The Virtues in Medical PracticeEdmund D. Pellegrino, M.D.Georgetown University

Virtue EthicsOldest, most durable basis for Ethics

Universal across cultural lines

Character of moral agent ineradicable to any moral theory

Ancient Origin Medieval Synthesis Enlightenment Erosion Modern Revival

Oldest Tradition in Professional Ethics

Some DefinitionsPlato: Excellence in Knowledge of the Good

Aristotle:A state of character which makes a man good and makes that person do his work well (NE 1106 a 22-24)Aims toward human flourishing and the good in every human actA mean between extremesA teleology oriented to the good

Aquinas: Essentially same definitions as AristotleS.T. IIa - IIae 46-56, Ia - IIae 55-67

Classification of the VirtuesMoral Virtues orient to the good (Life and Work)Justice, Courage, Temperance(Plato, Aristotle, Aquinas)

Intellectual Virtues orient to the truthUnderstanding, Knowledge, Wisdom and Prudence(Aristotle, Aquinas)

Supernatural Virtues orient to union with GodFaith, Hope, Charity(Aquinas, St. Paul, Christian Theologians)Part I:

Post-Medieval TransformationsChallenges to Medieval Theology and Metaphysics

Move to:Realism about Human Nature (Hobbes, Locke)Moral Psychology (Hutcheson and Hume)Rise of Rights (Locke); Duties (Kant)Utility (Bentham and Mill)

Anti-Virtue TheoriesThrasymuchus, Machiavelli, Nietzsche, Rana

Prima Facie PrinciplesRoss

Contemporary RevivalIneradicability of character in moral life

Insufficiency of more modern theories

Over-emphasis on puzzles and problems

Conflicts between and among Post-Enlightenment theories

Stimulus of E. Anscombe and A. MacIntyre

Shortcomings of Virtue TheoriesNo Clear Action Guidelines

Multiplicity of Definitions

Conflict Between Virtues

Tendency to Subjectivism

Circular Logic

Links to Principles and Duties Unclear

No Agreement on the Good for Humans

Part II: The Practice of Virtue in the Health Professions

Virtue ethics is the oldest tradition in professional ethics

Hippocrates, The Stoics, Scribonius Largus, Maimmides, T. Percival, John & James Gregory, F. Peabody, F. Nightingale

A. Phenomenology of the Clinical EncounterThe Patientanxious, in distress, dependent, forced to trustThe Physicianoffers help, i.e. expectations of competence in the patients interestThe Relationshipinequality of power

(Promise)(Means)Act of Profession Art of Medicine

Good of the Patient(Telos Promise of Fulfillment)

B. The Act of Professionthe starting point of the Professional RelationshipA public or private declaration or promise to be competent, and to put competence at the service of the person in need of help. This promise entails certain virtues and character traits if it is to be authentic and serve the telos of end of the relationshipthe good of the patient.

C. The Components of the Good of the PatientThe Medical or Clinical GoodThe Patients Perception of his GoodThe Good o the Patient as a Human BeingThe Spiritual, Transcendent Good

D. Virtues Entailed by the Act of ProfessionMoral VirtuesGood as Telos:

Fidelity to PromiseBenevolenceEffacement of Self-interestIntellectual HonestyCourageJustice

Intellectual Virtues essential to technical correctness, truth as telos

Art the practical application of medical knowledgeKnowledge capacity to reason and demonstrateIntuitive Reason grasp of universal truthTheoretical WisdomPrudence deliberation about action

(Phronesis in Aristotle)most important intellectual virtue in professional ethics, what are the best means to an endthe good of the patienttechnically and morally, both are essential. (Prudence in Aquinas)D. Virtues Entailed by the Act of Profession (cont.)

a good action and its opposite cannot exist without a combination of intellect and character (NE 1139a33-34)

Aquinas: Prudence is: right reason about things to be done (and this is not merely in general but also in practice) (S.T. I-II, Q5E, Art. 5)

Aristotle: Phronesis is: a true and seasoned capacity to act with regard to the things that are good or bad for man (NE 1140a24-b21; 1140b4-5)

How Virtue Ethics Shapes Responses to Special Issues

Models of the Helping RelationshipCovenants vs. ContractCommodification of Medicinepro bono workCare of the Non-CompliantConflicts of InterestRetaliative and Self-Protective MedicineAuthentic ProfessionalismStewardship of Medical Knowledge

Can Virtue be Taught?

"Can you tell me, Socrates, is virtue something that can be taught? Or does it come by practice or is it neither teaching nor practice that gives it to a man, but natural aptitude or something else?" (Meno)

1.Indoctrination in school, family, church, communityCourses in ethicsRole models:Teachers, paradigm persons and casesProfession as a virtue sustaining communityCharacter formation in medical school

Part III: Theoretical Implications of a Teleological Virtue Ethic

A. A way for Virtue Ethics out of circular logic Terminus a quo Terminus ad quem (Origin) (Destination)

Relationship to other theories

Relationship to principles, duties, rules, culture

Closer relationship of intellectual and moral virtues

Response to Contemporary Concepts

Theoretical Implications of a Teleological Virtue Ethic (cont.)A theory of medicineits nature and telos

A theory of justificationin terms of telos, healing

Integration of insights from principle-based, virtue, caring, casuistic theoriesin terms of the telos of medicine

Relation of general and special ethicsEthics of health care as a paradigm case

Foundation of a Moral Philosophy of Authentic Professionalism

The telos or end of clinical medicine (nursing, etc.) is a technically right and morally good decision and action for a particular human being. It is what is professed at the outset of the relationship. Prudence keeps the technical and moral in proper relationship to each other.