Since Alasdair MacIntyre's landmark book, After Virtue, there has been renewed interest
in the role of the virtues in the moral life and attention paid to reappropriating the
Aristotelian notion of a "practice." (1) Recent
reappropriations of the virtues and virtue theory in medical ethics have contributed to
conceiving more adequately the nature of good medicine. In this paper, I wish to explore
some of these insights and the special relevance the notion of a practice has in an
account of good medicine. Yet, I want to suggest, too, that much remains to be done. This
renewed attention to the virtues needs to be supplemented by a similar reappropriation and
transposition of the notion of nature in order to navigate successfully the Dardanelles of
an ahistorical essentialism and the Bosphorus of a historical relativism. (2)
Practices are essentially cooperative endeavors. In order to satisfy some need,
individuals perform certain acts in the hope of relieving some distress or of attaining
some object. Rarely if ever, though, can either be done through one's own efforts alone.
When we act, we participate in already expected and agreed upon ways of doing things, and
our participation in them is structured in large measure by mutual sets of expectations to
which we hold each other accountable. Because it makes possible the attainment of desired
goods on a regular basis, this pattern of cooperative human activity is itself a good. For
this reason, Bernard Lonergan termed the actual functioning of human institutions a
"good of order." (3) While particular goods may
satisfy some human want or need, the regular and recurrent enjoyment and the ordering of
human action are themselves distinctly valuable. Indeed, for Lonergan, it takes
precedence. For the attainment of particular goods is conditioned by the cooperation of
any number of individuals, and breakdowns in this framework spell that enjoyment of these
goods will be at best precarious and sporadic. In the case of medicine, the good of a
practice is confirmed not simply in a person being treated successfully on a given day but
that many are cared for everyday. This provision of health care is conditioned by a vast
array of organizations including not only hospitals and clinics but also universities and
research institutes and those insurance corporations and government organs which finance
the operations of all of them. Thus, medicine is never merely a private practice. Its
continued success depends upon the well-functioning of a score of medical, economic, and
political institutions.
As frameworks of human cooperation, practices or institutions set the concrete
conditions for the acquisition of habits and skills. Practices demand the regular and
recurrent performance of certain tasks, and their swift, adept, if not masterful
performance depends upon the acquisition of the appropriate competences. Under the weight
of large numbers of individuals in demand for these services and the complexity of human
organizations, this exigence is only heightened and the demand for the required habits and
skills that much more keenly felt. As a case in point, the provision of health care has
become enormously complicated involving the specialized activities of hosts of individuals
occupying a myriad of roles, from physicians and nurses of various sorts, to teachers,
researchers, and lab technicians, to financial officers and billing clerks. The proper
functioning of these institutions depends upon the competent performance of all these
tasks.
Practices are the concrete contexts for the process of socialization. Tasks are usually
assigned to certain individuals occupying specific roles, and these roles are defined and
enjoy or lack the status and privilege that they do by virtue of the practice. In the case
of medicine, the duties and status belonging to a "doctor" or a
"nurse" are specified in light of the current organization and delivery of
medical care. Furthermore, social relationships are concretely mediated by practices and
institutions. That is, we meet and address one another as occupying certain roles. As a
result, revisions in any one practice affect our interpersonal relations. For example, the
changes in the provision of medical care in only the last couple of decades has radically
refashioned not only the role of the physician but also our relations to individual
doctors. Since then, medicine has become a set of specialities and subspecialities and the
payment for their services more labyrinthine. Not surprisingly, our relations to doctors
have become more hurried and businesslike. These changes have not only affected our
relations to them; they have transformed their own self-understanding. The revisions in
the practice of medicine and the role of the physician has reshaped doctors' understanding
of the nature of their work, of their duties and obligations to their patients, and,
hence, the meaning and purpose of their lives.
Practices not only condition our relations to one another; our interpersonal relations
in turn condition the functioning of these same practices. Practices consist in sets of
mutual expectations, and accordingly, they do function well unless participants can
reliably depend upon each other. It is in this sense that Bellah and his associates
identify trust as vital to the operation of democratic institutions and fear that this
trust is unnoticeably being eroded. (4) Similarly, medical
relationships and the healing which is sought through them are conditioned by the trust
that physicians, nurses, and patients have in each other. The so-called "placebo
effect" bears witness that the personal relations between patients and the ones who
care for them are integral to the healing sought despite its often being viewed as
extrinsic by medical science. Thus our actions involve us in rather complex interactions
and relations with others. What is more, practices, as MacIntyre put it, are enacted
narratives, or, as Bellah and his associates expressed it, institutions are the bearers of
social meaning. (5) Because a culture consists in that
ongoing reflection upon the meaning and value embedded in that society's institutions and
the ways of life they make possible, the process of habituation and socialization is thus
also a process of acculturation. That is, individuals are initiated into the meanings and
values embodied within practices through their participation in them. As Bellah and his
associates put it, institutions are educative: we learn various lessons about life as our
lives are shaped through our involvement in them. (6) By
playing certain roles, individuals take part then in an unfolding drama. Its constitutive
meanings and values are very often recalled in recounting the exemplary achievements and
failures of the past. Thus, these narratives orient individuals historically. The
collective experience of the past provides that moral compass which directs one's future
endeavors. Again, it is through instruction and training that participants come to
appreciate the genuine value of the practice and to criticize and reform its shortcomings.
In so doing, novices are invited to conform their performance to the standards of the best
practitioners of the past. In this way, apprenticeship is an initiation into that ongoing
collaborative enterprise of a community of practitioners and its traditions. The substance
of this moral community and the vitality of its traditions is measured by the vigor of
conversation and debate concerning its professed aims and most deeply held commitments,
and that tradition is alive to the extent the conversation is lively. While individuals
may fail to live up to its highest ideals, they cannot live them down without abandoning
those values which give life its sense and purpose. Indeed, the virtues of individuals,
according to MacIntyre, strengthen and uphold traditions; their vices weaken and undercut
them. (7) Now medicine may be argued to be one such moral
community. (8) The moral fabric of this profession is still
tacitly recognized in those oaths to which new graduates swear their fidelity. Often these
oaths link their future practice with the profession's historic commitment to healing. The
virtues and virtue theory are helpful precisely in elucidating the moral orientation of a
practice. As MacIntyre has argued, the virtues are crucial conditions for the attainment
and enjoyment of goods which exist internal to practices. (9)
Now the virtues belong not to roles but to persons, and their virtues specify the ends
which they desire and to which their activities are directed. However much it is true that
persons are not reducible to some set of qualities and characteristics, persons are
nonetheless revealed by what and who they love and in what and in whom they delight. In
this spirit, the virtues may be conceived not as a permanent achievement or possession but
as characteristics of those who undertake the ongoing quest of living well.
It is in terms of this account of practice that I would like to consider the virtues
and their special relevance to the art of medicine. This is not the place to rehearse
fully Aristotle's treatment of the virtues in his Nicomachean Ethics, (10)
but any examination of the virtues must acknowledge its debt to his account. For
Aristotle, the moral virtues, like habits or skills, are acquired and perfected through
practice. Once they become inculcated, a person's soul is stamped, as it were, and he or
she easily and pleasantly perform those same actions which gave rise to these virtues.(11)
In this way, the virtues are the condition of the possibility of the regular performance
of noble acts. Furthermore, it is only through the acquisition of such skills and virtues
that one comes to appreciate fully the value of the practice itself. It is in this sense
that the exercise of the virtues conditions the enjoyment of those goods which a practice
makes possible. In addition, since a practice gives definition to one's life, the goods
internal to it are integral to the good of one's life as a whole. Consequently, if doctors
were to choose to mistreat patients, they would not only harm them, but they would also
injure the integrity of the practice itself, stain the reputation of other practitioners,
and operate at cross-purposes with their own good.
In this spirit, Edmund Pellegrino and David Thomasma have written eloquently upon the
crucial role of the virtues in good medical care in their articulation of a philosophy of
medicine.(12) When people are sick and therefore vulnerable
and dependent, they are compelled "to trust not just in their rights but in the kind
of person the physician is." (13) Because the
interactions between physicians and patients take place behind close doors, the question
of a physician's integrity is a pressing one. For them, the virtues designate not specific
actions but those qualities which are required for excellent medicine. For instance,
successful interactions between physicians and patients depend upon the honesty of both
parties. Honesty is expected from physicians in informing patients of the truth of their
condition; otherwise, in promoting the good of the body one may in fact harm the good of
the patient. Honesty is also expected of the patient in disclosing to a relative stranger
the intimate and perhaps embarrassing details of one's life; otherwise, the treatment
chosen may not respond to the real complaint. There follows, therefore, a corresponding
need to respect these disclosures as confidential, especially if physicians are to earn if
not retain the trust of those confiding in them. In a similar way, other virtues may be
understood in terms of those qualities which are most conducive to successful clinical
interactions. (14) Pellegrino's and Thomasma's emphasis upon
the need for virtue in medicine is salutary because technical expertise and moral
excellence are all too often conflated. These confusions may be in part spring from the
way in which technical competence is indeed necessary for good medical care. Many of the
injunctions of Hippocrates concerned safeguarding the healing arts from technical
incompetence. In much the same way, Richard Cabot articulated an ethic of medical
competence in the first part of this century. For him, the competent practice of
scientific medicine would be characterized by both diagnostic parsimony and therapeutic
elegance, and this "Cabotean ethic," as Albert Jonsen has argued, may be viewed
as an extension of the Hippocratic concern neither to undertreat nor to overtreat
patients. (15) Technical competence, however, is not
sufficient to ensure good medical care. Physicians may fail their patients by lacking
competence, but the story of Asklepios reminds us that medical competence may also be
wrongly used. The capacity to intervene medically does not give one license and
justification to do so. Rather, expertise still requires moral understanding to guide and
direct its exercise. Such wisdom is implicit in Hippocrates' insistence that his students
use the healing arts well. More recently, the moral context which this wisdom grasps has
been called medicine's "moral center." (16) The
elucidation of this center requires understanding the ultimate purposes of medicine. For
it is in light of the apprehension of these ends that the meaning and value of technical
competence may be discerned. Expertise may be able to answer how something may be done;
wisdom is needed in order to judge whether it should be done. Accordingly, excellent
medical care must be understood in light of the ends of medicine as a practice.
For Pellegrino and Thomasma, the end of medicine is "the good of the
patient." Most immediately, physicians intend to bring about the patient's biomedical
good. For that individual has sought and enlisted the aid of someone who professes to
heal, and in the clinical encounter, a "right and good healing action" (17)
would first seek to restore proper organic functioning. While the medically indicated
course of action may be the starting point for discussions between patients and their
physicians about courses of treatment, it is not the end of their conversation. The
"good of the patient" is rather a compound notion. (18)
In addition to a person's biomedical good, it includes, they argue, the good as perceived
by the patient, the good of that patient as a human being, and the Good, that good which
transcends our good as human and, hence, which pertains to our spiritual destiny. The
right and good healing action is that one which best integrates all these components of a
patient's good.
Medical techniques are, on the other hand, highly specialized activities. The good
intended by them is a partial one, and as in the case for any skill, the end sought is
separate from the actions chosen. Accordingly, medical procedures can be put in service
for base purposes and utilized for the sake of increasing a hospital's revenues or
augmenting a physician's position and privilege. If medicine is practiced simply as a
means for quite other ends, one may legitimately wonder whether that practitioner will act
for the sake of the patient even when no one is watching or and when one's reputation may
suffer. In contrast, medicine ought to intend the complex good of the person as a whole.
Unlike the ends accomplished by human skillfulness, this good cannot be so easily
separated from the activities of health professionals themselves. For medical
relationships are not simply means to the separate end of improved organic functioning.
Since it is not bodies but persons who are treated and healed, medical relationships are
instead integral to the healing which is sought; for we are most often healed through the
caring hands and ministrations of others. In this way, Pellegrino and Thomasma argue that
those dispositions such as honesty and trustworthiness, fortitude and justice, and wisdom
and integrity ought to characterize the practitioners of medicine. (19)
It is with an eye to and in terms of such excellent doctoring and nursing that precepts,
rules, and principles are to be formulated to guide and direct clinical encounters and
transactions.
Sadly many of us have experienced ourselves, however, the effects of individual
irresponsibility or, and even more devastatingly, systemic corruption. Indeed, human
practices themselves may be instituted for the sake of quite vile ends. At issue is not
only the rightness of particular actions but also the legitimacy of a practice itself, not
just fittingness of events recounted in a narrative, but the moral of the story. In this
matter, Lonergan made a helpful distinction between minor and major inauthenticity. (20)
Minor inauthenticity consists in the failure to live up to the ideals of a tradition.
Major inauthenticity, on the other hand, consists in living up to a tradition which itself
stands in need of serious reform if not condemnation. Since this distinction is oftentimes
neglected, virtue theory has its critics. Many have taken issue with MacIntyre's account
of the virtues and the correlative understandings of a practice and narrative. For
example, Kai Nielson has argued that for one could very well strive to live up some ideal
and to embody some virtues and, in doing so, to understand one's life story in terms of
some larger narrative, but these ideals, virtues and narrative may be worthy of great
censure; (21) National Socialists under Hitler's Germany
provide ready examples. Moreover, in the case of medicine, recent criticisms may in fact
be well deserved; for example, the increasingly frequent calls to regulate the medical
profession and to deprive it of its "guild-like" privileges are perhaps brought
upon the profession itself because doctors have acted more like artisans seeking to secure
their own advantage rather than the advantage of the ones they serve. Now to order medical
institutions in the light of the inauthentic practice of individuals so that doctors are
then systematically encouraged to view their livelihood as just another trade is to risk
losing what is special to the profession of medicine. Such neglect and oversight are, for
Lonergan, the sources of corrupted and corrupting traditions. To seek to be authentic to
them is to risk becoming authentically inauthentic.
Given then this account of the virtues and their relations to practices and traditions,
how is the self-correction of traditions of inquiry possible? The assertion of moral
principles here is not sufficient. Moral principles are abstract, and thus, they
themselves do not provide the needed moral insight to guide their application. Principles
by themselves do not instruct us as to whether and how they apply to particular
situations. Finally, appeals to principles are not sufficient to guarantee adherence to
them.
In our brief examination of social practices of medicine, we have already come upon
normative requirements which help define it as a moral art. In the first instance,
normative relations exist between particular goods and goods of order. For the latter make
possible the regular and recurrent enjoyment of the former. Inasmuch as we desire
particular goods not just once but again and again, we must also promote the integrity of
the corresponding goods of order; as Lonergan expressed it, we cannot "consistently
choose the conditioned and reject the condition, choose the part and reject the whole,
choose the consequent and reject the antecedent." (22)
The sweep of our own desiring entails that we go beyond satisfying our individual wants
and needs and concern ourselves with maintaining and enhancing the goods internal to a
practice.
Normative relations also exist between goods of order and interpersonal relationships.
That is, institutions mediate our relations to one another; their proper functioning is
conditioned by them in turn. As instituted forms of cooperation, any social practice
depends upon the degree of trust we have in one another, and they are undermined if we
hold each other in suspicion. We may and should ask whether the concrete operation of a
practice promotes or undermines the kind of interpersonal relations upon which the
practice depends for its long-term viability. In the case of medicine, we may ask whether
persons are genuinely cared for or whether they are dehumanized by the delivery of this
care. In other words, we must examine whether actually functioning goods of order ennoble
or debase us and our relationships through our participation in them.
While we may discern these exigences within institutions and goods of order themselves,
they lead us to consider the relations of these practices and their ends to the larger
ends of human living. Practical wisdom is that habit of the mind which enables one to
choose well not only with respect to a particular domain of human action but in the whole
of one's life. Hence, it orders human practice in ways most conducive to this more
comprehensive end. Often we do understand the ordering of social practices and the
constituting of a human life in narrative terms, and we do this by locating our lives and
stories in terms of our communities and their histories. The basis of criticizing the
stories we fashion is made more difficult for MacIntyre because of his rejection of what
he termed Aristotle's "metaphysical biology." (23)
For it was on the basis of normativity belonging to the nature of things and,
specifically, to human nature that ways of life were evaluated in classical philosophy.
But, what becomes of this basis of criticism if nature is no longer so regarded? What is
needed, it seems, is a reappropriation of nature and its normativity, though in a way that
transposes the metaphysical terms in which it was previously formulated. To retrieve such
a notion of nature is especially crucial with respect to the practice of medicine. For
medicine is one art especially concerned with human beings as natural, and it provides the
context in which we are confronted, and sometimes not gently, with the frailty of our
bodies and the mortality of our physical existence. In seeking to maintain and restore the
organic functioning of an individual, the good ultimately sought is not merely this.
Difficulties arise, however, when we consider the relation of this biomedical good and the
competences of medicine and this higher good we seek. In the recognition of the limits of
organic functioning and perhaps in the absence of more substantive apprehensions of where
our good really lies, we often turn to medicine and its powers in order to overcome not
only our bodily ills but life's misfortunes, not only physical pain but human suffering
itself.
It is here that practical wisdom is needed most of all. For at stake is the
apprehension of the human good and the relation of bodily health to that good. In this
regard, medicine has a special but limited place in the human quest for the good. For in
the interactions of physicians, nurses, and patients, we often face the limits of medicine
and finitude of being human. However, medicine oversteps its competence if it extends its
power and know-how in order to promote not organic health but human well-being. So while
practitioners may in fact desire the "good of the patient" as a whole, they do
so not as doctors and nurses but as human beings. Medicine has no special expertise when
it comes to answering life's great questions, but it is that special context in which
relative strangers recognize their shared humanity and their part in that grander mystery
of life and death.
Accordingly there is a need to renew efforts in fostering collaboration between moral
philosophers and theologians and medical professionals. In the case of this practice, we
need to illumine the exigences immanent to it which must be respected in medicine is to be
practiced well. This task includes explicating the features of sound clinical judgment and
the character of those who make them. It also involves examining the substance and ends of
medicine and reflecting thoughtfully upon medicine's historic role. Such creative
engagement need not be a return to a traditionalist medical practice but may issue forth
in innovative responses to the pressing issues of our day while still being faithful to
medicine's deepest commitments.
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