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Some conferences produce proceedings, others an inspiration to
labor, which finally leads to a published work. Such has been the
case with regard to this volume. In 1984, the Center for Ethics,
Medicine, and Public Issues held a conference with the title 'When
are Competent Patients Incompetent?' with the support of the Texas
Committee for the Humanities, a state-based program of the National
Endowment for the Humanities. Assistance was provided by both
Baylor College of Medicine and the Institute of Religion. This
conference evoked a con siderable interest in examining further the
moral status of competency determinations in the clinical setting.
This interest is realized in this volume, which now affords us an
opportunity to thank all those individ uals who made the conference
possible, only some of whom are acknowledged in this Preface. In
particular, we wish to express our gratitude to Baruch A. Brody,
Rebecca Dresser, the Honorable Jerome Jones, H. Steven Moffic,
Margery W. Shaw, Eleanor Tinsley, and Albert Van HeIden. The volume
took its shape through the labors of Earl Shelp and Mary Ann
Gardell Cutter, who inspired the further evolution of the papers
presented at the conference and attracted contributions from
individuals who had not attended. Earl Shelp and Mary Ann Gardell
Cutter have produced a volume following extensive reflection and
dialogue; they were ably assisted in the final preparation of the
manu script by Thomas J. Bole III and George Khushf, to whom
special thanks are due."
The encounter between patient and physician may be characterized as
the focus of medicine. As such, the patient-physician relationship,
or more accurately the conduct of patients and physicians, has been
the subject of considerable comment, inquiry, and debate throughout
the centuries. The issues and concerns discussed, apart from those
more specifically related to medical theory and therapy, range from
matters of etiquette to profound questions of philosophical and
moral interest. This discourse is impressive with respect both to
its duration and content. Contemporary scholars and laypeople have
made their contribution to these long-standing discussions. In
addition, they have actively addressed those distinctively modern
issues that have arisen as a result of increased medical knowledge,
improved technology, and changing cultural and moral expectation.
The concept of the patient-physician rela tionship that supposedly
provides a framework for the conduct of patients and physicians
seemingly has taken on a life of its own, inviolable, and subject
to norms particular to it. The essays in this volume elucidate the
nature of the patient-physician relationship, its character, and
moral norms appropriate to it. The purpose of the collection is to
enhance our understanding of that context, which many consider to
be the focus of the entire medical enterprise. The con tributors
have not engaged in apologetics, polemics, homiletics, or em
piricism."
Interest in theories of virtue and the place of virtues in the
moral life con- tinues to grow. Nicolai Hartmann [7], George F.
Thomas [20], G. E. M. Anscombe [1], and G. H. von Wright [21], for
example, called to our atten- tion decades ago that virtue had
become a neglected topic in modem ethics. The challenge implicit in
these sorts of reminders to rediscover the contribu- tion that the
notion of virtue can make to moral reasoning, moral character, and
moral judgment has not gone unattended. Arthur Dyck [3] , P. T.
Geach [5], Josef Pieper (16], David Hamed [6], and, most notably,
Stanley Hauerwas [8-11], in the theological community, have
analyzed or utilized in their work virtue-based theories of
morality. Philosophical probings have come from Lawrance Becker
[2], Philippa Foot [4], Edmund Pincoffs [17], James Wallace [22],
and most notably, Alasdair MacIntyre [12-14]. Draw- ing upon and
revising mainly ancient and medieval sources, these and other
commentators have ignited what appears to be the beginning of a
sustained examination of virtue.
The meaning and application of the principle of beneficence to
issues in health care is rarely clear or certain. Although the
principle is frequently employed to justify a variety of actions
and inactions, very little has been done from a conceptual point of
view to test its relevance to these behaviors or to explore its
relationship to other moral principles that also might be called
upon to guide or justify conduct. Perhaps more than any other, the
principle of benef icence seems particularly appropriate to
contexts of health care in which two or more parties interact from
positions of relative strength and weakness, advantage and need, to
pursue some perceived goal. It is among those moral principles that
Tom L. Beauchamp and James F. Childress selected in their textbook
on bioethics as applicable to biomedicine in general and relevant
to a range of specific issues ( 1], pp. 135-167). More narrowly,
The National Commission for the Protection of Human Subjects of
Biomedical and Behav ioral Research identified beneficence as among
those moral principles that have particular relevance to the
conduct of research involving humans (2). Thus, the principle of
beneficence is seen as pertinent to the routine delivery of health
care, the discovery of new therapies, and the rationale of public
policies related to health care."
Theologians and theologically educated participants in discussions
of bioethics have been placed on the defensive during recent years.
The dominance of religious perspectives and theological voices that
marked the emergence and establishment of "bioethics" in the late
1960s and 1970s has eroded steadily as philosophers, lawyers, and
others have relativized their role and influ ence, at best, or
dismissed it entirely, at worst. The secularization of bioethics,
which has occurred for a variety of reasons, has prompted some
prominent writers to reflect on what has been lost. Daniel
Callahan, for example writes, " . . . whatever the ultimate truth
status of religious perspectives, they have provided a way of
looking at the world and understanding one's own life that has a
fecundity and uniqueness not matched by philosophy, law, or
political theory. Those of us who have lost our reli gious faith
may be glad that we have discovered what we take to be the reality
of things, but we can still recognize that we have also lost
something of great value as well: the faith, vision, insights, and
experience of whole peoples and traditions who, no less than we
unbelievers, struggled to make sense of things. That those goods
are part of a garment we no longer want to wear does not make their
loss anything other than still a loss; and it is not a neglible
one" ([2], p. 2).
We who live in this post-modern late twentieth century culture are
still children of dualism. For a variety of rather complex reasons
we continue to split apart and treat as radical opposites body and
spirit, medicine and religion, sacred and secular, private and
public, love and justice, men and women. Though this is still our
strong tendency, we are beginning to discover both the futility and
the harm of such dualistic splitting. Peoples of many ancient
cultures might smile at the belatedness of our discovery concerning
the commonalities of medicine and religion. A cur sory glance back
at ancient Egypt, Samaria, Babylonia, Persia, Greece, and Rome
would disclose a common thread - the close union of religion and
medicine. Both were centrally concerned with healing, health, and
wholeness. The person was understood as a unity of body, mind, and
spirit. The priest and the physician frequently were combined in
the same individual. One of the important contributions of this
significant volume of essays is the sustained attack upon dualism.
From a variety of vantage points, virtually all of the authors
unmask the varied manifestations of dualism in religion and
medicine, urging a more holistic approach. Since the editor has
provided an excellent summary of each article, I shall not attempt
to comment on specific contributions. Rather, I wish to highlight
three 1 broad themes which I find notable for theological ethics."
Some conferences produce proceedings, others an inspiration to
labor, which finally leads to a published work. Such has been the
case with regard to this volume. In 1984, the Center for Ethics,
Medicine, and Public Issues held a conference with the title 'When
are Competent Patients Incompetent?' with the support of the Texas
Committee for the Humanities, a state-based program of the National
Endowment for the Humanities. Assistance was provided by both
Baylor College of Medicine and the Institute of Religion. This
conference evoked a con siderable interest in examining further the
moral status of competency determinations in the clinical setting.
This interest is realized in this volume, which now affords us an
opportunity to thank all those individ uals who made the conference
possible, only some of whom are acknowledged in this Preface. In
particular, we wish to express our gratitude to Baruch A. Brody,
Rebecca Dresser, the Honorable Jerome Jones, H. Steven Moffic,
Margery W. Shaw, Eleanor Tinsley, and Albert Van HeIden. The volume
took its shape through the labors of Earl Shelp and Mary Ann
Gardell Cutter, who inspired the further evolution of the papers
presented at the conference and attracted contributions from
individuals who had not attended. Earl Shelp and Mary Ann Gardell
Cutter have produced a volume following extensive reflection and
dialogue; they were ably assisted in the final preparation of the
manu script by Thomas J. Bole III and George Khushf, to whom
special thanks are due."
It may be unnecessary to some to publish a text on sexuality in
1986 since the popular press speaks of the sexual revolution as if
it were over and was possibly a mistake. Some people characterize
society as too sexually obsessed, and there is an undercurrent of
desire for a return to a supposedly simpler and happier time when
sex was not openly dis cussed, displayed, taught or even,
presumedly, contemplated. Indeed, we are experiencing something of
a backlash against open sexuality and sexual liberation. For
example, during the '60s and '70s tolerance of homosexual persons
and homosexuality increased. Of late there has been a conservative
backlash against gay-rights laws. Sexual intercourse before
marriage, which had been considered healthy and good, has been, of
late, characterized as promiscuous. In fact, numer ous articles
have appeared about the growing popularity of sexual abstinence.
There is a renewed vigor in the fight against sex education in the
schools, and an 'anti-pornography' battle being waged by those on
the right and those on the left who organize under the guise of
such worthy goals as deterring child abuse and rape, but who are
basically uncomfortable with diverse expressions of sexuality. One
would hope that such trends, and the ignorance about sex and
sexuality that they reflect, would not touch medical professionals.
That Dr."
It may be unnecessary to some to publish a text on sexuality in
1986 since the popular press speaks of the sexual revolution as if
it were over and was possibly a mistake. Some people characterize
society as too sexually obsessed, and there is an undercurrent of
desire for a return to a supposedly simpler and happier time when
sex was not openly dis cussed, displayed, taught or even,
presumedly, contemplated. Indeed, we are experiencing something of
a backlash against open sexuality and sexual liberation. For
example, during the '60s and '70s tolerance of homosexual persons
and homosexuality increased. Of late there has been a conservative
backlash against gay-rights laws. Sexual intercourse before
marriage, which had been considered healthy and good, has been, of
late, characterized as promiscuous. In fact, numer ous articles
have appeared about the growing popularity of sexual abstinence.
There is a renewed vigor in the fight against sex education in the
schools, and an 'anti-pornography' battle being waged by those on
the right and those on the left who organize under the guise of
such worthy goals as deterring child abuse and rape, but who are
basically uncomfortable with diverse expressions of sexuality. One
would hope that such trends, and the ignorance about sex and
sexuality that they reflect, would not touch medical professionals.
That Dr."
When confronted by the concerns of human sexual function or dys
function, American medicine finds itself well impaled on the horns
of a dilemma. Currently it is acceptable medical practice to treat
sexual dysfunctions, disorders, or dissatisfactions that arise from
psy chogenic etiologies, endocrine imbalances, neurologic defects
or are side effects of necessary medication regimes. In addition,
implanta tion of penile prostheses in cases of organic impotence is
an increas ingly popular surgical procedure. These clinical
approaches to sexual inadequacies, accepted by medicine since 1970,
represent one horn of the dilemma. The opposite horn pictures the
medical profession firmly backed into a corner by cultural
influences. For example, when hospital admissions occur, a
significant portion of the routine medical history is the section
on system review. A few questions are asked about the
cardio-respiratory, the genito-urinary, and the gastro-intestinal
sys tems. But in a preponderance of hospitals no questions are
permitted or, if raised, answers are not recorded about human
sexual functioning. Physicians tend to forget that they are victims
of cultural imposition first and of professional training a distant
second."
When confronted by the concerns of human sexual function or dys
function, American medicine finds itself well impaled on the horns
of a dilemma. Currently it is acceptable medical practice to treat
sexual dysfunctions, disorders, or dissatisfactions that arise from
psy chogenic etiologies, endocrine imbalances, neurologic defects
or are side effects of necessary medication regimes. In addition,
implanta tion of penile prostheses in cases of organic impotence is
an increas ingly popular surgical procedure. These clinical
approaches to sexual inadequacies, accepted by medicine since 1970,
represent one horn of the dilemma. The opposite horn pictures the
medical profession firmly backed into a corner by cultural
influences. For example, when hospital admissions occur, a
significant portion of the routine medical history is the section
on system review. A few questions are asked about the
cardio-respiratory, the genito-urinary, and the gastro-intestinal
sys tems. But in a preponderance of hospitals no questions are
permitted or, if raised, answers are not recorded about human
sexual functioning. Physicians tend to forget that they are victims
of cultural imposition first and of professional training a distant
second."
We who live in this post-modern late twentieth century culture are
still children of dualism. For a variety of rather complex reasons
we continue to split apart and treat as radical opposites body and
spirit, medicine and religion, sacred and secular, private and
public, love and justice, men and women. Though this is still our
strong tendency, we are beginning to discover both the futility and
the harm of such dualistic splitting. Peoples of many ancient
cultures might smile at the belatedness of our discovery concerning
the commonalities of medicine and religion. A cur sory glance back
at ancient Egypt, Samaria, Babylonia, Persia, Greece, and Rome
would disclose a common thread - the close union of religion and
medicine. Both were centrally concerned with healing, health, and
wholeness. The person was understood as a unity of body, mind, and
spirit. The priest and the physician frequently were combined in
the same individual. One of the important contributions of this
significant volume of essays is the sustained attack upon dualism.
From a variety of vantage points, virtually all of the authors
unmask the varied manifestations of dualism in religion and
medicine, urging a more holistic approach. Since the editor has
provided an excellent summary of each article, I shall not attempt
to comment on specific contributions. Rather, I wish to highlight
three 1 broad themes which I find notable for theological ethics."
Interest in theories of virtue and the place of virtues in the
moral life con- tinues to grow. Nicolai Hartmann [7], George F.
Thomas [20], G. E. M. Anscombe [1], and G. H. von Wright [21], for
example, called to our atten- tion decades ago that virtue had
become a neglected topic in modem ethics. The challenge implicit in
these sorts of reminders to rediscover the contribu- tion that the
notion of virtue can make to moral reasoning, moral character, and
moral judgment has not gone unattended. Arthur Dyck [3] , P. T.
Geach [5], Josef Pieper (16], David Hamed [6], and, most notably,
Stanley Hauerwas [8-11], in the theological community, have
analyzed or utilized in their work virtue-based theories of
morality. Philosophical probings have come from Lawrance Becker
[2], Philippa Foot [4], Edmund Pincoffs [17], James Wallace [22],
and most notably, Alasdair MacIntyre [12-14]. Draw- ing upon and
revising mainly ancient and medieval sources, these and other
commentators have ignited what appears to be the beginning of a
sustained examination of virtue.
The encounter between patient and physician may be characterized as
the focus of medicine. As such, the patient-physician relationship,
or more accurately the conduct of patients and physicians, has been
the subject of considerable comment, inquiry, and debate throughout
the centuries. The issues and concerns discussed, apart from those
more specifically related to medical theory and therapy, range from
matters of etiquette to profound questions of philosophical and
moral interest. This discourse is impressive with respect both to
its duration and content. Contemporary scholars and laypeople have
made their contribution to these long-standing discussions. In
addition, they have actively addressed those distinctively modern
issues that have arisen as a result of increased medical knowledge,
improved technology, and changing cultural and moral expectation.
The concept of the patient-physician rela tionship that supposedly
provides a framework for the conduct of patients and physicians
seemingly has taken on a life of its own, inviolable, and subject
to norms particular to it. The essays in this volume elucidate the
nature of the patient-physician relationship, its character, and
moral norms appropriate to it. The purpose of the collection is to
enhance our understanding of that context, which many consider to
be the focus of the entire medical enterprise. The con tributors
have not engaged in apologetics, polemics, homiletics, or em
piricism."
The meaning and application of the principle of beneficence to
issues in health care is rarely clear or certain. Although the
principle is frequently employed to justify a variety of actions
and inactions, very little has been done from a conceptual point of
view to test its relevance to these behaviors or to explore its
relationship to other moral principles that also might be called
upon to guide or justify conduct. Perhaps more than any other, the
principle of benef icence seems particularly appropriate to
contexts of health care in which two or more parties interact from
positions of relative strength and weakness, advantage and need, to
pursue some perceived goal. It is among those moral principles that
Tom L. Beauchamp and James F. Childress selected in their textbook
on bioethics as applicable to biomedicine in general and relevant
to a range of specific issues ( 1], pp. 135-167). More narrowly,
The National Commission for the Protection of Human Subjects of
Biomedical and Behav ioral Research identified beneficence as among
those moral principles that have particular relevance to the
conduct of research involving humans (2). Thus, the principle of
beneficence is seen as pertinent to the routine delivery of health
care, the discovery of new therapies, and the rationale of public
policies related to health care."
Bioethics is a discipline still not fully explored in spite of its
rather remark able expansion and sophistication during the past two
decades. The prolifer ation of courses in bioethics at educational
institutions of every description gives testimony to an intense
academic interest in its concerns. The media have catapulted the
dilemmas of bioethics out of the laboratory and library into public
view arid discussion with a steady report of the so-called 'mira
cles of modern medicine' and the moral perplexities which
frequently accom pany them. The published work of philosophers,
theologians, lawyers and others represents a substantial and
growing body of literature which explores relevant concepts and
issues. Commitments have been made by existing in stitutions, and
new institutions have been chartered to further the discussion of
the strategic moral concerns that attend recent scientific and
medical progress. This volume focuses attention on one of the
numerous topics of interest within bioethics. Specifically, an
examination is made of the implications of the principle of justice
for health care. Apart from four essays in Ethics and Health Policy
edited by Robert Veatch and Roy Branson 4] the dis cussion of
justice and health care has been occasional, almost non-existent,
and scattered. The paucity of literature in this area is
regrettable but perhaps understandable. On the one hand, Joseph
Fletcher, one of the contemporary pioneers in bioethics, can hold
that "distributive justice is the core or key question for
biomedical ethics" ( 1], p. 102)."
Bioethics is a discipline still not fully explored in spite of its
rather remark able expansion and sophistication during the past two
decades. The prolifer ation of courses in bioethics at educational
institutions of every description gives testimony to an intense
academic interest in its concerns. The media have catapulted the
dilemmas of bioethics out of the laboratory and library into public
view arid discussion with a steady report of the so-called 'mira
cles of modern medicine' and the moral perplexities which
frequently accom pany them. The published work of philosophers,
theologians, lawyers and others represents a substantial and
growing body of literature which explores relevant concepts and
issues. Commitments have been made by existing in stitutions, and
new institutions have been chartered to further the discussion of
the strategic moral concerns that attend recent scientific and
medical progress. This volume focuses attention on one of the
numerous topics of interest within bioethics. Specifically, an
examination is made of the implications of the principle of justice
for health care. Apart from four essays in Ethics and Health Policy
edited by Robert Veatch and Roy Branson 4] the dis cussion of
justice and health care has been occasional, almost non-existent,
and scattered. The paucity of literature in this area is
regrettable but perhaps understandable. On the one hand, Joseph
Fletcher, one of the contemporary pioneers in bioethics, can hold
that "distributive justice is the core or key question for
biomedical ethics" ( 1], p. 102)."
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