Virtue Ethics and the Practice of Modern Medicine

Abstract

Named Robert Veatch, claimed that the virtue theory is not only irrelevant but potentially dangerous in medical ethics. I argue that virtue is a far more prominent factor in contemporary medical practice than Veatch admits. Even if ‘stranger medicine’ is taken as the norm, proper conduct on the part of physicians depends on certain character traits in order to be maintained consistently over a long period of time and in situations which run counter to the physician's own interests. Right conduct, which Veatch argues is the central moral issue in the physician patient relationship, is intertwined with certain virtues. Moreover, the virtue of integrity and the concept of a unified life narrative are especially useful in analyzing an important factor missing in modern medicine. Since medicine relies necessarily on some concept of human flourishing I argue that virtue theory can play a central role in helping to determine the goals of medical practice.

Related to such data, many organizations including the Institute of Medicine and the Association of American Medical Colleges appear to have rejected the notion of relying on physician virtue as a safeguard of participants and patients, particularly in the face of financial conflicts of interest. The Institute of Medicine Report Conflict of Interest in Medical Research, Education, and Practice observes that “some research suggests that small gifts can contribute to unconscious bias in decision making and advice giving.” The report included an appendix, “How psychological research can inform policies for dealing with conflicts of interest in medicine,” that focuses on the self serving bias described in the following terms research showing that when individuals stand to gain by reaching or getting a particular conclusion, they tend to unconsciously and unintentionally weigh evidence in a biased fashion that favors that conclusion. Furthermore, the process of weighing evidence can happen beneath the individual’s level of awareness, such that a biased individual will sincerely claim objectivity. Similarly, when the Association of American Medical Colleges Task Force on Industry Funding of Medical Education issued its report in 2008. “The Scientific Basis of Influence and Reciprocity: A Symposium,” which explored data from neuroscience, psychology, and behavioral economics on the influence of conflicts of interest on physicians. As with the Institute of Medicine report, a prominent conclusion was that “self interest unconsciously biases well intended people, who give themselves bounded ‘moral wiggle room’ to engage in unethical behavior with an easy conscience.” This unconscious nature of self-serving bias, noted in both reports, helps to explain why most physicians believe that their colleagues are influenced by industry marketing although they themselves are not. The shift from prudence to public policy The IOM and the Association of American Medical Colleges reports both offer broad-ranging policy recommendations in response to the potentially toxic combination of financial conflicts of interest and physician self serving bias. Consistent with some of these recommendations, the Physician Payments Sunshine Provisions of America’s Affordable Health Choices Act of 2009 requires U.S. drug and device manufacturers covered under Medicare, Medicaid, or the State Children’s Health Insurance Plan to report annually a broad array of payments to physicians, including payments for consulting and service, honor aria, gifts, food, entertainment, and support for education and research, thus ushering in a new era of transparency and accountability that bypasses the need to rely on physician disclosures. Concessions and challenges In this article, we do not contest data indicating that humans frequently act in ways that are unconsciously self-serving. Nor do we contest the wisdom of having some policies to guide the financial relationships of physicians; Such policies were developed in response to real abuses of relationships. Rather, we argue the following: A persistent need for physician virtue and self-regulation exists; external regulations alone cannot adequately address conflicts of interest, which are ubiquitous. Several habits can increase the likelihood that physicians will act in virtuous ways, that is, ways that promote the primary goals of medicine even when these goals conflict with maximizing physicians financial self interest. Physicians require the virtue of humility to support use of the habits, or “compensatory strategies,” that will enable physicians to prioritize the goals of medicine over their own self interest. The Persistent Need for Virtue Nowhere in the Institute of Medicine or Association of American Medical Colleges reports does the word virtue appear, and the concept of integrity is never invoked as something physicians must possess.

The problem with the current approach to addressing professionalism in the face of financial interests is that virtues are ignored as a safeguard even though they are still desperately needed. Conflicts of interest are ubiquitous Only a small subset of financial conflicts of interest is readily identifiable and easily controlled through oversight. Many of the worst financial crimes in medicine have occurred through simple fee for service mechanisms rather than as entanglements with industry. And not only industry, but also patient advocacy groups, hospitals, insurers, and state and federal governments try to influence physician behavior, threatening the objectivity and beneficence of physicians’ judgments a recent set of stories by physicians on financial relationships described the following: A practice manager who reported weekly on physicians’ relative value units while encouraging the physicians to order more tests; a hospital CEO who required physicians to take calls from an inappropriately broad catchment area to increase enrollment in his tertiary care center; and physicians in a practice who continued to perform expensive invasive cardiac procedures when medical management was better supported by the evidence. In each case, physicians’ own self-interest might be viewed as satisfying their business partners to increase earnings and maintain job security That is, in principle, the dynamic of self-serving bias might be activated in these situations every bit as much as in a situation involving a relationship with industry. Yet none of these scenarios requires disclosure or management under current conflict-of-interest policies, nor is it clear that disclosures are necessary, as it seems well known by patients that physicians bill for services and work for hospitals. Current policy solutions have limitations Policy-based oversight systems have significant limitations: Loopholes are inevitably found. Identifying these loopholes takes time, and closing them requires new layers of administrative burden. Current conflict-of-interest policies rely on self-reporting, yet physicians often interpret the rules differently, enforcement is inconsistent, and compliance is spotty. Further, administrative solutions to conflicts of interest may be ineffective: Some evidence suggests that disclosure the philanthropic, a requirement largely a result of later Christian influence.

Nevertheless, by the third century B.C.E, a foreshadowing of Christian influence began to affect attitudes toward virtue and health. Mainly due to the influence of Stoicism, Epicurean-ism, and Cynicism, emphasis on physical health as arete began to decline. At the same time the 'gentler' virtues - kindness, charity, forgiveness - came to be emphasized. This spirit reached the practice of medicine, which subsequently came to be viewed as a vehicle for compassion. Thus, according to the authors, late classical shifts in conceptions of the virtues and of medicine anticipated and prepared the way for the subsequent influences of Christianity. The historical review by Darrel Amundsen and Gary Ferngren is extended through the sixteenth century in their second contribution. They first examine the general topic of virtue as it developed from the era of the New Testament to the Protestant Reformation. Texts from the New Testament, especially Pauline works; the Church Fathers, Ambrose, Boethius, and Augustine; Aquinas, representing the classic Roman Catholic position; personalities of the Renaissance; and Luther and Calvin are examined. Particular attention is given to the Reformation dispute over the relative values of faith and works, as interpreted in the terminology of virtue. Following this conceptual study, the relation between medicine and virtue in a Christian context is explored. They review answers to the question, 'Are the practice and use of medicine consistent with the demands of Christian virtue?' Behind this query is the worry about whether illness is a result of God's will, in which case submission to physical distress is virtuous for the Christian and medical intervention is vicious. The chapter concludes with a survey of conceptions of the virtuous Christian in the roles of patient and of physician. SHELP Dietrich Von Engelhardt extends the historical inquiry into the Enlightenment in Germany. The author examines German Enlightenment thought on ethics and medicine, with particular emphasis on the place of the virtues. He identifies three centers or Foci of interest for medical ethical writers of the period, viz., the physician, the patient, and the state. In three substantive sections the contribution made to each by physicians, philosophers, theologians and jurists is surveyed. Throughout the chapter, emphasis is placed on the impact which eighteenth century changes in social structure, such as the transition from an aristocratic to a bourgeois society, had on the contemporary conceptions of ethics and medicine.

Review of medical morality during the eighteenth and nineteenth centuries in England and America concludes the historical section. Laurence McCullough finds precedents during this period for modern attempts to locate virtue in medical ethics. John Gregory (18th century) is seen as a philosophical fore bearer of virtue-based Anglo-American medical ethics. Gregory based his account of the physician's moral responsibility in sympathy, understood as a disposition to experience the feelings of another. Sympathy led to benevolence for the physician because it directed the physician's attention to the best interests of the patient. His system possessed a high degree of completeness, since it comprised an account of the physician's moral duties and the virtues and etiquette appropriate to the role. Anglo-American medical ethics in the century following Gregory's work saw a dissolution of his comprehensive, sympathy-based approach. Pivotal to this dissolution were the work of Thomas Percival and the original Code of Medical Ethics of the AMA. For they had the effect, first of destroying the systematic connection between duties, virtues, and etiquette established by Gregory; and, second, of grounding the moral duties of physicians in the power, importance, and prestige of the profession, rather than the best interests of the patient. The second grouping of essays analyze virtue philosophically and theologically. Bernard Gert initiates the inquiry by providing an account of the virtues which takes its lead from Hobbes.

According to Gert, there is a fundamental cleavage between the personal virtues (vices) and the moral virtues (vices). Personal virtues (vices) are character traits which all (no) rational persons want for themselves. Moral virtues (vices) are character traits which all impartial rational persons want everyone (no one) to have. Gert's account of personal virtues (vices) is a situation, in the sense that virtue is defined in terms of what it would be reasonable to expect a person to do in a given situation. For example, in a situation where, because of fear or danger, it would be reasonable to expect a person to act irrationally, and introduction that person nevertheless acts rationally, the virtue of courage has been displayed. Similarly for the vices. The concept of acting (failing to act) rationally plays a role in the deflection of all the personal virtues (vices). What distinguishes them, according to Gert, is the nature of the situation in which the rational or irrational action occurs. Gert takes issue with the view that acting rationally is just acting to maximize the satisfaction of one's desires. He urges that rationality is not coextensive with self-interest; that it is also rational to be interested in the good of others. His definition of the moral virtues casts them as character traits which, when had by everyone (or nearly everyone), would tend to result in the least suffering overall. These virtues, like the personal ones, are distinguished from one another situation. Unlike the personal ones, the moral virtues are coordinated with rules. Nevertheless they do not involve blind or exception less following of rules. Rather, in Gert's view, having the appropriate moral virtue means that one will be disposed to act in accord with the coordinated moral rule in all cases except those in which one could publicly advocate violation of the rule. One of the central problems for Gert is the resolution of apparent conflicts of virtues. As an example, Gert considers the physician who is deciding whether to inform a patient of a grim diagnosis. It seems the virtue of truthfulness inclines the physician to tell, while the virtue of kindness inclines him not to tell. Gert resolves such problems by suggesting that given situations often provide opportunities for exemplifying more than one virtue, though it is not possible to exemplify them all simultaneously. Edmund Pincoffs has concerns similar to Gert but pursues a different path to resolve them. Pincoffs's major purpose is to provide a definition of virtue and to take first-steps toward a taxonomy of the virtues that avoids a reductionism that, in his judgment, characterizes many other attempts in this direction. His definition of virtue is functional, i.e., 'determinable dispositions to behavior which can serve as grounds for preference/avoidance in human choice, not of acts, but of persons.' The liberality of this definition is developed by comparing it with other, reductive ones.

The virtues then are classified as instrumental and non-instrumental, aesthetic, ameliorating, mediating, temperamental, and moral. He concludes with specific criticisms against the theories of G. H. von Wright, Lester Hunt, Maurice Mandelbaum, Alasdair MacIntyre and James Wallace. The work of Alasdair MacIntyre is subjected to further analysis by Kai Nielsen. Nielsen begins by distinguishing Kantian and utilitarian moral theories, which take the fundamental task of moral theory to be formulation. Justification of basic principles of conduct to guide human choice; and virtue ethics, which seeks to define the ultimate ends or goods of human life and to characterize, in terms of those goods, what it is to be a good person. Nielsen views McIntyre's After Virtue to be the most significant step in the direction of providing a contemporary virtue-based ethic. On Macintosh's account, virtue-ethics requires a reasonably determinate conception of the good of a human life conceived of as a unity. The unity of a life is achieved when the human agent to some extent understands one's actions as part of an ordered narrative sequence. What is best for the individual is whatever one could do in order to live out that other sensory concepts) are ways of our being-in-the-physical-world, so moral virtues are instructions or guidelines for our being-in-the-social-world. A lengthy penultimate section discusses the possibility of virtue-conflicts, as well as some ways in which the virtues of medicine may be exaggerated in certain directions to the point of vice. Next a physician considers the topics of virtue and medicine. Allen Dyer argues that two distinct approaches to medical ethics, bioethics and professional ethics, are presently handicapped by their failure to take explicit account of the concept of virtue. Bioethics (or medical ethics proper) is seen as inappropriately abstract and aloof from the realities of the clinical setting. Ethics comes to be viewed as a rival discipline to medicine, the province of professional 'ethicists'.

This trend toward specialization, Dyer claims, has had the effect of depersonalizing not only ethics, but medicine as well. It implies that the physician is a scientific technician whose clinical judgments may be made in a value-neutral fashion. Professional ethics, on the other hand, is characterized by Dyer as 'reflection upon the moral standards of the professional group by which its members define their identity as professionals and by which they determine standards of inclusion or exclusion.' He argues that some concept of virtue already operates here - at least at a tacit level of awareness - especially in medical 'gate keeping' decisions. He feels that, by becoming more explicit about the place of virtues in the profession, their legitimacy and importance would be further enhanced. A possible objection to an emphasis on virtue can be derived from a Weberian sociological analysis of the medical profession. On such an analysis, groups such as the AMA are seen simply as trade organizations which attempt to monopolize markets and promote self-interest. Dyer believes that virtue, as a trust-inducing trait of the physician, would be viewed by a Weberian as yet another way of placing the consumer in the hands of the professional, and of further monopolistic interests such as price-flexing. Dyer attempts to introduction describe a more optimistic role than this for virtues in the medical context. He provides a sketch of the psychological reasons for the centrality of two such virtues, trustworthiness and confidentiality, and ends with a brief note on some virtues appropriate to the patient. Shifting the discussion from the profession of medicine to the traditional Victorian qualities such as intellectual subordination to and reliance upon (male) physicians. This tension has become more pronounced in the twentieth century as widespread changes in the political, economic and sexual roles of women has forced re-evaluation of many predominantly female endeavors, including nursing. The authors conclude by surveying some of the results of this modern re-thinking of the virtues of nursing. Turning from the profession of medicine and the providers of medical care, the fmal two essays explore the relevance of virtue to patients and to public health. Karen Lebacqz, in an essay on 'The Virtuous Patient,' understands virtue quite broadly as 'any kind of perfection'.

Lebacqz asks whether there are perfections of character which the estate or circumstances of being a patient calls forth. The circumstances of being a patient include the stresses of pain, discomfort, physical limitation, loss of autonomy, violation of privacy, vulnerability, and erosion of self-concept. Traditionally the 'good' patient has been conceived of as long-suffering, compliant, obedient, conscientious - in short, one who 'makes the best of everything'. Lebacqz challenges this conception, and proposes instead fortitude, prudence and hope as the chief virtues of the patient. Marc Lappe's study of 'Virtue and Public Health' concludes the third section of the collection. Lappe attempts to fill a void in contemporary medical-ethical studies. He observes that there has been a tendency to apply concepts of virtue to individuals only, overlooking the possibility of their application to collectives. A natural setting for a discussion of virtuous collective endeavor is the area of public health. A persistent theme of Lappe is that, to count as virtuous, an action must entail some abrogation, or at least down-playing, of the interests of the actor - some element, that is, of selflessness. Thus, virtue in public health requires that the collective's response to individual needs and vulnerabilities transcend, to some extent, considerations of cost-effectiveness and be characterized by extraordinary effort, generosity, and altruism. As with individual virtue, institutional or collective virtue must be characterized in terms of the goods or goals sought by institutional action. Lappe discusses three interdependent public health goals whose achievement requires both individual and collective action: health promotion, health maintenance, and health protection. He attempts to defme the boundaries of collective/institutional responsibility in the virtuous - as opposed to the minimal, cost-constrained - pursuit of each of these goals. The fmal section of essays contains three responses to the discussion of virtue ethics in general and to the linkage of virtue to medicine in this volume. Tom Beau champ is concerned to forestall what he considers the over-emphasis which philosophers and others tend to attach to their preferred forms of moral theory. Many of the essays in this volume, he claims, over value virtue-theory, rights-or-duty-based theories, as the correct approach to medical ethics; while in other places the converse overvaluation is the order of the day. To counteract this tendency, which he feels ill serves the purposes of doing medical ethics in the first place, Beau champ argues for two principal theses. The first is that virtues, rights and duties, and the theories that accompany each, need not and ought not be viewed as competitors for the title of best moral entity or viewpoint. Rather, virtues, rights, and duties are to be seen as correspondents and correlatives of one another in the sense that, for any instance of one of the three categories, an appropriately corresponding instance of the others either exists or can be constructed.

Beau champ is frank in his evaluation of the difficulties with this view, but argues that most of the difficulties are surmountable. His second thesis is that virtues, rights, and duties 'are all instruments, or means' to the ends of life which it is the business of moral theory to recognize and prosecute. Beau champ's consequential ism allows equal importance to each of these types of instruments as viewed from the overall standpoint of the ultimate goods to be attained; while, viewed from the standpoint of appropriateness within a given context or social situation, it allows that one might be preferred to the others. Moreover, it is entirely likely that, even within a given context (such as the practice of medicine), some features of the ultimate goods of life will best be achieved by reliance on persons of good character (virtue), while other features will best be achieved by emphasis on the more juridical instruments of rights/duties. For these reasons Beau champ counsels toleration rather than parochialism in the construction of ethical theories. Robert Veatch takes a less tolerant view in his critique. He clearly demarcates the field of discussion through a definition of virtue as praiseworthy character traits for persons in given social roles. He thereby distinguishes virtues both from principles of right action and from right actions themselves, correcting what he sees as an occasional confusion and conflation of these concepts by writers on virtue. He then proceeds to argue for the difficulty and question the desirability of developing a theory of virtue for medicine. These remarks are intended to serve as a corrective to the exuberant optimism, evident in many of the volume's essays, regarding virtue theory as the best candidate for an ethics of medicine. Veatch's criticism seeks to establish four main points. The less controversial of these are, first, that no one set of virtues is appropriate to every social role; and, secondly, that even within practices, such as medicine, the variety of conceivable professional and lay roles testifies against the existence of a unique set of character traits which we could call the virtue of medicine. These points serve as a reminder of the great difficulty to be encountered in an attempt to formulate a virtue theory for medicine; the desirability of such a theory is called in question by the more controversial of Veatch's claims. These are, thirdly, that even where a definitive set of virtues can be agreed on for a given social role, the possession of these virtues by persons in that role will not guarantee right action and may, if it engenders in the possessors a sense of moral over-confidence, actually result in wrong actions; and, fourthly, that in the context of what the author calls 'stranger medicine a theory of virtue is superfluous, since the desired moral standards of practice are more reliably secured via a theory of rights and/or duties.

Stranger medicine - the practice of medicine among people who are 'essentially strangers to one another' - is perhaps most clearly exemplified in the emergency room of a big-city hospital, but is, according to Veatch, to a greater or lesser degree the model on which nearly all medical care is provided in today's impersonal urban setting. Hence stranger medicine represents the form of medical practice with which most persons, both as patients and as health care providers, are likely to encounter in an urbanized society. So to say that virtue theory is unnecessary in this setting is greatly to diminish the attractiveness of such theory as the preferred model for an ethics of medicine. Veatch's concluding section describes a medical setting within which virtue theory might actually be the preferred type of ethical theory, but, as he points out in his introduction, practically no health care is today delivered in such a setting. The volume ends with a contribution by Stanley Hauerwas, one of the more active evangelists in the revival of virtue. Pointing to the abstract aloofness, in the clinical setting, of consequential and deontological normative ethical theories, Hauerwas finds reason to be generally sanguine about the recent heightening of interest in the virtues on the part of those engaged in medical ethics. For though he does not view an account of virtue as a candidate to replace normative medical ethics, Hauerwas does see this 'turn to virtue' as a sign that many moral philosophers and theologians have begun to recognize a major flaw in the ethical tradition of the past few centuries.

Hauerwas's general description of that flaw cites the failure of deontologists and consequential alike to recognize common goods pertaining to all members of society precisely as a result of their being members of one society. The only goods recognized have been those pertaining to individuals simple, with the result that the important ethical questions have tended to take the form 'What ought the individual in this situation to do?' The turn to virtue, with its emphasis on the common goods of practices and its descriptions, in terms of those goods, of the kinds of people we ought to be, is considered by Hauerwas to represent an important corrective of the presuppositions on which modern medical ethics - and modern ethics in general - has been carried out. Because the subject of virtue has received so little attention in ethical literature over the past several hundred years, the author believes that 'almost everything remains to be done'. In the latter half