The Virtuous Physician: The Role of Virtue in Medicine: 114 (Philosophy and Medicine)

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Contents

  1. Philosophy of Medicine
  2. Diagnostic error, overconfidence and self-knowledge | Palgrave Communications
  3. II. THE UNITED STATES IN THE TWENTY-FIRST CENTURY
  4. The Role of Virtue in Medicine

His work represented "the emergence of medical ethics as a medical school subject, especially at religiously affiliated schools" Burns, , p. In the Catholic Hospital Association issued Ethical and Religious Directives for Catholic Health Facilities revised in and , which obliged all physicians and health professionals working in Catholic institutions to follow Catholic moral tenets with regard to a number of specific medical procedures U. Catholic Conference. Catholic reflection on medical moral issues continues in the Linacre Quarterly, published by the National Federation of Catholic Physicians' Guilds since The Catholic tradition, in its doctrine of natural law , has affirmed that moral questions can be analyzed from a philosophical viewpoint, without explicit reference to revealed theological truths.

Thus, common ground can be found with those who do not share the Catholic faith. This somewhat nonsectarian approach has allowed Catholic analysis of problems to have a significant influence on the intellectual development of secular bioethics. The Protestant denominations, while not producing a detailed analysis of medical-moral problems, had taken positions on such questions as suicide, euthanasia, abortion, and contraception.

He offered reflective, humane, literary, but unsystematic commentary on such problems as truth telling, prolongation of life, and euthanasia as the era of medical technology was opening.

Philosophy of Medicine

Four years later, Episcopal theologian Joseph Fletcher published the groundbreaking and prescient study Morals and Medicine. Fletcher's work was the first to emphasize the patient's rights as the center of an ethics of medicine and to argue "the ethical case for our human rights … to use contraceptives, to seek insemination anonymously from a donor, to be sterilized and to receive a merciful death from a medically competent euthanasist" p. He strongly asserted the patient's right to be told the truth about his or her diagnosis and prognosis. Fletcher's book is the pioneering work of the new medical ethics.

Sixteen years later, Methodist theologian Paul Ramsey produced the foundational work of bioethics, Patient as Person. Ramsey, professor of religion at Princeton University , took the unusual step of spending a year in intense dialogue with physicians, scientists, and students at Georgetown University and immersing himself in the clinical activities of the Georgetown University Hospital. Patient as Person, first delivered as the Beecher Lectures at Yale University in , examined questions, such as organ transplantation, experimentation with human subjects, and the use of life-supporting technologies, that had not been on the agenda of previous commentators on the moral aspects of medicine.

Although he spoke from a very different theological ground than did Fletcher, Ramsey also placed the freedom and rights of the patient at the center of his ethic but subsumed patients and physicians within the scope of a theologically defined covenant.

Diagnostic error, overconfidence and self-knowledge | Palgrave Communications

Despite the theological tone and language of Ramsey's work, its cogent analyses of issues such as consent were widely influential Ramsey, b. At about the same time, James Gustafson of Yale Divinity School produced thoughtful essays on the implications of medical and scientific advances. In the Park Ridge Center for the Study of Health, Faith, and Ethics was founded under the auspices of the Lutheran Hospital Association to foster religious reflection on the issues of bioethics.

The center has published a fine series of volumes describing the teachings about medicine and morality of major Christian denominations and other world religions Marty; Vaux. The distinctive features of modern bioethics begin to appear in Fletcher and Ramsey: attention to the effects of new technologies, affirmation of the centrality of the patient as free and responsible agent, and the invocation of the concepts and method of moral analysis from the classical disciplines of theology and philosophy.

The Jewish faith has an ancient tradition of reflection upon questions of life, death, health, and medical care. Issues in medical ethics, such as allocation of scarce resources, risk—benefit evaluation, quality of life, abortion, contraception, and indications of death, are discussed in great detail in Talmudic literature. The doctoral thesis of Immanuel Jakobovits, published in as Jewish Medical Ethics, drew these teachings together and brought them into contact with modern scientific advances. In so doing, Jakobovits gave a distinct identity to a field of study that had not been previously singled out in Jewish scholarship.

The influence of moral philosophy came rather late to the analysis of medical-moral questions. Although the first AMA Code of Ethics was strongly influenced by the English physician Thomas Percival — , who was affected to some extent by the philosophers of the Scottish Enlightenment , American philosophers paid scant attention to these questions. In Chauncey D. Leake noted in his edition of Percival's Medical Ethics that all of the classic codes represented "medical etiquette" or the tenets of professional courtesy rather than medical ethics. In words that predict the bioethics movement of the s, Leake called for a medical ethics that would bring the systems of moral philosophy to bear on the problems of medical practice.

He undertook to do this in a dialogue with philosopher Patrick Romanell Leake and Romanell. Three decades later, moral philosophers were important figures in the elaboration of ethics of healthcare. Secular academic philosophy did not find it easy to approach the practical problems posed by evolving science and medicine. In the s philosophical ethics was struggling with the diverse theoretical challenges of naturalism, relativism, utilitarianism, Marxism, linguistic analysis, and positivism; hardly any attention was paid to the analysis of actual moral problems.

This began to change in the s as students vociferously raised questions about the moral legitimacy of the war in Southeast Asian and racial discrimination with their professors of moral philosophy. Interest in practical philosophy slowly appeared within academic philosophy. The questions of life and death raised by new technologies began to intrigue some philosophers. In Nicholas Rescher wrote an early article on the allocation of "exotic medical lifesaving therapy," such as dialysis and transplantation.

Medical ethics began to be taught as an undergraduate philosophy course for which textbooks were produced Gorovitz et al. Daniel Callahan, trained in the analytic philosophy tradition at Harvard University , realized the ethical dimensions of the new medicine and in founded, with psychiatrist Willard Gaylin, the Institute of Society, Ethics, and the Life Sciences , later renamed the Hastings Center.

Although slower to enter the field of practical ethics than the theologians, philosophers such as Baruch Brody, K. Danner Clauser, Tom Beauchamp, and Stephen Toulmin made significant contributions to the methods and substantive analysis of biomedical problems. Indeed, as Toulmin has claimed, "Medical ethics saved the life of philosophy," imparting an intellectual vitality and moral urgency to a field that had turned from the moral concerns of personal and social life to arid speculation.

Legal scholars were also prominent in the early years of bioethics. John Noonan wrote perceptively on abortion and contraception. As the issues surrounding death and dying became prominent, particularly with the Karen Ann Quinlan case in , lawyers became deeply involved, because law has always taken a serious interest in the determination of the causes of human death.

Similarly, the evolution of the doctrine of informed consent has been strongly influenced by jurisprudence and judicial opinion. It is difficult to distinguish between the lawyer and the bioethicist in such figures as George Annas, John Robertson, Alexander Capron, and William Winslade. Indeed, one of these scholars, in a book, asserted, "American law, not philosophy or medicine, is primarily responsible for the agenda, development and current state of American bioethics" Annas, p.

II. THE UNITED STATES IN THE TWENTY-FIRST CENTURY

Many physicians and scientists have become interested and adept in bioethics. As the field developed, however, the majority of its practitioners came from theology and philosophy; relatively few physicians have devoted themselves to scholarly productivity. They bring to their contributions the sense and sensitivity of the practicing physician.

Although ethics was once taught in American colleges as the summit of the curriculum often by the president of the college , as the twentieth century opened, ethics had retreated from that academic prominence to a refined and remote subspecialty of philosophy. Many believed that ethics was "caught" rather than taught. Medical ethics, it was said, was best conveyed to medical students by the example of prominent physicians, such as William Osler, as well as by the role models of the leading teachers in individual medical schools.

Their lives and writings were common touchstones of discussion. Moreover, resolution of ethical issues tended to emphasize the need for the excellent overall character and reputation of the physician, that is, an ethics of virtue. This emphasis on the good intentions of the physician was congruent with the model of practice then supported by the AMA—the independent practitioner in contract with the individual patient.

Medical jurisprudence, the study of the relationship between medical practice and the law, had been taught in American medical schools with some regularity during the nineteenth century. No course on medical ethics as such is known to have been offered until the late s, except in the Catholic medical schools. The curriculum of the first known course in a secular medical school, offered by Park White at Washington University School of Medicine, St.

Louis, in , included discussion of group practice, consultations, relations with other practitioners, quackery, eugenics, euthanasia, and birth control Burns, In the AMA recommended that medical ethics be made part of the medical curriculum. By it was reported that 43 percent of the sixty-seven American medical schools offered a course in medical ethics, most of these courses in the required curriculum.


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Approximately the same level was maintained through the s, although course time was stretched to cover other subjects, such as medical sociology and economics, and it is unclear what topics were covered as medical ethics. During this era, Richard Cabot, who was both professor of medicine and professor of social ethics at Harvard University, was a dominant figure.

He stressed the importance of personal integrity and honesty in the physician, as had the earlier professional ethics, but he placed this within the evolving framework of scientific medicine: Integrity must be manifested in clinical competence, the primary ethical obligation of the practitioner Burns, As the century progressed and the social and psychological sciences spread in collegiate education, discussion of the art of character development became increasingly over-laid with psychological and psychiatric analysis of the physician's character.

Indeed, in the s and s, the Freudian model of psychological dynamics and of the doctor—patient relationship became prominent in the analyses of the virtues of physicians Binger. Meanwhile, the increasing midcentury confidence in the social sciences tended to displace ethics terminology with concepts of "professional development," "human engineering," and so forth, sometimes even denigrating the admonitions of traditional morality as no more than "taboos.

Medical Ethics, History of the Americas: II. The United States in the Twenty-First Century

In the secular climate of that time, any formal acknowledgment of ethics was suspect: Even the National Endowment for the Humanities, which eventually became a strong supporter of bioethics, originally excluded ethics from the list of the humanities whose study it would fund. Thus, ethics was rarely taught in higher education and even more rarely in medical education. This hiatus in the teaching of medical ethics during the s may be seen as a prelude to the bioethics movement, in which neglected ethical questions forced their way back into the consciousness of the profession and the public alike.

The Role of Virtue in Medicine

The first national conference on the teaching of medical ethics was held in under the sponsorship of the Institute of Society, Ethics, and the Life Sciences and the Columbia University College of Physicians and Surgeons. By this time, out of medical schools, only three required an ethics course and only thirty-three offered ethics as an elective Veatch, Gaylin, and Morgan.

In the decade that followed, the number of schools providing organized teaching of ethics increased, and faculty members, often philosophers and theologians, were appointed. The content of the course shifted from the traditional topics, such as truth telling, confidentiality, care of the poor, care of the dying, and relations among practitioners, to the newer problems raised by technology and the social setting of modern medical care.

In ninety-five American medical schools reported that they required a course in medical ethics, and the Association of American Medical Colleges strongly urged the inclusion of ethics in the curriculum Bickel.

The Morality of Medicine

Although medical students received little formal instruction in ethics, nursing schools developed a strong tradition of ethics teaching. Several major works on ethics were published by nurses at the turn of the century, notably Nursing Ethics by Isabel Hampton Robb Although her text is marked by a stern and self-sacrificing message to nurses, it includes sensitive discussion of many aspects of nurse—patient and nurse—physician relations.

Textbooks on nursing ethics published in the first two decades of the century went through many editions before fading from popularity in the s and s. Notable among the authors were Charlotte Aikens and Thomas Verner Moore, whose books made extensive use of case studies.