The Philosophy of Medicine Reborn

Where is the profession of medicine going? Has it become simply applied biology, another “job” among equally good ways of earning a living? What kind of person should the physician be? What about bioethics? Is patient autonomy the only viable moral absolute? Oh, and¯who is Dr. Edmund Pellegrino?

In The Philosophy of Medicine Reborn: A Pellegrino Reader , Tristram Engelhardt, a bellwether of bioethics, and Fabrice Jotterand, who holds a dual appointment within the University of Texas system as assistant professor of philosophy and “psychiatry and clinical sciences,” have answered these questions by offering nineteen selections from Edmund Pellegrino’s six hundred articles and twenty-four books.

At one time or another, Pellegrino was director of the Kennedy Institute of Ethics; president of the Catholic University of America; professor of medicine at Yale University; president and chairman of the board of directors at Yale“New Haven Medical Center; and dean of the School of Medicine at the State University of New York, Stony Brook. He was the founding editor of the Journal of Medicine and Philosophy and has seen patients and taught junior clinicians throughout his career.

Pellegrino currently chairs the President’s Council on Bioethics and is Professor Emeritus of Medicine and Medical Ethics at the Center for Clinical Bioethics at Georgetown University Medical Center. (In the foreword of the Pellegrino Reader, “Apologia for a Medical Truant,” he admits to be being “a trespasser in the olive groves of Academia.”)

In sixty years as a physician, his pursuits, though seemingly disparate, are yet of a piece, contributing to the articulation of a theory of medicine that ends in a praxis oriented toward the patient’s good. Engelhardt and Jotterand’s collection traces the elaboration of this theory over twenty-five years of published writing. The collection is divided into four sections. Essays on “The Philosophical Foundations of Medicine” and “The Medical Profession” comprise part one. The “Physician-Patient Relationship” is discussed next. “Virtue in Medical Practice” considers the importance and relevance of a physician’s character to his work. There is an interesting essay here: “The Physician’s Conscience, Conscience Clauses, and Religious Belief: A Catholic Perspective.” One only wishes the folks at the American College of Obstetricians and Gynecologists had read it before drafting their recent Ethics opinion. (See Christopher Kaczor’s First Things Daily Article, “Pro-Life Doctors: A New Oxymoron?”)

Finally, “Humanism and Hippocrates: Facing the Future” treats the humanities and the Hippocratic tradition. In “Bioethics at Century’s Turn: Can Normative Ethics Be Retrieved?” Pellegrino provocatively asks how much “ethics” is left in the field of “bioethics.” The answer will be “not much” unless bioethics does some serious soul-searching. He states, “The first item on the agenda of the bioethicist for the next century will be to decide whether bioethics will be authentically an enterprise of ethics, or, instead, it will become an amorphous expanding universe of preferences, opinions, feelings, or value choices filled with exquisite detail but enfeebled by a lack of normative content.”

Pellegrino reminds us that etymologically norm comes from the Latin norma , a carpenter’s square. Whatever it is, a carpenter’s square that cannot approximate a ninety-degree angle is simply not a carpenter’s square. In a similar manner, to be normative, the prescriptions and proscriptions of bioethics must be judged against¯and pass the muster of¯some standard. Without a foundation, bioethics will only guide medicine and human lives to a deleterious end. Thus, “if society is to avoid a teratological species of morality, some recovery of stable moral truths is mandatory.” Accordingly, the philosophy of medicine takes on great importance, and not simply of the academic kind.

Naturally, a book about the philosophy of medicine should state the nature of its subject. In “What the Philosophy of Medicine Is,” Pellegrino observes, “The philosophy of medicine consists in a critical reflection on the matter of medicine¯on the content, method, concepts, and presuppositions peculiar to medicine as medicine.” But how is this any different from what goes on in medical schools?

Pellegrino maintains that medicine is not simply applied biology; rather, it “embraces activities beyond those inherent in the pursuit of scientific knowledge.” For example, whereas scientists study the epidemiology, histology, and pathophysiology of squamous cell carcinoma, such knowledge, though used by medicine, is not proper to it until that cancer is placed in the context of the effects, manifestations, and outcomes on a given patient¯in short, until it is oriented toward the practical end which medicine serves: “the health and healing of human beings.”

“Medicine qua medicine,” writes Pellegrino, “comes into existence in the clinical encounter or in public health when the knowledge of the sciences basic to medicine is employed for a specific end, i.e. for the cure, containment, amelioration, or prevention of human illness in individuals and societies. Medicine qua medicine, therefore, is shaped not just by the ends and purposes of the sciences. Medicine uses scientific knowledge for its own specific ends, which are healing, helping, curing, and preventing illness and disease and promoting health.” This is the concern of the medical-school classroom or clinic.

The philosophy of medicine, on the other hand, is occupied by “concepts and conceptions like healing, helping, curing, health, illness, disease, care, the good of the patient, and the moral claims of the sick on the well, on society, and on the health professions.” It operates on a level above medicine as it studies “the nature and phenomena of the clinical encounter.” The philosophy of medicine discerns what should or should not be pursued within medicine, whether something comports with the nature of medicine or not. Consequently, it is necessary both to ground the norms of bioethics and to define the nature of medicine.

Pellegrino accomplishes this by elaborating an ethics “internal” to medicine. This “internal morality” arises out of the “kind of activity medicine is¯one based in the healing relationship and one founded in the phenomena of that relationship as well as competence in knowledge and skill appropriate to a healing relationship.” The first principle of the internal morality is “the good of the patient.” Its pursuit defines the “end of medicine.” Actions accord with the internal morality when they further the quadripartite good of the patient: the biomedical good, the patient’s perception of the good, the good for the patient as a person, and the spiritual good.

Thus, competence is enjoined on the physician because it is necessary for achieving the biomedical good¯for example, should a fluoroquinolone or penicillin antibiotic be used here? Paternalism is rejected because beneficence excludes violating the patient’s own plan for life, his own view of what is good, as well as his good as a human person who possesses the ability to choose. For example, if the competent patient decides to leave a hospital against medical advice in order to attend his daughter’s wedding, a surreptitious dose of general anesthetic is not the morally acceptable solution. Finally, and most important, the physician must serve the “spiritual good” of the patient. Pellegrino gives as one example blood transfusion and the Jehovah’s Witnesses. A transfusion might be medically indicated, but how could it be a healing act if it were for that patient tantamount to bloodshed?

What may strike some as frustrating about Pellegrino’s conception is the way the philosophy of medicine takes ontological priority over questions of “value”¯for example, the liceity of abortion, euthanasia, and embryonic stem cell research. After all, these are the questions impinging on the public square and straining the very meaning of medicine. Yet, as Aristotle and St. Thomas remind us, a small error in the beginning leads to a great error in the end. Pellegrino’s approach is to find the incontestable moral truths and to seek, in the nature of medicine, a first principle on which the various parties in our pluralistic medical and social milieu can agree. An elaboration of convincing, defensible, and agreeable answers to substantive questions is sure to follow the discovery of such a foundation.

Moreover, the internal morality of medicine is meant to be just that: internal. It is a limited thing. Pellegrino admits that this internal morality “is not intended to be a complete morality for all the ways medical knowledge can be used.” The internal morality of medicine may not be able on its own¯or at least not yet?¯to resolve many of the dilemmas that occupy our attention, such as whether it would be acceptable or not to use embryonic stem cells in treating a particular patient. Nevertheless, in the limited circumstance of professional ethics, it forbids some actions arising from the clinical encounter¯for example, because the patient is vulnerable. This is the unconscionable “moral Machiavellianism” that would permit “dumping” the patient who is unable to pay or encourage the physician to become “society’s fiscal agent.” On the physician’s part, the internal morality of medicine entails some effacement of self-interest.

This is not to say the “content questions” of bioethics are unimportant. Indeed, Pellegrino consistently sides with the Catholic position on these matters in a manner decidedly unlike, say, Frances Kissling or Mario Cuomo. It is just that the internal morality is presently incapable of solving these problems due to the erosion of the Hippocratic tradition and visceral disagreements internal to medicine. Further reflection on the nature of medicine may well lead to agreement among physicians about the incompatibility of abortion or embryonic stem cell research with their profession. But meeting these issues by this route will take time.

For Pellegrino, medicine is “the most humane of sciences, the most empiric of arts, and the most scientific of humanities.” Pellegrino observes that “all problems of human life¯alienation, affection, social and cultural relationships, and even salvation¯come to a focus in the existential laboratories we call hospitals. Every humanistic question takes on poignancy when embedded in the concrete situation: to discuss the value of life when deciding whether or not to abort, to relieve pain, to desist from overtreatment in hopeless situations.”

This practical bent of the healer’s life¯choosing one treatment over another, weighing both the existential and economic costs of a particular action, and so on¯demands a moral framework within which conflicting ideas about what is good may be resolved and that may guide the actions of the physician in the unique encounter with the patient before him. The Philosophy of Medicine Reborn does much to lay a foundation on which such a moral framework might be built. In fine, Pellegrino’s thought gives hope that at least some of the ethics in bioethics will indeed be retrieved.

Patrick C. Beeman was formerly a lecturer in philosophy at Cleveland State University. He is currently the president of the Catholic Medical Students Association and a Pellegrino Fellow at the Georgetown University Center for Clinical Bioethics. He is also a second-year medical student at the University of Toledo College of Medicine.

References

The Philosophy of Medicine Reborn: A Pellegrino Reader

The President’s Council on Bioethics

Christopher Kaczor on the ACOG’s Ethics Opinion: “ Pro-Life Doctors: A New Oxymoron? ”