- Modern Vs. Contemporary Medicine: The Patient-Provider Relation in the Twenty-First Century
The revolution in medical ethics of the past quarter century has begun reshaping the patient-provider relation in such a way that it will never be the same. 1 Dramatic changes have occurred at the level of specific decisions such as consent, forgoing treatment, and birth technologies, but the most significant impact will be on the way the relation is conceptualized and the kinds of authority each party in the relation will be assumed to possess. The change is so fundamental that it deserves to be called a change from modern to contemporary medicine.
Contrasting Modern and Contemporary Medicine
Medicine of the modern period can be said to have had its origins in the sixteenth century with the emergence of the scientific mentality in such figures as Francis Bacon, but it really took off in the enlightenment of the eighteenth century. While intellectuals in medicine up to that time tended to be in conversation with those of philosophy, theology, and the arts, the emergence of medicine as a science changed that communication.
The effect of the scientizing of medicine was that physicians tended to lose contact with the humanists. It was as if a physician, if he mastered the medical science, could, without any intervening value judgments, know how to treat the patient. In fact, for some conditions, there was (and still is) so much consensus [End Page 366] on the values that it is as if they were not present at all. If a patient has pneumonia, the most important element in a clinical decision seems to be pharmacological knowledge of whether a drug can produce a cure. The clinician knowledgeable of penicillin seems all that is needed.
Upon reflection a suppressed premise becomes obvious: if it is better to live with the penicillin than to die without it, then one ought to take the penicillin. Since almost no one doubts the wisdom of that value judgment, all that seems to be needed is pharmacological knowledge. This view of medicine implies that certain treatments are “medically indicated,” as if the knowledge of the science could demonstrate that certain treatments were appropriate, in fact, were “treatments of choice.”
Of course, on rare occasions, someone would question the value presumption. We discovered that certain patients with metastatic cancer who developed pneumonia might not automatically agree that it is better to live with the penicillin. Also Christian Scientists might deny that use of the drug led to the best possible consequences. These were set aside as unusual cases, ethically exotic problems, to be addressed outside the normal bounds of medical science. We still believed that medical science together with competent diagnostic skills were the critical factors in deciding what the appropriate treatment was.
Some clinicians spoke as if these decisions could be made with no value judgments at all (except in cases in which outside “religious” or “cultural” influences contravened). Many more sophisticated clinicians, however, understood all along that an implicit value system was built into the medical profession. Some have even claimed that the very concept of medicine contains within it a set of norms or goals or values that are “intrinsic to the practice” (Pellegrino and Thomasma 1988, p. 116). For many those values are encapsulated in the Hippocratic tradition, particularly the core Hippocratic principle that the physician should act always for the benefit of the patient according to his ability and judgment.
When physicians began spending their time learning medical science, the richness of their conversation with the philosophical and religious traditions of the day was lost. Clinicians, without a rich knowledge of those traditions, hit upon the Hippocratic ethic, embracing it as the epitome of their goals without real understanding of its implications and potential conflicts with other ethical traditions (cf. Veatch and Mason 1987).
The most critical contribution of the medical ethics of the current generation has been the calling into question of the Hippocratic ethic, especially the presumption that science by itself (or aided by a single, core ethic intrinsic to all practice of medicine) is sufficient to practice medicine. This generation’s medical ethics...