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Revista Bioética

versão impressa ISSN 1983-8042versão On-line ISSN 1983-8034

Rev. Bioét. vol.25 no.2 Brasília maio/ago. 2017

http://dx.doi.org/10.1590/1983-80422017252185 

Update

Hermeneutics and decision making in clinical ethics

Oscar Vergara1001 

1001Doctor vergara@udc.es – Universidade da Coruña, Coruña/España.

Abstract

Modern hermeneutics deals with the conditions of the possibilities of human understanding. Its contributions are particularly pertinent to clinical ethics, where patient and doctor seek to mutually understand one another in order to establish a determined care plan. Nevertheless, this approach is far from useful for the formulation of a concrete standard for decision making in this area. Hermeneutics is effective in putting the focus on dialogue, rather than method. But it overlooks the fact that dialogue, according to Gadamer, is directed towards truth. The present article aims to highlight this point, and seeks to establish the connection between this notion of truth and ideas of good, history and community.

Key words: Ethics, clinical; Hermeneutics; Decision making

The present work analyzes the contribution of the hermeneutical approach to clinical ethics, particularly in relation to decision making in the field. Initially, the question is posed as to whether it is possible to form some kind of methodological system from hermeneutics (section 1). Faced with the difficulties of doing so, the attention of the study then turns to the tool of dialogue. This idea plays a prominent role in all hermeneutic approaches, but without an ontological base, one wonders to what extent the dialogue between doctor and patient makes sense. This question is addressed in sections 2 and 3. Finally, we consider if the humanistic training provided by the moral sciences may have some role in decision-making and under what conditions (section 4).

The problem of interpretation

As Gadamer points out, health is a hidden concept. It is a state of internal measurement that is not easily determined through simple objective evaluation. It is vital, therefore, to observe and listen to patients 1. For K. M. Hunter, the patient comes to resemble a ‘text’ to be understood by the doctor. From determined data – the patient’s main complaint, other symptoms, the clinical signs, the results of tests – the doctor forms a hypothesis that must be compared once again with the data, in order to fine-tune or correct the diagnosis, in a process that Hunter denominates the “diagnostic circle” 2, due to its similarity to the hermeneutic circle.

For Thomasma, the raison d’etre of hermeneutics lies in the need for the doctor and patient to understand each other across the distance that inevitably separates them. Thus, hermeneutics is conceived of as an act of interpretation across boundaries 3. For the author, ethical judgment is included in clinical evaluation, so it is artificial to formulate an ethics applied to medicine. This rejection of an applied ethics is a general feature of all hermeneutic approaches to clinical ethics.

The hermeneutical approach helps us to understand how we form a clinical and ethical judgment, but it does not tell us which treatment is good from a clinical standpoint, nor does it guide us about what treatment (or the absence of treatment) is good from an ethical point of view. Thomasma rejects the decision-making models that emerge from both principles and cases. Instead, he proposes what he calls ‘contextualism’, which differs from casuistry – which in his opinion, depends on the theory of natural law 4 – and which starts from the basic idea that the context serves to adjust values related to concrete circumstances. According to Thomasma, there are several factors on which the relative weight of values and principles of each case depends.

These factors are, primarily: the medical specialty involved; the personal values of the patient, their family or social group; the personal and professional values of the health personnel, and the institutional framework in which the problem arises 5. For example, the principle of autonomy will have more weight in the context of primary care than in tertiary care, where autonomy may be diminished. However, this approach is not especially practical. As can be imagined, it provides only indications on how to make decisions.

Context (as opposed to applied theories or abstract principles) is also a key element in the ‘interpretive ethics theory’ of Have 6. Here, doctor and patient are not beings removed from history or culture, but are part of communities in which diverse traditions are shared. His interpretive theory aims, therefore, to be based on the internal professional standards of the practice of care (although without neglecting its connection with external morality). This theory takes into consideration four parameters 7:

  • The starting point for medical activity is the patient’s moral experience. Determining what is lacking in this requires interpretation. Firstly, because the experience of disease in each patient is unique and unrepeatable. Secondly, because the contexts of the interpretation of doctor and patient are different and, so therefore, are their preconceptions;

  • Moral experience primarily involves feelings. Only secondarily can these become the object of moral reflection. The role of medical ethics is not so much to explain and apply ethical theories and principles, but to interpret and evoke all that encompasses moral experience: not only acts and their effects, but also attitudes and emotions;

  • Thirdly, the interpretation of a patient’s situation is not the individual undertaking of the doctor. Instead, the work of physicians is guided by a series of cultural assumptions about the nature of the world and of the body and the consequence of the historical evolution of medical knowledge;

  • Finally, the fact that all interpretation is tentative, and that more than one meaning is always possible, should not be overlooked.

From these parameters, it follows that one must be aware of the historical determination of all understanding. Yet while this may help us discard solutions based on unjustified prejudice, it does not determine a concrete solution. Have stated that dialogue serves to reveal the particularities of our prior judgments and, through it, allows us to obtain a greater degree of understanding 8. While this is correct, it is too generic to solve concrete problems.

Similarly, Leder believes that top-down methodologies (such as Kantianism and utilitarianism) can obscure the rich complexity of cases. Hermeneutics, on the other hand, is capable of dealing with multiple contexts, which is its most useful feature. In his view, the hermeneutics of the twentieth century tends to reject the possibility of univocal interpretations, admitting an indefinite variety of readings. The hermeneutical approach would consist, in his opinion, of listening to the voices of all the characters in the drama.

Specifically, Leder aligns himself with the hermeneutics of suspicion in the manner of Ricoeur, because, he claims, neither the patient nor the physician are aware of the underlying relations of power (such as the market, consumerism, and gender) 10. Junges proposes completing the casuistic approach with a hermeneutics of suspicion that interprets the ethical, anthropological and socio-cultural assumptions that determine how the realities of life and health are understood in the current society and culture 11.

Seeing social relations in terms of power is highly debatable. But even if it were not, it is worth asking if all the voices mentioned are equally valid. It is also not clear how it is proposed to move from careful listening to practice. Leder realizes that one cannot remain in an endless state of interpretation, but that cases must be resolved. Hermeneutics, he says, does not imply relativism. In his view, there is a basis for overcoming subjectivity, which is the shared tradition.

He proposes, furthermore, that dialogue allows us to become aware of the inevitable prejudices that accompany understanding. In a divided society such as the west, the hermeneut must contribute to the articulation of the perspectives of the participants, bringing the different contexts to the debate. His role, he says, is not that of a provider of answers, but that of a Socratic interlocutor, through the invitation to dialogue 12.

All this is interesting, but insufficient for the determination of the correct interpretation. Hermeneutics does not provide a method, but an awareness of our mediated ability to reach the truth. One wonders whether it is necessary to presuppose this truth, because, in another case, it may not be clear what sense dialogue will have.

In an even more indeterminate manner, Lingiardi and Grieco propose that the doctor should become a philosopher 13, and that a true dialogue between doctor and patient must be formed. The patient cannot be in a position of mere passivity. But it is not just about listening to the patient. The philosopher’s task is to ask.

For these authors, it is important to note that the doctor shares with the patient a mortal body, which is also vulnerable. A doctor ‘with wounds’, they say, can activate the healing capacity of the patient 14. This goes beyond mere empathy and is based on the Platonic idea of the doctor, not as someone who dispenses from above, but an individual who simply initiates the process of healing in another 15.

In light of the above, we can agree with Cadorè, who states that the hermeneutic approach to clinical ethics is different from a method for solving problems 16. It is significant that Gadamer, in The Enigma of Health, refrains completely from formulating anything like a method for biomedical ethics 17.

The question of dialogue

According to Gadamer, what the tool of method does not achieve must – and really can – be achieved by a discipline of asking and inquiring, a discipline that guarantees the truth 18. All previous hermeneutic approaches emphasize the need for the physician and patient to listen to each other. But it is an active listening that takes place through dialogue. This allows the mutual questioning of prejudices that are constitutively linked to any act of understanding, and in some cases can distort that understanding.

In fact, through dialogue, the doctor – or the patient – is able to understand the motives of the patient – or the doctor – and, through this understanding, question their own motives, discovering the prejudices that have given rise to them. This characteristic of dialogue is not a psychological opening to the other, which is understood as mere empathy, the putting of oneself in the place of the other, but is an opening of an ontological nature. Svenaeus is right when he states that: truth in Gadamer’s philosophy, however, is to be understood primarily as openness to the other and his world and not only to my own world 19.

This statement falls short, however, and reduces the Gadamerian approach. Because, radically, it is neither my truth nor your truth, but a truth to which, despite the inevitable subjective conditions of understanding, it is possible to accede in one form or another. It is not that I impose myself, or that another imposes himself, as in a relationship of power. The relationship between doctor and patient is not primarily a power relationship. Instead, it is the subject matter itself, the truth, that imposes itself.

That is why Gadamer affirms: undoubtedly the important thing for understanding here is still understanding the subject matter, the substantive insight; It is neither a historical nor a psychological-genetic procedure 20. And, as he points out in another context, understanding a text and agreeing in a conversation have something in common: that all understandings and agreements have something before them; which is that both deal with allowing one to talk of the same thing 21. If the patient does not have a health problem – in the broadest sense of the term – the dialogue between doctor and patient (as such) lacks does not make sense.

It is a mistake to think that what is involved in understanding is only the revealing of the subjective sense of the intention of the author of the text. When Gadamer resorts to dialogue and the Socratic method of questioning as a way of moving towards truth, he does so on the basis of allowing things to surface and to assert themselves, when faced with the opinions and prejudices that dominate the individual 22.

It is not, therefore, correct to reduce hermeneutics to a dialogue of perspectives, in which doctors, patients, committee members and others perform an approximation of positions as they reciprocally approach other horizons of understanding 23. It is a fact that this occurs. The question is why it occurs. In a radical sense, why approach what is distant? If all the perspectives, such as those of the doctor and the patient, are valid, it is congruent to try to impose them because they are one’s own.

If this is not in fact so, it is not because, in the Hobbesian manner, discord is replaced by concord and war by peace, but because each and every one of these perspectives may also be mistaken with respect to reality, or biased by prejudices. This presupposes that, for many of the aspects presented, there is some kind of access, albeit partial, to objective truth.

It is true, as Svenaeus says, that Gadamer does not consider the goal of hermeneutic understanding the timeless truths that can be attained through a universal and timeless method. Truth, Svenaeus aptly points out, is always concrete and depends on the meeting of two concrete horizons of understanding, a meeting that is directed towards the accomplishment of an end (goal) 24. This end is healing. As healing is a good thing 24 and a morally valuable end, the hermeneutics of medicine presents a ‘normative structure’.

This approach is clearly Aristotelian. In fact, for Aristotle, phronesis or prudence, which is the virtue responsible for decisions, is normative 25, for the reason just noted. But this virtue, though intellectual in nature, is not practicable as it is based on moral virtue, as Svenaeus admits. In spite of this, and recognizing that the ethics of virtue is one of the possibilities of developing an ethics that revolves around phronesis, he supports hermeneutic phenomenology 26.

And although he need not, Svaneaus returns to the starting point, appealing to dialogue and the need for doctors to understand their patients, their preferences and their ideas; opening themselves, in turn, to their horizons 27,28. For Svenaeus, the ‘good hermeneut of medicine’ is phronetic in the sense that he or she is dialogically skillful 29.

But this is a reduction of the Aristotelian approach. Unlike Svenaeus’ position 30, medical activity does not seem specifically phronetic. It is true that it pursues a good end, health, and to this extent is part of phronesis. But, as Aristotle teaches, this virtue is not directed at a particular good, health for example – as expressly stated – but to living well in general 31.

Moreover, in the light of the Aristotelian approach, the individual who must procure health is not primarily the doctor, but the patient. As Aristotle points out, prudence deliberates on what is good and convenient for oneself 31. Similarly, in the world of law, the just is the person who wants to give to each their own. The jurist is the person who knows what is due to each individual.

Something similar happens in medicine. The patient is the one who desires health; the doctor, the individual who knows how to recover it. In short, medicine participates to some extent as phronesis, but for the above reasons – it is directed at a particular good and at another subject – it seems to be closer to the techne.

An ontic base

Svenaeus states that: truth in Truth and Method is meant as a basic experience of being together with others in and through language and not as a criterion for the correct interpretation of texts 32. This should be further qualified. According to Dasein, using Heideggerian terminology, not only is ‘being with’ inherent, as Svenaeus points out, but also ‘being in the world’, with the sense of thrownness or ject in relation to the world 33.

For Heidegger, ‘to be there with’ is essentially already evident in the ‘coencounter’ and in the ‘counderstanding. 34 To understand the other is not so much an understanding of the other, a grasping of their subjectivity and eventually a compromise with it, as much as an understanding together with another, a counderstanding. You cannot understand the other if you do not understand the world. The world is a criterion of correction.

Certainly, as Heidegger states, truth is relative to Dasein: entities are discovered as soon as Dasein is. But Dasein is, at the moment it is constituted by the state of openness, essentially in the truth 35. Thus, to say that Newton’s laws were not true before their formulation by Newton does not mean that the entities that these laws discovered did not exist before 36. It is thanks to this that an intersubjective agreement is possible.

In the field of the humanities, dialogue is directed at the discovery of things. As Gadamer points out, in principle understanding means understanding one another. It is to begin agreement. But agreement is always about something. It tries to reach an agreement and this is done remaking the way towards the subject.

The real problem of understanding occurs when, in an effort to understand a content, the reflective question arises as to how the other has come to his or her opinion. To understand, the decisive element remains understanding the subject matter, the substantive insight; It is neither a historical nor an evolutionary-genetic procedure 37. Gadamer writes: whenever someone strives to understand (...) they are indirectly operating a reference to the truth that is hidden in the text and must come to light 38. In his view, the aim of all understanding and of any consensus based on it is agreement on the thing itself.

Gadamer’s views about the text can equally be applied, in the context of a dialogue, to the mutual understanding between doctor and patient. The text, or the words that these individuals exchange, are no longer understood as mere vital expression, but are considered seriously in their own claim to truth. The symptoms that the patient reports are true as they occur in their body. Also, the treatment indicated by the doctor is truly good if it is intended to cure the patient.

Therefore, in general, little dialogue between doctor and patient is necessary. It is not them, but the subjects themselves, that determine agreement. Health is an end that qualifies the measures conducive to it as truly good. Thus for Aristotle, prudence – as far as it serves health in the broader context of a good life – is the true and practical rational mode of respecting what is good and bad for man 39.

The problem comes with difficult cases. In particular, when the patient or his/her representatives request a measure contrary to the clinical judgment of the physician. It is true, ut supra, that it is the patient who has to decide what is good in the case of their own health. But it is also true that his life is dependent on the doctor, ethically speaking, when the latter is doing his job properly. That is why conscientious objection is so important. In this type of cases, two basic types of good are at stake, respectively: health, whether physical or spiritual, for one, and his mission for another.

Good is in a varying conflict with will, which has to be suitably strengthened with custom so that it can operate with phronesis or prudence. Talking of ‘values’ does not allow us to see this deeper reality. The values are abstract and can be assumed like someone choosing a product in a catalog. This is not realistic.

Going back to the point of legal comparison, in passing just sentences, the judge has firstly to want to be just, in the sense that he has this disposition. There is no prudence without moral virtue 40. If the doctor and the patient are prudent, agreement will be easier. If one of the two is not, the subject becomes complicated, but that does not mean that there is no practical truth, since everything that is good can be measured in terms of what Aristotle calls things that are good in themselves, 41 here qualified under current usage as basic human goods 42.

Thus it is found that mere intersubjectivity is not enough to escape relativism. As Garcia Llerena has pointed out, the only way to escape relativism – and also its opposite, absolutism – is to turn to an objective and transcultural referent: being. This author advocates a hermeneutic ontology that does not attempt to operate with objective criteria, a task not yet undertaken in the bioethical field 43.

Community and tradition

That practical reasoning finds support in the basic human goods that guide it does not mean that it provides absolutely objective knowledge. Following Heidegger, Gadamer shows that all understanding is continuously determined by the anticipatory movement of pre-comprehension 44. This consists of an anticipation of meaning which guides understanding in an inescapable manner, as it constitutes a structural ontological moment of such comprehension 44.

Pre-understanding is not merely an act of subjectivity, but is determined from the community that unites us with tradition. 44 MacIntyre has emphasized this aspect, as shown by Gadamer:

What I am, therefore, is in key part what I inherit, a specific past that is present to some degree in my present. I find myself part of a history and that is generally to say, whether I like it or not, whether I recognize it or not, that I am one of the bearers of a tradition 45.

For MacIntyre all reasoning takes place within the context of a traditional way of thinking. In turn, a tradition is always partially constituted by a reasoning about goods, the search for which gives that tradition its point and its purpose 45. For example, medical tradition involves a continuous discussion about what medicine is or should be. This has nothing to do with traditionalism, since traditions are a living stream, in constant transformation. For example, the medical tradition has undergone important transformations in the last decades, moving from the previously accepted paternalism to a growing respect for patient autonomy. In short, tradition conditions understanding, but, in turn, understanding conditions tradition.

Understanding not only dialogues with a text – or a patient – but also establishes a dialogue with tradition. This dialogue is not merely theoretical, however, but applies to the texts or people we try to understand at each moment. As Gadamer says, written tradition, from the moment it is deciphered and read, is so pure in spirit that it speaks to us as if it were current 46.

This dialogue is enriching because it illuminates, hence the importance of training. And the humanities are essential for training. A doctor with a humanistic background is better prepared to make decisions. Undoubtedly, clinical ethics are important, but so is the history of medicine and the humanities in general. Studies in medicine and literature have been introduced in some countries, and have proved very useful. This is a point in favor of narrative bioethics 47. We often recognize good through example.

As Aristotle teaches: thus although actions are entitled just and temperate when they are such acts as just and temperate men would do, the agent is just and temperate not when he does these acts merely, but when he does them in the way in which just and temperate men do them 48. It has been commonplace since antiquity to describe the importance of the narration of events from the past to the present. Plutarch, in writing his “Parallel Lives”, points out that at the beginning of this work he considered others (their lives), but adds: during its progress and continuation I have also looked at myself 49. Indeed, history is a ‘mirror’ that allows one to adorn assimilate their life to each of the virtues of others 49. And in the opinion of Julian de Toledo, the narration of triumphs comes to the aid of virtue, emphasizing in general the importance of the narration of the facts of the past for the present 50.

It is significant that Gadamer considers that the humanities are part of moral knowledge 51. In fact, the object of the humanities is precisely man and what he knows of himself. That is why he states: and to understand this [the text and tradition], [the interpreter] may not look away from himself and the concrete situation in which he finds himself. He must relate the text to this situation, if he wants to understand at all52.

With this reflection, the author is stating that the application of a text is not an ultimate and eventual part of the phenomenon of comprehension, but is determined from the beginning, and from the text as a whole 53. Under this presupposition, Gadamer considers that when reconstructing the old unit of the hermeneutical problem in which the jurist, theologian and philologist 54 are found, a historian must be added 55. In general, it must be said that every reading must contain an application 56.

Commenting on Gadamer, Grondin points out that a distinctive feature of humanism is not to produce measurable results, but rather to contribute to training 57. For Gadamer, training is, together with the sensus communis, the capacity for judgment and taste, one of the four basic elements of humanism. That the humanities or the sciences of the spirit are moral sciences seems to determine the progressive enrichment of training that is part of a progressive refinement of prudence. In the same way as taste or aesthetic sensibility presupposes training, so does the capacity for moral judgment. After all, training requires memory (a type of selective memory) and memory is one of the parts of prudence 58.

Training is not experience, which is a lived knowledge, but it can be updated and refreshed like experience if the humanities are seen as moral sciences, the understanding of which constitutively involves their application to the present. As Conill points out, the central concept of training, such as the ingredients of practical humanistic knowledge (common sense, judgment and taste), has a recognized moral significance. This practical knowledge has a formative potential that is very useful in applied ethics, such as, for example, in the training of professionals with a humanist and not merely a technicalist sense59.

The humanities have the ability to contribute to the integral formation of a person and we must not forget that, unlike the facere of technology, the whole being of a person participates in the agere of prudence. Precisely because of this, Aristotle stresses the importance of knowledge for the prudent. In a general sense, he points out that in every subject he carefully judges the individual who is both being instructed in that subject and, in an absolute sense, being instructed in everything. But he warns that when it comes to politics - and here we could include ethics - a young man is not an appropriate student, since he has no experience of life. He writes:

Hence a young man is not a proper hearer of lectures on political science; for he is inexperienced in the actions that occur in life, but its discussions start from these and are about these; and, further, since he tends to follow his passions, his study will be vain and unprofitable, because the end aimed at is not knowledge but action. And it makes no difference whether he is young in years or youthful in character; the defect does not depend on time, but on his living, and pursuing each successive object, as passion directs. For to such persons, as to the incontinent, knowledge brings no profit; but to those who desire and act in accordance with a rational principle knowledge about such matters will be of great benefit 60.

Indeed, our judgments not only deal with the actions of life, but, as Aristotle asserts, ‘start from these’. This refers to virtue, which is formed by habit, because, as Stagirite teaches, none of the ethical virtues occurs in us through nature, as nothing that exists by nature is modified by custom 61. As such, through practicing justice, we become justice; virile, by practicing virility 62.

But if we have not attained virtue, knowledge does not profit. That is why we will not make good politicians: neither the young man, who lacks maturity in virtue, nor the incontinent or wanton man, who has formed the habit of contrariness. As Aristotle states elsewhere, the incontinent and the bad man obtain from reasoning that which they propose to see, so that they will have consulted rightly, but have procured for themselves a great evil. But to have consulted well appears to be a certain good, for such a rectitude of consultation, as becomes the mean of obtaining good, is good consultation 63. Aristotle argues that he who makes use of knowledge in practical matters is one who guides his actions and his desires according to reason, and this is prudence 64.

Final considerations

There is a hermeneutic dimension to the doctor-patient relationship. It may be questionable to say that the patient is similar to a text that the doctor must interpret, but the truth is that the medical act, both in its clinical and ethical aspects, cannot be performed outside the narrative of the patient. The hermeneutical approach helps us to understand how we form clinical and ethical judgment, but just as it does not tell us which treatment is good from a clinical standpoint, so it does not guide us about what treatment (or the absence of) is good from an ethical point of view. It is therefore difficult, unlike what some hermeneutic approaches claim, to replace the usual decision-making models by a methodological scheme inspired by hermeneutics.

The aforementioned hermeneutic perspectives do not have at their disposal the tool of method, but the tool of dialogue, which occupies a central place in all such approaches. Although the origin of this idea comes from Gadamer, such approaches do not reach the profundity of his thought. In fact, it is not only a matter of being open to another and to his or her truth, in the sense of not imposing one’s own truth, and being able to discover one’s own prejudices, but, from a more radical point of view, of the subject itself. In fact, for Heidegger, Dasein is not only inherent in “being with”, but also in “being-in-the-world”, in the sense of thrownness or ject in relation to the world. Therefore, one cannot understand another if one does not understand the world. For this reason, for Aristotle, prudence is a practical, truthfully rational form of being in terms of what is good and bad for man.

All understanding is determined by the anticipatory movement of pre-understanding. This is not a mere act of subjectivity, but is determined from the community that unites us with tradition. In understanding, one does not only dialogue with a text – or a patient – but also with tradition. It is a dialogue that enhances understanding and shows the importance of humanistic training for the prudent individual who must make decisions. It is not without reason that the humanities form part of moral knowledge.

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Received: August 9, 2016; Revised: February 14, 2017; Accepted: February 24, 2017

Correspondêcia. Facultad de Derecho, Campus de Elviña, s/nº 15071. Coruña/España.

Declara não haver conflitos de interesse.

This work is part of the El discurso de los bioderechos. Bases filosóficas y jurídicas para su fundamentación, caracterización y aplicación (The Discourse of Bio-rights - philosophical and legal bases for its foundation, characterization and application) (DER2014-52811-P) research project, directed by José Antonio Seoane and financed by the Ministry of the Economy and Competition. I would like to thank Professors José Antonio Seoane, Viviana García Llerena and Carolina Pereira for their enriching observations

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