Introduction

“Virtuous physicians are the beacons that show the way back to moral credibility for the whole profession (1:237-55), wrote Pellegrino, and reawakened a view of medical ethics that contrasted with the writing of Beauchamp and Childress.

Few books have had such a huge influence on the teaching and practice of medical ethics as Principles of Biomedical Ethics by Beauchamp and Childress (2). Here were set out four principles that should guide medico-moral decision making: autonomy, non-maleficence, beneficence and justice (fairness). These four principles soon acquired an independent status in much ordinary discussion of medical ethics. They were popularised in the UK by Raanon Gillon in a series of BMJ articles, subsequently published as Philosophical Medical Ethics (3) Gillon’s long tenure as editor of the Journal of Medical Ethics and influence in medical ethics spread the “four principles approach” into medical school curricula. It is no exaggeration to say that for many doctors with no special interest in medical ethics, the four principles were medical ethics – often renamed as the “Georgetown mantra” after the Kennedy Institute of Ethics at Georgetown University, Washington DC,USA.

The advantages of the “four principles approach” were considerable. It provided simplicity, and freedom from abstruse philosophical discussion that was thought unattractive to doctors as ‘practical’ men and women. The approach was easy to understand and appeared free of metaphysical justification. Unfamiliar terms such as ‘autonomy’ or ‘beneficence’ could be absorbed and quoted. The four principles could be used as a tool-box: any ethical problem could, apparently, be analysed by applying each principle in turn to the issue under discussion. As such the four principles appeared in medical examinations, often with examiners whose grasp of ethical theory was limited. The principles were applied to clinical analysis of bedside problems, in clinical ethics committees, while deliberating policy in professional organisations, and even in the regulatory activities of research ethics committees. The result has been to define an ethically aware practitioner as one who knows the principles and can go some way in applying them. (Education in ethics has usually included a distasteful nod in the direction of utilitarian theory, although professional bodies may find utility an easier tool in deciding or advising on issues that are essentially epidemiological.) It is as if the model for ethical practice is legal, rule-based and concerned with determining what is permissible rather than what is good.

This approach places the emphasis on actions, rather than on agents; on deeds, rather than on motives or intentions. It is true that conscience needs to be informed. Ignorance may be culpable. We might say that “good intentions are not enough” if expertise is lacking. Yet it is worth remembering that one of the great figures in western ethical thinking, Aristotle, described virtues. Of these, the key virtue of practical wisdom, phronesis, was seen primarily as an intellectual and not a moral virtue.

The idea of the ‘reflective practitioner’ has been widely discussed (4): an ideal of an individual who examines himself critically in an effort to improve performance. The reflective practitioner should be capable of insights into motives, ignorance and weaknesses that are not obvious to the outsider. Motives and intentions can never be known with certainty by a third party. An emphasis upon the virtues sees performance as requiring the art of practising well. Little of this appears explicitly around the ethics committee table. Virtue ethics represents the renewal of an approach to ethics, according to which the basic judgements in ethics are judgements about character (5).

Moral theory without virtue ethics is incomplete. Education for health care practitioners requires a fresh input from virtue ethics: for ethics and ethicists in the multi-professional context. Virtue ethics is a system that sits alongside duty based ethics (deontology) and utilitarianism. Deontological ethics is particularly associated with Kant; and utilitarianism with Bentham and Mill. Virtue ethics remains grounded in the work of Aristotle and Thomas Aquinas.

A renewed approach

The last 30 years has seen growing interest in virtue ethics, described (6:2) “as a rival to deontological and utilitarian approaches, as interestingly and challengingly different from either as they are from each other”. Is rival status the best way to construe these developments? Might it be that virtue ethics could be assimilated into one of the other approaches with benefits in daily practice? “It would be a pity,” writes Crisp (7:5) “were virtue ethics never to engage with… Kantianism. Is there any hope of bringing this about?” I want to suggest that there are weaknesses in both virtue ethics and deontology that could be addressed by synthesis.

Ethical theories – even theistically grounded ones – start from a view of humanity. Mill’s account of happiness, central to his utilitarian doctrine, attempts to derive its force from the empirical observations of how human beings do in fact behave. Kant starts from the rational human being, as befits an Enlightenment thinker in the Age of Reason. Aristotle (and Aquinas) starts from a view of the end (telos) of man and an idea of human perfection. Unsurprisingly, therefore, different theories often lead to different conclusions.

Understanding virtue ethics

In an influential paper in 1958, Anscombe (8) proposed a return to an Aristotelian view of ethics, in which our moral norms are not legalistically based, but founded on a consideration of human flourishing. Virtues are developed by studying and copying the life well lived, a relationship like that of an apprentice towards a master. Virtues are excellences that contribute towards human flourishing. We see the life that flourishes and emulate its exemplar with his practical demonstration of how to live. We might even say that we follow a person rather than his creed. Virtue ethics requires a conception of the good of a human life conceived as a unity and demonstrating man’s creative, rational, social and communicative qualities to an excellent degree. Aristotle’s ethics is teleological, but not consequential. It rests upon a consideration of the attainment of some good – the starting point of his Nicomachean Ethics (9). Kant expounds a duty-based ethics, Aristotle a virtue-based one.

In virtue ethics, goodness is defined, not as rightness, but as a human excellence; and for this reason, the practice of a virtue must aim at a perfection. Its underlying question is not: “What should I do?” Rather, it is: “How should I live?” Virtue ethics emphasises the character of the agent and accepts that the self is morally important. Virtue, therefore, applies to traits of character, to dispositions and to character patterns that lead to behavioural consequences. Moral development, therefore, takes time as character forms and dispositions to do good develop. By contrast, deontology places its emphasis on action. Deontology sets out principles and rules in a quasi-legal manner, with practice seen as obligation; virtue interprets practice as the expression of an underlying character, sensitive to culture and community traditions. Reason plays a larger part in deontology, compared to emotion in virtue ethics.

The virtuous person will act in a certain way because he wants to act in this way, because acting like this will realise a virtuous end. In acting, character and disposition are developed. This contrasts with deontology where a person will act out of obedience to a principle, whether he wishes to act in this way or not. Someone whose ethics were based on principles would act consistently, whereas the virtuous man would vary behaviour to the context in order to apply the particular virtue. If deontology could be caricatured as a rule based cook-book, value ethics is more akin to a connoisseur sampling a fine food. This difference of approach necessitates an entirely different emphasis on the moral agent. The exemplar from whom the virtuous man will learn is likely to be someone with great experience of life and wisdom. While not everyone who has experience has the wisdom that comes from reflecting on it, without experience the ability to respond in different situations will be less developed. Virtue ethics seems to have a built-in respect for the older citizen.

For Aristotle, the concept of practical wisdom (phronesis or prudence), an intellectual virtue, has a key place in his ethical theory.

Virtue is then not solely moral. It is also intellectual, an excellence of the mind to discern how a virtue can be realised. And for some practical activities, virtues may extend beyond the moral. Punctuality, for example, would not normally be considered a moral virtue (10). We do not condemn someone as immoral because they are late, unless this has had major adverse consequences for others. Foot (11:2) points out that arête and virtus of Aristotle and Aquinas refer also to arts, “and even to excellencies of speculative intellect whose domain is theory.” If deontology defines the moral sphere, then a consideration of the virtues may go beyond it.

Someone with the virtue of generosity, for example, will contribute willingly to relieve the distress of others, not because he feels under an obligation to do so, but because of a seemingly instinctive feeling towards his fellow human beings. The duty-based individual may struggle to give to others, may do so grudgingly or, in practice, just find himself unable to do it. The pure in heart have no such difficulty. A fully human being will give naturally, because it is in his nature to give. Similarly a virtuous person will tell the truth because she is committed to the virtue of truthfulness, not out of respect for the autonomy of the listener and the action rules that flow from that. The virtuous person will have a situation and culturally sensitive approach. Truthfulness is a virtue, but is not the same as compulsive truth telling. Personal virtues are situation-, not rule- dependent. When it is morally wrong not to deceive, a truthful person deceives. He does not tell the Gestapo where the Resistance are hiding. Finally, it should be added that virtue, for Aristotle, is a disposition:

“..in which when it has to choose among actions and feelings, it observes the mean relative to us, this being determined by such a rule or principle as would take shape in the mind of a man of ‘phronesis’. We call it a mean condition as lying between two forms of badness, one being excess and the other deficiency; and also for this reason, that, whereas badness either falls short of or exceeds the right measure in feelings and actions, virtue discovers the mean and deliberately chooses it”. (9:66)

Thus courage is a mean between recklessness and cowardice; and so on. This is applicable to many virtues, but not others such as justice. How could one be too just or unjust?

Problems with virtue ethics

To the four classical ‘cardinal’ virtues of courage, temperance, wisdom (prudence) and justice, Aquinas added the three ‘theological’ virtues of faith, hope and love. An immediate response list of seven is to point to what is missing: where, for example, is patience? And what about…? (insert your own favourite). For Aristotle (12), the paradigm of excellence was the Athenian gentleman; for Homer, the warrior. Hence Homer considers strength as a virtue. The New Testament also adds humility (9); Benjamin Franklin adds cleanliness, silence and industry. A cursory examination of these lists reveals not only different rankings but also contradictions. Humility does not sit easily with magnanimity, for example. Then there are the pseudo-virtues (10): competitiveness is widely admired in a market economy, but may involve abrasiveness, selfishness and insensitivity. The number of incompatibilities is startling: none appears to offer any clearer justification than any other! Virtue ethics seems impracticable. Differences between Attic Greece, classical Athens or mediaeval Christian Europe are no more than the differences within many modern societies. Multicultural western societies, in particular, lack a unifying concept of the good: consider what modesty might mean to a devout Muslim, compared to a model on the catwalk. The problem of definition is insuperable. Courage is admired in the timid person who puts his life at risk to save another; courage in the burglar is asserted (sic) to be no courage at all, merely ‘bravado’.

It is a weakness in virtue ethics that we just select (connoisseur-like) the features that promote eudemonia, human flourishing, without the metaphysical justification that stems from the nature of human rationality. Why follow Gandhi rather than Stalin? The practice of rightness is based on an action guide that is external to us, not an internal justification of what makes up a virtuous person. In any case, self respect and integrity are spiritual virtues, not primarily action related at all. The legalistic structure of Kantianism may appear unattractive, but it has an obvious applicability in the way law itself is made. The law gives us rights and there is a parallel between moral and legal rights – indeed often confusion between the two. In making law, whether in parliamentary debate or in the court decisions of judges, it would be impossible to proceed on the basis of promoting a virtue. Societies require absolute prohibitions against certain practices, whether in local laws, administration of justice or sexual relations (13). Absolute prohibitions cannot be achieved either by assessment of moral character or by referring to how characteristic a pattern of behaviour might be. In the structuring of our society, virtue ethics isn’t fit for the purpose.

Additionally (13), it is easy to redefine the boundaries under the temptations of flattery and wealth, to become less sensitive to the needs of others. New influences can change us. With an emphasis on the agent’s character, it becomes easy to overlook individual shortcomings (or excellences). We deceive ourselves, and backslide. Virtue ethics evaluates the agent when acts should be the primary focus.

Bringing deontology and virtue together

Having argued that virtue ethics cannot be accepted as a freestanding alternative to deontology, I suggest reasons for a synthesis. The emphasis of virtue ethics on the moral agent could hardly contrast more with Kant’s apparent dismissal of the agent’s character and his emphasis on the supremacy of duty:

…if nature had implanted little sympathy in this or that man’s heart; if he were cold in temperament and indifferent to the sufferings of others…would he not still find in himself a source from which he might draw a worth far higher than any that a good-natured temperament can have? Assuredly he would. It is precisely in this that the worth of character begins to show – a moral worth and beyond all comparison the highest – namely, that he does good, not from inclination, but from duty (14; 11).

Yet Kant does not go far enough. It is surely better, more conducive to a desired and good outcome, if we are drawn by impulse to the good. We find it hard to admire a mother who cares for her children, or a spouse for a partner, out of duty alone. Aquinas writes:

It pertains to the perfection of moral goodness that a man should be moved towards the good not only by his will but also by his sensitive appetite (15:214 ).

Of course, it is better to do an act of kindness even though it goes against the grain, than not to do it at all: and it is hard to admire an act done solely to obtain a pleasurable feeling. But for Aquinas it is better to do acts of kindness with pleasure, than to do them with gritted teeth, as it were. Ideally, the whole person should be attracted by the good.

Attitudes owe much to inheritance and upbringing. They are also something we can, in some measure, develop. Habits, in the sense of bodily dispositions to act in one way rather than another, can be chosen. In the development of habits we perfect our behaviour. We develop responses that are almost spontaneous – what Copleston (15) calls “good operative habits or virtues” that give us a relative, though not absolute, stability in acting morally.

For example, if reliability and trustworthiness are qualities that patients seek in their doctors, a disposition to act in a certain way needs to be developed in all doctors (16).

The point is simple. Motivation to obey the moral law is more likely in one who is virtuous, who has a disposition to realize its demands.

In a discussion of Kant’s gloomy philanthropist, Hursthouse (6:91-107) argues that even for a virtue ethicist he should not be regarded as having mere continence because of the circumstances of his life in which he acts well. Quoting Foot, she argues that resolving the conflict requires acknowledging “that some things that ‘make it hard’ for someone to act well do not pertain to their character; rather there are circumstances in which the virtuous character is ‘severely tested’ and comes through…. the harder it is for him the more virtue he shows”. Kant’s duty ethics can therefore be reconciled with virtue ethics profitably in this respect.

“Virtues are dispositions not only to act, but to feel emotions, as reactions as well as impulses to action.” (6:108). Some are appropriate, some not, some exclusive to humans (pride, shame, regret). Broadly, emotions concern thoughts or perceptions of value. They can be retrained or rationally educated, at least in part (“I shouldn’t feel this way”). Here again Aristotle adds to Kant in his account of human rationality. As Hursthouse says, “The Kantians can repudiate Kant’s unattractive claims about the cold-hearted, as Aristotelians discard Aristotle’s unattractive claims about women and natural slaves, without dismembering the philosophy.” (6:108)

No matter what principles we hold, some problems are insoluble: not so much radical moral disagreement between parties as the impossibility of discriminating between options, tragic choices: actively killing one conjoined twin to improve the chance of salvaging the sibling or intervening to feed a demented patient. The virtuous agent will think carefully and thoroughly. Respect is demonstrated by following a process that ensures that all involved have the opportunity to express opinions. A decision is made seriously and over a reasonable time. Instant or casual decisions, regardless of outcome, do not show the same respect. A third party would judge that they acted well. Elsewhere I have termed this the ethics of process (17:47). Here again the virtues add to the Kantian approach.

Finally, I turn to the neglected subject of supererogation. The idea of doing more than obligation demands is common. We talk about working beyond contract, doing more than our duty, going the extra mile. The idea of ‘going beyond’, ‘over and above’ etc, is explicit in public honours and systems of professional recognition. Kantianism seems to say little (18). The moral law concerns what must be done; it extends no further. Although virtue ethics has no place for supererogation, it does provide an alternative concept: the ideal of eudemonia involves the perfectibility of virtues. The good man will do more than he is obliged to do. So the synthesis again has much to add.

In conclusion

A normative ethic must be comprehensible, comprehensive, grounded on a justifiable metaphysical foundation and correspond to the experiences of life as lived by ordinary human beings. Whatever the shortcomings of virtue ethics or Kantianism in its understanding of the moral agent, a synthesis would benefit a continuing dialogue on a multiprofessional basis. We should respond to the growing interest in virtue ethics and integrate this with principlism in our teaching and practice.