The Origins of the Application of Virtue Ethics to Medicine

Virtues, in Aristotle’s understanding, are required for all worthwhile roles in life. As has been discussed, this is what distinguishes virtues from technical skills. However, the virtues may take particular forms or have particular significance in different roles. To take some examples, the honesty of the judge or the courage of the soldier can be described in more detail and have very specific functions within their professions. We might also say that for certain roles, certain virtues become central, as indeed is the case for the honesty of the judge and the courage of the soldier, and their absence renders effective fulfilment of those roles impossible. Looking at medicine in a similar way, we see that it is a discipline, a body of knowledge, and a set of skills. However, it is also a profession, an ethical undertaking shaped by a particular commitment to certain virtues. For example, within the medical pro- fession, the tact and sensitivity that are needed to communicate clearly with patients are different from the kind of communication needed by a barrister or a journalist, a politician, or a school teacher. In each case, the context of the communication shapes which aspects of communication will be more important and which failures will be more harmful. The con- text for the communication between a doctor and a patient is distinguished by inequality of knowledge, sensitive personal information, emotional vulnerability, and sometimes im- paired capacity on the part of the patient, and all of this often coupled with an urgent need for a decision. Managing such an inequality of vulnerability, requirement for trust, and de- cision making well is therefore far from straightforward, since the doctor has considerable moral and technical demands placed on his or her shoulders. The practice of medicine is therefore difficult, and requires the virtues if it is to be done well, for the benefit of the pa- tient and the well-being of the doctor.
The practice of reflecting ethically on medicine has a long history, going back certainly as far as Hippocrates, or at least to the oath attributed to him.37 Regardless as to whether the oath is actually his, or simply an acknowledgement of his status as one of the founding fathers of medicine, what is clear is that Hippocrates was a philosopher–physician, and saw the intimate connection between his role as a physician and his need to reflect philosoph- ically on what he was doing as a physician. In fact, philosophy would seem to have been at the heart even of the birth of medicine as a separate discipline.38 The Hippocratic Oath, and its variants, have been used as a framework for the ethics of medical practice for three millennia. When we look at the Hippocratic Oath in its earliest form, we see a text which gives an ethical framework to a code of practice for the physician.39 The text itself has this ethical framework expressed in terms of practices which should not or should be carried out, such as, ‘I will not give a drug that is deadly to anyone if asked for it’ and ‘into as many houses as I will enter, I will go for the benefit of the ill’. Such expressions have the character- istics of a rule-based, deontological ethical system, but might also be argued as consistent with an Aristotelian teleological framework with the end goal of medicine stated, and with exceptionless norms which are in accordance with that framework.40 We likewise see an

37 For examples of the works of Hippocrates, the oath attributed to him, and its analysis, see WHS Jones, ET Withington, WD Smith, et al (trs), Hippocrates (Harvard University Press, 2014); and SH Miles, The Hippocratic Oath and the Ethics of Medicine (Oxford University Press, 2005).
38 Pellegrino (n 15) 401–23.
39 Miles (n 37) xiii–ix.
40 Ibid.

emphasis on the character of the physician as one who is viewed as trustworthy by those who are treated by him. Such an emphasis has a distinctly virtue-based ethic for the practice of medicine.
Similarly, when we look at Thomas Percival’s highly influential early eighteenth-century work, ‘Medical Ethics’, we find a concern almost exclusively with professional conduct of medical professionals. Indeed, the work itself is subtitled ‘A Code of Institutes and Precepts Adapted to the Professional Conduct of Physicians and Surgeons’.41 Percival provides descriptions of the character and disposition of doctors and surgeons, so that they might best serve their patients through the good exercise of their craft. Besides those characteristics which mark excellence in particular skills, the doctor should also exhibit dispositions such as tenderness, steadiness, condescension, authority, and temperance, so that they might in- spire confidence in their patients.42 The fact that his ethical framework contains these kinds of dispositions as important perhaps owes much to the Hippocratic framework, which is relatively untouched by post-Enlightenment concerns found in the moral philosophy of that time.
While Hippocrates and Percival are only two examples, they give an insight into the pre- occupations of medical ethics before the rise of bioethics in the second half of the twentieth century. And we also see the main preoccupation as the relationship between the physician and the patient, and the expression of codes to regulate the interactions. The concern is to do with the physician and that physician’s action. The language is influenced by ideas of dispositions of character, and both technical and moral rectitude of the practitioner of medicine. The patient is arguably a silent, vulnerable recipient of treatment and care; albeit one who is protected by codes which recognize that vulnerability and seek to promote good practice and character among practitioners.