E.E. Shelp - Böcker

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.

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).

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.

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.

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.

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.

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.

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.

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).