Medical theory
Medical theory or theory of medicine generally describes the attempt to reflect on medicine on a philosophical-theoretical level. Seldom used terms for this are also philosophy of medicine or Iatrology (English Philosophy of medicine ).
It deals with the ontological , epistemological , methodological , conceptual and linguistic basics and issues of medicine in research and practice. In a broader sense, medical theory also includes the areas of practical philosophy with medical ethics , action-theoretical topics and parts of bioethics .
Although the basic questions of medicine have always been thematized in philosophy - and vice versa - there was a greater interest in systematic reflection only from the second half of the 20th century. Since the beginning of the 21st century, medical theory has established itself as a branch of the philosophy of science, which emerged at the end of the 19th century and established as an independent philosophical subject at the beginning of the 20th century, with independent topics and questions. A generally recognized definition and delimitation of medical theory has not yet established itself. There are different views on the topics and content, the methods and the status of medical theory within philosophy and medicine. Large parts of medicine are in an epistemological reflection deficit.
Current medical theoretical discussions and publications are almost exclusively limited to so-called Western medicine , as well as its tradition, plurality and further development.
Medicine and philosophy
"Philosophy is the sister of medicine ( medicina soror philosophiae )"
Medical theory addresses the special position of medicine in several ways. Medical practice can be described as an idiosyncratic (individual case) healing art or as a nomological (lawful) science. It is true that general laws and rules can be formed, but their practical application always relates to a specific individual case. Furthermore, human medicine belongs to the anthropological sciences in which humans are both subject and object of observation. Thus, in addition to the scientific paradigm, subjectivist modes of knowledge and methods are also discussed in medical theory. Since human medicine includes many existential life phenomena such as birth, illness, suffering and death , questions of value, meaning and ethics have always been the subject of every philosophical reflection on medicine. In the sense of the positivist three-stage law , however, many ideological issues were suppressed from the 19th century. Other subject areas that are both the subject of medicine and philosophy include consciousness , the relationship between body and psyche, perception and language .
Every medicine needs a particularly high level of justification and legitimation of its therapeutic action when dealing with sick and suffering people. This takes place on the one hand through social and political acceptance. Careful tracing back to its scientific theoretical foundations through medical theory should further increase this acceptance. However, the focus on the therapeutic aspect of action in medicine also means that its theoretical foundations do not have to be free from defects in order to still be able to practice good healing art.
Proponents of a culturally relativistic concept of medicine emphasize that the basic attitude of a society and culture to illness, frailty and death and how they deal with them also influences the characteristics as well as the cognitive and behavioral methods of its medicine. Notions of death and concepts of illness determine how people deal with illness and death and the intensity with which a society struggles for the health and survival of the individual, and the economic price it is willing to pay for it. While, for example, in ancient Greece and the Christian Middle Ages, individual death was related to community, spiritual salvation and eternal life , in the secular modern era there is an extensive loss of thanatology (the science of death and dying) and an individualization of the Dying and death rituals as well as a taboo made of ideas of death.
Large subject areas that overlap between philosophy and medicine can also be discussed under the mind-body problem or the concept of nature . For example, advocates of a substance-dualistic approach (matter and spirit exist independently) do not agree to life extensions at any cost or they try to cure a physical illness with purely mental and spiritual forms of therapy. In the 19th and 20th centuries, materialistic monism largely prevailed in both philosophy and medicine in the western world . There are, however, several unsolved problems associated with this, such as the question of the naturalization of intentional and phenomenal states.
Philosophy of medicine
Exactly what role the philosophy of medicine should play in the academic field is part of the discussions in medical theory. The most common definition that was established in the 1980s is that philosophy should provide methods to articulate, clarify and critically question philosophical topics in medicine (ED Pellegrino, D. Thomasma, 1981) Arthur Caplan the independent existence of such a subject in the early 1990s due to a still lacking connection to other subject areas and an equally missing fixed core topic from standard works and tasks. A controversial issue is the question of whether the philosophy of medicine should be thematically narrow or broad. Edmund D. Pellegrino sees the danger that the subject with a broad definition will lose its identity and advocates a medical theory that functions as an auxiliary science to established medicine and its methods. Kenneth Schaffner, on the other hand, calls for the inclusion of all philosophical topics that have a relationship to medicine, whereby both natural and human science topics should be treated.
Medical philosophy
Occasionally, a medical philosophy (or "clinical philosophy" in Karl Hermann Spitzy ) is suggested as a medical practice. The basis is essentially dietetics , a teaching about a lifestyle that contributes to maintaining health and healing. In ancient Greece, a dietary lifestyle included rules for both a physically and mentally healthy lifestyle. In addition to diet and (sporting) exercise, a moral lifestyle was also prescribed. Arthur Schopenhauer took up these dietary elements again. In his opinion, the moderation of all passions - in addition to physical exercises - should reduce the suffering and pain in life. Friedrich Nietzsche , on the other hand, places “great health” at the center of his medical philosophy. Those who can accept illness as a natural part of life and recognize the meaning in it will experience increased vitality, healing powers and joie de vivre. Nietzsche, on the other hand, sees no reason and no possibility to define disease more precisely and to combat it, or to strive for health. Common to all approaches of a "medical philosophy" is the demand for self-knowledge and personal responsibility.
The epistemological status of medicine
The lack of a general and binding definition of a scientific term is particularly noticeable in the evaluation of the diverse medical theory and practice. Even in ancient times there was a dispute as to whether medicine was a science or an art. In the course of the 19th century, more and more knowledge and methods from the natural sciences found their way into medical practice.
In order to distinguish the incipient scientific and positivistic orientation of medicine from other medical concepts, Joseph Dietl wrote :
"Just as our ancestors were more concerned about the success of their cures, so we are more concerned about the success of our research."
From the 1840s onwards, medicine is increasingly referred to as a science.
At the beginning of the 20th century, a much-quoted sentence by the pathologist Bernhard Naunyn became famous, who stated in the dispute over the status of medicine:
“Medicine will be a science or it won't be. But it is more difficult for us than the others because after all we have to rely on people for our reflections. - And here humanity and piety set us narrow limits. "
In doing so, he separated medicine from the art of healing. However, for Naunyn the primacy of healing over gaining knowledge and humanity over scientific practice still applies .
In spite of its proximity to the natural sciences, modern medicine is mostly not considered a natural science today . Every rational justification for a therapeutic act, i.e. the application of a rule to an individual case, is subject to judgment . But this is an essential difference to natural science, which gains general rules and places them in dependence. On the other hand, medicine is more often referred to as applied science , which applies scientific knowledge and methods to sick people . General scientific knowledge is then converted into a concrete decision and a real action.
But this view is also contradicted. Medicine uses numerous sources of knowledge in addition to the natural sciences and creates new knowledge itself. More often, medicine is classified in medical theory as an action science, which is primarily understood in terms of its purpose, the healing of sick people. The subject area of the human sciences (in a broader sense including the humanities, cultural and social sciences) also includes topics and questions that cannot be understood without considering human ideas, goals and value judgments. If medicine includes the people involved in its methods, then medicine is a human science. For Richard Koch , however, medicine is not a science at all, as long as it is about a technical and practical benefit. Natural sciences and humanities, on the other hand, are all about knowledge. For Karl Eduard Rothschuh , too , medicine has no goals of knowledge, only goals of action. Fritz Hartmann defines medicine as the scientific part of total medicine. This leaves room for an area of practical medicine that does not have to face any scientific discussion.
William Osler formulates similarly :
"Medicine is an art based on science."
history
Until the middle of the 20th century, the history of medicine was understood in a positivist historiography as an imperative scientific progress. Events, processes and people who did not fit this picture were called the wrong track. In the last few decades, however, social constructivist and anti-realistic interpretations have been discussed more broadly.
Early days
In the early days of human history, magical-mystical powers as well as spirits, gods and demons were held responsible for health disorders. Illness had a social dimension and always affected the community as well. Healing could only be successful with the help of contact with the supernatural. Methods such as a change in the healer's consciousness or astrology were used for this purpose . The actual therapy, however, could contain many different elements such as incantations , penance and trepanation . The Asklepios healing cult, which began in the late 6th century BC. Occurs in Greece, on the other hand, is viewed as a theurgical medicine concept. In some advanced cultures such as Egypt, India, China and Tibet, a specialized medical profession developed during this time. Characteristic there is a juxtaposition of empirical-rational and magical-religious healing practices.
Greek antiquity
The pre-Socratic Greek antiquity developed a holistic, cosmological- anthropological understanding of illness and health. The entire way of life is related to illness and health, but also to nature as a whole. In the school of the Pythagoreans , harmony is the focus; Health was understood as the restoration of a balance between people, society and the world. At the same time, the first quality pathologies, such as humoral pathology , probably arose .
With Hippocrates of Kos the medical art of healing receives a closed, comprehensive and written explanation system for the first time. A third state ("neutralitas") is characteristic of this conception of medicine, in addition to the two extremes of illness and health. A natural way of life (“ dietetics ”) is the key to any therapy. The causes of illness are increasingly explained naturalistically. With the equation of moral perfection and physical beauty, as well as the individually natural and the state useful in Plato , euthanasia , suicide and assisted suicide can be justified. On the other hand, Hippocrates' oath is clearly differentiated. Suicide and euthanasia are expressly prohibited by him. In the Corpus Hippocraticum , humoral pathology was developed as a basic disease and health theory. Important elements of the medical treatment were the inclusion of traditional medical reports and the close observation of the sick person. Semeia were signs (symptoms) that were interpreted for the prognosis, which was more important than the therapy.
From today's point of view, however, Hippocratic medicine lacked a sound theoretical basis and, in particular, a systematic classification of diseases and their causes ( nosology ). The Roman doctor Galenus of Pergamon added little that was new to the Hippocratic understanding of disease. Its importance lies in the schematization of the treatment and in the attempt to create a systematic, scientific basis for its teaching.
The medicine of the Islamic Middle Ages
Medicine in the medieval Islamic world adopted Greco-Roman medicine concepts via the Byzantine Empire . With the Canon medicinae by the Persian doctor Avicenna and by the doctor and philosopher Isaak ben Salomon Israeli , trend-setting works on the theory of medicine are created. Persian-Arabic medicine made significant advances, particularly in medicine and surgery .
Christian Middle Ages
The Christian Middle Ages once again experienced an increase in the importance of religious motifs in the art of healing. Anthropological and cosmological elements were related to transcendence . An Iatrotheology became the predominant medical concept , in which all elements of medicine such as illness and therapy were understood as part of a divine plan of salvation. A theistic ontology led to a reorientation for all concepts of meaning and values in medicine. The therapy became an accompaniment in the doctor-patient relationship. The disease embodied Christian suffering. It is a necessary station in the healing process , and transcendent salvation is superior to illness, but also to individual health. Dietrich von Engelhardt : “ Quality of life is measured by the relationship between people and creation and their creator, with nature and culture and their happy relationship, and not with the length of life or the ability to enjoy, love and work. “As a result, the hospitals are not limited to healing the sick, but offer help to people in need from all social classes and individual reasons. Suicide, euthanasia and termination of pregnancy are taboo for medical practice.
In the early medieval so-called monastery medicine , the Christian monasteries and their hospitals took on the role of healers. Therapy with the help of medicinal herbs became particularly important. In addition to medical care, the monasteries also ensured the collection, translation and transmission of ancient medical writings. From the 12th century it was decided at several councils to separate the monasteries from the medical tasks. As a result, the establishment of medical schools and universities throughout Europe was promoted.
Secular modern times
From the 16th to the 18th century there was a considerable selection of medical concepts, therapy options and healers for the population. Dominant medical concepts often replaced within a few decades.
- Renaissance
For medicine, the Renaissance meant a turn to the Roman and Greek classics such as Galen, Hippocrates and Aulus Cornelius Celsus . With anatomy , however, a separate research practice also emerged. The old scripts were no longer trusted, but autopsies were used to test and expand knowledge. New diseases such as English sweat and syphilis intensified the search for causes and new models of disease. The first medical regulations were the reaction to an increasingly differentiated health system.
- Paracelsus
In this transition of thinking styles, Paracelsus created a remarkably holistic medical system by combining cosmological, anthropological and transcendent elements. The causes of illness can therefore be very diverse and come from all five "levels of being"; they are expressed in an imbalance in the alchemical principles of sulfur , mercury and salt . Paracelsus replaced the humoral pathological concept of medicine with an iatrochemical one . The medical historical significance of Paracelsus is disputed; he did not establish a school or an influential subject. Its importance due to the turning away from authoritarian, scholastic medicine is undisputed . Like many other doctors of his time, he rejected this and called for a medicine that itself conducts natural research.
- 17th Century and Age of Enlightenment
Several medical concepts were formulated in Europe in the 17th century. In addition to iatrochemistry (the empirical-iatrochemical approach of the 17th century, however, no longer had much to do with Iatrochemistry at Paracelsus), an iatrophysics was developed based on the first established scientific theories . The turning away from conceptions of the hereafter also directed the goal of medicine towards increasing individual abilities. Illnesses become disorders of the organism. The “healing dimension” of illness as an opportunity and probation will remain in art and theology in the following centuries. The separation of spirit ("res cogitans") and body ("res extensa") in Descartes provided the opportunity to view illness and health as technical mechanisms free from theological tradition. The technical-mechanical medical model subsequently made it possible to apply the physical-chemical discoveries to master the human body and its functions. Since then, concepts and controversies in medical theory have mostly been dominated by this view. In the Age of Enlightenment, the social component of illness moved more into focus again. The importance of a state health policy was recognized; the first hospitals and nursing homes were built. The desire to control nature, which increases with the possibilities, is also reflected in a general health policy . But vitalistic medicine concepts such as the psychodynamics of Georg Ernst Stahl have their starting point in the Age of Enlightenment.
- Natural philosophy of romanticism
The radical turn to a mechanistic conception of disease led to a violent counter-movement around 1800, which only lasted a few decades. Under the influence of literature and philosophy, mechanicism is opposed to vitalism and causality to teleology . The unity of body and mind as well as of man and nature, physics and metaphysics, individuality and generality became a leitmotif for broad strata of society in Central Europe - also for medicine. With its doctrine of inner and outer stimuli, Brownianism met the attitude towards life of (German) Romanticism .
- 19th and 20th centuries
In the course of the 19th century, the empirical-analytical paradigm of medicine gained increasing importance in Europe and North America with the help of further developments in physics and chemistry. Individual performance becomes the benchmark for health and quality of life. Medicine can achieve many impressive successes in this as well as in life extension.
For Rudolf Virchow, the cause of illness is no longer an external disturbance, but the inability to react to a disturbance. The patient is increasingly becoming a passive object of treatment. The subjective aspect, such as the responsibility of the patient or the doctor-patient relationship, is becoming less important. The medical theoretical ideas follow scientific principles and focus on material, reductionist and mechanistic interpretations. Cosmological, anthropological and social models of interpretation of illness and health are being pushed out of medicine. However, counter-movements remain present in literature, theology and philosophy. These lingering controversies led to the development of psychoanalysis and the emergence of neovitalism at the turn of the century . The Psychosomatics , the medical psychology and medical sociology , which all began as "alternative medicine", here have their starting point.
After the first hospitals of today's form had been built at the end of the 18th century, the health system was increasingly under state influence in the following decades. Tasks such as disease control and vaccination came into the hands of the state from regional and local administrations. The separation of doctors and surgeons ( surgeons ) was abolished and permanent positions with management functions in hospitals became the rule.
Metaphysics and ontology
Medical models are based on a variety of philosophical preliminary considerations. These include ideas about the basic elements of reality, their structure and interaction. In the philosophy of medicine there is the view that stipulations at this point have decisive effects on the theory formation and research methodology of medicine.
Philosophy of mind
The biomechanical model of modern medicine is based on the assumption of a mechanistic, materialistic monism. One element of this view is the belief that matter is the only substance. One of the consequences of this is that medicine ultimately suspects a physical cause for all mental illnesses. The second assumption of the mechanical world view describes the arrangement and function of material substance. For the biomedical model, this means that humans are viewed as a collection of parts (organ systems, organs, cells, etc.) that work together like a machine. In modern medical theory, the question is discussed to what extent the biomechanical model even offers a possibility to map subjective, psychological, social and cultural aspects. A kind of human-scientific extension of the biomechanical model is based on a dualism. In addition to the physical, the spiritual (consciousness, soul, psyche, subjectivity) is an essential part of man and nature. Subjective and psychological aspects in medical practice should thus become central and equal elements in scientific modeling. Different views exist about the nature of the interaction between the mind and body. There are also holistic approaches. These consider not only the material and psychological as independent entities , but also, for example, social and cultural phenomena.
Reductionism and Emergence
In a consistent model, all phenomena and experiences must be traceable to its basic elements. One of the most important questions is to describe and explain the creation and interaction of subjective, psychological and social phenomena. There are several ways of doing this, which are discussed in the philosophy of medicine. On the one hand there are reductionist approaches that describe and explain all phenomena from a materialistic-mechanistic action. In order to better describe reductionist approaches, a distinction is made between ontological, epistemological and methodological reductionism. As an alternative to reductionist approaches, emergence theories have also been widespread since the middle of the 20th century . For example, psychological properties can be described in this way, but not directly attributed to the properties of the brain. This non-reductive materialism is also understood as a middle way between a vitalism and a biomechanical model.
Physicalism and organicism
Another distinction concerns the modeling of living beings . In a physicalistic model, the mathematical and technical formulation in physics and chemistry is also sufficient to fully represent biological facts. In contrast, an organic model assumes that physical and chemical laws for biological and ecological descriptions are becoming less important. Instead, the organization and structure of the organism itself is emphasized.
realism
When formulating disease models, the central question is what status diseases have. Are they independent objects that exist independently of specific illnesses ( realism ), or are they abstractions about specific illnesses? Ongoing discussions revolve around the question of whether some diseases are socially constructed or "real". An anti-realistic position sees disease models as helpful instruments of science without postulating real objects. An important realistic position in medical theory is taken by scientific realism . Entities such as cells and viruses, states and processes exist independently of the observer if and when correct scientific theories describe them. The question of the reality of diseases, but also of processes and pharmacological agents, has a great influence on the design of diagnosis and therapy, especially in neurology and psychiatry. So this discussion is fundamental to many other questions in the philosophy of medicine.
causality
The discussions about the concept of causality have been very diverse since ancient Greece. While Aristotle listed four different types of causes, at the beginning of modern physics only one was considered. The so-called " material causation " laid the foundation for the mechanistic worldview, in which the moving matter ultimately caused everything. At the latest with the findings in physics in the 20th century, the view of causality also changed. As a result, forces or events could also be seen as the cause. Aristotle, on the other hand, called this type of causality " effective cause ". In philosophy, the discussion about the concept of causality is therefore still topical, in biomedical science - as in the natural sciences - one deals with it more pragmatically, in that processes and conditions are recognized equally as causes.
The concept of causality is central in medicine for the possibility of repeatable diagnoses, for every justification and explanation, for the control of physical conditions, but also for every causal and thus rationally justifiable therapy. Doctors in the second half of the 19th century were of the widespread belief that rational therapies would soon be available for all clinical pictures. But the validity of a mathematical-physical, and therefore natural scientific, scientific term for medicine was increasingly disputed at the beginning of the 20th century. So were Max Verworn and David Paul von Hansemann believes that a konditionalistischer is more appropriate rather than a causal cause concept for epistemological formulations in medicine. Instead of a cause, only terms or conditions can be spoken of. The responsiveness of an organism and the multiple interactions with its environment are more important than the representation of a causal cause. The “plurality of conditions” noted by Verworn had a great influence on medical theory. At this time, teleological (“ purpose cause ”) concepts were again increasingly discussed in medical theory. For August Bier , health and illness as well as effect and therapy are finalistic (aimed at a goal), purpose-oriented terms. Teleological principles should not replace the causal, scientific approach, but complement it. Viktor von Weizsäcker and Gustav von Bergmann saw the equal application of causal and final principles as an opportunity to better describe and understand life phenomena. Critics of the teleological principle, on the other hand, demanded a strict separation of causal science and the finalistic principles of ethics and natural philosophy. The principle of teleonomy (expediency) should bring both principles together. Today systems- theoretical approaches or results of chaos theory are increasingly used to explain causes and effects.
Causes in medical practice are rarely deterministic and monocausal, but often probabilistic and multicausal. In epidemiology in particular, the causes of illness can only be narrowed down and named with difficulty. In 1965 Austin Hill compiled nine “aspects” such as “plausibility of the presumed mechanism” or “the strength of the dependency between two phenomena”. These became known as the Hill criteria and are now used to determine the causes of disease in epidemiology. Since the 1980s, evolutionary medicine has tried to use the course of evolution to give answers as to why people get sick. George C. Williams and Randolph Nesse created six categories of evolutionary causes of disease in 1996. Similar to the Hill criteria, these can also be helpful in finding the physiological causes of a disease, making them more accessible for biomedical research and treatment. Physicians and philosophers with a more human science orientation such as Eric Cassell and Stephen Toulmin see psychological and social reasons as just as important for explaining the causes of illness.
Body and body
Anthropologists, phenomenologists and representatives of pragmatism often place the body at the center of a medical theoretical discussion. For Max Scheler , the body is not an external assignment, but “a psychophysically indifferent phenomenal fact, without which the concept of sensation would be an absurdity.” The world experience of the body takes precedence over all thinking and knowledge. Friedrich Nietzsche interprets the world history of the "discovery of the mind" as "concealing the body" - an apparently empirical finding thus becomes a phenomenon of an appearance. Bodily existence, on the other hand, is of fundamental importance. For Hermann Schmitz , the body means what can be felt and, in contrast, the body means what can be perceived (and the idea of the body derived from it). In his opinion, western culture concentrated on the body and referred to the physical as organ sensation or zoenesthesia . For Schmitz, however, the tangible is (primarily) the real. For example, a so-called phantom pain is a physical sensation like any other, the phantom-like only arises in reflection. Sensations and movements can be used to influence pain, fears and physical complaints. The body philosophy of Hermann Schmitz avoids any separation in body, soul and spirit with the consideration of body sensation and body movement.
In a scientifically oriented medical concept, however, the body aspect no longer plays a role. In the Pschyrembel and other medical dictionaries, for example, no distinction is made between body and body.
Epistemology and methodology
There are many approaches, methods and technologies in medical research for the creation and presentation of medical knowledge. The most important epistemological question in the medical theory debate revolves around the validity , justification, and security of diagnostic and therapeutic knowledge. Already in ancient Greece, two basic methods of gaining and checking knowledge emerged, rationalism and empiricism . Rationalist positions put reason at the center. Knowledge can be obtained and tested through logic and reasonable thinking alone, but the senses and experience can be deceptive. The empiricists, on the other hand, claim that all logical rules and knowledge are only made possible and formed through sensory experience.
Rationalism and empiricism
In today's biomedical practice, rationalistic theory formation as well as empirical observation or experiment is an important part of research and practice. The disadvantage of the rational method has been shown to be that the specific facts in medicine are very complex. As a result, theories cannot include all relevant elements and can therefore only be assessed and checked with difficulty or not at all. As a result, empirical methods have become more important in recent decades. In clinical medicine, the so-called gold standard is now a randomized, placebo-controlled double-blind study . In the ideal case, these empirical studies in turn provide approaches for theories, although rationalists emphasize that an empirically proven effectiveness of a drug does not yet mean knowledge about it. Every empirical result must therefore be interpreted in a theoretical context in order to be available as general knowledge for therapies.
Science-oriented medicine adopts the concept of rationality from the paradigms of the natural sciences. This gives medicine the opportunity to participate in nature-dominating and manipulative technology. The human organism, the human psyche and illness are declared to be the subject of science, a scientific object. The scientific approach tries to capture all objects of knowledge in measurable and quantifiable parameters with the restriction to directly observable or indirectly technically measurable facts. As a result, every further perception, experience, explanation and action on these objects is experienced and carried out.
The subject area, the methods and theories of medicine are today more and more determined by the technologies used. In the course of the 19th century , the focus was first on organs, then tissue and cells, while in the 20th century the focus shifted to molecules and genes . The subject area of medical genetics not only requires new methods and hypotheses. With new technologies, biomedical research itself creates new subject areas and thus develops into technology and data-driven research.
Logic and reason
The experiment is the dominant method in biomedical research today. This empirical practice is embedded in a variety of rational approaches. Results of experiments have to be interpreted, new hypotheses are formed and checked, and finally new experiments are designed again. Just as medical research and practice require experiment and theory, inductive and deductive knowledge methods are also necessary.
In medical research, the results of an experiment can rarely be described directly in scientific hypotheses. That is why statistical methods are used, which derive a probability from the data. There is a wide debate in medical theory about the importance of the procedures used. If a frequentist concept of probability is used as a basis, a so-called null hypothesis (and its associated alternative hypothesis ) is checked using the specially determined data. If, on the other hand, one uses a Bayesian concept of probability as a basis, then several hypotheses are tested on the basis of existing data. This makes the Bayesian approach an assessment of the safety of an event (hypothesis), not its frequency. Both methods have advantages and disadvantages. However, both methods relate to data groups and not to individual cases, which is why all results must first be interpreted in practice.
In 1954 Paul E. Meehl published an analysis of the quality of therapy decisions as a comparison between purely statistical and individually intuitive decision-making. Its result is widely presented as the superiority of a statistical-mathematical model over an expert judgment. On the one hand, this leads to the question of which statistical methods are best suited for decision-making in everyday clinical practice. Today, many different models are available for this with simple linear methods, regression analyzes and heuristics . On the other hand, the question arises of how qualitative characteristics of the patient can be taken into account when making decisions.
Subjective ways of knowing
In recent decades, the topic of how subjective ways of knowing can again benefit medical practice has been increasingly discussed in the philosophy of medicine. While the objective, empirical-analytical approach of the biomechanical model largely excludes the subject from the cognitive methods, there are medical-theoretical approaches to include the moral and aesthetic value judgments of the patient. Here, between the disease and the illness distinguished as a subjective dimension. The way a sick person deals with their illness, but also with the therapy initiated, should be taken into account in comprehensive theoretical approaches. For Alfred I. Tauber , on the other hand, a separation into an objective and a subjective concept of illness is untenable, since every knowledge has to be interpreted subjectively. Laurence Foss brings both sides together under a so-called "infomedical" model in a neuropsychological approach. Body and person (mind) are connected via information. In models that are more oriented towards human science, the intuition and value judgments of the people involved should be integrated. Another approach, particularly by Linda Zagzebski and John Greco, is virtue epistemology . Statements about the knowledge of the medical practitioner should also be made with the help of his personal characteristics. Individual virtues such as openness, freedom from prejudice and reliability thus also influence the quality of the knowledge transported in this model approach. Considerations and methods from the areas of cybernetics , systems theory and information theory are used .
Concepts of medicine
In his standard work on medical history, “ Concepts of Medicine in Past and Present ” (1978), Karl Eduard Rothschuh distinguishes between twelve fundamentally different ideas about the causes and healing options for health impairments. According to this, a medical concept requires an image of man and a doctrine of illness and healing. These can be arranged and classified according to various aspects. They can either be more experiential or more rational. They get their justification and credibility from their proximity to general religious, social, philosophical and scientific views in society. Occidental culture in particular has produced a rich spectrum of different medical concepts.
| concept | Brief description | grouping | Example, expression |
|---|---|---|---|
| Iatra demonology | Animistic concept in which illness is caused by evil, invisible ghosts and demons | supranaturalistic | spread worldwide; in Europe in folk medicine with a climax in belief in witches |
| Iatrotheology | Medicine is systematically in a man-God relationship; Illness is a divine providence or sin . | supranaturalistic | especially in monotheistic , but also in polytheistic religions |
| Iatroastrology | Disease and healing factors are determined by astrological constellations. | supranaturalistic | in the advanced civilizations of Babylon, Egypt, India and China |
| Iatromagy | Magical thinking and acting for healing and strengthening | supranaturalistic | in archaic cultures and ancient high cultures |
| Empirical Medicine | Empirical medicine with a theory-free healing practice, healing with the help of intuition and the power of observation | theoryless | Greek Empirikerschule and the British empiricists of the 17th century ( John Locke , Thomas Sydenham) |
| Humoral pathology | Health impairments result from a disturbance of the body fluids; the healing through their harmonization. | naturalistic | Galen's medicine concept, Avicenna |
| Iatrophysics , Iatromechanics , Iatromathematics | Illness and health depend on measurable and calculable mechanical and physical functions. | naturalistic | Greek atomistics , body mechanics with William Harvey |
| Iatrochemistry | The material composition, properties, transformation and interaction in the body influence illness and health. | naturalistic | Paracelsus, Franciscus Sylvius , Thomas Willis |
| Iatrodynamics | Psychological forces, soul or life forces determine illness and health. | naturalistic or psychosocial |
Animism by Georg Ernst Stahl ; Mesmerism ; Psychosomatics ; homeopathy |
| Iatromorphology | The morphology (or anatomy ) determines sickness and in health. | naturalistic | Histology according to Xavier Bichat |
| Natural philosophy of romanticism | The whole of nature and medicine is explained from a few speculative principles of reason. | naturalistic or psychosocial |
"Romantic Medicine" from around 1800 to 1830 in Central Europe |
| Iatrotechnology | The mastery of physical and chemical processes determines healing. The technomorphic doctor-patient relationship (technician-machine) corresponds to the technomorphic conception of illness (defective machine). | naturalistic | from approx. 1840 in Europe and North America |
The distinction between the groups naturalistic and supranaturalistic is made from today's epistemological point of view; before 1850 it was largely unknown.
Cognitive methods
Axel W. Bauer distinguishes four basic methods of gaining knowledge in medicine.
- The axiom of the existence of supernatural persons and powers
- The belief in the effect of supranatural forces is not limited to ideas in the religions. In subjective disease theories, the axiom can have great significance for the patient. This paradigm has practically no prognostic value, but has a very high retrospective explanatory power.
- The axiom of the semiotic correspondence of phenomena
- Symbolic associations and analogies describe cosmological and anthropological laws. These are used to explain diseases and for therapy. Well-known examples are the " Yin and Yang " theory, astrology and homeopathy.
- The axiom of the causal law, mechanical-deterministic course of processes in nature
- This axiom essentially represents the paradigm of the natural sciences, which medicine joined in many areas in the 19th century.
- The axiom of the possibility of intersubjective understanding of human expressions of life through hermeneutic interpretation of verbal and non-verbal signs.
- In this axiom the subject is central. It is part of the basics in psychoanalysis , psychosomatics and psychiatry .
According to Bauer, these axioms cannot be proved, cannot be refuted , elude an ultimate justification and are not compatible with one another.
- Knowledge methods of scientific medicine
From these axioms four basic knowledge methods of scientific medicine can be derived (Seiffert, 1969; Hahn, 1988):
- the phenomenological methods
- the empirical-analytical methods
- the hermeneutic methods
- the dialectical methods .
These knowledge methods are to be used equally in a so-called group of methods in medical practice.
Decisions and judgments
Decisions for or against therapies in medicine are usually made with uncertainties and probabilities. The basis for well-founded therapy decisions is initially the analysis of the medical examination procedures. From these, the probabilities of existing diseases in the patient can be determined with further mathematical methods. These in turn can be used as decision tree are shown with endpoints (Engl. Outcome ) such as death, life expectancy, survival or satisfaction. Representatives of evidence-based medicine in particular hope to obtain this data on diagnostic procedures from the analysis of high-quality studies. In medical theory, however, the opinion is also held that this type of quantitative data and calculations are not sufficient to make therapy decisions. The advantages of a decision analysis using a decision tree, on the other hand, are the reproducibility and transparency of the decision-making steps, as well as the possibility of quantitatively comparing several therapy options.
In addition, a number of other factors influencing the therapy decision are mentioned. At the social level, it is patient associations, the pharmaceutical lobby or actors in the health system such as health insurance companies. In a specific decision-making situation, patient concerns and many other relevant factors can also come into play. However, since not all influences can be mapped in a decision tree, this is dangerously incomplete.
Medical explanations
Explanations provide an answer to the "why" questions. This makes what has been explained comprehensible. If phenomena or processes can be explained logically and technically with the help of general laws of nature and scientific theories, then they can also be controlled. With the deductive-nomological explanatory model of Carl Gustav Hempel and Paul Oppenheim , these same requirements were formulated in the 1940s. However, it is based on general, deterministic laws that are more likely to be found in the natural sciences, but only rarely in medicine. Statistical statements and regularities prevail there. Despite some philosophical difficulties in modeling causality, causal explanatory models are the most important ones in medicine. Wesley C. Salmon designed a causal-mechanical explanatory model to circumvent the unsolved question of the nature of causality. Causality is not understood as a general law, but ascribed to every phenomenon in the natural world. Today, medical knowledge is largely formulated in this causal-mechanical explanatory model. However, it remains doubtful whether causality always stands in a mechanistic context and what exactly a causal mechanism that is interpreted so far is.
If many influencing factors have to be taken into account in a model , the so-called ECHO model developed by Paul Thagard is a good choice . Hypotheses and data are linked in this model in order to determine the highest possible coherence . Ultimately, that hypothesis offers the best explanation, which is best associated with the modeled data, hypotheses and external influences. Thagard uses seven "principles" such as the symmetry and the analogue principle as well as coherence rules to decide whether individual statements are included in the statement system or not. In the tradition of of Charles Sanders Peirce formulated Abduktionsbegriffes developed Gilbert Harman also a model that as a conclusion as to the best explanation (Engl. Inference to the best explanation , shortly IBE) is known. By excluding worse-fitting explanatory hypotheses, the best explanation is determined in this model.
In addition, model types can be differentiated according to whether they are built up globally or locally. Global models try to unify the entire theoretical approach of natural science and thus enable an explanation with as few hypotheses as possible. Local models are based on phenomena and their underlying mechanisms. All explanatory models of this kind have the disadvantage that the “best” explanation may not necessarily be the “true” explanation. In addition, the terms coherence and explanation are controversial because of their vagueness.
Any part of a causal system can also be viewed as a means to an effect. If one puts the means-end relation at the center of the analysis, one speaks of functional explanations . For Ernest Nagel one function is the ability of a part to fulfill its causal role in the whole. In contrast, Hempel denies that functional explanations are legitimate at all. From a naturalistic point of view, it is not acceptable that a function explains not only the effect but also the existence of the agent. Functional explanations have a high level of intuitive explanatory power and are also increasingly used. However, there are still different views on what a functional explanation is and whether it can be formulated without teleological assumptions.
diagnosis
| Medical diagnosis | Scientific experiment Scientific hypothesis |
|---|---|
| The focus is on the subject | de-subjectivized |
| conditional | causal |
| individuality | representative |
| The goal is therapy and health | Cognitive goal |
| time related | Timeless |
| not correctable | correctable |
| practical statement | theoretical statement |
| Singular statement | general statement |
Diagnosis is of central importance in medical practice. It is not only the basis for the choice of therapy by combining medical knowledge with medical practice. A diagnosis also has an impact on the patient's personal well-being, his social role and thus financial, administrative and legal consequences.
According to its systematic category, a diagnosis is a statement that assigns a disease term to a specific patient at a specific time. Statements about the clinical picture, on the other hand, are the subject of clinical research. Linked to the statement character is a truth claim and the need for a justification. In contrast to statements in the natural sciences, the diagnosis is a singular statement . which cannot be generalized. Furthermore, scientific statements almost always quantified statements, however, the diagnosis is positive qualifying .
The scientific theory work in the field of scientific explanations can be transferred to the process of medical diagnosis. The deductive-nomological model for explaining an individual case with the help of causal relationships is less suitable. Since many conditions and relationships in the medical field only apply with a certain probability, the inductive-statistical model is more suitable here . A diagnosis itself is not an explanation. The question is whether the symptoms explain the disease or the disease explains the symptoms. Logically it makes no difference, but a doctor must be able to explain the patient's overall symptomatic picture in practice.
The diagnosis is therefore a boundary condition and not the goal of the explanation (the explanandum is the overall symptomatic picture). From a formal point of view, diagnostic practice is a search for the causes and conditions that fit a consequence. Any check of the correctness of a diagnosis can therefore only fall back on this explanatory model. Simply expanding the empirical search for further symptoms does not solve this problem.
In most cases, a diagnosis begins with the patient's subjective complaints. These lead the attending physician to medical examinations and hypotheses about the suspected disease. The diagnosis process usually ends when all further investigations (would) no longer lead to any new and relevant results and all but one hypotheses can be excluded. There are some suggestions for understanding the process of hypothesis formation, but no unified, generally accepted theory. Some cognitive psychological models are suggested to explain this .
therapy
From an epistemological point of view, the two most important properties of a therapy are medical effectiveness and safety. In order to develop and provide effective and safe treatment methods, two methods in particular are used: In addition to biotechnical research, randomized controlled studies . One goal - formulated in particular by evidence-based medicine - is to produce as many "high quality" studies as possible on all known methods, the results of which are then evaluated in meta-studies. The value of a study is then determined by several factors and parameters. The systematic and epistemological processing of these properties occupies a large space in medical theoretical research. In particular, the questions of how the study design can be optimized and the significance of the studies increased are discussed.
Language and semiotics
The language of medicine is the natural everyday language with technical terms, but without its own syntax and semantics . In contrast to the language of the natural sciences, its terms are insufficiently defined or not at all precisely defined. From the point of view of analytical philosophy , this is particularly noticeable in the poorly or not at all defined central terms such as “disease” or “clinical research”.
Medical semiotics deals with the observation, interpretation and assessment of medical signs. Since ancient Greece there has been a systematic teaching of signs in medical practice, especially in recognizing and understanding signs of illness, but also in the entire doctor-patient relationship. Sign theory has played a leading role in medicine for centuries. From around 1750 to 1850, medical semiotics enjoyed the status of an independent medical specialty. As a result of more and more diverse and differentiated diagnosis options, this has been transferred to today's diagnostics. This also changed the theoretical meaning of the symptoms. In a mechanistic interpretation of the symptoms, they are viewed as passive objects according to the intention to dominate, in a semiotic interpretation, however, according to the intention. the needs of the life processes themselves. Without the subjectivity of the sign-giver, sign theory also disappeared in favor of the causal relationship. In addition to the symptoms, the hormonal system or the genes can also be viewed in an information model and thus interpreted through semiotics.
All accessible information such as the medical history , physical examinations and results of scientific and technical tests represent medical signs. These differ in their validity and meaning. Newer diagnostic methods can enable better diagnostics (validity), but can also reveal irrelevant anomalies (meaning). Without medical semiotics, clinically insignificant diagnostic results can nevertheless lead to a great burden for the patient or to unnecessary and risky therapies. The doctor is therefore always required to interpret the medical signs in context.
Disease and health
The terms illness and health are central to medicine and the art of healing. They give the occasion and the goal of every medical activity and also have a wide range of social and legal effects. Decisions about illness and health have lasting effects on the distribution of resources in a society. Important groups in health policy such as patients, the pharmaceutical industry and the medical profession have an interest in defining the term disease as expansively as possible. This constellation is also referred to as medicalization and is the subject of medical theoretical discussion.
Based on the idea that a person is never completely sick or completely healthy, ancient Greece still knew a middle state, neutralitas . For Galenos there was therefore not only a disease theory, but also a health theory and a “doctrine of neutrality”. Today, there is no general definition of illness and health. There are various attempts to define both terms in a non-judgmental way; It is controversial whether this is possible without an evaluative (judgmental) and normative character. Often health is not only viewed as the opposite of illness, but also has other qualities such as independence and zest for life. On the other hand, illness is not always judged negatively.
The ontology of disease
The medical theorist Richard Koch opposes an ontological understanding of diseases. In the sense of Hans Vaihinger , he describes illnesses as fictions that should be seen as “useful abbreviations”.
The English physician Thomas Sydenham developed an ontological classification of diseases in the 17th century. Diseases are therefore independent entities that can be systematized like living beings or minerals. The name of individual clinical pictures and some colloquial descriptions still suggest a personification of the symptoms of the disease. Health and disease fought for man like good and bad. This ontological conception of disease is also the basis of the microbial theory of infectious diseases , which found more and more supporters in the middle of the 19th century, including Agostino Bassi and Louis Pasteur , and is still a common explanatory scheme today. Through further research, the importance of toxins (poisonous substances) and the individual disposition as disease factors were recognized. At the same time, a modern dynamic disease theory was developed, with the ideal of equilibrium at its center. Both disease theories exist today in parallel, whereby the ontological theory serves more to explain infectious and parasitic diseases, the dynamic theory more for dysfunctional or endocrine disorders.
Another criterion when determining disease concepts is localization. While in prehistoric times the illness of man was not separated from the community and the supernatural, the teaching of Hippocrates limited illness and health to the microcosm of man. Even with Galenos, individual organs could be considered sick. In the 19th century, Xavier Bichat first recognized that diseases affect the tissue of the organs, until finally Rudolf Virchow founded cellular pathology. Today, molecular medicine is increasingly seeing DNA as a location for possible pathologies.
Further discussions are held in medical theory on the conception of mental illnesses. Since “mental characteristics” can hardly or not at all be validly measured and operationalized, the existence of mental illnesses is in some cases completely denied. In response, there are attempts to relate psychiatry more to neurology , and mental illnesses become diseases of the brain . However, since the question of social norms and values is of great importance in the conception of mental illnesses, this topic is still highly controversial in medical theory.
The concept of illness
There is no generally accepted scientific term for disease. Not only between different sciences, but also between different schools and disciplines of medicine, the term is used differently and sometimes in contradiction. In general, a conception of human disease arises from interpretations of experiences and theories of all anthropological and biological aspects of human life. The central question discussed in medical theory is the relationship between scientific-empirical, subjective-evaluative and moral-normative approaches and ideas in the definition of the terms disease and health.
A common practical definition of illness is: an undesirable physical condition that is treated by doctors. In a similar positivistic approach, a disease is what is listed in a classification system like the ICD . However, counterexamples can be found for both approaches and they are not suitable for further epistemological analyzes. Attempts at defining disease (and health) in medical theory usually try to reconstruct a theoretical concept from the history and practice of medicine . A useful and theoretically desirable definition is then one that, conversely, also includes a practical use of the term and makes statements about the nature or ideal of the disease.
Christopher Boorse advocates a naturalistic, biostatistic definition of disease. What counts as a disease is determined solely by goals determined by evolutionary biology, such as survival and reproduction . With his functional theory of illness, Boorse also tries to avoid any reference to a concept of value. To do this, he constructs “natural” reference classes (for example children or older men) and determines a “statistical normality”. He relates this to a biological function. A disease occurs when the normal functionality is significantly undercut. Because of its naturalistic orientation, this approach has the advantages that it can be easily operationalized and can also be applied to all other species besides humans. However, this functional theory also has some weaknesses and limitations. On the one hand in the delimitation of the reference group or in the definition of "normal parameters" of a function. Also, some diseases are characterized by structural changes that are poorly functionally mapped, and there are widespread diseases such as dental caries that make it difficult to assume a “healthy” statistical reference group. The orientation towards functional units is still a teleological concept that is difficult to justify in a naturalistic approach. And finally, the patient's personal well-being is reduced to survivability and reproductive capabilities. In practice, biostatistical methods play an important role in diagnosis. For example, when evaluating blood pressure or using a so-called blood count , quantitative changes above a certain variation are regarded as a disorder.
An in-depth evolutionary biological perspective can also provide answers here. Thus, individual health is not necessarily a selection advantage in evolution. There are therefore limits to a disease definition based purely on evolutionary biology. On the other hand, there is hope that evolutionary biology will in future be able to clarify more precisely which functions are “normal” and thus contribute a biological instead of a statistical definition of normality to the definition of disease. Randolph M. Nesse distinguishes between eight causes of illness or reasons why illnesses occur, from an evolutionary perspective. For example, so-called pathogens such as bacteria also develop further and compete with their carriers.
Hugo Tristram Engelhardt Jr. chooses a more normative or lifeworld approach . It is undisputed that the concept of illness has an enormous normative effect with regard to social role and legal status. In addition, the detection of a disease requires responses and actions from both the community, the doctor and the patient. In addition to the biological, genetic, infectious and metabolic (metabolism) causal dimensions, Engelhardt also tries to include psychological and social aspects in the definition of the term. It is important, however, that medicine pursues a scientific generalization and no moral intentions. A decisive disadvantage of normative approaches for a further development of the theory of science is their cultural relativism. If a (negative) evaluation of a condition as a disease forms the definition, then it is difficult to find a universal criterion that the naturalistic approaches offer against it. However, the advocates of normative approaches assume that they do not necessarily include a culturally relativistic concept of illness. If one therefore uses universal values and norms as a basis, then one also obtains a universal definition as with a naturalistic approach. However, the possibility of universal values and norms is highly controversial. In the history of medicine, not only the statistical and ideal, but also individual standard terms are known. For a patient, the norm can also be in his biography.
Richard Koch takes a different approach. For him, 'sickness' is pure fiction. If one considers in particular the subjective dimension of suffering or experiencing the illness, the being sick . then the individual becomes the focus of the definition. Friedrich Curtius founded an individual pathology (Curtius, 1959) in which every illness is a singular event. Thomas Szasz's criticism is directed particularly towards psychiatry and mental illnesses . For him they are more like myths and metaphors, but not medically and scientifically useful terms and concepts.
Lennard Nordenfelt defines health as the possibility for a person to achieve their essential goals, whereby these goals should at least guarantee the person's “minimal happiness”. As a result of the difficulties in developing a theoretical pathology, there is a statement in the philosophy of medicine that it may not be possible to develop a uniform definition. The individual clinical pictures would then loosely belong together in a kind of family resemblance.
Therapy and healing
The concept of healing has no objective evidence. What is defined as a healing depends crucially on the paradigm and methods used. This results, among other things, in differences in the patient's well-being, the time horizon, the definition of goals in terms of the definition of health. While there are no differences between different paradigmatic approaches as to what is considered a healing in a particular case, healing can be conceived differently depending on the underlying paradigm. Psychotherapeutic approaches in particular can differ considerably from one another, whereas anatomical-surgical interventions are mostly undisputed. How healing is defined also depends on the definition of disease. If symptoms go away, it does not necessarily mean that the chronic illness that caused them has also been cured.
Disease Classifications
Definitions in the ontology have an important impact on the classification of diseases. In a cellular pathology, diseases are classified, for example, on the basis of cell characteristics. If, on the other hand, the focus is on the sickness of the individual himself, then it is more difficult to find general classes. Disease classifications are now based on practical considerations and scientific values, such as the validity and reliability of diagnoses and prognoses. An ontological concept of illness speaks in favor of the fact that, in addition to diagnosis and prognosis, disease classifications also serve the purpose of therapy and thus also the attempt to control reality (of the illness). Likewise, a classification of ontological disease definitions can more easily be converted into a classification of the causes of the disease and thus also into a therapeutic approach. The most vivid description of diseases is based on pathogens such as bacteria or parasites.
On the other hand, the advocates of a physiological (symptomatic, functionalistic) conception of disease point out that diseases can be represented in a much more complex way than is expressed in ontological concepts. They are therefore not only multifactorial, but also multidimensional. Genetic, metabolic, individual, social and psychological influences and effects could, however, only poorly be represented as a general entity.
Nosology
Current medicine is based on various terms of illness. Based on the ontological concept of illness, a pragmatically used concept of order and function is predominant today. In this sense, a disease is not just a unit that is separate from others, there is hope in this way to achieve a clear, closed and systematic coverage of all possible clinical pictures. Only in this way does it make sense to speak of a nosology , a system of disease units. Infectious diseases , which can often easily be differentiated from one another by special examinations, are ideal for this substantial classification . The designation is then usually based on the pathogen, which is then simply viewed as the causal cause. In addition to this etiological understanding of disease, a symptomatic understanding is also part of the current disease classifications. For example, systemic diseases or functional syndromes can often only be diagnosed with difficulty and clearly differentiated from one another. A disease unit is then a functional or fictional entity.
Altogether five criteria for classifying diseases can be distinguished for today's nosologies:
- etiologically according to the primary cause
- according to the potentially affected patient groups (epidemiology)
- localized, pathological (organ) changes, morphological or topographical-anatomical changes
- specific pathogenesis that regularly leads to syndromes; functional changes
- according to the time characteristic with a typical sequence of symptoms.
The hope is to structure the disease entities to such an extent that a closed and uniform system is created that is also suitable as an explanatory model for diseases. In practice, progress has been made in many cases in this regard. Nevertheless, many questions of medical theory remain open. These concern, among other things, the epistemological status of the criteria or the possibility of a naturalistic view of disease classifications. The question is whether there is a natural classification as with the elements in chemistry or the species in biology. For the creation and further development of so-called diagnostic classification systems, it remains to be clarified whether there are theoretical models as well as practical. The inclusion of a disease in the ICD is determined by expert consultation and not on the basis of theoretical models. There are also approaches to determine the disease definition with the help of fuzzy logic .
health
The World Health Organization (WHO) definition of health is often quoted :
"A state of complete physical, mental and social well-being and not just the absence of illness or ailment"
This definition shows a particular high regard for health, which is also criticized. On the one hand, health is equated with well-being without adding any added value to the conceptual definition. Critics also see the required “completeness” of well-being as an ideal that is unrealistic. Medical theory continues to address the fact that this definition is intended to medically interpret all social problems and deficits. This leads to an overestimation of medicine and its possibilities.
Medical ethics
Since ancient Greece, medical practice has always been accompanied and co-determined by medical ethical considerations and instructions. A central element of medical ethics in the western world is the so-called oath of Hippocrates to this day . It includes guidelines for doctor training, the doctor-patient relationship and the aspects of medical action, but on the other hand describes a purely paternalistic doctor-patient relationship that does not take patient autonomy into account. Writings on medical ethics can be found in the Christian Middle Ages as well as in the Renaissance. Paracelsus formulates a dichotomy for medical ethics into an ethics of knowledge and an ethics of action, which has persisted to this day. In 1803 Thomas Percival published his influential Medical ethics which, in addition to the doctor-patient relationship, regulates the relationship between the medical profession and the general public. For the first time, however, duties are imposed on society and the patient .
As a result of the technical possibilities of modern medicine, the limits of what is possible in medicine are shifting. Important topics in medical ethics today are, for example, research on humans, euthanasia and therapy decisions. Simple rules often seem inadequate for the complex requirements in practice. In medical ethics today there is no uniform and binding moral theory. In addition to the pluralism of traditional ethical or moral-philosophical theories, the diversity of values in society must also be taken into account in medical practice. The first question is therefore whether there can be any universal principles at all, such as the categorical imperative or the principle of utility maximization in utilitarianism in medical ethics. In practice, coherentist justifications of ethics are more important than universal moral principles. The four ethical principles (avoidance of harm, maximization of utility, autonomy, justice) of the moral philosophers Tom Beauchamp and James Childress have particularly proven themselves .
None of the principles has priority in this concept, which means that their application can be designed flexibly. However, this also gives rise to difficulties and disadvantages. For one thing, this set of principles does not provide general methods of application. On the other hand, each principle must be given individual and individual importance, because the approach of Beauchamp and Childress does not contain an “absolute principle” for a case-independent orientation. For example, justice can mean different things to everyone involved in a case. There are also the concepts of prima face obligations. For this purpose, all ethical requirements are named in a situation. For example, the doctor has the duty to avoid harm, the patient, however, to cooperate in the healing process. These duties are always relationships between people. The advantages of this model are its plurality, contextual orientation and transparency. It is questionable, however, whether the individual prima face duties are universal. Finding a consensus is also problematic, as many duties often lead to conflicts.
Proponents of anthropological medicine such as Karl Jaspers , Viktor von Weizsäcker or Viktor Emil von Gebsattel , on the other hand, build medical ethics on the characteristics of a contemporary doctor personality.
Medical theory in science and society
A worldwide philosophy of medicine is just emerging. For example, the discussions in Europe in the first half of the 20th century between positivism and neovitalism in the USA received little attention. Conversely, American medical theory is now more institutionalized than European. In addition, there are considerable ethnological and cultural differences in the content and methods of medical theory worldwide.
Research and Teaching
In what was then Prussia in 1861, the mandatory “Tentamen Philosophikum ” in medical studies was replaced by the “Tentamen Physikum ”. For several years now, several German universities have offered an elective again as part of a medical degree. In the German-speaking countries, medical history has been established as part of medical training in research and teaching for over 100 years . The first medical history institute was established in Leipzig around 1906. Already at the beginning of medical history research and teaching there was a desire for closer proximity to the humanities and especially ethics. In the 2003/2004 winter semester, the compulsory elective subject “History, Theory and Ethics of Medicine” (GTE) was included in medical studies. Since then, there has been an institute of the same name at many German universities with medical faculties.
Publications and conferences
Several international journals on the philosophy of medicine are published, such as the Journal for Medicine and Philosophy and Theoretical Medicine . In 1987 the European Society for Philosophy of Medicine and Healthcare was founded in Holland, which organizes conferences on the subject and publishes the journal Medicine, Health Care and Philosophy .
Current epistemological paradigms in medicine
As in all of European medical history, several medical concepts exist in parallel today. There are different images of man and models of organisms . These, in turn, are linked to various diagnostic and therapeutic approaches.
Science-oriented medicine
The medical model developed in the western world and now prevalent in almost all countries is the biomechanical, biomedical or defect repair model. The doctor tries to identify, treat and, if necessary, remove or replace the diseased part of the patient's body. With the help of many methods and technologies from the natural sciences and their technical applications, there are now significant opportunities for mastering biological functions and surgical intervention. During treatment, the doctor pursues the ideal of an objective view (“ emotially detached concern ”). This distancing as part of the doctor-patient relationship is a central theme in medical theory and the starting point for expanding the biomedical model to include elements from human science. Furthermore, the ever increasing use of technology and resource consumption is a limiting element of the biomechanical model.
Molecular medicine paradigm
In the 1960s a paradigm shift took place from medical microbiology to molecular medicine. Since then, genes have been regarded as the actual building blocks of the organism; their research using the methods of molecular biology and cell biology should ultimately help to recognize all physiological and pathological processes and structures. Diseases are more and more often described as errors in genetic and information processing processes. In medical theory, the question arises whether this also leads to a different medical approach, because traditionally human medicine deals with the phenotype (people in their appearance) and not with the genotype .
The biopsychosocial model
The biopsychosocial disease model was developed by George L. Engel in the late 1970s . Today it is considered to be the most important and best known model, which includes biological, psychological and social factors in a structured modeling of the disease process. A disease occurs when the organism loses the ability to regulate itself. In this system-theoretical consideration, there is no difference between body and psyche with regard to the causes of illness. Representatives of the bio-psychosocial disease model see it as a distinction from traditional psychosomatic medicine, which in some cases clearly attributes physical complaints to psychological causes. Restoring self-regulation (on all levels) is crucial for healing. The biopsychosocial model thus provides a theoretical basis for viewing illness and health as a dynamic interaction of many influencing factors. The origins of the model are therefore less in psychosomatics than, in addition to systems theory, in psychiatry, medical sociology and neuropsychology . Psychosomatic medicine is now mostly understood as bio-psychosocial medicine in the sense of George L. Engel, Thure von Uexküll and Wolfgang Wesiak. Simple interrelationships between body and mind hardly play a role in theory and practice.
Evidence-based medicine
So-called evidence - based medicine (EbM) is an approach that tries to provide the most effective therapy for individual medical treatment. On the one hand, medical research studies with the highest possible evidence class for all available therapies (and drugs) should be carried out. On the other hand, these studies should then be evaluated in meta studies in order to ultimately be able to make recommendations for clinical use. From an epistemological point of view, a review of hypotheses and theories is part of any scientific, empirical-analytical research. In this respect, the EbM is not a new approach. Rather, their emergence at the end of the 20th century is due to the largely unsuccessful attempt to convert the scientific findings for many diseases into effective and, above all, rational therapies . The strengths and objectives of evidence-based medicine, on the other hand, are more in the organizational and economic area.
In medical theory, on the other hand, the EbM's focus on empiricism is given special attention. The accumulated knowledge about the effectiveness of drugs and therapies allows a good comparability of the therapies, but no explanations about their mode of action. The models and theories on which the therapies are based are therefore of secondary importance for the EbM approach. EbM representatives also recognize the plurality of medical concepts and goals of medical action (improvement of the state of health, shortening of the duration of illness, lengthening of life span, reduction of side effects, improvement of quality of life). However, it is controversial to what extent it is sensible and rational to apply the epistemological and methodological standards of the EBM to other medical concepts with other methodological and evaluative standards. There is also a discrepancy between the retrospective meta-studies and the prospective individual case. The judgment of the doctor, the so-called internal evidence, is required even more by this circumstance. Even if the study situation is very favorable, the EbM would not necessarily suggest the most effective treatment for the patient, but rather the best documented one. There is also criticism from a medical ethical point of view. So it would be difficult to reconcile a patient's psychosocial situation with therapy recommendations from studies. The compulsion to adopt the 'gold standard' also tends to lead to ethically problematic study designs.
homeopathy
Contemporary homeopathy is also not based on a uniform theoretical concept. On the one hand, there are several different schools, some of which have very different ideas about their theories and methods, on the other hand, the original conception of Samuel Hahnemann is not always clear by today's scientific-theoretical standards. Ontologically Hahnemann presupposes a "life force" through which every healing takes place. Whether he interprets this more substantialist or more instrumentalist is disputed. The detailed anamnesis in classical homeopathy is another central element. This type of doctor-patient relationship is often seen as part of the interdependency of homeopathy. A special feature is the conception of the drug effect. This is paradigmatically assumed. The real task of the homeopath is then to match the characteristics of the homeopathic medicinal product (“drug picture”) to the characteristics of the patient. The abstract disease classes of the biomedical model serve only as a guide. The methodological foundations of homeopathic medicine consist of essential phenomenological , hermeneutic and dialectical elements.
Anthroposophy
Rudolf Steiner laid the theoretical and methodological foundations for anthroposophic medicine in his early philosophical work, drawing on Goethe's scientific research and the philosophy of German idealism . So he founded epistemologically an empirical, ontologically objective idealism with a concept of reality that on the one hand differentiates the areas of being matter , life , soul and spirit in man and nature , but on the other hand also connects them to one another in an overall conception without having to relate them to one another in a reductionist manner. Building on this universally realistic understanding of reality, he developed anthroposophy and then showed towards the end of his life how it can influence the practice of the most diverse areas of life. So he applied anthroposophy to medicine in the years 1920–1925.
Two fundamental concepts for anthroposophic medicine are the "four-way structure" of the levels of being and the functional "three-way structure" of the organ systems:
With the four levels of being in humans (and correspondingly also in nature) is meant in anthroposophy:
- The physical body that obeys the laws of physics and can be explored by conventional science .
- The etheric body , which - as with all living beings - as an organizational principle that goes beyond the physical, follows special laws that are peculiar to the living ("etheric"). The supersensible knowledge of this ethereal is called "imagination".
- The astral body , which is only present in sentient or animated organisms, i.e. in animals , but not in plants . The associated level of knowledge is called “inspiration”.
- The I , the spiritual individuality that elevates man above the animal kingdom. Every person has an I, but it is only recognized as such through the highest level of supersensible knowledge, the “intuition” (not to be confused with the conventional meaning of this word).
The four levels of being postulated by anthroposophy are thus in their actual essence not only recognizable through sensory perception , but only through a “supersensible” perception . The ability to do this can be achieved through a special meditative type of training , the methodology of which Steiner presented in various works (see on this anthroposophical training path ), or in individual cases through a special talent. However, all levels of being penetrate the sensual world and cause scientifically researchable phenomena in it.
Steiner formulated the concept of the "threefolding" of the human being into a nerve-sensory pole and a metabolic pole, as well as a mediating rhythmic system, as an overriding guiding point of view for understanding human beings. Steiner also drafted an anthroposophical doctrine of the senses with a phenomenological approach. Anthroposophic medicine also includes concepts of reincarnation and karma .
In the anthroposophical sense, illness consists, among other things, in the fact that the healthy interaction between the human beings is disturbed. The more detailed definition of this disorder in the present individual case essentially consists of the anthroposophical diagnosis based on human knowledge , which is viewed as an extension or addition to the conventional diagnosis.
Of the so-called alternative medicine directions, anthroposophic medicine is the youngest. It is based on other ontological basic assumptions than today's scientific medicine. Hence, it is considered unscientific or pseudoscientific. In doing so, it is not theoretically isolated: its representatives repeatedly point to points of contact with today's anthropological and medical-theoretical-methodological concepts that go beyond the current scientific paradigms and lead to higher-level points of view. A medical theoretical discourse is possible and will be held in the "Dialog Forum Pluralism in Medicine".
Psychoanalysis
Sigmund Freud formulated a structural model of the psyche from three instances with different functions: the id , the ego and the superego . These instances, however, do not form an ontological unit, but are viewed as changeable processes and structures. With this approach, however, not only the emotional and cognitive but also the biographical and social context of a person is part of the medical diagnosis and therapy. Psychoanalysis is one of the psychotherapeutic treatment methods, so the therapist-patient relationship is of central importance. The theoretical and methodological models of psychoanalysis today are very diverse and sometimes controversial.
literature
classic
- Richard Koch: The medical diagnosis. Contribution to knowledge of medical thinking. JF Bergmann, Wiesbaden 1920.
- Karl Eduard Rothschuh: Concepts of Medicine in the Past and Present. Stuttgart 1978, ISBN 3-7773-0442-5 .
- Thure von Uexküll , Wolfgang Wesiack : Theory of human medicine: Basics of medical thought and action. Urban & Fischer Verlag, 1998, ISBN 3-541-13503-4 .
- Edmund D. Pellegrino , David Thomasma: A Philosophical Basis of Medical Practice. Oxford University Press, Oxford 1981, ISBN 0-19-502789-2 .
General
- James A. Marcum : An Introductory Philosophy of Medicine. Springer, London 2008, ISBN 978-1-4020-6796-9 .
- Walter Pieringer; Franz Ebner: On the philosophy of medicine. 2000, ISBN 3-211-83446-X .
- Dietrich von Engelhardt : Philosophy and Medicine. In: Werner E. Gerabek , Bernhard D. Haage, Gundolf Keil , Wolfgang Wegner (eds.): Enzyklopädie Medizingeschichte. Walter de Gruyter, Berlin and New York 2005, ISBN 3-11-015714-4 , pp. 1150-1152.
- Dietrich von Engelhardt: Illness, pain and the art of living. A cultural history of body experience. CH Beck Verlag, Munich 1999, ISBN 3-406-42098-2 .
- Wolfgang Wieland: Diagnosis: considerations on medical theory. 2nd Edition. Verlag Hoof, Winterberg 2004, ISBN 3-936345-48-1 .
- Urban Wiesing: Who heals is right? About pragmatics and plurality in medicine. Schattauer-Verlag, Stuttgart 2004, ISBN 3-7945-2304-0 .
- Urban Wiesing: indication. Theoretical foundations and consequences for medical practice . Kohlhammer Verlag, Stuttgart 2017, ISBN 978-3-17-033010-8
- Axel Bauer (Ed.) Theory of Medicine. Dialogue between basic subjects and the clinic. Johann Ambrosius Barth Verlag, Heidelberg / Leipzig 1995.
- Kazem Sadegh-Zadeh: Handbook of Analytic Philosophy of Medicine. Springer, 2011, ISBN 978-94-007-2259-0 .
- Dov M. Gabbay, Paul Thagard, John Woods: Philosophy of Medicine - Handbook of Philosophy of Science. Volume 16, Elsevier, 2011, ISBN 978-0-444-51787-6 .
- Alvan Feinstein : Clinical Judgment. Williams & Wilkins, 1967.
- Josef N. Neumann: Medical theory. In: Werner E. Gerabek , Bernhard D. Haage, Gundolf Keil , Wolfgang Wegner (eds.): Enzyklopädie Medizingeschichte. De Gruyter, Berlin / New York 2005, ISBN 3-11-015714-4 , pp. 957-962.
Textbooks
- Wolfgang U. Eckart: History, theory and ethics of medicine. Springer, Berlin 2013, ISBN 978-3-642-34971-3 .
- Stefan Schulz, Klaus Steigleder, Heiner Fangerau: History, theory and ethics of medicine. Suhrkamp, 2013, ISBN 978-3-518-29391-1 .
- Ortrun Riha: Basic knowledge of history, theory, ethics of medicine. Huber Verlag, Bern 2013, ISBN 978-3-456-85267-6 .
- Thorsten Noack, Heiner Fangerau, Jörg Vögele (eds.): In cross section: history, theory and ethics in medicine. Urban & Fischer, Munich 2007, ISBN 978-3-437-41392-6 .
Single topics
- Jeremy Howick: The Philosophy of Evidence-Based Medicine. Wiley-Blackwell, Oxford, UK 2011, ISBN 978-1-4051-9667-3 .
- Hermann Schmitz: The body (basic themes of philosophy). de Gruyter, Berlin / Boston 2011, ISBN 978-3-11-025098-5 .
- Edmund Murphy: The Logic of Medicine. Johns Hopkins University Press, Baltimore 1997, ISBN 0-8018-5538-1 .
- Laurence Foss: The End of Modern Medicine: Biomedical Science Under a Microscope. NY, SUNY Press, Albany 2002, ISBN 0-7914-5129-1 .
- Wolfram Schmitt: Theory of health and " Regimen sanitatis " in the Middle Ages. Medical habilitation thesis Heidelberg 1973.
Web links
- Philosophy of Medicine Article in the Internet Encyclopedia of Philosophy
- Julian Reiss, Rachel A. Ankeny: Philosophy of Medicine. In: Edward N. Zalta (Ed.): Stanford Encyclopedia of Philosophy .
- Medical Theory , History, Ethics & Theory of Medicine ( Memento of September 8, 2005 in the Internet Archive ), Medical Ethics and Metaethics ( Memento of January 29, 2005 in the Internet Archive ) (Sites operated by Kazem Sadegh-Zadeh)
- Chair for medical theory at the University of Witten / Herdecke
- Elisha Bertlett An essay on the philosophy of medical science
References and comments
- ↑ Josef N. Neumann: Medical theory. In: Encyclopedia of Medical History. 2005, p. 957.
- ↑ Dietrich von Engelhardt, Heinrich Schipperges: The inner connection between philosophy and medicine in the 20th century. Scientific Book Society, Darmstadt 1980, p. 19.
- ↑ Wolfgang Wieland : Diagnosis. Medical Theory Considerations. Berlin 1975, p. 88f.
- ↑ Dietrich von Engelhardt, Heinrich Schipperges: The inner connection between philosophy and medicine in the 20th century. Wissenschaftliche Buchgesellschaft, Darmstadt 1980, p. 25ff, especially p. 27.
- ↑ James A. Marcum: An Indroductory Philosophy of Medicine. Springer, 2008, p. 3.
- ↑ Around the same time (1844), Elisha Bartlett's Essay on the Philosophy of Medical Science appears , which is considered the first medical theoretical work as we know it today.
- ↑ Dietrich von Engelhardt, Heinrich Schipperges: The inner connection between philosophy and medicine in the 20th century. Scientific Book Society, Darmstadt 1980, p. 122.
- ↑ Urban Wiesing: Who Heals Is Right? Schattauer, Stuttgart 2004, pp. 23/24.
- ↑ Axel W. Bauer: Axioms of Medicine. In: Walter Pieringer, Franz Eibner (Ed.): To the philosophy of medicine. Springer, Vienna / New York, 2000, p. 17.
- ↑ Reinhard Kamitz: Methods and areas of natural science and human science. In: Walter Pieringer, Franz Eibner (Ed.): To the philosophy of medicine. Springer, Vienna / New York 2000, pp. 154f.
- ↑ Dietrich von Engelhardt , Heinrich Schipperges : The inner connection between philosophy and medicine in the 20th century. Scientific Book Society, Darmstadt 1980, pp. 121/122.
- ↑ Axel W. Bauer: Axioms of Medicine. In: Walter Pieringer, Franz Eibner (Ed.): To the philosophy of medicine. Springer, Vienna / New York 2000, p. 16.
- ^ Dietrich von Engelhardt: Illness, pain and the art of living. A cultural history of body experience. Beck, Munich 1999, p. 19f.
- ↑ Wolfgang U. Eckart : History, Theory and History. Springer, Berlin 2013, pp. 8-10.
- ↑ So the Hippocratic oath did not represent the general medical-ethical ideal of its era.
- ↑ Thure von Uexküll, Wolfgang Wesiack: Theory of Human Medicine: Fundamentals of medical thought and action. Urban & Fischer Verlag, 1998, p. 103.
- ^ Dietrich von Engelhardt: Illness, pain and the art of living. A cultural history of body experience. Beck, Munich 1999, p. 43.
- ↑ Wolfgang U. Eckart: History, Theory and History. Springer, Berlin 2013, pp. 50–53.
- ^ Robert Jütte : Pluralism in medicine from a historical perspective. In: Susanne Michl, Thomas Potthast, Urban Wiesing (ed.): Plurality in medicine. Karl Alber, Munich 2008, p. 381ff.
- ^ Dietrich von Engelhardt: Illness, pain and the art of living. A cultural history of body experience. Beck, Munich 1999, p. 47ff.
- ^ Dietrich von Engelhardt: Illness, pain and the art of living. A cultural history of body experience. Beck, Munich 1999, p. 70ff.
- ^ Claudia Huerkamp: The rise of doctors in the 19th century. From the learned level to the professional expert. Göttingen 1985, pp. 58-61.
- ↑ James A. Marcum: An Introductory Philosophy of Medicine. London, Springer 2008, p. 19.
- ↑ This does not rule out that medical professionals make an individual effort to include these aspects in their work. However, this would then be a private matter for the doctor and is outside of the scope of scientific modeling, responsibility and reflection.
- ↑ James A. Marcum: An Introductory Philosophy of Medicine. Springer, London 2008, pp. 22-27.
- ^ Ian Hacking : Representing and Intervening: Indroductory Topics in the Philosophy of Natural Science. Cambridge University Press, Cambridge 1983, p. 21.
- ↑ The reality of pharmacological active ingredients is also discussed under the term " Medical Realism ".
- ↑ Urban Wiesing: Who Heals Is Right? Schattauer, Stuttgart 2004, pp. 13/14.
- ↑ Dietrich von Engelhardt, Heinrich Schipperges: The inner connections between philosophy and medicine in the 20th century. Wissenschaftliche Buchgesellschaft, Darmstadt 1980, pp. 102-109.
- ↑ James A. Marcum: An Indroductory Philosophy of Medicine. Springer, 2008, p. 36.
- ↑ Dietrich von Engelhardt, Heinrich Schipperges: The inner connection between philosophy and medicine in the 20th century. Scientific Book Society, Darmstadt 1980, p. 36.
- ↑ Hermann Schmitz: the body. De Gruyter, Berlin / Boston 2011, p. 5.
- ↑ Hermann Schmitz: the body. De Gruyter, Berlin / Boston 2011, p. 15ff.
- ↑ A third less important direction was the so-called methodical school of medicine , which rejected the search for causes and their theoretical understanding as superfluous. Only common sense and careful observation of the symptoms of the disease lead to healing.
- ^ Norbert W. Paul : Medical theoretical aspects of medical research. In: Stefan Schulz, Klaus Steigleder, Heiner Fangerau: History, theory and ethics of medicine. Suhrkamp, 2013, p. 275.
- ^ Library.mpib-berlin.mpg.de
- ↑ In the English-speaking world, this discussion is conducted with the opposing pair disease (illness) and illness (subjective illness). The third term sometimes also occurs sickness addition, the disease describes in a social context.
- ↑ Laurence Foss: The End of Modern Medicine: Biomedical Science Under a Microscope. SUNY Press, Albany, NY 2002, pp. 68ff.
- ^ Karl Eduard Rothschuh: Concepts of medicine in the past and present. Hippokrates Verlag, Stuttgart 1978, p. XIV.
- ^ Robert Jütte : Pluralism in medicine from a historical perspective. In: Susanne Michl, Thomas Potthast, Urban Wiesing (ed.): Plurality in medicine. Karl Alber, Munich 2008, p. 391.
- ↑ Axel W. Bauer: Axioms of Medicine. In: Walter Pieringer, Franz Eibner (Ed.): To the philosophy of medicine. Springer, Vienna / New York 2000, pp. 18ff.
- ↑ Peter Hahn: Science and Scientific Approach in Human Medicine. In: Walter Pieringer, Franz Eibner (Ed.): To the philosophy of medicine. Springer, Vienna / New York 2000, pp. 35ff.
- ↑ Hugo Tristram Engelhardt: Indroduction. In: Clinical Judgment: A critical Appraisal. D. Reidel Publishing Company, 1979, pp. Xi ff.
- ↑ Wiesing, Urban: Indication Theoretical Basics and Consequences for Medical Practice. Kohlhammer Verlag, Stuttgart.
- ↑ DF Ransohoff, Alvan R. Feinstein: Is decision analyze useful in clinical medicine? In: Yale Journal of Biology and Medicine. 49, 1976, pp. 165-168.
- ↑ James A. Marcum: An Indroductory Philosophy of Medicine. Springer, 2008, p. 138.
- ↑ S. Hartmann: Coherent explanatory pluralism. In: W. Hogrebe (ed.): Borders and border crossing. Sinclair Press, Putney 2002, pp. 141-150.
- ^ A b Wolfgang Wieland: Diagnosis. Medical Theory Considerations. de Gruyter, Berlin / New York 1975. ISBN 978-3-11-185190-7 . P. 46 and 63.
- ↑ Kazem Sadegh-Zadeh: Handbook of Analytic Philosophy of Medicine. Springer, 2011, p. 29ff, especially p. 49.
- ↑ Wolfgang U. Eckart: And don't put your words on screws - medical semiotics from the end of the 18th to the beginning of the 20th century. In: Reports on the history of science. 19, (1-4), 1996, p. 1.
- ↑ Thure von Uexküll, Wolfgang Wesiack: Theory of Human Medicine: Fundamentals of medical thought and action. Urban & Fischer Verlag, 1998, p. 55, p. 101 and chap. 2.
- ^ John F. Burnum: Medical diagnosis through semiotics. Giving meaning to the sign. In: Annals of Internal Medicine. 119, 9, Nov 1, 1993, pp. 939-943. PMID 7692781 .
- ↑ a b c Randolph M. Nesse: Why it is so difficult to define disease . In: Thomas Schramme (Ed.): Disease theories . Suhrkamp, Berlin 2012, ISBN 978-3-518-29611-0 , pp. 173, 182-183 ( d-nb.info ).
- ^ Arthur Caplan: The Concepts of Health, Illness and Disease. In: M. Robert (Ed.): Medical Ethics. Jones & Barlett Publishers, Sudbury 1997, p. 57.
- ^ Dietrich von Engelhardt : Illness, pain and the art of living. A cultural history of body experience. Beck, Munich 1999, p. 24.
- ↑ “Neutrality” in this sense is also sometimes referred to as “negative health” or “absence of illness”
- ↑ Richard Koch: Medical Thinking. Treatises on the philosophical foundations of medicine. Munich 1923, p. 57.
- ^ Dietrich von Engelhardt : Illness, pain and the art of living. A cultural history of body experience. Beck, Munich 1999, p. 56.
- ↑ Dietrich von Engelhardt, Heinrich Schipperges: The inner connection between philosophy and medicine in the 20th century. Scientific Book Society, Darmstadt 1980, p. 21.
- ^ Karl Acham : To the philosophy of human medicine. In: Walter Pieringer, Franz Eibner (Ed.): To the philosophy of medicine. Springer Vienna / New York 2000, pp. 114–120.
- ↑ Dietrich von Engelhardt, Heinrich Schipperges: The inner connection between philosophy and medicine in the 20th century. Scientific Book Society, Darmstadt 1980, p. 64.
- ↑ Thomas Schramme: Introduction: The terms "health" and "disease" in the philosophical discussion . In: Theories of Disease . Suhrkamp, Berlin 2012, ISBN 978-3-518-29611-0 , pp. 9-12.14 ( d-nb.info ).
- ↑ Peter Hucklenbroich: The scientific theory of the concept of disease. In: Thomas Schramme: Disease Theories. Suhrkamp, Berlin 2012, p. 158. ISBN 978-3-518-29611-0 .
- ↑ See Christopher Boorse: A Rebuttal on Health. In: James M. Humber, Robert F. Almeder. What is disease? , Springer 1997.
- ↑ H. Tristram Engelhardt: The terms "health" and "disease" . In: Thomas Schramme: Disease Theories. Suhrkamp, Berlin 2012, p. 49.
- ^ Richard Koch: The medical diagnosis. Contribution to knowledge of medical thinking. JF Bergmann, Wiesbaden 1920, pp. 130-131.
- ↑ Kazem Sadegh-Zadeh: Handbook of Analytic Philosophy of Medicine. Springer, 2011, p. 150.
- ^ Lennard Nordenfelt: Quality of Life - Health and Happiness. Avebury, Aldershot 1993, p. 8.
- ↑ Heinrich Schipperges (Ed.): Pathogenesis. Fundamentals and perspectives of a theoretical pathology. Berlin / Heidelberg / New York / Tokyo 1985.
- ↑ Urban Wiesing: He who heals is right. About pragmatics and plurality in medicine. Schatthauer, Stuttgart 2004, p. 51ff.
- ↑ Thomas Schramme: Disease Theories. Suhrkamp, Berlin 2012, p. 21ff.
- ↑ The pair of opposites ontological-physiological was also described by Henry Cohen (1961, p. 160) as the contrast between platonic, realistic, rationalistic and Hippocratic, nominalistic, empirical
- ^ H. Tristram Engelhardt, Jr .: The terms 'health' and 'disease'. In: Thomas Schramme: Disease Theories. Suhrkamp, Berlin 2012, p. 52.
- ↑ Wolfgang Wieland: Diagnosis. Medical Theory Considerations. de Gruyter, Berlin / New York 1975, p. 100ff. especially p. 110.
- ↑ Peter Hucklenbroich: The scientific theory of the concept of disease. In: Thomas Schramme: Disease Theories. Suhrkamp, Berlin 2012, p. 156ff.
- ^ Dietrich von Engelhardt : Illness, pain and the art of living. A cultural history of body experience. Beck, Munich 1999, p. 88.
- ↑ Daniel Callahan: The World Health Organization's Definition of Health. In: Thomas Schramme: Disease Theories. Suhrkamp, Berlin 2012, pp. 191-204.
- ↑ Urban Wiesing (Ed.): Medical ethics. Reclam Verlag, Stuttgart 2005, p. 38ff.
- ↑ Susanne Michl, Thomas Potthast, Urban Wiesing (ed.): Plurality in medicine. Karl Alber, Munich 2008, p. 11.
- ↑ Tom Beauchamp, James Childress: Principles of Biomedical Ethics. 6th edition. Oxford University Press, Oxford 2008.
- ↑ Marcus Düwell, Christof Hübenthal, Micha Werner (eds.): Handbook Ethics. Metzler, Stuttgart 2006, pp. 274ff.
- ↑ Oliver Rauprich: Universal ethical principles and diversity of ethical convictions. Susanne Michl, Thomas Potthast, Urban Wiesing (Ed.): Plurality in Medicine. Karl Alber, Munich 2008, p. 131ff.
- ↑ Dietrich von Engelhardt, Heinrich Schipperges: The inner connections between philosophy and medicine in the 20th century. Scientific Book Society, Darmstadt 1980, p. 88.
- ↑ For example: Bamberg, 2013; Würzburg 2010, Giessen
- ^ Stefan Schulz: Medical history (s). In: Schulz, Steigleder, Fangerau, Paul: History, theory and ethics of medicine. Suhrkamp, Frankfurt am Main 2012, p. 46.
- ↑ Founded as Metamed in 1977, then anonymous in Metamedicine .
- ↑ Urban Wiesing: Who heals is right? Schattauer, Stuttgart 2004, pp. 22/33; Urban Wiesing takes the model further training regulations of the German Medical Association as evidence of the institutionalized plurality in German medicine.
- ↑ Robert Jütte (2008, p. 393) refers to the Medicines Act of 1976 for the same reasoning .
- ^ Norbert W. Paul: Medical theoretical aspects of medical research. In: Stefan Schulz, Klaus Steigleder, Heiner Fangerau: History, theory and ethics of medicine. Suhrkamp, 2013, p. 271.
- ↑ James A. Marcum: An Introductory Philosophy of Medicine. Springer, London 2008, p. 20.
- ^ Daniel Strech: Concealed pluralism of value judgments in medical benefit evaluation. In: Susanne Michl, Thomas Potthast, Urban Wiesing (ed.): Plurality in medicine. Karl Alber, Munich 2008, p. 11.
- ↑ Monika Bobbert: 'Gold Standard' or plurality of methods in clinical research on humans. In: Susanne Michl, Thomas Potthast, Urban Wiesing (ed.): Plurality in medicine. Karl Alber, Munich 2008, p. 383.
- ↑ Heinz Eppenich: The scientific nature of homeopathy. In: Thomas Genneper, Andreas Wegener: Textbook Homeopathy: Basics and Practice of Classical Homeopathy. Haug, 2010, p. 363.
- ^ Walter Pieringer, Christian Fazekas: Basics of a theoretical pathology. In: Walter Pieringer, Franz Eibner (Ed.): To the philosophy of medicine. Springer, Vienna / New York 2000, p. 81.
- ↑ Rudolf Steiner: Basic lines of an epistemology of the Goethean worldview with special reference to Schiller (1896). GA 2, 8th edition. Dornach 2003, ISBN 3-7274-0020-X . (Full text)
- ↑ Rudolf Steiner: The Philosophy of Freedom , Fundamentals of a Modern Worldview, Psychological Observation Results According to Scientific Methods. GA 4, 16th edition. Rudolf Steiner Verlag, Dornach 1995, ISBN 3-7274-0040-4 . (Paperback edition TB 627, ISBN 3-7274-6271-X ) (full text)
- ^ A b Peter Heusser : Anthroposophic Medicine and Science. Contributions to an integrative medical anthropology . Schattauer Verlag, Stuttgart 2010, ISBN 978-3-7945-2807-3 (habilitation thesis). Book review here: Helmut Kiene : Anthroposophic Medicine - Thinking outside the box. In: Dtsch Arztebl. 108 (48), 2011, pp. A-2612 / B-2183 / C-2155 (online)
- ↑ a b Rudolf Steiner: The occult science in outline. 1910. GA 13th 30th edition. Rudolf Steiner Verlag, Dornach. 1989, ISBN 3-7274-0130-3 . (Full text)
- ↑ Lectures for doctors and medical students can be found in volumes 312–319 of the Rudolf Steiner Complete Edition (full text)
- ↑ a b c Rudolf Steiner, Ita Wegman: Fundamentals for an expansion of the healing arts according to humanistic knowledge . Rudolf Steiner Verlag, Dornach 1991 (first edition: 1925). (Full text)
- ↑ a b Rudolf Steiner: From soul riddles. Anthropology and Anthroposophy, Max Dessoir on Anthroposophy, Franz Brentano (An Obituary). Sketchy extensions. GA 21, 5th edition. Rudolf Steiner Verlag, Dornach 1983, ISBN 3-7274-0210-5 .
- ↑ Johannes Rohen : Morphology of the human organism - attempt at a Goethean theory of human shapes . Verlag frei Geistesleben, Stuttgart 2000, ISBN 3-7725-1998-9 .
- ↑ Rudolf Steiner: Anthroposophy, a fragment from 1910. GA 45. 5th edition. Rudolf Steiner Verlag, Dornach 2009, ISBN 978-3-7274-0452-8 . (Full text)
- ↑ Helmut Kiene : Complementary Medicine - School Medicine. The science controversy at the end of the 20th century. Schattauer, Stuttgart 1996, ISBN 3-7945-1734-2 .
- ↑ Helmut Kiene: Complementary methodology of clinical research. Cognition-based Medicine . Springer, Berlin / Heidelberg 2001, ISBN 3-540-41022-8 full text online
- ^ Dialogue forum on pluralism in medicine