A dialectical interpretation of the history of Western medicine : perspectives, problems and possibilities

Rossouw, Theresa Marie (2003-03)

Thesis (MPhil)--University of Stellenbosch, 2003.

Thesis

ENGLISH ABSTRACT: The health of the medical profession hangs in the balance. Scepticism, mistrust and legal restraints have entered its hallowed corridors and are threatening its integrity and independence. There are myriad seemingly intractable moral dilemmas that doctors, ethicists and judges are trying to resolve with the aid of available principles and rules of ethical discourse; yet, the answers remain elusive. Hegel, the eighteenth century philosopher, postulated that perplexity only exists because we do not look at the world correctly: because we tend to think in an oppositional way, we abstract from the complex interrelation of things. He therefore suggested that one should step back and think reflectively about the problem and seek the one-sided assumptions that led to the impasse. My proposition is that at the heart of many of the current medical dilemmas lies the opposition between paternalism and autonomy. These two fundamental concepts arose out of two different traditions, and now, because they have been abstracted from the contexts and histories that inform them, seem to be diametrically opposed. Paternalism arose out of the ethics of competence that originated in ancient Greece. The art of medicine was still in its infancy and physicians had to prove their ability and benevolence to a mistrustful public. Demonstration of competence became a necessary component of any successful practice. As the power of medicine grew with the scientific and technological advances of the Enlightenment, professionals' authority and competence were reinforced and systematically fostered a paternalistic attitude at the expense of adequate protection of the individual. In response to the power differential found in the political and social arena, individual human rights were promulgated in the eighteenth century. In the medical sphere, the culture of rights was translated into, among others, the fundamental right to autonomy. Patients now have the right to decide on interventions and treatment in accordance with their own conception of a good life. Paternalism thus developed out of a societal system that embraced the virtues and communal responsibility within the bounds of the polis of antiquity; autonomy arose out of the designs of the Enlightenment where the individual was hailed supreme. Remnants of both traditions are evident in contemporary medicine, but they have been abstracted from their original purpose and meaning, leading to perplexity and antagonism. Following the Hegelian method of dialectic, I postulate a thesis of paternalism, and in response to this, an antithesis of autonomy. I attempt to show that an intransigent insistence on one side or the other will only serve to strengthen the paradox and fail to lead to an acceptable solution. I aim to develop a synthesis where both concepts are embraced with the help ofa better understanding of human nature and the inevitable limits of human knowledge. Influenced by the work of the psychoanalyst Carl Jung, I firstly argue for the existence of a biological human need for compassion and thus the importance of virtue ethics, which embraces this need. Secondly, focusing on the ethics of futurity developed by Hans Jonas, I delineate the altered nature of human action and the derivative need for an ethics of responsibility. I propose possibilities for the future based on the ideas of compassion, virtue and responsibility and argue that they can only be reconciled in a pluralistic ethic.

AFRIKAANSE OPSOMMING: Die mediese professie het'n dokter nodig. Een wat kan sin maak van die wantroue en vyandigheid wat te bespeur is in die pasient-dokter verhouding en wat toepaslike terapie kan voorskryf Al die pogings tot behandeling deur middel van reëls, regulasies en etiese kodes het tot dusver misluk en het vele skynbaar-onoplosbare morele dilemmas agtergelaat. Die Duitse filosoof, Hegel, het in die agtiende eeu aangevoer dat verwarring onstaan bloot omdat ons die wêreld op die verkeerde wyse beskou: die mens is geneig tot opposisionele denke en neem daarom nie die komplekse onderlinge verbintenisse van die onderskeie elemente in ag nie. Hegel het dus voorgestel dat wanneer ons met sulke hardnekkige situasies gekonfronteer word, ons 'n tree terug neem en die situasie reflektiewelik ondersoek vir eensydige veronderstellings. My hipotese is dat baie van die etiese dilemmas wat op die oomblik in medisyne voorkom, voortvloei uit die opposisie tussen paternalisme en outonomitiet. Hierdie twee fundamentele beginsels het uit twee verskillende tradisies ontstaan en nou, omdat hulle nie meer in hulle oorspronklike konteks voorkom nie, vertoon hulle skynbaar teenstellend. Paternalisme het onstaan vanuit die etiek van bevoegdheid wat teruggevoer kan word na die tyd van Hippocrates. Medisyne was 'n nuwe professie wat nog sy eerbaarheid en welwillendheid aan 'n wantrouige publiek moes bewys. Bevoegdheid was dus 'n essensiële komponent van enige suksesvolle praktyk. Indrukwekkende vooruitgang in die dissiplines van wetenskap en tegnologie sedert die agtiende eeu het dokters se gesag en bevoegdheid bevorder en stelselmatig 'n paternalistiese houding gekweek ten koste van toepaslike beskerming van die individu. In respons tot die magsverskil in die politieke en sosiale sfeer het 'n beweging in hierdie tyd ontstaan om universêle mensseregte te bewerkstellig. In medisyne het hierdie regsbeweging gekulmineer in, onder andere, die fundamentele reg tot self-beskikking - in ander woorde, outonomiteit. Die pasient is dus nou geregtig daarop om selfte besluit oor ingrepe en behandeling op grond van sylhaar konsep van 'n goeie en sinvolle lewe. Paternalisme het dus ontstaan uit 'n samelewing waar die deugte en gemeenskapsverantwoordelikhede integraal was tot die funksionering van die polis; outonomie aan die ander kant, het ontstaan uit die idees van Die Verligting waar die individu as belangriker as die gemeenskap geag is. Volgens die Hegeliaanse dialektiese metode, postuleer ek dus 'n tesis van paternalisme en in respons daartoe, 'n antitese van outonomiteit. Ek voer aan dat 'n eiewillige aandrang op een of die ander die dilemma net sal verdiep. Ek poog dus om 'n sintese te ontwikkel wat albei konsepte inkorporeer met behulp van 'n analise van die aard van die mens en die noodwendige beperkinge van sy kennis. Geskool op die werk van die psigoanalis Carl Jung, bespreek ek die mens se biologiese behoefte aan medelye en stel dus die saak vir die belang van 'n etiek van deugte wat hierdie behoefte onderskraag. Tweedens, beinvloed deur die etiek van die toekoms, soos beskryf deur Hans Jonas, ontwikkel ek die idee van die gewysigde skaal van menslike dade en gevolglik die noodsaklikheid van 'n etiek van verantwoordelikheid. Ek postuleer dus 'n benadering wat wentel om die konsepte van medelye, deug en verantwoordelikheid wat slegs in die vorm van 'n pluralistiese etiek tot uiting kan kom.

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