Sustainable and responsible preventive medicine: Conceptualising ethical dilemmas arising from clinical implementation of advancing medical technology
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Background and setting Health care has become one of the most expansive activities in contemporary societies, and technology is one of its most influential factors. The modern medical-technological enterprise is however facing unprecedented practical, ethical and epistemic challenges. This thesis arises from a well-founded concern that medicine in general, and individually targeted preventive medicine in particular, may be about to become technified and dehumanised to an extent where its integrity and therapeutic as well as preventive potential may deteriorate. Aims The paramount objective of this project is to contribute to critical reflection and theory building in medicine by performing a systematic documentation, analysis and conceptualisation of possible unacknowledged ethical dilemmas arising from implementation of advancing, preventive, individually targeted medical technology in clinical practice. A secondary aim is to present “sustainable and responsible development” as a potential framework for addressing ethical and practical challenges of this kind. Theory, methods, and material Medicine is a moral enterprise. Thisrenders all medical research and practice basically value-laden activities. The important implications of this fact are currently not fully recognised among medical researchers and clinicians. This thesis represents an integration of five different studies into a theoretical reflection concerning the inevitable and partly neglected value-ladenness of medicine. According to this position and following the tradition of the humanities, the researcher’s frame of references is presented first, indicating the perspectives from where she wants her work to be regarded. The argument departs from the definitions and goals of medicine and comprises six fields of knowledge relevant for a theoretical exploration of the these goals: the concept of ‘health’; the nature of medical knowledge and ‘evidence’; the notion of ‘medical ethics’; the characteristics of medical technology; and finally, the topics ‘professional responsibility’ and ‘sustainable development’. The studies together address three distinct areas of clinical practice: ultrasound screening for chromosomal aberrations in the fetus, cardiovascular disease prevention in clinical practice, and the consultation in primary health care. Results All five studies in this thesis demonstrate that implementation of new, preventive medical technology at the interface between individually and population-oriented care can bring forth important and complex ethical dilemmas and even harmful consequences. The results of the papers can be condensed under the following headings: 1. issues related to the theoretical foundation of contemporary, individually based, preventive medicine; 2. topics inherent to applying evidence-based medicine to individual patients; 3. issues related to practical sustainability and the carrying capacity of the healthcare system; and 4. issues of professional responsibility for both knowledge production and implementation of research findings in clinical practice, – the latter heading representing a meta-perspective. Discussion The results of the five papers are introduced and discussed with reference to teachings and concepts originating from philosophers and medical scholars, such as Martin Heidegger, Hans Jonas, Michel Foucault, Charles Taylor, John Rawls, Arthur Frank, Drew Leder, Ian McWhinney and Eric Cassell. Furthermore, the findings are discussed within a framework that outlines a series of prerequisites for a sustainable and responsible preventive medicine: - A balanced theoretical approach to medical practice implies that a comprehensive body of medical knowledge about the human condition must build upon both the natural sciences and the humanities. - Environmental precaution means, in this context, that potential detrimental side-effects of medical activities must be systematically anticipated, supervised and kept at a minimum. - Equity addresses, in this context, the importance of keeping a sound balance between doctor-initiated, technological preventive activities aiming at ‘population care’ and medical activities that are directed by the expressed problems, concerns or wishes of people seeking care or advice. - Democratic goal-setting, participation and policy integration mean that all relevant stakeholders should be involved in defining, coordinating and evaluating the overall vision, philosophy and strategies of preventive medicine. Preventive recommendations in particular areas need to be harmonised and prioritised in accordance with an overall vision, and the expected impact of new recommendations on clinical practice should be estimated before guidelines are issued. - Planning for the future means, in the current context, that we should remember that our priorities and actions ought to appear justifiable and reasonable, not only from the point of view of evidence-based medicine as it appears here and now, but also as regarded from a more distant or even global perspective, or by the generations that will follow us who are making medical reality today. To achieve this, we need to continuously consider to what extent the scientific questions we ask and the decisions we make as professionals are concordant with what rings true and is important to us as fellow human beings. Key messages and implications The knowledge foundation of modern preventive medicine, targeting individual persons/patients in the context of the traditional clinical encounter, is currently too limited and thus an inadequate basis for clinical action. Ethical deliberation regarding the medical activities explored in this thesis has also been deficient.Despite the medical profession’s explicit intention of doing good, these two fundamental shortcomings imply a potential for inflicting medical harm. This inherent danger imposes the imperative of a paramount responsibility on medical researchers, administrators and practitioners. The practical and ethical impact of technological innovations in preventive medicine should be subjected to systematic and comprehensive analysis. Each particular new technology ought to be evaluated as for its own characteristics and consequences. It should also be measured against the overall goals, means and priorities of preventive medicine. These ought to be clearly defined and made accessible to critical scrutiny and open debate.
Has partsGetz, L; Kirkengen, AL. Ultrasound screening in pregnancy. Social Science & Medicine. 56: 2045-57, 2003.
Getz, L; Nilsson, PM; Hetlevik, I. A matter of heart. Scandinavian Journal of Primary Health Care. 21(1): 3-9, 2003.
Getz, L; Sigurdsson, JA; Hetlevik, I. Is opportunistic disease prevention in the consultation ethically justifiable?. British Medical Journal. 327: 498-500, 2003.
Getz, L; Kirkengen, AL; Hetlevik, I; Romundstad, S; Sigurdsson, JA. Ethical dilemmas arising from implementation of the European guidelines on cardiovascular disease prevention in clinical practice. Scandinavian Journal of Primary Health Care. 22: 202-8, 2004.
Getz, L; Sigurdsson, JA; Hetlevik, I; Kirkengen, AL; Romundstad, S. Estimating the high risk group for cardiovascular disease in the Norwegian HUNT 2 population according to the 2003 European guidelines. British Medical Journal. 331: 551-4, 2005.