My recent volume Practicing Medicine and Ethics[1] addresses a set of interconnected challenges that join together in the life and work of the health professional. These challenges pertain to patients in the dynamic of shared decision-making, to professionals themselves as they navigate the implications of conscientious practice, and to the wider community as professionals fulfill their social contract with society. This book offers a vision of healthcare that views medicine as a goal-oriented endeavor guided by both virtues and principles and reliant on the conscientious practice of the professional, especially when faced by the challenges of religious and philosophical pluralism. It culminates in an integrity- centered framework for practical wisdom in medicine that is intended to be clinically useful and theoretically transparent. In the following paragraphs I will summarize a number of the book’s key concerns.
Within the tradition of virtue ethics tracing back to Aquinas and Aristotle, practical wisdom is the foremost of the cardinal virtues because it shows us how to respond realistically—in the sense of being true to reality—when faced with a decision. This virtue gives us the ability to know what ends (or goals) are worth pursuing and what means are most likely to achieve them. Practical wisdom can be seen as having five core elements: (1) pursuit of worthwhile ends (goals) derived from a concept of human flourishing; (2) accurate perception of concrete circumstances detailing the specific practical situation; (3) commitment to moral virtues and principles that are interdependent and form an integrated moral framework; (4) deliberation that integrates ends (goals), concrete circumstances, and moral virtues and principles; and (5) motivation to act in order to achieve the conclusions reached by such deliberation.
These elements form a trajectory of moral decision-making that is guided by goals, responsive to empirical facts, directed by normative principles and virtues, organized through moral reasoning, and motivated by a desire to make actions consistent with beliefs.
Goals of care are, therefore, a vital part of practical wisdom in medicine. They provide clinically relevant objectives for the care of individual patients and usually involve one or more of the following: curing, living longer, improving function, being comfortable, achieving life goals, providing support for family, or clarifying the diagnosis or prognosis. Prioritizing goals of care helps patients, families, and clinicians articulate goal-oriented assessments and preferences that can guide shared decision-making and increase the likelihood that treatments will harmonize with patients’ values and the reality of their medical conditions. Once clarified, goals of care allow decision-makers to discuss whether a possible intervention makes sense by asking, “Will this treatment help achieve the agreed-upon goal(s)?” If goals are ignored, medical decisions may be dictated by immediate circumstances or “usual” care, rather than by the unfolding clinical realities and longer-term goals that reflect a patient’s enduring beliefs and values. Focusing on goals helps situate interventional options against a broader background of meaning and can counter the impression that a treatment may be advisable merely because it is available. Goals remind us to ask where we are going before we consider possible ways of getting there.
The importance of goal-oriented thinking is nowhere more apparent than in decision-making toward the end of life or in the management of chronic-progressive conditions (e.g., organ failure). It is therefore disappointing when instruments intended to facilitate decision-making under these circumstances focus primarily on interventions (e.g., cardiopulmonary resuscitation, artificially administered nutrition, intravenous fluids, or antibiotics), rather than on goals of care that would provide a basis to decide whether or not a given intervention makes sense in light of unfolding medical realities that often cannot be known very far in advance. Such intervention-oriented thinking is evident in Iowa’s Physician Orders for Scope of Treatment form which, like others in the POLST (Physician Orders for Life-Sustaining Treatment) paradigm, focuses on interventions without also clarifying goals (except for the goal of comfort, which is offered as the option of “comfort measures only” in contrast to “limited additional interventions” or “full treatment”). While we must acknowledge that there comes a time in the course of a patient’s illness when a decision to forgo life-sustaining interventions needs to be made, we should recognize that instruments codifying decision-making in terms of standardized interventional choices run the risk of doing a disservice if those choices are not guided by a patient’s current goals of care and the specific details of his or her current medical condition.
To care for patients wisely, clinicians need a wide range of knowledge that arises from direct interaction with patients; awareness of their individual psychological, social, and spiritual contexts; gathering of medical information; training in the diagnosis and treatment of diseases and disorders; and familiarity with the ways that healthcare can be delivered. In addition to understanding the patient’s goals of care, clinicians need to incorporate two other dimensions into shared decision-making to insure an accurate perception of what a patient believes and values. One of these is probabilities. Patients need to decide how much value they attribute to different goals in light of the statistical probabilities attached to the means of achieving those goals (e.g., what is the likelihood that, if a patient suffers cardiac arrest in the hospital, the performance of cardiopulmonary resuscitation will lead to survival and good brain function). Discussing probabilities can be challenging, but medical practice requires knowledge of an ever-flowing stream of probabilities that are integral to evidence-based practice. Another dimension of the patient’s reality is the willingness to endure suffering and bear the burdens of treatment, whether from physical or emotional pain, disability, dysfunction, social dislocation, rehabilitation, or financial or other hardships. A treatment may impose such a heavy burden that a patient is unwilling to accept it, even though in itself it might be seen as medically beneficial.
These three dimensions (goals, probabilities, and suffering) provide a realistic perception of patients as persons by knowing their personal, social, and medical details, their goals of care, the value they attach to outcome probabilities, and their willingness to bear the burdens that treatment entails. Some people might argue that another important dimension for clinicians to consider is financial cost. This dimension includes the financial burdens experienced by individual patients, but it is perhaps more frequently framed by professionals in terms of costs to society as a whole. In light of society’s challenges in controlling healthcare costs, some suggest that physicians have a dual and simultaneous responsibility: to care for individual patients, one at a time, and to control healthcare costs through bedside rationing of healthcare. But we need to consider seriously what this suggestion implies and avoid placing on the shoulders of clinicians more than they can bear. Given the moral limitations physicians face as human beings in their ability to distribute healthcare services without favoring some patients and discriminating against others, it would not be realistic to expect them to micro-allocate resources fairly. Though overarching decisions in healthcare are necessary to control costs, they need to be made through democratic processes of deliberation and administration that allow for a division of labor between those responsible for fair allocation procedures and those responsible for direct patient care.
Practical wisdom requires moral grounding so that the ends of decision-making, and the means to those ends, are guided and justified by identifiable moral standards that form a moral frame of reference. A normative ethical grounding of this kind can rely on virtue ethics, deontology, and limited consequentialism. Virtue-based and principle-based ethics enjoy a close and complementary relationship. As formal prescriptive norms, principles can be seen as having a certain objectivity that is external to the subjectivity of an individual’s character. This objectivity can provide rational justification in ethical deliberation. By contrast, virtues can be seen as providing the internal drive and motivation for moral action that principles, as abstract norms, lack.
Unlike principles and virtues, consequentialism provides a certain flexibility that arises from calculations that calibrate the moral rightness of particular actions according to the assessed value of predicted outcomes. This flexibility may be perceived as a weakness or strength. In the practice of medicine, where ethical judgments routinely include assessments of likely outcomes, reasoning based on likely consequences is intuitive and necessary. Predicted outcomes regarding benefits and risks are essential to moral assessments and stand unavoidably alongside principles and virtues. However, it is one thing to take into consideration the anticipated balance of consequences, and another to adopt consequentialism formally as a guiding conceptual framework. (Formal approaches to consequentialism adopt a single principle that defines some uni-dimensional good—such as happiness, preference satisfaction, or financial cost—as the measure of right action.) Well known problems with consequentialism should not keep us from taking consequences seriously. And we should note that to the extent moral action aims at goals—as is the case with virtue ethics—it inherently takes the consequences of action seriously. Having said this, we should remain clear on the features of consequentialism that set it apart from other frameworks and remember that virtue ethics ascribes a moral significance to virtues that is morally independent of consequences.
Moral reasoning faces special challenges in the setting of moral pluralism, a setting that deprives the health professions of a comprehensive moral consensus capable of specifying and prioritizing relevant virtues, principles, and consequences. The problem of pluralism cannot be resolved by supposing the existence of some morally neutral vantage point. Such a vantage point is unavailable. Ethical decision-making requires some sort of moral compass, whether provided by a developed moral framework or simply a statement of moral priorities. The need for such moral orientation raises questions about the foundational beliefs that justify and guide moral reasoning.
These foundational beliefs may be expressed in religious or philosophical terms, and given the debates that surround religion in western societies, it is important to clarify what religious beliefs should be taken to signify in the context of ethics. If we focus on the function of foundational beliefs in ethical reasoning, there is no compelling reason to draw a line of separation between religious and philosophical beliefs. This is the essential point John Reeder makes when he observes that the stereotypical division between religious and nonreligious moral traditions loses its relevance to ethics once it is recognized that all moral perspectives make claims about what is believed to be good in light of what is recognized as real.[2] On this account, all moral frameworks make claims that entail foundational beliefs about what is ultimately real and ultimately good—beliefs that in turn determine the values, commitments, and actions that characterize ethical decision-making. Foundational beliefs can therefore be religious or philosophical, and because all moral frameworks make fundamental claims about what is real and good, foundational beliefs are unavoidable in moral reasoning. And because these foundational beliefs represent the roots of our moral frameworks, they will inevitably have practical manifestations.
Integrity entails the imperative to live life with the goal of being at unity with oneself. The word integrity is instructive, as it brings to our minds the idea of integration and its relevance to the constellation of foundational beliefs, values, commitments, and actions that constitute our multifaceted moral lives. It refers to our need for personal wholeness and harmony and indicates the harm we experience when circumstances tempt or coerce us to live a double life by compartmentalizing our activities according to the different roles we play in different contexts.
The more one appreciates what integrity is, the more one sees that it is not helpful to speak about integrity without also speaking about ethics and moral reasoning. If we agree that integrity fundamentally involves moral reasoning and represents the culmination of one’s best efforts in moral decision-making, there are important implications for medicine and medical ethics. One of these is that integrity cannot plausibly be categorized as merely a private moral concern. Rather, it needs to be seen as something that can facilitate genuine moral dialogue. For when they are communicated, the reasons and reasoning of one person’s integrity become accessible to other persons and, thereby, part of shared moral deliberation.
This facilitation of dialogue is highly significant when one considers the mixture of privileges and responsibilities that flow within the so-called ‘social contract’ between health professionals and society. Within this relationship, society sometimes exercises its prerogatives in response to physician behaviors that disregard generally accepted features of a health professional’s fiduciary responsibilities. This can be seen, for example, in federal and state regulatory responses to conflicts of interest arising from financial relationships between physicians and healthcare companies. But in other contexts—such as abortion, contraception, or physician-assisted suicide—some clinicians perceive the expectations of society as imposing inappropriate demands that contradict their primary moral commitments. In such cases, there is the prospect of deep tension between society’s prerogative to impose its will on medicine and the medical professional’s prerogative to practice medicine with integrity. Within a morally pluralistic society, such tension will be less likely to arise if there is ongoing dialogue and consensus about clinical practices that should be considered controversial and therefore accompanied by protections that accommodate the professional’s freedom of conscience.
To mention conscience in a discussion of integrity reminds me to say that there are very good reasons to treat these two concepts as largely interchangeable. At times it is particularly helpful to use the language of conscience, such as when we are considering the negative work of conscience as expressed by conscientious objection. We should immediately note, however, that the reasons, feelings, and motivation that comprise conscience not only repel one away from morally objectionable actions, they also draw one toward morally desirable goals. Conscience therefore also does positive work, as expressed by conscientious practice, which captures the interdependence between a professional’s conscience and his or her motivation to serve patients. This motivation lies at the heart of an integrity-centered practice of medicine, and it warrants enduring respect and cultivation if health professionals are to be encouraged to integrate medicine and ethics in the care of their patients.
Practical wisdom in medicine depends on the moral beliefs and values that clinicians bring to their professional work. This dependence is most obvious in the need to decide which goals of care, virtues, and principles should serve as the guiding objectives and moral standards for patient care, and how these should be specified and prioritized in specific cases. The particular moral content that goes into a framework for practical wisdom will always require specification and affirmation by the individual using the framework. Once someone fills this or any other moral framework with particular moral content, he or she must reckon with the moral diversity of other persons involved. Engaging this diversity in western societies can test the consensus on which democracies rely to maintain shared commitments to moral expectations, policies, and laws. Though the practice of medicine enjoys a substantial degree of moral consensus around the general pursuit of health and healing, the challenges of moral pluralism are nevertheless real for healthcare professionals and, in some clinical contexts, can pose serious moral tensions and conflicts.
Given the dependence of practical wisdom on moral beliefs and values that are bound to be diverse in morally pluralistic societies, it is important to identify personal, professional, and social resources that can facilitate moral courage, shared decision-making, professional cooperation, and respectful social engagement and accommodation. There is reason to hope that such resources can be found when we pursue moral dialogue with moral imagination and humility. One of the reasons moral dialogue is of great importance arises from the fundamentally dialogical character of moral life that gives interpersonal moral dialogue a special relevance for moral identity.[3] On this view, as we communicate our beliefs and values to others in moral dialogues, we also increase our moral understanding of ourselves. Through dialogue, our moral identities are cultivated and sustained, and the act of articulating our beliefs and reasons strengthens our pursuit of the good that our beliefs and reasons represent. As clinicians articulate their reasons for pursuing a given course of action, their listeners are informed, their own reasons are opened to critical dialogue, and their own moral identities are strengthened.
A second reason for moral dialogue stems from the fallible nature of conscience (or integrity). If conscience is understood as involving practical moral reasoning, then it can err from mistakes in observation, interpretation of facts, or assessments of the moral values pertinent to those facts. Conscience can also be misled by self-deception and rationalization. Mistakes in moral reasoning, weaknesses in moral character, and self-deception explain why conscience should never be treated as if it were beyond dialogue and questioning, even if in the end it is respected as being finally authoritative for each individual. The fallibility of conscience is a potent reason for believing that moral deliberation in medicine needs humility.
Even when someone is compelled by conscience to stand firm in the strength of his or her moral convictions, humility encourages confidence without arrogance. Such humility is closely related to what some writers refer to as moral imagination—the ability to realize vividly the inner lives of those around us, to “be aware of others as persons, as important to themselves as we are to ourselves, and to have a lively and sympathetic representation in imagination of their interests and of the effects of our actions on their lives.”[4] Perhaps it would be appropriate to hear the need for moral imagination as a modern echo of the ancient call to love our neighbors as ourselves.
Seen in its full light, practical wisdom in medicine invites us to move discussions about medical ethics well beyond the dilemma-filled enclosures of principle- based ethics or the narrow lanes of proceduralism. It encourages us to see ourselves in our ethical deliberations as persons for whom integrity matters—persons on a journey who need to make sense of individual actions not just one at a time, as isolated episodes, but also as part of an unfolding life story that defines who we are and who we have become.[5]
[1] Lauris Kaldjian, Practicing Medicine and Ethics: Integrating Wisdom, Conscience, and Goals of Care (New York: Cambridge University Press, 2014).
[2] John P. Reeder, “What Is a Religious Ethic?” Journal of Religious Ethics 25, no. 3 (1997): 157–181.
[3] Charles Taylor, The Ethics of Authenticity (Cambridge, MA: Harvard University Press, 1991), 33–35.
[4] William Frankena, Ethics (Englewood Cliffs, NJ: Prentice Hall, 1973), 69.
[5] Alasdair MacIntyre, After Virtue (Notre Dame, IN:University of Notre Dame Press, 1984), 203.
Lauris C. Kaldjian, "Practicing Medicine and Ethics,” Dignitas 22, no. 4 (2015): 1, 4–7.
