2020/1, стр. 20 - 30

A VIRTUE-BASED MODEL FOR MEDICAL ETHICS AND PRACTICE IN EDMUND PELLEGRINO

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Philemon Ayibo
The John Paul II Catholic University of Lublin (Poland)

Abstract. This paper deals with the resurgence of interest in virtue ethics in professional ethics, specifically as it applies to Edmund Daniel Pellegrino’s account in medical ethics. Pellegrino investigates in a clear manner the ethical problems of contemporary medicine from a virtue ethics point of view and offers a virtue-based ethic for medicine as an effective tool and a practical guide for confronting the challenges of modern medicine. His account builds on a thesis of the indispensability of virtuous character traits for a sound medical practice. Pellegrino’s virtue ethics offers a plausible and distinctive alternative to utilitarian and Kantian (principlebased) approaches to understanding and evaluating professional roles. It is hoped that our exploration of Pellegrino’s account will underline the place of a virtue ethics in medicine and stimulate a similar inquiry into social welfare, and into other forms of human professions and disciplines.

Keywords: medical ethics; virtue ethics; principle-based ethics; medicine

Introduction

The history of contemporary philosophy has witnessed new issues arising from ethical theories and their practical applications to existential phenomena. Some of them are issues that are currently causing ethical commotion in the society. The modern man seems to be suffocating under the moral crisis of his time as he takes or makes daily decisions and choices in relation with others in the society. For this reason, there have been several development and revivals in ethical theories. One of those contemporary movements and revivals in ethical theories is the resurgence of interest in virtue ethics. Virtue ethics as captured in Lawhead (2007) is an ethical theory that focuses on those character traits that make someone a good or admirable person, rather than simply the actions the person performs. This ethical theory can trace its roots back to Socrates, Plato, the Stoics, and Confucius. However, Aristotle had the most influence on the development of this perspective. According to most previous ethical theories, the primary question in ethics is, “What should I do?” On the contrary, for virtue ethics the fundamental question in ethics is, “What sort of person should I be?”

In contrast to virtue ethics, Lawhead (2007) underlines that Kantianism and utilitarianism, the two major ethical theories in modern philosophy, are theories that are based on rules or principles and that focus on the ethics of conduct. Although these positions don’t ignore the importance of virtuous character traits, these traits are valued mainly for their tendency to lead us to perform the right actions.

The above background makes it clear that the ethical malaise that has come to the forefront of philosophy in recent decades is not only the problem of ethical theories but as well as the application of ethical theories to practical ethical problems, particularly as they are found in the various professions. The best-known example of the problem of applying ethical theories to concrete life situations is so pronounced in the field of medical ethics. The field of medicine today faces more professional ethical dilemmas than ever. This is probably because it deals with sensitive issues of life and death in a technologically advanced society. The issues that make the headlines (and the law courts) are, typically, abortion, euthanasia, physician-assisted suicides, surrogate motherhood, stem-cell research, and genetic engineering. However, there are many, more subtle ethical issues in medicine dealing with such topics as autonomy–paternalism, the physician–patient relationship, consent, disclosure, and issues concerning privacy or confidentiality (Lawhead, 2007). In addition to medical ethics, there has also been a growing demand for philosophers to clarify the ethical dimensions of professions such as business, accounting, journalism, and engineering, as well as the issues arising out of our environmental concerns. Pellegrino and Thomasma (1993) acknowledge that the most crucial dilemmas of medical ethics today are not those arising from medicine's scientific progress. Each of these dilemmas, although occasioned by technology, arises from changing roles of the profession in response to public and private expectations. They are dilemmas of professional ethics, those that go to the heart of what it is to be a physician. In these matters, medicine faces an unenviable choice.

Amidst the incommensurability and fragmentation of contemporary moral theory, modern day philosophers have established virtue ethics as a credible ethical theory. For instance, MacIntyre (2007) proposes a return to Aristotelian virtue ethics as way forward. The Aristotelian tradition can be restated in a way that restores intelligibility and rationality to our moral and social attitudes and commitments. He proposes a system based on virtue developed and enhanced through practices that are then converted into traditions of society. Practices require virtue, and practice will make one better at the virtue, which will ultimately develop into a habit. This is what is normative; the virtuous habit that is developed will guide one's action. According to him: “Practices then might flourish in societies with very different codes; what they could not do is flourish in societies in which the virtues were not valued, although institutions and technical skills serving unified purposes might well continue to flourish”. MacIntye (2007) strongly believes that virtue ethics – the study of moral character- constitutes an essential key for moral formation and building a just and morally sound society. He sees virtue as an acquired human quality the possession and exercise of which tends to enable us to achieve those goods which are internal to practices and the lack of which effectively prevents us from achieving any such goods.

This paper takes as its starting-point, the question on the need for a moral philosophy that would address the ethical dimensions of professions particularly in the field of medicine by asking a question, can moral philosophy, in particular character or virtue ethics contribute positively to the moral debates surrounding many contemporary vexing professional (medical and public-health) issues? In this context, the study adopts Edmund Daniel Pellegrino’s virtue ethics as an ethical model for shaping a sound moral philosophy for professions. The aim is to investigate whether a virtue-based ethics, -which is concerned with notion of human flourishing that is not primarily atomistic but intricately linked to the mutual well -being of others as understood in Pellegrino can be used as a catalyst for countering contemporary challenges in the practice of medicine. The paper briefly explores Pellegrino’s unique and distinctive framework on virtue ethics for medical ethics with its major objectives, assumptions and justifications.

Towards a moral philosophy of professions for medicine

Pellegrino (2008) begins his philosophical reflection on medicine by beautifully stating that in the relationship among the disciplines in medical field, moral philosophy remains the guiding discipline. For a physician to go beyond technique to contemplate the human object of his ministrations, he must turn to the humanities for those meaning which medical science alone cannot give. He is trying to say that good medical care needs more than its scientific orientation.

He conceives medicine as an ethical enterprise since it is aimed at the good of the patients not their harm, and, therefore, it must discern what is right and good, what ought to be done as well as what can be done. A philosophy of medicine would concentrate on the ethics “internal” to medicine-to those ethical issues arising in the kind of activity medicine is-one based in a healing relationship as well as competence in knowledge and skill appropriate to a healing relationship (Pellegrino, 2008). Defining philosophy of medicine as a critical reflection on medical issues, he argues that philosophical perspectives in medicine are more open to lived experiences of patient and physician and to the particularities of moral choice, suffering, dying, finitude and compassion. The existential, hermeneutics and phenomenological approaches to ethics today enables the philosopher to comprehend these medical phenomena in more concrete ways than is congenial in the analytical mode still dominant in contemporary Anglo-American philosophy (Pellegrino, 2008).

At the heart of his ideas were the notions that medical ethics cannot be separated from the philosophy of medicine, and that a phenomenological understanding of the fact of illness and the physician’s response to the vulnerable patient’s plight must provide a basis for medical ethics. He believed medicine had a definable telos — healing the sick — and that medicine therefore had an internal morality based on the reality of the human experiences of illness and death and on the goals of medicine as an enterprise established in response to these predicaments (Pellegrino & Thomasma, 1993). He conceives medicine as a philosophical enterprise and its practice, a moral activity. Amoral activity in the sense that the physician-relationship and the reality of disease of the process of healing exist within a mora column.

From the start to the present, Pellegrino has held that a philosophy of medicine can help fuse disparate themes in modern society, such as the control over our technology, the nature of human responsibility, personhood, and duties we have to one another (Thomasma, 2007). Pellegrino argued that just as in other professional and social roles, the virtues of medicine are derivable from the nature of medicine as a human activity. On the necessity and the indispensability of a sound professional ethics in medical practice, Pellegrino (2008) radically argues: “professional ethics, its groundings, the source of its moral authority, and the way they are justified are of concern for all of us. A philosophy of the profession that grounds the ethics of profession is therefore better than an idle academic exercise.” He bases his virtue theory on Aristotle’s philosophical assumption. For Aristotle, the teleological orientation of virtue is two-fold: the fulfilment of the natural end of human life, namely happiness, and the attainment of the end of human work. Aristotle links being a good person with doing well whatever the person does, and with achieving, to the greatest extent possible, the end of any human activity, whether it be the conduct of the whole of one’s life or the conduct of a particular work related to the role or roles one plays in everyday life (Pellegrino, 2008).

A teleological-based ethic of medicine is the only one tenable basis for an ethic of the healing profession as a whole in an era of widespread moral and social pluralism like ours. It is also the only basis for moral authority. Authority that derives from an understanding of the ends and purposes for which health professions are established (Pellegrino, 2008). The good of the patient as stated earlier is the telos, that is, the end toward which both the patient and the doctor are existentially oriented. Briefly the ends of medicine are ultimately the restoration or improvement of health and, more proximately, to heal, that is, to cure illness and disease or, when this is not possible, to care for and help the patient to live with residual pain, discomfort, or disability (Pellegrino & Thomasma, 1993). In the same vein, The essential role that ends play in virtue ethics reminds us that good decision making always has a goal in view, a goal that is presumed to be good and worthy of pursuit (Kaldjian, 2014).

The Virtues and the virtuous physician

Pellegrino begins his virtue theory in medical ethics by lamenting that modern society has lost consensus on a definition of virtue, and without moral consensus, there is no vantage point from which to judge what is right. According to him, the professions today are aicted with a species of moral malaise that may prove fatal to their moral identities and perilous to our whole society. This malaise is manifest in a growing conviction among the conscientious doctors, lawyers, and ministers that it is no longer possible to practice their professions within traditional ethical constraints (Pellegrino, 2008). We are now a morally heterogeneous society, divided on most fundamental ethical issues, particularly about the meaning of life and death. Without a common conception of human nature, we cannot agree on what constitute a good life and the virtues that ought to characterize it. As a result, the ethics of the professions especially the medical profession, have turned to the analysis of dilemmas and of the process of ethical decision-making. For many, ethics consists primarily in a balancing of rights, duties, and prima facie principles and the resolution of the conflicts among them. Procedural ethics has replaced normative ethics. This avoids the impasses when patients, clients, and professional hold fundamentally opposing moral views (Pellegrino, 2008).

More so, he laments that until very recently, ethics in general and biomedical ethics in particular has been largely principle-based; that virtue-based ethics was given scant attention. This principled-based form of ethics, for Pellegrino, fails to take into sucient account the character of the agent, as well as the nuances of real life that situate and define the moral quandary. As far as the standards and guidelines against which individuals, institutions, and society can measure their actions are necessary, they must be linked to a virtue-based ethic if a more complete picture of the moral life is to be obtained (Pellegrino & Thomasma, 1993). Pellegrino’s proposal also stems from the inadequacies and deficiencies perceived from the principled-based ethics that has come under fire for its almost formulaic approach to ethics. Pellegrino sees the profession of medicine as suffering more from a progressive erosion of its social and moral status than its scientific progression. He describes practice of medicine as marked by moral pluralism, relativism, the commodification of medical and health care, a shift from professional ethics to market ethics and the privatization of morality (Pellegrino, 2008).

Kant's respect for person and Bentham and Mill's utility established the idea of a "principle-based" ethic as distinguished from the traditional emphasis on virtue. Ethics was set on the road of emphasis on the act more than on the agent even though, in Kant's case, intention was paramount in moral acts and therefore resided in the agent. Rules or principles by themselves as too abstract and general to guide moral action (Pellegrino & Thomasma, 1993). In the face of these challenges, he calls physicians through his virtue theory to an act of profession that can tie them to their engagement in healing, so that they can come to appreciate professional virtues in terms of the telos of the clinical encounter: the patient’s good (Pellegrino & Thomasma, 1993). He saw the need to revisit the idea of professional commitment. Pellegrino was moved to propose a new openness to ethics with a desire to enrich the principle-based ethics and to construct a modern philosophy of medicine that will integrally link both principle and virtue approaches together. Virtue and principle-based theories in medical ethics must be closely linked with the nature of medicine itself, that is, with a philosophy of medicine (Pellegrino & Thomasma, 1993). He does this by selectively applying certain virtues to medical practice to see how they can make a difference in the way current disputes are analyzed in health care. More so, by linking virtues to a physician's character; he hopes to emphasize the skills needed to be a good person rather than only those needed to conduct a professional-that is, a technically proficient-life. He explores the natural virtues, that is, the philosophical foundations of virtue-based ethics, with their historical roots in the classical and medieval traditions, and the application of such theory to the practice of medicine today. Pellegrino appeals to the Aristotelian-Thomistic tradition in relating the virtues of medicine as a practice to the ends of medicine.

One major question asked by Pellegrino (2008) is whether there is a sound philosophical foundation in the nature of professional activity for resolving the tension between altruism and self-interest in favour of virtue and character. He answers the question in the armation: “I believe there is”. The fullest expression of Pellegrino’s thesis, which has remained remarkably consistent throughout his writings, is: the character of the moral agent, the physician in medical ethics, is an irreducible fact, regardless of the model of ethical reasoning one elects – principle or rule-based, duty-based, casuistic, situational, emotivist, egoistic, intuitionist, and so on. In every ethical theory there co mes a moment of opportunity, the use of the theory by a particular person in a particular circumstance (Pellegrino & Thomasma, 1993).

In order to attain the telos as conceived in Pellegrino’s philosophy of medicine, he argues that certain virtues are required. These are both moral and intellectual. They are the virtues incumbent upon the physician if she or he is to attain the ends of medicine. These virtues are neither optional nor merely admirable. They are entailed, on the physician’s part, by the nature and ends of medicine. By practicing the medical virtues, physician and person are united in the end they seek, that is, healing (Pellegrino & Thomasma, 1993).

In adopting the Aristotelian (teleological) concept of virtue as earlier mentioned, Pellegrino (2007) defines medical virtue as “a character trait, which disposes the physician habitually to act well and wisely with respect to the work of medicine, its ends, and purposes. A physician who exhibits these character traits is a good physician and a good person. Pellegrino (2008) lists among the virtues that should mark the good physician: Fidelity to trust and promise, benevolence, effacement of self-interest, compassion and caring, intellectual honesty, justice, and prudence. These habitual dispositions of virtues allow physicians to integrate the wide range of information and values that arise from scientific knowledge, patient preferences, their own moral commitments, and society’s expectations. Learning to bring these domains together is an essential part of becoming a physician, and it determines the ethics that guides the care of patients (Kaldjian, 2014).

The best approach to confront the contemporary ethical challenges in professions is to build than ethics that focuses on virtuous characters. An ethics that is humanitarian and builds on compassion and confidentiality. Pellegrino argues that the virtuous person is a beacon of moral sensitivity in the society. According to him, “No matter to what depths a society may fall, virtuous persons will always be beacons that light the way back to moral sensitivity; virtuous physicians are the beacons that show the way back to moral credibility for the whole profession(Pellegrino, 1985). Certainly, the person of character is still the indispensable unit of a morally good society (Pellegrino & Thomasma, 1993). Virtuous persons are distinguished agents, and their acts as well, by a capacity to be disposed habitually not only to do what is required as duty but to seek the perfection – the excellence, the arte of a particular virtue. Virtuous persons, on the thesis we are expounding, see themselves as bound to act as excellently as possible in achieving their ends. For the physician, that end is the healing of the patient. The virtuous person is impelled by his virtues to strive for perfection – not because it is a duty, but because he seeks perfection in pursuit of the telos of whatever it is, that he is engaged in. He cannot act otherwise. It is part of his character. He is disposed habitually to fill out the potential for moral perfection inherent in his actions because he wishes to be as close to perfection as possible. The virtuous person will interpret the span of duty, principle, or rule more inclusively and more in the direction of perfection of the good end to which the action is naturally oriented (Pellegrino & Thomasma, 1993).

In line with Pellegrino, Montgomery (2006) opines that the good character of the physician guarantees the patient’s well-being and serves as the basis of medical professional standards and practices. He writes, “Medicine’s success relies on the physicians’ capacity for clinical judgment. It is neither a science nor a technical skill (although it puts both to use) but the ability to work out how general rules – scientific principles, clinical guidelines – apply to one particular patient. This is – to use Aristotle’s word – phronesis, or practical reasoning”.

The virtues of the person are a reflection of the community; the virtues inherent to the practice of medicine are a reflection of the medical community. The virtuous person follows a moral standard, a maxim that animates the human being to pursue the good and reject evil. The virtuous physician must be guided by the obligation he has towards his patient: the obligation to work for a good outcome in the doctor-patient encounter – to be of benefit to the patient and not to harm him (Vizcarrando, 2013).

Drane (1995) is one virtue ethicist who like Pellegrino has also made systematic attempts to integrate virtue theory into medical ethics. His contributions are worth mentioning here because they are in-depth studies; however, any attempt to review his work at length in this paper would repeat Pellegrino's basic arguments. He believes that modern medical ethics has become depersonalized, partly through its use of rules and principles. It has forgotten that the context of medicine is that of one individual caring for another individual.

Final Considerations

Pellegrino’s virtue theory enjoys a wider acceptance amongst many contemporary ethicists because he took an approach that was shared by most ancient virtue ethicists that are still relevant and prevalent today. An approach in which the virtues are said to be those character traits that are essential to living a fulfilling human life, a life in which one both cares about the right things and has the wisdom and skill to act intelligently about those things (Russell, 2013). Professional roles as exemplified in Pellegrino’s account presents a particularly good example of how virtue ethics may be applied in practice, as the focus of virtue ethics on functions and ends fits well with professional practice, which can be readily regarded as having a teleological structure. The proper goals of a particular profession also tend to be clearer, more specific, and more widely recognized than do the characteristic functions and ends of human beings generally.

The commodification of healthcare and the “proletarianization” of physicians.

His virtue account contested the contemporary tendency to recast physicians not as professionals but as employees who could be manipulated by appeals to their self-interest into gatekeepers who would deny patients potentially beneficial services in the name of cost-containment. He championed a professionalism marked by the primacy of patient welfare and demanding at least a modicum of altruism on the parts of those who had sworn oaths to care for the sick. Costcontainment, on his view, was only ethical as a side effect of practicing good medicine. Good medical practice, as he argued, is always characterized by “therapeutic parsimony and diagnostic elegance,” aimed not at saving money but at what would be best for the patient, since too much testing and treating can be harmful (Sulmasy, 2013). Pellegrino had the best of competence in developing his justification because he thought not just as a philosopher but always also as a practicing physician (Sulmasy, 2013).

In evaluating Pellegrino’s theory of virtues in medical Practice, Biesaga (2003) remarks, “it can be said that Pellegrino formulated a comprehensive outline of the philosophy of medicine. He analyzed the main facts: the fact of the disease, the act of medicine, he recalled the telos of this specific activity, he described it in the form of four goods contributing to the well-being of the patient; he distinguished between internal and external goodwill in medical practice.”

However, Pellegrino’s proposal for relating virtue theory to medicine has faced some serious objections and reactions from different quarters. Most of these criticisms, which tend to invalidate Pellegrino’s theory, come from adherents of the principle-based approaches to ethics, largely from the proponents of deontological moral theory.

Veatch (1993) in objection to Pellegrino argues that the virtues and traits of the specific practice of medicine are not immediately evident. He demonstrated that a wide variety of virtues have been promoted throughout history, some of which are repulsive to an adult, autonomy model of the patient-physician relation. Decisions about which virtues to emphasize are culture bound. Thus, virtue theory will tend to produce wrong conduct when the virtues it chooses are the wrong ones.

Wiesel (1992) objects Pellegrino’s theory by arguing that training in virtues does not guarantee good results. Wiesel writes of a famous Jewish professor, Shimon Dubnow, whose own student, Johann Siebert, not only taunted him in the ghetto but also eventually killed him. Wiesel states: “I couldn't understand these men who had, after all, studied for 8, 10, 12, or 14 years in German universities, which then were the best on the Continent, if not in the world. Why did their education not shield them from evil? This question haunted me.”

Kilbreath (2000) criticizes Pellegrino’s approach as a distortion of virtue theory. He observes that Pellegrino’s desire to have virtue ethics assume a place of honor in medical ethics and his demonstration that virtue theory must be linked with the principles in an integrated medical ethics caused him to unite virtue theory with principle-based theory, which results in distortion of virtue ethics through reducing it to a version of principle-based theory.

Despite his undying defense of the necessity of virtues in medical practice, Pellegrino humbly acknowledges the philosophical diculties inherent in the concept of virtue itself.

First, its lack of specificity. Virtue theory does not tell us how to resolve specific moral dilemmas. It deemphasizes principles, rules, duties and concrete prescriptions. It only says that the virtuous person will be disposed to act in accordance with the virtues appropriate to the situation. This lack of specificity leads to a distressing circularity in reasoning (Pellegrino, 2008). Virtue-based ethics tends to be thin on moral guideline.

Furthermore, virtue theory cannot stand apart from some theory of human nature and the good. The more the vague our definitions of the human nature and its telos, the more dicult it is to keep virtue from becoming vice and vice versa. Since virtue ethics puts its emphasis on the character of the agent, it requires a consistent philosophical anthropology; otherwise, it easily becomes subjectivist, emotiontivist, relativist, and self-destructive (Pellegrino, 2008). Drane (1995) says that it is one thing to make a generic argument for the place of character and virtues in medical ethics and a more dicult thing to argue convincingly for those specific character traits which make a good doctor.

There is in our pluralistic society no agreed-upon philosophical anthropology or metaphysics. Lacking these, we lose the foundation upon which some common idea of the good for humans could be based. As a result, the telos toward which the virtues were thought to dispose the agent become vague. Differences in moral ends, consequently, become relativized, subjective, and negotiable in response to the exigencies of the moment. As a further consequence, the virtues ordered to those ends of necessity become problematic (Pellegrino, 2008).

Further diculties include the relations of intent to outward behavior. Is good intention a criterion of a good person? How do we determine the intention? Can good intention absolve the agent of responsibility for an act, which ends in harm- a physician telling a patient the truth out of the virtue of honesty, precipitating a serious depression or even suicide? Few are virtuous all the time. How does virtue ethic connect with duty and principle-based ethics, which gives the objectivity that virtue ethics, seems to lack (Pellegrino, 2008). In the face of these inherent diculties in propounding virtue ethics in medical practice, Pellegrino calls physicians to an act of profession that can tie them to their engagements in healing, so that they can come to appreciate professional virtues in terms of the telos of the clinical encounter: the patient’s good.

As a philosopher-clinician, Pellegrino’s primary aim according to him was to search for a moral philosophy of medicine based in the nature of medicine. Without this, medical ethics becomes what social convention, politics, economics or sheer pragmatics make it to be. Given its enormous power for good and evil, medical ethics cannot serve the personal and common good without clarity about its ends and purpose (Pellegrino, 2008).

In propounding his moral philosophy for professions, his hope was to stimulate critical thought on the part of physicians and more informed philosophizing on the part of ethicists and moral philosophers. As a solution to moral pluralism of our time, a teleologically based of medicine is the only tenable basis for an ethics of healing professions as a whole in an era of widespread moral and social pluralism of our time. Authority drives from an understanding of the ends and purposes for which the health professions where established (Pellegrino, 2008).

Pellegrino’s theory has contributed immensely to the development of virtue ethics by dwelling on some of the debates that focus on the nature of medicine, its task in society, the profession of medicine, and its moral center. His insights will continue to shape this discussion in the future. In conclusion, if the current debates in medical ethics are to shape the character and virtues of the physician of the next century, a comprehensive moral analysis in terms of rules, principles, and public health policies must be expanded by paying attention to the goals of medicine and the ends of the clinical encounter.

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