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From Square Problems to Round Reasoning: A Systems Theoretical View of Medical Ethics Problems and Their Solution Practices

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Ethik – Normen – Werte

Part of the book series: Studien zu einer Gesellschaft der Gegenwarten ((SZEGG,volume 1))

Abstract

This essay discusses three highly interconnected themes from a systems theoretical point of view: the evidence-based turn in biomedicine, the role and relevance of ethics in this current trend, and the practices of ethics organizations in the field of medicine. First, the origins and contours of evidence-based medicine (EBM) are outlined and put against the backdrop of their societal context. Then, the question of ethics and its contents in current EBM-informed medical practices are examined by asking what kind of problems are eventually labeled as ethical and why? In the latest section, the sites of ethical reasoning, medical ethics committees and commissions, are taken up for observation. The argumentation is based on an on-going empirical case study of a national ethics organization in Finland, the Advisory Board on Social Welfare and Healthcare (ETENE). The essay concludes by discussing the function of problem-based ethics organizations in polycentric society of the presents.

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Notes

  1. 1.

    My own empirical research (started in 2009) concentrates on a national Finnish ethics board, the National Advisory Board on Social Welfare and Healthcare, ETENE (www.etene.fi/en). The empirical interpretations are preliminary at this point.

  2. 2.

    The term evidence-based medicine first appeared in the published literature the previous year, in 1991. It was evidently this particular JAMA publication that brought both the term and the general idea of EBM to a wider medical public and started the triumphal march of the new paradigm (Montori and Guyatt 2008; see also Liberati and Vineis 2004 for a more critical summary). It is also possible to trace the roots of EBM back to Archie Cochrane’s lectures in epidemiology and research methods from 1972 (see Ashcroft 2004, S. 131).

  3. 3.

    In Finland EBM orientation began to take took root shortly after the original JAMA article and the first official EBM guidelines were published in Finnish in 1997 by the Finnish Medical Society Duodecim.

  4. 4.

    The Finnish EBMG-pages in English, based on the colossal international Cochrane-database (http://www.thecochranelibrary.com) can be found at the website http://www.terveysportti.fi/pls/ebmg/ltk.koti and include almost one thousand care guidelines, over 3,500 evidence summaries and over one thousand pictures, all of which can be downloaded onto mobile phones and hand-held computers, thus enabling physicians to use them during treatment.

  5. 5.

    All translations from Finnish to English are the author’s.

  6. 6.

    The demarcations of ethical problems are flexible as a matter of course and the gamut of issues described as ‘ethical’ by doctors seems to be fairly wide (see Du Val et al. 2001 and 2004) and differs from the definitions of professional ethicists (see Self et al. 1993).

  7. 7.

    Ethics agencies are not only on the receiving end of the emerging biomedical problems. In the case of fetal screenings, for example, parents carry the burden of particularly troublesome ethical decisions; medicine produces only (publicly expressed) value neutral information (Jallinoja 2002b; Helén 2004, S. 30–35).

  8. 8.

    Various agencies that focus on medical ethics cover the whole field of medicine. They extend from the multifaceted, often legislation-informing, nationwide advisory boards (e.g. in Finland, the National Advisory Board on Social Welfare and Healthcare, ETENE) to intra-professional committees (the Committee for Ethical Matters of Principle of the Finnish Medical Association) to general forums (the Physicians’ Ethics Forum) to various intra-organizational commissions and more free-forming local discussions (see Lötjönen 1999; Fuchs 2005, p. 28–29; Halila 2003, S.  357–361; cf. Kappel 2008, S. 25–27 and Kettner 2005, S. 4–5). On the early stages of hospital ethics committees, see Rosner 1985.

  9. 9.

    The symptoms of the scientific self-understanding of the medical profession is easily found, especially in efforts to close off all non-biomedical ways of healing from the medical sphere and from the focus on evidence-based diagnoses, treatment and prevention early on in medical training.

  10. 10.

    74 % of 344 American physicians who took part in a telephone interview stated that their last dilemma ending in ethical consultation was related to questions of the end-phase of life. These same dilemmas led to ethical consultations in every group of physicians interviewed. (DuVal et al. 2001 and 2004, cf. Saarni et al. 2008.)

References

  • Armstrong, D. (2007). Professionalism, indeterminacy and the EBM project. BioSocieties, 2(1), 73–84.

    Article  Google Scholar 

  • Ashcroft, R. E. (2004). Current epistemological problems in evidence based medicine. Journal of Medical Ethics, 30(2), 131–135.

    Article  Google Scholar 

  • Bauch, J. (2000). Selbst- und Fremdbeschreibung des Gesundheitswesens. Anmerkungen zu einem absonderlichen Sozialsystem. In H. de Berg & J. Schmidt (Eds.), Rezeption und Reflexion. Zur Resonanz der Systemtheorie Niklas Luhmanns außerhalb der Soziologie (pp. 387–410). Frankfurt a. M.: Suhrkamp.

    Google Scholar 

  • Boden, R., Epstein, D., & Latimer, J. (2009). Accounting for ethos or programmes for conduct? The brave new world of research ethics committees. The Sociological Review, 57(4), 727–749.

    Article  Google Scholar 

  • Bogner, A. (2009). Ethisierung und die Marginalisierung der Ethik. Zur Mikropolitik des Wissens in Ethikräten. Soziale Welt, 60(2), 119–137.

    Google Scholar 

  • Bora, A. (2009). Technoscientific normativity and the “Iron Cage” of law. Science, Technology & Human Values, 35(1), 3–28.

    Article  Google Scholar 

  • van den Daele, W. (2001). Von moralischer Kommunikation zur Kommunikation über Moral. Reflexive Distanz in diskursiven Verfahren. Zeitschrift für Soziologie, 30(1), 4–22.

    Google Scholar 

  • van den Daele, W. (2008). Streitkultur. Über den Umgang mit unlösbaren moralischen Konflikten im Nationalen Ethikrat. In D. Gosewinkel & G. Folke Schuppert (Eds.), Politische Kultur im Wandel von Staatlichkeit (WZB-Jahrbuch 2007) (pp. 357–384). Berlin: Edition Sigma.

    Google Scholar 

  • DuVal, G., Sartorius, L., Clarridge, B., Gensler, G., & Danis, M. (2001). What triggers requests for ethics consultations? Journal of Medical Ethics, ##############27(1), 24–29.

    Article  Google Scholar 

  • DuVal, G., Clarridge, B., Gensler, G., & Danis, M. (2004). A national survey of U.S. Internists’ experiences with ethical dilemmas and ethics consultation. Journal of General Internal Medicine (JGIM), 19(3), 251–258.

    Article  Google Scholar 

  • Evidence-Based Medicine Working Group. (1992). Evidence-based medicine: A new approach to teaching the practice of medicine. The Journal of the American Medical Association (JAMA), 268(17), 2420–2425.

    Article  Google Scholar 

  • Evidence-Based Medicine Working Group. (2002). The users’ guide to the medical literature. Introduction: The philosophy of evidence-based medicine (1A) (pp. 3–12). Chicago: The American Medical Association.

    Google Scholar 

  • Fateh-Moghadam, B., & Atzeni, G. (2008). Ethisch vertretbar im Sinne des Gesetzes—Zum Verhältnis von Ethik und Recht am Beispiel der Praxis von Forschungs-Ethikkomissionen. In S. Vöneky, C. Hagedorn, M. Clados, & J. von Achenbach (Eds.), Legitimation ethischer Entscheidungen im Recht—Interdisziplinäre Untersuchungen (pp. 115–143). Berlin: Springer.

    Google Scholar 

  • Fuchs, M. (2005). National ethics councils. Their backgrounds, functions and modes of operation compared. Berlin: National Ethikrat.

    Google Scholar 

  • Fuchs, C., Nagel, E., & Raspe, H. (2009). Rationalisierung, Rationierung und Priorisierung—was ist gemeint? DeutschesÄrzteblatt, 106(12), 554–557.

    Google Scholar 

  • Hacking, I. (1975). The emergence of probability. A philosophical study of early ideas about probability, induction and statistical inference. Cambridge: Cambridge University Press.

    Google Scholar 

  • Hacking, I. (1990). The taming of chance. Cambridge: Cambridge University Press.

    Book  Google Scholar 

  • Hafen, M. (2007). Mythologie der Gesundheit. Zur Integration von Salutogenese und Pathogenese (Mit einem Vorwort von Jost Bauch). Heidelberg: Carl–Auer–Systeme.

    Google Scholar 

  • Halila, R. (2003).The role of national ethics commissions in Finland. Bioethics, 17(4), 357–368.

    Article  Google Scholar 

  • Haug, M. R. (1988). A re-examination of the hypothesis of physician deprofessionalization. Milbank Quarterly, 66(Suppl. 2), 48–56.

    Article  Google Scholar 

  • Helén, I. (2004). Technics over life: Risk, ethics and the existential condition in high-tech antenatal care. Economy and Society, 33(1), 28–51.

    Article  Google Scholar 

  • Høyer, K. (2008). The ethics of research biobanking: A critical review of the literature. In S. Harding (Ed.), The ethics of research biobanking (Vol. 25, pp. 429–452). Nottingham: Nottingham University Press.

    Google Scholar 

  • Høyer, K. L., & Tutton, R. (2005). ‘Ethics was here’: Studying the language-games of ethics in the case of UK Biobank. Critical Public Health, 15(4), 385–397.

    Article  Google Scholar 

  • Jallinoja, P. (2002a). Genetics, negotiated ethics and the ambiguities of moral choices. Helsinki: Kansanterveyslaitos.

    Google Scholar 

  • Jallinoja, P. (2002b). Ethics of clinical genetics. The spirit of profession and trials of suitability from 1970 to 2000. Critical Public Health, 12(2), 103–118.

    Article  Google Scholar 

  • Jensen, U. J. (2007). The struggle for clinical authority: Shifting ontologies and the politics of evidence. BioSocieties, 2(1), 101–114.

    Article  Google Scholar 

  • Kappel, K. (2008). National ethics advisory boards: Do they have a legitimate role in liberal democracy? In S. Lötjönen & H. von Troil (Eds.), Bioethics, politics and business (pp. 26–44). Copenhagen: TemaNord.

    Google Scholar 

  • Kettner, M. (2005). Ethik-Komitees. Ihre Organisations for men und ihre moralischer Anspruch. Erwägen Wissen Ethik (EWE), 16(1), 1–16.

    Google Scholar 

  • Kristiansen, I. S., & Mooney, G. (Eds.) (2004). Evidence-based medicine: In its place. London: Routledge.

    Book  Google Scholar 

  • Kruger, M. (2010). The ethical approach to evidence-based medicine. South African Journal of Clinical Nutrition, 23(1), 69–70.

    Google Scholar 

  • Liberati, A., & Vineis, P. (2004). Introduction to the symposium: What evidence based medicine is and what it is not. Journal of Medical Ethics, 30(2), 120.

    Article  Google Scholar 

  • Lippman, A. (1991). Prenatal genetic testing and screening: Constructing needs and reinforcing inequities. American Journal of Law and Medicine, 17(1–2), 15–50.

    Google Scholar 

  • Luhmann, N. (1983a). Medizin und Gesellschaftstheorie. Medizin, Mensch, Gesellschaft, 8, 168–175.

    Google Scholar 

  • Luhmann, N. (1983b). Anspruchsinflation im Krankheitssystem. Eine Stellungnahme aus gesellschaftlicher Sicht. In P. Herder-Dorneich & A. Schuller (Eds.), Die Anspruchsspirale: Schicksal oder Systemdefekt? (pp. 28–49). Stuttgart: Kohlhammer.

    Google Scholar 

  • Luhmann, N. (1990). Der medizinische Kode. In N. Luhmann (Ed.) Soziologische Aufklärung: Konstruktivistische Perspektiven (Band V) (pp. 183–195). Opladen: Westdeutscher Verlag.

    Google Scholar 

  • Luhmann, N. (1991). Soziologie des Risikos. Berlin: Walter de Gruyter.

    Google Scholar 

  • Lötjönen, S. (1999). Ethics committees in Finland—biomedicine and research. Helsinki: The National Research Ethics Council of Finland, Ministry of Education.

    Google Scholar 

  • Mackie, J. L. (1974). The cement of the universe: A study of causation. Oxford: Oxford University Press

    Google Scholar 

  • Mayes, R. (2007). The origins, development, and passage of medicare’s revolutionary prospective payment system. Medicine and Allied Sciences, 62(1), 21–55.

    Article  Google Scholar 

  • Meskus, M. (2009). Elämän tiede. Tutkimus lääketieteellisestä teknologiasta, vanhemmuudesta ja perimän hallinnasta. (The science of life. A study of medical technology, parenthood and governing the heredity). Tampere: Vastapaino.

    Google Scholar 

  • Mol, A. (2002). The body multiple: Ontology in medical practice. Durham: Duke University Press.

    Book  Google Scholar 

  • Mol, A. (2008).The logic of care. Health and the problem of patient choice. London: Routledge.

    Google Scholar 

  • Montori, V. M., & Guyatt, G. H. (2008). Progress in evidence-based medicine. The Journal of the American Medical Association (JAMA), 300(15), 1814–1816.

    Article  Google Scholar 

  • Nassehi, A. (2006). Die Praxis ethischen Entscheidens. Eine soziologische Forschungsperspektive. Zeitschrift für Medizinische Ethik, 52(4), 267–277.

    Google Scholar 

  • Nassehi, A., Saake, I., & Mayr, K. W. (2008). Health care ethics committees without function? Locations and forms of ethical speech in a ‘society of the presents’. In B. Katz Rothman, E. Mitchell Armstrong, & R. Tiger (Eds.), Bioethical issues, sociological perspectives. Advances in Medical Sociology (Vol 9, pp. 129–156). Amsterdam: Elsevier Ltd.

    Google Scholar 

  • Pelikan, J. M. (2007a).Understanding differentiation of health and modernity by use of sociological systems theory. In D. V. McQueen, I. Kickbush, L. Potvin, J. M. Pelikan, L. Balbo, & T. Abel (Eds.), Health and modernity. The role of theory in health promotion (pp. 74–102). New York: Springer.

    Google Scholar 

  • Pelikan, J. M. (2007b). Zur Rekonstruktion und Rehabilitation eines absonderliches Funktionssystems—Medizin und Krankenbehandlung bei Niklas Luhmann und in der Folgerezeption. Soziale Systeme, 13(1 & 2), 290–303.

    Google Scholar 

  • Pelikan, J. M. (2009). Ausdifferenzierung von spezifischen Funktionssystemen für Krankenbehandlung und Gesundheitsförderung oder: Leben wir in der „Gesundheitsgesellschaft“? Österreichische Zeitschrift für Soziologie (ÖZS), 34(2), 28–47.

    Article  Google Scholar 

  • Ritzer, G., & Walczak, D. (1988). Rationalization and deprofessionalization of physicians. Social Forces, 67(1) 1–22.

    Article  Google Scholar 

  • Rosner, F. (1985). Hospital medical ethics committees: A review of their development. The Journal of the American Medical Association (JAMA), 253(18), 2693–2697.

    Article  Google Scholar 

  • Saake, I. (2003). Die Performanz des Medizinischen. Zur Asymmetrie in der Arzt-Patienten-Interaktion. Soziale Welt, 54(4), 429–460.

    Google Scholar 

  • Saake, I., & Kunz, D. (2006). Von Kommunikation über Ethik zu “ethischer Sensibilisierung”: Symmetrierungsprozess in diskursiven Verfahren. Zeitschrift für Soziologie, 35(1), 41–56.

    Google Scholar 

  • Saake, I., & Vogd, W. (Eds.) (2008). Moderne Mythen der Medizin. Studien zur organisierten Krankenbehandlung. Wiesbaden: VS Verlag für Sozialwissenschaften.

    Google Scholar 

  • Saarni, S., Halila, R., Palmu, P., & Vänskä, J. (2008). Ethically problematic treatment decisions in different medical specialties. Journal of Medical Ethics, 34(4), 262–267.

    Article  Google Scholar 

  • Sackett, D. L. (2002). Clinical epidemiology: what, who and whither. Journal of Clinical Epidemiology, 55(12), 1161–1166.

    Article  Google Scholar 

  • Schimank, U. (2005). Organisationsgesellschaft. In W. Jäger & U. Schimank (Eds.), Organisationsgesellschaft. Facetten und Perspektiven (pp. 19–50). Wiesbaden: VS Verlag für Sozialwissenschaften.

    Google Scholar 

  • Self, D. J., Skeel, J. D., & Jecker, N. S. (1993). A comparision of the moral reasoning of physicians and clinical medical ethicists. Academic Medicine, 68(11), 852–855.

    Article  Google Scholar 

  • Stollberg, G. (2009). Das medizinische System. Überlegungen zu einem von der Soziologie vernachlässigten Funktionssystem. Soziale Systeme, 15(1), 189–217.

    Google Scholar 

  • Sulilatu, S. (2008). Klinische Ethik-Komitees als Verfahren der Entbürokratisierung? In I. Saake & W. Vogd (Eds.), Moderne Mythen der Medizin. Studien zur organisierten Krankenbehandlung (pp. 285–306). Wiesbaden: VS Verlag für Sozialwissenschaften.

    Google Scholar 

  • Suomen Lääkäriliitto. (2005). Lääkärin etiikka. (Physician’s Ethics). Helsinki: Suomen Lääkäriliitto.

    Google Scholar 

  • ten Have, H. A. M. J. (2001). Genetics and culture: The ‘geneticization thesis’. Medicine, Health Care and Philosophy, 4(3), 295–304.

    Article  Google Scholar 

  • Timmermans, S., & Berg, M. (2003). The gold standard. The challenge of evidence-based medicine and standardization in health care. Philadelphia: Temple University Press.

    Google Scholar 

  • Timmermans, S., & Kolker, E. (2004). Evidence-based medicine and the reconfiguration of medical knowledge. Journal of Health and Social Behaviour, 45(1), 177–193.

    Google Scholar 

  • Timmermans, S., & Mauck, A. (2005). The promises and pitfalls of evidence-based medicine. Health Affairs, 24(1), 18–28.

    Article  Google Scholar 

  • Vineis, P. (2004). Evidence-based medicine and ethics: A practical approach. Journal of Medical Ethics, 30(2), 126–130.

    Article  Google Scholar 

  • Vogd, W. (2002). Professionalisierungsschub oder Auflösung ärztlicher Autonomie. Die Bedeutung von Evidence Based Medicine und neuen funktionalen Eliten in der Medizin aus system- und interaktionistischer Perspektive. Zeitschrift für Soziologie, 31(4), 294–315.

    Google Scholar 

  • Vogd, W. (2005). Medizinsystem und Gesundheitswissenschaften—Rekonstruktion einer schwierigen Beziehung. Soziale Systeme, 11(2), 236–270.

    Google Scholar 

  • Worrall, J. (2010). Evidence: philosophy of science meets medicine. Journal of Evaluation in Clinical Practice, 16(2), 356–362.

    Google Scholar 

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Authors and Affiliations

  1. Universität Helsinki, Helsinki, Finland

    Mikko J. Virtanen

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  1. Mikko J. Virtanen
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  1. Ludwig-Maximilians-Universität München, Germany

    Armin Nassehi

  2. Institut für Soziologie, Ludwig-Maximilians-Universität München, Germany

    Irmhild Saake

  3. Ludwig-Maximilians-Universität München, Germany

    Jasmin Siri

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Virtanen, M. (2015). From Square Problems to Round Reasoning: A Systems Theoretical View of Medical Ethics Problems and Their Solution Practices. In: Nassehi, A., Saake, I., Siri, J. (eds) Ethik – Normen – Werte. Studien zu einer Gesellschaft der Gegenwarten, vol 1. Springer VS, Wiesbaden. https://doi.org/10.1007/978-3-658-00110-0_13

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