Table Of ContentInternational Library of Ethics, Law, and the New Medicine 60
Richard M. Zaner
A Critical
Examination of Ethics
in Health Care and
Biomedical Research
Voices and Visions
International Library of Ethics, Law,
and the New Medicine
Volume 60
Series editor
David N. Weisstub, Montreal, Canada
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Richard M. Zaner
A Critical Examination
of Ethics in Health Care
and Biomedical Research
Voices and Visions
RichardM.Zaner
AnnGeddesStahlmanProfessorEmeritus
ofMedicalEthicsandPhilosophyofMedicine
DepartmentofMedicine,Primary
VanderbiltUniversity
Nashville,TN,USA
ISSN1567-8008 ISSN2351-955X (electronic)
InternationalLibraryofEthics,Law,andtheNewMedicine
ISBN978-3-319-18331-2 ISBN978-3-319-18332-9 (eBook)
DOI10.1007/978-3-319-18332-9
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Preface
Ishouldnoteattheoutsetthatanearlyversionofthisbookwaspublishedseveral
yearsagoinMandarinChinese.1Thereasonforthisisthatagoodfriend,Chen-yun
Tsai,ProfessorofPhilosophyattheNationalChengchiUniversityinTaipei,asked
meifIwouldwriteabookthatwouldlayouttheprincipaltopicsandthemesofmy
severaldecadesofworkinmedicalhumanitiesandclinicalethics.Sinceonlytwo
ofmybookshadatthattimebeenpublishedinTaiwan,bothincludingonlyclinical
ethicsnarratives,hewasconcernedthatpersonsinthatstill-developingfieldthere
shouldknow ofmyphilosophicalviews onthoseandotherthemes.Hisinvitation
cameattheconclusionofaseven-lecturetourofuniversitiesinTaiwanin2004,and
it was with the many responses to and discussion of those lectures in mind that I
agreedwithProfessorTsai’ssuggestion,butonlyafterhehadagreedtoundertake
thebook’stranslationintocomplexChineseMandarin,usedamongprofessionalsin
collegesanduniversities.Workingwithhimandtheeditorofhisuniversity’spress,
Chu-po Chen, the book was in due course completed and the translation done—
although,Imustadd,giventhecomplexitiesofthelanguage andthoseoftransla-
tion,especiallyfrommyownnotalwaysStandardEnglishusages,thistookseveral
yearstocomplete.
WhenIdecidedtotryandpublishthebookinEnglish,however,itwasclearto
me that it had to be thoroughly rewritten. In the years that had passed since I
undertookthatproject,rereadingthatinitialtextbroughthometomethatmuchofit
needed rethinking and some restructuring. I am hopeful that the result, presented
here,willbefoundtobehelpfultoreaders.
Ihadalreadycometoappreciate,asInotedinoneofmyearlybooks,thattheact
ofwritingandpublishingabookseemsaudacious.That’strue,initsway;buthow
1PublishedasVoicesandVisions:ClinicalListening,NarrativeWriting,tr.byCheng-yunTsai,
National Chengchi University Press (NCCU), Taipei, Taiwan, 2009 (published in Mandarin
Chineseonly).
v
vi Preface
muchmoreaudacious,then,iswritingthisbook,onewhichtakesupthemajorparts
ofalifetimeofwritingandattemptstoputitalltogetherinasingleplace?Indeed.
Still, as thingshaveworked out, there is much thatis quite newhere. Morethan
that,thisistheonlyplacewheremanyoftheseideascanbefoundconnectedtogether,
wheretheyareabletoknockupagainstaswellascomplementeachother.So,Idonot
hesitateatallatthistimeinmylifetotryandsharetheseideaswithothers,togive
themakindofpublicpresence,availabletooneandall.Iamthushappytoengagethe
challengeofyetanotherbook,exploringthemesthathavelongbeenaclosepartofmy
lifeasaphilosophermakingmywayintheworldofclinicalandresearchmedicine.
Imustsay,too,thatseveralofmycolleagueshaveplayedanimportantpartinmy
efforts to articulate my vision and find my voice. Principal among these are Stuart
G.Finder2andMarkJ.Bliton,3bothofthemcolleaguesformanyyearsatwhatIfirst
set up as the Center for Clinical and Research Ethics at Vanderbilt University
Medical Center. The three of us worked very closely together at both Vanderbilt
and in the clinical ethics program where we were asked to set up at Nashville’s
St.ThomasHospital(1991–1994).Dailyconversations,jointteaching,writing,and
publicationwentonformorethanadecade,oneresultofwhichwashelpingmeto
articulateandclarifytheconceptionofclinicalethicsthatfindsexpressionhere.From
what I know, too, this conception has been carried over to a good many other
institutions—bythem,andbyanumberofoutstandinggraduatestudentswhoworked
andstudiedwithusattheCenterandhavesubsequentlybecomewellknownintheir
own right. Prominent among these are Tarris “Terry” Rosell, DMin, PhD, the
Rosemary Flanigan Chair at the Center for Practical Bioethics4; DeniseDudzinski,
PhD, Associate Professor and Director of Graduate Studies in the Department of
BioethicsandHumanitiesattheUniversityofWashington5;andPaulFord,Director
andAssociateProfessorofBioethics,theClevelandClinic.6
Iamgratefultoallofthemandformuchofwhatwetogetherachievedatwhen
we were together.7 Clearly, I learned much from each of them, then and later
throughtheirwritings.
2Director,CenterforHealthcareEthics,Cedars-SinaiMedicalCenter,LosAngeles,CA.
3After serving as Associate Professor in the program at Vanderbilt, Mark moved to Kaiser
PermanenteinLosAngeles,workingasheadofEthicsandAppliedPhilosophy.
4Terry is also Professor at the Central Baptist Theological Seminary in Kansas City; Clinical
AssociateProfessor,attheSchoolofMedicine,UniversityofKansasMedicalCenter;andClinical
AssociateProfessor(Ethics)attheUniversityofKansasMedicalCenter.
5AssociateProfessorinBioethicsattheUniversityofWashington,sheisalsoAdjunctAssociate
ProfessorintheSchoolofLaw,AdjunctAssociateProfessorinFamilyMedicine,andAffiliate
FacultyintheTreumanKatzCenterforPediatricBioethics.SheisChiefoftheEthicsConsultation
ServiceandAssociateChairoftheEthicsAdvisoryCommitteeattheUniversityofWashington
MedicalCenter.
6HeisalsoDirectoroftheNeuroethicsProgram.
7TherewereofcoursemanyotherswhoworkedandstudiedwithusintheCenterandinvarious
academicprogramsatVanderbilt,especiallyasFinder,BlitonandIwereactiveinvariousgraduate
programs.
Preface vii
Iwantalsotobesuretomentionmylovelywife.Ithasbeenmydeepestjoyto
have been with her for nearly 59 years and not only for her warmth as my close
companion. For during all the time I’ve spent in teaching and writing, she has
becomeanimpressiveandimportantartist,workinginmanyfields:sculpture(stone
andsteel),drawingandpainting,softsculpture,fashiondesign,andmorerecently
becomingknownandpublishedasanimportantpoetandfictionwriter.Ihavebeen
profoundlyinspiredbyherandhermany,manyworks.Ihavebeenmostfortunate
indeedtohavebeenwithherandtheothersforsomanyyears.
Nashville,TN,USA RichardM.Zaner
Contents
1 Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
2 ThemesandSchemes:APrelude. . . . . . . . . . . . . . . . . . . . . . . . . . . 13
2.1 PreliminaryReflectionsonThemes. . . . . . . . . . . . . . . . . . . . . . 13
2.2 IssuesRemainComplicated,OftenOpaque. . . . . . . . . . . . . . . . 17
2.3 ABitofHistory. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
2.4 ThePhilosopher’sResponsetothePhysician’sAppeal. . . . . . . . 22
2.5 HowDidPhysiciansRespondtoThisResponse?. . . . . . . . . . . . 25
2.6 BriefOverviewofMedicine. . . . . . . . . . . . . . . . . . . . . . . . . . . 27
2.7 AnInterlude:Gyges,AesculapiusandtheHistory
ofMedicine. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
2.8 Medicine’sClinicalPractice. . . . . . . . . . . . . . . . . . . . . . . . . . . 34
2.9 IllnessandDisease. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
3 AttheBeginningandEndofLife:AMeditation
ontheSubtleHoaxofMatter. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
3.1 IntheEarlyDays. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
3.2 AnOverview. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
3.3 SocialStructureofClinicalEncounters. . . . . . . . . . . . . . . . . . . 45
3.4 OnEmbodiment:Preliminary. . . . . . . . . . . . . . . . . . . . . . . . . . 46
3.5 AsymmetryofthePhysician-PatientRelationship. . . . . . . . . . . . 49
3.6 HistoricalIronies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
3.7 ExcursusonSelf.. . . . .. . . . .. . . . .. . . . .. . . .. . . . .. . . . .. 53
3.8 ConflictingValues. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56
3.9 OnEmbodiment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
3.10 Birth,BecomingandtheEcstasisofSelf. . . . . . . . . . . . . . . . . . 61
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62
ix
