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II. The Role of Virtue in Recent Moral Philosophy
III. Bioethics and the Ethics of Virtue
IV. Continuing Problems for an Ethics of Virtue
“Virtue” is the translation of the ancient Greek arete, which meant any kind of excellence. Inanimate objects could have arete, since they were assumed to have a telos, that is, a purpose. Thus, the arete of a knife would be its sharpness. Animals could also have arete; for example, the strength of an ox was seen as its virtue. Though an animal could possess arete, the Greeks assumed natural potentialities in men and women to be virtues requiring enhancement through habits of skill. Therefore, Aristotle defined virtue as “‘a kind of second nature’ that disposes us not only to do the right thing rightly but also to gain pleasure from what we do” (Aristotle, 1105b25–30).
Because there are many things that “our nature” as humans inclines us to do, Aristotle argues, there can be many human virtues. How particular virtues are constituted can vary with different understandings of “human nature” and the different social roles and their correlative skills. Yet the virtues, according to Aristotle, are distinguished from the arts, since in the latter excellence lies in results. In contrast, for the virtues it matters not only that an act itself is of a certain kind, but also that the agent “has certain characteristics as he performs it; first of all, he must know what he is doing; secondly, he must choose to act the way he does, and he must choose it for its own sake; and in the third place, the act must spring from a firm and unchangeable character” (Aristotle, 1105a25–30).
The word hexis, which Aristotle uses for “character,” is the same word that denotes the habitual dispositions constitutive of the virtues. Character, therefore, indicates the stability that is necessary so that the various virtues are acquired in a lasting way. Character is not simply the sum of the individual virtues; rather, it names the pattern of thought and action that provides a continuity sufficient for humans to claim their lives as their own (Kupperman). However, the material form associated with character may vary from one society to another. Therefore any definition of virtue, the virtues, and character can be misleading because it can conceal the differences between various accounts of the nature and kinds of virtues as well as character.
II. The Role of Virtue in Recent Moral Philosophy
Ancient philosophers as well as Christian theologians, though offering quite different accounts of the virtues, assumed that any account of the well-lived life had to take virtue into consideration. Modern moral philosophy, in contrast, treats virtues—if it treats them at all—as secondary to an ethics based on principles and rules. The attempt to secure an account of morality that is not as subject to variations as an ethics of virtue certainly contributed to this displacement of virtues.
In his widely used and influential introduction to philosophical ethics, William Frankena manifests the approach to ethics that simply assumed that considerations of virtue were secondary. According to Frankena, ethical theory should be concerned primarily with justifying moral terms and clarifying the differences between appeals to duty and consequences. The virtues, to the extent they were discussed by theorists such as Frankena, were understood as supplements to the determination of right and wrong action. The virtues in such a theory were seen more as the motivational component in more basic principles, such as benevolence and justice. As Frankena put it,
—We know that we should cultivate two virtues, a disposition to be beneficial (i.e., benevolence) and a disposition to treat people equally (justice as a trait). But the point of acquiring these virtues is not further guidance or instructions; the function of the virtues in an ethics of duty is not to tell us what to do, but to insure that we will do it willingly in whatever situation we may face. (Frankena, p. 67)
Frankena’s understanding of the nature and role of the virtues drew on the commonsense view that in order to know what kind of person one ought to be, one needs to know what kind of behavior is good or bad. Unless one knows what constitutes acts of truth-telling or lying, one has no way to specify what the virtue of truthfulness or honesty might entail. Ethical theories were assumed to be aids to help people make good decisions on the basis of well-justified principles or rules. Virtues were secondary for that endeavor.
This account of ethics seemed particularly well suited to the emerging field of bioethics. It was assumed that the task of medical ethics was to help physicians and other healthcare providers make decisions about difficult cases created by the technological power of modern medicine. Whether a patient could be disconnected from a respirator was analyzed in terms of the difference between such basic rules as “do no harm” and “always act that the greatest good for the greatest number be done.” The case orientation of medical decision making seemed ideally suited to the case orientation of ethical theory exemplified by Frankena.
In their influential book, Principles of Biomedical Ethics, Tom L. Beauchamp and James F. Childress retain the structure of ethics articulated by Frankena. Their account of biomedical ethics revolves around the normative alternatives of utilitarian and deontological theories and the principles of autonomy, nonmaleficence, beneficence, and justice. Each of these fundamental principles has correlative primary virtues—that is, respect for autonomy, nonmalevolence, benevolence, and justice—but these “virtues” play no central role. Beauchamp and Childress justify leaving an account of virtue to the last chapter by saying that there are no good arguments for “making judgments about persons independent of judgments about acts or … making virtue primary or sufficient for the moral life” (p. 265).
Both philosophers (Pincoffs) and theologians (Hauerwas) have challenged the assumption that ethics in general and biomedical ethics in particular should be focused primarily on decisions and principles. It is a mistake, they argue, to separate questions of the rightness or goodness of an action from the character of the agent. To relegate the virtues to the motivation for action mistakenly assumes that the description of an action can be abstracted from the character of the agent. To abstract actions from the agent’s perspective fails to account for why the agent should confront this or that situation and under what description. Those who defended the importance of virtue for ethics argued, following Aristotle, that how one does what one does is as important as what one does.
The renewed interest in the nature and significance of virtue ethics has been stimulated by the work of Alasdair MacIntyre, in particular his book After Virtue (1984). MacIntyre’s defense of an Aristotelian virtue theory was but a part of his challenge to the presuppositions of modern moral theory. MacIntyre attacked what he called “the Enlightenment project,” the attempt to ground universal ethical principles in rationality qua rationality—for example, Kant’s categorical imperative (Kant). MacIntyre agrees that principles and rules are important for ethics, but he rejects any attempt to justify those principles or rules that abstracts them from their rootedness in the historical particularities of concrete communities. The narratives that make such communities morally coherent focuses attention on the virtues correlative to those narratives. For the Greeks, for example, the Odyssey acted as the central moral text for the display of the heroic virtues. To separate ethics from its dependence on such narratives is to lose the corresponding significance of the virtues.
MacIntyre’s defense of an ethics of virtue is part of his challenge to the attempt to secure agreement among people who share nothing besides the necessity to cooperate in the interest of survival. Enlightenment theories of ethics, MacIntyre argues, falsely assume that an ahistorical ethics is possible; a historical approach tries to justify ethical principles from anyone’s (that is, any rational individual’s) point of view.
Renewed interest in the ethics of virtue has accompanied a renewed appreciation of the importance of community in ethics. Those commentators who emphasize the importance of community presume that morally worthy political societies are constituted by goods that shape the participants in those societies to want the right things rightly. Therefore ethics, particularly an ethics of virtue, cannot be separated from accounts of politics. Such a politics cannot be reduced to the struggle for power but, rather, is about the constitution of a community’s habits for the production of a certain kind of people—that is, people who have the requisite virtues to sustain such a community.
III. Bioethics and the Ethics of Virtue
In the past the practice of medicine was thought to be part of the tradition of the virtues. As Gary Ferngren and Darrel Amundsen observe, “If health was, for most Greeks, the greatest of the virtues, it is not surprising that they devoted a great deal of attention to preserving it. As an essential component of arete, physical culture was an important part of the life of what the Greeks called kalos kagathos, the cultivated gentleman, who represented in classical times the ideal of the human personality” (p. 7). It should not be surprising, therefore, that not only was health seen as an analogue of virtue but medicine was understood as an activity that by its very nature was virtuous. In medical ethics, the “ethics of virtue” approach tends to focus on the doctor-patient relationship. The trust, care, and compassion that seem so essential to a therapeutic relationship are virtues intrinsic to medical care. Medicine requires attention to technical knowledge and skill, which are virtues in themselves; however, the physician must also have a capacity— compassion—to feel something of patients’ experience of their illness and their perception of what is worthwhile (Pellegrino). Not only compassion but also honesty, fidelity, courage, justice, temperance, magnanimity, prudence, and wisdom are required of the physician.
Not every one of these virtues is required in every decision. What we expect of the virtuous physician is that he will exhibit them when they are required and that he will be so habitually disposed to do so that we can depend upon it. He will place the good of the patient above his own and seek that good unless its pursuit imposes an injustice upon him, or his family, or requires a violation of his own conscience. (Pellegrino, p. 246)
The importance of virtue for medical ethics has been challenged most forcefully by Robert Veatch. According to Veatch, there is no uncontested virtue ethic. The Greeks had one set of virtues, the Christians another, the Stoics another; and there is no rational way to resolve the differences among them. This is a particularly acute problem because modern medicine must be practiced as “stranger medicine,” that is,
medicine that is practiced among people who are essentially strangers. It would include medicine that is practiced on an emergency basis in emergency rooms in large cities. It would also include care delivered in a clinic setting or in an HMO that does not have physician continuity, most medicine in student health services, VA Hospitals, care from consulting specialists, and the medicine in the military as well as care that is delivered by private practice general practitioners to patients who are mobile enough not to establish long-term relationships with their physicians. (Veatch, p. 338)
Virtue theory is not suited to such medicine, Veatch argues, because “there is no reasonable basis for assuming that the stranger with whom one is randomly paired in the emergency room will hold the same theory of virtue as one’s self” (p. 339). The ethics of “stranger medicine” is best construed, Veatch contends, on the presumption that the relationship between doctor and patient is contractual. Such a relationship is best characterized by impersonal principles rather than in terms of virtue. The virtues make sense only within and to particular communities, and therefore only within a “sectarian” form of medicine.
Veatch’s argument exemplifies what Alasdair MacIntyre calls the Enlightenment project. Yet MacIntyre would not dispute the descriptive power of Veatch’s characterization of modern medicine. He thinks medicine is increasingly becoming a form of technological competence, bureaucratically institutionalized and governed by impersonal ethical norms. MacIntyre simply wishes to challenge the presumption that this is a moral advance. Put more strongly, MacIntyre challenges the presumption that such a medicine and the morality that underlies it can be justified in the terms Veatch offers. In particular, he asks, how can one account for the trust that seems a necessary component of the doctorpatient relationship without relying on an ethic of virtue?
Contrary to Veatch, James Drane and others argue that medicine does not exist within a relationship between strangers, but in fact depends on trust and confidence, if not friendship, between doctor and patient. Ethics, they hold, is not based on principles external to medical care and then applied to medicine; rather, medicine is itself one of the essential practices characteristic of good societies. Medicine thus understood does not need so much to be supplemented by ethical considerations based on a lawlike paradigm of principles and rules; on the contrary, medical care becomes one of the last examples left in liberal cultures of what the practice of virtue actually looks like. Those who work from an ethics of virtue do not come to medicine with general principles justified in other contexts, to be applied now to “medical quandaries”; rather, they see medicine itself as an exemplification of virtuous practices. Here medicine is understood in the Aristotelian sense, as an activity—that is, as a form of behavior that produces a result intrinsic to the behavior itself (Aristotle). In MacIntyre’s language, medicine is a practice in which the goods internal to the practice extend our powers in a manner that we are habituated in excellence (MacIntyre). Put simply, the practice of medicine is a form of cooperative human activity that makes us more than we otherwise could be.
MacIntyre’s account of practice and Aristotle’s account of activity remind us that the kinds of behavior that produce virtue are those done in and for themselves. Thus virtue is not acquired by a series of acts—even if such acts would be characterized as courageous, just, or patient—if they are done in a manner that does not render the person performing the actions just. As Aristotle says, “Acts are called just and self-controlled when they are the kinds of acts which a just and self-controlled man would perform; but the just and self-controlled man is not he who performs these acts, but he who also performs them in the way that the just and selfcontrolled men do” (1105B5–9).
There is an inherently circular character to this account of the virtues that cannot be avoided. We can become just only by imitating just people, but such “imitation” cannot be simply the copying of their external actions. Becoming virtuous requires apprenticeship to a master; in this way the virtues are acquired through the kind of training necessary to ensure that they will not easily be lost. How such masters are located depends on a social order that is morally coherent, so that such people exhibit what everyone knows to be good. Medicine, because it remains a craft that requires apprenticeship, exemplifies how virtue can and should be taught.
William F. May suggests that the very meaning of a profession implies that one who practices it is the kind of person who can be held accountable for the goods, and corresponding virtues, of that profession. Medicine as a profession functions well to the extent that medical training forms the character of those who are being initiated into that practice. This does not imply that those who have gone through medical training will be virtuous in other aspects of their lives; it does imply, however, that as physicians they will exhibit the virtues necessary to practice medicine.
In Becoming a Good Doctor: The Place of Virtue and Character in Medical Ethics, James Drane suggests that the character of the doctor is part of the therapeutic relationship, and that there is a structure to the doctor-patient relationship that is based on the patient’s trust that the physician will do what is necessary to help the patient heal. The physician’s task, Drane argues, is not to cure illness but to care for patients, and such care depends on the character of the physician. Drane, in contrast to Robert Veatch, argues that medicine must remain a virtuous practice if it is to be sustained in modern societies. Paul Ramsey’s insistence that the focus of medicine is not the curing of illness but the care of patients “as persons,” can be interpreted as an account of medicine commensurate with an emphasis on the virtues. The particular character of the judgments clinicians must make about each patient is not unlike Aristotle’s description of practical wisdom, or phronesis. According to Aristotle, ethics deals with those matters that can be other; a virtuous person not only must act rightly but also must do so “at the right time, toward the right objects, toward the right people, for the right reasons, and in the right manner” (1106B20–23). Similarly, physicians must know when to qualify what is usually done in light of the differences a particular patient presents. From this perspective, medicine is the training of virtuous people so they are able to make skilled but fallible judgments under conditions of uncertainty. The increasing recognition of the narrative character of medical knowledge (Hunter) reinforces this emphasis on virtue and character. That the disease entities used for diagnosis are implicit narratives means medicine is an intrinsically interpretative practice that must always be practiced under conditions of uncertainty. Accordingly, patient and physician alike bring virtues (and vices) to their interaction that are necessary for sustaining therapeutic relationships.
IV. Continuing Problems for an Ethics of Virtue
To construe medicine as a virtue tradition establishes an agenda of issues for investigation in medical ethics. How are the virtues differentiated? Are there some virtues peculiar to medicine? How are different virtues related to one another? How is the difference between being a person of virtue and character, and the possession of the individual virtues, to be understood? Can a person possess virtues necessary for the practice of medicine without being virtuous? Can a person be courageous without being just?
Such questions have been central to the discussion of the virtues in classical ethical theory. For example, Aristotle maintained that none of the individual virtues could be rightly acquired unless they were acquired in the way that the person of practical wisdom would acquire them. Yet one could not be a person of practical wisdom unless one possessed individual virtues such as courage and temperance. Aristotle did not think the circular character of his account was problematic because he assumed that the kind of habituation commensurate with being “well brought up” is the way we were initiated into the “circle.”
Yet in what sense the virtues are habits remains a complex question that involves the question of how the virtues are individuated. For Aristotle some of the virtues are “qualities” that qualify the emotions, but not all the virtues are like courage and temperance in that respect. Aristotle’s resort to the artificial device of the “mean” for locating the various virtues has caused more problems than it has resolved. These matters are made even more complex by the importance Aristotle gives to friendship in the Nicomachean Ethics, where it is treated as a virtue even though it is not a quality but a relation.
The Christian appropriation of the virtues did little to resolve these complex issues. For Saint Augustine the virtues of the pagans were only “splendid vices” insofar as they were divorced from the worship of God. In “Of the Morals of the Catholic Church,” Augustine redescribed the fourfold division of the virtues as four forms of love:
that temperance is love giving itself entirely to that which is loved; fortitude is love readily bearing all things for the loved object; justice is love serving only the loved object, and therefore ruling rightly; prudence is love distinguishing with sagacity between what hinders it and what helps it. The object of this love is not anything, but only God, the chief good, the highest wisdom, the perfect harmony. So we may express the definition thus, that temperance is love keeping itself entire and uncorrupt for God; fortitude is love bearing everything readily for the sake of God; justice is love serving God only, and therefore ruling well all else, as subject to man; prudence is love making a right distinction between what helps it toward God and what might hinder it. (p. 115)
Thomas Aquinas, influenced profoundly by Augustine and Aristotle, provided an extraordinary account of the virtues that in many ways remains unsurpassed. According to Aquinas, charity, understood as friendship with God, is the form of all the virtues. Therefore, like Augustine, he maintained that there can be no true virtue without charity (Aquinas). Unlike Augustine, however, Aquinas grounded the virtues in an Aristotelian account of human activity, habits, and passions. For Aquinas, therefore, the virtues are dispositions or skills necessary for human flourishing.
Aquinas’s account of the virtues does present some difficulties, however. Even though he followed Augustine’s (and Plato’s) account of the four “cardinal” virtues—prudence, courage, temperance, and justice—neither he nor Augustine successfully argued why these four should be primary. (Aristotle does not single out these four as primary.) Indeed, it is clear from Aquinas’s account that he thought of the cardinal virtues as general descriptions that required more specification through other virtues, such as truthfulness, gentleness, friendship, and magnanimity.
These issues obviously bear on medicine considered as part of the virtue tradition. Are there virtues peculiar to the practice of medicine that require particular cultivation by those who would be doctors? If the virtues are interdependent, can a bad person be a good doctor? Or, put more positively, do the virtues required to be a good doctor at least set one on the way to being a good person? If the Christian claim that the “natural virtues” must be formed by the theological virtues of faith, hope, and charity is correct, does that mean that medicine as a virtue requires theological warrant?
Some of these questions have not been explored with the kind of systematic rigor they deserve. MacIntyre, however, suggests some promising directions. For example, he has argued that practices are not sufficient in themselves to sustain a full account of the individual virtues, their interrelations, or their role in areas such as medicine. Practices must be understood within the context of those goods necessary for the display of a whole human life and within a tradition that makes the goods that shape that life intelligible (MacIntyre). Those initiated into the practice of medicine, for example, might well have their moral life distorted if medicine as a virtue was not located within a tradition that placed the goods that medicine serves within an overriding hierarchy of goods and corresponding virtues. Yet what such a hierarchy would actually consist of remains to be spelled out.
These matters are made more complex to the extent that those who stand in virtue traditions cannot draw on the distinction between the moral realm and the nonmoral realm so characteristic of Kantian inspired moral theory. Once distinctions between the moral and the nonmoral are questioned, strong distinctions between deontological ethics, consequential ethics, and the “ethics of virtue” are equally questionable. L. Gregory Jones and Richard Vance argue, for example, that to assume that the virtues are an alternative to an ethics of principles and rules simply reproduces the assumption that there is a distinct realm called “ethics” that can be separated from the practices of particular communities. It was this assumption that led to the disappearance of virtue from modern moral theory.
For example, Aristotle thought that how a person laughed said much about his or her character. Therefore, what we consider matters of personal style and/or etiquette were considered morally significant by the ancients. For the virtues to encompass such matters as part of human character makes problematic the distinction so crucial to modernity—that is, the distinction between public and private morality. Thus, from such a perspective, what physicians do in their “private time” may well prove important for how they conduct themselves morally as physicians.
Equally troubling is the role luck plays in an ethics of virtue. For example, Aristotle thought that a lack of physical beauty made it difficult for a person to be happy: “For a man is scarcely happy if he is very ugly to look at, or of low-birth, or solitary and childless” (1099A35–37). Modern egalitarian sensibilities find it offensive to think that luck might play a role in our being virtuous (Card), yet the Greeks thought it unavoidable for any account of the virtuous and happy life. Indeed, as Martha Nussbaum has argued, the very strength the virtues provide create a “fragility” that cannot be avoided. Illness may well be considered part of a person’s “luck” that limits the ability to live virtuously. Medicine may thus be understood as the practice that can help restore a person to virtue.
How medicine and an ethics of virtue are understood differs greatly from one historical period to another as well as from one community to another. To the extent that medicine can no longer be sustained as a guild, perhaps it should no longer be construed in the language of the virtues. As Mark Wartofsky asks, “How is benevolence, as a distinctively medical virtue, to be interpreted in those forms of the practice where the individual patient is literally seen not as a person but only through the mediation of the records, laboratory reports, or a monitoring of data in a computer network?” (p. 194).
Yet many continue to argue that any treatment of medicine that makes the virtues of both physician and patient secondary cannot be a medicine anyone should desire or morally support. Truthfulness, for example, is a virtue intrinsic to the care of patients; without it, whatever care is given, even if it is effective in the short run, cannot sustain a morally healthy relationship between patient and physician. Good medicine requires communication and participation by the patient that can be secured only by the physician’s telling the patient the truth as well as the patient’s demanding truthful speech. Without such truthful communication, the patient, as Plato argued, is reduced to the status of a slave (Drane). Ironically, in the name of freedom, the kind of medicine Veatch envisioned looks like a medicine fit for slaves—admittedly an odd conclusion since Veatch assumes that a contractual relation between physician and patient is the condition for a free exchange. Moreover, even Veatch continues to assume that truthtelling is a virtue necessary for medicine to survive as a practice between strangers.
For his part, Drane raises issues at the heart of any account of the virtues as well as of medicine as a virtue tradition. If it is true that truthfulness is a virtue intrinsic to the practice of medicine, can that virtue conflict with, for example, the virtue of benevolence? Plato and Aristotle assumed the unity of the virtues. Accordingly, the virtues would not conflict with one another if they were rightly oriented to a life of happiness. Aquinas held that the virtues might conflict during the time we are “wayfarers,” but not in heaven. Drane resolves the possibility of such conflict by suggesting that medicine requires the truth to be spoken, but benevolently. One may doubt, however, whether this attractive suggestion resolves all questions about the conflict among the virtues, particularly in medical care.
If medicine is to be construed in the tradition of the virtues, the virtues and character of patients must be considered. The very term patient suggests a necessary virtue that is closely associated with Christian accounts of the virtues. If we must learn to live our lives patiently, then illness may appear in quite a different light than it does in those accounts of the moral life that have no patience with patience. For example, if suffering is thought to be an occasion to learn better how to be patient, then a medicine of care may be sustainable even when cure cannot be accomplished.
Karen Lebacqz suggests that the circumstances in which patients find themselves, especially the circumstance of pain and helplessness, can invite them to become accepting and obedient. These traits, which may appear virtuous, may just as likely be vices if they are not shaped by fortitude, prudence, and hope. Lebacqz suggests that these virtues are particularly relevant to the condition of being a “patient,” because they provide the skills necessary to respond to illness in a “fitting” manner. No one way of expressing these virtues suits all patients; yet they do provide the conditions for our learning the tasks required in health and illness.
Questions of virtue also relate to issues of justice in the distribution of healthcare. For if the patient can ask medicine to supply any need abstracted from a community of virtue, then there seems no way to limit in a moral way the demands for medical care. In such a situation, those who have more economic and social power can command more than is due medically, since medicine seems committed to meeting needs irrespective of the habits that created those needs. Liberal political theory has often tried to show how a just society is possible without just people; a “medicine of strangers” may result in a maldistributed medicine.
There is no consensus about the nature of virtue and/or the virtues that a good person should possess. That should not be surprising: the attempt to introduce the virtues into bioethics has gone hand in hand with an emphasis on the inevitable historical character of ethical reflection. If, as MacIntyre has argued, the virtues can be described only in relation to a particular tradition and narrative, then the very assumption that a universal account of ethics—and in particular, of medical ethics—is problematic. Yet the very character of medicine as a practice whose purpose is care for the ill remains one of the richest resources for those committed to an account of the moral life in the language of the virtues.
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