Virtue in Medical Ethics in Contemporary Thought

To date, the most significant attempts to bring virtue theory and medical ethics to the fore- front, and specifically the ethics of medical practice, have come from the work of Edmund Pellegrino and his collaborators, in particular David Thomasma. The framework chosen by Pellegrino for his virtue ethics is the Aristotelian one already outlined, though supplemented by insights from the work of Thomas Aquinas. We can also see hints of the im- portance of elements of MacIntyre’s work, After Virtue, and especially his understanding of the importance of medicine as a practice in the setting of virtue ethics. Pellegrino and Thomasma’s application of virtue ethics to the practice of medicine is based on an under- standing of the nature of medical practice and, in particular, a philosophical account of the nature of medicine, and its technical and moral components. A key part of the development of their understanding of the role of virtue in medicine comes from their examination of the reality of illness and the vulnerabilities that it brings about in the patient.43 This is allied to a sense of the privileged position of the medical practitioner as one who has specialist training and knowledge which that practitioner is duty-bound to use for the benefit of the patient; specifically to be used to assist the patient in regaining health, as much as that is possible.44 They acknowledge that medical practice involves negotiating the clear inequality between the patient and practitioner, the importance of a relationship of trust between them, and the responsibility for making medical decisions which have a moral character and which morally involve the medical practitioner in the outcome of any intervention which that practitioner may carry out on a patient.45
The ethical framework which they outline has a teleological structure which shapes the virtues required to carry out the task well. The end they suggest is the restoration and improvement of health through the cure of underlying pathologies, and where this is not possible, the care and relief of suffering of the patient. Because of this, the overarching principle of medicine is the good of the patient—their best interests. Every intervention is to be carried out in accordance with this end, and the virtues have a role in guiding the action of the medical practitioner towards it.46 Pellegrino and Thomasma propose a set of eight key virtues which guide the action of a medical practitioner in line with the end or purpose of medicine, and give an account of how each of them guides action in the relationship be- tween the practitioner and the patient. They are fidelity to trust, compassion, phronesis, justice, fortitude, temperance, integrity, and self-effacement. In what follows, the four cardinal virtues will be presented as they occur in Pellegrino and Thomasma’s thought, supplemented with other thinkers.
The key virtue of medical practice is Aristotle’s phronesis, or prudence as it is commonly known. Prudence has a negative association with caution and inaction in common par- lance, yet in reality it sits as the ‘capstone’ of the virtues in medical practice because, as for Aquinas and others before them, it shapes and guides the formation and development of the other virtues.47 This virtue is important because it is the disposition by which reasoning about what should be done in a given situation is perfected. It has a key role in medical prac- tice because it brings together the intellectual, technical, and moral aspects of medicine, linking knowledge, technical skill, and judgement with a moral evaluation of the good of the patient in their specific situation, and guides clinical judgement accordingly.48 As such, it is not simply a virtue which guides things solely from the medical practitioner’s view- point, but also takes into account the relevant features of the patient’s view of their situation. We might therefore say that it includes reasoning about the patient’s diagnosis; the med- ical and surgical means available to assist the burdens, risks, and side effects of using such means; and the various factors of importance to the patient, such as their psychological condition, values and beliefs, family circumstances, and so on.49 Prudence does what a simple principle-based ethic cannot achieve, namely, enables a dynamic dispositional re- sponse to the technical and moral challenges presented by a given patient in their unique circumstances.50

Several scholars have commented on the importance of prudence in medical practice. For example, Devettere develops an account of prudence as the archetypal virtue of the doctor, and like Pellegrino and Thomasma uses the thought of Aristotle and Aquinas to this end.51 In acknowledging the importance of the details of specific situations in prudential reasoning, he uses prudence as a way of analysing specific cases, as a way of determining a course of right action. Similarly, Montgomery sees prudence in a similar light, as a way of navigating the contingency and moral complexity of real clinical situations, while Marcum develops a similar line to Pellegrino and Thomasma.52 There have also been some critical accounts of seeing prudence as the most important of the virtues for medicine. Hofman has suggested that Pellegrino and Thomasma have misunderstood the Aristotelian notion of prudence, and that what they describe as prudence could be more adequately described by the idea of techne in the Hippocratic tradition.53 Kristjánsson has also noted the variety of ways in which Aristotelian phronesis is understood in the literature, and how that has led to a divergence of use in the medical ethical literature.54 The fact that such divergence is pre- sent shows how a deeper understanding of the idea of prudence is required to improve its usefulness in medical ethics.
When it comes to the interaction between prudence and medical law, there are several
possible points of interaction. One such point of interaction comes from the law related to medical negligence. The key case which informs medical negligence is that of Bolam v Friern Hospital Management Committee, which led to the development of what is now re- ferred to as the ‘Bolam test’, whereby a ‘doctor is not guilty of negligence if he has acted in accordance with a practice accepted as proper by a responsible body of medical men skilled in that particular art’.55 One might argue that the features of medical treatment and the ac- tions of doctors in cases of medical negligence are assessments not only of skills, but also of the exercise of prudential reasoning in decision making and execution. Perhaps one might suggest that the additional weight of Bolitho v City and Hackney Health Authority, which indicates that scrutiny of the logical structure of medical decision making in negligence cases should be made, further opens questions of alleged medical negligence to scrutiny at the level of prudential reasoning on the part of the doctor who stands accused of that neg- ligence.56 What is clear is that the virtue of prudence itself, which perfects reasoning about what should be done in a given situation, is one which helps doctors to act in such a way as to prevent negligence and therefore harm to patients.
The virtue of justice can be defined as the ‘strict habit of rendering what is due to others’.57 In common parlance, justice has a whole range of meanings, and the virtue itself often is subdivided into justice towards individuals (commutative justice) and as it relates to the common good (distributive justice).58 Justice is often thought of more as a principle with normative implications rather than as a virtue, and in medical ethics we see this in the fact

that it is given as one of Beauchamp and Childress’s principles.59 For the doctor, justice is not simply a normative principle for action, but is the disposition which makes sure that the doctor acts in such a way that each patient is given what they are due. It is rooted in a profound sense of both the worth of the patient and their dignity, and thus regulates the relationship with the patient in many ways. The virtue of justice shapes the one-to-one inter- action between the doctor and the patient (commutative justice), and also wider questions of the fair allocation of finite resources (distributive justice). The fact that a virtue is required to act well towards the patient and give them what they are due is not surprising, given how difficult a task being just is. Many factors can come into play which might jeopardize the giving of appropriate time, attention, treatments, and resources to patients, including the ‘self-interest, comfort and preferences of the doctor’.60 However, as the doctor negotiates these complexities and decides in favour of what is just for the patient, the virtue of justice can be cultivated. Justice is a key example of where virtue ethics, in the Hippocratic and Aristotelian traditions, has something to say about certain actions as excluded, because they are incompatible with virtue.
The oath attributed to Hippocrates gives a clear statement that actions which are unjust and cause harm are incompatible with the role of the doctor. Such acts which are specifically mentioned are counselling a patient to take a drug with the purpose of ending their life, pro- viding such a drug with the purpose of ending life (ie assisting suicide), actions which lead to an abortion, and the breaking of patient confidentiality.61 In Aristotelian terms, such actions have no mean, are incompatible with the good of the patient, and are therefore unjust. We might also extend the Hippocratic logic to include within the category of inherently unjust actions such harms as treatments or procedures which have not been consented to by the patient, or failing to provide adequate information about risks of treatment and pro- cedures.62 The virtue of justice is required to ensure that a doctor has the right disposition to avoid such actions. It is a point of departure from traditional Hippocratic medical ethics that a system of justice might allow some actions which until recent times have been seen as inherently unjust, and therefore incompatible with justice as a virtue, such as is the case with the Abortion Act 1967. The debate both for and against the moral permissibility of abortion is well known, and can be examined in a variety of sources.63 The law in England and Wales as it currently stands does not allow a doctor to advise a patient on actions which would lead to their killing themselves, although attempts have been made to introduce le- gislation to allow assisted suicide for those who have a terminal illness, are over 18, and have capacity.64
Justice conceived as a ‘strict habit of rendering what is due to others’ has much to say about other aspects of medical law, not least as a way of reflecting on how finite financial and human resources are allocated within medicine.65 The QALY metric enables health-care

economists to conduct a cost/benefit analysis of new treatments which can be used to inform allocation decisions. As the principle of autonomy can be invoked by patients to demand the provision of a desired treatment or procedure, or can be used to refuse an un- wanted treatment or procedure, likewise the principle of utility can be invoked by doctors, or by Hospital Trusts, to justify withholding expensive treatments that would offer the patient only marginal benefit.66 While QALY-based decisions are not per se part of medical law, they are used by the National Institute of Health and Clinical Excellence (NICE) as a basis for assessing resource allocation decisions, which are themselves often subject to judicial review, and such reviews are an opportunity for assessment of the decisions made in the light of what is according to the virtue of justice.67
The virtue of fortitude, often known as courage, has a key role to play in medical practice. Such a term as courage is used in a whole variety of ways, depending on context. However, not all such actions are necessarily courage as a moral virtue. We might consider, for ex- ample, the person taking life-threatening risks for the sake of taking a ‘selfie’ as a case in point. An action might be described as fearless, but this does not make it virtuous, because the risk is entirely disproportionate to the benefits, and therefore does not conform with the appropriate mean between allowing fear to overcome a person, leading to the extreme of cowardice, and of a fearless rash behaviour at the other extreme. For doctors, this is an extremely important virtue, since doing what is right for patients is not simple.68 There is often, for example, the threat of disease and its possible transmission to the doctor, which might cause a doctor to fail to care for the patient properly out of an excessive fear. In the other direction, the doctor might not give due attention to the risks involved with such patient, thereby exposing him- or herself, or indeed others, to unnecessary risks.69 Here, we can see the strong reliance of courage on prudence, which helps to set the mean, taking into consideration all the specific features of the case.
Another example of the need for the virtue of courage comes from consideration of the relationship between the doctor and the patient, and specifically as regards communication with the patient. The obvious example is the need for the virtue of courage when breaking bad news to patients, or speaking to patients who are volatile or hostile for some reason. The temptation to shrink back in such situations, or even to speak indirectly, such as hiding behind technical language, is understandable. Perhaps also a brusque and very direct approach might also be tempting, not allowing the fear of a negative reaction to enter into consideration. However, the virtuous doctor will be able to moderate between these two extremes. In a similar way, the virtue of courage will be required to negotiate the bureaucratic and administrative landscape of medicine as it impacts on the ends of medicine with regard to patient care.70 The virtue of courage has a particular interaction with law in the question of whistle-blowing, whereby a doctor needs to report problems relating to patient care which are critical of a colleague or a group of colleagues. Many have commented that raising such concerns is far from simple, both in terms of procedure and in terms of the risks involved for the whistle-blower themselves.71 Such an activity involves a prudential assessment of the situation, and the courage to take a risk in order that what is seen as right for the sake of patient safety and well-being is carried out.
The final cardinal virtue for consideration is temperance. This virtue, like prudence, suffers from an image problem, because of an association exclusively with abstinence from alcohol. However, in virtue ethics it has a much richer understanding which includes, more broadly, the idea of self-integration and self-mastery.72 This might include, therefore, the correct disposition as regards bodily pleasures such as food and drink and sexual desire, but also broader concerns to do with the wider issues of self-control and restraint, including patience, a civility in communication, humility, and other allied qualities, which have obvious importance within the practice of medicine.73 Even in the narrower sense of the virtue of temperance as regards their own relationship to, say food and drink, a doctor who is self-integrated in these aspects has the advantage of being well disposed to a healthy attitude to themselves which should facilitate the relationship with the patient. There are many examples of cases involving what might be termed intemperate behaviour by doctors in their personal lives or professional lives which have been seen as having a bearing on their fitness to practice, such as sexual misconduct, issues of anger management, or issues with alcohol and other substances.74 Some such behaviour is not only an issue of professional misconduct, but also of criminal conduct, and was specifically prohibited in the original Hippocratic framework.75
The broader sense of temperance, which includes humility, civility, and patience, clearly concerns qualities, which if absent, could lead to serious problems in the relationship with patients, families, and, of course, colleagues. One key problem with medical practice has been identified as the issue of paternalism, which at its worst can take the form of ‘playing God’, whereby the doctor’s knowledge and technical ability, and the status and power that these may bring, are not used for the patient’s benefit.76 Thus, temperance allows the self- mastery necessary to have the clarity of mind to recognize the condition of the patient, to communicate effectively with them and their families, and to use the interventions necessary for their good, and in conformity with their wishes, rather than to be driven by self- interest. It is possible to see that the virtue of temperance is a key virtue in ensuring that the doctor keeps him- or herself responsive to his or her patient’s needs.