Beyond the surgeon's skill

The scientific attainments of medical science have advanced greatly in this generation. The art of the practice of medicine has not kept pace. The kindly spirit, unselfish service, and spiritual uplift which were characteristic of most physicians in the "horse-and-buggy days" are needed more today than they were a generation ago. A combination of medical science and spiritual counseling will do much to relieve the sufferings of mind and body. The personal physician-patient relationship and the building up of the patient's confidence in his physician are a most important aspect of the physician's duty. A belief in God and a knowledge of the availability of help from above is of great benefit to both physician and patient.     

Lethal injection,autonomy and the proper ends of medicine

Gerald Dworkin has argued that it is inconsistent with the proper ends of medicine for a physician to participate in an execution by lethal injection. He does this by proposing a principle by which we are to judge whether an action is consistent with the proper ends of medicine. I argue: (a) that this principle, if valid, does not show that it is inconsistent with the proper ends of medicine for a physician to participate in an execution by lethal injection; and (b) that this principle is not valid, and this is because it mistakenly views the promotion of patient autonomy as one of the proper ends of medicine. Rather, I propose, we should view respect for a patient's autonomy as a constraint on the pursuit of the proper ends of medicine, rather than as one of the proper ends itself. With this revised understanding of the proper ends of medicine, we can conclude that it is inconsistent with the proper ends of medicine for a physician to participate in an execution by lethal injection.     

BEYOND THE SURGEON'S SKILL

The scientific attainments of medical science have advanced greatly in this generation. The art of the practice of medicine has not kept pace. The kindly spirit, unselfish service, and spiritual uplift which were characteristic of most physicians in the “horse-and-buggy days” are needed more today than they were a generation ago. A combination of medical science and spiritual counseling will do much to relieve the sufferings of mind and body. The personal physician-patient relationship and the building up of the patient''s confidence in his physician are a most important aspect of the physician''s duty. A belief in God and a knowledge of the availability of help from above is of great benefit to both physician and patient.     

The Flexner Report--100 years later

The Flexner Report of 1910 transformed the nature and process of medical education in America with a resulting elimination of proprietary schools and the establishment of the biomedical model as the gold standard of medical training. This transformation occurred in the aftermath of the report, which embraced scientific knowledge and its advancement as the defining ethos of a modern physician. Such an orientation had its origins in the enchantment with German medical education that was spurred by the exposure of American educators and physicians at the turn of the century to the university medical schools of Europe. American medicine profited immeasurably from the scientific advances that this system allowed, but the hyper-rational system of German science created an imbalance in the art and science of medicine. A catching-up is under way to realign the professional commitment of the physician with a revision of medical education to achieve that purpose.     

Postmodernist theory and the physician-patient relationship

The author discusses the postmodernist claim that the "grand theories" have lost credibility, even in the field of medical science and practice. Rather than representing a shared reality among physician and patient, illness represents two quite distinct realities - the meaning of one being significantly and distinctively different from the meaning of the other. However, existential clinical narratives can function as important bridges between the world of the patient and the world of the physician. Such narratives provide important information regarding the patient's biographical situation and, particularly, the personal and cultural meanings which are a function of the biographical situation. At the same time, these narratives provide physicians with useful information for the practice of medicine.     

Imaging and the new fabric of the human body

A short historical survey recalls the main techniques of medical imaging, based on modern physico-chemistry and computer science. Imagery has provided novel visions of the inside of the body, which are not self-obvious but require a training of the gaze. Yet, these new images have permeated the contemporary mind and inspired esthetic ventures. The popularity of these images may be related to their ambiguous status, between real and virtual. The images, reminiscent of Vesalius' De humani corporis fabrica, crosslink art, science and society in a specific way: which role will they play in the "empowerment" of the tomorrow patient?     

Medical professionalism: crossing a generational divide

A comprehensive discussion of professionalism in medicine must include its impact on successive generations of physicians. Fifty years ago, doctors acting professionally emphasized medicine as a calling and an ability to act as the authority for patients in crisis at home and in hospitals. Therapeutic options were limited relative to the modern era, and the laying on of hands was practiced as science and art. Today, doctors balance increasing demands on time and efficiency with the sense of primacy of patient care. Technological innovation and patients' increasing access to medical knowledge through varying media of inconsistent quality challenge physicians in novel ways. Fifty years in the future, doctors will have access to vast amounts of information through a multitude of noninvasive diagnostics. Progressively more personalized medicine should inspire doctors to become even more adept at communicating effectively with patients. Professionalism in medicine throughout these generations embodies similar fundamental behaviors, such as demonstrating compassion, respect, and humility; adhering to high ethical and moral standards; subordinating personal interest to that of others; and reflecting on actions and decisions. Despite the dynamic nature of the profession itself, the omnipresent need for such traits will define medical professionalism for decades to come.     

Observation and visualization: reflections on the relationship between science, visual arts, and the evolution of the scientific image

The connections between biological sciences, art and printed images are of great interest to the author. She reflects on the historical relevance of visual representations for science. She argues that the connection between art and science seems to have diminished during the twentieth century. However, this connection is currently growing stronger again through digital media and new imaging methods. Scientific illustrations have fuelled art, while visual modeling tools have assisted scientific research. As a print media artist, she explores the relationship between art and science in her studio practice and will present this historical connection with examples related to evolution, microbiology and her own work. Art and science share a common source, which leads to scrutiny and enquiry. Science sets out to reveal and explain our reality, whereas art comments and makes connections that don’t need to be tested by rigorous protocols. Art and science should each be evaluated on their own merit. Allowing room for both in the quest to understand our world will lead to an enriched experience.     

Epistemological reflections on the art of medicine and narrative medicine

This article challenges the widespread view that there is both a science and an art of medicine. Through examination of recent work in medical humanities --Jodi Halpern's From Detached Concern to Empathy (2001), Kathryn Montgomery's How Doctors Think (2006), and Rita Charon's Narrative Medicine (2006)--I argue that while a variety of epistemic techniques are important in medicine, it is not helpful to dichotomize them as "science" versus "art." I assess the epistemic strengths and weaknesses of narrative medicine, a recent exemplar of humanistic medicine.     

Pharmacogenetics: Implications for drug development,patients and society

Clinical diagnosis and prescribing is a highly sophisticated art, requiring many years of training. Despite this, the response of individual patients to medicines (where efficacy and safety have been proven in large clinical studies) can still be somewhat variable. Knowledge of the likely response of an individual patient to a medicine will enable physicians to select the most effective and well-tolerated treatment for that patient. Pharmacogenetics is the use of genetic science and technology to provide new insights on the likely response to a particular medicine. (This contrasts with the more conventional use of genetics to elicit information about diseases.) Pharmacogenetic medicine response profiles could take the form of either gene-specific profiles, which will determine the gene variants that affect the mode of action and the metabolism of the medicine, or abbreviated single nucleotide polymorphism profiles, which are correlated with medicine-related phenotypes. In general, pharmacogenetic medicine response profiles will be unlikely to provide additional information about the patient's disease or predict any other diseases. The ethical, legal and social issues associated with medicine response profiles are clearly of a quite different magnitude from those associated with the gene-specific tests for disease.     

The Oslerian Tradition and Changing Medical Education: A Reappraisal

Although only 21 of Sir William Osler''s 45 years in academic medicine were spent in US medical schools (1884 to 1905), he played a major role in shaping modern medical education in this country. The integration of scholarship with patient care, together with the science and art of medicine, was central to Osler''s teaching and writing throughout his career. A classic generalist and a charismatic clinical teacher, he taught by example and was as concerned with the ideals of medicine as with its science and knowledge.Many changes have reshaped the content, process and concerns of American medical education since Osler''s time. Subspecialization and balkanization of medical education and practice have become dominant. Many of the important issues in medicine today do not fit neatly into the domain of any of the established specialties or medical organizations. There is now an urgent need to promote generalist attitudes in medicine, and the Oslerian tradition has much to offer in approaching today''s problems in medical education and practice.     

Change and permanence: reflections on the ethical-social contract of science in the public interest

Modern science, dedicated since its 17th century origins to the mastery and possession of nature for the relief of man's estate, is a source of great social change, affecting our opinions, practices, and ways of life. It thus exists necessarily in tension with law and morality, our institutions of stability and order. This tension between change and permanence, between science and law or morals, was institutionalized by the American Founders who sought to encourage, under law, the progress in science and the useful arts, by means of the copyright and patent laws. American science and technology have flourished under the patent law, an ingenious ethical and social contract between scientists and the polity, through which private right and interest and public good generally coincide. Nevertheless, this contract has its limitations. Some of these limitations are vividly seen through the recent Supreme Court decision (in the Chakrabarty case) to permit the patenting of living microorganisms. Analysis of this case shows why the contract between science and the polity embodied in the Patent Laws may not always serve the public good and may also be harmful to science itself. Also, permitting ownership of living species shows how close we have come in our thinking to overstepping the sensible limits of the project for the mastery and possession of nature.     

Science and craftsmanship: the art of experiment and instrument making

In his two-volume monograph Untersuchungen über thierische Elektricit?t, the Berlin physiologist Emil du Bois-Reymond described the relation between nervous electricity and muscle mechanics by way of a long series of experiments. This work is a key text in the history of the experimental life sciences. But it not only contains new findings about the functioning of muscles and its nerves. Du Bois-Reymond practiced an art of experimentation in which aesthetics of mechanical craftsmanship allied itself with the science of physiology. Experimentation, as du Bois-Reymond understood it, was simultaneously an epistemic and an aesthetic practice. The goal of his science was thus producing both knowledge and aesthetic success.     

Change and permanence: Reflections on the ethical-social contract of science in the public interest

Summary Modern science, dedicated since its 17th Century origins to the mastery and possession of nature for the relief of man's estate, is a source of great social change, affecting our opinions, practices, and ways of life. It thus exists necessarily in tension with law and morality, our institutions of stability and order. This tension between change and permanence, between science and law or morals, was institutionalized by the American Founders who sought to encourage, under law, the progress in science and the useful arts, by means of the copyright and patent laws. American science and technology have flourished under the patent law, an ingenious ethical and social contract between scientists and the polity, through which private right and interest and public good generally coincide. Nevertheless, this contract has its limitations. Some of these limitations are vividly seen through the recent Supreme Court decision (in the Chakrabarty case) to permit the patenting of living microorganisms. Analysis of this case shows why the contract between science and the polity embodied in the Patent Laws may not always serve the public good and may also be harmful to science itself. Also, permitting ownership of living species shows how close we have come in our thinking to overstepping the sensible limits of the project for the mastery and possession of nature.     

A creative collaboration between the science of ecosystem restoration and art for sustainable stormwater management on an urban college campus

This article presents an interdisciplinary, on‐campus, student project, titled “The Rain Project” that I designed as an urban ecosystem restoration model as well as a collaborative pedagogical approach between ecological science and art at George Mason University (GMU), Virginia, U.S.A. A group of students from several disciplines (e.g. environmental science, art, civil engineering, biology, communication, and film/media) participated in designing and constructing a floating wetland for a campus stormwater pond as part of sustainable stormwater management. The Rain Project has numerous implications for college education, scholarship, and service while presenting a novel way of building a sense of community among undergraduate students for ecological awareness and literacy. The work of Jackie Brookner, a renowned eco‐artist who worked extensively on stormwater, and its relevance to the project is discussed. I strongly suggest the need for linking art and the science of ecosystem restoration to best obtain improvements in much‐needed communication for the success of community participatory restoration projects. I also believe that this kind of interdisciplinary, campus project can facilitate the changes we need to train higher education students to be able to both think differently and communicate effectively. The Rain Project introduced students to new learning strategies that connected “systems thinking” with art, ecological science, and restoration practices.     

Conceptual tensions between theory and program: The chromosome theory and the Mendelian research program

Laudan's thesis that conceptual problem solving is at least as important as empirical problem solving in scientific research is given support by a study of the relation between the chromosome theory and the Mendelian research program. It will be shown that there existed a conceptual tension between the chromosome theory and the Mendelian program. This tension was to be resolved by changing the constraints of the Mendelian program. The relation between the chromosome theory and the Mendelian program is shown to be a good illustration of the influence of science itself on the rational standards governing scientific development.I thank A. A. Derksen, N. Roll-Hansen and the anonymous referees for their helpful comments.     

Opportunities for health promotion and disease prevention in the clinical setting.

Advances in medicine offer unprecedented opportunities to improve health. New diagnostic, care, and treatment approaches are having a tremendous impact; yet, the leading causes of morbidity and mortality in the United States are intimately linked to preventable factors such as smoking, improper nutrition, alcohol misuse, lack of exercise, and maladaptive behaviors. Compelling evidence indicates that reducing risk factors yields substantial overall health benefits and saves lives. Prevention efforts can be applied effectively at many points in a disease process, and clinical medicine has a significant role. Nonetheless, a number of barriers may interfere. These include physician education and attitudes; patient education, expectations, and motivations; and aspects of the health care delivery system itself, such as access and reimbursement. The situation has been complicated by the apparent lack of consensus on the appropriate frequency and scope of such activities.     

Functional gastrointestinal disturbances; recognition and treatment

The recognition of functional gastrointestinal diseases depends essentially on certain positive features characteristic of them. When there are evidences of associated functional disturbances in other organ systems or in the patient as a whole, or characteristic clinical syndromes are present, and there is lack of symptomatic or objective evidence of organic disease on careful examination, the diagnosis of functional gastrointestinal disorder is likely. Treatment of functional gastrointestinal disturbances rests fundamentally on the art of medicine in the treatment of the patient and not on the science of medicine in the treatment of a disease. The essential steps in successful treatment include convincing the patient of the diagnosis, improving and relieving symptoms and avoiding or adequately controlling recurrences.Psychotherapy is a keystone in the treatment of functional gastrointestinal disorders. Not often, however, are the services of a psychiatrist necessary. Given, as needed, mild sedatives, certain forms of specific treatment in specific conditions, general measures and good hygiene and sympathetic understanding, the patient may be expected to recover or improve.     

Doing what the patient orders: maintaining integrity in the doctor-patient relationship

No profession has undergone as much scrutiny in the past several decades as that of medicine. Indeed, one might well argue that no profession has ever undergone so much change in so short a time. An essential part of this change has been the growing insistence that competent, adult patients have the right to decide about the course of their own medical treatment. However, the familiar and widely accepted principle of patient self-determination entails a corollary that has received little attention in the growing literature on the ethics of physician-patient relations: if patients are to direct the course of their own medical treatment, then physicians are at least sometimes to be guided in their actions on behalf of patients by values that are not, and may even be incompatible with, their own values. Unless it is supposed that it would be best if physicians were simply to accommodate any and all patient requests, a possibility I consider and reject in this paper, there are bound to be numerous instances of legitimate moral conflict between the preferences of physicians and patients. In this paper, I examine the implications of this sort of moral conflict from the standpoint of the integrity of the physician....I have also considered the common practice of patient referral from the standpoint of physician integrity, and asked whether a physician who refuses to treat a patient as a matter of conscience can consistently refer the patient to another physician for the same treatment....     

Gene therapy: trials and tribulations

The art and science of gene therapy has received much attention of late. The tragic death of 18-year-old Jesse Gelsinger, a volunteer in a Phase I clinical trial, has overshadowed the successful treatment of three children suffering from a rare but fatal immunological disease. In the light of the success and tragedy, it is timely to consider the challenges faced by gene therapy--a novel form of molecular medicine that may be poised to have an important impact on human health in the new millennium.