Table Of ContentTHE ETHICS OF DIAGNOSIS
Philosophy and Medicine
VOLUME 40
Editors
H. Tristram Engelhardt, Jr., The Center for Ethics, Medicine and Public Issues, Baylor
College of Medicine, Houston, Texas
Stuart F. Spicker, School of Medicine, University of Connecticut Health Center,
Farmington, Connecticut
Editorial Board
George J. Agich, School of Medicine, Southern Illinois University, Springfield, Illinois
Edmund Erde, University of Medicine and Dentistry of New Jersey, Camden, New
Jersey
Patricia A. King, J.D., Georgetown University Law Center, Washington, D.C.
E. Haavi Morreim, Department of Human Values and Ethics, College of Medicine,
University of Tennessee, Memphis, Tennessee
Kevin W. Wildes, S.J., The Center for Ethics, Medicine and Public Issues, Baylor
College of Medicine, Houston, Texas
The titles published in this series are listed at the end of this volume.
THE ETHICS
OF DIAGNOSIS
Edited by
JOSE LUIS PESET
Instituto Arnau de Vilanova
Condejo Superior de Investigaciones Cientificas, Madrid
and
DIEGO GRACIA
Complutensis University of Madrid
w
KLUWER ACADEMIC PUBLISHERS
DORDRECHT / BOSTON / LONDON
Library of Congress Cataloguing-in-Publication Data
The Ethics of diagnosis / edited by Jose Luis Reset, Diego Gracia<
p. cm. — (Philosophy and medicine ; v. 40)
Includes index.
ISBN 0-7923-1544-8 (HB : alk. paper)
1. Diagnosis—Moral and ethical aspects. I. Reset Reig, Jose
Luis. II. Garcia. Diego. III. Series.
[DNLM: 1. Diagnosis. 2. Ethics. Medical. W3 PH609 v. 40 / WB
141 E84]
RC71.3.E8 1992
174' .2—dc20
DNLM/DLC
for Library of Congress 91-35370
ISBN 0-7923 1544-8
Published by Kluwer Academic Publishers,
P.O.Box 17, 3300 A A Dordrecht, The Netherlands.
Kluwer Academic Publishers incorporates
the publishing programmes of
D. Reidel, Martinus Nijhoff, Dr W. Junk and MTP Press.
Sold and distributed in the U.S.A and Canada
by Kluwer Academic Publishers,
101 Philip Drive, Norwell, MA 02061, U.S.A.
In all other countries, sold and distributed
by Kluwer Academic Publishers Group,
P.O. Box 322, 3300 AH Dordrecht, The Netherlands.
Printed on acid-free paper
All Rights Reserved
© 1992 by Kluwer Academic Publishers
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.
Printed in the Netherlands
TABLE OF CONTENTS
PREFACE Vll
H. TRISTRAM ENGELHARDT, JR./Introduction 1
SECTION I / HISTORICAL PERSPECTIVES
PEDRO LAfN-ENTRALGO / The Ethics of Diagnosis in Ancient
Greek Medicine 13
DIEGO GRA CIA/ The Ethics of Diagnosis in Early Christianity
and the Middle Ages 19
AGUSTlN ALBARRACfN / The Ethics of Diagnosis in the Modern
and Contemporary Worlds 29
JOSE LUIS RESET / Medical Diagnosis and Institutional Settings 41
DARREL AMUNDSEN / Some Conceptual and Methodological
Observations on the History of Ethics of Diagnosis 47
H. TRISTRAM ENGELHARDT, JR. / Observer Bias: The
Emergence of the Ethics of Diagnosis 63
SECTION II / ANTHROPOLOGICAL INTERPRETATIONS
H. TRISTRAM ENGELHARDT, JR./The Body as a Field of
Meaning: Implications for the Ethics of Diagnosis 75
JOSfi ALBERTO MAINETTI / Embodiment, Pathology, and
Diagnosis 79
DREW LEDER / The Experience of Pain and its Clinical Implications 95
STUART F. SPICKER / Ethics in Diagnosis: Bodily Integrity,
Trust-Telling, and the Good Physician 107
THOMAS J. BOLE, III /Bodily Norms and the Ethics of Diagnosis 123
SECTION III / THE SOCIO-CULTURAL DIMENSION OF
MEDICAL KNOWLEDGE
MARX WARTOFSKY / The Social Presuppositions of Medical
Knowledge 131
VI TABLE OF CONTENTS
HANS-MARTIN SASS / Diagnosing the Eleven Month Pregnancy:
Some Aspects of Moral and Cultural Foundations in Medical
Judgment 153
MARY ANN GARDELL CUTTER /Value Presuppositions of
Diagnosis: A Case Study in Diagnosing Cervical Cancer 163
SECTION IV / COMPUTER AUGMENTED DIAGNOSIS
EDMUND D. PELLEGRINO / Value Desiderata in the Logical
Structuring of Computer Diagnosis 173
KENNETH F. SCHAFFNER/ Problems in Computer Diagnosis 197
HENRIKR. WULFF/ Computers and Clinical Thinking 243
EDMOND A. MURPHY / Critique of Diagnostic Formalism 255
EUGENE V. BOISAUBIN/ Human Values in Computer Diagnosis 269
SECTION V / THE ETHICS OF DIAGNOSIS IN
THE POST-MODERN WORLD
GEORGE KHUSHF/ Post-Modem Reflections on the Ethics
of Naming 275
NOTES ON CONTRIBUTORS 301
INDEX 303
PREFACE
This volume is the product of a moveable intellectual feast of reflections
on the intertwining of evaluation and explanation in health care. The
themes addressed were first encountered by some of the participants in
discussions in the late 1960s. In particular, the volume is in debt to con
versations between one of the series editors and Corinna Delkeskamp-
Hayes in Bonn in 1969 and early 1970. Over the last two decades she
contributed in many ways to the discussions that produced this volume.
Reflections on the interplay of values, theories, and facts constituted the
primary focus of the first volume in this series, Evaluation and
Explanation in the Biomedical Sciences, published in 1975, in which a
number of the contributors to this volume participated. These themes
were developed further in subsequent volumes and at various meetings in
different parts of the world. One of the crucial meetings in the develop
ment of this volume was the Simposio Interdisciplinar Sobre Filosofia y
Medicina, organized through the support of the Fundacion Juan March
(Madrid), the Fritz Thyssen Stiftung (Cologne), and the Instituto Amau
de Vilanova (Madrid) and held at the Fundacion Juan March, March
21-23, 1979, with the theme "Etica del diagnostico". Special gratitude in
regard to this conference is due Eric Cassell, Valentin Corces, Dietrich
von Engelhardt, Enrique Najera, Alberto Oriol, Carlos Paris, Diego
Ribes, Ricardo Saiegh, Jose M.' Segovia de Arana, and the late Ignacio
Ellacuria, S.J. The series editors are in particular debt to Pedro Lain
Entralgo, who generously served as President of the conference, and Jose
Luis Reset and Diego Gracia, who served as secretaries.
The conversations and reflections developed at this symposium led to
others, and ultimately to the essays in this volume. Along the way, dis
cussions occurred again in Germany, this time at the Institute for
Advanced Study in West Berlin, in 1989. They were sustained in Texas
with the help of Mary Ann Gardell Cutter. Special thanks are owed as
well to the New England Journal of Medicine for permission to reprint
the material found in the Appendix to Kenneth Schaffner's article. The
result is a volume that bears only a limited resemblance to any of the
Vll
viii PREFACE
preceding particular discussions. Yet, the final product is in debt to them
all. Most particularly, the series editors are in debt to George Khushf,
who orchestrated the final discussions, fashioned the essays into their
final form, and made many helpful suggestions regarding the
Introduction that follows.
March 2, 7992 H. TRISTRAM ENGELHARDT, JR.
STUART F. SPICKER
H. TRISTRAM ENGELHARDT, JR.
INTRODUCTION
Knowledge is always value-laden. It is value-laden in the sense that the
acquisition of knowledge involves costs. Knowledge is value-laden as
well in that the structure given to information derives in part from epis-
temic and non-epistemic values, from the ways in which one regards
certain forms of knowledge as having greater excellence or greater use
fulness. Knowledge takes on value from its implications for action.
Various values, goals, and purposes cast their light and shadow across
that which is known. What we seek to know and how we structure what
we see depends on what we expect to see and want to see. In order to
move from poorly structured to well-structured problems, one needs
already to know what will generally count as information or noise.
Background assumptions direct the psychology of discovery, so that one
recognizes certain things and ignores others. Choices among ways of
seeing the world have costs and are directed by values. Diagnosis is
value-laden and invites moral reflection.
Clinicians seek to know not in order to know truly, but in order to act
effectively. Physicians are interested in knowing truly, insofar as
knowing truly is useful for their therapeutic ends. Which is to say, the
medical sciences are applied, not pure. They are embedded in practices
and institutions aimed at changing the world. Because these practices are
part of large-scale social practices, concerns about costs and benefits
become quite salient in health care policy discussions. But even at the
very micro-level of a patient and a physician, costs, benefits, goals,
values, and social expectations must be considered. Medical knowledge
must be evaluated in terms of its likelihood of being true or false and the
costs of error. To acquire more information in order to make a more reli
able diagnosis is itself not without significant costs. Yet delay itself can
be costly. This point is made in Eugene Boisaubin's essay, where he
underscores the need of turning first to consider those diagnoses for
which a quick intervention is important in being life- or health-saving. In
addition, one must bear in mind the morbidity and mortality costs of
diagnostic interventions. If to establish a diagnosis one must perform an
invasive procedure, then one must consider if making the diagnosis is
1
J. L. Reset and D. Gracia (eds.), The Ethics of Diagnosis, 1-10.
© 1992 by Kluwer Academic Publishers. Printed in the Netherlands.
2 H. TRISTRAM ENGELHARDT, JR.
worth the risk of discomfort, pain, and perhaps death involved. Because
the process of estabhshing a diagnosis imposes monetary costs and often
morbidity and mortahty costs, one must consider how successful the
treatment will be if the diagnosis is made, and how bad the disease will
be if left untreated. Therefore, as Edmund Pellegrino, Kenneth Schaffner,
and Henrik Wulff underscore, one must take into account the context of
the patient, when one frames diagnoses.
This volume explores the ethical and value questions associated with
medical knowledge, in particular, with diagnosis. The essays bring to the
reader the obvious but often under-explored circumstance that important
moral, ethical, and value decisions are involved in choosing among dif
ferent ways of coming to know, of knowing, and of regarding the prob
lems of patients. Bioethics thus includes the bioethics of medical
knowledge, an area where moral theory and the theory of knowledge,
evaluation and explanation intertwine. To begin with, there are moral
issues in knowing truly in the sense of appropriately minimizing errors of
diagnosis. Concerns with knowing truly in the sense of making diagnoses
on the basis of sufficient information and careful analysis are, as Lain
Entralgo shows, at least as old as Greek medicine.
Such concerns compass not just the due diligence that physicians
should have in making diagnoses, but issues in the sociology of medical
knowledge in the sense of the social conventions accepted by physicians
in establishing particular diagnoses. Thus, for example, to see or regard a
particular pathological specimen as benign or malignant, one must
already have decided how many mitotic figures with what amount of
aneuploidy per high power microscopic field justify the conclusion that
there is a malignancy. The criterion axis employed in distinguishing
between malignant and non-malignant findings depends on judgements
made against background views regarding the appropriate balancings of
the costs of over- versus under-treating for possible malignancies. This
therapeutically-oriented way in which medical knowledge and reality is
organized is especially clear in the staging and grading of cancer. In
grading cancers, one divides a continuum of cell abnormalities into units
to aid physicians in choosing therapies and providing prognoses.
Similarly, one stages cancers into neat categories in order better to pursue
prognostic and therapeutic goals. There are also choices to be made
among alternative, theoretically-based ways of construing medical diag
nosis. Many diseases can be seen as infectious, genetic, or environmental
diseases. Depending on how one characterizes particular diseases (e.g..
