Prof. Dr. Maarten Verkerk – The Challenge of Western Healthcare: Professional Practices and User Practices
In Western countries healthcare faces enormous challenges. Rising costs make strong demands on economies, the rise of individualism undermines the idea of solidarity, and the dominant medical approach clashes with the social and spiritual needs of patients. In addition, it appears an uphill battle to convince citizens to adopt healthier lifestyles, when increasing prosperity encourages new epidemics like obesity. One might get the impression that our health care system will collapse under the weight of its own success.
These observations have stimulated a number of scholars to analyze the state of health care and to propose new solutions. Michael Porter and Elizabeth Olmsted Teisberg argue in their book Redefining Health Care for a radical re-orientation of healthcare policy. They believe that the problems of health care only can be cured by focusing on ‘value for patients’.
Christian philosophers have contributed strongly to the understanding of health care. The so-called normative practice model has been developed to understand medical practices (Jochemsen&Glas, 1997; Jochemsen, 2006). This model focusses on the consulting room: the place where the health care professional meets patient. The practice model appears to be very fruitful by unravelling the complexity of professional practices and by the identification of values and normativity. This model also has been elaborated in the field of technology and organization (Verkerk, 2014).
In this paper, we would like to extend and to refine the ‘classical’ normative practice model in order to understand the problems in in present western health care and to focus on the value for patients. Firstly, we would like to recognize that modern healthcare is not a ‘single event in the consulting room’ but a process that consists out of many parallel and serial steps. Secondly, we would like to emphasize that healthcare has to focus on the needs of the patients. This focus only can be realized when we understand the context of the individual patient. This context will be indicated with the word ‘user practice’. The extensions and refinements of the normative practice model are inspired and illustrated by a case study in orthopedics.
Jochemsen, H. & Glas, G., 1997, Responsible medical care (in Dutch), Buijten&Schipperheijn: Amsterdam.
Jochemsen, H., 2006, ‘Normative Practices as an Intermediate between Theoretical Ethics and Morality’, PhilosophiaReformata 71:96–112.
Verkerk, M.J., 2014, ‘A philosophy-based “toolbox” for designing technology: The conceptual power of Dooyeweerdian philosophy’, Koers – Bulletin for Christian Scholarship 79(3), Art. #2164, 7 pages. http:// dx.doi.org/10.4102/koers. v79i3.2164
Porter, M.E., & Teisberg, E.O., Redefining healthcare. Creating value-based competition on results, Harvard Business School Press, Boston.
In current-day postphenomenological ( Ihde, 1990; Verbeek, 2000, 2005) philosophy of technology ( hereafter: PPT) it is sought to understand in what way technologies ‘mediate’ ( Ihde, 1990; Verbeek, 2000, 2005) the relation between subject and object, human and the world-out-there. PPT – in the slight deviation it has taken from its origin in the work of Verbeek ( Verbeek, 2000, 2005) – PPT maintains that both subject and ‘world’ arise out of a constitutive interplay between subject and world. This account of ´what things do´ ( Verbeek, ) in our perception of world and engagement in world is based upon Martin Heidegger´s ´ existential analytic´ ( Mensch, 2015) in Being and Time. More recent approaches focus on the role technologies play in the constitution of the moral subject ( Verbeek, 2011). Drawing on – amongst others – Foucault, it is sought to understand in what way technology constitutes us as moral subject because this mediation renders the modernistic approach to the moral, autonomous subject merely an ´illusion´ ( Verbeek, 2011). The future of ethics of technology, then, does not depart from moral agency as the source of morality but is aimed at assessing ´the quality´ (Verbeek, 2011, p. 156) of human-technology relations. The ´good life´ is as PPT maintains, present within human-technology relations and ethics as ´accompaniment´ of these relations requires ´ skill in order to give shape to our mediated morality´ (Verbeek, 2014, p. 161). PPT in that sense returns to a form of Aristotelian virtue-ethics.
PPT has shown that morality cannot have autonomy at its origin for our moral subjectivity is to a large extend mediated by technology. In this approach, PPT has however failed to acknowledge that sociality also problematize the Kantian notion of autonomy. We are not free from technology but we are likewise not free from others. I believe that PPT at this point can be complemented by an approach towards ethics that departs from Emmanuel Levinas´s existential analytic in Totalility and Infinity ( Levinas, 1961). Levinas approach is a particularly suitable candidate to complement PPT for mainly three reasons. First it departs from embodied, vulnerable being in the world and thereby fully acknowledges our dependency on our material – that includes technologies – environment. Second, this dependency is assessed by Levinas in moral terms, for in ´experiencing´ our needs as Enjoyment we become independent from them and so acquire a form of autonomy that is unlike Kant for Levinas is ´embodied´ ( Mensch, 2015). Embodied autonomy is however – just like PPT (Verbeek, 2014) – in need of a measure capable of putting ´the spontaneity´ ( Levinas, TI, 34) of Enjoyment under criticism. Levinas provides with this measure in the form of the other who through conversation, ´calls into question´ ( Levinas, TI, p. 43) our embodied autonomy. This being called into question, however is only possible because there is first embodied autonomy.
With my Levinas-inspired approach I will have accounted for the fact that humans and technology are ´interwoven´ (Verbeek, 2011, p. 153) and even ´deepened´ this relation by tracing it back to our embodied and thus vulnerable being in the world. I will have moralized this relation but also provided for a measure that is outside our relation with technologies and placed inside our (unmediated) face-to-face relation with other human beings. The face-to-face relation requires autonomy but this autonomy is challenged through language and conversation. Language ´objectifies´ our private existence and brings it under the criticism of public existence.
Levinas, Emmanuel, ( 1961), Totality and Infinity: an essay on Exteriority, trans. J.M. Tillema-de Vries, Lemniscaat, Rotterdam
Heidegger, Martin ( 2009), Beingand Time, Trans. M. Wildschut, Sun, Nijmegen
Verbeek, Peter-Paul ( 2005), what things do, trans. R.J. Crease, Penn State University Press, Pennsylvania
Verbeek, Peter- Paul ( 2011), moralizing technology: understanding and designing the morality of things, University of Chicago Press, Chicago
Mensch, James R. ( 2015), Levinas´s existential analytic: a commentary on Totality and Infinity,North-Western University Press, Evanston
Prof. Dr. Gerrit Glas – Reinventing Professionalism – Public Responsibility in Current Medicine and Psychiatry
The story of medical professionalism is one of increasing division of labour and of negotiations about the jurisdictions and the autonomy of the professional (Freidson 2001). In the middle of the previous century professions were seen positive and important. The sociologist Talcott Parsons, for instance, defended a favourable view, which was inspired by the idea that professions served as institutionalized safeguards of certain public goods against corruption and decay.
The sixties until the eighties were characterized by a thoroughgoing demise of medical professionalism because of its tendency to paternalism and egoism (Larson 1977). The nineties of the previous century showed, again, a slow and partial reappraisal of professionalism. This reappraisal implied a recognition of the intrinsic values of the medical profession.
After this brief historical overview, the paper will focus on current challenges for the medical (and associated) professions. I will argue for the relevance of the so-called normative practice model for a fundamental rethinking of the professions (Hoogland & Jochemsen 2000). This is needed in view of the considerable challenges for medicine. To mention only few important issues: the division of labour still has not come to an end; today’s health care is marked by fragmentation of care and by severe financial problems in many countries. Introduction of market impulses has led to more awareness of the factors that form necessary conditions for a modern health care, such aseconomicleadership, but has also led to new problems, for instance with respect to equal treatment, solidarity, and the split between haves and the have-nots, which has become larger in the last decades.
I will discuss in my paper the answer the normative practice model gives to new initiatives with respect to the professions in medicine, such as the idea of ‘a continuum of competencies’ (with concomitant blurring of the boundaries and identities of current professions), the need for a more general applicability of competencies (‘broader, overlapping profiles between the professions’), and the emphasis on self-management and shared-decision making (Bombard et al. 2011). I will defend a normative practice approach as a way to show a new, Christian way of taking public responsibility. I will show how the model may give a more solid foundation for leadership for professionals from whatever religious brand.
Bombard, Y., Abelson, J., Simeonov, D., Gauvin, J.-P. (2011). Eliciting ethical and social values in health technology assessment: A participatory approach. Social Science & Medicine, 73, 135-144.
Freidson, E. (2001). Professionalism, the third logic: on the practice of knowledge. Chicago: The University of Chicago Press.
Hoogland, J., Jochemsen, H. (2000). Professional autonomy and the normative structure of medical practice. Theoretical Medicine and Bioethics 21 (5):457-475.
Larson, M.S. (1977). The rise of professionalism. Monopolies of competence and sheltered markets (edition 2013 with a new introduction by the author). New Brunswick & London: Transaction Publishers.