The importance of being a person. Ethical and existential dimensions of medicine

Edvin Schei, Norway

Background: The rise of high-tech medicine in post-modern society poses a number of challenges to clinicians, to medical research, to health policy makers and, increasingly, to individual patients and relatives. While it is easy to agree that the purpose of medical activities is to do that which is "the good and the right" for the patient (1), it is becoming increasingly difficult to determine what may constitute "good and right" decisions in the individual case. The success of biotechnology has been parallelled by an increasing demand for medical ethics education and consultation, a rise in the number of legal controversies, more negative attention to medical issues in the media, an increase in costs that seems to yield only marginal health benefits, a growing market for alternative medicine in Western societies, and increasing dissatisfaction and psychological problems among doctors (2). To function well, medical students as well as practicing physicians need to reflect on the causes of, and possible constructive attitudes towards, personal ambiguity, scientific uncertainty and ethical dilemmas in clinical practice, research and health politics (3, 4). Both pre- and post-graduate medical education need to adapt to the new situation by developing competence and educational strategies that will allow doctors to cope with rapid cultural and professional changes, while at the same time strengthening their ethical judgement and ability to understand, communicate with and offer real help to patients in modern, multilayered societies. The fundamental aim of the current project is to strengthen the humanistic dimensions in Western medicine.

The complicated relationships between technological progress and problematic cultural changes in Western societies have been studied and debated by social and political scientists, historians and others ever since the time of Durkheim (5) and Weber (6), who coined the terms "anomie" and "the iron cage of rationality", respectively, to indicate mechanisms by which modern man "disenchants" his life-world by applying strict rationality to all kinds of problem-solving. The Holocaust, nuclear weapons, global heating and international terrorism are central examples of man-made catastrophies and threats made possible by technical advances and cultural attitudes with roots in the enlightenment distinction between facts and values (7), most clearly stated as an ideal of intellectual pursuit by the positivist philosophy of the mid-twentieth century. The possibility of a radical distinction between facts and values is a central tenet of natural science, including medicine, which prides itself of its ability to study the body's physiology and disease processes in objective and detached ways, thereby unveiling the universal characteristics of health and healing. The triumphs of medical technology, including antibiotics, anaesthetics, imaging techniques, transplantations, etc, did long keep medicine above serious critique of its methods and worldview. It is only recently, with the post-war changes in social structure and the upsurge of medical ethics and legal controversies over the last 30 years, that criticism of fundamental epistemological ("how do we know that our methods of gaining knowledge are adequate?") and ontological ("how do we know that our understanding of reality is adequate?") assumptions have reached medicine (8).

The present project takes as its point of departure that medicine is a combination of two indispensable strands: natural science and humanism. Over the last 100 years, Western medicine has increasingly identified itself with science (9, 10)."Humanism", the knowledge, competence and attitudes that allow doctors to address problems of social, psychological and spiritual character, has been marginalised in medical education (11). For the patient, the humanistic dimension is of course central, as it concerns identity, realtionships, suffering, anxiety, comfort, support, hope and the preservation of meaning when existence is threatened. Humanistic concerns are also highly relevant to the doctor, as they open the doors to a better understanding of different patients' needs, of the therapeutic tasks and how they may be fulfilled, and of the physician's existential needs, as a person living his or her life in a demanding profession (13).

Objectives: By using my experience from nearly twenty years of practicing and teaching medicine, in combination with insights from philosophy and the social sciences, I want to make a contribution to the ongoing reorientation in medical thinking. I will use my stay at the Center for Philosophy and History of Science at Boston University to deepen my knowledge of the philosophical topics and historical processes most central to medicine, publish international papers on these issues, and merge old and new insights in a book which I intend to be understandable and of practical use for medical students and faculty, as well as practicing physicians.

My second main objective is to become personally acquainted with American colleagues who work in my field. Informal professional networks of researchers and clinicians interested in medical philosophy exist in Norway and the other Nordic countries. Expanding these networks to the USA has already proved very valuable, and further expansion will strengthen the possibilities for future cooperation in research, teaching, and student exchange. Active networks in which enthusiastic colleagues may join forces are indispensable for real change to be effected. Improving my English proficiency is an important objective of the stay.

Methodology:
During my stay in Boston I will have the opportunity to work on and further develop ideas that are present in many of my publications from the last 10 years, mainly Norwegian texts (listed in my CV, publications 2-5, 7, 9-14, 23, 25, 29-37). The project has its philosophical foundations in phenomenology and existentialism, whose central perspectives on human life I will contrast and combine with knowledge acquired during many years of clinical work and teaching. Main sources are the works of philosophers in the tradition of Martin Heidegger: Levinas, Løgstrup, Sartre, Merleau-Ponty, Gadamer, Habermas, Boss. I will also use works from anthropology and sociology, by Kleinman and Good (both at Harvard University, Boston), Bauman, Foucault, Canguilhem and others (13-22).

I plan to prepare a minimum of three international publications, on autonomy, clinical communication and relational ethics, respectively. These three topics are central to an adequate understanding and management of the therapeutic relationship in medicine. The physician-patient relationship is not a purely technical, nor a commercial, nor a contract-governed interaction. The medical relationship is bound to be asymmetrical in knowledge and power, and can only function well if characterized by trust, benevolence and responsibility. A short outline of the three papers follows:

1. Autonomy. This paper will describe contrasting conceptions of autonomy and analyze the implications for the physician-patient relationship. If a "person" is conceived as an isolated atom in the human environment, "autonomy" will designate an individual's right to be protected against infringement of its rights by other individuals, and a contract-based physician-patient relationship will develop. Based on arguments proposed by Tauber (2003), I will argue that an atomistic perception of personhood is misleading, and harmful to the therapeutic relationships. "Persons" are social phenomena, whose fundamental characteristics, such as language and thought, cannot develop outside human relationships. Relational vulnerability and interdependence among humans are unavoidable, because they are inherent aspects of life-long learning and growth processes. In the therapeutic setting, the vulnerability of the patient is at the same time an ever-present opportunity for the doctor to help by stimulating the patient's thought processes, self-conception and personal development. To be able to do this without inflicting harm on the patient is a central competence in clinical medicine (12).

2. Communication. The interaction between doctor and patient is a continuous communication process, challenging to the doctor because of the power asymmetry of the relationship and the everpresent possibility of making mistakes with serious consequences. It is also often difficult for the patient because of anxiety, relative lack of knowledge, and inferior status in the encounter. In this paper I will outline a number of basic communicative competences that doctors need to realize the therapeutic potentials, based on a relational understanding of personhood and autonomy, as outlined in paper 1.

3. Relational ethics. In this paper I will investigate the medical relevance of the philosophies of Emmanuel Levinas (19) and Knud E. Løgstrup (21), European thinkers of the 20th century who argue that the fundamental source of responsibility in human interaction is the immediate perception of the other person's vulnerability, and trust, in everyday social interaction. Medicine's fundamental aim is to do that which is "good and right" for the patient - in other words it is a moral obligation. The paper will explore some of the theoretical and practical implications of relational ethics for the clinical encounter.

The book that I plan to write during the last part of my stay in Boston, entitled "The importance of being a person. Ethical and existential dimensions of medicine", will contain chapters dealing with the following topics, largely based on previous publications:

1. What is a person?
2. Health as subjectivity
3. Suffering and existential loneliness
4. Empathy
5. Dignity and the "how" of dialogues
6. Autonomy, freedom and responsibility
7. The doctor's power
8. The doctor's uncertainty
9. The doctor as a leader Phronesis - practical wisdom
10. Teaching medical humanism - the role of role models

Significance: Over the last ten years I have been able to make significant contributions to Norwegian medical philosophy, and I believe that my stay in Boston may benefit not only my own faculty of medicine, but also be of some importance on the national and international levels. Despite the increasing unease surrounding medical issues, especially advances in epidemiology and risk mapping, biomolecular sciences, genetic engineering etc, relatively little is being done in medical schools to change medical education and strengthen the individual doctor's ability to reflect and communicate (23). There is an urgent need to stimulate debate, strengthen research and establish networks of physicians, scientists, philosophers and educators in medicine, across national boundaries, to heighten awareness and competence in medical philosophy, including philosophy of science, ethics, clinical communication and medical education.

Discussions with American colleagues, such as my host professor Tauber, who is both a physician and a philosopher and has been several times to Norway, indicate that I may contribute to the American debates in bioethics and medical humanism by referring to experiences and perspectives from Scandinavia. Professor Tauber has invited me to give a presentation on these topics during my stay, in the well-known Boston Colloquium for Philosophy of Science. Norway differs from the United States not only in the political organization of the welfare state, but also in the widespread practice of patient-centered medicine and student-centered teaching. My department at the University of Bergen is a central proponent of these approaches to clinical practice and teaching, and several of my Norwegian publications concern such topics.

Evaluation and Dissemination: The papers will be published in refereed journals, and the book will be internationally available. Informal results will de disseminated through my work in Filosofisk Poliklinikk, the Rosendal seminars, as a teacher etc.

Justification for Residence in the United States for the Proposed Project:
The United States is the locomotive for all kinds of medical research, and in bioethics. Boston is the Mecca of academic medicine. The Center for Philosophy and History of Science at Boston University offers a unique environment for development in my fields of interest, there is (as far as I know) nothing similar in any European country. For these reasons, a stay in USA will entail not only a unique opportunity to learn and publish internationally, but also lend authority to my work and increase its impact in Norway. My chances of obtaining a full professorship at the University of Bergen depend to a great extent on my stay in Boston.

Bibliography:

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18. Canguilhem G. The normal and the pathological. New York: Zone Books, 1989.
19. Levinas E. Den annens humanisme. Oslo: Aschehoug, 1996.
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21. Løgstrup KE. Den etiske fordring. Oslo: Cappelen, 1999 (1956).
22. Stivers R. Technology as magic. The triumph of the irrational. New York: Continuum, 1999.
23. Christakis NA. The similarity and frequency of proposals to reform US medical education. Constant concerns. JAMA. 1995 Sep 6;274 (9):706-11.

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