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Einführung: Was ist „Geschichte, Theorie und Ethik der Medizin“?

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Geschichte, Theorie und Ethik der Medizin, SoSe 2010
Einführung: Was ist „Geschichte, Theorie
und Ethik der Medizin“?
13. April 2010
Ch i
Christoph
hR
Rehmann-Sutter
h
S
Prof. für Theorie und Ethik der Biowissenschaften
rehmann@imgwf.uni-luebeck.de
www.imgwf.uni-luebeck.de
Der Kurs „Geschichte, Theorie und Ethik der
Medizin“ (GTE) im Überblick
1. Vorlesung (Di 10-11): (6 Termine obligatorisch) Einführung –
Hippokratischer Eid und Antike Medizin – Medizin und Technik –
F
Forschungsethik
h
thik – Medizin
M di i und
d Dikt
Diktatur
t – Die
Di W
Wende
d zur M
Medizin
di i als
l
Naturwissenschaft – Ethische Probleme am Lebensbeginn –
Organtransplantation – Psychiatrie und Gesellschaft – Ethische Probleme
am Lebensende – Lübecker Impfskandal – Prothetik,
Prothetik Enhancement,
Enhancement
Transhumanismus – Therapeutisches Ethos.
2. Nachgespräch (Di 11-12): als Wahlpflichtfach 1-stündig. Jeweils
p
Thema, p
passend zur Vorlesung.
g
spezielles
3. GTE-Seminare: eines obligatorisch, mit Hausarbeit.
•
•
•
•
•
•
•
Ethik d. med. Genetik: Gentests, Gentherapie, Enhancement (Rehmann-S.)
Organtransplantation (Kanz)
Irren ist menschlich: Psychiatriegeschichte (Borck)
Bioethik und Biopolitik (Rehmann-Sutter)
Medizin und Nationalsozialismus (Weiss)
Technisierung der Medizin (Weiss)
The free will and scientific determinism in brain research (Borck)
Medizin ist nicht vom Himmel gefallen.
•
•
•
•
•
•
Welche Rollenverständnisse, welche Ethik orientierten Medizin in
früheren Zeiten und heute? (Medizingeschichte, Medizinsoziologie)
Durchschauen scheinbarer Selbstverständlichkeiten in der eigenen
beruflichen Praxis, Vermögen der Reflexion und der moralischen
Wahrnehmung gehören zur Exzellenz als Arzt.
A
Ausgewogenes
und
d kkritisches
iti h V
Verständnis
tä d i d
der A
Aufgaben
f b und
dd
der
Grenzen der Medizin ist notwendig, um eine Medizin zu praktizieren,
die gegenüber den Patientinnen und Patienten vertretbar ist.
Wandel des Verständnisses von Gesundheit und Krankheit
Krankheit, von
Leiden, Heilen, Pflegen, von Wissen und Wissenschaft etc.
(Medizintheorie)
Daraus: aktuelle Trends verstehen: Genetisierung, Biomedizin,
prädiktive Medizin, regenerative Medizin, Apparatemedizin etc.
Welche Ethik soll diese Medizin orientieren? (Medizinethik, Bioethik)
Luke Fildes, The Doctor, 1881 (©Tate, London 2006)
Wo ist die Medizin im Bild von Fildes?
•
•
•
•
•
•
Medikament
Ärztlicher Blick, Diagnose,
g
medizinisches Wissen/Nichtwissen
Beziehungstriade Az – Pt – Angehörige
Ethos des Heilens und der Fürsorge
as hinter
te dem
de Arztt ste
steht:
t Wissenschaft,
sse sc a t, Wissen,
sse , Apotheken,
pot e e , Sp
Spitäler,
tä e ,
Was
Gesundheitswesen, Staat
Geschichte der Medizin
„Medizin“ ist nicht nur das, was Ärztinnen/Ärzte tun, sondern ein soziohistorisch bestimmtes und sich wandelndes Geflecht aus
heilberuflichen Professionen, ärztlicher Kunst, medizinisch-biologischer
Wissenschaft, Geräten/Heilmitteln/Technik, Praxis, Ökonomie,
Ö
Recht,
Visionen, Erwartungen und Wahrnehmungen.
Geschichte, Theorie und Ethik eröffnen drei zusammenhängende
Dimensionen für die Reflexion auf die Wirklichkeit und auf die
Möglichkeiten der Medizin.
Beginn der naturwissenschaftlichen Medizin Ende des 19. Jh:
•
•
•
•
Bakteriologie (Louis Pasteur, Robert Koch)
Bakteriologisch begründete Hygiene in der klinischen Praxis
Röntgenstrahlen (entdeckt 1895)
Laborforschung
– künstliche
kü tli h B
Befruchtung
f ht
d
des Sä
Säugetiereis
ti i (S
(Samuell L
Leopold
ld S
Schenk
h k 1878)
1878),
– experimentell-naturwissenschaftliche Methodik (Claude Bernard)
•
•
•
•
•
Aufbau des Sozialversicherungswesens mit Krankenkassen und
g
Krankenhäusern,, Heilstätten und Fürsorgestellen
Voranschreitende Spezialisierung in der klinischen Medizin
Entstehung des „biomedizinischen“ Paradigmas: Mensch ist ein
organisches System mit Funktionen, deren Störung die Ursache sind
für die Krankheiten
Krankheiten.
Organersatzkonzept und erste Organtransplantation (Schilddrüse,
durch Theodor Kocher 1883)
Herausforderung der therapeutischen Beziehung durch
Biotechnologien: Mary Wollstonecraft Shelley (1818), Frankenstein, Or:
The Modern Prometheus
Ethik des Bösen? Medizin im Nationalsozialismus
Arthur L. Caplan: The Ethics of Evil: The Challenge and the Lessons of Nazi Medical
Experiments (in: William LaFleur, Gernot Böhme, Susumu Shimazono, eds.:
D kM
Dark
Medicine.
di i
R
Rationalizing
ti
li i U
Unethical
thi l M
Medical
di l R
Research.
h Bl
Bloomington:
i t
IIndiana
di
UP 2007, pp. 63-72)
„Most
M t histories
hi t i off medical
di l ethics
thi llocate
t th
the origins
i i off bi
bioethics
thi iin th
the ashes
h
of the German concentration camps. The Nuremberg Code is
frequently held up in courses and textbooks on medical ethics as the
‚constitution
constitution‘ of human subjects research
research. But very little is said about
the actual experiments that generated this document. And even less is
said about the moral rationales those involved in the horrific research
gave in their defense
defense. Why?“
Why? (63)
„One reason is that the events of the Holocaust are so horrid that they
speak for themselves. What more is there to sayy about mass murder
and barbaric experimentation except that it was unethical?“
„Perhaps
Perhaps the most important reason for the absence of commentary on the
ethics of the research done in the camps is that such questions open a
door that few bioethicists wish to enter. If moral justifications can be
given for why
g
y someone deemed mass murder appropriate
pp p
in the name
of public health or thought that it was right to freeze hapless men and
women to death or decompress them or infect them with lethal doses of
typhus
yp
– then to p
put the q
question p
plainly
y – what g
good is ethics?“ ((63f))
The Nuremberg Trials:
Trial One.
One The Doctors‘ Trial 1946
Quotes from trial transcripts. See full text
on:
http://nuremberg.law.harvard.edu
IMT Defendants and Defense Attorneys (Dec. 10, 1945)
„COUNT TWO -- WAR CRIMES 6.
Between September 1939 and April 1945 all of the defendants herein
unlawfully, wilfully, and knowingly committed War Crimes, as defined by
Article II of Control Council Law No. 10, in that they were principals in,
accessories to, ordered, abetted, took a consenting part in, and were
connected with plans and enterprises involving medical experiments
without the subject's consent, upon civilians and members of the armed
forces of nations then at war with the German Reich and who were in the
custody of the German Reich in exercise of belligerent control, in the
course of which experiments the defendants committed murders,
b t liti
brutalities,
cruelties,
lti
ttortures,
t
atrocities,
t iti
and
d other
th iinhumane
h
acts.
t S
Such
h
experiments included, but were not limited to, the following:
Prisoner Who Has Been Subjected to Low Pressure
Experimentation (KZ Gedenkstätte Dachau)
(A) HIGH ALTITUDE EXPERIMENTS. From about March 1942 to about
August 1942 experiments were conducted at the Dachau Concentration
C
Camp
ffor the benefit
f off the German
G
Air Force to investigate the limits off
human endurance and existence at extremely high altitudes. The
experiments were carried out in a low-pressure chamber in which the
atmospheric conditions and pressures prevailing at high altitude (up to
68,000 feet) could be duplicated. The experimental subjects were
placed in the low-pressure chamber and thereafter the simulated
altitude therein was raised. Many victims died as a result of these
experiments and other suffered grave injury, torture, and ill treatment.
(B) FREEZING EXPERIMENTS. From about August 1942 to about May
1943 experiments were conducted at the Dachau Concentration Camp
primarily for the benefit of the German Air Force to investigate the most
effective means of treating persons who had been severely chilled or
frozen In one series of experiments the subjects were forced to remain
frozen.
in a tank of ice water for periods up to three hours. Extreme rigor
developed in a short time. Numerous victims died in the course of these
experiments. After the survivors were severely chilled, rewarming was
attempted by various means. In another series of experiments, the
subject[s] were kept nake[d] outdoors for many hours at temperatures
below freezing.
g The victims screamed with p
pain as p
parts of their bodies
froze.
(C) MALARIA EXPERIMENTS From about February 1942 to about April
1945 experiments were conducted at the Dachau Concentration Camp
in order to investigate immunization for and treatment of malaria.
Healthy concentration camp inmates were infected by mosquitoes or by
injections
j
of extracts of the mucous g
glands of mosquitoes.
q
After having
g
contracted malaria the subjects were treated with various drugs to test
their relative efficacy. Over 1,000 involuntary subjects were used in
experiments. Many of the victims died and others suffered severe pain
and permanent disability.
(D) LOST (MUSTARD) GAS EXPERIMENTS. At various times between
September 1939 and April 1945 experiments were conducted at
Sachsenhausen, Natzweiler, and other concentration camps for the
benefit of the German Armed Forces to investigate the most effective
treatment of wounds caused by Lost gas.
gas Lost is a poison gas which is
commonly known as Mustard gas. Wounds deliberately inflicted on the
subjects were infected with Lost. Some of the subjects died as a result
of these experiments and others suffered intense pain and injury.
(E) SULFANILAMIDE EXPERIMENTS. From about July 1942 to about
September 1943 experiments to investigate the effectiveness of
sulfanilamide were conducted at the Ravensbruck Concentration Camp
for the benefit of the German Armed Forces. Wounds deliberately
inflicted on the experimental subjects were infected with bacteria such
as streptococcus, gas gangrene, and tetanus. Circulation of blood was
interrupted by tying off blood vessels at both ends of the wound to
create a condition similar to that of a battlefield wound. Infection was
aggravated
gg
by
y forcing
g wood shavings
g and g
ground g
glass into the
wounds. The infection was treated with sulfanilamide and other drugs
to determine their effectiveness. Some subjects died as a result of
these experiments and others suffered serious injury and intense
agony.
(F) BONE, MUSCLE, AND NERVE REGENERATION AND BONE
TRANSPLANTATION EXPERIMENTS
EXPERIMENTS. From about September 1942 to
about December 1943 experiments were conducted at the
Ravensbruck Concentration Camp for the benefit of the German Armed
Forces to studyy bone,, muscle,, and nerve regeneration,
g
, and bone
transplantation from one person to another. Sections of bones,
muscles, and nerves were removed from the subjects. As a result of
these operations, many victims suffered intense agony, mutilation, and
permanent disability.
disabilit
(G) SEAWATER EXPERIMENTS. From about July 1944 to about
September 1944 experiments were conducted at the Dachau
Concentration Camp for the benefit of the German Air Force and Navy
to study various methods of making seawater drinkable. The subjects
were deprived of all food and given only chemically processed
seawater. Such experiments caused great pain and suffering and
resulted in serious bodily injury to the victims.
(H) EPIDEMIC JAUNDICE EXPERIMENTS. From about June 1943 to
about January 1945 experiments were conducted at the
S h
Sachsenhausen
h
and
dN
Natzweiler
t
il C
Concentration
t ti C
Camps ffor th
the benefit
b
fit off
the German Armed Forces to investigate the causes of, and
inoculations against, epidemic jaundice. Experimental subjects were
deliberately infected with epidemic jaundice, some of whom died as a
result, and others were caused great pain and suffering.
(I) STERILIZATION EXPERIMENTS. From about March 1941 to about
Januaryy 1945 sterilization experiments
p
were conducted at the
Auschwitz and Ravensbruck Concentration Camps, and other places.
The purpose of these experiments was to develop a method of
sterilization which woul[d] be suitable for sterilizing millions of people
with a minimum of time and effort. These experiments were conducted
by means of X-Ray, surgery, and various drugs. Thousands of victims
were sterilized and thereby suffered great mental and physical anguish.
(J) SPOTTED FEVER EXPERIMENTS. From about December 1941 to
about February 1945 experiments were conducted at the Buchenwald
and Natzweiler Concentration Camps for the benefit of the German
Armed Forces to investigate the effectiveness of spotted fever [i.e.,
typhus] and other vaccines. At Buchenwald numerous healthy inmates
were deliberately infected with spotted fever virus in order to keep the
virus alive; over 90% of the victims died as a result. Other healthy
inmates were used to determine the effectiveness of different spotted
fever vaccines and of various chemical substances. In the course of
these experiments 75% of the selected number of inmates were
vaccinated with one of the vaccines or nourished with one of the
chemical substances and, after a period of three to four weeks, were
infected with spotted fever germs. The remaining 25% were infected
without
ith t previous
i
protection
t ti iin order
d tto compare th
the effectiveness
ff ti
off th
the
vaccines and the chemical substances. As a result, hundreds of the
persons experimented upon died. Experiments with yellow fever,
smallpox, typhus, paratyphus A and B, cholera, and diphtheria were
also
l conducted.
d t d Si
Similar
il experiments
i
t with
ith like
lik results
lt were conducted
d t d att
Natzweiler Concentration Camp.
(K) EXPERIMENTS WITH POISON. In or about December 1943
and in or about October 1944 experiments were conducted at
the Buchenwald Concentration Camp to investigate the effect of
various poisons upon human beings. The poisons were secretly
administered to experimental subjects in their food
food. The victims
died as a result of the poison or were killed immediately in order
to permit autopsies. In or about September 1944 experimental
subjects were shot with poison bullets and suffered torture and
death.
(L) INCENDIARY BOMB EXPERIMENTS. From about November
1943 to about January 1944 experiments were conducted at the
Buchenwald Concentration Camp to test the effect of various
pharmaceutical preparations on phosphorus burns
burns. These burns
were inflicted on experimental subjects with phosphorus matter
taken from incendiary bombs, and caused severe pain,
suffering and serious bodily injury
suffering,
injury.“
Welche Gründe haben die angeklagten Ärzte zu ihrer
Verteidigung vorgebracht? (nach Caplan 2007, a.a.O.;
Nuremberg Trial transcripts)
„… many of who committed the crimes of the Holocaust were competent
physicians and scientists who acted from strong moral convictions. Not
one of the doctors or public health officials on trial at Nuremberg
pleaded for mercy on the grounds of insaninty. A few claimed they
were merely following legitimate orders, but almost no one alleged
coercion.“ (65)
Th morall rationales
The
ti
l given
i
iinclude:
l d
1. Those who were subjects had volunteered. Prisoners might be freed if
they survived the experiments.
2 Only people who were doomed to die were used
2.
used.
3. Participation in lethal research offered expiation to the subjects;
subjects could cleanse themselves of their crimes.
4. Scientists and p
physicians
y
had to act in a value-neutral manner.
5. They had done what they did for the defense and security of their
country, to preserve the Reich during ‚total‘ war.
6. It was reasonable to sacrifice the interests of the few in order to benefit
the majority.
majority
Was ist da geschehen?
Wie kann man über das Böse sprechen?
Hannah Arendt: Über das Böse. Eine Vorlesung zu Fragen der
Ethik (Mü
Ethik.
(München:
h
Pi
Piper 2006)
„Bei den größten Schurken [in der Literatur] gibt es in den Tiefen immer
Verzweiflung und den Neid, der zur Verzweiflung gehört. Dass alles
Radikal-Böse
Radikal
Böse aus den Tiefen der Verzweiflung kommt, hat uns
ausdrücklich Kierkegaard gesagt – und wir hätten es von Miltons Satan
und vielen anderen lernen können.”
“Doch ist nicht offensichtlich, dass es selbst in diesem Neid aus
Verzweiflung noch immer so etwas wie Vornehmheit gibt, von der wir
wissen, dass sie mit der wirklichen Sache äußerst wenig zu tun hat?
Nach Nietzsche respektiert der Mann, der sich selbst verachtet,
zumindest denjenigen in ihm
ihm, der verachtet! Doch das wirklich Böse ist
das, was bei uns sprachloses Entzetzen verursacht, wenn wir nichts
anderes mehr sagen können als: Dies hätte nie geschehen dürfen.” (S.
44f))
Wenn es die „Instrumentalisierung“ ist, die Nazi-Experimente
unethisch/böse machten, was ist dann mit…
… dem Benützen einer nach IVF übriggebliebenen befruchteten Eizelle mit
Zustimmung des Paares für die Stammzellforschung?
… dem Abstreiten eines Kunstfehlers im Rahmen einer teilweise
experimentellen OP (mit Deckung der Kollegen) gegenüber den
Angehörigen der verstorbenen Patientin?
… der
d B
Behandlung
h dl
einer
i
L
Lungenentzündung
t ü d
mit
it A
Antibiotika
tibi tik b
beii einem
i
alten, multimorbiden Patienten, der sterben möchte?
… der Untersuchung des Genoms von gesunden kleinen Kindern in einem
Projekt zur Erforschung der Ursachen psychischer Krankheiten?
Wo sind die Differenzen? Gibt es Gemeinsamkeiten? Was heißt
Instrumentalisierung? War es wirklich die Instrumentalisierung
Instrumentalisierung, die
Nazi-Experimente unethisch/böse machten? Worin ist der Unterschied
zwischen Recht und Unrecht in der heutigen medizinischen Ethik
begründet?
g
Lehrziele
Wenn Ärztinnen und Ärzte lernen, scheinbare Selbstverständlichkeiten
bezüglich ihrer Basiskategorien gesund/krank, Wissen/Nichtwissen
etc.,
t der
d Rollenverständnisse,
R ll
tä d i
d
der Z
Zusammenarbeitsformen
b it f
mit
it
anderen Berufen, der Ethik etc. im gesellschaftlichen und historischen
Zusammenhang kritisch zu durchschauen, können sie ein
ausgewogeneres Verständnis der Aufgaben und auch der Grenzen der
Medizin entwickeln: ein Verständnis, das für die Bedürfnisse der
Patientinnen und Patienten sensibler ist und in die Zukunft weist.
Reflexive und kommunikative Kompetenz!
Erfüllung von §1 der Approbationsordnung von 2002, die verlangt, dass
die ärztliche Ausbildung die „geistigen, historischen und ethischen
Grundlagen ärztlichen Verhaltens auf der Basis des aktuellen
Forschungsstandes“ vermitteln soll.
Übersichtsliteratur zu GTE
Walter Bruchhausen / Heinz Schott: Geschichte, Theorie und Ethik
der Medizin. Göttingen: Vandenhoeck & Ruprecht 2008 (UTB)
Stefan Schulz et al. (Hg.): Geschichte, Theorie und Ethik der
Medizin. Eine Einführung. Frankfurt aM: Suhrkamp 2006.
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