif ifie ie healing sy syst stem em is th the e sa sati tisf sfac acti tion on of the the pa patie tient nts s with the the resu result lts s Gev evit itz z, 1993). Furthermore, when biomedicine attempts to control the so-called

undesirable, i t becomes a moral enterprise

Freidson, 1988). Too often,

biomedi biom edicine cine is  n unsat unsatisfac isfactory tory mor moral al en enter terpr prise ise.. The Th e expe peri rie ence of illn llness is personal. For the the patient who

is

su suff ffer erin ing, g, the

physician is a figure of more importance than a counselor or a partner

in

the

decisi dec isionon-mak making ing proces process. s. The imme immediat diate e nee of re relilief ef ob oblilite tera rate tes s an any y oth other er ra rati tion onal al

•

thi nki ng.

If caring fo forr the diseased or underprivileged has a long history, the

iden identi tifi fica cati tion on of th thiis figu figure re with th the e phy hys sici ician is rece recent nt and sh shor ortt-l -liv ive ed. A tr trus usti tin ng

 

pattien pa entt anly surrendered to a car ariing physi sic cian between een 18 1880 80 and 19 195 50. Be Beto tore re th that at

•

peri pe riod od,, ph phys ysic icia ians ns we were re so some meti time mes s th thre reat ats s ta th thei eirr pa pati tien ents ts;; sinc since e then, pa pati tien ents ts have ha ve grow grown n di dist stan ance ced d tr tram am th the e me medi dica caff pr prof ofes essi sion on th thro roug ugh h self self-d -dia iagn gnas asis is and aut auto o tr trea eatm tmen ent. t. Ph Phys ysiici cian ans s to toda day y ar are e seen by th thei eirr pa pattien entts as drug dispe dispens nsers ers Sh Shor orte ter, r, 1990). Forr Ba Fo Bars rsk ky 1988), there app ppea ears rs to be a de decl cliine ln satIsfaction

With

personal

heal he alth th.. Peo eopl ple e report an ev ever er-g -gro rowi wing ng nu numb mber er of dist distur urbi bing ng so somat matic ic sym sympto ptoms ms an and d m o r e fe elin gs of general iIIness than ever before. A t the s a m e time, there is a grow growiing lack of co conf nfiide denc nce e in bi biom omed ediici cine ne;; alte altern rnat atiive therap erapiies vacu va cuum um.. The lack

•

 

f1 u urris h in

the

c onfiden ce is so significant that patients do n ot tell their

phys ph ysic icia ians ns that that th they ey are se seek ekin ing g oth other er he heal alin ing g sys system tems s S Sel elig igso son, n, 19 1998 98). ). Pa Pati tien ents ts and/ an d/or or thei theirr soci social al ne netw twor orks ks ar are e so mo moti tiva vate ted d by fr frus ustr trat atio ion n rega regard rdin ing g bio biomed medici icine ne s inad ade equat ate e treatment of a ca case se that they express their preference for ethnie or cult cu ltur ural al pr prac acttic ices es N Neu eube berg rger er an and d Wo Wood ods, s, 19 1990 90). ). Wh What atev ever er th the e rea eas son, wh what at th the e patient is looking fo forr is the po poss ssib ibil ilit ity y of bu buiildi ding ng a tran transf sfer eren enti tial al rela relati tion onsh ship ip with a h ealer, transforming him o r h e r in a care-giver. This can only be done if an in indi divi vidu dual al app ppro roac ach h is id iden enti tiffie ied d by th the e patient nt.. Th The e ind ndiividu vidual al ap appr proa oach ch is on one e of the

char ch arac acte teri rist stic ics s of th the e ho holi list stic ic me medi dici cine ne syst system em Froh Frohoc ock, k, 19 1992 92). ). Ho Holi list stic ic med medic icin ine e also app ppea ealls in ma many ny ot othe herr ways: ac acce cept ptab able le ex expl plan anat atio ions ns fo forr th the e sick sickne ness ss,, using part pa rts s of bi biom omed ediici cine ne as an ex expl plan anat ator ory y too ooll to toge geth ther er wi with th my myst stic ical al idea ideas s wh when enev ever er necessary.

•

In

add ddiition on,, th the e he heal aler ers s of offe ferr tim ime, e, symp sympat athy hy,, an and d freq freque uent ntly ly a forma ormaii

prom promiise of cure. With a more pleasant emotional relation with healers there is a growing sh shiift to se sellf ca care re as can be eas asiily se seen en in sta stati tisti stics cs demo demonstr nstrati ating ng that 4

 

 

o

•

50

the pat atiien ents ts in the Unite ited State tates s used alt lter erna nati tive ve the therapies in 1997 me mean anin ing ga increa inc rease se sin since ce 1990 (Reuters, 1998 . Pat atie ien nts do no nott kn know ow wh what at ta do with their physicians. The They y no nott on only ly fea fear bu butt

al also so are al also so rea ready to su surr rren ende derr co comp mple lete tely ly if this would warra arran nt hi his s or her atte attent ntio ion n and good will, or in Kah Kahn n s wo word rds: s: Ugetting a re refe ferr rral al,, being ing prep prepar ared ed,, be bein ing g spec specif ifie ie,, and brin ing g ap appr prec ecia iati tiv ve are are way ays s of ob obta tain inin ing g be bett tter er ca care re fro from a do doct ctor or.. Sh Show owin ing g up la late te,, ov ove erloo rlooki king ng the su supp ppor ortt staf taff, igno norring ing the the doctor, and be bein ing g adv dve ersa rsaria rial are defi de fini nite tely ly no nott wa ways ys of ge gett ttin ing g a doctor1s atte attent ntio ion n (1998, p 91). Fe Feel elin ing g tha thatt ther there e is

  o

more mo re any kind of personal care, patients do not reward emotionally their

physicia phys icians ns any anymor more e (Kov (Koven en,, 1998 . If pa pati tien ents ts co comp mpla lain in abo about ut ph phys ysic icia ians ns,, do doct ctor ors s

•

al also so com ompl pla ain abou outt the their patients. There are sorne behaviors exhibited by the patie ien nts that ar are e regarded as pr pro one ta raise barriers between the them and the the health c a r e t ea m .

D ucanis a nd G ol i n

(1981)

describe the the

manipulativ ive e,

the

Uunm Uu nmot otiv ivat ated ed,, the probl problem em and the the yeayea-saye sayer, r, demo demonstra nstrating ting that any beha behavior vior betw be twee een n de dema mand ndin ing g (m (man anip ipul ulat ativ ive) e) an and d tota totall su surr rren ende derr (yea (yea-s -say ayer er), ), be betw twee een n ea easy sy goi oin ng (unmotivated) and diff diffic icul ultt (pro (probl blem em)) is a ba barr rrie ierr for for the the prac practi tice ce of med edic icin ine. e. Maybe the practice of a good me medi dici cine ne,, on one e that that would no nott crea create te prob proble lem m s e i th e r

fo forr ph phys ysic icia ians ns or for for pa pati tien ents ts is on one e biom biomed edic icin ine e witho ithout ut the the clin clinic ical al enco encoun unte ter. r. Wha hatt happens inside the body when struck by a disease if it is not seen as in inco com mpr pre ehe hen nsi sibl ble e, it is at leas leastt unexpected. Inst Instru rume ment nts s of the We West ster ern n pa past st,, used ta dea eall wit ith h the dise diseas ase, e, wh wher ere e Iink Iinked ed ta the the po pow werful rful su supe pern rnat atur ural al.. On Only ly recently tly,

•

bi biom ome edic ical al knowledge about health and disease started ta substitute the old conceptions. If the way the the health lth ca care re system tem and its memb member ers s ch chan ange ged d the the way

 

 

they the y se see e di dise seas ase e llay ay pe peop ople le me mean anin ing g the us user ers s

•

 

the the he heal altth ca care re sy syst stem em may

not. Fo Forr pa part rt of the population at large d diisease is still Iinked to som someth ething ing mo more re pawe pa werf rful ul tha than n they are if it cann cannat at be the gods s so o let it be the healer. Th The e many possib pos sible le int interp erpre retat tatio ions ns of issue issues s re rela late ted d to heal altth together together with the coe coexis xisten tence ce of two paradigms o on ne for the physician and ano notther for the patient b bu uild up a pr prog ogre ress ssiv ive e mi misu sund nder erst stan andi ding ng of me mean ans s and aims aims or a clas ash h of rationalities.

TR NS T ON

Si Sinc nce e it is ide identi ntifie fied d as a sc scie ienc nce e bio biomed medici icinene-cli clinic nical al prac practi tice ce prod produces uces a serie ries of compromises and expectations in the imaginations of lay-people. •

Physicians are also to sorn sorne e ex exte tent nt aff affect ected ed by the the sam same e ex expe pect ctat atio ions ns.. Eve Everyb rybody ody s e ems to believe that biomedicine-clinical practice can fulfill man y of the exp xpec ecta tattio ions ns attributed to bio iome med dic icin inee-sc scie ienc nce e; ma many ny identify the bi biom omed edic ical al trea treatm tmen entt or pr proc oced edur ure e as th the e ma mate teri rial al re real aliz izat atiion of this his fulf ulfil illlme ment nt.. Whi hile le phy hysi sic cians ians an and d pa pati tien ents ts sh shar are e the same so soci cie ety they li live ve in different culltur cu ures es.. The clinical encou oun nter assumes the role of a negotiation tabl table e where

beliefs and an d tru truths ths along with th the e inst instru rume ment nts s used to build them ar are e con consta stantl ntly y pu putt on trial.   s w e sa w ph phys ysic icia ians ns ar are e not not on only ly me memb mber ers s of thei theirr profession bu butt also also the

desi de sign gner ers s of thei theirr sc scie ienc nce. e. Ph Phys ysic icia ians ns de deci cide de bi biom omedi edici cine ne s do doma main in:: the they y de deter termin mine e the tools of the trade and the comparative and determinant value o f each •

procedure. Biomedicine is completely designed by physicians. There is no sin here.

 

 

Physic Phy sicist ists s sh shap ape e ph phys ysic ics, s, eco econo nomi mist sts, s, ec econ onom omy, y, mat mathem hemati aticia cians, ns, mat mathem hemati atics, cs,

•

and so forth. We can argue tha that ail professions and scie scienc nces es influ fluen enc ce in one way or an anot othe herr the life of hu hum manity; ty; hawever, the im impa pact ct exerted by biom ome edicin icine e is of anot an othe herr sort. Biom Biomed edic icin ine e ha has s a dire direct ct and acut acute e impac impactt on the qu qual alit ity y and Iife ife sp spa an of each individual, sa the here re is an imp implie lied d commitm commitment ent in the the resu result lts. s.  

li live ve by ou ourr so soci cial al raies, yet these raies are are construed his histor torica ically and

culltu cu tura rall lly y. Ta ch chan ange ge them we need time. One mu must st real realiz ize e that that un unde derl rlyi ying ng the the role role of taday s healer, there is still a shaman or a priest, wh who o po powe werf rful ully ly indu induce ces s tran transf sfer eren ence ce

Stei Stein n and Apprey, 1985). Our sick-role is still dominated by

id ide enti tifi fica cattio ion ns with a supernatur tural healing sys ysttem; the the paradigm of the healing

•

sys ysttem sh shiifte ted d from sup uper erna natu tura rall ta sci scien enttific ific,, bu butt pa pati tien ents ts are still un unaw awar are e of the shif sh iftt when ve vest sted ed in the the sic sick-r k-role. ole.

•  

 

Chapte Cha pterr Thre Three e

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NEGOTI NEG OTI TING TING THE THE UNNE UNNEGO GOTI TI BLE BLE According to Pellegrino and Thomas ma 1981, p.69), medicine is the

cogn co gnit itiv ive e art ûf ap appl plyi ying ng scie scienc nce e and persuasion thrûugh a complex human interaction in which a mu mutu tual ally ly sa sati tisf sfac acto tory ry stat state e of well-being is so soug ught ht,, an and d in whic ich h the uniqueness of values and disease, and the kind of institution in which care ca re is delivered, de dete term rmin ines es the na natu ture re of th the e jud judgm gmen entt ma made de.. o n e seeks help, whereas on the other, sameone offers help,

•

ex exch chan ange ge Ra Rabi bino nowi witz tz,, 19 1980 80). ). Wit Withou houtt th this is int intera eracti ction on

 

n the on one e hand,  

there is an

inte intent ntio ions ns,, ther there e wo woul uld d be

no me medi dici cine ne.. An Any y ex exch chan ange ge im impl plie ies s so some meth thin ing g offe offere red d by both sides; if this trade is sa sati tisf sfac acto tory ry for both, th ther ere e will be no con confl flic ictt rega regard rdin ing g the the ne nego goti tiat atio ion n proc proces ess s and out outeo eome me..  t  twill soci ciet ety y no long longer er recognizes the serv ervices ices of will be a fair deal. Yet so biom biomed edic icin ine e as a fair deal; this gave rise to th the e ne need ed for for me medi diat ator ors: s: om ombu buds dspe pers rson on,, pati pa tien enes es ad advo voca cate te,, sp spec ecia iall or foca focall in inte tere rest st grou group, p, an and d bioe bioeth thic icis ists ts.. Whatever are the reasons for the development o f modern bioethics, it orig origin inal ally ly represented an attem empt pt ta solve conflicts between the system and its

users. These contentions may have been as general as the choiee of resource allo alloca cati tion on am amon ong g ma many ny he heal altth prog progra rams ms,, or as sp spec ecif ifie ie as the the ap appr prop opri riat aten enes ess s of th the e procedure ta obtain an informed consent o f a given patient for a given

•

cire cireum umst stan ance ce.. Id Idea ealllly, y, bi bioe oeth thic ics s sh shou ould ld be the ne neut utra rall jud judge ge of the the ap appr prop opri riate atene ness ss  

th the e behavior of the system and of the user; it sho hou uld be the indic dicato ator of the the ma mast st

adeq ad equat uate e be beha havi vior or in ea each ch an and d ev ever ery y ci cire reum umst stan ance ce..

 

 

•

The major aim of this chapter is ta evaluate the raie of bioethics in the context

 

the practice of biomedicine. To do sa so sorn rne e is issu sues es reg egar ard ding ing beli belief efs s

rela relate ted d ta cu cult ltur ures es in ge gene nera rall an and d bio biomed medici icine ne in par partic ticula ularr must be clarified.

Sect Se ctio ion n

THE THEORY THEORY  

THE PRAC PRACTI TICE CE  

BIOMED BIO MEDICI ICINE NE AND AND

BIOETHICS

As expl explai aine ned d by Hardin 19 198 88), ut util ilit itar aria iani nism sm is the the mor oral al theo theory ry that that judg judges es th the e go good odne ness ss of outcomes, and bio iom med edic icin ine e is a uti utilitari arian sci cien ence ce Sha haw w and Barr Ba rry, y, 1995). Th This is af affi firm rmat atio ion n is bas ase ed on th the e desi sig gn of the the cl clin inic ical al me meth thod odol olog ogy, y, wher wh ere e stat statis isti tica call just justif ific icat atio ions ns ar are e alwa always ys give given n ta st stan anda dard rdiz ize e the the proc proced edur ures es ba base sed d •

ùn the physiological behavior of a majority. In ad addi diti tion on,, the the idea ideall cl clin inic ical al con consul sultat tation ion has a uti tillit itar aria ian n design. However, the aim of the co cons nsul ulta tattion is the patient s we welll being, which would be measured by the individual values of each client. This relat rel ativ ivis isti tic c do doct ctor or-p -pat atie ient nt re rela lati tion onsh ship ip ha has s Iitt Iittle le tech techni niea eall su supp ppor ortt from biom biomed edic ical al science. The practice of biomedieine can be seen as having two main tasks: to cornfort and to heal Dixon, 1978, p 1). Although co corn rnfo fort rt can be understood in

differ dif feren entt wa ways ys,, pr prof ofes essi sion onal ally ly it ca can n be surnrnarized as the the alle allevi viat atio ion n of sy syrn rnpto ptoms ms:: it is fram framed ed rela relati tivi vist stic ical ally ly.. Wha Whatt re resi side des s in th the e fram frame e

 

the healing task is a seed

of confHet between users and healers. Wh What at insiders

biom omed edic iciine defi efine in a

ut util ilit itar aria ian n tash tashio ion n as healing is qu quit ite e di diff ffer eren entt tram wh what at ou outs tsid ider ers s un und ders erstand tand or,

•

more mor e irnp irnpor orta tant ntly ly,, te teel el..

 

•

Th e co nce pt of

s e p a r a b i l i ty

mu st be introduced here. It means that

Uspatially sep separa arate ted d syste systems ms al alwa ways ys ha have ve ind indepe epende ndentl ntly y def defina inable ble pro proper perti ties es an and d existence and th thes ese e pr prop oper erti ties es ex exha haus ustt the de desc scri ript ptio ion n of an any y syst system em ma made de up of these the se su sub b syst system ems s (C (Cus ushi hing ng,, 19 1989 89,, p.1 0). It follows that if we consid sider a human bein g as an individual, distinct from the rest

of

the humanity, we m u s t find

philosoph phil osophicai icai ways to Inte Integra grale le ea each ch in indi divi vidu dual alit ity y inlo th the e st stat atis istl tlcal cal con conseq sequen uences ces of the the biom biomed edic ical al mo mode del. l.

 

must note that a person can only be co con nsider ere ed as an

organism independent from the rest of hu hum man anit ity y if he or sh she e is no nott env nviisa sage ged d as a organic orga nic-soc -social ial-cul -cultura turall com complex plex,, i e

only as an organic entity, the one that

bi biom omed edic icin ine e de deal al with with in it its s co cont ntro roll lled ed tr tria ials ls.. Ab Abst stra ract ctin ing g ail ail bu butt a few ph phys ysio iolo logi gica call

•

functions in a study study tr tran ansf sfor orms ms a pe pers rsan an into a pa para rame metr tric ical al en enti titty. Wh When en ph phys ysic icia ians ns exc ex cha han nge ged d the pa pati tien entt an and d the the iIIne ness ss,, that that is, the indi indivi vidu dual al pe pers rsan an in : . so soci cial al and cultural context, for sc sciience' e's s disease, or statistical result (Savitt, 1995), the trad tradit itio iona nall chara charact cteri erist stic ics s of the the doc docto tor-p r-pat atie ient nt re rela lati tion onsh ship ip an and d th the e hea healer ler soci social al role role chan ang ged, without a corresponding adaptation of the sick-role, which was still attac ache hed d to an outd utdated model of a caring healer. hermeneu neuti tic c en ente terpr rpris ise e rath rather er th than an Medi Me dici cine ne wo woul uld d be bet better ter un unde ders rsto tood od as a herme as scie scienc nce, e, si sinc nce e the ph phys ysic icia ian n in fac factt in inte terp rpre rets ts the iII persan. If the patient is to be

interpreted as a dy dyna nami mic c te tex x

(B (Ba aro ron, n, 1990), wr writ itte ten n in a meta metaphori phoricall callangu anguage, age,

four four such such text texts s ex exis ist: t:   1) th the e ex expe peri rim men enttal al,, or ho how w th the e pa pati tien entt lives th the e exp xpe erie rienc nce, e,   2) the the na narr rrat ativ ive, e, ob obta tain ined ed du duri ring ng the the me medi dica call his histor tory-t y-taki aking, ng,   3) th the e ph phys ysic ical al,, wh whic ich h

•

comp co mpri rise ses s the the ob obje ject ctiv ive e find findin ings gs an and d   4) the in inst stru rum men enta tal, l, co cons nstr true ued d with th the e us use e of

di dia agn gno osti stic procedures (Leder, 1990). The pa pattient ient brings the fi firs rstt two into the

 

9

•

cons co nsul ulta tati tion on,, dur urin ing g which the the na narr rrat ativ ive e text text atte attemp mpts ts to de desc scri ribe be th the e expe experi rime ment ntal al:: th the e oth other er two ar are e inte interp rpre reta tati tion ons s of the the pa pati tien ent. t. Phys Ph ysic icia ians ns feel corn ornered ered by thei theirr relat elatio ions nsh hip with bi biom omed edic iciine-s ne-sci cien ence ce.. In Inap appr prop opri riat ate e therapies are are rooted

in

a lack

 

knowledge about the patho

physiology of a disease as weil as a lack of awareness about the limitations of th the e

unco un cont ntro roll lled ed while clinic nical tr triials als in univer ivers sit ity y ho hosp spit ital al sett ttiing ar are e believed

to

be

trus usttwor ortthy Cuzzani and Lie, 1991). What What rema remain ins s fo forr th the e phys ysiicia ian n is th the e choi choice ce to f o l l ow t he lead of tertiary care o r

to

expe ex perrie ien nce or opinions do not not co coun untt

cour co urtr troo ooms ms,, even if phys physic icia ians ns record and

act base based d

on

in

risk malpractice. His or her personal

wha wh at the they hear, not what the patients say say or mean. What What is interpreted

within bi biom omed edic icin ine e as the the pa pati tien entt s view, op opin inio ions ns,, wi wis she hes, s, valu values es and beli belie efs, fs, ar are e •

nothing mo more than

artifa art ifact ct of the the prof profes essi sion onal al perc percep epti tion on Arms Armstr tron ong, g, 1984 1984). ).

an

Ther Th ere e appe appear ars s to be a disp dispro ropo port rtio ion n betw betwee een n anno announ unce ced d di disc scov over erie ies s and th the e obtain obt ained ed res result ults. s.

It

is diff diffic icul ultt to translate a value of 8

of a certain disease

ta

one o f the

more mo re relative than accuracy. A 1

 

2

success

in

th the e treatm treatment ent

of the fai aillur ures es.. However, there is nothing

error in biom biomed edic ical al sc scie ienc nce e is a nearnear-pe perl rlect ect hi hit. t.

The Th e same same err rror or in warfare me mean ans s aiming at Ne New w York and blasting Montreal. For   iomedicine science 8

is an intel ntelli ligi gibl ble e value, yet yet fo forr the patient, ther ere e is no

8

of a pe pers rsa an. Biom Biomed edic ical al sp spee eech ch is inco incomp mpre rehe hens nsib ible le for la layy-pe peop ople le,, not not becau because se of its teehn hniicality ty,, but but be bec cau ause se its sc scal ale e of values is di diff ffer ere ent nt.. Pro roba babl bly y the gr grea eate tes st ach ieve ment biomedicine offered ta humanity was, and still is, a better

•

understa unde rstandin nding g of physiolo i ph phen enom omen ena. a. Me Medi dici cine ne does does not not pr prov ovid ide e th the e re rest stor orat atio ion n of well-being. The biomedical aim is corporeal, biologieal. and influenced by

 

 

•

per erso sona nal, l, social, ec econ ona amic, ic, and po poli liti tic c agendas. This is not what one one woul would d expe expect ct fram a care system. Care can on ly be measured individually, in a ane to one relationship. To su sug ggest gest that that biomedicine-c1inical prac practi tice ce is not sc scie ient ntif ific ic is th the e sa same me as asser sserti ting ng its uncertainty, while removing its predictive power. Of course, this predicti pred ictive ve po powe werr

is

what wh at st stre reng ngth then ened ed the the li link nks s of bi biom omed edic icin ine e with th the e econ econom omic ic

and pot otit itiic power. It is this this pred predic icti tive ve po powe werr that that su subs bsta tant ntia iate tes s

 n

important impor tant part part  

th the e st stan anda dard rd of care are de defi fini niti tion ons. s. Neve Ne vert rthe hele less ss,, scie scienc nce e an and d the the de defi fini niti tion ons s th that at sc scie ienc nce e of offe fers rs ar are e acce accept pted ed only when they do no nott co conf nfli lict ct with high higher er personal valu value es. A good exam exampl ple e of th the e

•

cont co ntti tict ct re reg gar ard ding a so-ea o-eall lled ed sc scie ient ntif ific ic tr trut uth h is the di disp sput ute e betw betwee een n crea creati tion onis ists ts an and d evol ev oluti ution onis ists ts that that is st stil illl

Section

 

in

progress.

1BELIE 1BE LIEVE VE VO VOU U BEL BELIEV IEVE E

 Beli Beliet ets s are the lens lenses es thr through ough which

w

 

T

Y

BELIEVE

view view th the e wor orld ld

Wrig Wright ht,, Wats Watson on

and Bel Bell, 1996, p.19). Beliefs provide the toundation fo forr ail our experiences and interactions with the r

l

worrld, wo ld, so tha thatt we build a subj subjec ecti tive ve truth, or in indi div vid idua uall view,

of reality. Truth and reality are no t the same thing. Scientific and ideological knowledge may coexist as forms of beliefs since scientific practices produce ideo ideolo logi gica call kn know owle ledg dge e Youn Young, g, 1981 1981,, p.38 p.385) 5).. Huma Hu mans ns tend to buiId pe pers rson onal al ex expl plan anat atio ions ns about about the worl world d that that surr surrou ound nds s •

them. Sorne of these explanations are acquired through observation, study, religion,

 

 

•

o r teaching, while others are the result

 

rational thinking. Sorne of these

expl ex plan anat atio ions ns are un univ iver ersa sall tr trut uths hs,, wh whilile e ot othe hers rs repr repres esen entt pe pers rson onal al or cu cult ltur ural al myths. myths. The set set of thes these e expl explan anat atio ions ns abou aboutt th the e uni nive vers rse e we live in is the set of our beliefs. This se sett of beliefs is construed during our our lives. It is influenced  y ou ourr soci societ ety, y, cult cultur ure, e, re reliligi gion on an and d

h

r i t

g

~

it will de dete term rmin ine e th the e w y we in inte terp rpre rett the so soci cial al roles

and how we defi fin ne our truths Wright, Watson and Bell, 1996 . Truth is a hum uma an c on st r uc t and, as such, it can only be applied to nature in arder t

qual qu alif ify y the

cont co ntex extt of hu huma man n ex expl plan anat atio ions ns of na natu tura rall phen phenom omen ena. a. As a rati ration onal al co cons nstr truc uct, t, there there are as many di diffferently construed truths as there are rational human beings. By being subja ubjace cent nt ta ail the exchanges th that at chara aract cte eriz rize relationships, ou ourr bell bellef efs s

•

inte interf rfer ere e and infl influe uenc nce e th thei eirr ou outc tcom omes es.. Science offers a specifie

understanding about the universe,

this

understanding is qual qualit itat ativ ivel ely y di diff ffe ere rent nt from the one offered by philosophy and religi rel igion on an and d

 

on. Th This is scie scient ntif ific ic ex expl plan anat atio ion n answers a cert certai ain n ty type pe of sc scie ient ntif ific ic

ques qu esti tion on.. Wha hatt is impo import rtan antt he herre is that, as  n epi episte stemic mic op oper erat atio ion, n, th the e sci scienti entific fic explanation precludes the existing knowledge that will be modified by th the e new know kn owle ledg dge, e, which im impl plie ies s a hi his sto tori rica call view view of th the e expla xplan nat atio ion n Tuch cha ansk nska, 1992 1992 . This Thi s hi hist stor oric ical al bas basis is int interf erfere eres s in th the e re resu sult lt sinc since e it is und underly erlyin ing g every rytthin ing g th that at is going ta reb ebu uild ild fr from om th that at mome moment nt on. As Mack Macken enzi zie e 199 1999 ind indic icat ates es,, kn know owle ledg dge e

is no nott un unan anim imou ous. s. Diff Differ eren entt ba back ckgr grou ound nds, s, me meth thod odol olog ogie ies s or us use es, al allo low w fo forr different different leve vells of acce accept ptan ance ce of a sp spec ecif ifie ie know knowle ledg dge, e, whi hic ch me mean ans s th that at th ther ere e is latitude in

•

the the ac acce cept ptan ance ce of ex expl plan anat atio ions ns or cons constr true ued d tr trut uths hs.. The The ex expl plan anat atio ion n is acce accept pted ed for person per sonal al re reas ason ons s   rch choi oic ce, an and d co cons nsti titu tute tes s a belief, al albe beit it ba bas sed on science.

 

 

•

A be beli lie ef be beco com mes truth fo forr the person who believes. Scie Scienc nce e has a te tend nden ency cy ta function as a se sett of beliefs between the practitioners and users, who exhibit a defe de fens nsiv ive e be beha hav vio iorr that validates it des espi pitte challenges and ano anoma malo lou us results   Tambiah, 1989). Science wa wass not al alwa ways ys Iinke inked d to tec techno hnolog logy y an and d app applie lied d scie scienc nce. e. The Th e use use of so-ca -called scientific proc oces esse ses s in ou ourr dail daily y rou outi tine nes s is only recent. A fr fram ame e of re refe fere renc nce e is the point of depa depanu nure re of an any y mo mode dern rn sc scie ient ntif ific ic ende endeav avor or.. The comp co mpar aris ison on of expe experrim imen enta tall lly y obta obtain ined ed data data ag agai ains nstt a st stat atio iona nary ry st stan and dard ard is a n embl em blem emat atic ic comp compon onen entt of wh what at we cali the sc scie ient ntif ifiic me meth thod od Hiley, Bo Boh hman man and 8husterman, 1991).  y bu buil ildi ding ng in into to th the e bi biom omed edic ical al sc scie ient ntif ific ic meth method od a prov provis isio ion n wher wh ere e the the pa pati tien ents ts tr trut uths hs co coul uld d be ac acce cepte pted d in th the e refe refere renc nce e fram frame, e, an and d th ther eref efor ore e

•

mult mu ltip iply lyin ing g the the unco uncont ntro roll llab able le va vari riab able les s ta an imm immen ense se va valu lue, e, an imme immense nse numb number er of different truths arises. When one one affirms that there is no such thing as only one tr trut uth, h, the the un unav avoi oida dabl ble e na naiv ive e conc conclu lusi sion on is tha thatt th ther ere e is no such thing as a st stat atio iona nary ry standard, a ref efer ere ence nce fr fram ame e or valid scien cienc ce. However, th the e wide array   possible truths and interpretations of these possible truths should not be seen as a deco de cons nstr truc ucti tion on of the class assical ai aim m of sc scie ienc nce: e: one one si sing ngle le,, and and si simp mple le,, ex expl plan anat atio ion n of ai aill nat natur ura al ph phen enom omen ena. a. n  re real alit ity, y, th this is mult multip ipli lici city ty of real realit itie ies s shou should ld be seen as th the e onl only true reality of nature. Interpreting Peirce   1955 1955,, 195 1957, and 1998), if we shap sh ape e ou ourr reality acc accord rdiing ta di diff ffer eren entt We Welt ltan ansc scha hauu uung ngs, s, we end end up wi with th di diff ffer eren entt

truths. n  other wor words ds,, we have val alid id scie scienc nce e wi with thou outt one sin single gle trut truth h Oau auer er,, 1989; Dickson, 1988; Hayek, 1979; Margolis, 1993; Piaget, 1967; Pi Pick cke ett tt,, Kola Kolasa sa and

•

Jones, 1994

 

 

•

The fact is that the paradigm tends to function as a set of beliefs for the practitio prac titioners ners,, accordi according ng to Tamb mbia iah h (1989) and, as such uch, are stro strong ngly ly de defe fend nded ed by the professionaJ community.

Scientists firmly believe their theories and

met eth hod odol olo ogy gy.. Th Thes ese e held theo eorries ies prov oviide a basis for for resistance ta any change (Barber, 1961). It seems that science builds the belief that will be adopted by practi pra ctitio tioner ners. s. Scien Scientists tists in general udo not Iike Iike to read what outsiders have ta sa say y aboutt science (Ab abou (Abir-A ir-Am, m,   982 p.28 p.281) 1);; they they re resi sist st,, Iike Iike ev ever eryb ybod ody y else else,, to anything that m ay resemble a threat to their beliefs. Indeed, it is difficult to ultimately di diff ffer eren enti tiat ate e be betw twee een n be belilief efs s an and d kno knowle wledge dge (M (Mur urph phy, y, 19 1997 97,, p.15 p.159) 9).. In this this se sens nse, e, beli be lief efs s are are th the e br brid idge ge between ont ontol ology ogy and ep epis iste temo molo logy gy..

•

 

develop Uhabits of mind parallel to beliefs that Margolis qualify as  

Uentrenched responses that oc occu curr with withou outt con onsc scio iou us attention, and that even if noticed are hard ta change (1993, p.?). Th The e ha habi bits ts of mind ind derived from from pe pers rson onal al expe ex peri rien ence ce are are ha hard rder er to be noticed as such than those that have been learned. Habits of mind can be de desc scri ribe bed d simp simplilist stic ical ally ly as a pa patt tter ernn-re reco cogn gnit itio ion n tool tool,, just Iike Iike tha hatt used by the prac practi titi tion oner er in the the bio biomed medici icine ne s dec decis isio ion-m n-mak akin ing g proce process. ss. Th e ward

model

is

in general, expected to be Iinked to scientific

metho me thodo dolo logy gy;; ho howe weve ver, r, when used to describe ilfness, belief systems also co cons nsti titu tute te mode models ls (Engel, 1977). Th Ther ere e are are two two ma majo jorr curr curren ents ts of tho though ughtt rega regard rdin ing g

th the e in inte terp rpre rettat atio ion n of disease. Th The e fir first, iden identi tifi fied ed with so soft ft medic edica al sy syst stem ems, s, is the the personalis isttic etiology, which co corr rrel ela ates tes ail misf isfortu rtunes. According ta this view,

•

medi me dici cin ne, re reli ligi gion on,, and ma magi gic c are are inse insepa para rabl ble. e. He Heal aler ers s ha have ve su supe pern rnat atur ural al po powe wers rs and th the eïr prim primar ary y role is diag diagno nost stic ic.. Th The e othe otherr view, iden identi tifi fied ed with biom biomed edic icin ine, e, is

 

 

•

natu na tura rali list stic ic,, wh wher ere e iII IIn nes ess s

is

not correlated to other misfortunes; the healer

is

conc co ncer erne ned d wi with th ther therap apeu euti tic c proc proced edur ures es,, an and d ha has s no su supe pern rnat atur ural al po powe wers rs Fo Fost ste er, 1976).

Mem ber s

of

biomedicine

co nsi de r

unco un conv nven enti tion onal al,, or alte altern rnat ativ ive e ther therap apie ies s ta

be

unorthodox,

complementary,

cuits since they are dogmatic or

based on beliefs tha hatt exclude scientific experience and evidence Shapiro and Shap Sh apir iro, o, 19 1997 97). ). Th This is is ho how w biom biomed edic icin ine e cu curr rren entl tly y de deal als s

with

other oth er hea healin ling g pr prac acti tice ces. s.

The naturalistic view invokes the scientific method and thus requires a su suit itab able le sta standa ndard rd for me meas asur urin ing g

b th

biomedic biom edical al hyp hypoth otheses eses  nd re resu sult lts. s. Th The e ba basi sic c

biom bi omed edic ical al st stan anda dard rd of me meas asur urem emen entt is the the so so-c -cal alle led d normal va valu lue, e, wh whiich

w s

described above. Personalistic views cannat be interpreted this way. For the

•

physic phy sicia ian, n, normalcy is the leit leitmo moti tiff of his his or he herr scie scient ntif ific ic be beli lief ef Ca Cang ngui uilh lhem em,, 19 1982 82); ); for for the pa pattie ient nt,, the ab abse senc nce e of symp sympto toms ms is the the ma main in ex expe pect ctat atio ion n Ba Ballllin int, t, 1984 1984). ).

 or  o r

th the e in insi side ders rs,, the the resu result lts s ob obta tain ined ed thro throug ugh h stud studie ies s tha thatt ob obey ey the sci scient entifi ific c met method hod ar are e th the e on only ly trut truths hs , wh whil ile e for for the the ou outs tsid ide ers, rs, any proc proced edur ure e th that at can po pote tent ntia iall lly y al alle levi viat ate e the the su suff ffer erin ing g

is

truth. For the physician , if

bi biom omed edic ical al cu cult ltur ure, e, the pa pati tien entt

is

he

or she

is

intent on abiding by the

st stiill a st stat atis isti tica call event, even whe hen n fa fact ctor orin ing g in the

individual ch char arac acte terr of the clinical pra practic ctice. e. The pa pati tien entt im ima agin ine es th that at he or she is the only one. Th Thes ese e two different clas classe ses s are are th thus us pr pres esen entt The do ct o r patie atient nt relationship is  

in

no

in

th the e cl clin inic ical al en enco coun unte terr

way di diff ffer eren entt

tr

any other

relationship. The anxiety, tension, and expectations that are present consultation are but a reflection

•

experienced

in

ot

in

a

th the e anxieties, tensions, and expectations

ail ail oth other er so soci cial al se sett ttin ings gs.. Di Diff ffer eren entt in inte terp rpre reta tati tion ons s of wh what at co cons nsti titu tute te

truth and the the pos oss sibl ible nu num mbe berr of truths on onlly ma mak ke it mo more re tr trou oubl bles esom ome. e.

 

101

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The ba back ckgr grou ound nd of ea eac ch pa part rtic icip ipan antt is taken for gran grante ted d in a doc doctortor-pat patient ient relationship. As discussed above, the physician is an insider, with his o r her sci scien enttif ifie ie culture, but but the patient is an outsider, with his or he herr laie vision

 

the

healt lth h care syst ystem. There is a strong contrast between what is perceived by the out utsi side derr from the system, its user, and that pereeived by the insider, the the healer (Last, 1981). To th the e outsi tsider, ap appa pare rent nt di diff ffer ere ent me medi dica call idea ideas s are are ta the the insi inside derr a homo ho moge gene neou ous s me mean ans s fo forr de deal alin ing g with iIIness. However, as with any othe otherr ep epis isod odes es in hu huma man n lif ife e, si sick ckne ness ss ep epis isod odes es ar are e Iinked to a sp spec ecif ifie ie set of be beli lief efs. s. Th Thes ese e be beli lief efs s

will de dete term rmin ine e th the e patte tern rn of actio ction n the people will foll follow ow while ile fulfil filling thei theirr roles (Young, 1995). Cul ulttur ura al be beli lief efs s also lso in infl flue uenc nce e ho how w peo people ple man manage age illn illnes ess s an and d de deal al

•

with th thei eirr ph phys ysic icia ians ns,, and how ph phy ysici sician ans s ma man nage the their ir pa pati tien ents ts.. The Th e co con ncep eptt of health is basic in the bi biom omed edic ical al co cons nstr truc uct. t. So Sorn rne e de defe fend nd a posi po siti tion on th that at he heal alth th is val alu uee-IIad ade en, de derrivin iving g the idea idea from from::  1 the the as assu sump mpti tion on that that heal he alth th/d /dis isea ease se ju judg dgmen ments ts ar are e pr prac acti tica call ju judg dgme ment nts s with with a tre treatm atmen entt as an aim, or  2 th that at health has a po pos sitiv itive e me mea anin ing g, contrasted with the the ne neg gati ative co conn nno otati tation ons s of disease. For 80 800r 0rse se (1977), health is value-free sinc since e the definition of normal biel bielog ogic ical al fu func ncti tion on is stat statis isti tica cal. l. Lade den n or tree, the co conc ncep eptt of health is taken as truth biomed medica icall fi fiel eld, d, wh whic ich, h, in tum, becomes a belief. Once health is held as a belief, in bio it will always be value-Iaden and will co coller the clinical prac practi tic ce. Wha Whatt is referred to

biom biomed edic icin inee-cl clin inic ical al pr prac acti tice ce is ba base sed d on an art of de dete term rmin inin ing, g, trom trom ce cemp mple lex x and

•

subt su btle le inte interp rpe erson rsonal al eues and in interaction with the patient, the nature of the diseas dis ease e an and d the app approp ropria riate te treatmenf (1990, p.21 p.211) 1)..

 

102

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Patie Pa tients nts and phys physic icia ians ns ex exhi hibi bitt di diff ffer eren entt cu cult ltur ures es,, role les s, pa parradig adigms ms,, ai aims ms,, and expe expect ctat atio ions ns in the same consultation space. In thi this chaotic tic scenario, philosophers proposed bioethics as the tool to balance cultures, roles and paradigms, or at least aims and expectations, by promoting a dialogue and an unde un ders rsta tand ndin ing g of di diff ffer eren entt val alue ues s. Good comm commun unic icat atio ion n is key ta res esp pect for for a ut o n o m y

Gillon, 1986 . Facing so many in inc consist istencies, crisis, internai

contradictions, conflicts, flaws, and unab/e to open channels of negotiation, biomedicine had to dev eve/ e/op op sor orn ne kind kind of patch. The The soc socia iall move moveme ment nt that that crit critic iciz ized ed expo pose sed d thes these e fl flaw aws s was was bi bioe oeth thic ics. s. Thus why not alter bioethics ta give a new and ex and mo morre respectful face to the same same old model?

•

Sect Se ctio ion n III

BI BIOE OETH THIC ICS S  

CUSHION

First, one has to keep in mind th that at et ethi hics cs cann cannot ot exis existt with withou outt sorne sor ortt of re rela latio tions nshi hip p be betw twee een n peop people le or entit entitie ies s in wh whic ich h val alu ues ar are e exch exchan ange ged d Flew, 1984, p 112-114 , alt lth houg ough rel ela ati tio onsh nship ips s can exis existt with withou outt ethic thics s. Ethical behav ehavio iorr or

conc co ncer ern n is thus thus co conc ncep eptu tual ally ly depe depend nden entt on va valu luee-in infu fuse sed d rela relati tion onsh ship ips. s. One One can say that that what the patient is expressing in th the e sick sick-r -rol ole e is the result of a set of values. Also lso, biom biomed edic icin inee-cl clin inic ical al prac practi tice ce is th the e expr expres essi sion on of a se sett of val alue ues s that that deri de rive ves s tr trom om biom biomed edic icin inee-sc scie ienc nce. e. As we saw, they are not the same, and are

some so meti time mes s even opposite. Ethics is the in ins stru trument ent that deals with diffe ifferrent and

•

oppo op posi sing ng va valu lues es when th they ey are are pres presen entt in th the e same same contexte

 

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Acco Ac cord rdin ing g to Ca Cass ssel el (1 (199 991) 1),, th ther ere e are three co comm mmon on er errrors when the goals of me medi dici cine ne are eva valu lua ate ted d in relation ta society: (1) The erro rorr of vacuity, which mea me ans that that the aim of me medi dici cine ne is th the e restoration of th the e well-being, and to restere autonomy is to as ask k more ore of the disc discip iplline ine and an d its agents than it or th they ey can provide; (2) the error of social relativism, which means th that at the main aim of medicine is social, and neglects the organic basis of disease and the corporeal identity pers pe rson ons: s: and  3

 

th the e error of neutr tra ality, wh whiich me mean ans s tha hatt ne neut utra rali lity ty ca can nnot be

appl ap plie ied d ta bi biom omed edic icin inee-sc scie ien nce ce.. Biom iomed ediicine cine does no nott exist in a vacuum. It is stro st rong ngly ly in infl flue uenc nced ed by so soci ciet ety' y's s co cons nstr truc ucti tion on of its own agen enda da.. Ba Batth bi biom omed edic icin ine e sci cien enc ce and clinical practice are exercised by people that have the right ta live

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acco ac cord rdin ing g to theïr own be beli lief efs s, wh whet ethe herr or no nott th thes ese e be beli lief efs s ar are e ne neut utra ral. l. Medi Me dica call util utilit itar aria iani nism sm is clea clearl rly y de defi fine ned d fo forr bi biom omed edic icin inee-cl clin inic ical al pr prac acti tice ce by Gill llo on (1986) when he admits that the societal moral duties of the physician are hierarch hier archical ically ly sup superi erior or than those owed to a single patient. A counterpoint is pr pres esen ente ted d by Si Sing nger er (199 (1993) 3),, who prop propos oses es a re rela lati tivi vist stic ic ut utililit itar aria iani nism sm,, de deci cide ded d cas case e by-case, where the normal standard is only marginal to th the e decisi decisionon-mak making ing proc pr oces ess. s. However, if so some meon one e ex expe pect cts s to be di diag agno nose sed d and tr trea eate ted d in the sa same me cons co nsul ulta tati tion on,, a no norm rmal aliz ized ed stan standa dard rd and a rela relati tivi vist stic ic ap appr proa oach ch can cannot not be pr pres esen entt at the sa same me time. To be pre prese sen nt simultaneously, th they ey mu must st be neg negoti otiate ated, d, wh whic ich h is som,ething tha that dema demand nds s ti time me,, an elem elemen entt that that is la lack ckin ing g in toda today's y's cons consulta ultatio tions. ns.

It is unacceptable ta use morality and moral value as the standard of

•

meas me asur urin ing g the goals of a sc scie ienc nce e (Thomasma, 1984 84)); nev eve ert rth hele les ss, th they ey are the only on ly useful tools for for un unde ders rsta tand ndin ing g thes these e goals and re rela lati ting ng them to th the e social us use e

 

•

of sc scie ient ntif ific ic knowledg dge e. It is in this se sens nse e that ta cus cushi hion on th the e opposing ch char arac acte terr th that at was present in healt alth care, bioethic hics evolved or orig igin inal ally ly  s a tool for the unde un ders rsta tand ndin ing g of the the va valu lues es an and d inte intere rest sts s involved in th the e hea healt lth h care system and bi biom omed edic icin ine e in general. Bioe Bioeth thic ics s qu quic ick kly evolved to an ap appl plie ied d field with the re- empo em powe werm rmen entt of the patient as its goal. Historically, bio ioe eth thiics never tried to be neutral; instead, biomedicine was viewed  s having an imposing character, exercising an unnecessary power upon a defenseless patient Katz, 1984). Bioe Bioeth thic ics s was one form of pati patien entt adv dvoc ocac acy y. As a fo forrma mali list st theory, bioe bioeth thiics is supposed ta be polit itiical allly and cu culltu tura rallly neut ne utra ral, l, sa  s it can  e useful in any context. The co cons nseq eque uenc nce e of the ideolo eolog gy of

•

neut ne utra ralility ty make makes s ethi ethics cs vu vuln lner erab able le to be bein ing g co co-o -opt pted ed.. Indeed Indeed,, th this is is wh what at occurr occurred ed when the biomedical heal ealth care system gave itself a ne new w face. Carson indi ndicat ate es th that at the Iimits of bioethics  are thos those e of procedural

  r admi administ nistrativ rative e

approa approach ch

p. p.52 52). ). Car Carson sonls ls op opini inion on is no nott the last word on this issu issue e and do not represent the m a j o r trend, but i t best explains certain issues

 

bioethics that relate to

bi biom omed edic icin ine, e, ma main inly ly the the fr freq eque uent nt view view of bioe bioeth thic ics s as a med medica icall sp spec ecia iali lity ty,, no nott only only by outs outsid ider ers s bu butt  y ph phys ysic icia ians ns as weil. For Pe Pell lleg egri rino no and and Tho Thomas masma ma 1981 81)), a phil philos osop ophy hy of medi medici cine ne is urgently needed. According ta the aut autho horrs, thi this phil ilo osop sophy of medi medici cine ne mus must ar aris ise e from th the e pr prac acttic ice e of medicine ne.. Bioeth ethics had a view about the natu nature re of medicine, and thi his s

vi view ew is th that at medi medici cine ne is a prac practi tica call art art and a healing re rela lati tion onsh ship ip Th Thom omas asma ma and

•

the healing re rela lati tion onsh ship ip is the same as basi basing ng Pelllleg Pe egri rino no,, 19 1981 81). ). Basi Basing ng bioe bioeth thics ics in the it in the the bi biom omed edic ical al me metho thodol dology ogy.. As de desc scri ribe bed d ab abov ove, e, the bi biom omed edic ical al re relat latio ions nshi hip p

 

105

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designs the the doct doctor or-p -pat atie ient nt rela relati tion onsh ship ip with the out outcom come e in mind. The goal of the encount enco unter er is to ob obta tain in the the requ requir ired ed info inform rmat atio ion n for the deci decisio sionn-ma makin king g pr proc oces ess. s. Unlik Un like e ot othe herr form forms s of pa pati tien ents ts sup uppo porrt move moveme ment nts s such as fo foca call in inte tere rest sts s gr grou oups ps,, bi bioe oeth thic ics s found its plac place e insi inside de biom biomed edic icin ine e main mainly ly beca becaus use e it in inhe heri rite ted da fram fr amewo ework rk bas based on the old me medi dica call deontol tological codes es,, or pe perh rhap aps s bec becau aus se sorne of its tirst practitioners were physicians. In the 1960 5, ap appl plie ied d et ethi hics cs di disc scov over ered ed med medicin icine e and star tarted ted to use the applied action guide as a reasoning to tool ol,, which ich cons consis iste ted d of cho hoos osin ing g the the relevant prin princi cipl ples es of each case case,, en enum umer erat atin ing g them the m acco accord rdiing ta a flowchart, and, where there was contlict, reconcil ciling th them em to an et ethi hica call lly y sa sati tisf sfac acto tory ry so solu luti tion on.. Ac Acco cord rdin ing g to Ca Cars rson on,, th this is mode model, l, whic which h was ve very ry

•

simila sim ilarr ta the the de deci cisi sion on-m -mak akin ing g pro proce cess ss used in bi biom omed edic icin ine, e, perp perpet etua uate tes s a view view of a so soci cial al co con ntraet for the moral experience of iIIness   1990, p.52) that connects biomed bio medici icine ne an and d bioe bioeth thic ics s thro throug ugh h a co com mmo mon n pr proe oees ess s

of

reasoning.   According ta

Agic Ag ich h 1981), Thom Thomas asma ma and Pellegrino foeus on th the e healing rela lattionship as the way ta give medieal ethics a philosophical foundation. For Thomasma and Pell Pe lleg egri rino no 1981 1981), ), medi medica call ethi ethics cs is an intr ntrins insic pa part rt of th the e medi edical cal ar art. t. When applied ta bioethics, relativism does no nott appe appear ar ta solv solve e anything. It narr na rrow ows s foun founda dati tion onal al prob proble lems ms into into a single gle sc scru ruti tini nize zed d case. The The in inve vers rse e occu occurs rs when we apply uti utilit litari ariani anism. sm.

We

gain the dimension of the whole, without the

deta de tail ils s of the particular. Con Consen sensus, sus, according ta Casar asaret ett, t, Daskal and La Lan ntos

  1998), is the tool of bioethics. It is at the core of a moral theory for pluralistic

•

Ablatant example is the popular book  eUnical Ethics by Jonsen, Sie Siegl gler er and Wi Wins nsla lade, de, tirst published in 1982 and already in its four fourth th edil edilio ion. n. This This manual redu reduce ces s bi bioe oeth thic ics s to a prot protoc ocol ol Iike f1owchart. as if ethical issue ssuess coul could d be tre reat ated ed in a simila similarr fash fashio ion n as a clinica condition. '17.

 

106

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d e moc ratic societies. If the health care system needs sameone to negotiate con co nsensuses, it is be beca cau use bath pa pattie ient nt an and d me memb mber ers s of the syst system em ca cann nnat at reach it by themselves. However, con ons sensu ensus s is a ve very ry ge gen neri eric term erm; no on one e can kn know ow for fact ct wa want nt co cons nsen ensu sus. s. Fu Furt rthe herm rmar are, e, biom biomed edic icin ine e is sure su re if the parties inv nvol olv ved in fa neither plur plurali alisti stic c

 

democr dem ocrati atic. c. The con consen sensus sus in biom omed ediicin cine is a tab able le of normal

physioiogic physio iogicai ai vaiue vaiues. s. ln cert certai ain n ci circ rcum umst stan ance ces, s, we can ta talk lk abo about ut a l moral oral expe expert rtis ise e repr repres esen ente ted d by the bi bioe oeth thic icis istt (S (Sza zaba bado dos, s, 1987). Ne Neve vert rthe helles ess, s, suc uch h a tit itle le is no nott en enou ough gh:: the exer ex erci cise se of an exp expert ertise ise,, espe especial cially ly in the case of bioethics, should indicate a rede des signi nin ng of the field. Medical ethics should no nott be based on the argan rganiicism cism of

•

biamedicine. Its ba basi sis s should be the pat atiien entt (Wear. 1981), bu butt by de deri rivi ving ng me meth thod ods, s, aims aims,, an and d re resp spec ecta tabi bili lity ty

tr

bi biom omed edic iciine ne,, bi bio oet ethi hic cs also also su sufffe fers rs from th the e same

fl flaw aws, s, inter nterna naii co cont ntra radi dict ctio ions ns,, an and d de dest stin iny y of biom biomed edic icin ine. e. Ac Acco cord rdin ing g to He Hell llst strô rôm m (199 (1993) 3),, Ha Habe berm rmas as de desc scri ribe bes s th three ree ma maiin hu huma man n ac acti tivi viti ties es::  1 praxis,  2 work, and  3 se self lf reflection. Tran Transp spos osin ing g th thes ese e to th the e co cont ntex extt of this pap ape er, praxis would be

biomedi bio medicine cine--sc --scienc ience, e, wark woul would d be biom biomedic edicineine-eli elinic nical al prac practic tice, e, and self self-refl -reflecti ection on woul wo uld d be bioe bioeth thiics. cs. Ind ndee eed, d, bi biae aeth thic ics s shou should ld be the ins instru trumen mentt tha thatt wo woul uld d ev eval alua uate te the values, beliefs, methods, results, and behavior of biomedicine. To do so, it shou should ld de deve velo lop p simi similar lar el elem ement ents s in indep depend enden entt of biom biomed edic icin ine e in arde arderr to av avoi oid d the same sa me bias. Th The e di disc scus ussi sion on ab abou outt au auto tono nomy my and po powe werr of bo botth pa pati tien entt an and d do doct ctor or ex exem empl plif ifie ies s the the curr current ent un unst stab able le po posi siti tion on he held ld by bioe bioeth thic icis ists ts..

Medical ca re in North America has moved away from a patemalistic

•

appr ap proa oach ch ta pa pati tien entts tow owa ard an em emph phas asiis on pat patien ients ts aut autona onamy. my. Autono Autonomy my may

 

lO

•

el elim imin inat ate e paternalism if th that at is th the e desire of the patient, since a se self lf--det deter erm min ine ed p atie nt can opt for il. Moreover, autonomy must be culturally sensitive in a mult mu ltic icul ultu tura rall so soci ciet ety y su such ch as Ca Cana nada da..

 n

indi indivi vidu dual al is nev never er al alon one. e.

Bi Bioe oeth thic icis ists ts appear ta be divided ov over er the de degr gree ee of res esp pec ectt for au auto tono nomy my one on e sh shou ould ld ex exer ert. t. For ex exam ampl ple, e, Ma Mack cklilin n (1998) Ii Iimi mits ts th the e re resp spec ectt or to tole lera ranc nce e to towa ward rd beli be lief efs s and pr pra act ctic ice es if wh what at sh she e calls alls ex exce cess ssiv ive e tol toler eran ance ce can pr prod oduc uce e ha harm rm to these thes e pa pati tien ents ts.. La Late terr in the sa same me paper, she div divid ides es th the e bel eliief efs s betw twe een th thos ose e th that at are are cu cult ltur ural ally ly relative and thos those e that that rest

on

univ un iver ersa sall et ethi hica call pr prin inci cipl ples es.. Th Thus us th the e

heal he alth th pr prof ofes essi sion onal al co coul uld d choo choose se ta resp respec ectt the the un univ iver ersa sall pr prin inci cipl ples es wh whilile e forget forgettin ting g the cultu ltural ones. This

•

is

whatt ha wha happ ppen ens s

s am am e issue, Baker (1998) states that

in

an

biomedi bio medicine cine-eli -elinica nicall pra practi ctice. ce.

On

the

international bioethics should be a

nego ne goti tiat ated ed mo mora rall orde orderr with a ca care refu full ap appr prai aisa sall of th the e ar area eas s of no nonn nneg egot otia iabi bilility ty.. 1 will re rese serv rve e for for the the ne nex xt paragraph the the con once cept pts s of nego tiat ated ed mora rall orde orderr negoti

and

 careful

appr pra ais isa al of the areas of nonnegotiability. Quill and Brody (1996) propose an  enhan  enh ance ced d auto autonomy nomy mo mode del, l, wh whic ich h en enco cour urag ages es pa pati tien ents ts

and

physicians

to

actively

exch ex chan ange ge id ide eas as,, ex expl plic icit itly ly ne nego goti tiat ate e diff differ eren ence ces s and sh shar are e po powe werr to be bett tter er ser serve ve th the e so  ca callled patient s best inte intere res sts ts.. This proposition is nothing more than the  

realization that that the actual mode dell is not working or cr crea eate tes s more problems than it salves. Nevertheless, it is not through generalities Iike exchange ideas or  nego negotiat tiate e dif diffe feren rence ces s tha thatt one will so solv lve e de deep ep cu cult ltur ural al and id ideo eolo logi gica call di diff ffer eren ence ces s betw etween practitioners and patients, or solve par ara adi dig gma mati tic c incon ons sist ste enc nciies. To

elim el imin inat ate e barrier iers, s, the pa part rtie ies s invo volv lve ed mu must st fi firs rstt be re rea ady ta ch cha ang nge, e, be beca caus use e if

•  

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108

these barriers could be easily and painlessly removed, it would have already occurred. ln the la s t paragraph, the revision of t h e literature presented us with:  n  neg egot otia iate ted d mora morall order order and care carefu full appr apprai aisa sall

 

the the ar area eas s of nonn nonneg egot otia iabi bili lity ty

to toge geth ther er with other other gene generi ric c conc concep epts ts.. The The majo majorr pr prob oble lem m wit with these these pr prop opos osit itio ions ns is that it is not poss ossible to use them in the biomedical model as it is designed today. Biom Biomed edic icin ine e cannot cannot nego negoti tiat ate e its basi basic c assu assump mpti tion ons, s, and tech techno nolo logy gy stri strips ps its mor oral al aspe as pect cts s. This di disc scou ours rse e is, no matt matter er its mer eriits

  rflaw flaws, s,

si simpl mply y a disc discou ours rse. e. 28

O t he he r mo d e ls of autonomy can b e cited. O n e is the the Ilin Ilinde depe pend nden entt choi choice ce

 

mode mo dell of deci decisi sion on making king,, in which phys physic icia ians ns obje object ctiv ivel ely y pr pres esen entt pat patients nts with opti op tion ons s and odds odds but but withhol old d their own expe experi rien ence ce and re reco comm mmen enda dati tion ons s to avoid •

overty influencing patients. This model confuses the concepts o f independence and autonomy and a s s u me me s that the physician s exercise of power and influence inevi nevita tabl bly y dimi dimini nish shes es th the e pat patient ent s abil abilit ity y ta choose choose fre reel ely. y. It sacr sacrif ific ices es comp compet eten ence ce for control, and it di disc scou oura rage ges s acti active ve pers persua uasi sion on when when diff differ eren ence ces s of opin opiniion exi exist betw be twee een n phys physic icia ian n and and pati patien entt (Quill and and Brod rody, 1996 1996). ). They They pr prop opos ose e an   en hanced auto au tono nomy my mode model, l, whic which h enco encour urag ages es pati patien ents ts and physi physici cian ans s ta active actively ly ex exch chan ange ge idea deas, expl explic icit itly ly negot negotia iate te di diff ffer eren ence ces, s, and and shar share e powe powerr and and infl influe uenc nce e ta serv serve e the

Frohock  1992, p.276) states that:  in recent Iiberal traditions, the secu secular lar self self is considered autonomous because it is separate fram the influences of ethers and ins instit tituti utions ons.. A distin distinct ct and even ato atomis mistic tic self self is the bearer of autono autonomy. my. Bu Butt in spirit spiritual ual tra tradit dition ions s the self is typically jeined to other reaUties and entities. Autonomy is iIIusory if dep depict icted ed as a distin distinct ct and independent

•

power. An indiv sorn rne e mor more e comp individua iduall surrend surrenders ers to, or is merged in, so comprehen rehensive sive reality reality as a condition for 5uccessful direction. The self ferms part of a di direc rectiv tive e line extending to powers the sel self. f. On outside the One e gains mast master eryy over one s Iife in spi spiritu ritual al persp perspec ectiv tives es only only as a consequ con sequence ence of abandoning liberal notions of aut autono onomy. my. ln societies Iike the North American extreme, me, thi hiss statement is disturbing, while for the health care that defend autonomy at its extre system, as designed by bio biomed medicin icine, e, it is an ideal to be reached.

 

  9

•

pati tien entt s best best int interes rests. ts. Recomm mme endat atio ion ns are offered that pro promote mote an in inte ten ns e coll co llab abo ora rati tion on betw betwee een n pati patien entt and phys physic icia ian n sa that that pa pati tien ents ts ca can n auto autono nomo mous usly ly make choices that are informed by both the medical facts and the physician s experience. 8ioet ioethi hics cs is not or should not be simp simply ly re rega gard rded ed as an evaluatio tion of the valu va lues es invo involv lved ed or th the e posi positi tion ons s as assu sume med d by each party, reg regardless of the the name of th the e model or th the e proc proces ess s of re rea asonin ing g. Bi Bio oet eth hics ics should assu assume me a posi positi tion on in the dispute because th the e pra rac cti tice ce of neut neutra rali lity ty willle willleave ave a void behind that that will be filled by the system. Every tim ime e the bio ioe eth thiicis istt is undecided, he or she in fac fact de deci cide ded d in and d how the re favor of the system.  n example of th this is an res search rch comm commun unit ity y sees

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bi bioe oeth thic ics s can can be in infe ferr rred ed from th the e evol evolut utio ion n of the Tr Trii-Co Coun unci cill Poli Policy cy St Stat atem emen entt on human research Medical Research Council of Canada, Natural Sciences and Engineering Research Council of Canada, Social Sciences and Humanities Research Council of Canada). The fi firs rstt draft draft 1994) has has a phil philos osop ophi hica call ap app proac roach. h. The second 1996) is more a legal and deontological document. The third and appro rov ved draft draft   1998) is a practical guide of what to do in each described ci rcumstance.

Bioe Bioeth thic ics s deal deals s with arbi arbitr tra ati tio ons and con conflic flicts ts that that re req quir ire e negoti gotia ation tion.. n  general, these are system problems because the system is im impe pers rson onal al.. The The fu fun ncti tio on of bioet ioethi hic cs appears ta be the evaluation of the moral component of a problem with withou outt movi moving ng th the e sys syste tem m. Bi Bioe oeth thic ics s is an al ally ly of the the syst system em.. Th The e whole

system is bui uilt lt on th the e expectation th that at th the e patie tient will always agre agree e or ac acce cep pt the

•

dete term rmiinati nation ons s of bi biom omed edic icin ine, e, subm submit itti ting ng him or hers hersel eltt ta the the do doct ctor or s op opin inio ion. n. If

 

11

•

th they ey do no nott th the e question abou aboutt th thei eirr co comp mpet eten ence ce is raised. This co comp mpet eten ence ce is rarel arely y qu ques esti tion oned ed when th the e pa pati tien entt agr gree ees s with the the trea treatm tmen entt so wh when en pa pati tien ents ts cons co nsen entt a bi bioe oeth thic icis istt is no nott ca calllled ed.. A bioe bioeth thic icis istt is how howeve everr fre freque quentl ntly y calle called d wh when en the here re is no con ons sent nt.. The hea ealt lth h ca care re sy syst stem em is ge gear ared ed towa toward rd au auto toma mati tic c co cons nsen entt which no none neth thel eles ess s gives th the e im impr pres essi sion on th tha at patients ar are e taki taking ng pa part rt in the dec decisi ision on making. Bi Bioe oeth thiics comforts the sy sys ste tem m by giving the the im impr pres essi sion on that that the the sy syst stem em is being bei ng moni monitore tored d as a homo homoeo eost stat atic ic va valv lve e or a feed feedba back ck de devi vice ce.. Ho Howe weve verr bioe bioeth thic ics s is n ot a monitoring or teedback device and an d can never be given the actual ci circ rcum umst stan ance ces s b bec eca aus use e it is no nott a re rec cog ogni nize zed d biom biomed edic ical al sp spe eci cial altty. Wi Witho thout ut this stat st atus us

•

bi bioe oeth thic ics s

ju just st an anot othe herr pa parrame med dica call se serv rvan antt field

is weak ta face

biomedicine. The main stage for bioethics is the same as the one for biamedicine: the doct do ctor or-p -pat atie ient nt re rela lattions ionsh hip. ip. Ye Yett th this is ar aren ena a is not ail that that bi bio oethi thics inh nhe erite rited d

tr

bi biom omed edic icin ine. e. Wit itho hout ut a pe pers rson onal alit ity y of its its own bi bioe oeth thic ics s reta retain ins s the raie of me media diator tor betw be twee een n the syst system em and an d th the e us use er d dig iges esti ting ng va valu lues es an and d retu retumi ming ng co compr mpromi omises ses tha thatt usua us uall lly y va vali lida date te the sy syst stem em.. At an any y rate bi bioe oeth thic ics s sh shar ared ed with and de deri rive ved d tram biomedicine s cu cult ltur ure e an and d in time became a tamed voice inside the system. Bioethics is now just another reliable servant of biomedicine. However the biaeth bia ethici icist st is stil stilll an uno noff ffiicia cial me memb mber er of the sys yste tem. m. Th The e bioe bioeth thic icis istt mus mustt ther theref efor ore e stru strugg ggle le to ma main inta tain in a pr prof ofes essi sion onal al pos positi ition on in a system that that is ye yett in inse sens nsib ible le to his or her her ne nece cess ssit ity. y. Up to wha hatt po poin intt sh shou ould ld this fragil gile prof profes essi sion onal al co comp mpro romi mise se his

 

•

h er position by facing the system? If it is difficult to establish the raie of a

bio ioet ethi hic cis istt in a health care tea eam m it is also also dif diffic icu ult ta es esta tabl blis ish h what sh shou ould ld be his

 

 

•

or her qu qual alif ific icat atio ion n t be beco come me a bio bioeth ethici icist st an and d to gain the sta status of me memb mber er   the team Yoder, 1998 . This is pa part rtic icul ular arly ly true true sinc since e the mo mora rall au auth thor orit ity y   r expertise  

the the bi bioe oeth thic icis istt is frequently co conf nfou ound nded ed with th the e raie of the bi bioe oeth thic icis istt Ca Casa sare rett tt,,

Dask Da skal al and La Lant ntos os,, 1998 . Bi Bioet oethi hics cs an and d the the

d o

t o r ~ p

t i e n t

rela relati tion onsh ship ip mut mutual ually ly in infl flue uenc nce e eac each h ot othe her. r.

Medi Me dica call et ethi hics cs dea dealt lt wi witth etiq etique uett tte. e. Bioe Bioeth thic ics s tr trie ies s to provide  n easy so sollut utiion to a system t hat contains numerous flaws. The raie of bioethics, by dealing with individual cases, delays the imb mbal alan ance ce of power by not tacing it as a co cons nstr truc uctt or th the e co cont ntex extt wh wher ere e a de deh hum uma anize nized d co cont ntex extt is normal . If we do not face th the e system, we will remain forever in the symptom. Bioethics seems ta be reinforcing the

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sy syst stem em by de deal alin ing g on only ly with sm lt pa part rts s or separat ate ed parts of bi bio omed ediici cin ne, and not cr crit itic iciz izin ing g it ov over eral alll . Bioe Bioeth thic ics s is ne neve verr fully de defi fine ned; d; it w s created  y a pe perc rcei eive ved, d, bu butt su supe perf rfic icia iall need. It was not designed ta address systemic problems; it also rejects anth an thro ropo polo logi gica call and so soc ciolo ologic gical ap appr proa oach ches es.. Bi Bioe oeth thic ics s is case or orie ient nted ed.. As a to tool ol,, it is effi effici cien ent. t. It is no nott looking fo forr sy syst stem emic ic probl ble ems and raies. Only the su surf rfac ace e is seen. see n. Po Poli lici cies es in th this is kind of ap appr proa oach ch are a me mere re ag aggr greg egat ate e of individual cas ase es. Bi Bioe oetthi hics cs pro rote tect cts s the system from the law. Po Poli lic cie ies s are bl bles esse sed d  y bio bioeth ethicis icists ts fo forr th the e sa sake ke an and d relief of the practitioners. The bioethicist works for the syste stem and should  e a pa pati tien entt ad advo voca cate te . Bioe Bioeth thic icis ists ts,, pat patien ientt adv advoca ocates tes an and d omb ombudsp udspers ersons ons ar are e offices created by the system. Th The e system absorbed bioethics, bu butt be bec came

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i mmu mmun n e to it by developing resistance. Bioethics is onl y a cushion; i t is more comfort com forting ing tha than n ch chaf afle leng ngin ing. g.

 

Il

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TR NS T ON

Up to this this point 1t 1trried to de demo mons nstr trat ate e th that at the struggle for power or its effecti effe ctive ve cont contro roll is acut acute e in bi biom omed edic icin ine e wh whil ile e blan land or no non· n·ex exis iste tent nt in ma many ny other other professions Biomedicine is th the e on onlly pr prof ofes essi sion on be besi side des s th the e prie priest sth hood ood th that at deal deals s wi with th the ho hope pes s of over overco comi ming ng de deat ath h or at leas leastt prol prolon ongi ging ng lif ife e Fu Furt rthe herm rmor ore e th the e vallid va ida atio tion of symp sympta tams ms also conf confir irms ms th the e role of bath phys physic icia ians ns and pa pati tien ents ts Profes Pro fession sionali alizat zation ion be best stow owed ed medic medicine ine with a mon ono opo polly ov over er the process of defining valid validating ating and and reg regain aining ing healt health h H Healt ealth h on the ot othe herr hand is differently defined by each individual and by the system If If biomedicine could offer a

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univ un iver ersa sall lly y ac acce cept pted ed cert certai aint nty y or bett better er yet be be bas based on uni univers versally ally acce accepted pted values

s sch schola olarty rty me medic dicin ine e once once w s ma mayb ybe e then th the e internai ca canf nfli lict cts s th that at aris arise e

fro from its its pr prac acti tice ce woul would d be les less acu cute te and and one one si sing ngle le de defi fini niti tion on wo woul uld d be universally accepted acce pted Howeve Howeverr biomedica biomedicall cult culture ure alth although ough empow empowered ered by the soci societ ety y at larg large e to care care

nd to de defin fine e ca care re in it its s own terms terms is noneth nonethele eless ss co conf nfro ront nted ed by ail ot othe herr

cult cu ltur ures es that that comp compos ose e soci societ ety y   nd want defi fini niti tion ons s of care in oth other er te term rms s On One e cann ca nnot ot say say tha hatt bi biom omed ediicin cine is wrong in de defi fini ning ng its te term rms s si sinc nce e th this is is part of its mandate yet

 

the same time no one can say that society is wrong for not

accepting the va valu lues es of bi biom omed edic icin ine e So Some meho how w a comp compro romis mise e must be reac reache hed dt make ma ke the re rela lati tion onsh ship ip be betw twee een n so soci ciet ety y an and d bi biom omed edic icin ine e oper operat atio iona nall Oesig esigne ned d an and d de deffin ined ed by in insi side ders rs bi biom omed ediical cal prof profes essi sion ona als the ai aim m of

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biomedicine is ex exte tern rnal al ta it itse self lf sinc since e it invo involv lves es th the e pati patien entt Usin Using g pa para rame metr tric ical al resu result lts s abt btai aine ned d tr tram am pre revi viou ous s en enca caun unte ters rs with pati patien ents ts as to tool ols s bi biom omed edic icin ine e is

 

113

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used by thes these e prof profes essi sion ona als for three aims ms::  1 their way of earn a living

2 the

acquis acq uisiti ition on of mor more e exp experi erienc ence e an and d know knowle ledg dge e an and d  3 the ap appl plic icat atio ion n of kn know owle ledg dge e and exp exper erie ienc nce e to al alle levi viat ate e di dise seas ase. e. The These se th thre ree e aims ar are e how howev ever er se self lf serv servin ing: g: the mo more re kno now wledg dge e and experience the more pati tie ents due to fame the more econ ec onom omic ic gai ain n tthe he mo more re ex expe peri rien ence ce.. Ef Effi fici cien ency cy is a by pro produc ductt of th this is cycl cycle. e. In the case ca se of biomedicine it can be measured by the same pa para rame metr tric ical al in inst stru rume ment nts s used to de defi fine ne the be best st trea treatm tmen entt and the the be best st ou outc tcom ome. e. This by prod produc uctt is highly praised by the health care system because it is measurable and can be easily conv co nver erte ted d into into en entr trie ies s in the the ac acco coun unti ting ng books wh whic ich h wo wou uld th thus us pe perp rpet etua uate te th the e bi biom omed edic ical al mon monopo opoly ly of he heal alth th se serv rvic ices es..

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The doct doctor or p pati atient ent rela relati tion onsh ship ip ap appe pear ars s as th the e cradle cradle of misu misund nder erst stan andi ding ngs. s. Thes ese e are rooted in wh what at is perceived as an imp impers ersona onall care care.. The re resu sult ltin ing g conf conflilict cts s range tram small frictions to important legal issues. People have unreal expectations about biomedicine. These unreal expectations are defeating biomedicine.

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Chapter Chap ter Four ON E

M O NG M N Y FUTURE S

When Whe n biom biomedic edicine ine is co cont ntra rast sted ed wi with th ot othe herr me medi dica call syst system ems, s, it its s commit commitmen mentt te a stan standa darrd of care reduces the patient te one mor ore e persan that will receive an imper imperso sonal nal and and st stan anda dard rd pr pres escr crip ipti tion on,, des design igned ed in som some e un univ iver ersi sity ty cente centerr for pe peop ople le wi witth di diff ffer eren entt Iife Iife expe experi rien ence ces, s, di diffe ffere rent nt cult cultur ural al and soci social al back backgr grou ound nds, s, and and even di diff ffe ere ren nt anatomical and physiological designs Froom and Froom, 1992). The patie atient nt wants individual care, but individual treat eatme men nt is not an entry in the

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bi biom omed edic ical al ph phar arma maco copo poei eia. a. If th ther ere e is no in indi divi vidu dual alit ity y in th the e proc proces ess s

of

diagnosis

and in the design of the treatment, how can we rec econ onc cile ile noti notion ons s such as autono aut onomymy-a a conc concep eptt related to one one 5el elff-- and and bi biom omed edic icin ine e Furthermore,

 

statistica stati sticall science? science?

mos t large clinical trials are financially supported

by the

phar ph arma mace ceut utic ical al indu indust stry ry Ha Hamp mpto ton n and Ju Julilian an,, 1987), an and d si sinc nce e th they ey are are co cons nsid ider ered ed by the ind ndu ustr stry as an inv nves estm tmen entt, th ther ere e is an expe expect ctat atio ion n of econ econom omic ic retu retum. m. Both the the em emph phas asis is upon and the subject of th the e re rese sear arch ch are dic dicta tate ted d ou outs tsid ide e acad academ emia ia.. The Th e comm commer erci cial aliz izat atio ion n of hea eallth care has has pr prog ogre ress ssed ed si since nce 1980 and the mark market et or orie ient nted ed he heal alth th syste system m inf influe luence nces s pra practi ctici cing ng phy physic sician ians s Relma Relman19 n1991) 91).. Acc Accor ordi ding ng to Do Doug ughe hert rty y 199 990, 0, p. 275

incr increa ease sed d com compet petiti ition on subverts physic physician ian coll collegi egialit ality, y,

draws hospitals into for-profit owncrship and behavior, and leads clinical investi stigator tors into se secr crec ecy y and poss possib ibly ly in into to bias and abus abuse. e. Med Medic icin ine e fa face ces s a de

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professionalization professionalizat ion evi eviden denced ced in loss of control over th the e clinical setting and over self se lf-r -reg egul ulat atio ion. n. He Heal alth th care care be beco come mes s a co comm mmod odit ity y rely relyin ing g on cultivation of desires

 

  5

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instea ins tead d of sati satisf sfac acti tion on

o

needs, even as man many basic needs go unmet. Patients

beco be come me cons consum umer ers s empo empowe were red d with laws lawsui uits ts and th the e co conn nnec ecti tion on of medi medici cine ne to th the e re reli lief ef of suff suffer erin ing g is atte attenu nuat ated ed.. Me Medi dica call en enco coun unte ters rs are are incr increa easi sing ngly ly im impe pers rson onal al,, domin do minate ated d by sp spec ecia ialiliza zati tion on,, tech techno nolo logy gy,, an and d bu bure reau aucr crac acy. y. Pati Patien ents ts are are losi losing ng the their ir physician-advocates ta new co conf nfli lict cts s of inte intere rest sts, s, ph phys ysic icia ians ns ar are e losi losing ng th thei eirr im impu puls lse e to ch char ariity, ty, and tr trus ustt in the doc doctor tor-p -pat atien ientt re rela lati tion onsh ship ip an and d in med medici icine ne ge gene nera rall lly y is eroding. Mechanic (1985) blames growing consumerism and skepticism about autho thori ritty to have caused pati atient ents to seek an acti tiv ve role in th thei eirr he heal alth th ca care re,, even if

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most

still dete deterr to the their phys ysiicians judgment. It is his opinion that threats to

phys hysic icia ian n autonomy ha have ve their roots in the increasing co comp mpet etit itio ion n from oth the er doc do cto tors rs,, new new forms of prac practi tice ce orga organi niza zati tion ons, s, an and d th the e rise in malpr malpractic actice e lit litiga igatio tion. n. Tech Te chno nolo logy gy si simp mply ly ad adde ded d a ne new w thre threat at to old old va valu lues es and at atttit itud udes es.. Due to th this is ev ever er evol ev olvi ving ng soci societ ety, y, both oth ph phys ysic icia ians ns and pa pati tien ents ts need need to change and adapt. It may may seem se em obvi obviou ous, s, but but 1have to st stre ress ss here tha that physi hysic cians ians are me memb mber ers s of the soci ociety; in rel ela ation to change, they they suff suffer er the sa same me pres pressu sure res s as any ot othe herr people.

Are the goals o f biomedicine-science and health the same? Ooes the know kn owle ledg dge e gene genera rate ted d by biom biomed edic icin inee-sc scie ienc nce e mean mean he heal alth th resu result lts s as defi define ned d by th the e pati pa tien ent? t? Th The e mult multip iple le pe pers rson onal alit ity y of health brings certain un unav avoi oida dabl ble e co con nfl fliict cts s. Biomed Bio medici icine ne sc scie ienti ntist sts s are co confr nfront onted ed with so soci ciet ety y and and the cl clin inic icia ians ns;; th the e heal health th ca care re syst system em is confronted with the the providers and u : ars; th the e insti institut tutio ions ns ar are e co conf nfro ront nted ed with with heal health th care care prof profes essi sion onal als s and pa pati tien ents ts;; the the prac practi titi tion oner ers s are are co conf nfro ront nted ed wit with

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pati pa tien ents ts.. Wh What at make makes s thes these e con onffront rontat atiion ons s more more diff diffic icul ultt is tha thatt ins insider iders s are also lso one e or an anoth other er circ circum umst stanc ance. e. In this scenario, it do does es not not matt matter er  t ail outsiders in on

 

l

•

what wh at the goa goals

bi biom omed ediici cine ne ar are, e, if any 29

of

  he meaning of

healt hea lth-r h-rela elated ted terms

vari va ries es from cult cultur ure e ta culture wi with thau autt a poss ossib iblle tra ran nsl slat atiion on sight. Sorn Sorne e

of

the

healt hea lth-r h-rel elat ated ed terms, terms, su such ch as we ll being, ar are e in indi divi vidu dual ally ly defi define ned, d, but but this his shri shrink nks s  l

 

the not notion ion of cult cultur ure, e, When

 r

heal ealth care care purp purpos oses es,, ta one one si sing ngle le indi ndivi vidu dual al..

sa m e o n e

c o n t e mp l a t es

onesel f,

th e

in d i v id u a l

becomes

simu simult ltan aneo eous usly ly th the e obse observ rver er and obse observ rved ed,, subj subjec ectt and and abj abject ect. Th This is re refl flex exiv ivit ity y is the the essen ssenti tial al fe feat atur ure e of the self self Mann, 1991), it allows us ta learn and add knawledge, interp int erpret ret and and

•

ad d

interpr int erpreta etatio tions ns ta

ou r

Weltanscha chauung. ng. This This is one of the many many

dyads pres presen entt in a human being. Howeve ever, two posi posittions ions can be used to summarize ail dyads. On the the one hand, we ha have ve a real posi posittion, on, while on the other, an unreal.

It must must be st stre ress ssed ed that these hese posi positi tion ons s are real

or

unreal in relation to eac each othe otherr

and not not in rel relat atiion to a hypot ypothe hettical universal tru rutth. Sinc Since e bat bath contend to be real, a conf confli lict ct of values is present, and bi bioe oetthics shou should ld be the adeq adequa uatte forum for for its dis discussi ussio on. However, ver, one does not not see see a di disc scus ussi sion on,, only only an adap adapttatio ation n of bel belief iefs, valu va lues es,, and and tr trut uths hs.. 1n th is c ha ha p tte e r 1 will ov over ervi view ew and cr crit itiici cize ze the the curr curren entt biomedical modal dal. Bioethics, by maki making ng use of the same same model, shar shares es with biom biomed edic icin ine e its stre streng ngth ths s and its weak weakne ness sses es,, and will be crit ritici cize zed d on th the e same same gr grou ound nds. s.

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Thomasma  1984, p 43 states: Uthe goal goals s of me medi dici cine ne are are vi virt rtua ualllly y none nonexi xist sten ent. t. Medi Medici cine ne suffers fram an abundance of me mean anss and a pove povert rty y of en ends ds..  9

 

  7

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Sect Se ctio ion n

MODELS MODELS

According to Rorty's metaphor, human minds are webs of beliefs and desi de sire res, s, webs that that rere-we wea ave them themse selv lves es ta ac acco comm mmod odat ate e new atti attitu tude des s (1991, p.59). This set of beliefs is dynamic, and is part of what hat is called the self. lf. However, the se self lf is also a Western construct. It is the way we Wes Weste terne rners rs und unders erstan tand d and descr de scribe ibe refl reflex exiv ivit ity y (T (Tay aylo lor, r, 19 1991 91). ). We refl reflec ectt on and ab abou outt the world tha thatt su surr rrou ound nds s us re reco cons nstr truc ucti ting ng it as an im imag age e in ou ourr mi mind nds. s. Th This is con onst stru rued ed no noti tio on of the the world,

initia iallly a belief, is tra transf nsfor orm med in ide ideolo ology gy wh when en we act in the wo worl rld. d. Sc Scien ientif tific ic medicine can and is used by those within it as an ideo ideolog logic ical al veh vehicl icle e (Ste (Stein in and

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Apprey, 198 985 5). Stev Steven enso son n and Wi Will llia iams ms st stat ate e, Ideo Ideolo logy gy inv involve lves the the dist distor orte ted d or bi bias ased ed an and d rati ration onal aliz ized ed rath rather er tha than ob obje ject ctiv ivel ely y reas reaso one ned d evalua uattion of iss issue ues s. It serves to ju just stif ify y an and d defe efend rela relati tio ons of do domi mina nati tion on (1988 p.93). In the case of biomed bio medici icine, ne, the dom domina ination tion is about the profession - medicine - and its objective - he heal alth th,, Iinked toge togeth ther er by biom biomed edic ical al cu cult ltu ure, re, me meth thod odol olo ogy gy,, an and d technology. Ali th them em are bas ased ed on a mode model. l. Inside the ranks of biomedicine, a number of voices realized that the biological model was, to say the leas . inconsistent. For example, Lynn and DeG De Grazi razia a wrote that that the so called fixfix-if if'' model, where facing an abno abnormal rmality ity the the phy ph ysic icia ian n in inte terv rven enes es to bring the the orga organi nism sm ba back ck to no norm rmal alit ity, y, mu must st be co cont ntra rast sted ed with the ou tcomes mes mo mode del, l, in which futu future re po poss ssib ibil ilit itie ies s are judge dged in term terms s of the outco patients' patien ts' val values ues,, in orde orderr to ac achi hiev eve e the be best st futu future re po poss ssib ible le as rank ranked ed by pa pati tien ents ts

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pr pref efer eren ence ces s (1991 91)). Bu Butt is this this the the cu curr rren entt biom biomed edic icin ine? e? Kl Klei einm nman an (198 (1988) 8) prop propos oses es

 

 

•

a meaning centered model specially for the care of the ehronically il patient, wher wh ere e cultur ura al meaning ngs s and values are brou brough ghtt forward in the decisio decision-m n-maki aking ng pr proc oces ess. s. White White  1988) ag agre rees es that that me medi dici cine ne sh shou ould ld make make an effort to go be beyo yond nd th the e biological

in

its

biopsychosocial,

conceptual with the

framework.

social

and

Th ese

psycho

models

proposed

are

parts also Westernized,

Chri Ch rist stia iani nize zed d and biom biomed edic ical aliz ized ed.. So ther there e is no nott a proposai of a new model de facto, ju just st a redecoration of the old. The pr pres esen entt biom biomed edic ical al mo mode dell is no long longer er adeq adequa uate te for de desc scri ribi bing ng scientific scientific and social responsibilities. For Engel (1977), this crisis stems tirst from the defi de fini nittio ion n of disease in purely somatic terms, leaving social and psycho psycholog logica icall

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issues outside of physicians scope. This is rooted in the bi biol olog ogie ieal al molecular molecular desc de scri ript ptio ion n of dis diseases. Wh What at is worse, ac acco cord rdin ing g to Engel, is that there is an attemp att emptt to medieaHze ail no nonn-bi biol olog ogic ical al-m -mol olec ecul ular ar caus causes es of di dise seas ase. e. The The idealis idealistic tic defi de fini niti tion on of health sponsored by the World orld Heal altth Organization be bec comes omes litt little le more, in biomedic dicine, ne, than a figure of speec eech, one mor ore e metaphor amon among g many many.. According to Engel (1987) the present biomedical model fails because: (1) it criter erio ion n for scienc science e rep epre rese sen nts a li limi miti ting ng ca case se and ther theref efor ore e cann cannot ot be used sed as a crit in medicine,  2)  2 ) any attempt to apply the biomedical model ou outs tsid ide e its Ii Iimi mits ts is

unscie uns cienti ntific fic,, and and  3) medi dica call scie scienc nce e requ requir ires es a pa para radi digm gm encompass assing th the e huma human n  3 ) me domain.   have to po poin intt he here re tha thatt me meth thod odol olog ogy y of scie scienc nce e can only be applied to the scientific realm: Health defined as the psycho physiologieal capacity ta ac actt or respon res pond d appropria appropriately tely in a wide va vari riet ety y of situ situat atio ions ns,, is enhanced by many many means means

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ot other her than than preve revent ntin ing g and tr trea eati ting ng dise diseas ase e and inj njur ury. y. Therefore no choice o f a

 

  9

•

part articular medic edical al intervention is li like kely ly to maxim aximiz ize e heal healtth for for ail peop peoplle with (or (or at the ris risk for) a gi give ven n di dise seas ase e (Whi (Whitb tbec eck, k, p.35, 1981 1981)) Worsley Wors ley stat states es that hat the bi biom omec echa hani nist stic ic mode modell wi with thin in whic which h the the prof profes essi sion onal al formation a n d deformation of the doctor take place in our culture, one such metamedical metamed ical framew framework, ork, is b y no mean means s universal (198 (1982 2, p.31 p.315) 5).. This This mean means s that that

biomedicine is a cultural project. Worsley explains that al medicine has a meta me tame medi dica call cont contex ext, t, which mean means s that that conc concep epts ts of iIIness and and its reli relief ef are are al ways embe em bedd dded ed in a wid ider er cultural fr fram amew ewor ork k (p.327). Th The e biom biomed ediica call model, whic which h is th the e foun founda dati tion on of th the e cont contem empo pora rary ry Weste estern rn sc scie ient ntif ific ic med ediicine cine,, is based on the biolog bio logic ic theory.30 It is this theory th that at dictates the physician s approach ta the diagnos nosis and and treatment of disease. Gillick (1985) points out that lay people in

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general think hink abou aboutt iIIness and it its s caus causes es and cure cures s in diff differ eren enttly than doct doctor ors s do. He further poin points ts out out that these popu popula larr models are are so diff differ eren entt tram the biom biomed edic ical al model that that th they ey shoul ould not be conf confus used ed with sc sciience ence.. Thes These e diff differ eren ence ces s betw betwe een the mode models ls may ac acco coun unt, t, ac acco cord rdiing to Gil illi lick ck,, for for the the wi wide dely ly repo report rte ed diss dissat atis isfa fact ctio ion n of pati patien ents ts wi with th mode modern rn medic edicin ine. e. There is an abundance of mode models ls that atte attem mpt to explain and pro rop pose new new aven av enue ues s ta the the doct doctor or-p -pat atie ien nt re rellat atio ions nsh hip ip.. However, ail 1 had the op oppo port rtun unit ity y to exam ex amin ine e are simpl simple e re re-a -ada dapt ptat atio ions ns of th the e same ame bank bankru rupt pted ed biom biomed edic ical al one.

Biomedicine is a na natu tura rali listi stic c and and in inter terna naliz lizin ing g medi medica call syste system, m, wh whic ich h me mean ans s that that dis disea eases ses have have natu natura rall expl explai aina nabl ble e cau cause ses s ac acti ting ng in th the e inte interi rior or of the the bo body. dy. In this this model, dise diseas ase e is a patho-ph path o-physiol ysiologic ogical al phen phenome omenon non:: normal normal bodily bodily fu func nctio tions, ns, as defin defined ed by bioc biochemi hemistry stry and and ph physi ysiola olagy gy.. are alte altered red b y path pathog ogen enic ic fa facto ctor, r, wh whic ich h resu result lts s in an ab abno norm rmal al func functi tion on,, tran transl slat ated ed clin clinic ical ally ly inta inta symptoms symptoms (H (Hap apps ps,, 1966 1966;; Sieg Siegen enth thal aler er,, 1977 1977;;   alenti Ma Mazze zzeii and and Mas Masnat natta, ta, 197Q) 97Q).. By read readin ing g the the sYmp sYmpto toms ms and and veri verify fyin ing g what what fu func ncti tian ans s are are alte altere red, d, it is the theore oretica tically lly pos possib sible le to 3

or

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kn know ow wh what pat pathog hogeni enic fa fact and sub uentl remo remove , caci ne neut utra rali ze. ev en kili 1994).  hat e the effec effect t of th this is acct cti ioctor nor is is caan lledd subseq th the e seque cu cure re; ; ntly they more mo re ve, effi effica ciou ous slize an. d effi efeven fici cien entki t lithe thite (Wilson. cu cure re,, the the more mor e quick quickly ly and in inte tegr gral ally ly th the e or orig igin inal al fun functi ctions ons are rest restor ored ed..

 

12

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Anot An othe herr pr prob oble lem m with ith th the e cu curr rren entt mo mode dell is me medi dica caliliza zati tion on..

31

There is a stro strong ng

tend tenden ency cy toda today y to me medi dica cali lize ze so soci cial al is issu sues es (B (Boo oors rse, e, 197 975) 5).. Ps Psyc ycho holo logi gica call as aspe pect cts s of he heal alth th are be bein ing g su sub bstit stitut uted ed by ne neur uros osci cien ence ce,, and so soc cial ial as aspe pec cts by genetics, rendering the old World Health Organization s definition of health ta a simple phys ph ysio iolo logi gica call mo moda dal. l. Whe When n the the Wo Worl rld d He Heal alth th Or Orga gani niza zati tion on de defi fine ned d he heal alth th in a biopsycho-social model, it did so to reinstate society with part of the control of the defi de fini niti tion on,, co cons nstr truc ucti tion on and use of health related as aspe pect cts s. Wh What at happened was a med ediica cali liza zattion ion of ail th thre ree e as aspe pect cts s of the or orig igin inal al de defi fini niti tion on.. Me Medi dica cali liza zati tion on of da dail ily y Iife gives rise to unrealistic expectations about the power and capabilities of biom biomed edic icin ine. e. The firs firstt co cons nseq eque uenc nce e is th that at pa pati tien ents ts se seem em to ac acce cept pt less of the limits

•

 

biom biomed edic icin ine e wh when en fac acin ing g an un untr trea eata tabl ble e di dise seas ase e (B (Bar arsk sky, y, 1988). Biom Biomed edic icin ine e

runs the risk of be bein ing g seen as th the e su subs bsti titu tute te to religion in tech techno nolo logi gica call societies, whic wh ich h le lead ads s to ov over er-m -medi edica cali lizat zatio ion n in thes these e so soci ciet etie ies. s. (T (Tho homa masm sma. a. 19 1984 84)) Today s bi biom omed ediica call pr prac acti tice ce is the so so-c -cal alle led d ev evid iden ence ce-b -bas ased ed me medi dici cine ne.. It is fash fashiion ona able ble be bec cau ause se it is tho hou ugh ghtt to be mor more e effi effici cien entt an and d ca cast st-e -eff ffec ecti tive ve.. In this practice, objec jectiv ive e findin ing gs ar are e th the e on one e th that at co coun unts ts;; ther there e is no room for for su subj bjec ecti tive ve reas ason onin ing. g. It is th the e me medi dica cali liza zati tion on of the bi biom omed edic icin ine e fie field. The Th e mo most st me medi dica cali lize zed d of ail processes is inde indeed ed the the clin clinic ical al en enco coun unte ter. r. Th This is pr proc oces ess s starts with ith a doubt, the healt lth h co cond ndit itio ion n of the the patient. This do doub ubtt suff uffers a transformation into information that will later be transformed by biomedical know kn owle ledg dge e into into a reco recogn gniz izab able le bi biom omed edic ical al trut truth. h.

3

Medicalization is  t the he process whereby domains of Iife that we werre not not previously 5

come

•

under the aegi aegiss of med medica icall practi practitio tioners ners and/or and/or medic medical al theori theories es (J (Jord ordano anova. va. 1995 p 367

 

 

•

It may may ap appe pear ar from the stud study y

 

the cur curre rent nt Ii Iite tera ratu ture re de deal alin ing g with dis diseas eases es

and thei theirr tr trea eatm tmen entt that that bi biom omed edic icin ine e is the the so sole le tr trut uth h and th that at th the e ph phys ysic icia ian n is it its s sole so le inte interp rpre rete ter. r. Ho Howe weve verr truth is trea treate ted d he here re as an un undi disp sput uted ed co conc ncep ept: t: th ther ere e is only on ly on one e sc scie ient ntif ific ic truth and only th thos ose e bestow towed with the bi biom ome edi dica call cu cult ltur ure e ar are e able to understand il. Moreover if they are able to understand they are by extension able to jud judge ge wh what at is and wh what at is no nott tr trut uth. h. ln its hi hist stor oric ical al jo joum umey ey We West ster ern n ci civi vili liza zati tion on had a st stro rong ng re reli ligi giou ous s fa facet cet tha thatt very ve ry rece recent ntly ly ap appe pear ars s ta be fading. Wi With th th the e rise of sc scie ienc nce e and te tech chno nolo logy gy on one e ca can n obse ob serv rve e the the su subs bsti titu tuti tion on of th the e cruc crucif ifix ix in many ins instit tituti utions ons by th the e ca cadu duce ceus us.. In Inde deed ed the judiciary system and the educational system to to cite ju just st two institutions

•

medi me dica cali lize zed d ma many ny as aspe pect cts s of thei theirr do doma main ins. s. Th The e pr pred edic icti tive ve po powe werr of bi biom omed edic icin ine e can be seen as the main reason for this phenomenon. However if the statistical tr trea eatm tmen entt of the pop opul ulat atio ion n appears ta bring a reasonable po poli licy cy tool this same same tr trea eatm tmen entt when tran transl slat ated ed into in ind div iviidu dua al ca care re do does es no nott ap appe pear ar to fu func ncti tion on th that at we weil il.. Phy Ph ysi sic cia ian ns are seen een as inhuman ane e wh when en deal aliing with suffering and phy hysi sici cian ans s regard thei theirr pa pati tien ents ts as un unco coop oper erat ativ ive e whe hen n face faced d th the e ex exig igen enci cie es of scie scien nce. ce. The Th e me memb mber ers s

 

the biomedical field are in an aHen world of ideas and

beli be lief efs s when co comp mpar ared ed wit with th thei eirr pa pati tien ents ts.. In a consul consultat tation ion tw two o dif differ ferent ent cult cultures ures live in the same room without managing to reach a consensus. The patient mettap me apho horric ical al world is begging for for tran ransf sfe eren rence so som met ethi hing ng th that at the physician is unprepared to conce onced de there is no mi mind nd in the bo body dy th that at the physi ysici cia an will trea reat. The pati atien entts iIIness is translated into the biomedical disease a an nd th the e th ther erap apeu euti tica call pr proc oced edur ure e do does es not not nec necess essari arily ly reac reach h pa pati tien ents ts ex expe pect ctat atio ion. n. It will not

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al so s at i sf y the physician, used t o crude descriptions o f physiological and path tho olog logica ical events, and not tra train ine ed to disc iscuss dif ifffere ren nt out utc comes th tha an th the e one desi de sign gned ed in th the e manu manual als. s. Bi Bioe oeth thic ics s att tte empted to reveal a new dime imensio ion n to biomedicine, the one one of shar sh ared ed resp respo onsib nsibil ilit ity y. However, neith neither er pati patien entt nor nor phys physic icia ian ns in genera rall want to shar share. e. Withou Withoutt ot othe herr re res sourc ource e, bioe bioeth thic icis ists ts to toda day y deal with fo foun unda dati tion onal al is issu sues es in a one-t ne-too-o one basis, using the sa same me meth method odol olog ogy y and cu cult ltu ure of th the e phys physic icia ians ns th they ey were we re supposed to monitor. When When bio ioe eth thic ics s was tra transfo forrmed in a para parame medi dica call fu fun ncti tio on, it lost lost it its s right to spe speak in th the e name name of pat atie ien nts and socie iety ty.. The Th e glob globa aliza lizati tio on of Weste:rn soci societ ety y is ta taki king ng bi biom omed edic icin ine e to soci social al gr grou oups ps

•

that th at ar are e abso absolut lutely ely unpr unprep epar ared ed to receiv receive e it. Bio Biome medi dici cine ne is id iden enti tify fyin ing g healt health h issues issues in cult ltu ure res s th that at did not until then re rea aliz lize th that at th the ey were sic ick k. No Now w th the ese soci societ etie ies s are

waiting for a Western treatment th tha at they cannot understand and afford. Even Weste We stern rners ers cannot cannot af affo ford rd bi biom omed edica icall treatm treatmen ents. ts. The Th e current ideology of healt lth h care promised Americans, according to Trista Tri stam m Enge Engelh lhar ardt dt 1998 :  1 th the e best best care,  2 equal care to ail,  3 ch cho oic ice e of phys ph ysic icia ian n and and  4 no in incr crea easi sing ng co cost sts. s. Ever Everyb ybod ody y in invo volv lved ed in this pro roje ject ct,, from gove go vemm mmen entt of offi fic cia iais is to users, to th the e pr prof ofes essi sion onal als s knows ows th that at th this is is im impo poss ssib ible le.. If it is imp impossib sible in the United States, what can be said about Canada? First, we must mu st reme rememb mber er th that at th the e phys physic icia ian n is

 t

the same ti tim me a cons consum ume er and a mana manage gerr

o f the Canadi an health care system. T he health care system has as its main fu fun nction th the e provision of the reso esource rces fo forr any and ail inte terrventi tio ons eventuall lly y nece ne cess ssar ary y to main mainta tain in the norm normal alcy cy,,

 r

health, of the population, as defi fin ned by

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123

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biomedicine-science. To ensure physical fitness and therefore economic pro rodu duct ctiivi vitty of the the population, the sy syst stem em en ensu sure res s it its s in inco come me th thro roug ugh h taxes es.. Co Cost sts s of big me medi dici cine ne are are rising and an d it ap appe pear ars s th that at mo most st att tte emp mpts ts ta control them ar are e fail failin ing g (Sch (Schwa wart rtz, z, 1988 .32 With the system accepting the standard of care as defined by the biomedical field, this sarne field is being identified by society as beiing so be sole lely ly res espo pons nsib ible le for its priee tag, and reacting ac acco cord rdin ingl gly y by insi sis sti ting ng on iden identi tifi fiab able le re resu sult lts s that that are are defined by the the co comm mmon oner er.. A free-for-all health care system is absolutely impossible for Canadian society, and an d if this this so soci ciet ety y alre alrea ady has man many y et ethi hica call qu quar arre rels ls with bi biom omed edic icin ine e du due e ta its mu mult ltii-cu cult ltur ural al co con nstituti ution, a mo modi difi fica cati tion on of th the e system ta pri riv vat ate e or se semi mi

•

pr priv ivat ate e will mul multip tiply ly the the qu quar arre rels. ls.

Section  

P

R

IGMS  N

TREN

S

The times in which we live do not have any comparison in history. Tech Te chno nolo logy gy,, com commu munic nicat ation ions, s, ec econ onom omy, y, so soci cial al se serv rvic ices es,, and po poli liti tica call aw awar aren enes ess s guar gu aran ante tee e toda today y s citi citize zens ns the cu cust stom oms s an and d po poss ssib ibil ilit itie ies s tha thatt we werre ba bare rely ly im imag agin ined ed until the recent past past.. A soc ocie iety ty tha hatt prev previo ious usly ly ranked its ci citi tize zens ns,, pr prof ofes essi sion ons, s, an and d cult cu ltur ures es,, no now w ha has s ta face face a global co comm mmun unit ity y whe herre hi hier erar arc chi hica call di divi visi sion ons s am amon ong g people no lon longer ger hav have e prac practi tica call me mean anin ing. g. Kn Know owle ledg dge e is a very imp import ortant ant re rea aso son n for this this.. It al alon one e pr proc oces esse ses s ail that is requ requir ired ed for sur surviv vival. al. If at one time, one could be a plumber, a farm farmer er and a veterinarian, while building a barn in the spare ti time me,,

Out of this discussion is a deeper tr treatment eatment of the problem  cost of health

care

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12

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toda today y the hese se pr prac acti tice ces s need tech techni nica call kn know owle ledg dge, e, to tool ols s and proc proced edur ures es tha hatt ha have ve tr tran ansf sfor orme med d th thes ese e ro role les s into pr prof ofes essi sion ons. s. To sum umm mariz rize, su surv rviiva vall in the modern world wor ld de depe pend nds s on spec specia iali liza zati tion on ra rath ther er than than ho holi list stic ic know knowle ledg dge. e. As pe peop ople le leam leamed ed m o r e about their works and crafts, they gained another dimension of selfawareness, with an incre rea ase sed d inte intere rest st in th thei eirr own rights and va valu lues es,, sinc since e so soci ciet ety y needed each of th them em on equal term terms s Ha Hair ire, e, 1962 33 Pat ate emali alism is no long longer er seen a s a sign of beneficence waived by the higher classes, but as an inadmissible exer ex erci cise se of po powe werr and op oppr pres essi sion on.. Pr Priv ivac acy y an and d au auto tono nomy my are are

no w

values.

As realists, scie scient ntiists sts try to find ou outt wh what at rea really ha happ ppen ens, s, bu butt as em empi piri rici cist sts, s,

th they ey pay more at atte tent ntio ion n to the stat statis isttic ical al as asso soci ciat atiion ons s betwee een n phenomena. In moder n social medicine, which is mainly empiricist, there is little interest in •

ontological and metaphysical questions. However, modem medicine has ontological ques qu esti tion ons s that that will re rema main in un unan answ swer ered ed by the the cu curr rren entt pa para radi digm gm.. Th This is an anti ti-r -rea eali lism sm of

the the em empi piri rici cist sts s ne nece cess ssit itat ates es the the re rede defi fini niti tion on of co conc ncep epts ts Iike Iike ca caus usal alit ity, y,

l

wof

nature and ob obje ject ctiv ivit ity y that that tend to ab abst stra ract ct re real alit ity y Casse ssell, 19 1991 91 . Ph Phys ysic icia ians ns to toda day y crea create te a pictu cture of re real alit ity y tha hatt can be ev eval alua uate ted d em empi piri rica call lly, y, th throu rough gh labo labora rato tory ry and imag im agiing tests. Th The e pa pati tien entt they se see e is a metap etapho hori rica call im imag age e of th the e real patient. We read th the e world through ou ourr own signifiers, the ea easi sies estt being the body; thes these e si sig gnifi nifier ers s ar are e the tool tools s for re rea ading the the body, and dise diseas ase e beco becomes mes a lang langua uage ge or

a metaphor. Th The e se sellf is a more co com mpl ple ex construct: the body is a mo more re organized

hier hierar arch chic ical al,, ve veri rifi fiab able le,, vi vis sible an and d touc toucha habl ble e mi mirr rror or or real realiity.

 h e

body may be

An Anot othe herr au auth thor or imp import ortant ant to th the e unde unders rsta tand ndin ing g th the e th thou ough ghts ts 1am pr pres esen enti ting ng he here re is Wi Wien ener er  1984 .

33

•  

1   . -

•

pol iitt i c i ze d and so, explored ideologically. T he he body can b e used as a tool, and explo lore red d econ conomic omica ally lly as such. Th The e body can also be used as language, and as such

may beco become me a metaphor or art. T h e body is, in the co nt e xt

of

th this is pape paper, r,

para pa rado doxi xica call lly, y, the the outs outside iderr wher wherea eas s biom biomed edic icin ine, e, a cons constr truc uct, t, is th the e in insi side der. r. To er erec ectt bi omedici ne, the out si der was used as a passive so ur c e of in info form rmat ation ion.. This This pass pa ssiv ivit ity y is al als so the the etymo tymolo log gical ical roo root of the the word pati patien ent. t. Th e pa pati tien entt is th the e sour source ce of

in info forrmatio ion n and and the the objec ject of the the acti actio on of bi biom ome edi dici cin ne. The The representa tattiv ive e

pati pa tien ent, t, the image image that that phys physic icia ians ns port portra ray y

of

one, is not not a bell bellig iger eren entt auto autono nomo mous us

patient. The pati patien entt we can see see in the artic rticle les s and te text xtbo book oks s do no nott expr expres ess s th thei eirr will or opin iniion; inst instea ead, d, the they ar are e pass passiv ive e abje abject cts s fo forr th the e phys physic icia ian n s man manipul ipula ati tion on..

•

Th e

pati tie ent only only voic voices es him or hers hersel elff ta answ answer er the doctors questions. The Th e phys physic icia ian n beca became me powe powerf rful ul becau because se th the e paradi paradigm gm J wa was s buil builtt th that at way,

placing

 il

th the e instr instrum umen ents ts to gathe gatherr and pr proc oces ess s th the e re rele leva vant nt in info form rmat atio ion n only only in the

phys ph ysic icia ian n s hand hands. s. 8iomed 8iomedici icine ne rele relega gate tes s even even ail th the e param paramed edica icall prof profes essi sion ons s to a seco second ndar ary y ra raie ie,, instructions

of

5

people

in

other oth er para parame medi dica call profe profess ssio ions ns simply simply ca carr rry y out th the e

the phys physici ician an35 (Fre (Freid idso son, n, 1988 1988;; Sha Shah, 1994 1994). ).

Forr Froh Fo Frohoc ock k (1992 (1992 p.27 p.27), ),

  he

foll follow ows s di diff ffer eren entt unde unders rsta tand ndin ings gs

disp disput ute e is over caus cause e and and affect, and clo los sely

of

e v i d e n c e and i n f e r e n c e .

ln the past,

psychoanaly lys sis and and homeopathy, just just to cite two example les s, were considered legitimate legit imate trends trends of medic edicin ine, e, both oth with ith a re rec cog ogn niz ize ed scie scient ntif ific ic appro roa ach. Toda Today y

There ar There are e many many defin definit ition ions s of paradigme Her Here, pa para radi digm gm is cons consid ider ered ed to oe a un univ iver ersa sall lly y re reco cogn gniz ized ed scien scienti tifi fic c achiev achieveme ement nts s that that for a time time prov provide ide mo mode dell prob problem lems s an and d solu soluti tion ons s to a commun com munity ity of practi practitio tioner ners s (K (Kuh uhn, n, as ci cite ted d in Sta Stanbu nbury ry  1995 p.522).  4

35

Bi omed edic icin ine e was wa built built,1984) by ph phys icia ians ns fo forr ph phys ysic icia ians ns.. They They are are the the one ones s tha thatt ga gain ined ed with with its its instBiom institut itutionali ionalizatio zation. n.s(Katz,1984 (Katz )ysic

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  26

•

they they are co cons nsid ider ered ed plac placeb ebos os.. Wh Whic ich h elem elemen ents ts of ou ourr scie scient ntif ific ic bi biom omed edic icin ine e will, in th the e fu futu ture re,, be considered un unsc scie ient ntif ific ic rema remain ins s to be seen. Fr Froh ohoc ock k al als so pl pla ace ces s th the e restoration of health maintenance of Iife as one of the acceptable aims of bi biom omed edic icin ine e (p.275). Thes These e are are very ery reas reason ona able ble ideals, ho howe weve verr th thei eirr go goal als s are stil stilll described from within the realm of biomedicine. Biology builds constraints, sociology builds roles, and human beings cannot choose to live without one or another, n or can a person prioritize one over the other; a culture or society, conv co nver erse sely ly,, is ab able le to do

5

Cont Co ntra rary ry to the ph phys ysic icia ian n s belief, ab abse senc nce e of no norm rmal alit ity y is no nott ab abn nor orma mallit ity y (Canguilhem, 1982). Normality does not necessarily mean health, nor does

•

abn bno orma mallity mean disease. Furthermore, disease does not mean illness and bio iom med edic ica al health is no nott ne nece cess ssar aril ily y the ab abse senc nce e of symp sympto toms ms in the pat atiient ent. By barring iIIness from the realm of clini linica call co conc ncem ems, s, bi biom omed edic icin ine e di dire rect cts s it itse self lf ta what Kl Klei einm nman an,, Ei Eise senb nber erg, g, an and d Go Good od (197 (1978) 8) cali ve vete teri rina nary ry pra practi ctice ce of me medic dicin ine. e. What biomedicine targets is not necessarily what the patient wants to be targeted. Howeve How ever, r, bio biomed medici icine ne pre presen sents ts us with ce cert rtai ain n results; th thes ese e results are used to vali valida date te th the e pr prof ofes essi sion onal al po powe wer. r. In exch exchan ange ge for power biom biomedic edicine ine of offe fers rs scien scientific tific cert ce rtai aint nty y. Predictive po powe werr is th the e en entticing lure th that at at attr trac acts ts th the e go gov vernm nme ent that need ne eds s of pr pred edic icti tion ons s for po polilicy cy im impl plem emen enta tati tion on and in insur suranc ance e co compa mpani nies es to assess ri risk sk factors. factors. When Wh en a eritic states that biomedicine is not a science, it may sound Iike it is bein be ing g re remo move ved d

tr

it its s sc scie ient ntif ific ic value or pr pre edi dict ctiive po powe wer. r. It is exactly this

predi redic cti tive ve power that provides its greatest economic significance, not only for

•  

[

•

gove go vemm mmen entt of offi fici ciai ais s but but al also so for for the the insu insura ranc nce e indu indust stry ry..   e must remember here here that it is this pr pred edic icti tive ve powe powerr that that stre streng ngth then ened ed the the li link nks s of bi biom omed edic icine ine with the

ec o no mi c power. I t is this predictive p ow er that allows an i mp mp o r t an an t part of the  standard of care definitions. Philosophers may agree that medi medici cine ne is not a scien cience ce.. However, does does the patie atien nt know it? Does the indu indust stry ry and the the he heal alth th ca carre sy syst stem em knows it? Doe Does th the e phys physic icia ian n kn know ow it?  t a dis ista tan nce, ce, one one ma y re rema main in wi with th the impr impres essi sion on that that know knowle ledg dge e abou aboutt the the issu issue e is not not the the point int. The inst instit itut utio ions ns have no int intere erest st  n qu ques esti tion onin ing g such such foun founda dati tion onal al issu issues es.. For For Khus Khushf hf (1997), it is time for a recon econfi figu gurrat atio ion n of the rela relati tion ons s betw betwee een n medi medici cine ne,, bioe bioeth thic ics, s, and the phil philos osop ophy hy of medic edicin ine e in or orde derr ta reco cov ver the the lost lost ca cari ring ng dime dimens nsio ion n of biom biomed edic ical al pr prac acti tice ce..

•

t h e tirst place, 1 am am n o t s u r e i f bi o m e di c i ne e v e r h ad a ca r in g d i m e n s i o n ;

 n

 n

the

seco second nd,, Khus Khushf hf s reco reconf nfig igur urat atio ion, n, ag agai ain n leav leaves es the the pa pati tien entt outsi outside. de. Axerlroad (1984) states that there is a need ta redefine the raie of the physician as a hea healt lth h car are e provider, with the the add addit itio ion n of th the e raies of sci scient entists ists and and that at sc scie ien nce is nece necess ssar ary y in heal health th care, but of so soci cial al work worker ers. s. Seli Seliko koff ff (1984) adds th c l e ar l y not sufficient. In this scenario, bioethics should have a crucial role by pr prov ovid idin ing g th the e guid guidel elin ines es and and inte interp rpre reti ting ng the the doct doctor or-p -pat atien ientt re rela lati tion onsh ship ip,, as weil as in inte tegr grat atin ing g the the mu mult ltii-di disc scip ipli lina nary ry heal ealth team team.. Howe Howeve ver, r, it ca can n only only fulf fulfiill its raie if di divo vorc rced ed trom trom the the biom biomed edic ical al mode model. l. The Th e exis existe tenc nce e of dise diseas ase e is impl implic icit it in bioe bioeth thic ics s (Mur (Murph phy, y, 1981, p. p.28 284) 4).. This This mean me ans s that hat bi bio oethi thics shar hares th the e sa same me model wit with biom biomed edic icin ine. e. It is not il illn lnes ess s th that at the the pa pati tien entt ex expe peri rien ence ces, s, but but dise diseas ase, e, the medi medica cali lize zed d desc descri ript ptio ion n of an or orga gani nic c dy dysf sfun unct ctio ion n upon whic which h a phys physic icia ian n will inte interv rven ene e and and hope hopefu full lly y elim elimin inat ate. e. It is no

•

 

12H

•

wond wo nder er that that foun founda dati tion onal al is issu sues es of bi bioe oeth thic ics s are are co cons nsid ider ered ed in inse sepa para rabl ble e from th the e pr prac acti tice ce of medicine. Bioethics have have a strong appeal to phys hysic iciians, ns, who want or nee eed d a di dirrect ect answ answer er to a speci pecifi fic c pract ctiical pr prob obllem. em. Th The e more the an answ swer er ma matc tche hes s th the e co comm mmon on me medi dica call pr prac acti tice ce   al alle levi viat ates es le lega gall risks, th the e bett better er.. If ther there e is no re reco cogn gniz izab able le in indi divi vidu dual alit ity y in th the e trea treatm tmen ent, t, how can so some meon one e cope co pe with the unf nful ulfi fill lle ed socia cial raie raies? s? If bi biom omed edic icin ine e coul could d be pra practi cticed ced wi with thou outt th the e intervention of one person - the do c to r - upon another - the patient - than there woul wo uld d be no need for bi bioe oeth thic ics s sinc since e th ther ere e would b e n o frust frustra rated ted expect expectati ations ons an and d no c on f li ct of values. Also, there would not be any interaction and thus no care would be given. A science free o f any human interference is t h e dream o f ail meth me thod odol olog ogie ies; s; ho howe weve ver, r, scie scienc nce e is a hu huma man n en ende deav avor or and shou should ld al alwa ways ys have the

•

bene be nefi fitt of humanit ity y in mind. nd. Th The e sc scie ienc nce e itse sellf does not have et ethi hics cs.. Et Ethi hic cal is iss sues ues, as 1ha 1hav ve alr lre eady statAd, only ar aris ise e from in intterac eracttio ion ns, which me mean ans s th that at they hey will appear in the appl applie ied d sc scie ienc nce, e, and th the e mor ora al va valu lue e is only one of th the e many many int nte erest rests s driving the use of th the e scien cience ce.. Toda To day y s co code des s pl plac ace e ph phys ysic icia ians ns in a seco second ndar ary y raie in the decisi decisionon-mak making ing process proc ess Ke Keys yser erli ling ngk, k, 1998). Th e role of advisor is still ta be construed in the bi biom omed edic ical al field th that at on only ly re reco cogn gniz izes es th the e he heal aler er-r -rol ole. e. At th the e same ti time me,, ac acco cord rdin ing g ta Spic ick ker, Ratzan an and d Richard   1990), Pe Pell lleg egri rino no de desc scri ribe bes s four lass lasses es in those who wh o fall iII:  1 free freedo dom m of ac acti tion on,,  2 freedom to mak make e rati ration onal al choic choices, es,  3 freedom fro rom m ot othe hers rs power, an and d  4 the sens sense e of in inte teg gri rity ty of the self. It is in inde deed ed ve very ry di diff ffic icul ultt to reconcile a h ea le r wh who o cannot exert paternalism with a patient who is surre sur rende nderi ring ng autono autonomy. my.

•

 

  9

•

On a personal level of the doctor-patient relationship, we condemn patemalism. patemal ism. Ho Howe weve ver, r, we surrender to it so soci cial ally ly an and, d,

in

sorn sorne e circ circums umstan tances ces,, even ven

st stim imul ulat ate e it. Sla lata tan nt exa xamp mple les s ar are e the ma mand ndat ator ory y use of se seat atbe belt lts, s, a legi legisl slat atio ion n that that comp co mpel els s an otherwise free, au auto tono nomo mous us and ratio tional citiz itizen en to a sp spec ecif ifie ie be beh hav avio iorr inside his or her property, based

on

studies derived tram bio biome med dical data and

sponsored by insurance companies. Another example is the requirement of a physician s pre prescri scriptio ption n

in

order to obtain drugs, a me mea asu surre aime med d

 

curtai cur tailin ling g the

misu mi suse se or hann of an ot othe herw rwis ise e tre tree, au auto tono nomo mous us an and d rati ration onal al pop popula ulatio tion. n. Th The e fact fact th that at th this is ob obli liga gati tion on pe perp rpet etua uate tes s bi biom omed edic ical al mon monop opol oly y is no nott ev even en qu ques estio tione ned. d. Th This is hypo hy pocr crit itic ical al be beha havi vior or to towa ward rd pa pate tern rnal alis ism m is, ta say the the leas least, t, mor morall ally y co conf nfus usin ing. g.

•

One si sing ngle le pe pers rson on is a uni nit, t, ho howe weve verr fin finite, ite, indi indivi visi sibl ble, e, an and d sel self-s f-suff uffici icient ent:: or she

is

he

selfself-lilimi mite ted d an and d thu thus s de depe pende ndent nt on exte extern rnal al real realit itie ies s Che Chemiak miak an and d Ta Taub uber er,,

1992). It is difficult for biome med dicine-science to deal with the individual, but it

is

diff diffic icul ultt fo forr biom biomed edic icin inee-cl clin inic ical al pr prac acti tice ce ta de deal al with stat statis isti tica call sa samp mple les. s. Th This is is mo more re th tha an an op oppo posi siti tion on;; it is a maj major or inte terrnai co cont ntra radi dict ctio ion. n. Bi Bio ome medi dic cin ine e ca cann nnot ot so solv lve e th the e co cont ntra radi dict ctio ions ns aris arisin ing g tram the the ev evol olut utio ion n of a soci so ciet ety y th that at is no lo long nger er sa sati tisf sfie ied d with the the se serv rvic ices es it rec receive ives. Diss Dissat atis isfa fact ctio ion n with th the e biomedical model arises not because the patient

is

misu mi sund nder erst stoo ood d by the

physician, bu butt because the mo mod del is unfitted ta bath. Scien cience ce,, trom the the last last ce cent ntur ury y on, is held ta provide a set of truths. These truths are believed by lay-people

to

tr tran ansc scen end d th the e baundarie ies s of natio tion, religion, and po poli liti tics cs Sy Synu num, m, 19 1990 90). ). Th They ey also also brin bring g al alie ien n va valu lues es th that at ar are e in inco cong ngru ruou ous s with ith so soci ciet ety. y. Biomed Bio medici icine ne ev evol olve ved d

•

tr

an

art ta a science. Based on the science,

bi biom omed edic icin ine e bui uilt lt its culture. Th The e scie scient ntif ific ic bi biom omed edic ical al cu cult ltur ure e can cannat nat cape with the the

 

 

•

individ ividu ual needs th that at are expressed during a consultation. The doc octo torr-p pat atie ien nt relation rela tionshi ship, p, mor more e th  n a simp simple le en encou counte nterr wh wher ere e bio biomed medici icine ne

c n

fl flex ex it its s mu musc scle les s

against a disease, is the expected moment where the patient s illness will

 e

al alle levi viat ated ed.. Th The e scien scientif tific ic co cons nstru truct ct Ildi Ildise seas ase e ha have ve no none ne corre orrela lati tion on wit ith h th the e soc ocia iall  

cons co nstr truc uctt Iillness. Doctor and patie tient are, thus, not differentt univ differen universe erses. s. It is time for a paradigm shift.

•

•

in

opposing fi fie eld lds s bu butt

in

 

 

•

ON LUS ON

Clin Clinic ical al med medici icine ne sh shou ould ld be the the ap appl plic icat atio ion n of bi biom omed edic icin inee-sc scie ienc nce, e, an and d th the e physi phy sici cian an,, mo more re than than an agent, would ide ideally ally be th the e ad adap apte terr of th the e gen ene era rall sc scie ienc nce e to individual needs. However, this does not occur. Both the physician and the patient pat ient be beco come me frus frustr trat ated ed in the process. Clinical medicin ine e is not only wha hatt the phys ph ysic icia ian n does, it is also also the info inform rmat atio ion n he or sh she e tr tran ansm smit its. s. Th The e cl clin inic ical al enc encoun ounter ter and the information generated there follow diff ffe eren entt paths. The information is contextualized by biomedical culture, and, although it should serve th the e whole society, it almost be beco come mes s the property of the health care system. It is a mistake

•

to co conf nfus use e me medi dica call-pr prac acti tice ce styl style e of reas reaso oning ning wi with th me medi dica call-te text xt styl style e of re reas ason onin ing g. While Whi le the the la latt tter er uses uses rhe heto tori rica call co conv nven enti tion ons, s, th the e fo form rmer er uses me meta taph phor ors s Yo Youn ung g, 1995) 19 95).. The inf inform ormati ation on ge gene nera rate ted d in relat relation ionsh ships ips with with pa patie tient nts s ex excl clud udes es pat patien ients ts as re read ade ers and us user ers, s, pa pate tern rnal alis isti tica call lly y co cons nsid ider erin ing g th thes ese e scie scient ntif ific ic re resu sult lts s as th the e standard of care toward a community that cannat judge its fairness or appropriateness, sinc since e peer review is exa xact ctty ty wh what at it me mean ans s and the pa pape pers rs will be review rev iewed ed onl only y by peers. Cana Ca nada da is a mu mult ltii-eu eult ltur ural al so socie ciety ty,, wh wher ere e mul multiti-cul cultur turali alism sm is und unders erstoo tood d as  a social intellectual movement that promotes the value of diversity as a core principle and in insi sist sts s that that ail cult ultura ural gro group ups s be tr trea eate ted d with re resp spec ectt and as eq equa uats ts Fowers and Richardson, 1996). Biomedicine is a culture. More, it is elitist, id ideo eolo logi gica cal, l, and high highly ly hier hierar arch chic ical al.. The rela relati tion onsh ship ip of this cu cult ltur ure e with th the e ot othe herr

•

cult cu ltur ures es that that co cons nsti titu tute te the the so soci ciet ety y can be ex exem empl plif ifie ied d by bi bioe oeth thic ics. s.

 

132

•

Opti Op tim mal rela relati tion onsh ship ip betw etween do doct ctor ors s and pati patien ents ts may not st stre ress ss tr trad adit itio iona nall ethical duty, and it may may not be de deri rive ved d eith either er fr from om th the e pati patien ents ts ri righ ghtt ta heal health th care. A claim for health care is a social claim, not one directed to physicians in their indi indivi vidu dual al re rela lati tion ons s with with the the pa pati tien ents ts Zuge Zugerr an and d Miles 1987). In ot othe herr word words, s, et ethi hica call  u

Y is not the same same as professional duty. Indeed, med medica ical syst system ems s existed for aeons without a patient-directed ethical standard. Not ail simi simila larr acts are equal et ethic hicall ally. y. Simi Simila larl rly, y, not ail simi simila larr med edic ical al ac acts ts are equal ual. Ci Circ rcum umst stanc ances es give ive each peri pe riar arme med d ac actt a pa part rtic icul ular ar and an d un uniq ique ue es esse senc nce, e, which escape escapes s st stati atist stic ics. s. Bioe Bioeth thic ics s incr increa easi sing ngly ly became became a ne nece cess ssit ity y in ou ourr ti time mes s due to th the e freque frequent nt contHct of in inte tere rest sts s betwee ween pra ract ctit itiianer aners s and users of the he heal alth th car are e sy syst stem em.. Desi Design gned ed ta be crit itic ica al, bioethics became, with time, another paramedical activity, deriving from

e/

Eve e n if bi biam amed edic icin ine e its lang langua uage ge,, mod odel el,, meth method od,, an and d deci decisi sion on-m -mak akin ing g pr proc oces ess. s. Ev according to Spicker 19 1998 98), ), we ca cann nnot ot talk talk ab abou outt one bi bioe oeth thic ics s in ail circumstances

and an d contexts, the goal of bioethics migrated from an ou outs tsid ide e evaluatian of the syst system em,, to an insi inside de und nder erw wri riti ting ng of proc proced edur ures es,, whi hich ch con connec nects ts it its s de dest stin iny, y, in this para pa radi digm gm,, ta th that at of biom biomed edic icin ine. e. Medicine in the the last 30 ye year ars s eval evalve ved d fram Dr Kild Kildar are e to ER. In the tirst, a bene be neva vale lent nt de dedi dica cate ted d an and d

p

t ~ m

l i s t i

figure personified not on only ly the romantic

imag im age e that the publ publiic had about phy hys sicia cians but also the id idea eallisti istic c care giver they thought thou ght do doct ctor ors s were were.. In the the se seco cond nd,, pa patem temali alism sm wa wass sh shif ifte ted d fr from om th the e pr prof ofes essi sion onal al to tech techno nolo logy gy;; the the hass hassle le and hu hust stlle of a mo mode dem m hospital beca became mes s an are arena na wh wher ere e life is a pr priz ize e co conq nque uere red d than thanks ks ta the competence of a te tea am. In bath, the reality of Iife and death, he heal alth th and disease, su suffferi fering ng and relief, ar are e at atte tenu nuat ated ed in favar of ra rati ting ngs, s, amuseme amusement, nt, and and ad adver vertis tisers ers.. In bath, medicine is ju just st a sh show ow..

•

 

 

•

Most of us do not wa want nt prim imee-ttim ime e TV images of reality.

 e

want sof soft-co t-core re

programs ta help us dige ges st dinner. The problem with this de desi sire re is tha that we ac acce cept pt stere tereo otype types s in ma mass ssiv ive e da daiily dos ose es, and the they shape the the way we se see e reality. ty. Th Than anks ks to the the media, as McLuhan 1967 pointe nted, we end up bei eing ng the the con onte tent nt,, a pas ass siv ive e and an d mo mold ldab able le ma mass ss wi with thou outt a co coll llec ecti tive ve pe pers rson onal alit ity. y. Bio iome med dicin icine e is part of this mass-d -drream: a powerful tool that that will so some med day conquer ail suffering, and will, at the sa same me time, bestow us with with imm immort ortali ality, ty, bea beauty uty,, and etemal youth. Whil While e this is on only ly a dream ream,,

we

curs curse e ail he heal alth th care care prof profes essi sion onals als

f or their unfulfilled promises; we punish biomedicine denying it the power of

•

auto au tono nomo mous us ex exer erci cise se of the the prof profes essi sion on that that almo almost st ail othe otherr prof profes essi sion ons s ha have ve;;

we

hol old d ph phys ysic icia ians ns pe pers rson onal ally ly resp respon onsi sibl ble e for for the the un unce cert rtai aint nty y of the their ir scie scienc nce. e.

are

 e

angry because the dreams we have are no nott true. The healt h care system and the patients orbit the physician, and the phys ph ysic icia ian n or orbi bits ts biom biomed edic ical al sc scie ienc nce, e, ye yett this this biom biomed edic ical al scie scienc nce e face faces s cont co ntra radi dict ctio ion. n. The aim

of

biom biomed edic icin ine e is Ii Iink nked ed

ta

an

internai

the health of the patient. The

defi de fin nitio ition n of he heal alth th and healt alth rela latted is issu sues es can be co cons nstr true ued d from the insi inside de of the the science, or from outside of it. Th The e problem arises when the the sc scie ienc nce e im impo pose ses s to the comm co mmun unit ity y at larg large e it its s de defi fini niti tion ons, s, es espe peci cial ally ly if this com commun munity ity alre alread ady y ha has s di diff ffere erent nt defini def inition tions. s. Biome Biomedicin dicine e is le left ft wit ith h a scie scienc nce e that that ca can nna natt be full fully y ex exer erci cise sed d be beca caus use e of the the cultural re res sis ista tan nce exe xerrted ted by the the obj bjec ectt of its prac practi tice ce.. The bi biom omed edic ical al mo mode del, l, wh whic ich h aris arises es tro trom a di diff ffer eren entt ti time me an and d so soc ciety iety,, ca cann nnot ot adequate adeq uately ly func function tion promises

•

of

in

it its s an anti tiqu quat ated ed stat state. e.

 e t

we

stil till nee eed d ph phys ysic icia ians ns with thei theirr

cures. According to Kuhn 1978 , a paradigm shift, o r at least a

 

  4

•

Hege egelian lian qual qualit ita ative tive ju jump mp is abou aboutt to occur cur. It appear ars s ta me that that a refo reform rmul ulat atio ion n of th the e bio iom medic dical parad radig igm m meanin aning g th the e mole molecu cula larr and biol biolog ogic ical al basi basis s of today today s medi me dicin cine e is mand mandat ator ory. y.

 h atdo does es

not not mean mean that that the the pr pres esen entt model is wrong this this

is not not a ques questi tion on of right vers versus us wrong it only only mea means tha that is crea creati ting ng more more prob proble lems ms th than an solu soluti tion ons. s.

  ha twill

in

my opin opinio ion n biome biomedic dicine ine

be biom iomedic icin ine e s new new fac face is

nott th no the e aim aim of th this is mono monogr grap aph. h. 1ca 1can howe howeve verr fan fantas tasiz ize e that that the the bi biop opsy sych cho osoci social al def efin init itio ion n of healt lth h would be less less medi medica cali lize zed d and and sc scie ient ntif ific ic meth method od will open open

ne w

aven av enue ues s wher ere e in ind divid ividu ual expre xpress ssio ions ns such uch as iIIness will be respected ted. For

ho w

long bi bioe oeth thic ics s will be need needed ed we

•

 

this new paradigm remains ta be seen. However.

can al almo most st ta take ke it fo forr cert certai ain n th that at once once th the e con confl flic ictt betwe etween en pati patie ents nts iI iIIn Ine esses

and an d phys physici ician ans s dise diseas ases es are so solv lved ed most most of the fue fuel for for bi bioe oeth thic ical al in inte terv rven entio tions ns wi willll be exha exhaus uste ted. d. A new new heal health th ca care re sy syst stem em wou would al also so incl includ ude e a pr prog ogre ress ssiv ive e Iicen Iicensi sing ng and in ins surin ring of pr prac acti titi tion oner ers s of alte altern rnat ativ ive e me medi dici cine nes s as as is alre alread ady y being ing the the case case with midwives in Quebec parame par amedica dicall profes professio sions. ns.

•

in

and a redesign of the raies o f many

i f n o t ai l

  35

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R F R N

S

Abir-Am AbirAm,, PG: PG: Ho How w Sc Scie ient ntis ists ts Vie iew w Th Thei eirr Her ero oes: So Sorn rne e Re Rema mark rks s on the the Me Mech chan anis ism m o f Myth Con Constru structi ction. on. Journal of th the e Hist istorv of Bi Biol olo ogy. gy. 15: 2811-3 315, 1982. Abramo Abra movi vitc tch, h, H and Sc Schw hwar artz tz,, E: Thr hree ee Sta Stages ges o f Medical Dial Dialog ogue ue.. Theoretical Medi Me dici cine ne 17 2): 175175-18 187, 7, 1996 1996.. Ackerkne Ackerk nech cht, t, EH: Anticontagionism Betw Between een 1821 562-5 56 2-593 93,, 1948 1948..

 nd

1867. Bull Bull.. Hi Hist st.. Med. 28:

Ackerknec Ackerk necht, ht, Erwi Erwin n H: A SHOR SHORT T HISTO ISTORY RY O F ME MEDIC DICINE INE.. Balt Baltim imor ore: e: The The John Johns s Hopkin Hop kins s Univ Univer ersi sity ty Pres Press, s, 19 1992 92.. Agich,   J The Fou Founda ndatio tion n

of

31-3 -34, 4, 1981 1981.. Medical Et Ethi hics cs.. Metamedicine.   : 31

Alexander, F: M E D I C I N A PS I C OS S O MA TI CA - Pri nci pi os e Apl icaç6es  P Psyc sycho hoso soma mati tic c Medi Medici cine ne - Prin Princi cipl ples es and and Appl Applica icatio tions ns). ). Sao Sao Paul Paulo: o: Edito Editora ra Arte Artes s Médicas, p 44, no date te.. •

Arluke, A; Kennedy, L a n d Kessler, R C: Reex Reexami amini ning ng the the Si Sickck-Ro Role le Co Conc ncep ept: t:   n lth h and Soci Social al Beha Behavi vior or,, 20 3): 300-36 36,, 1979. Ernpirical Ernpiric al Assessment. Journal of Healt Armstrong,

 

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  6

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Barsky,   J:

 h

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Bates, D Sch Scholar olarly ly ways ways of Kn Know owin ing: g: an In Inttrodu roducctition on.. In: KNOW KNOWLED LEDGE GE AND THE THE SCHOLARLy TR TRAD ADIT ITIO IONS NS.. Cambri Cambridge dge,, Cambrid Cambridge ge Un Univ ivers ersitityy Pr Pres ess, s, 1995 1995,, p 1 22. Beauch Beau cham amp, p, TL an andd Ch Chilildr dres ess, s, JF: JF: PRINCI PRINCIPLE PLES S OF BI BIOME OMEDIC DICAL AL ETHI ETHICS CS.. New York Yo rk:: Ox Oxfo ford rd Univ Univer ersi sity ty Pres Press, s, 1983 1983.. Beauchamp, TL and Mc Cul l ou gh, LB: MEDICAL E TH I C S - The Moral New w Jer Respons Res ponsibi ibilit lities ies of Physicia Physicians. ns. Ne Jersey sey:: Pr Pren entitice ce-H -Hal all,l, In Inc. c.,, 1984. 1984. Ber nard, J; Lemaire, J F; Larcan, A dir.): L A CTE DE N A I S S A N C E DE LA SANT NTÉ. É. Paris: MÉDECINE M ODE RNE . L A C R É A T I O N D E S É C OL E S DE SA Synthé Syn thélab labo, o, 1995 1995.. Bers Be rst, t, J: Radar. PC Comp Comput utin ing. g. 12 4): 13, 199 1999. Boinet , E : LES D O C T R I N E S M É D I C A L E S - Leur Évolution. Paris Flam Flamma mari rion on,, Édit Éditeu eur, r, 1911 1911,, p. p.22 et seg.

 

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Ern es t