Moral agents in medical research and practice

Abstract

The first three papers in this issue deal with the physician– patient-relationship. Helge Skirbekk focuses on the microethical issue of trust in the physician–patient-relationship. In most of the medical encounters trust is taken for granted as an implicit phenomenon. Patients often simply assume that they can trust their physician. But the physician– patient-relationship can be made a topic for negotiations if either party finds reason for it. Examples are non-compliance of the patient and doctors who drink too much. Negotiating trust is something one cannot always avoid in order to build an adequate physician–patient-relationship. Andreas Langer et al. focus on the physician–patient-relationship from a somewhat unusual perspective. They attempt to build a bridge between economic theory and medical ethics by applying elements of new institutional economics to ethically relevant dimensions of the physician–patient-relationship. Physicians cannot always give the best possible treatment for their patients because of financial restrictions. Andreas Langer et al. present a new version of the principal-agent-theory in order to analyse this dilemma of medical doctors. Their model of the so-called dual principal-agent relationship can be used to widen the perspective of medical ethics. Individual ethics of the physician–patient-relationship should be complemented with institutional, especially economic, considerations. In their paper, Kjetil Rommetveit and Rouven Porz tell the story of a patient facing the tough decision of whether to be tested for Huntington’s disease or not. They interpret this story from two different philosophical points of view: Aristotle’s perception of Greek tragedy and Karl Jaspers’ notion of boundary situations (Grenzsituationen). The authors argue that philosophical-anthropological positions like these two may be useful for elucidating ethical dilemmas in the clinical setting and for gaining a deeper understanding of these dilemmas. They can be seen as hermeneutic tools for situating clinical dilemmas in a broader cultural and philosophical perspective. The next three papers can be subsumed under the heading of research ethics in a pluralistic society. Lars Oystein Ursin tackles the problem of informed consent in biomedical research. Taking consent for biobank research as an example, he argues that in ethical considerations there is often a confusion of autonomy with liberty interpreted as freedom of choice. In his view we need to make a clear distinction between two ways of understanding the notion of personal autonomy, that is, a proceduralist conception linking autonomy with authenticity and a substantivist conception linking autonomy with control. Informed consent requirements in medical research may bring about a conflict between a participant’s interest in personal autonomy with his or her interest in liberty. Ilhan Ilkilic and Norbert Paul also focus on biomedical research, especially on genome diversity research. An important part of genome diversity research is taking blood and tissue samples from indigenous populations. The authors widen the scope from micro issues such as informed consent and autonomy of probands to a wider approach in which also cultural–philosophical, meta-ethical, and phenomenological aspects are taken into account. They show a few limits of current guidelines used in international genome diversity studies and end up with some conclusions to further develop these international guidelines. From this paper it is not a big step to the following one. Chris Durante’s paper does not deal with clinical medicine or biomedical research, but with bioethics in a pluralistic society. In his view, many theorists fail to take into consideration the W. Dekkers (&) B. Gordijn UMC St Radboud Nijmegen, P.O. Box 9101, Nijmegen, The Netherland e-mail: v.hulsman@iq.umcn.nl