Virtue Ethics can be traced back to Mencius and Confucius, as well as Plato and Aristotle. In this course, we will be primarily using an Aristotelian framework for understanding virtue. The virtues are defined as excellenttraits of character. Though there is disagreement over what it means for a trait of character to be excellent, most agree that it is the sort of trait that is fundamental to flourishing or living well (what Aristotle calls eudaemonia). For instance, courage, compassion/sympathy, truthfulness, trustworthiness, humility, empathy, respectfulness, these are all traits that are taken to be critical to flourishing as individuals and as a society.
The key for Aristotle is that our traits of character depend on excellent habitualization (we learn from others and practice habits with others). So, virtues are significantly dependent on social support. This can mean that being trustworthy is something that comes easily to you in part because you were raised to be trustworthy, but it also means choosing to be trustworthy because it is an excellent trait as you develop greater capacity to make choices. Some contemporary interpretations of Aristotle add that virtue can be dependent on sociality in another sense, virtue requires normative structures and systems that encourage and support it. For instance, when hospitals place higher value on numbers of patients than time with patients, it could be at the cost of empathy. Likewise, oppressive -isms (racism, chauvinism, ablism, etc.) can hamper virtue (e.g. being respectful of someone when social norms tell us that a feature of their identity is not worthy of equal respect, or e.g. being trustworthy when no one trusts me).
Some key virtues in the medical profession include (but are not limited to): empathy, sympathy, compassion, beneficence, respectfulness, justice, curiosity, humility, courageousness, trustworthiness, truthfulness, etc.
Physicians and patients alike will agree that empathy is integral to patient care. But it is not as easy as we might think. Empathy is not unlike other clinical skills and practices. Take learning to listen to a heart. We begin with simple instructions about how to use a stethoscope and then slowly build more precise attunement to any irregularities in heartbeat. In empathy, we begin with simple questions like “how do you feel today?”, but experience, practice, and knowledge will create greater attunement to the feelings of others. This article by Dr. Shapiro is just one step in the direction of building the knowledge necessary to becoming an excellently empathically attuned physician.
The conversation in this video is an excellent example of what it means to be curious, humble and empathic in conversation with others and across sameness/difference. Sunaura Taylor is an artist and writer, she articulates the social model of disability and demonstrates its effect on her life excellently. Taylor and Butler call on us to think about how what our bodies can do in the world depends on what the world allows physically and through social norms. Most importantly, Taylor and Butler show us how important it is to know about the experiences of others by talking with them and privileging their perspective by always remaining curious and open.
If you’re feeling eager for more… explore this article on How to Teach Doctors Empathy which talks about the growing emphasis on empathy training for health care professionals and describes a few such trainings across the country.
We share core professional values but sometimes our values conflict with those of another (perfectly reasonable) team member. The training and practice of an occupational therapist emphasizes safety, which was in direct conflict with patient autonomy in this specific patient case.
Conflicting opinions are a normal part of working in teams. Successful teams a) assume positive intent, b) listen to each other, c) make sure every person on the team expresses their view, and d) concludes conflicts by negotiating a plan for next step/s.
Place the patient at the center of the team. Understanding the patient’s perspective on health and healthcare places the patient at the center of the team’s conversation, and can help all team members get behind a plan that meets the patient’s needs.
Listening and speaking up are critical team skills. Listen as much (or more) than you speak. But speaking up is important for all team members to share their concerns or new information.
We can’t always be the hero. Sometimes we can’t “save” a patient. When we have different goals or health beliefs than a patient, we may not always feel good about our what we are able to do (allowed to do) for a patient or the patient’s outcome.
Don’t take it personally. When you feel challenged by a patient, ask other team members how it’s going for them. Don’t assume you’re the problem, or are the only one having difficulty. If you’re frustrated, it’s likely others on the team are too.
Talk to your team first. When you feel challenged by a patient, don’t go it alone. Use your team to help you problem solve. Difficult patients can split us as teams. Knowing other’s roles and responsibilities and using them to full potential can share the burden of high maintenance patients.
Think broadly when you think “team”. Physicians, nurses, pharmacists and social workers practice in close proximity, often rounding together, but other team members may not be in the loop. Remember to include everyone in challenging care decisions.
Support your team members. Especially when we have a challenging patient, we need to rely on and trust our team members to do their jobs. Work together to adopt a common approach.
Working with Challenging Patients
“Difficult” patients: Challenging behavior is often a sign that, from the patient’s perspective, her/his needs aren’t being met.
Engaging patients: Exploring patient’s preferences in a non-judgmental way is key to enhancing motivation and engagement, both of which are essential to effective care.
Respect for patient autonomy: Ultimately, patients make their own decisions. The challenge for providers is to take the journey with them, work creatively to bridge medical aims and patient priorities, and provide support.
Some object to prenatal diagnosis on the basis that it ‘expresses’ a discriminatory attitude towards those with (dis)ability. Namely, the act of screening for genetic information that might demonstrate risk for certain forms of (dis)ability (e.g. developmental (dis)ability associated with Down Syndrome) so that one might then choose to terminate the pregnancy endorses normative assumptions that treat those with (dis)ability negatively or as unequal in moral worth.
It is important in weighing this objection against other considerations to consider the perspective of those who have a screened for or similar genetic trait. Likewise, you might consider how you would feel if any genetic trait that you have were screened for regularly and pregnancies were regularly terminated because of it.
For further reading…
Boardman, FK. (2014). The expressionist objection to prenatal testing: the experiences of families living with genetic disease. Social Science & Med, 107:18-25.
Edwards SD. (2004). Disability, identity and the “expressivist objection”, J Med Ethics, 30(4):418.
Kittay, E. and Carlson, L. (2010) Cognitive Disability and its Challenge to Moral Philosophy, Wiley-Blackwell: Oxford.
Though we often talk about a patient’s right to be informed about the risks and benefits of treatment options or about prognosis, there is a correlative right not to be so informed (or not to know).
This right has become particularly prevalent in the field of genetics, where patients could come to know that they are at risk for a serious disease for which there is no effective treatment (e.g. Huntington’s disease). Under such circumstances, some patients may decide that they do not want to know their risk and respecting that choice may be both a matter of respecting autonomy and ensuring beneficence.
However, the existence of this right is contested. And even for those who agree that there is such a right, what that right entails is complicated by risk to the patient (e.g. some patients may ask not to know even when there are potentially effective treatments) and by risk to others (e.g. when genetic testing reveals genetic information that would affect family members).
For further reading…
Berkman and Hull (2014). The “Right Not to Know” in the Genomic Era: time to Break From Tradition? Am J Bioeth, 14(3):28-31.
“Paternalism is the interference of a state or an individual with another person, against their will, and defended or motivated by a claim that the person interfered with will be better off or protected from harm. The issue of paternalism arises with respect to restrictions by the law such as anti-drug legislation, the compulsory wearing of seatbelts, and in medical contexts by the withholding of relevant information concerning a patient’s condition by physicians.” (https://plato.stanford.edu/entries/paternalism/)
There is disagreement over classification of paternalism in practice and the ethical justification for it in any given case. One of the classic cases of paternalism that occurred at the birth of bioethics as it is known today is the case of Dax Cowart (see BH website: https://depts.washington.edu/bioethx/tools/ceintro.html). Dax was a patient with severe burns over 65% of his body who was assessed as having decision making capacity and refused care, but care was provided over his objections for the purpose of benefiting Dax (by saving life and restoring significant quality in his life).
“The term beneficence connotes acts of mercy, kindness, and charity. It is suggestive of altruism, love, humanity, and promoting the good of others. In ordinary language, the notion is broad, but it is understood even more broadly in ethical theory to include effectively all forms of action intended to benefit or promote the good of other persons. The language of a principle or rule of beneficence refers to a normative statement of a moral obligation to act for the others’ benefit, helping them to further their important and legitimate interests, often by preventing or removing possible harms. Many dimensions of applied ethics appear to incorporate such appeals to obligatory beneficence, even if only implicitly. For example, when apparel manufacturers are criticized for not having good labor practices in factories, the ultimate goal of the criticisms is usually to obtain better working conditions, wages, and benefits for workers.” (https://plato.stanford.edu/entries/principle-beneficence/)
When thinking about beneficence as a principle in case analysis we are typically considering the consequences, specifically how to bring about the most good and the least harm. One should consider all perspectives (e.g. patient, family, clinicians, community, etc.), and all forms of harms and benefits (e.g. physical, spiritual, social, etc.), and as questions like: Which course of action is likely to produce the greatest benefit (e.g. quantity or quality of life) over harm (e.g. bio-psycho-social pain and suffering) for the patient?For everyone involved?