When the doctor substituted for the complaint of the patient and his subjective representation of the Cause S of sound badly, which rationality constrained to recognize like the truth of its disease, the doctor therefore did not reduce the subjectivity of the patient. He allowed him a badly different possession of sound. And if he did not seek of to dispossess it, by affirming to him that he is reached of no disease, he did not always succeed in dispossessing it of his belief in itself sick, and sometimes even of his kindness in itself sick. In short, it is impossible to cancel in the objectivity of the medical knowledge subjectivity of the lived experiment of the patient. It is thus not in this impotence that it is necessary to seek the failure characteristic of the exercise of the Médecine. It takes place in the lapse of memory, in its direction freudien, of the capacity of unfolding specific to the doctor who would allow him to project itself in the situation of patient, the objectivity of his knowledge being not repudiated but being put in reserve. Because it is allocated to the doctor to be represented who he is a potential patient and who he is not better assured than are to it its patients to succeed, if necessary, to substitute its knowledge for its angoisse' . " Georges Canguilhem
The relation doctor-patient traditionally followed what one could name the “paternalist model”. In this model, the Médecin is persuaded to know and to be objective. He sees himself like the guard of the interest of the Patient. He makes the decisions for him, by respecting a principle of benevolence simply. The principle of benevolence could be clarified as being:
- the duty not to harm;
- the duty to prevent the evil or the suffering;
- the duty to remove the evil or the suffering;
- the duty to make the good or to promote the good. (Parizeau, 1993)
Besides the Hippocratic oath includes on this subject the especially not to harm (in Latin primum not nocere ). The patient is perceived in the paternalist model like not being more one person reasonable, able to decide for itself in the way in which she wants to live or die. The doctor positions as being that which has the knowledge. The doctor is an expert and, for its part, the patient is in ignorance. All that the patient can do is to agree to the therapeutic model of the doctor and its freedom is limited then to being able to change attending physician.
It is in reaction to the clinical experiments carried out by the Nazi S on prisoners, that appears in 1947 in the Code of Nuremberg the concept of enlightened Consentement of the patient. Since the majority of the Western countries passes gradually from this paternalist model to a new paradigm which one could name “deliberative model”. It is for example the case in Belgium with the law on the patient's rights which introduces the concept of contract therapeutic.
Science and democracy
The doctor-patient ratio is an example characteristic of the way in which the Occidental cultures manage the relationship between science and democracy. Indeed whereas the misadventures of technology invade our contemporary more and more and undoubtedly modify our relation with the others or our way of feeling us human, it is always via the medical one that the citizen lambda is most closely confronted with science.
H.T. Engelhardt for example studied how the debate Bioéthique could fit in the ethical of the discussion of Jürgen Habermas. Habermas seeks to create an ethics of the discussion in the hope to choke violence, since if I can speak with the other it is that I have already a common rationality with him. The objective is not thus to arrive at a Consensus but well at a common rationality. One finds behind bottom of the design of Habermas the idea that the knowledge is emancipator and that to discuss allows to release itself from the opinion (the doxa of the old Greek ). Television, for example, makes pass from the ideas without advancing the rules of the game of their stating. So the Télévision shows a violence symbolic system, to use a concept of Pierre Bourdieu. The ethics of the discussion aims to remove this violence symbolic system by the means of the discussion.
For H.T. Engelhardt the bioethics questions are basically democratic problems. The objective there either is not to lead to a consensus, but to an agreement here and now. Nevertheless, in a secularized culture where science is all-powerful and pushes the other fields of knowledge like art or to the religion with the adequate portion, it seems obvious that the scientific experts (those which know) decide for the popular mass (those which are unaware of). It appears important to us to wonder whether we are not there opposite a drift which puts at evil the base even of the democracy?
The question of the experts
To know if the capacity of science does not put at evil the base even of the democracy is a fundamental question in works of Bruno Latour (Latour, 1987) and of the philosopher of Brussels Isabelle Stengers which underlines in Sciences and capacities (Stengers, 1997) that expressions such as “it is proven that”, “from the scientific point of view”, “objectively”, “the facts show that”, “actually”, often are used by those which control us to cut any debate.
Indeed, if “the facts show that”, that can we say against the facts themselves? Michel Callon (Callon, 2001, pp. 168) and its collaborators observe in fact that the citizen delegates his decisions to two authorities, the academic world to determine what is real and the political world to make the decisions on the basis of description of reality made by the scientists. The citizen thus abdicates his democratic capacity by delegating it to these two spheres: the scientist and the policy.
The Idéologie of science affirms to have access to reality such as it is and when a politician calls upon the scientific research to justify his decisions, he thus affirms us that reality itself is of agreement with him. Reality being such or such, its decision is only logic. What can make the ordinary citizen against reality itself? Would there be an abduction of the democracy by the experts? This kind of expressions, as for example “It is proven that”, come from what Bruno Latour calls the finished science (in English ready made science ), but on the level of science being made ( science in the making ) the things are obviously far from being also simple. Bruno Latour encourages to make the difference between the scientific Idéologie, which arises generally like applying a simple epistemology falsificationist as stated by Karl Popper (Popper, 1972) , and the effective science, i.e. that which make the scientists indeed in their laboratories and their publications. It is certain that when one deepens, that it is in practice of research or by the epistemology, the way in which science is done indeed, these expressions are shown more and more slipping. The made are born and are carried by a paradigm. They are never neutral and are finally never reality such as it is but already an interpretation of this one. (see in particular: Popper, 1972, Feyerabend, 1975, Chalmers, 1987 and Sardar, 2000 )
But how the citizen, without scientific formation, can position compared to the scientistic ideology dominant, while at the same time science wants to be exclusive, reserved for a certain group of people, the academics? And the things all the more become complicated when one notes that the States are not any more able to finance research and that it is the private one, for example the pharmaceutical firms, which pay for it. We are thus vis-a-vis an acute problem of political philosophy: how the Néolibéralisme and science interact do? It is in the sense that Isabelle Stengers and others can present science as being finally a kind of being able oppressor.
That raises the question to know which is the position of the universities in our company: the role of the university is to be closed again on itself (scientific articles addressing itself only to pars, with other scientists) or must it play an active role in the company, democratizing the knowledge for the greatest number? For the ethics of the discussion of Habermas, the scientist must take ethical share with the discussions S by considering that the remarks of its interlocutor are relevant, and not as an expert who explains the solution with the ignorant interlocutor.
Also, from this point of view, the significance of the knowledge of the researchers will depend in a crucial way of their capacity to meet other knowledge. The development of the “therapeutic tests” on the AIDS has emblematic value of this tension as it caused polemical sharp between various philosophies of tests in the presence of the side of the doctors and the statisticians ( Dodier, 2004 ) in the time even where the Mouvements of patients made of it the field of a battle of the knowledge and capacity in their will to defend their own place in the production of knowledge on the disease ( Epstein, 2001 and Barbot, 2002 ).
The deliberative Model
Contrary to the paternalist model, the deliberative model wants to found a dialog between the doctor and the patient. The assent (Parizeau, 1993) of the patient is defined as the act authorizing the doctor to be implemented at a treatment which it has, au préalable, clarified with the patient.
The difficulty emerges immediately, with the reading of this definition, since certain people are unable to give an assent to an medical act: the child, the fetus, the mentally handicapped person, the comatose person or confused elderly. These people are those which do not return in the definition of a person given per H.T. Engelhardt. The concept of contract therapeutic is based indeed on the fact that the patient is (or was) a person with the direction or H.T. Engelhardt, following E. Kant, defines it: to be a person, it is necessary:
- a self-awareness;
- a minimum moral direction.
Another difficulty is in the articulation of the principle of autonomy of the patient and the principle of benevolence of which we spoke at the beginning about this article as being one about the bases about the paternalist model. If the patient does not have medical knowledge, it is however able to evaluate the impacts of the medical decision on its lifestyle, its values, its personal history and the direction of its existence. It with the possibility of exerting its judgment and of evaluating if the treatment suggested is acceptable, taking into account its individual specificity.
But to be able to exert his judgment, the patient must have access to the medical information! A dialog is thus necessary. If the patient of a doctor is (or was) a person, it must let to him make the decisions which will affect its life. The contract is constituted in a deliberation between the will of the patient and the doctor. The two wills intervene in the consensus with equal share. When a team frames the patient, the discussion is carried out with the whole of medical staff and is not any more one decision taken only by the doctor at the top of the hierarchy of the speakers, a such good father of family. The nurses, for example, must take share with the decision. It is not to the doctor to make decisions of life (and dead) instead of the people. Nobody is placed better than the person itself to decide what is best for it.
In the field of the Mental health, the criticism of science as a capacity oppressor particularly crystallized with the current of the Antipsychiatrie. For Michel Foucault (Foucault, 1972) , it is well the Psychiatrie which started to biopouvoir it and not the Biotechnologies. Psychiatry indeed modified the way of thinking the concept of Nobody about which we spoke higher.
Let us give like example of the aspect potentially oppressor of psychiatry celebrates it search for David L. Rosenhan (Rosenhan, 1981) , Être healthy in an environment malade, in which it sent false patients to be made intern in psychiatric hospitals.
The false patient presented to the office admissions while complaining to have heard voices. The question of knowing what the voices said, he answered that they were often not very clear, but that they seemed to him to say “empty”, “hollow”, “choking”. On this very light basis, they were allowed under the diagnosis of Schizophrénie.
Once admitted, the false patients acted completely normally, reacting naturally to all the situations of enfermements in the psychiatric hospital. However, once admitted in the establishments, all their behaviors were interpreted by medical staff as being symptoms of their schizophrenia. One had asked them, for example, to take notes; what was interpreted by medical staff as being a symptom. In the same way, the fact of waiting the table of the meals in advance was interpreted by a psychiatrist who passed by-there as being the proof of a fixing of the false patient to the oral stage, whereas the false patient explained thereafter to David L. Rosenhan until it waited there in advance because there was not strictly anything else to make like activity in the establishment.
None the establishments reconsidered the diagnosis of schizophrenia, which is obviously given to life with the patient, and the various subjects were finally returned on their premises as being schizophrenes in remission.
Let us take a concrete example with the often discussed question of the blood transfusion at the Témoins of Jéhovah. The Witnesses of Jéhovah believe that the blood of a person is crowned and that it is not allowed to them to receive it or to introduce it. They thus refuse the blood transfusion. The ethical problem arises to the doctor if a child of Witness of Jéhovah requires for a transfusion and that his/her parents oppose it for religious reasons. It should be known that there exist alternative treatments in many cases but not all. Can the doctor, if it does not subscribe by to these beliefs, pass in addition to the request of the parents under pretext which them belief is, according to him, “pure rubbish”? In practice, the French right recognizes with the doctor the right to require a provisional placement near the Public prosecutor in order to carry out a blood transfusion necessary (Article 375 of the civil code, article 42 and 43 of the Code of conduct). Vis-a-vis an emergency the doctor can even, if time does not allow him, abstain from requesting his agreement from the court (Article 32 and 9 of the Code of conduct). Nevertheless, jurisprudence punishes all resorts systematic to the provisional placement without proof of the character urgent and necessary of this one, moreover the new law of March 4th, 2002 relating to the rights of the patients and the quality of the health system obliges the doctors sought the assent of the minor (Article L. 1111-4 subparagraph 5)
If thus the doctors must work out a therapeutic contract with their patients, we find the same kind of difficulty on the more total level of the company with the alternative medicines or complementary. The problem raised by these alternative medicines, like homeopathy for example, is their lack of scientificity. The movement skeptic does not hesitate to name these practices of pseudo-sciences.
In this nebulous field of the alternative medicines also all the people are who think of being able to look after by the simple laying on of hands, and which with the eyes of the scientists makes finally only hypnosis of mass (Joe Nickell, 2001) . Besides one finds very often in these approaches of the elements of magic thought (Stevens, 2001, Ruscio, 2001) . The scientific community explains the results of these various approaches by the Effet placebo (French, 2001) . However, scientific medicine for its part balks to use the placebo effect, and this same if the psychosomatic approach in psychology of health encourages the doctors to exploit the psychological component in the care of the diseases.
The using experts the alternative approaches maximize the placebo effect in their approaches. Even if their treatments did not receive a strong empirical support by experimental research as a double blind man, they nevertheless are convinced of the effectiveness of their treatments. This confidence is based on their clinical experiment of hundreds of patients satisfied and their lack with knowledge in alternative explanations to explain the improvement of health. Consequently, they are extremely trustful in the effectiveness of their diagnostic skills, their explanations of the disease in question, and in the effectiveness of their treatments. This confidence is transmitted to their customers, raising their waitings as regards success of cure, which results in to maximize the placebo effect. Further, these therapeutists will spend a very long time listening to with empathy their customers, taking very with serious all their symptoms, even vague. Contrary, the general doctor has a schedule very charged and it will not be able to be allowed to listen to each patient very a long time.
The popular success of these alternative practices pose problem at the universities. Do they have to include them in their course of studies (De Robertis, 2001) ? Vis-a-vis do these alternative practices, how have to react the doctors and the scientific community? What to make if a patient asks has to have resorts within the framework of its therapeutic contract to this kind of approach? The doctor would be tempted to put his veto at this kind of request, but exceed doesn't its role then? Shouldn't it be satisfied to inform its patient of the manner clearest, comprehensible and simple possible?
Moreover, these alternative practices can improve, would be this only for a time, the subjective wellbeing (by helping it to manage its stress related to the disease) and objective (by the placebo effect) of the person. Of which right the doctor would deprive it of this support by explaining to him that this therapy “is not worth anything”? It is strong trying for the experts to try to impose their point of view on the question and “to fight” against these alternative medicines and complementary. It what the movement skeptic wants to do, but is it is legitimates for the scientists to impose their opinion on the question? Of which right the scientists should prohibit people from accepting astrology and to go to consult an astrologer? Shouldn't a democratic dialog on the contrary be established? Science seems at the beginning to be there only to study the world, not to impose a point of view on others.
This article tackled the question in medicine of the passage of the “paternalist model” towards the “deliberative model”, which wants to found a dialog between the doctor and the patient.
If the deliberative model is more respectful of the person, it is not without difficulty. A first difficulty is in the fact that certain people are unable to give an assent to an medical act: the child, the fetus, the mentally handicapped person, the comatose person or confused elderly. Another difficulty is in the articulation of the principle of autonomy of the patient and the principle of benevolence.
In spite of its difficulties in the practical application of the deliberative model, it seems essential that, if the patient is (or was) a person, the doctor must let to him make the decisions which will affect its life. Nobody is placed better than the person itself to decide what is best for it.
For better showing this new sight, it would undoubtedly be more judicious to speak about the “Relation patient-doctor”.
" (.) The diseases are ordered in a kind of classification hierarchical corrspondant roughly with the gravity of anatomical deteriorations… which one can suppose that they are accompanied. Malheuresuement this classification hierarchical does not apply only to the diseases, but also to the patients… who ratttachent themselves there. The patients whose disorders can be brought back to anatomical or physiological deteriorations… are of a higher category, while the neurotics are to some extent the dregs which remain when all the remainder was eliminated…. One of the corollaries of this irrefutable fact is that the doctor feels to trust to have detected the diagnosis of an organic disease, but which he confesses with a certain embarrassment the discovery of a diagnosis of neurosis. That becomes comprehensible if we remember that the diagnosis neurosis perhaps formulated by no matter whom whereas the diagnopstic of a physical disease requires a professional competence of expert… " Michael Balint.
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