Edmund D. Pellegrino

Toward a Virtue-Based Normative Ethics for the Health Professions

Virtue is the most perdurable concept in the history of ethics, which is understandable given the ineradicability of the moral agent in the events of the moral life. Historically, virtue enjoyed normative force as long as the philosophical anthropology and the metaphysics of the good that grounded virtue were viable. That grounding has eroded in both general and medical ethics. If virtue is to be restored to a normative status, its philosophical underpinnings must be reconstructed. Such reconstruction seems unlikely in general ethics, where the possibility of agreement on the good for humans is remote. However, it is a realistic possibility in the professional ethics of the health professions where agreement on the telos of the healing relationship is more likely to arise. Nevertheless, virtue-based ethics must be related conceptually and normatively to other ethical theories in a comprehensive moral philosophy of the health professions.

Toward a reconstruction of medical morality

At the center of medical morality is the healing relationship. It is defined by three phenomena: the fact of illness, the act of profession, and the act of medicine. The first puts the patient in a vulnerable and dependent position; it results in an unequal relationship. The second implies a promise to help. The third involves those actions that will lead to a medically competent healing decision. But it must also be good for the patient in the fullest possible sense. The physician cannot fully heal without giving the patient an understanding of alternatives such that he or she can freely arrive—together with the physician—at a decision in keeping with his or her personal morality and values. In todays pluralistic society, universal agreement on moral issues between physicians and patients is no longer possible. Nevertheless, a reconstruction of professional ethics based on a new appreciation of what makes for a true healing relationship between patient and physician is both possible and necessary. * Originally published in The Journal of Medical Humanities, 8(1), Spring/Summer 1987. Reprinted with permission from Springer Science and Business Media.

Clinical Medical Ethics

Clinical medical ethics is a new medical field, developed and named in the 1970s, that helps patients, families, physicians, and other health professionals reach good clinical decisions by taking into account both the specific clinical situation and the patient’s values and preferences. The field of clinical medical ethics is much broader and encompassing than its component of ethics consultations; it applies across the entire spectrum of routine, daily medical practice. For clinicians today, applying clinical medical ethics standards in patient care is not an elective matter but rather has become the standard of care in the United States and is mandated legally and professionally. For example, in caring for their patients, physicians must apply clinical ethics standards such as speaking truthfully to their patients, negotiating informed consent for clinical decisions, protecting patient confidentiality, assessing the patient’s decisional capacity, and, when appropriate, working with surrogates or proxies to reach clinical decisions. In contrast to the 1970s, clinical medical ethics discussions have now become a part of everyday clinical discourse and are used to reach clinical decisions in outpatient and inpatient settings across the country. The goal of clinical medical ethics is to improve patient care and patient outcomes. The MacLean Center for Clinical Medical Ethics at the University of Chicago is one of the leading clinical medical ethics programs in the world and has helped to create, name, and develop this new field.

The Healing Relationship: The Architectonics of Clinical Medicine

In his devastating novel of the destructive force of human passion, the Spanish philosopher-novelist, Miguel de Unamuno y Jugo records this conversation between the painter, Abel Sanchez, and the doctor, Joaquin Monegro: The habit of giving titles to paintings is peculiar to the literati; something like the doctor’s habit of giving names to diseases they can’t cure. And whatever told you that the real purpose of medicine was to cure illnesses? What is it, then? Knowledge, a knowledge of disease. The end of all science is knowledge. I had thought it was knowledge to cure. What use otherwise of having tasted the fruits of good and evil, if not to free ourselves of the evil? And the end of art, what is it? That is its own end; it contains its purpose. It is an object of beauty and that’s enough ([6], p. 366).

Teaching Medical Ethics: Some Persistent Questions and Some Responses.

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The nature of bone carbonate.

Models of the bone salt and its synthetic analogues have been strenuously, and sometimes emotionally debated since the late nineteenth century. The main protagonist in the drama is the ubiquitous CO3=ion whose role has never been clearly understood. Initially regarded as an essential part of the calcium phosphate crystal complex, it came to be dubiously designated as a separate phase CaCO3, as an adsorbed ion, or even as a mere contaminant. More recent studies provide evidence that the original impression may be more nearly correct. Of particular interest in defining the role of CO3= in bone are the reactions involved in the formation of CO3-apatite under conditions approximating the physiological. These observations suggest that the synthesis of bone mineral involves hydrolysis of an initial acidic calcium phosphate precipitate to octacalcium phosphate, which is then converted to octacalcium phosphate carbonate (OCPC) by virtue of the replacement of PO4 identical to (HPO4=) by CO3=. OCPC satisfies many criteria for a satisfactory definition of the nature of the bone mineral. It can explain its solubility behavior and the intrinsic relationship between PO4 identical to (HPO4=) and CO3=, the normal variations in bone composition, the sequence of events in bone mineral maturation, and the loss of CO3= under normal and pathological conditions.

The Virtuous Physician, and the Ethics of Medicine

In the opening pages of his Dominations and Powers, Santayana asserts that “Human society owes all its warmth and vitality to the intrinsic virtue of its members” and that the virtues therefore are always “hovering silently” over his pages ([32], p. 3). And, indeed, the virtues have always hovered over any theory of morals. They give credibility to the moral life; they assure that it will be something more than a catalogue of rights, duties, and rules. Virtue adds that extra ‘cubit’ that lifts ethics out of its legalisms to the higher reaches of moral sensitivity.

The Anatomy of Clinical Judgments

Richard Cabot, one of the most celebrated of American diagnosticians, labelled his attempts to anatomize the process of diffential diagnosis “a very dangerous topic — dangerous to the reputation of physicians for wisdom. … Physicians are naturally reluctant on such matters, slow to put their thoughts to paper, and very suspicious of any attempts to tabulate their methods of reasoning” ([8], p. 19).

Beneficence, Scientific Autonomy, and Self-Interest: Ethical Dilemmas in Clinical Research

The ethics of clinical research may be viewed from three different perspectives: the process of acquiring new knowledge, the moral use of the knowledge acquired, and the ethics of the investigator seeking this knowledge.

Pulmonary Alveolar Microlithiasis—A Family Study

Excerpt Pulmonary alveolar microlithiasis is a rare disorder characterized by small calcific concretions in the alveoli. The classical description of the disease was given by Harbitz (1) in 1918, a...