|Bioethics and Medical
Virtue and the Practice of Medicine
ABSTRACT: Since Alasdair MacIntyres landmark book After Virtue, there has been renewed interest in the role of the virtues in the moral life and attention paid to reappropriating the Aristotelian notion of "practice." Recent reappropriations of the virtues and virtue theory in medical ethics have contributed to conceiving more adequately the nature of good medicine. I wish to explore some of these insights and the special relevance the notion of practice has in an account of good medicine. Yet, I also want to suggest that much remains to be done. This renewed attention to the virtues needs to be supplemented by a similar reappropriation and transposition of the notion of nature in order to navigate successfully the Dardanelles of an ahistorical essentialism and the Bosphorus of a historical relativism.
Since Alasdair MacIntyre's landmark book, After Virtue, there has been renewed interest in the role of the virtues in the moral life and attention paid to reappropriating the Aristotelian notion of a "practice." (1) Recent reappropriations of the virtues and virtue theory in medical ethics have contributed to conceiving more adequately the nature of good medicine. In this paper, I wish to explore some of these insights and the special relevance the notion of a practice has in an account of good medicine. Yet, I want to suggest, too, that much remains to be done. This renewed attention to the virtues needs to be supplemented by a similar reappropriation and transposition of the notion of nature in order to navigate successfully the Dardanelles of an ahistorical essentialism and the Bosphorus of a historical relativism. (2)
Practices are essentially cooperative endeavors. In order to satisfy some need, individuals perform certain acts in the hope of relieving some distress or of attaining some object. Rarely if ever, though, can either be done through one's own efforts alone. When we act, we participate in already expected and agreed upon ways of doing things, and our participation in them is structured in large measure by mutual sets of expectations to which we hold each other accountable. Because it makes possible the attainment of desired goods on a regular basis, this pattern of cooperative human activity is itself a good. For this reason, Bernard Lonergan termed the actual functioning of human institutions a "good of order." (3) While particular goods may satisfy some human want or need, the regular and recurrent enjoyment and the ordering of human action are themselves distinctly valuable. Indeed, for Lonergan, it takes precedence. For the attainment of particular goods is conditioned by the cooperation of any number of individuals, and breakdowns in this framework spell that enjoyment of these goods will be at best precarious and sporadic. In the case of medicine, the good of a practice is confirmed not simply in a person being treated successfully on a given day but that many are cared for everyday. This provision of health care is conditioned by a vast array of organizations including not only hospitals and clinics but also universities and research institutes and those insurance corporations and government organs which finance the operations of all of them. Thus, medicine is never merely a private practice. Its continued success depends upon the well-functioning of a score of medical, economic, and political institutions.
As frameworks of human cooperation, practices or institutions set the concrete conditions for the acquisition of habits and skills. Practices demand the regular and recurrent performance of certain tasks, and their swift, adept, if not masterful performance depends upon the acquisition of the appropriate competences. Under the weight of large numbers of individuals in demand for these services and the complexity of human organizations, this exigence is only heightened and the demand for the required habits and skills that much more keenly felt. As a case in point, the provision of health care has become enormously complicated involving the specialized activities of hosts of individuals occupying a myriad of roles, from physicians and nurses of various sorts, to teachers, researchers, and lab technicians, to financial officers and billing clerks. The proper functioning of these institutions depends upon the competent performance of all these tasks.
Practices are the concrete contexts for the process of socialization. Tasks are usually assigned to certain individuals occupying specific roles, and these roles are defined and enjoy or lack the status and privilege that they do by virtue of the practice. In the case of medicine, the duties and status belonging to a "doctor" or a "nurse" are specified in light of the current organization and delivery of medical care. Furthermore, social relationships are concretely mediated by practices and institutions. That is, we meet and address one another as occupying certain roles. As a result, revisions in any one practice affect our interpersonal relations. For example, the changes in the provision of medical care in only the last couple of decades has radically refashioned not only the role of the physician but also our relations to individual doctors. Since then, medicine has become a set of specialities and subspecialities and the payment for their services more labyrinthine. Not surprisingly, our relations to doctors have become more hurried and businesslike. These changes have not only affected our relations to them; they have transformed their own self-understanding. The revisions in the practice of medicine and the role of the physician has reshaped doctors' understanding of the nature of their work, of their duties and obligations to their patients, and, hence, the meaning and purpose of their lives.
Practices not only condition our relations to one another; our interpersonal relations in turn condition the functioning of these same practices. Practices consist in sets of mutual expectations, and accordingly, they do function well unless participants can reliably depend upon each other. It is in this sense that Bellah and his associates identify trust as vital to the operation of democratic institutions and fear that this trust is unnoticeably being eroded. (4) Similarly, medical relationships and the healing which is sought through them are conditioned by the trust that physicians, nurses, and patients have in each other. The so-called "placebo effect" bears witness that the personal relations between patients and the ones who care for them are integral to the healing sought despite its often being viewed as extrinsic by medical science. Thus our actions involve us in rather complex interactions and relations with others. What is more, practices, as MacIntyre put it, are enacted narratives, or, as Bellah and his associates expressed it, institutions are the bearers of social meaning. (5) Because a culture consists in that ongoing reflection upon the meaning and value embedded in that society's institutions and the ways of life they make possible, the process of habituation and socialization is thus also a process of acculturation. That is, individuals are initiated into the meanings and values embodied within practices through their participation in them. As Bellah and his associates put it, institutions are educative: we learn various lessons about life as our lives are shaped through our involvement in them. (6) By playing certain roles, individuals take part then in an unfolding drama. Its constitutive meanings and values are very often recalled in recounting the exemplary achievements and failures of the past. Thus, these narratives orient individuals historically. The collective experience of the past provides that moral compass which directs one's future endeavors. Again, it is through instruction and training that participants come to appreciate the genuine value of the practice and to criticize and reform its shortcomings. In so doing, novices are invited to conform their performance to the standards of the best practitioners of the past. In this way, apprenticeship is an initiation into that ongoing collaborative enterprise of a community of practitioners and its traditions. The substance of this moral community and the vitality of its traditions is measured by the vigor of conversation and debate concerning its professed aims and most deeply held commitments, and that tradition is alive to the extent the conversation is lively. While individuals may fail to live up to its highest ideals, they cannot live them down without abandoning those values which give life its sense and purpose. Indeed, the virtues of individuals, according to MacIntyre, strengthen and uphold traditions; their vices weaken and undercut them. (7) Now medicine may be argued to be one such moral community. (8) The moral fabric of this profession is still tacitly recognized in those oaths to which new graduates swear their fidelity. Often these oaths link their future practice with the profession's historic commitment to healing. The virtues and virtue theory are helpful precisely in elucidating the moral orientation of a practice. As MacIntyre has argued, the virtues are crucial conditions for the attainment and enjoyment of goods which exist internal to practices. (9) Now the virtues belong not to roles but to persons, and their virtues specify the ends which they desire and to which their activities are directed. However much it is true that persons are not reducible to some set of qualities and characteristics, persons are nonetheless revealed by what and who they love and in what and in whom they delight. In this spirit, the virtues may be conceived not as a permanent achievement or possession but as characteristics of those who undertake the ongoing quest of living well.
It is in terms of this account of practice that I would like to consider the virtues and their special relevance to the art of medicine. This is not the place to rehearse fully Aristotle's treatment of the virtues in his Nicomachean Ethics, (10) but any examination of the virtues must acknowledge its debt to his account. For Aristotle, the moral virtues, like habits or skills, are acquired and perfected through practice. Once they become inculcated, a person's soul is stamped, as it were, and he or she easily and pleasantly perform those same actions which gave rise to these virtues.(11) In this way, the virtues are the condition of the possibility of the regular performance of noble acts. Furthermore, it is only through the acquisition of such skills and virtues that one comes to appreciate fully the value of the practice itself. It is in this sense that the exercise of the virtues conditions the enjoyment of those goods which a practice makes possible. In addition, since a practice gives definition to one's life, the goods internal to it are integral to the good of one's life as a whole. Consequently, if doctors were to choose to mistreat patients, they would not only harm them, but they would also injure the integrity of the practice itself, stain the reputation of other practitioners, and operate at cross-purposes with their own good.
In this spirit, Edmund Pellegrino and David Thomasma have written eloquently upon the crucial role of the virtues in good medical care in their articulation of a philosophy of medicine.(12) When people are sick and therefore vulnerable and dependent, they are compelled "to trust not just in their rights but in the kind of person the physician is." (13) Because the interactions between physicians and patients take place behind close doors, the question of a physician's integrity is a pressing one. For them, the virtues designate not specific actions but those qualities which are required for excellent medicine. For instance, successful interactions between physicians and patients depend upon the honesty of both parties. Honesty is expected from physicians in informing patients of the truth of their condition; otherwise, in promoting the good of the body one may in fact harm the good of the patient. Honesty is also expected of the patient in disclosing to a relative stranger the intimate and perhaps embarrassing details of one's life; otherwise, the treatment chosen may not respond to the real complaint. There follows, therefore, a corresponding need to respect these disclosures as confidential, especially if physicians are to earn if not retain the trust of those confiding in them. In a similar way, other virtues may be understood in terms of those qualities which are most conducive to successful clinical interactions. (14) Pellegrino's and Thomasma's emphasis upon the need for virtue in medicine is salutary because technical expertise and moral excellence are all too often conflated. These confusions may be in part spring from the way in which technical competence is indeed necessary for good medical care. Many of the injunctions of Hippocrates concerned safeguarding the healing arts from technical incompetence. In much the same way, Richard Cabot articulated an ethic of medical competence in the first part of this century. For him, the competent practice of scientific medicine would be characterized by both diagnostic parsimony and therapeutic elegance, and this "Cabotean ethic," as Albert Jonsen has argued, may be viewed as an extension of the Hippocratic concern neither to undertreat nor to overtreat patients. (15) Technical competence, however, is not sufficient to ensure good medical care. Physicians may fail their patients by lacking competence, but the story of Asklepios reminds us that medical competence may also be wrongly used. The capacity to intervene medically does not give one license and justification to do so. Rather, expertise still requires moral understanding to guide and direct its exercise. Such wisdom is implicit in Hippocrates' insistence that his students use the healing arts well. More recently, the moral context which this wisdom grasps has been called medicine's "moral center." (16) The elucidation of this center requires understanding the ultimate purposes of medicine. For it is in light of the apprehension of these ends that the meaning and value of technical competence may be discerned. Expertise may be able to answer how something may be done; wisdom is needed in order to judge whether it should be done. Accordingly, excellent medical care must be understood in light of the ends of medicine as a practice.
For Pellegrino and Thomasma, the end of medicine is "the good of the patient." Most immediately, physicians intend to bring about the patient's biomedical good. For that individual has sought and enlisted the aid of someone who professes to heal, and in the clinical encounter, a "right and good healing action" (17) would first seek to restore proper organic functioning. While the medically indicated course of action may be the starting point for discussions between patients and their physicians about courses of treatment, it is not the end of their conversation. The "good of the patient" is rather a compound notion. (18) In addition to a person's biomedical good, it includes, they argue, the good as perceived by the patient, the good of that patient as a human being, and the Good, that good which transcends our good as human and, hence, which pertains to our spiritual destiny. The right and good healing action is that one which best integrates all these components of a patient's good.
Medical techniques are, on the other hand, highly specialized activities. The good intended by them is a partial one, and as in the case for any skill, the end sought is separate from the actions chosen. Accordingly, medical procedures can be put in service for base purposes and utilized for the sake of increasing a hospital's revenues or augmenting a physician's position and privilege. If medicine is practiced simply as a means for quite other ends, one may legitimately wonder whether that practitioner will act for the sake of the patient even when no one is watching or and when one's reputation may suffer. In contrast, medicine ought to intend the complex good of the person as a whole. Unlike the ends accomplished by human skillfulness, this good cannot be so easily separated from the activities of health professionals themselves. For medical relationships are not simply means to the separate end of improved organic functioning. Since it is not bodies but persons who are treated and healed, medical relationships are instead integral to the healing which is sought; for we are most often healed through the caring hands and ministrations of others. In this way, Pellegrino and Thomasma argue that those dispositions such as honesty and trustworthiness, fortitude and justice, and wisdom and integrity ought to characterize the practitioners of medicine. (19) It is with an eye to and in terms of such excellent doctoring and nursing that precepts, rules, and principles are to be formulated to guide and direct clinical encounters and transactions.
Sadly many of us have experienced ourselves, however, the effects of individual irresponsibility or, and even more devastatingly, systemic corruption. Indeed, human practices themselves may be instituted for the sake of quite vile ends. At issue is not only the rightness of particular actions but also the legitimacy of a practice itself, not just fittingness of events recounted in a narrative, but the moral of the story. In this matter, Lonergan made a helpful distinction between minor and major inauthenticity. (20) Minor inauthenticity consists in the failure to live up to the ideals of a tradition. Major inauthenticity, on the other hand, consists in living up to a tradition which itself stands in need of serious reform if not condemnation. Since this distinction is oftentimes neglected, virtue theory has its critics. Many have taken issue with MacIntyre's account of the virtues and the correlative understandings of a practice and narrative. For example, Kai Nielson has argued that for one could very well strive to live up some ideal and to embody some virtues and, in doing so, to understand one's life story in terms of some larger narrative, but these ideals, virtues and narrative may be worthy of great censure; (21) National Socialists under Hitler's Germany provide ready examples. Moreover, in the case of medicine, recent criticisms may in fact be well deserved; for example, the increasingly frequent calls to regulate the medical profession and to deprive it of its "guild-like" privileges are perhaps brought upon the profession itself because doctors have acted more like artisans seeking to secure their own advantage rather than the advantage of the ones they serve. Now to order medical institutions in the light of the inauthentic practice of individuals so that doctors are then systematically encouraged to view their livelihood as just another trade is to risk losing what is special to the profession of medicine. Such neglect and oversight are, for Lonergan, the sources of corrupted and corrupting traditions. To seek to be authentic to them is to risk becoming authentically inauthentic.
Given then this account of the virtues and their relations to practices and traditions, how is the self-correction of traditions of inquiry possible? The assertion of moral principles here is not sufficient. Moral principles are abstract, and thus, they themselves do not provide the needed moral insight to guide their application. Principles by themselves do not instruct us as to whether and how they apply to particular situations. Finally, appeals to principles are not sufficient to guarantee adherence to them.
In our brief examination of social practices of medicine, we have already come upon normative requirements which help define it as a moral art. In the first instance, normative relations exist between particular goods and goods of order. For the latter make possible the regular and recurrent enjoyment of the former. Inasmuch as we desire particular goods not just once but again and again, we must also promote the integrity of the corresponding goods of order; as Lonergan expressed it, we cannot "consistently choose the conditioned and reject the condition, choose the part and reject the whole, choose the consequent and reject the antecedent." (22) The sweep of our own desiring entails that we go beyond satisfying our individual wants and needs and concern ourselves with maintaining and enhancing the goods internal to a practice.
Normative relations also exist between goods of order and interpersonal relationships. That is, institutions mediate our relations to one another; their proper functioning is conditioned by them in turn. As instituted forms of cooperation, any social practice depends upon the degree of trust we have in one another, and they are undermined if we hold each other in suspicion. We may and should ask whether the concrete operation of a practice promotes or undermines the kind of interpersonal relations upon which the practice depends for its long-term viability. In the case of medicine, we may ask whether persons are genuinely cared for or whether they are dehumanized by the delivery of this care. In other words, we must examine whether actually functioning goods of order ennoble or debase us and our relationships through our participation in them.
While we may discern these exigences within institutions and goods of order themselves, they lead us to consider the relations of these practices and their ends to the larger ends of human living. Practical wisdom is that habit of the mind which enables one to choose well not only with respect to a particular domain of human action but in the whole of one's life. Hence, it orders human practice in ways most conducive to this more comprehensive end. Often we do understand the ordering of social practices and the constituting of a human life in narrative terms, and we do this by locating our lives and stories in terms of our communities and their histories. The basis of criticizing the stories we fashion is made more difficult for MacIntyre because of his rejection of what he termed Aristotle's "metaphysical biology." (23) For it was on the basis of normativity belonging to the nature of things and, specifically, to human nature that ways of life were evaluated in classical philosophy. But, what becomes of this basis of criticism if nature is no longer so regarded? What is needed, it seems, is a reappropriation of nature and its normativity, though in a way that transposes the metaphysical terms in which it was previously formulated. To retrieve such a notion of nature is especially crucial with respect to the practice of medicine. For medicine is one art especially concerned with human beings as natural, and it provides the context in which we are confronted, and sometimes not gently, with the frailty of our bodies and the mortality of our physical existence. In seeking to maintain and restore the organic functioning of an individual, the good ultimately sought is not merely this. Difficulties arise, however, when we consider the relation of this biomedical good and the competences of medicine and this higher good we seek. In the recognition of the limits of organic functioning and perhaps in the absence of more substantive apprehensions of where our good really lies, we often turn to medicine and its powers in order to overcome not only our bodily ills but life's misfortunes, not only physical pain but human suffering itself.
It is here that practical wisdom is needed most of all. For at stake is the apprehension of the human good and the relation of bodily health to that good. In this regard, medicine has a special but limited place in the human quest for the good. For in the interactions of physicians, nurses, and patients, we often face the limits of medicine and finitude of being human. However, medicine oversteps its competence if it extends its power and know-how in order to promote not organic health but human well-being. So while practitioners may in fact desire the "good of the patient" as a whole, they do so not as doctors and nurses but as human beings. Medicine has no special expertise when it comes to answering life's great questions, but it is that special context in which relative strangers recognize their shared humanity and their part in that grander mystery of life and death.
Accordingly there is a need to renew efforts in fostering collaboration between moral philosophers and theologians and medical professionals. In the case of this practice, we need to illumine the exigences immanent to it which must be respected in medicine is to be practiced well. This task includes explicating the features of sound clinical judgment and the character of those who make them. It also involves examining the substance and ends of medicine and reflecting thoughtfully upon medicine's historic role. Such creative engagement need not be a return to a traditionalist medical practice but may issue forth in innovative responses to the pressing issues of our day while still being faithful to medicine's deepest commitments.
(1)See Alasdair MacIntyre, After Virtue: A Study of Moral Theory, (Notre Dame, IN: University of Notre Dame Press, 1981) esp. Chapter 14, pp 174-189. Since the publication of this text, others have taken up his lead in offering Aristotelian accounts of the moral life, and in many this notion of practice is central; for example, in the area of business ethics, see Robert C. Solomon, Ethics and Excellence: Integrity and Cooperation in Business, (New York: Oxford University Press, 1992), esp. Chapter 13, pp. 118-124. In still other analyses, "institution" is a synonymous term, so long as an institution is distinguished from particular organizations. Robert Bellah and his associates use the term, institution, in this way in their Habits of the Heart: Individualism and Commitment in American Life, (New York: Harper&Row, 1984), and in The Good Society, (New York: Vintage, 1990). Similarly, Bernard Lonergan employed the term, institution, in his treatment of the human good; see his Method in Theology, Chapter 2, pp. 48-50.
(2) Marx Wartofsky correctly identifies this to be nature of the problem before us; see his "Virtues and Vices: The Social and Historical Construction of Medical Norms," in Virtue and Medicine, ed. Earl Shelp, (The Hague: D. Reidel Publishing Company, 1985), pp. 175-199.
(3) Cf. Bernard J.F. Lonergan, Method in Theology, (New York: Seabury Press, 1972), Chapter 2, esp. pp. 48-50; see also, Lonergan, Collected Works of Bernard J.F. Lonergan, Volume 3: Insight: A Study of Human Understanding, Eds. Frederick E. Crowe and Robert M. Doran, (Toronto: University of Toronto Press, 1992), Chapter 18, esp. pp. 619-621.
(4) Cf. Bellah et al., The Good Society, esp. Introduction, pp. 3-18.
(5) See MacIntyre, After Virtue, Chapter 15, pp. 190-209; see also, Bellah et al., The Good Society, Chapter 1, p. 40. Likewise, institutions and goods of order, for Lonergan, belong to "the world mediated and constituted by meaning"; see Lonergan, Method in Theology, Chapter 3, pp. 73-81.
(6) See Bellah et al., The Good Society, Chapter 1, esp. pp. 38-42.
(7) See MacIntyre, After Virtue, Chapter 15, pp. 206ff.
(8) This case is made in Edmund D. Pellegrino and David C. Thomasma, The Virtues in Medical Practice, (New York: Oxford University Press, 1993), esp. Chapter 3, pp. 31-50.
(9) Cf. MacIntyre, After Virtue, Chapter 14, pp. 178ff.
(10) Aristotle, Nicomachean Ethics, trans. Martin Ostwald, (New York: Macmillan Pub. Co., 1962).
(11) Cf. ibid., Book II, 2; 1104a27-29.
(12) Theirs has been a long and fruitful collaboration. In addition to their book, The Virtues in Medical Practice, see Pellegrino and Thomasma, A Philosophical Basis of Medical Practice: Toward a Philosophy and Ethic of the Healing Profession, (New York: Oxford University Press, 1981); For the Patient's Good: Toward a Restoration of Beneficence in Health Care, (New York: Oxford University Press, 1988). Individually, they have written numerous articles upon these same issues. Especially noteworthy among these is, Edmund Pellegrino, "The Virtuous Physician, and the Ethics of Medicine," in Virtue and Medicine, pp. 237-255.
(13) Pellegrino, "The Virtuous Physician, and the Ethics of Medicine," p. 238; emphasis in the original. See also, Pellegrino and Thomasma, For the Patient's Good, Chapter 9, p. 112.
(14) Attending to the virtues operative in good medical relationships thus avoids the difficulties of casting them in terms of the opposition between autonomy and paternalism. Indeed, renewed interest in the virtues with respect to the practice of medicine has been spurred in large measure because of the shortcomings in framing the medical morality in terms of this conflict. It enables us therefore to conceive of their interaction principally not as a contending after individual satisfactions but as their sharing in a good common to them both.
(15) Cf. Albert R. Jonsen, The New Medicine and the Old Ethics, (Cambridge: Harvard University Press, 1990), Chapter 1, pp. 26ff.
(16) Cf. Willard Gaylin, Edmund Pellegrino, Leon Kass, and Mark Siegler, "Doctors Must Not Kill," JAMA, Vol. 259 (1988), pp. 2139-2140. Such is also the meaning of the Second Part of Leon Kass's, Toward a More Natural Science: Biology and Human Affairs, (New York: The Free Press, 1988), entitled, "Holding the Center: The Morality of Medicine," pp. 155-246.
(17) Cf. Pellegrino and Thomasma, For the Patient's Good, Chapter 9, p. 117; see also, Pellegrino, "The Virtuous Physician, and the Ethics of Medicine," p. 244.
(18) Cf. Pellegrino and Thomasma, For the Patient's Good, Chapter 9, pp. 117-118; see also, Pellegrino, "The Virtuous Physician, and the Ethics of Medicine," pp. 244-246.
(19) In their most recent work, Pellegrino and Thomasma discuss individually each of these virtues in addition to the virtues of temperance, compassion, and self-effacement; see The Virtues in Medical Practice, pp. 65-161. See also, Pellegrino, "The Virtuous Physician, and the Ethics of Medicine," p. 246, and Pellegrino and Thomasma, For the Patient's Good, Chapter 9, p. 118.
(20) See Lonergan, Method in Theology, Chapter 3, p. 80.
(21) See Kai Nielson, "Critique of Pure Virtue: Aniadversions on a Virtue-Based Ethic," in Virtue and Medicine, pp. 133-150. Robert Veatch's criticism is, in part, similar (see his, "Against Virtue: A Deontological Critique of Virtue Theory in Medical Ethics," in Virtue and Medicine, pp. 329-345). If one defines virtue as a praiseworthy habit or characteristic, then it may very well be the case that what is praised is in fact neither good nor right. For this reason, the virtues must be defined not in terms of praise and blame but in terms of the ends of medicine and the good it seeks.
(22) Lonergan, Insight, Chapter 18, p. 629.23 See MacIntyre, After Virtue, Chapter 12, p. 139.121