By V. Kerth. Asbury College.

As Pellegrino reminds us order trileptal 600 mg amex medicine wheel images, the classical me- dieval synthesis understood virtue as excellence of character cheap trileptal 300mg with amex treatment authorization request, as a trait appropriately oriented to defning ends and purposes, as an excellence of reason, not emotion, as centered in practical judgment, and as a trait acquired by practice. Pellegrino contrasts this account with Alasdair Mac- Intyre’s account, which regards virtues as dispositions or acquired quali- ties necessary (1) to achieve the internal good of practices, (2) to sustain the communities in which individuals seek the higher good of their lives, and (3) to sustain traditions necessary for the fourishing of individual lives. Despite his defense of virtue ethics, Pellegrino frankly acknowledges the difculties of virtue-based accounts: (1) virtue-based accounts tend to be circular (i. All of this leads Pellegrino to underscore that virtue-based accounts cannot stand alone and must be lodged within a more comprehensive moral phi- losophy, which he acknowledges does not now exist. This problem is com- pounded in medicine, where the Hippocratic tradition is, at best, in dis- array. The practice of medicine is marked by moral pluralism, relativism, and the privatization of morality. In the face of these challenges, Pellegrino calls physicians to an act of profession that can tie them to their engage- ment in healing, so that they can come to appreciate professional virtue in terms of the telos of the clinical encounter: the patient’s good. Pellegrino lists among the virtues that should mark the good physician: fdelity to trust and promise, benevolence, efacement of self-interest, compassion and caring, intellectual honesty, justice, and prudence. Having spoken to professional virtue in the clinical context, Pel- legrino turns in the next essay to challenges to the physician’s moral con- science. His focus is on the conficts engendered as a result of practicing medicine in an often afrmatively secular culture. This tension is rooted in the circumstance that traditional Christians know things about medical morality unrecognized within secular society. In “The Physician’s Con- science, Conscience Clauses, and Religious Belief: A Catholic Perspec- tive,” Pellegrino lays out a geography of some of the resulting moral conficts, giving special attention to the rising reluctance of the state and others to confront honestly what should count as violations of conscience. For example, although religious exemption laws and conscience clauses have protected physicians from being directly coerced to engage in abor- tion or physician-assisted suicide, there is nevertheless often a require- ment that they refer patients to others to do things the Christian physician knows to be immoral (that is, since abortion is equivalent to murder, then referring a woman to an abortionist is equivalent to referring someone to the services of a hit man, even if one will not engage directly in the mur- der oneself). In addition, there are growing constraints on religious insti- tutions, once they receive tax funds, to provide services they would recognize as immoral, though their co-religionists have been forced to pay those very taxes. Among the failures in such public policy approaches is © 2008 University of Notre Dame Press An Introduction not appreciating that institutions, in order to maintain an integrity and commitment to virtue, must preserve the character of their commitments to the particular communities that brought them into existence and sus- tain them. It is through institutions such as sectarian hospitals that indi- viduals realize their concrete lives in moral communities, with the result that the moral integrity of the individual is put at jeopardy if they are not able to protect and maintain the moral character and integrity of their institutions and their moral communities. The last section ofers Pellegrino’s analysis of the ambiguities of hu- manism, the limitations of the Hippocratic Oath, and the challenges to framing a medical ethics for the future. The frst subsection, “Humanities in Medicine,” brings together essays exploring the role of humanism in medicine and medical education. The frst essay, “The Most Humane of the Sciences, the Most Scientifc of the Humanities,” already partially quoted in this introduction, is an early manifesto that in many ways in- spired the development of humanities teaching in medical schools. It in- cludes Pellegrino’s famous synopsis of the relationship of humanities and medicine: “Medicine is the most humane of sciences, the most empiric of arts, and the most scientifc of humanities. Its subject matter is an ideal ground within which to develop the attitudes associated with the human- istic and liberally educated. As he stresses, the humanities have traditionally been recognized as quite diferent from the liberal arts. Pellegrino also stresses a point underscored by Abraham Flexner: “the pull toward specialization and scholarship” tends to transform the study of the humanities from the pursuit of wis- dom to the pursuit of information and pedantry. This point is developed further in the second essay, “The Humanities in Medical Education: Entering the Post-Evangelical Era,” where Pellegrino again emphasizes that the liberal arts, from classical times, have compassed “the intellectual skills needed to be a free man. The humani- ties must be made integral to the life of the medical student and the physi- cian. In actual practice, medical students and physicians must see how the medical humanities support the physician’s virtuous response to actual patients. The next essay locates concerns regarding humanism and the virtue of the physician in the context of Roman Catholic perspectives on medical morality. In “Agape and Ethics: Some Refections on Medical Morals from a Catholic Christian Perspective,” Pellegrino reviews the recent Roman Catholic dialogue with “the dominant cultural ideas of the time” and the competing accounts of morality and ethics which this has produced. He selects for his focus what he terms an agapeistic ethic: a virtue-based ethic which afrms charity as the principle that should structure the relation- ship between physicians and patients.

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The answer is certainly yes buy generic trileptal 300 mg on line medicine you can give dogs, because every tumour is heterogeneous and for any tumour type in a patient we can fnd the possibility of exploiting this buy trileptal 300 mg medicine song, but the path and the pace are different tumour by tumour. Also, clinical trials should be done to try to obtain more knowledge on the mechanisms of the disease. The era of very large clinical trials – of 5000 patients in a randomised clinical trial in which we investigate standard chemotherapy plus or minus a new agent – has ended. Every time that a patient signs a consent form to enter a clinical trial, the patient is hoping to receive a better treatment. But whatever comes from that individual experience, the trial should also be useful in gathering knowledge that can be used for other patients. So donating tumour tissues, blood samples, and other parts of the body is a very important issue. Maybe when I retire as a physician we will still be working on that, because fghting cancer is not so easy. Some 30 or 40 years ago we were talking about cancer as not being a curable disease. We are working to cut out the ‘not’ from the defnition of cancer, but personalisation of medicine requires not only a lot of awareness by the patient and a lot of awareness by patient focus groups, but also requires putting pressure on the governing bodies. There are some concerns that personalisation of medicine is going to be too expensive. On the other hand, personalisation of medicine represents trying to get the best possible results for the individual patient, and the issue of cost is something that comes after. The main reason for the slow progress is the lack of mature scientifc insights through which we have something to offer. In order to test a treatment in 100 patients we sometimes need dozens of centres, with one or two patients per centre. We really have to strengthen and reinforce in the future all the collaborative ways to work, without any – or minimal, at least – competitive ways of thinking. We have to work together to make the science evolve and forget about the national or regional representation of research that we have had in the past. The real advantages of personalised medicine are, of course, that we will be able to provide a given patient with a much higher level of care, a much higher level of therapeutic effcacy than we can attain now. There will also probably be other ways of monitoring patients, of maybe having repeat samples taken for doing molecular diagnosis; otherwise we cannot personalise the treatment. These are the two aspects that we will have to work on in the next few years to implement personalised medicine in clinical practice. For patients to beneft from these targeted therapies, a tumour sample must be sent for analysis, and this biomarker analysis can take one week or longer. The survey concluded that the majority of patients (74%) would be ready to delay treatment for this period to undergo additional tumour testing, in the hope that they may beneft from personalised therapy. The same survey found that the majority of patients would allow hospitals to retain their tumour samples for future research. This is a major topic, because patients must be aware that nowadays several new examinations can be performed on their tissues and tumour samples, but that these examinations can delay their treatment. Patients must be aware that the examinations are performed mainly on their biospecimens. Biospecimens are materials taken from the human body, such as tissue, blood, urine or saliva, which can be used in directing patient care or be processed and stored for future medical research. In the majority of cases these tissues are the same as used for the diagnosis of cancer. Therefore patients do not undergo any additional steps, other than to consent to the use of their biospecimens for the examination. In recent years an awareness has grown that the characteristics of tumours may change and patients may be asked to submit to a new biopsy to re-personalise their therapy. Therefore there is a clear value in collecting biological material for doing research. The term “biobanks” can be defned in many ways, but the defnition adopted here will be “an organised collection of human biological material and associated information stored for one or more research purposes”.

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