The need for virtue ethics

The traditional view of medical ethics as a collection of prescriptions and prohibitions, so-called ‘code ethics’, such as the General Medical Council's guidance Good Medical Practice8 does not describe how these rules are to be followed, or even clearly articulate why they should be, apart from creating trust. I do not discount the value of trust,9 but the deeper question of how such codes promote the goals of medicine remains unexplored. Code ethics is incoherent unless placed within a comprehensive theory of human morality and is described as ‘the archeological ruins of a doctrine of medical virtue’.10 Ethics is also depicted as tools to be picked up or discarded depending on the situation at hand. We now have ‘medical ethics for dummies’11 and ‘toolkits’ for dealing with ethical dilemmas.12 These may be valuable and useful to busy clinicians, but they convey the notion that ethics is a simple acquisition of technical skills, rather than a more demanding (and life-long) requirement to develop, hone and practise the virtues, to take responsibility as moral agents and to fully acknowledge the humanity of others. Ethics-as-tools renders moral thought and action extrinsic to individuals’ identity.13 Furthermore, rules and tools simply cannot address core features of clinical ethics—the dynamic relationships between clinicians and patients, the desirable attributes of clinicians or how emotions and reasons are intertwined at the clinical encounter and in clinical–ethical decision making. They ignore the indeterminacy and contingency of life and fail to take into account how institutional culture—‘the hidden curriculum’13—or the sociopolitical zeitgeist can influence ethical humane practice.14

Compassion, in brief, cannot be readily accommodated within a utilitarian, Kantian or even rights-based ethical theory. In contrast, it fits naturally within neo-Aristotelian virtue ethics15 and is gaining support in medical ethics discourse.16 ,17 The healing relationship can provide the phenomenological grounding for a normative ethic based on the virtues.18 Medicine, within this paradigm, represents a social practice with complex cooperative activities that yield goods internal to the practice. These, unlike external goods, enrich the whole community and are achieved by the flowering of the virtues. Personal identity and integrity are founded on a life narrative that we tell ourselves and that we share with others as part of a larger shared tradition.

Moral reasoning and the evasion of emotion

Another oft-stated goal of medical ethics, proficiency at moral reasoning, although important, does not necessarily translate into ethical behaviour.19 Between the intellectual problem solving in the abstract and facing the concrete reality of persons, there may be a disconnect.20 Bridging this divide requires a dynamic interplay between detachment and engagement, cognition and emotion and a capacity for self-awareness and honest reflection.21 Aptitude in moral reasoning may even sometimes correlate with skills in deception.22 Deliberative decision making can make us less altruistic and compassionate.23 This leads to another lacuna in much of the discourse and teaching of medical ethics: the emotional dimension.24 In this context, emotions are often viewed as a hindrance, rather than an aid, to making sound decisions.25–27 The revival of virtue theory, which incorporates emotions within rational ethical decision making, the inclusion of philosophical emotion theory28 and neuroscientific knowledge29 in clinical ethics are thankfully reversing this trend.30–32

The neglect of everyday ethics

Medical ethics tends to favour the dramatic or complex ‘dilemmas’. While recognising that medical ethics needs a broader canvass,33 I advocate for a greater focus on the multiple encounters between clinicians and patients (and their families) that form the bulk of medical ethics. ‘Microethics’ is ‘not just the terrain of rare spectacular cases involving heroic decisions’, but the field of ‘day-to-day communication and structured, complex interactions, of subtle gestures and fine nuances of language.’34 Ethics emerges from a process of dialogue involving philosophy, personal values, cultural assumptions and political and religious beliefs. Within this dialogue new meanings are created and individuals define who they are. During conversations between doctors and patients, ethical decisions are interwoven with technical decisions in a dynamic iterative process. This perspective shifts the focus from abstract discourse to an exploration of the messy world of intersubjectivity within which moral decisions are made. Clinicians need to connect with the lived experience, the ‘lifeworld’ of their patients.35 ‘Conversational ethics’ values and recognises our social embeddedness and the moral significance of the individual and of reflection.36 ,37

Suffering

It is troubling that patients and laypersons consider the relief of suffering to be one of the primary ends of medicine, yet the medical profession neglects it.38 This neglect is attributed to the mind–body dichotomy in medical theory and practice. Furthermore, the dichotomy is asymmetrical, with the sciences viewed as ‘hard’ and the humanities ‘soft’, creating a ‘double-blinded dichotomous clinical gaze’.39 We are social, embodied creatures and this can predispose us to suffering. Persons suffer from what they have lost of themselves. Cassell's rich multilayered concept of suffering relates this loss to any facet of personhood: one's life story, plans or hidden dreams, relationships, particular roles or spirituality. Suffering is experienced with the lost capability to do enjoyable or routine activities or to participate in the political realm. ‘The body is no longer seen as a friend but, rather, as an untrustworthy friend’.40 The ‘latent’ role of the clinician is to ‘lend strength’—show solidarity—apart from easing the burden of illness with medical or surgical interventions.41

Existential neglect

A large empirical study in a hospital setting revealed how the biomedical focus over-rode important existential aspects of the consultation—the personal and human dimensions of the patients’ suffering, their feelings and meanings—were systematically excluded. The doctors were courteous, but showed little interest or curiosity about the patients as individuals. Rather, patients were treated as medical objects and often more attention was paid to the computer than to them. The researchers describe this disregard for the patients’ humanity as a ‘moral offence’.42 A study in general practice yielded similar findings with the patients’ lifeworld often blocked or ignored.43 Yet creating ‘caring conversations’ which recognise the patient as person does not require added time or effort, but greater attentiveness.44 Patients’ narratives describe existential neglect and how this intensifies suffering. Sweeney,45 faced with a terminal illness, poignantly relates how fellow doctors ‘showed a hesitation to be brave’ and lacked a ‘willingness to accompany him in the kingdom of the sick’. He describes how the transactional aspects of his care were timely and technically impeccable, but that the relational aspects were often sadly lacking, leaving him feeling abandoned. Carel46 describes a nurse's cold indifference to her distress when discovering that her lung function has undergone a rapid decline. She does not ask for ‘ feel-good chatting’ but wonders if the encounter has to be ‘so impersonal, so guarded’—cannot some ‘genuine care’ be brought in? The lament ‘Why am I not treated as a person?’ is almost universal. The answer is complex, but suffice to say that we can only claim to be ‘doing good medical ethics’ by responding well to both medical needs and existential suffering.47

Some counterarguments

Compassion receives a mixed reception in the context of medical ethics. On the one hand, it is championed as the basis for medical education,31 but on the other hand, some authors reject it as an obligatory element of ethical clinical practice.53 Compassion is like a flickering flame: a number of factors, explored in depth elsewhere, can extinguish it.47 Although we need virtuous organisations for its flourishing that does not mean morality is entirely socially situated or the virtues are fictional.54 Some argue that etiquette may suffice for good medical practice.53 ,55 Certainly, adherence to etiquette could ensure courtesy and may even foster the habituation of some virtues, but will fail to address existential issues, or give guidance for responding to distress.41 ,56 Contrary to broadly-held belief, the enactment of compassion is rewarding, not depleting. ‘Compassion fatigue’ stems from a lack of self-compassion and unbalanced, unreflective emotional empathy (with which it is often confused), not compassion.57 There is, Aristotle would argue, a ‘golden mean’.58 Compassion alone is insufficient for healing and needs to be unified with the other virtues, particularly discernment, temperance and phronesis or practical wisdom.58