Philosophy of medicine

Medicine as a science is “a specific unity of cognitive and value forms of reflection and transformative activity”. It accumulates knowledge about health and disease , treatment and prevention, the norm and pathology , and the impact on people of natural, social and spiritual factors. ^[4] Medicine has all the attributes of a specific field of knowledge. In addition to its own subject, it has its own methods of study, and the scope of practical application, namely: the prevention and treatment of diseases, as well as health promotion. “Through the subject of research, medicine is associated with social disciplines. Such branches of medicine as occupational health, nutrition, housing and recreation are closely connected with a number of social disciplines. ” Since medicine studies biological processes in the human body, it is close to such sciences as biophysics , biochemistry , genetics , physiology , embryology , anthropology , microbiology , etc. ^[5]

Since the second half of the 19th century, medicine in its theoretical settings was considered as part of biology, therefore the most common views in the field of philosophical issues of modern medicine come from the principles of a theoretical and methodological community of biology and medicine. However, the basic concepts of medicine - health, norm, disease, etiology , pathogenesis , nosological unit - although they intersect or overlap with a number of concepts of biology, in terms of their content they are not reduced to and are not absorbed by them. The undoubted relationship of medicine with other sciences is actually determined by the fact that a person as an object of medicine is the highest unity. ^[6]

Illness and Health

Modern medicine considers the disease as the result of a "dialectically contradictory interaction" of the body and the environment , the internal characteristics of the body and the external influences of the environment. External influences in most cases are not able to give rise to a disease in the absence of internal favorable conditions - the “predisposition” of the body to the disease. By virtue of this, the disease is a consequence of the interaction of the internal substrate of the body with external etiological factors. However, some external influences in large doses (radiation, intoxication, etc.) can cause one or another disease even in the absence of an “predisposition” of the body to the disease. The relationship of external and internal in pathology is a problem of the interaction of environmental factors with the individual state of the body. ^[7] "Every disease is a complex set of pathological processes, but not every pathological process is already a disease." The pathological process is only part of the disease, it is a local manifestation of the disease: local changes in the tissues and organs that together give the disease. A correct understanding of the relationship between the concepts of “pathological process”, “disease” and “health” is of great importance not only for clinical, but also for socially-preventive medicine. ^[eight]

Numerous transitional and intermediate stages are often observed between health conditions and illnesses (doctors say: “I am no longer healthy, but not sick yet”). This condition is called subclinical. The presence of transitional forms from physiological to pathological, as well as from pathological to physiological, is a "deeply dialectical process." Upon reaching the threshold level, one opposite goes into another. This transition can occur in a fleeting, one-time or protracted form. The use of concepts such as micro- and macro-jumps helps to correctly understand the relationship of physiological and pathological, disease and health. “The transition from a normal, physiological state to a painful, pathological one is a transition from one qualitative state to another, or a macro jump. But within the framework of this macro jump, there can be several small qualitative transformations, or micro jumps. ” ^[9]

The structure of medical reality includes not only illness, but also health ^{[K 3]} , so theoretical medicine should act just like a theory of health and disease ^[6] . In addition, “the philosophical attitude to the phenomenon of health, which we already find in the most ancient concepts of world understanding,” and the consideration of these philosophical concepts can give modern researchers an example of the embedded concept of health in the subject of philosophy as a whole ^{[11] [K 4] [K 5]} .

I. V. Davydovsky wrote: “A person does not notice his health until it is broken; then he is interested in the cause of this violation, remaining still in the dark about what health is. It is only obvious that the latter is not reducible to the absence of the disease. ” ^{[14] [K 6]}

Health is the body’s ability to adapt, adapt to changes in nature or society, as well as the individual’s ability to maintain normal health, a mood for self-development, and self-improvement. ^{[16] [K 7]} Human health is determined by the harmonious state of his life, due to the combined action of both biological and social determinants, and in addition to its objective, or material, content, it also has an assessment-epistemological and regulatory-installation component. “This is a comprehensive, high-quality state of the body and human personality. It is indivisible, single, synthetic and personal. ” Along with bodily and mental health, it is important to keep in mind spiritual health (meaning “close to moral health”), which personifies “a full-blooded life filled with the ideals of humanism and mutual assistance, riddled with socially optimistic aspirations”. ^{[18] [K 8]}

Integrity Principle

One of the most important principles that make up the theoretical foundation of medicine is the principle of integrity . Only with this principle in mind can we understand the complexity and identity of the interaction of physical, chemical and biological processes that occur under conditions of both normal and pathological functioning of the human body at the biomolecular, cellular, tissue, organ, systemic and organismic levels. Without taking this principle into account, it is impossible to understand the complex relationship and interdependence of local and general, local and generalized in the occurrence and development of diseases. ^[20]

In the philosophy of medicine, the debate around the provisions of reductionism and holism leads, for example, to the question of the possibility of "reducing the disease to its constituent components." In a broad sense, reductionism is a philosophical principle according to which complex objects can be fully described using characteristics that describe their components. In other words, the properties of the whole are simply the sum of the properties of its constituent parts. Such reductionism, in contrast to epistemological reductionism, is often called metaphysical, or ontological, reductionism. Epistemological reductionism, however, turns to the study of complex objects and phenomena and related factors using a technique that isolates individual components for subsequent analysis. Epistemological reductionism explains complex objects and phenomena and related factors only in terms of their individual components. Holism is a philosophical principle that proceeds from the qualitative originality and priority of the whole in relation to its parts and proclaims that the properties of the whole are not reducible to the properties of its components. ^[21] In ontology, holism is based on the principle: the whole is always more than the simple sum of its parts. Accordingly, its epistemological principle states: the knowledge of the whole must precede the knowledge of its parts. ^[22] The development of life sciences and clinical practice increasingly shows the leading role of the general, integral state of the body. ^{[23] [K 9]}

Medical Diagnostics

In accordance with the main provisions of the theory of cognition , medical diagnostics should be considered as a specific form of cognition, in which at the same time its general laws are manifested. ^{[24] [25]}

In general theoretical terms, it is possible to consider diagnostics as a “purely recognizing and recognizing”, algorithmic (performed according to previously known rules) process. At the same time, diagnostics is presented as a search within the framework of a well-known, ready-made, formed and, as a rule, generally recognized and already used by doctors clinical knowledge. Proponents of this approach, in essence, understand the diagnosis in strict accordance with the literal meaning of the term: diagnosis is recognition. Recognition comes down to recognizing an already known one that does not contain any new knowledge about the object. ^[26] However, when making a diagnosis, the doctor, based on the known, at the same time learns the unknown, specifically associated with a particular patient. Any disease is a complex and contradictory unity of the general, repetitive and specific, unique, as well as known and unknown. “The diagnosis can be seen as summing up the individual under the general by recognizing this common in a separate.” ^[27] A. M. Anokhin wrote:

“In medicine, the clinician encounters at every step such a problem as the external manifestations of the disease, the patient’s complaints and the available data of objective examination, the correct interpretation of which is one of the aspects of understanding the phenomenon and essence . Objective symptomatology does not always fit into the physician’s subjective idea of ​​the disease, individual symptoms seem random, atypical. Also, the identity between the data of various methods of instrumental examination is not always found. All this requires the doctor not only the ability to distinguish from the variety of available data the most important, the most significant in the symptoms, but also the ability to take into account a single, random in the clinical picture of the disease. " ^[28]

Doctor's Code of

Modern medicine is based on the philosophical and moral teachings of Hippocrates , Galen , Cicero , Kant about moral duty and has firmly merged with the demand for selfless service to people. Such philosophical and moral requirements have been substantiated in deontology as the theoretical basis of professional medical ethics. ^[29]

In 1979, American philosophers T. Bouchamp and D. Childres in the book "Principles of Biomedical Ethics" formulated four postulates of modern medical ethics. ^{[30] [31]} Their proposed scheme is currently the most widely recognized. ^{[3] [K 10]} In addition to the four principles, the scheme contains a number of rules based on them. The rules, in turn, serve to provide a moral basis for decisions and actions in specific situations. Briefly, the principles are as follows:

1. "Do no harm".
2. “Do good.”
3. “Respect patient autonomy.”
4. "Be fair." ^[3]

The first principle, dating back to Hippocrates and the oldest in medical ethics, is widely known in its Latin formulation: “primum non nocere”. It requires minimizing the damage to the patient during medical intervention. ^{[32] [33]}

The second principle emphasizes the duty of the doctor to make effective efforts to improve the patient's condition. ^{[34] [3]}

The third principle proclaims the autonomy (independence) of the patient. ^[35] Respect for patient autonomy means that his choice, no matter how at odds with the position of the doctor, should determine the actions of the latter. One of the sources of this principle is the categorical imperative of Kant , according to which a person should always be considered as a goal, and not as a means. This principle plays an important role in situations when it comes to a serious and, especially, an incurable disease. ^[36]

The latter principle emphasizes the need for the provision of medical care, both fair and equal treatment of patients, and an equitable distribution of resources, which are usually limited. ^[37] In specific cases, claims arising from these principles may conflict with each other. For example, the principle of respect requires reliable informing the patient about the diagnosis and prognosis of the disease, even if this prognosis is extremely unfavorable. But telling the patient such information can cause severe stress, exacerbating the disease, which would violate the “do no harm” principle. In such cases, one has to violate one of the principles, that is, they are not absolute, they have to be derogated from in specific situations. ^[3]

Doctor-Patient Relationship

Traditionally, the main model of the doctor-patient relationship has been paternalism , expressed by the aphorism: “the doctor knows best” ^[38] . The “ paternalistic model ” is characterized by the fact that here the attitude of the doctor to the patient resembles the paternal attitude of the parent to the child or the priest to the parishioner. In many cases, it remains the most appropriate and expected by the patient. However, the drawback of such a model of relations is that it infringes on the rights of the patient as an autonomous person who seeks to independently and freely make vital decisions. ^[39]

The modern patient often has a high level of culture and is sufficiently informed not only in matters of science or technology, but also in medicine. He can critically evaluate and adequately understand some of the features of medical care and act as an interested and useful partner in discussing a number of issues of examination, treatment and prevention. ^[40] In this case, a “ collegial model ” of relations between a doctor and a patient is appropriate, which provides great opportunities for realizing the values ​​of a free person. In the framework of this model, the patient appears as an equal party in his interaction with the doctor. In order to play this role, the patient must receive from the doctor a sufficient amount of “truthful information” about his state of health, treatment options and the prognosis of the development of the disease. Despite all the advantages of such a model, its use is limited. But it can find application in cases of long-term chronic diseases, when the "competence" of the patient in the relevant field of medical knowledge may well approach the volume of professional knowledge of the doctor. ^[39]

The “ contract model ” of the relationship between the doctor and the patient is the most perfect in terms of protecting the moral values ​​of an autonomous person. Within the framework of this model, the principles of preserving freedom, dignity, truthfulness, fidelity to obligations and justice are given priority. Here the doctor is regarded as a provider of medical services, and the patient as a consumer of these services. ^{[41] [42]}

The “ scientific model ” is the most morally flawed. In this model, the solution to the “scientific” problem is of decisive importance: with the help of medical equipment and devices maintained by relevant specialists, to diagnose and eliminate the disease as a “malfunction” or “breakdown” in the patient’s body, considered as a kind of “impersonal mechanism”. Here, the patient for the doctor is only an object described by an established set of parameters, and therefore the attitude towards him is devoid of any emotions, in turn, the patient’s role is absolutely passive. ^{[43] The} prevalence of such a model is stimulated by the development of the technical aspect of medicine and the growing specialization of medical services. To some extent, its existence is becoming inevitable today, since in many cases the patient is dealing not only with the attending physician, but with a whole team of medical workers, most of whom perform rather narrow technical functions. ^{[44] [45] [K 11] [K 12]}

The sphere of interests of the philosophy of medicine also extends to alternative medicine as a field of practice that is not related to medical science, but related to human health. The attitude of professional doctors and philosophers towards alternative medicine is usually negative. ^{[48] [49] [50] [51] [52]} However, a paradoxical fact was noted: if the patient, instead of going to a professional doctor, prefers to consult a friend of a nurse, pharmacist or physiotherapist, and in this way to cope with his illness, then these people who seem to be related to official medicine, in fact, act as healers. ^[53]

The point of view was expressed that one of the main reasons for maintaining the quackery and other forms of “unscientific healing” is the worldview immaturity of part of the population, the preservation of religious prejudices ^{[K 13]} and superstitions. Believers and superstitious people most often turn to various kinds of healers and “wizards”: the “healing” creed of religion has largely remained unchanged in our time. ^[55] The main reason for avoiding the services of “homegrown doctors” is that at present there is an opportunity for the early diagnosis of many diseases and developed effective methods for their treatment. ^[56]

A purely biological view of the person and the disease determines the appropriate approach to treatment methods. It is assumed that “breakdowns in the biological system” can be eliminated only in a materialized way — medicinal, surgical, etc. Using drugs, some doctors do not always take into account that they have a healing effect not only in a chemical, but also in a psychotherapeutic way ^[57] . So the “psychological field” in a person that is not occupied, not used by doctors, is successfully exploited by representatives of alternative medicine. ^[58]

Departure from a systemic, holistic and personal understanding of the patient by some doctors, “one-sided orientation only on his somatics, some cult of laboratory and instrumental research methods”, the use of not always appropriate diagnostic and therapeutic technologies, create favorable conditions for the spread and prosperity of “occult medicine”, healers, outwardly oriented to a personal approach to the patient, to his inner psycho-emotional world. Overcoming one-sided biologized orientation among some doctors, eliminating the elements of somatocentrism is one of the conditions necessary to strengthen the position of medicine in the fight against various manifestations of “anti-medicine”. ^{[58] [K 14]}

It has been suggested that in the future, an increasing number of people will become "alternative doctors" for themselves, abandoning the role of the object of healing. Having access to medical information, including methods of treatment, they will take responsibility for their health themselves, they will decide on the necessary measures and carry out (at least in cases where surgical intervention is not required) “appropriate medical actions”. ^[60]

in Russian

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in other languages

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• Edmund D. Pellegrino Center for Clinical Bioethics Website.