Medicine As A Moral Practice: Reconsidering The Role Of Moral Agency In The Patient-physician Relationship
bioethical theory, ethics, healthcare, law, medicine, physician-patient relationship, virtue ethics
F Jotterand. Medicine As A Moral Practice: Reconsidering The Role Of Moral Agency In The Patient-physician Relationship. The Internet Journal of Law, Healthcare and Ethics. 2002 Volume 1 Number 2.
In this paper, I reconsider the notion of agency often neglected in contemporary moral theory. More specifically, I examine what the relationship taking place between the physician and the patient entails from a moral perspective. The discipline of medical ethics focuses mostly on the four principles of autonomy, justice, nonmaleficence, and beneficence as the foundational precepts guiding the physician through a consultation. However, the nature of medical practice, i.e., medicine as moral practice, requires a much richer vision of the reality of moral life. The physician, due to his or her special status, is de facto liable as a moral agent because of the fiduciary nature of the relationship with the patient and the kind of knowledge he or she possesses. In other words, although medicine requires scientific and technological knowledge, it is first and foremost oriented towards what Edmund D. Pellegrino calls a "healing relationship" that demands moral accountability.
In the last four decades, the progress of medicine has increasingly challenged ethicists, physicians, theologians, and philosophers to provide justifications of new medical innovations. Some very important issues, such as organ transplants, abortion, physician assisted suicide, genetic manipulation, IVF technologies, and cloning have moved to the center of political and public discussions as never before. In the 1960s, in response to the increasing social concern about the moral implications of these new enhancements in medicine, physicians turned to lay people – mostly theologians, philosophers and lawyers – to consider the morality of particular issues. This shift in prerogative gave birth to the discipline of bioethics. 1 Although many streams of influence shaped this new form of moral philosophy from its beginnings, today’s most dominant form of moral reasoning encountered within the field of bioethics is oriented toward examining quandaries and act analysis. In the following essay I do not aim to critique such methodology per se but rather consider one aspect that is often disregarded in bioethical theory, that is, the importance of agency in moral reasoning and how it relates to medical practice. This is for one specific reason.
Moral reasoning in Western society has shifted historically from an ethic based on virtue (agent-oriented ethics) to an ethic based on principles, duties, social contract, and rules. Edmund D. Pellegrino and David C. Thomasma, in their volumes
An important element must be kept in mind in our analysis. In the criticism formulated against current bioethical theory it is not argued that medical ethics ought to be based uniquely on the concept of virtue ethics. Rather, it is the incompleteness of moral theories within the field of bioethics that is at the core of the discussion. It is argued that the current stress in most moral theories on principles (and casuistry) is unable to give a complete picture of the moral reality of human existence. Consequently, efforts to link a virtue-based ethic with a principle-based ethic must be undertaken. 4 Such efforts have been unsuccessful to this point because, in the end, virtue ethics is relegated to a secondary role. The above statement of Tom Beauchamp and James Childress epitomizes this claim:
The special role of virtues in ethical theory should not be construed as evidence for a primary role, as if a virtue-based theory were more important than or could replace obligation-based theories. The two kinds of theory have different emphases, but they are compatible and mutually reinforcing. 5
The tension in moral philosophy between an ethic construed in terms of principles and technical knowledge and one construed in terms of virtue-agency requires a redefinition of the quest for moral knowledge. Some scholars, such as philosopher Alasdair MacIntyre for instance, argue for the necessity of rediscovering a moral vision that would enable society to envision the moral sphere as a means of contextualizing morality rather than as an arena of the
In what follows I aim to demonstrate the importance of an “agency oriented ethic” in the healing relationship that occurs between the physician and the patient.
We might be tempted to conceive medicine as a discipline the purpose of which is uniquely the advancement of the
Medicine is not only a science; it is also an art. Science is primarily analytic, art primarily synthetic. Medicine is likely to remain an art, however hard we may try to make it more and more scientific, and however much we may attempt to master its scientific contents. For medicine deals not with impersonal atoms, elements, plants with tropisms, or animals with instinct mechanisms, but with humans with a ‘soul’ and ‘free will.’” 9
It is precisely because medicine deals with human beings that morality occupies a fundamentally important place in medicine. Indeed, the art of medicine is a
First, medicine is a form of
Moreover, medical research deals with universal phenomena, empirically tested and verifiable, but medical practice is an attempt to apply empirical data to particular patients who may or may not respond favorably to the laws of medical science. While the physician depends on scientific information for the elaboration of a diagnosis, he or she ultimately processes them according to an “internal dialogue” conformable to “the canons of the liberal arts.” 12
These two aspects of medicine (relationship and interpretation of scientific data) suggest, as asserted by Pellegrino and Thomasma, that medical practice entails a moral aim as its ultimate purpose.
Medicine is a process aimed to an action taken in the interest of the specific patient. Its chief aim is not discovery of the laws of nature. The end of medicine, its justifying principle, is, in the final analysis, a moral one: the “good” of a person seeking help. The choice of what ought to be done turns on questions of value, morality, and interpersonal dynamics. These questions can be studied scientifically, to be sure, but they cannot be defined by scientific considerations alone. 13
Although Pellegrino’s and Thomasma’s contention is significant in our reflection, it nevertheless raises two important issues. First, the content of the moral undertaking of medicine still remains unspecified and uncertain especially in our pluralistic society. How ought we determine which morality should be applied? On what basis and who should ultimately decide the criteria for medical practice? Those questions are certainly at the center of the medical ethical discourse and are not easily answered. Although, I will not try to answer those important issues, I will assert that the morality of Western medicine is closely bound to Hippocratic medicine and therefore any attempt to specify the morality of our traditional medicine must be considered in the light of the Hippocratic corpus.
Second, I will argue that the two aspects of the practice of medicine – the healing relationship and the interpretation of empirical data – imply an ethic virtue, that is, an ethic emphasizing the notion of moral agency in which a person makes the correlation between agency (reasons, motives, intentions) and actions. The character of an individual is one aspect of his or her self that determines an action through “a mode of social existence.” 14 Hence, if this description of what constitutes the moral reality of the self is correct, it follows that the medical relationship depends on the doctor’s ability to implement scientific knowledge according to moral values inherent in his or her self. Indeed the relational and interpretative character of medicine represents the moral nature of medical practice. 15 Medicine “is an intrinsically interpretative practice that must always be practiced under the conditions of uncertainty [the uncertainty of each illness’ narrative]. Accordingly, patient and physician alike bring virtues (and vices) to their interaction that are necessary for sustaining therapeutic relationships. 16
The close relationship between the agency of the doctor and the act of interpretation of medical facts requires the crucial role of virtue ethics in medical practice for two main reasons. First, on the medical level, the type of relationship between the doctor and the patient implies that each participant engages his or her moral discernment (as a moral agent) in order to find the best prognosis (action) for a specific medical issue. The doctor must exercise what Stanley Hauerwas calls the “wisdom of the body” which entails the manifestation of some character traits (or virtues) intrinsic to medical practice. 17 Second, each illness in itself represents a kind of narrative that demands a reconsideration of the notion of virtue and character – or agency. Because each disease implicitly carries the particularities of the patient’s health history, the physician has to use moral and interpretative discernment during the consultation in order to finalize a diagnosis for the best interest of the patient.
This capacity to perceive the good for the patient in the healing relationship entails the idea that within the practice of medicine there are certain standards of excellence inherent in such human activity. To that we shall now turn.
The Internal Goods and Standards of Excellence Intrinsic to Medicine
Medicine as a form of human activity implies a reliance on
Finally, by virtue of the kind of covenant established between the patient and the physician, there is an implicit
I would like to thank Professor Elizabeth Heitman who reviewed and made helpful comments on an early draft of this article.