Miguel Kottow

Conflicts of interest are receiving increased attention in medical research, clinical practice and education. Criticism of, and penalties for, conflicts of interest have been insufficiently discussed and have been applied without adequate conceptual backing. Genuine conflicts of interest are situations in which alternative courses of action are ethically equivalent, decision-making being less a matter of moral deliberation than of personal weighing of interest. In contrast, situations usually thought of as conflicts of interest are mostly temptations to follow an attractive but undue option that causes harm by failing to uphold well-entrenched ethical standards. Examples of moral quandaries that pose as ethically neutral conflicts of interest are healthcare providers enticed to favour certain products; patients being referred to non-therapeutic trials entailing risks and non-optimal healthcare; industry-supported scientists failing to deliver unbiased research results and reports or participating in ghost-writing; and sponsored educators who praise their supporters beyond objective evidence. All these are moral blemishes, where integrity gives way to material incentives at the cost of provoking risky and harm-producing situations, thus constituting false conflicts of interest when they are in fact ethical misdemeanours. Disclosure has been the most widely recommended response to avoid the concealment of conflicting and ethically suspect interests. Regulations regarding disclosure reveal a utilitarian stance that shows more concern for the magnitude of support or sponsorship than for the underlying ethical transgression. Education and oversight should directly address and help correct the moral attitude towards undue influence of inducements and marketing strategies falsely posing as conflicts of interest.

Phenomenology in medicine’s main contribution is to present a first-person narrative of illness, in an effort to aid medicine in reaching an accurate disease diagnosis and establishing a personal relationship with patients whose lived experience changes dramatically when severe disease and disabling condition is confirmed. Once disease is diagnosed, the lived experience of illness is reconstructed into a living-with-disease narrative that medicine’s biological approach has widely neglected. Key concepts like health, sickness, illness, disease and the clinical encounter are being diversely and ambiguously used, leading to distortions in socio-medical practices such as medicalization, pharmaceuticalization, emphasis on surveillance medicine. Current definitions of these concepts as employed in phenomenology of medicine are revised, concluding that more stringent semantics ought to reinforce an empirical phenomenological or postphenomenological approach.

The FME symposium on teaching medical ethics takes up the issue of competence and responsibility in matters concerning bioethics (1). Foreseeably, the medical participants argue that physicians are prepared, or can be easily prepared, to handle all relevant aspects of medical ethics. The contrary position is sustained by the philosophically trained participants, who believe that physicians do not, in fact cannot, sufficiently manage medico-ethical problems. This paper sees a role for both parties. Medical ethicists should properly be involved in medical education and in analytical and systematic study of medical ethics. They should not generally be involved in clinical medico-moral decision-making, which is properly the realm of patient and (ethically competent) doctor

The multidisciplinary provenance of bioethics leads to a variety of discursive styles and ways of reasoning, making the discipline vulnerable to criticism and unwieldy to the setting of solid theoretical foundations. Applied ethics belongs to a group of disciplines that resort to deliberation rather than formal argumentation, therefore employing both factual and value propositions, as well as emotions, intuitions and other non logical elements. Deliberation is thus enriched to the point where ethical discourse becomes substantial rather than purely analytical. Caution must be exercised to avoid this formal permissiveness from accepting empty and incorrigible statements that are but flatus voci since they can neither be supported nor falsified. It is therefore suggested that deliberation in bioethics should comply with three sets of conditions: (1) Be understandable, truthful, honest and pertinent, as suggested by communicative ethics; (2) Allow for second order, thick judgements as suggested by pragmatism; (3) Abide by additional criteria as here proposed: Doxastic propositions should be bolstered by a cognitive element; statements should be specific and proportional to the issue at hand, and they should be arguable and coherent