Abstract
Medical doctors should be studying in the future not only about the “alleviation of physical and mental pain and suffering” but also about the “restoration of social functioning of their patients. Medical professionals are urged to carry their culture of helping and caring as contributions to society. They also assume responsibility for the careful use of available resources and their equitable distribution. Central values of medicine are respect for human dignity, respect for self-determination and autonomy, the primacy of patient welfare, the principle of noninjury, and solidarity. Questions of values deal with particularly complex areas of personal identity, because values are causes and reasons for decisions and actions. The potential damage of medical interventions is not automatically justified by the desire to help. The ratio between benefit and risks of medical measures must always be critically appreciated. The professional medical ethic is the basis for the contract between medicine and society with three basic principles: primacy of patient welfare, respect for the rights of self-determination (autonomy) of patients (informed consent), and promoting social justice in health care (solidarity). From these principles, normative values are derived, indispensably connected with medical responsibilities and obligations. Development of these values is discussed in the light of the philosophical background of the dignity of the individual person and the process of decision-making.
Introduction
Values are present in the name of the hospital where I am working for 30 years: the name “Valens” is derived from the Latin word “valere”: “value, valuable, important, effective” (Nomen est omen).
The following personal views are not intending nor pretending to present a list or set of values, applicable for everyone—rather a guide as to how we may produce and acknowledge values and how we may come to esteem and value them, and act according to them.
Much of what has led to great successes of modern medicine, but also to unsatisfactory biases, can be described in a horizontal plane: genetic, molecular, statistical, organizational, and so on. For a comprehensive design of a space, however, a vertical dimension in addition is essential. It cannot be derived any longer just from old dogmas.
As neurologists, we may use the brain as a metaphor for the world, where the two halves of the brain are two complementary ways of viewing and interpreting the world and acting upon it. 1 At which values do we want to orient ourselves in medicine of our time? What is important to us? When listening only to political and journalistic statements, one often gets the impression that the Zeitgeist appears characterized by widespread dissatisfaction and discomfort. 2
At the site of our modern clinic (www.kliniken-valens.ch) in the Tamina Gorge in Eastern Switzerland, Theophrastus Bombastus von Hohenheim (1493–1541), called Paracelsus was working as a spa doctor in 1535 and he wrote the first scientific book about balneology here. He was a doctor not just following the mainstream of his time. He had achieved successes with his methods of treatment, also among prominent patients. This led some established physicians to denounce it as work of devil and witchcraft, as idleness and vanity anyway.
A certain amount of opposition is expressed in his chosen name of Paracelsus: set against but also enlarging in parallel the then dominant medical science derived from Celsus. He brought about pioneering thoughts and practical applications to various medical fields. He did use chemical methods, including antibiotic therapy, but more important for us should be his motto: “The best remedy for man is man. The most basic of the drugs is love.” 3
With all the many objects and processes that we put between us and the patients today from the scalpels to X-rays and tablets, we should not forget to build a relationship with the patients 4 precisely: we have something to offer and to invest in the relationship. Our teaching should also go in this direction. To have no time or no interest for these dimensions would be disastrous.
Science and metaphysics
Our modern medicine is influenced by many things that can be expressed in numbers and maps or can be calculated. Computers dominate as working tools. This may be good and interesting and has enabled a lot of progress. The predominant method of working and thinking is the “calculus of reason.” This way of thinking and practical approach could be described as a horizontal plane in which causal links predominate. It investigates causes and fights against them.
The human body is thus seen as a machine and is disassembled and repaired like a machine. Correspondingly, the greatest successes of medicine have been in areas where mechanical, predictable effects on humans have distorted and disrupted the normally finely balanced physiological equilibrium, for example, in cases of accidents, in hostile invasions (such as from bacteria) from everyday wear, and tear of joints or cataracts. At this level, values exist only as deviations from the norm: blood values, values of liver or kidney functions, and so on. There are no “brain values”; perhaps normative values about frequencies of electric waves detectable (EEG)-detectable electric waves, or the number of words or the length of sentences an average person (!) speaks, how high the median or mean voice frequency is, but there are no values concerning content or substance—which surely would actually be the most interesting aspect.
For the greater part of diseases, however, particularly for the long-lasting ones, chronic, fluctuating mood disturbances that significantly affect or make up quality of life, no such causes can be found, which might be eliminated with relatively simple interventions. To learn how to deal with them and their reasons (which are not the same as causes) necessitates a picture of the person, in which the patient is seen as an individual with his/her background and history, his environment, and his own future in the center. There are reasons that determine our actions, not causes effective and efficient in space and time.
Such an idea or view of man (Menschenbild) must go beyond the mere mechanics, molecular biology, and statistics. 2 The individual patient must not only be reduced to being a carrier of more or less intact organs or functions, nor to only a percentage of a general statistic. In the dim milk glass of an only collective view and statistics, individuality is about to lose its identity.
We must find and cultivate uplifting forces which are inborn but have to be developed actively. In psychological terms: resilience; in neurobiology: neuroplasticity; in neurorehabilitation: recovery of function; in common sense: learning. In phylogeny, these uplifting movement, standing up, and up-righting forces during development with the liberation of the hands and the reshaping of the head are so characteristics for human beings, and we want to set this view into practice in order to encounter a patient as a conversation partner at eye level whom we want to try to understand and to treat.
Resilience may be described and cultivated in different dimensions. 5
There is a long tradition which has sought the vertical in the spiritual and religious dimensions, often by neglecting and annihilating the body. This way in its rigid adherence to formula, partly threatening, often without practical engagement and visionless, for us today is not open enough any longer, after many unhappy experiences. We can no longer go back behind the happy experience which can arise from the fact that what is being alleged and supposed must be checked. We cannot give up as a method of knowledge or exchange for dogmas the possibility and opportunity to experiment, in material as well as in spiritual matters. I believe (!) that the experiment with its inherent laws, across and thanks to our history, has become second nature to us.
Brain as a metaphor for the experience of the world
Neurologists may use the brain as a metaphor for describing the experience and interpretation of the world. And musicians might use the orchestra as a metaphor for the brain: as in the orchestra, there are several specialized institutions, specialists at work—everyone can and should contribute something to the whole and will do so according to his possibilities and constraints and will do it with a certain attitude. Each setting and attunement will change the result. The adjustment is made by someone, by somebody.
For this tuning and setting system, we have the apt and beautiful expression of the person or personality: it is “what sounds through—per sonare,” although not independent of the body, but rather through and across it and expressing concomitantly its history. Every orchestra needs a conductor and a composer too. In the brain, these functions are associated with the frontal lobes. This frontal part of the brain in the animal kingdom is not developed to such a degree as it is the case in humans. The frontal lobe has connections to all parts of the brain. Here, everything is organized. However, it is not so that the ego is sitting here—stationary.
But it is me—I am needing and using that part of brain. This is beautifully illustrated in the Sistine Chapel in the fresco of the Creation of Adam by Michelangelo: the mantle of God is uniquely shaped like a brain in the side view from the left: there, where he is pointing to the expectant Adam, it looks like the frontal lobes, the foldings behind correspond to the cerebellum, the feet point to the brain stem and for those who will know more precisely: there is a hippocampus-like structure in the blond curling hairs in the temporal lobe…
This picture shows very clearly: It is here through the frontal lobes that man is made (or becomes) man, because where God is pointing to with his fingers, Adam is sitting and is coming into the world. This is my interpretation—and I am sure it is true, but I am not quite sure if Michelangelo had known this consciously.
For creating and experiencing values, the functional differentiation of the brain’s two hemispheres is of importance. Not that they were entirely separated or could be split off from each other (except perhaps in pathological states or after operations with transection of the corpus callosum), but the functioning of individual persons, each with its own history and its special environment, but also at different times in their different “Zeitgeist” are dealt with differently by the two hemispheres. We only arrive at wholeness, if we create an equilibrium or balance between the different ways of experiencing the world and the possibilities of acting upon it. This is an active, creative power. “There is no sound from one-hand-clapping” as Fromm 6 reminds us in his “Art of Loving” quoting the Muslim mystic Rufi. If we choose expressions for the different functions of the two hemispheres, it could be about the following 7,8 :
Values cannot be found or created if only the “left-brain mode” is active, as it is the dominating way in our time and culture. Values are comprehensive. We should try not to be too much only on one side but rather strive for reaching a union or equilibrium of opposite pairs and give value to complementarity, which is somewhat implied in the description of the functions of the two brain hemispheres: Formula—form; calculus—idea; equation—parable; proof—note, from the consumer world to the real world. 9 –11
Freedom
In a Menschenbild which values the searching for and finding meaning, questions concerning freedom must be addressed.
In modern debates in neuroscience, there seem to be some unbridgeable contradictions between purely materialistic medicine or natural science (Murphy 12 ), which do not take into account or ignore completely the spiritual tradition, and practicing physicians who encounter so many unresolved issues in everyday life that make a co-orientation at the humanities essential. 12,13
In 2004, 11 neuroscientists who describe themselves as the “leading” ones wrote a manifesto about the present and future of brain research, published in the journal “Brain and Mind” 14 which since then produced huge waves in the discussions on the question of “free will.”
Here it is stated: …data obtained with modern imaging techniques, point out that all intra-psychic processes are associated with neural processes in certain brain areas—for example, imagination, empathy, the experience of feelings and making decisions or the deliberate planning of actions…that all these processes may generally be described by physico-chemical processes.
With the now-standard, fantastically developed, high-tech imaging methods, the moment can be captured when the ratio of oxygenated blood to less oxygenated blood is changed while a given task is solved. It can be shown, which brain regions are more colorfully stained, when, for example, a motor or a linguistic, or even when a mental problem is solved. Such procedures can, however, demonstrate nothing about the content of the linguistic or mental process or of creatively developed thoughts. And it cannot teach anything about the history behind the actions or feelings.
It is also very difficult just to define a real “resting state” of the brain from which the deviations are to be measured. In everyday life, however, the content of what is spoken and understood is more interesting than mere speech itself. Although some brain areas may show more activity in decision-making, it cannot be deduced from the images whether the decision was right or wrong, for decisions always stand in a social and historical context that precisely cannot be investigated with such procedures.
In reality, we never behave in isolation but always in interaction with the environment, which can be divided into the more tangible and the social one.
15
–17
If these interactions are not considered in the studies, they cannot succeed in what is expected in this manifesto, namely that …in the next 20 to 30 years, brain research will be able to explain the relationship between neuro-electric and neuro-chemical processes on the one hand, and perceptual, cognitive, mental and motor abilities on the other hand to such a degree as to make predictions possible on these relationships in both directions with a high degree of probability…so that mind, consciousness, feelings, acts of will and freedom of action will be considered without contradictions as natural processes, because they are based on biological processes.
All actions would therefore have to be defined in the context of scientifically and physically explainable processes and might not happen otherwise, because natural laws are strict. These postulates themselves are based on metaphysical, unprovable assumptions (determinism). A moral assessment of actions requires a more or less limited free will, or at least the solution of the contradiction between the personal-moral and sub-personal scientific descriptions. Without an idea of freedom, people would not even be able to determine their own will, or be made accountable for their actions. Moral judgments and emotions would have no meaning anymore; it would become impossible to blame any offenders and they would thus also become disenfranchised, being put under tutelage.
Everyday experience tells us, however, that we choose some of our activities, wishes, and thoughts and also values quite freely or may interrupt a course of action at will, but no reasonable person would think that such a will is absolutely free. “Common sense” is suffering still a deficit of dissemination—it is “the least common of all senses” (Oscar Wilde). Who would want to identify freedom with the absence of any stipulations? Such a concept would be a contradiction in itself: for if one’s own will would not be determined by anything, such a will would not be free at all, but simply a chance.
It is important to take into consideration, by what the will is limited (Bieri 2001 20 ). Of course, there are courses of action that we cannot reverse at will: if we want to go through a door, we must open it before (vice versa is impossible), taking the run comes before the jump over the ditch, eggs are advantageously boiled first and peeled later. I cannot fly myself, but I can get together with people who have learned how to build aircrafts according to their personal history and they may offer me their capacities for something in return, for example, flying.
When I am writing, reading, and loving (or even murdering), it is me, I am the one who does it—not a homunculus in my brain whom I can make responsible when things go wrong. Of course, together with my actions, desires, thoughts, probably also valuations, chemical and electrical processes are associated which can be detected in my brain with suitable experimental setups, but they are not there to perform some action or make a sensation instead of me, in my place.
Freedom can be experienced as an equilibrium which has to be set in balance constantly according to one’s own skills and the requirements from the environment. The possibilities are subject to change with the times—learning is always associated with biological changes (neuroplasticity). 15
We always behave in ways as to find recognition and praise on the one hand or else to avoid punishment on the other, moving between anxiety and boredom, depending on the relationship between challenges and our abilities. Diseases and disabilities restrict this freedom, and they always have also a compulsive aspect and are usually associated with anxiety. They bring the balance out of kilter, tilt it on the one hand into addiction, obsession, fear, and panic or on the other side into retreat and refusal, social phobia.
On both sides, everyone would talk about loss of freedom. Medical practice aims at helping to correct dysbalances among the patients.
To what is, according to the manifesto “perhaps the most important insight of modern neuroscience,” namely that “mind and consciousness are not fallen from the sky, but have emerged gradually in the evolution of nervous systems” everyone who occasionally looks at the sky and looks at what might fall out of it will agree and accept it. In what has “emerged gradually,” he will especially be interested in the individual history and the demands from the environment which contribute to the observable actions.
At the end, the manifesto is full of hope: “…Then even the heavy questions of epistemology can be tackled: the ones of consciousness, of ego-experience and the relationship of perceiving and perceived objects. For in this future moment our brain will set out to seriously recognize itself.” A brain on its own was never seen as serious and none has ever been set itself to something and accordingly it also will never be able to recognize itself.
At the temple of Delphi, there was just the invitation to a person: “Know thyself” and even the invitation to keep and maintain the balance: “Nothing in excess!”
Perhaps “leading neuroscientists” may once come to regret similarly as did an earlier writer of a (Communist) manifesto, when they realize what they do with their words to reality and to real persons. It is best to be taught by masters, so when we turn to philosophical questions, we should turn to true philosophers 19 –22 and a sick person looks for a competent doctor, who is able to listen and, from experience, to do something appropriate.
Values in medicine
Within the project “Future of Medicine in Switzerland,” the Swiss Academy of Medical Sciences published a report 23 on the objectives and tasks of medicine in the 21st century. It states “The Swiss medical doctors should be studying in the future not only about the ‘alleviation of physical and mental pain and suffering’ but also about the ‘restoration of social functioning of their patients’.” Medical professionals are urged to carry their culture of helping and caring as contributions to society. They also assume responsibility for the careful use of available resources and their equitable distribution.
Central values of medicine are respect for human dignity, respect for self-determination and autonomy, the primacy of patient welfare, the principle of noninjury, and solidarity
Questions of values deal with particularly complex areas of identity, because values are causes and reasons for decisions and actions.
The medical profession is bound by rules in order to protect performers and the patients against abusive treatment. The two central commandments of the oldest professional ethics, the Hippocratic rules state the duty to help the sick (“salus aegroti suprema lex”) and the requirement not to harm the patients and that all actions aim at the welfare of patients (“primum nil nocere”). In addition, doctors may not take advantage of their privileged position, which leads to the precept of sexual restraint and patient confidentiality. Physicians also have the obligation to share medical knowledge and pass it to the best of the next generation.
The potential damage of a medical intervention is not automatically justified by the desire to help. The ratio between benefit and risks of medical measures must always be critically appreciated. Risks of iatrogenic injury may never be entered lightly in any case.
The professional medical ethics is the basis for the contract between medicine and society with the three basic principles: the primacy of patient welfare, respect for the rights of self-determination (autonomy) of the patients (informed consent), and promoting social justice in health care (solidarity). From these principles, normative values are derived, indispensably connected with medical responsibilities and obligations
5,12
: Expertise Truthfulness in dealing with patients Confidentiality Maintenance of appropriate relations with patients Continuous quality improvement Preserving access to medical services Equitable distribution of limited healthcare resources Use of scientific knowledge Appropriate conduct regarding conflicts of interest
Respect for human dignity 20 and respect for the autonomy of the patient are the basis of any medical action. Any medical intervention must be justified both by a medical indication and by what can be inferred from the patient’s wishes. Medical concepts which are derived only from the personal responsibility of the patient may ignore, however, that this cannot be assumed without further ado from any sick and suffering person. The value of self-determination and autonomy is not only true for patients but also for medical professionals in order to provide a therapeutic space to preserve the intimacy and specificity of the doctor–patient relationship but also to secure it against social and economic pressures and to enable a patient-oriented medicine taking the individual needs into account.
“In addition to the welfare of the individual, it is also the common welfare, at least partially within the control of medicine, which can lead to tensions. With the value of solidarity, the demand is brought about for active contributions by doctors for adequate health care accessible for all and which should not entirely be left to market forces. The explicit recognition of a commitment to an economically responsible approach to medical resources counteracts the tendency for medical decisions to be taken only acting under economic and legal aspects. A medicine with a character of just material goods and merchandise and a “defensive medicine” must be prevented. It may be avoiding legal intricacies and constraints but no longer represents the special needs of patients in the first place.
Footnotes
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.