engleski

"Beauty, Truth and Goodness" or Where is Plato in Today's Medicine?

To enrich the debate on one of the eternal questions in all-time philosophy, i.e. the relationship between ethics and esthetics, I would like to present a very particular case, which I encountered at the Clinic for Maxilofacial and Oral Surgery in Rijeka. Our 68 years old patient visited our Clinic for the first time in 1971 when a right side jaw tumor mass was diagnosed. He refused both biopsy and operation and for 20 years avoided any examination. In 1991 he presented a large tumor size of a child’ s head localized at the right half of the jaw, crossing the median line. Tumor mass was present in the entire oral vestibule with protrusion in oral cavity and tongue, and partially the cheek skin, which presented multilocal scares and purulent fistulations. He was not able to speak and swallowed with great difficulties. This time he agreed to biopsy, which showed a planocellular cancer. He underwent extensive surgery during which subtotal mandibular, maxillary and tongue resection were performed. Due to metastatic lymph nodes a radical neck dissection on the right side, and a selective one on the left side were performed. At the time (he was hospitalized four times in six years) he underwent reconstructive surgery using microsurgical radial free flap and microsurgical fibula free flap. Due to postoperative infections and fistulations of the cheek skin, additional reconstructive surgery was done using tubular inguinal flap. We could say that general esthetic result was non satisfactory, but general functional result was very good. The patient regained breading, swallowing, and talking abilities. The donor regions presented very good healing, and no signs of recidives in the operation field were found. However, a conflict of interest occurred, because the surgical team insisted on further reconstructive surgery, in order to regain a more satisfying appearance of the patient, but the patient was persistent in refusing any further operation. Namely, as he stated on several occasions, the reason why he underwent surgery in the first place was the loss of function, and not the disfigurement. The article by Daniel P. Sulmasy (Otolaryngol Head Neck Surg 2002 ; 126:4-7) presents interesting and important observations on ethical issues concerning otolaryngology and head and neck surgery, and therefore could be used as a frame within which this case could be discussed. Sulmasy enters this particular debate leaning on Plato’ s philosophical system consisting of three basic values (forms): Beauty, Truth and Goodness. In the above mentioned article Sulmasy considers two situations in which surgeons confront ugliness and deformity, first when they have to undertake procedures that cause deformity, and second by restoring the natural beauty ravaged by injury or disease. Since both situations were present in the above mentioned case – first was actually done, and the second one was the aim of the surgical team, I would like to approach those situations with a question “ In the name of Beauty, Truth and Goodness, by what authority might any person claim to do such things?” , but taking into consideration - especially in dealing with the second situation which was clearly not the patient’ s whish - Plato’ s argument that Goodness and Truth are deeper than the mere appearance of Beauty. This is where this discussion makes a turn towards more modern concept of the body as an object of bioethical deliberation and enters the frame of one of four main bioethical principles, i.e. the principle of autonomy, more precisely the procedure of decision-making and giving/obtaining Informed Consent especially considering issues regarding the quality of life. Considering this context we could deliberate on this case by commenting on Sulmasy’ s statement “ The beauty you strive to restore must be for the good of the patient. And any beauty you forgo for the sake of cure or palliation must be for the good of the patient.” with the question: Who has the authority to decide what is for the good of the patient? Let us presume that that should be the patient itself. Namely, in our case the patient resolutely decided not to submit himself to any further procedures because, by his opinion, he obtained the satisfying stage of appearance exactly by regaining satisfying function. By his perception, the adequate level of the quality of life has been attained.

ethics; esthetics; autonomy; informed consent; quality of life

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