Catholic Medical Quarterly Volume 63(4) November 2013

A Brief Sketch of the Ethical Theories used in Medical Practice

Dr Julia Hynes

Introduction

At medical school the student may be introduced to a number of ways of approaching an ethical dilemma in preparation for clinical practice. These approaches may include the four principled approach, (non-maleficence, beneficence, autonomy, justice),[1] the four quadrant approach, (medical indications, patient preferences, quality of life, and contextual features),[2] the structured case analysis model by Bowman which refers to the virtuous healthcare practitioner or Seedhouse’s ethical grid.[3] This grid consists of a set of 20 tiles upon which are inscriptions to denote different ways the doctor may proceed, (for example keep promises, minimise harm, tell the truth, and do most positive good). One doctor or a clinical team may brainstorm to examine a particular ethical dilemma by eliminating or adding tiles until the key aspects of the issue are represented by the remaining few key tiles. The foregoing are just a sample of the ethical approaches a healthcare professional may adopt in practice and it may be argued that there are three main moral theories from which these approaches may, in part, spring, namely virtue ethics, deontology and consequentialism. [4]

Consequentialism

In simplistic terms, a consequentialist will find that the best way forward resides in the best outcome or consequences. In other words attention is focused on the end product as opposed to what means is used to achieve this end. The ‘means’ to achieve this end may be viewed as ethical or unethical. Let us consider two examples. Firstly, a patient with cancer has the option of enduring what may prove to be extremely unpleasant therapy (chemotherapy or radiotherapy) yet the end result may mean the absence of cancerous cells and many years of life. Is this process ethical? One could consider the burden of treatment against the end result in order to reach a decision.

Secondly, let us consider the end result of the IVF process. The consequences of this process is the conception of a child, which would be a wonderful outcome for the parents; and the child, in this situation, will no doubt grow up in a loving family. However this process usually produces surplus embryos which may be donated or experimented upon. If these embryos are not used in this way, or are not implanted into the mother’s womb, then the embryos must usually be destroyed after ten years in accordance with HFEA (Human Fertilisation and Embryology Authority) guidelines.[5] Is this process ethical? If one’s values and principles are encapsulated by Catholic theology the answer would be in the negative for a variety of reasons not least because it may involve the destruction, or cryopreservation (freezing), of embryos.[6]

Utilitarianism, a branch of consequentialism, ‘consists of consequentialism together with the identification of the best state of affairs with the state of affairs in which there is most happiness, most pleasure, or the maximum satisfaction of desire’.[7] The right end of any utilitarian act seeks the greatest happiness of the greatest number according to Jeremy Bentham (1748-1832), the classical Utilitarian. On the surface this sounds plausible but in practical terms it means, at times, there is little room for the individual voice and so the person, as an individual, may not be heard.

On the surface utilitarianism sounds plausible but in practical terms it means, at times, there is little room for the individual voice and so the person, as an individual, may not be heard.

The term ‘happiness’ is also open to different interpretations: utilitarianism, correlates pleasure with happiness and the absence of suffering, therefore one may argue that in such terms a person is happy when their desires or appetites are met.

St Thomas Aquinas, a doctor of the Catholic Church, (1225-1274), would, most probably, have found fault with utilitarian thought in this regard. For the person, in Benthamite terms, pleasure is confined to the satisfaction of the appetites. Every individual may encounter numerous dilemmas concerning one’s appetites on a daily basis. In Thomistic terms, in the sense appetite (where the object of desire is perceived by the senses as opposed to the intellect)[8] a desire may be of great strength, for example a person suffering from alcoholism may desire alcoholic beverages frequently. How one responds to one’s desires, especially in the chosen example, will either enable both personality and life to blossom or else authorize its destruction.

St Thomas offers us the virtue of Temperance, within his moral schema to direct us. This virtue is not an instant solution to our misdirected desires but it will enable us to practice a measured response to one’s desires/appetites, and promote the promise of healthy habits and in turn gain a measure of happiness.  His treatise on happiness, and his entire ethical theory, may be summarized in the short sentence: ‘Virtue’s true reward is happiness itself......' [9]

Virtue’s true reward is happiness itself
Aquinas

Thomistic happiness, in this life, is a by-product of another activity. Let us take intellectual activity to demonstrate this point. The medical student will labour for a number of years to become a doctor. Such labours will inevitably involve angst to some degree but much fruit is harvested from such endeavours not least the delight felt on graduation day and Thomas reminds us that happiness ‘cannot be without a concomitant delight’.[10]

As utilitarianism links pleasure with happiness, and the absence of anguish, one may therefore conclude that in such terms a person is happy when their desires or sense appetites are met. In this regard it could be argued that Bentham’s notion of happiness denies the intellect, as it concentrates on the fulfilling of the sense appetites and in so doing, may deny a significant part of the person, namely the intellectual appetite, that part of the person which separates us from brute animals.[11]

St Thomas, on the other hand, maintains that true happiness comes from good character and the virtues. In his treatise on happiness, Thomas endeavours to relate happiness to the attainment of the virtues. Thomistic happiness cannot be found in any external goods but only, ultimately, in the contemplation of truth. If life contains no happiness (pleasure) as perceived by the utilitarian he/she may opt for assisted suicide (physician or family assisted) to end the suffering. One may deeply and fully appreciate a person’s wish to bring an end to their own suffering or that of someone whom they love. But however difficult things may be, St Thomas teaches us to view suffering as a means of bringing the patient closer to God under the condition that the patient accepts God’s help and does not turn to despair (the vice attached to hope); and alienate oneself from oneself and in turn from God. The struggles one may endure along this path cannot be underestimated and must not be negated even in discussion. However if the ultimate goal of the Christian (or the Thomist) is to attain the vision of God and the very essence of human happiness is to know God, then by not deliberately cutting life short due to suffering is an acknowledgment that God has ordained each of our days. By accepting this path the Thomist in turn moves closer to that ultimate goal, to happiness.

Deontology

The second moral theory which I will discuss briefly is Deontology, which in itself pertains to a duty-based schema of ethics. Immanuel Kant (1704-1804) 18th century philosopher is thought of as one of the great deontologists. In the practical clinical situation this means, in broad terms, that the moral acts of the doctors are to be judged in terms of their conformity to rules, duties or obligations. Broadly speaking, the doctor would attend to each patient with the same set of rules, ones which are pre-set and unbreakable and there is no room for manoeuvre in varying situations. The difficulty here, it may be argued, is that given that each patient is a unique person with individual health needs, one set of rules will inevitably not suit every patient. Michael Stocker, contemporary ethicist, rejects both Utilitarianism and Deontology on this basis. He maintains that these views take the focus away from the person and transfer the light of importance to principles, rules and obligations. [12] St Thomas would in no way advocate a morality based solely upon rules.[13] The evidence we can supply to back this assertion can be found in his virtue of prudence which encompasses the associated virtue of Gnomê. Thomas recognizes that there is no concrete rule book since all situations are different. Therefore, in the unusual situation, he would support the use of the associated virtue of Prudence namely, ‘Gnomê’, which simply means ‘to wit or judge’. This associated virtue is invoked when judging a situation that is unusual and the rules normally used do not suffice.[14]

Virtue Ethics

The third and final moral theory I will outline is known as the virtue based approach: and I would argue, after paying an intellectual debt to Aristotle, finds its deepest expression in the writings of St Thomas Aquinas, 13th century philosopher and theologian. The moral philosopher Elizabeth Anscombe may be lauded for the revival of virtue ethics. Contemporary philosophers and bioethicists such as Alasdair MacIntyre, Leon Kass, and Edmund Pellegrino would advocate a virtue based approach in medical practice.

Conversely, virtue in medicine takes something of a back seat in the writings of Raanan Gillon, Tom L. Beauchamp and James F. Childress. William Frankena offers front stage to decisions and principles. Robert Veatch goes to the extreme of this point of view by denying the existence of a virtue-based approach in medical ethics. [20]

The Four Cardinal Virtues

Prudence,
Justice,
Fortitude,
Temperance

In brief the four cardinal (moral) virtues are prudence, justice, fortitude and temperance.  Prudence is right reason applied to action[19] which, it could be argued, is the key virtue in good ethical decision making, justice is giving each person (patient) their due.  Fortitude is moral courage in the face of death (which the doctor may encounter on a daily basis).  Finally, temperance leads the person away from things which seduce the appetite from obeying reason,[15] and so the doctor will keep his/her relationship with his/her patients free from self-interest. Self-interest could take the minor form of receiving presents right up to forging the last will and testament of patients, an act which Harold Shipman was convicted of doing as well bringing about the death of many his patients.

I will briefly show how the virtues work in medical practice. Prudence consists of three cognitional activities; the first of which is ‘to take counsel’. This simply means that prior to diagnosing the patient, the doctor will take the patient’s history, may conduct a physical examination, order a battery of tests depending on the hypotheses and interview the patient, perhaps on a number of occasions, to gather more information and familiarise him/herself with the tune of the patient’s story. Secondly, is the activity that Thomas calls the ‘judging of what one has discovered’ [21]. For example, the doctor might deliberate as to what is the cause of the illness, ruling out various hypotheses after receiving key information and will undoubtedly seek further counsel from members of the patient’s multi-disciplinary health care team. Third and finally, there is the activity termed ‘command’. This is the precept applying to action the things counselled and judged. ‘Command is nothing else than the act of the reason directing, with a certain motion, something to act’.[16] It results in action. Command is the activity that is closest to the goal of practical reason. Hence, Thomas regards it as the principal act of prudence. At this point the doctor executes an appropriate treatment plan in collaboration with the patient. Prudence, therefore, brings the doctor through the process from hypothesis to diagnosis and in turn to the implementation of an appropriate treatment plan.

St Thomas teaches us that a virtuous character comes with practise. Just like playing the violin, a virtue is a settled disposition. The junior doctor can be taught how to be virtuous by their senior consultant. How then does this translate into medical practice? In Thomistic terms a virtuous practitioner is one who treats patients and makes decisions in accordance with the virtues of prudence, justice fortitude and temperance. The virtuous agent then becomes familiar with doing ‘the medical good’. The practitioner can use these four cardinal virtues in a secular setting. The three theological virtues; faith, hope and love, may be set aside in such a setting without damaging the use of the cardinal virtues. However the virtuous character is more complete with the theological virtues and I would argue that each good doctor practises the virtue of love on a daily basis in a certain form. The subject of personal belief is a sensitive topic in medicine and the GMC has just introduced guidelines regarding this matter. [17] I would argue that regardless of whether the doctor is a theist or atheist the affective dimension between doctor and patient is rooted in the love that is friendship.[18] Thomas labels this love amor amicitiae. It is a sacred type of love, for it asks for nothing in return: it is sovereign to the love of need or desire. The fundamental component in amor amicitiae is to will what is good for the patient, solely for that patient’s own sake. Thomas captures succinctly the kernel of this type of love in the Latin word benevolentia, i.e. to will or wish the good. In amor amicitiae the love moves towards the patient in a straight line, it rests with the patient for it does not return in a curve to the doctor; it seeks nothing in return. This love, that is friendship, is of greater intrinsic value than the love that is characterized by need or desire. The doctor is constantly giving to his or her patients and in this sense it may be argued that to become a doctor is indeed a vocation.

Dr Julia Hynes, Assistant Professor (Medical Ethics and Law Lead)
St George's, University of London medical programme
Delivered in Cyprus by the University of Nicosia Medical School

This article is a shorter form, with further clinical examples, of an article originally published in Thomas Aquinas: Teacher and Scholar the Aquinas Lectures at Maynooth, volume 2: 2002-2010.
Edited by James McEvoy, Michael Dunne & Julia Hynes. Published Four Courts Press 2012
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