Table Of ContentMEDICAL CHALLENGES FOR THE NEW MILLENNIUM
Medical Challenges
for the New Millennium
An Interdisciplinary Task
Edited by
STEFAN N. WILLICH
Charite Medical School,
Humboldt University of Berlin, Germany
and
SUSANNA ELM
University of California at Berkeley, U.S.A.
Springer-Science+Business Media, B.V.
Library of Congress Cataloging-in-Publication Data
Medical challenges for the new millenniwn : an interdisciplinary task I edited by Stefan
N. Willich and Susanna Elm.
p.cm.
Includes index.
ISBN 978-90-481-5685-6 ISBN 978-94-015-9708-1 (eBook)
DOI 10.1007/978-94-015-9708-1
1. Medicine--Congresses. 2. Medical care--Philosophy--Congresses. 3.
Medicine--Philosophy--Congresses. 4. Medical ethics--Congresses. 5.
Health--Congresses. I. Willich, Stefan N. II. Elm, Susanna.
R723 .M359 2001
610--dc21
2001029309
ISBN 978-90-481-5685-6
Printed on acid-free paper
All Rights Reserved
© 200 I Springer Science+Business Media Dordrecht
Originally published by K.luwer Academic Publishers in 200 I
No part of the material protected by this copyright notice may be reproduced or
utilized in any form or by any means. electronic or mechanical,
including photocopying, recording or by any information storage and
retrieval system, without written permission from the copyright owner.
TABLE OF CONTENTS
List of contributors Vll
Introduction
Stefan N. Willich and Susanna Elm IX
I. Historical Perspectives
Developments in Ancient Medicine-Models for Today's Challenges?
Contemporary Medicine and the Christianisation of the Roman Elite
a Parallel
Susanna Elm 3
"Dying Well" and the Doctors
Thomas W. Laqueur 21
II. From Alternative to Integrative Medicine
Complementary Care in the United States
David Riley 33
Alternative Medicine in Germany
Personal Views of a Critical Observer
Henning Albrecht 39
III. Restructuring Health Care Systems
Rationing Health Care in Germany: Constitutional Opportunities
and Limits
Martin Nettesheim 49
Structural Changes in Health Care Systems -the Advent of "e-healthcare"
Stefan N. Willich 73
IV. New Technologies
Minimally Invasive Robotic Telesurgery
Frank Tendick and S. Shankar Sastry 89
The Strange Case of Molecular Medicine- Dr. Jekyll and
Mr. Hyde Revisited?
Martin Paul 113
v
vi TABLE OF CONTENTS
V. Ethical Reflections
Ethical Dilemmas in Medicine at the Beginning and the End of Life
Dieter Koch-Weser 127
The Idea of Progress in Medical Ethics
Jonathan Glover 133
LIST OF CONTRIBUTORS
Henning Albrecht
Director, Karl and Veronica Carstens-Foundation, Essen, Germany
Susanna Elm
Professor of History, University of California at Berkeley, USA
Jonathan Glover
Professor and Director, Center of Medical Law and Ethics, Kings College,
University of London, UK
Dieter Koch-Weser
Professor em. of Preventive Medicine, Harvard University, and Educational
Development Center, Boston, USA
Thomas W. Laqueur
Professor of History, University of California at Berkeley, USA
Martin Nettesheim
Professor of Constitutional Law, International and European Law, University
of Tiibingen, Germany
Martin Paul
Professor and Director, Institute for Clinical Pharmacology and Toxicology,
and Dean, Benjamin Franklin Medical Center, Free University of Berlin,
Germany
David Riley
Editor in Chief, Alternative Therapies in Health and Medicine, Santa Fe, USA
S. Shankar Sastry
Professor of Engineering, Department of Electrical Engineering and Computer
Science, University of California at Berkeley, USA
Frank Tendick
Professor of Surgery, University of California at San Francisco, USA
Stefan N. Willich
Professor and Director, Institute for Social Medicine and Epidemiology,
Klinikum Charite, Humboldt University of Berlin, Germany
vii
STEFAN N. WILLICH AND SUSANNA ELM
INTRODUCTION
In 1978, the World Health Organization (WHO) designated the year 2000 as
the "due date" for world health. The Alma Ata declaration set the turn of the
century as the target for a level of health that would permit all people of the
world to lead a socially and economically productive life.' At that (magic but
arbitrary) date most infectious diseases and many chronic conditions,
including diabetes and cancer, were expected to have been eradicated or at
least controlled. Such predictions were based on solid foundations. In the
201h century, and particularly since the 1970's, Western science and
technology based (or "modern") medicine has made quantum leaps in
numerous areas as diverse as pharmacology, genetic and molecular biology,
surgical techniques, infertility treatments, and pre- and neo-natal care. This
impressive trajectory of progress, which continues unabatedly, gave every
reason to assume that come the year 2000 humanity would finally be free
from many of its ancient scourges.
However, as we are all too well aware, the new millennium witnesses
also ever more terrifying threats to our health as a result of the emergence of
AIDS in the early 80's,2 the resurgence of infectious diseases such as
tuberculosis and malaria, now drug resistant,3 the absence of significant
breakthroughs in the treatment of cancer and cardiovascular diseases, and the
continuing dramatic gap in health care between industrialized and
developing countries, to mention but a few examples. Moreover, some of
medicine's very successes have given rise to new concerns. Thus, smallpox
is now returning in man-made form as a biological weapon, all the more
lethal precisely because its eradication in 1976 has left us without auto
immunization and without sufficient vaccination.4
In short, Pandora's box has yet to be closed. Furthermore, the realization
that high-tech-medicine, despite its tremendous successes, has not helped us
conquer many common-place illnesses such as "the flu," but has instead
burdened us with new ethical dilemmas -when and how to die, which life to
preserve, whether to create life, and how to pay for it all - has created a
sense of unease and lingering dissatisfaction with arguably "the greatest
benefit to mankind," modern medicine.5 One avenue through which this
dissatisfaction has found its expression has been "alternative" medicine.
ix
X STEFAN N. WILLICH AND SUSANNA ELM
Long reduced to the side-lines of "school-medicine," "alternative care" is
becoming "complementary" simply through the force of popular demand,
aided by the pocket-book: according to a recent study, 4 out of lO patients in
the United States now use alternative therapy, and the number of patient
visits to practitioners of alternative therapies exceeds the number of patient
visits to primary care physicians.6 "Alternative" methods appear to work, at
least for certain disorders, and definitively cost less, while the spiraling costs
of conventional medicine have led to the development of managed care and
health economy assessments with their own highly controversial
consequences.
Thus, a number of pressing and urgent issues confront the medical
community today. Medical practitioners must address these responsibly and
guided by their professional ethics. To phrase it differently, the medical
profession must respond to these challenges proactively. Physicians, health
care providers, medical researchers must take an active role in shaping the
future development of health care, they must do so now, and they must do so
creatively. The risks of simply reacting to increased managerial and political
intervention in the care of patients are too great. "Physician, heal thy
profession," as it were, and in order to do so, a stringent diagnosis of the
current ills, but also of the current strengths of health care is required.7
An interdisciplinary symposium held on September 25, 1999 at the
Charite Medical School, Humboldt University of Berlin, Germany, sought to
make its contribution by sparking precisely such a diagnostic discussion. It
gathered in one room experts in the field of techno-surgery, genetics,
medical ethics, preventive health and health economics, historians and legal
scholars. Historically, highly trained professional associations such as the
medical profession today have faced similar periods of dramatic change.
Problem solving approaches and pro-active methods developed during such
periods may provide insights and creative ways to address at least some of
the challenges facing medicine today, while some of the most cutting-edge
advances may in fact resurrect habits of the past, thereby resolving pressing
issues from unexpected angles. To give one example: remote surgery
techniques such as the Robosurgery presented by Professors Sastry and
Tendick have as their ultimate goal "home-care," which was the gold
standard of health care prior to the emergence of the hospital institution in
the l91h century. 8 If indeed surgery could be performed at home, this would
eliminate the risk of nosocomial infections as well as reduce the cost of
hospital care.
The present volume assembles the contributions of all speakers present at
the symposium, including relevant bibliography. It begins with Historical
Perspectives. First, Susanna Elm, who specializes in complex organizations
INTRODUCTION xi
and the means by which they transform themselves, presents a case-study
from the later Roman empire, where a highly trained elite, much like today's
medical profession, was forced by popular demand to accept an
"alternative," which represented a fundamental challenge to its own long
held and highly valued scientific methods. Yet, through pro-active
approaches, the leading members of this elite not only accepted this
alternative, but they made it their own, and in so doing they significantly
shaped the future by developing Christianity as we now know it. Thomas
Laqueur, author of a highly acclaimed book on the history of medicine,
Making Sex: Body and Gender from the Greeks to Freud, addresses a toJ'ic
historically not the domain of medicine: death and the art of dying well. In
his paper, he highlights the complex set of factors which have made death
and dying one of medicine's "growth-areas," thus forcing doctors to become
experts in what used to be called ars moriendi.
The next section, From Alternative to Integrative Medicine, is devoted
to the growing importance of holistic approaches in health care made evident
by the transformation of alternative medicine into complementary care.
David Riley, a prominent complementary care physician in the United States
and editor in chief of Alternative Therapies in Health and Medicine
discusses current trends in Complementary Alternative Medicine (CAM),
highlighting the importance of developing and implementing an integrated
scientific basis for CAM derived both from randomized controlled trials as
well as case series and long-term observational studies. These demands are
echoed and reinforced by Henning Albrecht, Director of the Karl and
Veronica Carstens-Foundation, and as such in charge of the largest funding
agency for research in natural medicine in the world. His contribution
focuses on the medical community's continuing disregard of an ever
increasing body of scientific evidence for the effectiveness of homeopathy, a
clear sign of the kind of resistance to change which this symposium seeks to
redress.
The section entitled Restructuring Health Care Systems focuses on
issues that may well have the greatest impact on medicine as traditionally
practiced, managed care and its economical, medical, and legal implications.
All industrialized nations are currently faced with the same dilemma:
demand on their health-care systems is increasing exponentially, and
spiraling costs must be curped. Therefore, drastic reductions in health-care
are unavoidable, and the ethical and legal implications of such rationing
have to be discussed. Martin Nettesheim, a specialist in international and
German constitutional law, analyzes some of the controversies facing the
legal community as a result of the restructuring of health care. In so doing,
he elaborates the constitutional framework for the decision making process
