Abstract
The Philosophy and Medicine series, to which this book contributes, is dedicated to the project of gaining clarity about how the traditional Hippocratic ethos was replaced by bioethics. It explores how the moral code of a guild, after having passed the stage of virtue-ethical accounts of the “good physician,” gave way to a more general, philosophically framed “medical ethics,” and how the latter mutated into a “bioethics” that addresses not only medical professionals, but also employees in medicine’s auxiliary occupations, hospital managers, patients, insurances, pharmaceutical industries, and the healthcare system all the way up to legislators and policymakers shaping that system’s political framework.
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Notes
- 1.
The term bioethics in this volume will thus be used in a more restricted sense than has become established in the more recent German literature, as, e.g., in Sturma & Heinrichs, 2015.
- 2.
Thus also, the bioethics monography by Düwell & Steigleder, 2003, seeks to render the theory and method reflections developed in the USA accessible to non-English-speaking German readers.
- 3.
Frewer, 2011, even charges English-speaking bioethicists with having suppressed the German contribution to the field. But even in Germany, the fact that the first Journal on medical ethics after the Second World-War appeared 10 years before the publication of English-language journals on the subject is usually overlooked. (On the reason for this neglect, see below, note 63.) Some of the newer bioethics monographs make a point in recapturing specifically German, or at least continental European sources of the field; see, e.g., Ach et al., 2014, and Bauer, 2017. An interesting East German case of emphasis on nationality is Löther’s insistence (in this volume, Chap. 3) on the German origin of the term bioethics, cf. also Steger et al., 2014.
- 4.
- 5.
- 6.
This is why thinkers like Hübner avoid the term altogether. He instead widens the concept of “medical ethics” or “ethics in medicine” so as to cover those very political, legal, and economic concerns that come with a publicly subsidized health care, and which the international literature subsumes under “bioethics.”
- 7.
The memory of this distortion undergirds the country’s refusal to sign the Oviedo Convention threatening to overrule Germany’s relatively strong legal protection of human life before birth (see, e.g., Grafenecker Erklärung, 1998, pp. 191f) – even if, as Paul, 1998, pp. 67f, observes, Germany’s confessed protectionism is waning. That same memory also still frames Germans’ inability to address their nation’s persistent and dramatic demographic demise, and it is still prominent in end-of-the-century bioethics monographs (see, e.g., part I of the essays in Tröhler & Reiter-Theil, 1997). Even more, only 2 years ago, that same memory still informed the sense of relief with which the editors of Germany’s leading bioethical journal greeted the invitation the World Medical Association (WMA) extended to the German Physicians’ Chamber, (“Bundesärztekammer”), asking that body to head the work group charged with revising the WMA’s Geneva Oath (cf. Montgomery et al., 2018).
- 8.
See Korff et al., 1998.
- 9.
It should be remembered, after all, that the Deutsches Reich legally continued to exist as a single legal entity up to the 2 plus 4 agreement after re-unification in 1990.
- 10.
- 11.
An example of such internalization is the revival of an idea that originally had undergirded socialist medicine in the GDR, namely, that the relationship between physician and patient should be kept “free” of financial considerations (cf. Spaar, Chap. 5). The continued salience of this idea can still be identified in the persistent German emphasis on equality of access, widespread hostility against private medical insurance, and the refusal of politicians to address the financial sustainability of a health care that tends to recognize “rights” for everyone to everything. All of this marks mainstream media approaches to health care in Germany, as criticized, e.g., in Haverkate, 1999a, pp. 120 ff.
- 12.
- 13.
The bitterness of that struggle can perhaps be better understood if one remembers that the German “Stand,” as in “Ärztestand” or in “Standesethik”, does not exactly correspond to either “guild” (which also corresponds to the somewhat dated “Zunft”) or to “profession,” a term commonly used in English accounts of medicine. In German, “Stand” carries the connotation of a vocation (“Beruf,” Berufsstand”), which also covers civil servants and craftsmen, but in addition has theological connotations within Protestantism (cf. Schäfers, 2003, pp. 378f).
- 14.
Cf. the tardiness of institutionalization of an ethical reflection on medicine in Germany, as noted by Reiter-Theil, 1997, p. 356.
- 15.
- 16.
See the ‚Anweisung an die Vorsteher der Kliniken, Polikliniken und sonstigen Krankenanstalten’ in Zentralblatt für die gesamte Unterrichtsverwaltung in Preussen, 1901, pp. 188–9, as quoted in Schulz et al., 2006, p. 249, or Reichsminister des Inneren, ʽRundschreiben betreffend Richtlinien für neuartige Heilbehandlung und für die Vornahme wissenschaftlicher Versuche am Menschen vom 28.2.1931, 1931.
- 17.
Even below the level of their insufficiency, the Nuremberg Code has frequently been charged with having altogether failed to provide useful guidance, see, e.g., Krause & Winslade, 1997, pp. 209ff, 212 f.
- 18.
It also took some time (until 1985) before the German Berufsordnung took an at least formal (cf. Herranz, 1997, p. 175) notice of the need to ethically regulate research in response to the Nuremberg- and Helsinki codes.
- 19.
In 1975, such careless relegation encouraged the Halle-based Leopoldina to sponsor studies in celebration of the medical ethicist Emil Abderhalden, whose collectivist moral principles (understandably welcomed in a socialist environment) had previously undergirded his prominent support of National Socialism (cf. Kaasch & Kaasch, 2001).
- 20.
A scathing criticism of the misrepresentations encouraged by such official denunciation is offered by Burkart, 1979, in regard to Spaar’s, 1978 critique of capitalist medicine. But obviously, it is difficult to judge to what extent the production of such negative reports may have been part of the permission procedure for participation in a Western conference.
- 21.
As Leist, 1993, p. 21, observes, such agreement in the endorsement of an important “value” (here: life) between value conservatives in the West and socialists in the East also reflects the opposition endorsed by both against a (classical) liberal conception of bioethics that prioritizes autonomy along with market forces.
- 22.
A good example is the turn to Albert Schweitzer and his ethics of life in the later work of Ernst Luther. To him, Schweitzer seemed to provide common moral ground for all medical ethics worldwide.
- 23.
A similar quest for common ground, in fact, also had marked the willingness of most mainstream Western theologians to de-emphasize dogma and ritual in favor of a society-wide endorsement of social justice – a position that is well illustrated in Hübner’s essay.
- 24.
Some of East Germany’s leading bioethicists managed to continue their academic work even after German re-unification. Their major commitment was and still is to advocate those aspects of socialist medicine they continue to consider superior to the medicine offered within the market economy framework of the West. They argue for implementation of such aspects along with the socialist ideals informing them. Thus, the Rosa Luxemburg Foundation still maintains a journal devoted to promoting such goals right into the twenty-first century (see, for example, Rausch et al., 2000; Spaar, 2001; and Schubert-Lehnhardt, 2002).
- 25.
For a critical discussion of that general trend toward socialist ideas in Western European health care, see Delkeskamp-Hayes, 2015, pp. 40–2.
- 26.
- 27.
An interesting modification of Toellner’s account is offered by Brumlik, 2008; most National Socialist physicians who had committed medical crimes not only lacked scientific expertise, but pursued a “holistic” approach to medicine.
- 28.
Cf. Staatsratsvorsitzender W. Ulbricht, 1961, p. 56.
- 29.
- 30.
- 31.
Absence of dialogue, of course, characterized only the narrowly medical realm. As research in the areas of sociology and political theory makes clear, a dialogue of negotiation in a setting of government-regulated health care permeated the relationship between representatives of medical practitioners, their agencies for reimbursement administration (the “Kassenärztliche Vereinigungen”), and the state-sponsored insurance agencies; see, e.g., Döhler & Manow-Borgwardt, 1992.
- 32.
It must be kept in mind, however, that such recognition, at least with regard to infant mortality, was earned through a decision to count live births of 1000 g and under as dead births, and thus as abortions that did not appear in the statistics (Gries, 2002, pp. 242–246).
- 33.
- 34.
Cf. Engelhardt, 1996, pp. 105 ff.
- 35.
Cf. Habermas, 1981, vol. 1, pp. 30ff.
- 36.
Patzig’s relationship to Habermas is complex. He distances himself from reduction of claims about “truth” to statements of interest, as reflecting the Marxist tendencies still affirmed by the early Habermas. But while Patzig’s own account of “objective knowledge” about what he wishes to be recognized as “values” wavers between affirming knowledge about what people (as a matter of fact) value and knowledge about those values themselves, his understanding of the former as heuristic for the latter again comes close to what the later Habermas affirmed. The mature Habermas indeed sees the process of discursive generation of a societal consensus about “what is valued” as heuristic for the objective validity of those values (or their approbation as “reasonable”). The same assumption informs Patzig’s aspirations for the discussions of bioethics, as promoted by the Academy. Here as well, a gradual adjustment of participants’ initial value commitments to the emerging consensus is expected and affirmed. Here as well, in other words, value commitments are to be treated like party interests which can, and must, be modified in the course of political negotiation. When concluding with an endorsement of a “properly domination-free societal value discourse,” Patzig in fact signals agreement with (that later) Habermas.
- 37.
See, for example, the discussion on physician-assisted suicide in Kress, 2020. Insisting on the dialogical nature of the relationship between physician and patient, Kress takes human life to be better protected by counseling services than by legal constraints. He disregards the extent to which reliance on counseling services in the case of abortion has disappointed similar hopes in Germany. For another example, see Meister, 2020, on the possibility of PAS in church-operated hospitals. A good recent summary of the resulting dissensus, both between Roman Catholics and Protestants in Germany and among various representatives of the latter, is offered by Bingener, 2020.
- 38.
Distant memories of that ethos are still alive in some of Germany’s federal states. Graduates here receive a framed print of a physician’s oath together with their diploma. A shortened version of that oath also still introduces medical Berufsordnungen (professional guidelines) in those states (cf. Muster-Berufsordnung, 2011).
- 39.
- 40.
Obviously, the meanings can also be reversed. In Kant’s moral theory, e.g., the “moral” presents the framework for a diversity of “Sitten” or ethoi, the latter of which is also often associated with the term “ethics.”
- 41.
That un-resolvability can of course in turn be understood either in a merely epistemological sense (as the unavailability of discursively rational tools to overcome moral pluralism) or in a more ambitious metaphysical sense (as an ontological claim about the moral universe).
- 42.
- 43.
An alternative approach to anthropology, with markedly different bioethical implications, is offered for example in a monography on philosophic-theological approaches to bioethics edited by Löw, 1990, pp. 11–27.
- 44.
Given the much-discussed disadvantages of principlism, it is remarkable how persistent faith in their bioethical fruitfulness has remained (see, e.g., Siebel & Tiesmeier, 2019).
- 45.
For the counterproductive consequences in view of the interest of research subjects, see Baumgartner, 2000, pp. 214 ff.
- 46.
For a recent summary of the ethical problems involved in medical error in the united German state, see Schmidt et al., 2012.
- 47.
Unofficially, of course, an appeal to “material self-interest” could not be avoided, cf. Bley, 1963, p. 78.
- 48.
For the special case of claims to compensation on the basis of failure to secure informed consent, a helpful historical summary of adjudication in Germany (as distinguished from Austria and Switzerland) is offered by Beppel, 2007.
- 49.
Unofficially, of course, such self-reporting would risk physicians’ status within their healthcare institution. They would be held responsible for the increased pressure imposed on their institution by more restrictive preventive measures (cf. Bley, 1963, pp. 80ff, 87, 126).
- 50.
As mentioned above (cf. Note 44), these principles had been adopted into the bioethics mainstream all over Europe, encouraging concern about “justice” to interfere with the primacy of concern for the particular patient respectively ‘at hand.’ Surely, physicians always must contextualize that primacy in view of the finitude of their own (time and energy) resources. According to Germany’s legal framework for medicine (see Bundesministerium der Justiz und für Verbraucherschutz, Bundesamt für Justiz, 1961, § 1), the physician’s obligations are to address health not only in their individual patients but also in society. In exceptional emergencies (“triage”), he must even allocate scarce societal resources. Still, justice, as understood in modern social democracies like Germany, imposes an additional regard for equality (in particular: equality of access to medical services). It is this further regard that may interfere with the traditional ethos of “doing justice” to the patient here and now. For a typically German criticism of such interference, as also implied in imposing a regard for economic issues of health care, see Wiesing, 1999, pp. 188ff; Taupitz, 1999, pp. 351f; and Haverkate, 1999b, p. 364.
- 51.
- 52.
Unlike in other countries, conservative Evangelicals are only a minority in Germany. Their most prominent bioethical representative is Ulrich Eibach; see his discussion of human dignity at the margins of life (2004).
- 53.
Thus, bioethical problems involved in – e.g. – contraception, abortion, stem cell research, a socially “helpful” definition of brain death, and physician-assisted suicide are claimed to be resolvable by recourse to Roman-Catholicism-style rational (‘natural law’) principles.
- 54.
The shortcomings presented by both alternatives become visible, once one recalls what the Christianity invoked on both sides originally implies. Conceiving of one’s medical performance as “Christian” has always meant not only seeking to follow the model of Christ the healer in lovingly relieving patients’ suffering. It has also imposed the task of discerning when a patient needs to be reminded to repent and “sin no more,” (John 8:11) or else to be invited to accept his medically un-relievable suffering as his God-given cross. Such Christian health care also recognizes that patients need support through prayer. Both Roman Catholicism’s turn to rationality and mainline Protestantism’s focus on a love that envisages nothing beyond the immanent and finite thus fail to prioritize the personal (and eucharistic) quest for an encounter with Christ, outside of which human efforts at helping others are in vain.
- 55.
Patzig’s own generally not unfriendly but still distanced and suspicious regard for Christian principles opens up a common ground between secularism and the modernized Christian mainstream. Here even socialist philosophers are accommodated, if they appreciate the humanitarian Christianity of an Albert Schweitzer. The secular priority accorded to “reasonableness” here still allows for a Christianity whose moral norms, stripped of their link with dogma, liturgy, and spiritual discipline, have boiled down to an endorsement of “values.”
- 56.
One example for the resulting well-adjusted understanding of religiousness is offered by Platzer & Zissler, 2014.
- 57.
The latter, of course, is even more invasive: Hübner’s vision of cooperative group discussion revolves around problems that arise in the context of an urgent decision that must be taken under time pressure. The goal is to determine conditions under which a common solution can be worked out, which allows all those affected by the final decision to be “at peace” with that decision. Such “peace” here reflects the fact that in dramatic conflict situations one may have to settle for a lesser of evils. The “relativization” here remains limited; it requires nothing beyond the willingness to refrain from imposing one’s respectively own moral view on dissenting others. Even while doing so, in other words, one may keep one’s own convictions intact. In the case of Habermas, as endorsed by Patzig, the same moral concern about avoiding such imposing arises not in view of urgent decision-making in very particular cases. It arises for those who pursue a universal historical project, the project of designing generally binding moral guidance. The required relativization here is not only about abstaining from imposing one’s own views on others. Instead, each participant must accept a principled downgrading of all validity claims to statements about personal preference. He must be willing to remove all barriers that might hinder his exposing his convictions to modification in the course of a collective learning process. He, in other words, must be willing to altogether change the “preferences” undergirding those convictions. Only such resolute renunciation of stable axiological commitments can qualify discussion partners for the eventual “blending” that facilitates societal agreement.
- 58.
An extreme form of such social learning is advocated in an earlier essay by Patzig. Here he recommends liberalizing the prohibition against physician-assisted suicide or active euthanasia for a set period of time, in order to gain experience with the consequences and thus to develop a basis for their subsequent societal evaluation as desirable or undesirable, so that the respective legal consequences can be adjusted; cf. Patzig, 2012.
- 59.
The project of establishing a “just” society through Habermas-style public deliberation aims at agreements that can be established as “generally acceptable” (Habermas, 1973). It requires participants in that deliberation (and thus ideally all members of a given society) to translate whatever fixed moral positions they bring to the table into “moral viewpoints.” Such viewpoints, conceived in the likeness of personal, and therefore private, interests, must be (re-)construed as resting on respectively subjective “preferences” or “choices.” Only under this condition, after all, can such initial moral positions be treated as flexible or open to modification and accommodation in the course of the social learning the discussion is to facilitate. What each participant starts out with as his affirmed truth and rejected falsehood thus gets modified through a discursive process that aims at a final ‘truth’ which, for each stage in the discussion, can be claimed as “absolute” (in the sense of: collectively agreed on). Only with such accepted personal moral flexibility can the politically disruptive potential of serious moral diversity be conceived to be discursively redeemable (Habermas, 1993, pp. 174ff). Only through the resulting agreements – so it is further assumed – can a society-wide consensus be reached, which can be trusted to reveal (or “establish”) moral norms and desirable goods that are accepted as ‘valid’ or ‘indispensable’ (cf. the “accepted form of life” in Habermas, 1993, p. 168).
- 60.
Oddly, during the process of German re-unification, similarly restrictive conditions are claimed to have also been imposed, and imposed in the name of Habermas’ theory, against communist believers; cf. Hecht, 1997, p. 17.
- 61.
We are covering with polite silence here the unfortunate alternative strategies of burning or exiling dissenters.
- 62.
The term “open society” was, of course, coined by Karl Popper. In spite of Popper’s opposition to Habermas during the “Positivismusstreit” in Germany’s 1960s, both agree in endorsing a society that rests on democratically legitimized principles, and thus on dominance-free public deliberation (cf. Haller, 2017, p. 2).
- 63.
As a recent dissertation shows (Leu, 2015, pp. 20ff), that silencing has also kept the origin of German studies in medical ethics, as provided by the Catholic journal Arzt und Christ published since 1954, one of the best-kept secrets in the later bioethical mainstream. This is remarkable, given the fact that the editors of that journal had been willing to weaken its original Christian (and Catholic) commitments in favor of alternative religious and cultural variety. This process of self-mainstreaming, which had started around 1989, even led to a re-naming as Zeitschrift für medizinische Ethik in 1993, so that the Catholic profile of the Journal today is visible mostly in the fact that the journal is edited by the Catholic Görres Society. Still, the religious background seems to have remained noticeable enough to warrant exclusion from the mainline academic bioethics discourse.
A more recent protest against such silencing, as promoted in the name of ‘anti-discrimination’ by the mainstream’s liberal lobby for ‘diversity in sexual orientation,’ is exemplified by a press release of the MEDRUM information platform with an appeal signed by numerous scholars and physicians in the interest of freedom of speech and therapy (2009).
- 64.
The difference between (a) traditional and (b) post-traditional renderings of “moral truth” turns on either (a) using that latter concept in a literal (i.e., confession-oriented) sense as something objective, eternal, and faithfully received by those who affirm its validity, or else (b) accepting only its constructivist reduction. That difference, in other words, turns on either (a) opposing or (b) (somewhat paradoxically) confessing another kind of absolute faith in a very particular form of discursive process as heuristic for what all can acknowledge as reasonably valid. That latter (Habermasian model, i.e., b) condemns the former model (a) to “entropy” (1993, p. 176), allowing only the latter (b) to shape the intended social consensus. Its declared goal of accommodating diversity only in its post-traditional forms, however, also exposes the self-defeating impact of that strategy. Once the traditional sources of cultural diversity have been ‘post-traditionalized’ into merely aesthetic preferences, their power to sustain such diversity in the midst of social change is weakened. As the famous dictum of the former judge of the Federal Constitutional Court, Ernst Wolfgang Böckenförde, warns (1967, p. 75 footnote), the freedom-affirming secular state lives on presuppositions (i.e., the internal drives and binding forces traditional religious faith communicates to believers), which that state cannot secure on its own. That is to say, in the end, the liberal ‘entropy’ threatening those traditions will also swallow the diversity resources required for the freedom affirmed.
- 65.
Such disparagement, of course, targets conservative evangelical Protestants with even greater passion, because (as Patzig argues) they – unlike Roman Catholics –do not even appeal to some – if deviant – rationality, about which one could disagree. But since the essays in this volume do not include a fitting representative, this side of the problem of diversity tolerance can be left un-addressed.
- 66.
Cf. Habermas, 1983.
- 67.
For a recent analysis of problems involved in commitment to such participation, see Hansen et al., 2018, p. 303.
- 68.
The resulting “consensus-dictatorship” and conformism is prominently criticized not within bioethics, but by artists like Botho Strauss (e.g., 2020).
- 69.
Examples can be found, most prominently in discussions about how the medical profession’s social mission of having to serve whatever is proclaimed as “medical needs” in Germany can be harmonized with respect for physicians’ moral opposition to a practice like abortion, which the German penal law still classifies as illegal (§ 218), except (§218a) under certain conditions. Recent cases are discussed in [No author], 2017, idea, and Becker, 2020. Such opposition may also underlie the general unwillingness of German physicians to offer information about abortive medication (cf. Arp, 2013). A helpful legal summary is offered by Ärzte für das Leben, 2007.
- 70.
An admirable summary of constitutional bases, legislation, and court judgments in view of bioethical issues is offered by Dreier, 2013.
- 71.
- 72.
On the conceptual problems presented by that framework‘s own moral-political claim, see Delkeskamp-Hayes, 2005.
- 73.
Cf. the corresponding claims for unambiguous guidance offered by the German Physicians’ Chamber, as criticized by Kliesch, 2013, p. 173.
- 74.
It was only in 2009 that the German Bundestag ratified a modification of its Civil Law guardianship law that institutionalized such advance directives (§§ 190a and b) about conditions, under which further life-sustaining interventions should be avoided or discontinued. That law also provides resources for allowing guardians or authorized persons to implement such directives.
- 75.
Cf. Bundesgerichtshof, 2016.
- 76.
- 77.
Our discussion of conceptual problems focuses on situations that arise primarily in critical therapeutic decision-making, not necessarily in view of the (indisputable) need to distinguish between therapy and research, or to prioritize therapy over research, as discussed in Baker, 1997.
- 78.
Corresponding criticism of the applicability of the concept of autonomy, as developed by J. S. Mill, is offered by Kaufmann, 2015, pp. 19, 186ff. For a helpful recent discussion of problems involved in attributing autonomy to patients, see Hermann et al., 2016. Important further systematic treatments are offered in Wiesemann & Simon, 2013, and in Becker, 2019.
- 79.
Cf. the very clear account in Wittwer, 2020.
- 80.
Cf. Deutscher Bundestag, 2015. The implications of this change for physicians are unclear. Already the principles about care for the dying issued by the Bundesärztekammer in 2011 had weakened the previous classification of assistance in suicide as incompatible with the physician’s ethos. There principles merely asserted that such assistance does not represent a medical service. In 2017, the Bundesärztekammer responded to the new law by clarifying penal implications of various scenarios. Still in 2019, seven out of seventeen federal physician chambers have liberalized their professional code in view of physician-assisted suicide, while the other ten chambers still prohibit the practice (de Ridder, 2019). A good Protestant summary of the difficulty of attributing autonomy to patients in the context of the option of PAS is offered by Eibach (n.d.), and a Roman Catholic parallel account by Spaemann et al., 2015.
- 81.
In February 2020, the German constitutional court declared the 2015 prohibition of “repetition-oriented PAS” unconstitutional, thus once again aggravating the moral impact of the undiscerning call for “autonomy.” For critical Roman Catholic and secular responses, see for example Heereman, 2020, and Duttke, 2020.
- 82.
See the interview with palliative physician Thomas Sitte in Arnold, 2020.
- 83.
Disregard for the problem involved in top-down efforts at helping patients morally to live up to the autonomy recognized by the law also hampers attempts at “empowering” reproductive “autonomy” in PND settings; cf. Rubeis et al., 2020.
- 84.
It is revealing that Beppel, 2007, p. 172, identifies increasing anonymization in the relationship between physicians and patients as cause for the latter’s increasing tendency to sue for perceived damages or failings.
- 85.
Among the sources of von Uexküll’s holistic approach, the concept of “Gestaltkreis”, as developed by Viktor von Weizsäcker, is most prominent (cf. von Uexküll, 1987). Both physicians advocated a psychosomatic re-orientation of medicine. Since the extent of von Weizsäcker’s involvement with National Socialism is still a disputed matter today (see, e.g., Brumlik, 2008), reference to that earlier project is often perceived as unhelpful for the cause of psychosomatic medicine in Germany. A more balanced counterexample is Achilles, 2008.
- 86.
Neumann’s account (1993, pp. 107 f.) of the quest for holistic medicine during Germany’s Weimar republic closes with a reminder of Richard Koch’s critical reserve against such aspirations, and with a proposal to re-conceive that same quest in terms of a mutuality of agreement about therapeutic interventions between physicians and their patients.
- 87.
One may recall here the discussion of patient information in the essay by Günther; here as well, physicians were granted considerable authority. They could frame their communication with patients in ways they judged helpful for securing cooperation with what they, as physicians, considered medically necessary.
- 88.
More recent German discussions of similar problems involved in terminal nursing care are offered by Giese et al., 2006, especially pp. 138 ff.; Rabe, 2017; and for the parallel situation in Austria, Eisele, 2017. See also the more general account of ethics in nursing in Monteverde, 2012, and Kohlen et al., 2015.
- 89.
The German term „Beruf“(as mentioned above in note 13) indicates a higher status than “work” or “occupation” (“Arbeit, Tätigkeit”). It carries an element of “higher calling” (“Berufung”). But it still differs from “Stand” (guild), which signals autonomy, authority in self-regulation, along with a specific moral commitment. The English “profession” occupies an intermediate position between Beruf and Stand. Its use in Hahn’s essay should be understood as referring to a Beruf plus moral commitment. It thus differs from the Freiberuflichkeit (professional freedom) still claimed by German representatives of the medical profession today, as in an interview with the new head of the Hessen physicians’ chamber (Karb, 2018.)
- 90.
Regrettably, similar conclusions can be drawn for caretaking in the unified German state today, see, e.g., Giese, 2019.
- 91.
- 92.
Widespread awareness of the conceptual problems presented by psychotherapy is well exemplified by Helmchen, 1998, pp. 78–80.
- 93.
1983, pp. 330–338.
- 94.
An example of such a “modern” view is offered by Unschuld, as quoted in Eigler, 1997, p. 158.
- 95.
For a representative example of this view, see Baier, 1999, pp. 40 f.
- 96.
It might be helpful here to remember that one of the founders of German medical ethics, Albert Moll (1862–1939), had separated the duties of collegiality (the Standespflichten in the narrow sense of the term) from what he referred to as the profession’s moral duties (cf. Maehle, 2001, p. 46), and thus from those requirements of due diligence and commitment to the well-being of the individual patient at hand, which the authors of this volume, and thus also this Introduction, treat as an integral part of medicine’s professional ethos. Moll’s distinction held for a period, in which only the first two of the developmental stages noted above had been achieved.
- 97.
For a criticism of this development, see, e.g., M. Simon, 2013, pp. 102–106.
- 98.
Obviously, the limits inherent in such a commitment among those engaged in medicine (and in killing bacteria in order to save patients) had already been noted by the first person to use the term “bioethics,” even if in a non medicine-related sense, i.e., by Fritz Jahr (1927, p. 3 f.).
- 99.
Cf. Baier, 1999, p. 44. It is important to note at this point that our discretely voiced criticism of the way in which Germany’s strongly solidarity-oriented social democracy tends to instrumentalize medicine for its own (disputably) moral agenda does not (at least not prima facie) extend to the (indisputably) legitimate way in which that same state charges the medical profession with the task of securing “adequate” medical care for the population in exchange for recognition of still considerable professional autonomy. On the genesis of that Sicherstellungsauftrag and on the threat its more recent political implementation has been presenting for medicine as a “free” profession, see Richter, 2012.
- 100.
A good example illustrating awareness of the need for such leadership is offered by Lipp’s reminder that – ideally – patients must be able to “entrust themselves” to their physicians (2020, p. 261). Regrettably, of course, such important reminders must be contextualized today by concern for that merely apparent paternalism of care which hides an insidious paternalism of abuse; cf. Wirth & Schmiedebach, 2019.
- 101.
One prominent locus of such upgrading are the guidelines issued by the Federal Physicians’ Chamber (the Richtlinien der Bundesärztekammer), offering regular responses to new legislation or court decisions and developing suggestions for further legal adjustments.
- 102.
In Germany, this diversity has received attention in the discourse on medical ethics and bioethics mostly in relation to Roman Catholicism. The latter’s moral norms are frequently at variance with those affirmed by the secular public (and sometimes get supported by a vocal minority of Evangelicals). Here the initiative of one of the legal health insurance agencies is noteworthy; the Wiesbaden-based BKK IHK (Barmer Krankenkasse/Industrie und Handelskammer) attempted to implement respect for moral opposition to abortion among their voluntary members. The insurance agreed with those members on having them sign a declaration that they will not by themselves ask for, or even wish to support abortions through their premiums. The insurance would reward such declaration by a 300 Euro bonus for each childbirth. (Eiger, 2012). However, the project was soon declared illegal by the superior administration (the “Bundesversicherungsamt,” cf. Buschmann, 2012).
In another and more recent case of moral dissensus, however, diversity won out. Since 2017, the Bundesärztekammer has to tolerate diverse professional guidelines concerning physician-assisted suicide among its federal members (see note 80 above, and also Kliesch, 2013, pp. 333 ff, and, for the special case of medical caretakers challenged by the ethical ambiguity of patients’ voluntary stopping to eat and drink, Starke, 2020, pp. 182 ff). For a more systematic discussion of the need for such diversification, see Delkeskamp-Hayes, 2005, esp. pp. 152 ff.
- 103.
I follow here the arguments developed by H. T. Engelhardt, Jr., 19962, pp. 294 f.
- 104.
- 105.
The list offered here is limited. It excludes the whole realm of ethical reflections on psychiatry. It represents only issues which have already invited systematic reflection in bioethical survey publications, or which have been discussed in academic or professional journals. Again, as with the selection of contributions to this volume, publications on “bioethics” are considered only to the extent that they remain related to (human) medical ethics and the ethos of the profession. Large areas of what today is treated in “bioethical terms” (i.e., the treatment of animals, of the environment, of the climate and such) remain un-addressed.
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Delkeskamp-Hayes, C. (2022). Introduction. In: Delkeskamp-Hayes, C. (eds) From Physicians’ Professional Ethos towards Medical Ethics and Bioethics . Philosophy and Medicine, vol 140. Springer, Cham. https://doi.org/10.1007/978-3-030-78036-4_1
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