Zbigniew Szawarski

The concept of the art of healing is intrinsically connected with the idea of healing powers. There are at least three possible approaches to that idea and all of them have different implications for the problem of medical wisdom. These are: the idea of the healing powers of nature, the idea of the healing powers of science, and the idea of the healing powers of physician's personality. Having critically discussed those ideas I sketch an ideal of a wise physician as someone who has a particular kind of knowledge, good judgement, and self-trust. Medical knowledge is certainly a necessary condition of being a wise doctor but it is not the sufficient one. And this is why patients generally prefer to seek help of “naturally wise physicians”

Said Paracelsus – “All substances are poisonous; there is none that is not a poison. The right dose distinguishes a poison and a remedy.” Most clinical problems can be boiled down to the following practical syllogism: “If a patient has a condition p, then he should be treated with q, r, or t or whatever combination of them. The patient X has the condition p. Therefore, the patient X should be treated with q, or r, or t, or whatever combination of them.” It is evident that the conclusion of this syllogism is a result of two different kinds of knowledge: first, medical knowledge understood as general and universal knowledge of health, disease and treatment which is contained in standard medical textbooks and which, according to the present fashion, is called evidence based medicine; and second, clinical knowledge which is specific knowledge of a particular patient in terms of his unique narrative identity.. Acquisition and application of medical and clinical knowledge are governed by ethical rules. The basic rules of human subjects research ethics are presented and discussed. I conclude that even a perfect evidence based medical knowledge is not enough to make a correct clinical judgment. Because every individual may have a specific reaction to a drug, each treatment is always experimentation on human. One of those rules is respect for moral autonomy of the patient which is reflected in the moral, legal, and clinical doctrine of informed consent; another, the principle of an acceptable risk-benefit balance. Both these principles are examined in the context of psychiatric treatment.

Human life is a process. It is the process of becoming and ceasing to be a human being and it is a process of becoming and ceasing to be a human person. I accept the distinction between being a human being and being a human person and distinguish further – future, present, and past human persons. The main problem of the paper is when do we become past persons? Having distinguished and presented four distinctive modi of human dying I concentrate on the problem of good death and ask what are the goods of the dying person. The goods are: life, the good of the mind, the good of the body, the good of the communal life, and the good of death. The decision who is a terminal patient is a moral one and implies two different strategies with regard to life: the affirmation of life, and the affirmation of death strategy. The first one, based on the concept of respect for human life, ignores the value of human dignity. The second one assumes that we should respect not only human biological life, but the whole human person, and we cannot respect the whole person if we do not respect her freedom of choice and her right to self-respect. Care for the artificially sustained but absolutely personless human life, is not a proper terminal care but rather is post-terminal care, and as such requires other, special justification.

In lieu of an abstract, here is a brief excerpt of the content:LettersZbigniew Szawarski and Jacek A. PiatkiewiczPolish Code of Medical EthicsMadam:In the December 1992 issue of the Kennedy Institute of Ethics Journal you published the Polish Code of Medical Ethics with introductions by Jacek A. Piatkiewicz and Robert Baker. Jacek Piatkiewicz writes (p. 362), and Robert Baker follows him, that the new code "was approved by an overwhelming majority (449 for, 75 against, 58 abstaining)." I am afraid that these figures are inconsistent with the data supplied by the Polish mass media. The leading Polish newspaper, Gazeta Wyborcza (16 December 1991), states that 354 delegates voted for the new code and 317 against it. The same figures are quoted by the most authoritative Polish political weekly, Polityka (4 January 1992).Mr. Piatkiewicz does not mention either that 40 delegates left the convention before the vote in protest over the undemocratic proceedings. If we add those 40 potentially negative votes to the 317 votes against, then the result is not at all "an overwhelming approval" for the new code.I am not a physician myself, and I was not present at the Second National Congress of Physicians in Bielsko-Biala, however, I find this discrepancy disturbing. Respect for facts seems to me equally imperative as respect for human life.Jacek A. Piatkiewicz Replies:In his letter Mr. Szawarski denies the data I presented on the vote approving the Polish Code of Medical Ethics. He has quoted the figures published by the Polish mass media as the true ones. Interestingly enough, he did not try to confirm them with the Polish General Medical Chamber, which has the original documents on the Extraordinary Second National Congress of Physicians. The figures I cited regarding the Code's approval are clearly stated on page 63 of the Congress proceedings.So where do the figures presented in Mr. Szawarski's letter come from? As Mr. Szawarski states, these figures have been published in some Polish newspapers, among them "the most authoritative Polish political weekly, Polityka" (a description that was especially accurate during the Communist period of Poland's history). The figures are simply untrue. The figures presented refer only to the result of the vote on article 37 of the Code, which concerns abortion. The very narrow margin (354 for, 317 against, 38 abstaining) decided the formulation of the exceptions to the abortion ban, which are "saving the mother's life and health" and "when pregnancy is the result of a criminal act." But what was the alternative considered in the vote? It was the single exception, "to save the mother's life," that was in the [End Page 355] original draft of the Code (page 44 of the Congress proceedings).Mr. Szawarski finds the discrepancy in the figures cited disturbing. I am disturbed too, but the cause of my concern is of a completely different nature. Why does Mr. Szawarski not try to reconcile "the discrepancy" by asking organizers of the Congress for an explanation?Zbigniew SzawarskiCentre for Philosophy and Health Care University of Swansea, WalesJacek A. PiatkiewiczGeneral Medical Council of PolandCopyright © 1993 The Johns Hopkins University Press...

The article presents three stages of the emotive theory of ethical disagreement. Paragraph 1 deals with problems of ethical disagreement in the first stage of emotivism. Paragraph 2 shows Stevenson’s theory of ethical disagreement. Paragraph 3 discusses P. Edward’s conception. Confronting the successive stages of the emotive theory of ethical disagreement, the author finds no changes to have taken place in the characteristic definition of ethical disagreement as a disagreement in attitudes. But the theory of the resolution of ethical disagreement undergoes considerable transformation. It is expressed mostly in the endeavour!to add precision to the concepts of justification for ethical judgements, and to the concept of settling of ethical disagreement. That is especially manifest in Edward’s conception. The author demonstrates that there is very little difference in Edward’s conception from Stevenson’s theory, but he at the same time points out the presence in that conception of trends new to emotivism, namely trends tending to find objective criteria for settling ethical disagreement. In conclusion it is stated that the essential line of development of the emotive theory of ethical disagreement undergoes no changes. What does change considerably is the tone of the statements – from the extreme radicalism of Ayer, from the striking, indeed drastic, formulations of Russell, to the pondered assertions of Stevenson and Edwards; from a nonchalant neglect of the subject of ethical disagreements, to their most conscientious and penetrating examination.

One of the most commonly adduced arguments in the discussions on abortion says that a foetus is a human being. The article presents three classical types of criteria used to establish what is a human being: the genetic criterion, the criterion referring to development of the foetus, and the criterion of being born from human parents. The article takes up the problem of the perspectives for establishing a definition of man. The author believes that the concept of men is an open concept and that philosophical analysis of this concept cannot provide normative solutions to the moral problem of abortion. This is not to say that the moral problem of the right evaluation of abortion cannot be rationally solved. But if it can be, a no definition can be adopted as a starting point. The problem: what is a human being? which is a problem of appropriate definition should be substituted by a prescriptive problem: what may we do with a conceived being of which we do not know whether it is a human being or not? The rationally supported principle of behavior is in these circumstances the principle of potentiality. This principle disapproves of breaking the potentiality of a being conceived by human parents. Acceptance of this principle does not preclude implementation of a conscious and rational population policy. It is permissible to destroy potentiality of one human being for the sake of potentiality of other human being – not yet conceived, unborn or living. The acceptance of this principle implies approval of some controversial philosophical assumptions. But on this ground the foregoing arguments cannot be disposed of.

After a presentation of over ten different cases of suicide the author gives a brief review of the definitions of suicide found in the literature. Then he suggests a definition of his own: ‘A wo/man commits a suicide if s/he consciously initiates a sequence of events leading to her/his death.’ This definition does not entail any value statement about the act of suicide. We may agree that some acts of terminating one’s life deliberately command admiration as feats of heroism, while others are deplorable as acts of cowardice. However, the principle of double effect does not permit to distinguish incontrovertibly a case of a suicidal death from a heroic death, says the author.

Suffering is a constitutive attribute of human existence. I cannot be a fully-fledged human being if I am not a sentient being. The authors points out a number of important differences between pain and suffering and argues that the modern reductionist biomedical model of disease totally ignores that distinction and treats equally a person in pain and a suffering person. Medicine can control pain but it is not always able, and perhaps it should not always control suffering. It is for the patient to accept and make sense of his suffering. It is a tragic paradox of modern medicine that although death is sometimes the only effective way to eliminate suffering, some doctors aim to do everything to delay death even if this means a dramatic increase of suffering.

If my body is my property, then I have a right to use it according to my will: I can sell it, donate it, or destroy it. There is, however, an important difference between a living body and a dead body, which is often ignored in the discussion of transplantation ethics. I claim that my living body is not my property. However, this does not determine property status of my dead body and of all the cells, tissues, organs and body products extracted from my living body. Even if we accept ethics of solidarity and ban all commercial transactions in body parts, we shall still have a problem if it is possible to donate a living human eye. I analyse this question to conclude that although it is possible to maintain biological life in the extirpated eye it will be dead as a human seeing eye. I have to kill part of myself if I am to donate my living healthy eye. It explains our repulsion against donating or selling living eyes. Although transplantation medicine saves many lives, I think that in the long run it may bring more harm than benefit.

We report the results of a survey of the attitudes and practices of paediatricians in Warsaw, Poland, with respect to the treatment of infants born with severe handicaps. The results are compared with a similar survey conducted by Australian researchers (1). In the Polish medical community surveyed, unconditional respect for life is a dominant attitude. Our study has revealed a deeply-entrenched paternalistic attitude among Polish doctors and a strong unwillingness to distinguish between 'ordinary and extraordinary means' of prolonging life, as well as an ambivalent attitude towards legal regulations binding in Poland

This paper attempts to define the concept of placebo as it is used in the clinical context The author claims that X is a placebo if and only if X has such a property dp, that whenever in a therapeutic situation T a stimulus S appears, then in attending conditions A, it will cause a beneficial reaction R in the patient. Formally, the same structure may be used to define any pharmacologically active drug. The main difference between the drug and a placebo is in the range of possible substitutions for X and the property d. For the active drug there is only one possible substitution for X and property d and it can be scientifically explained why, and how the drug works. In the case of a placebo a set of possible substitutions for X and d is open, and so far it is impossible to offer any scientifically valid explanation of the action mechanism of placebo.