One of America’s greatest physician–educators in the areas of professional ethics and bioethics was Edmund D. Pellegrino, MD. Pellegrino was Professor Emeritus of Medicine and Medical Ethics at the Center for Clinical Bioethics at Georgetown University Medical Center since 2001. In 2004, he was named to the International Bioethics Committee of the United Nations Educational and Scientific and Cultural Organization, and in 2005, he became the chairman of the President’s Council on Bioethics. Pellegrino was a prolific author and founding editor of the Journal of Medicine and Philosophy.
Philosophy of Medicine and Bioethics
While bioethics and the philosophy of medicine may be viewed as a theoretical dilemma perhaps too overwhelming and time consuming for the busy practitioner, the Pellegrino reader comes to understand that recognition of such profound notions is as important as taking patients’ vital signs. Indeed Pellegrino makes a convincing argument that the philosophy of medicine, bioethics, and the physician–patient relationship cannot be separated from one another, and in fact these exist in a very complex and entwined relationship in which each affects the other. Pellegrino reminds us that there is a moral bond between a healer and his patient that must be cherished and safeguarded.
Although we may not view ourselves as philosophers, I believe all healers are “non-philosopher philosophers,” because at a minimum we wonder. And, according to Plato, Socrates cites in Theaetetus, “all philosophy begins with wonder.”1
Pellegrino explains, “The first principle of medical ethics, the end to which it is directed, is the good of the patient.” This principle can be traced back to the time of Hippocrates:
I will follow that system or regimen which according to my ability and judgment I consider for the benefit of my patient and abstain from whatever is deleterious and mischievous.2
The Medical Profession Today
In his essay, The Commodification of Medical and Health Care,3 Pellegrino begins with a passage from Book I of the Republic, in which Socrates asks Thrasymachus this question: But tell me, your physician in the precise sense of whom you were just speaking, is he a moneymaker, an earner of fees, or a healer of the sick?4
Pellegrino applies this notion to modern times, that today many people view our profession as having undergone a paradigm shift from a profession to a business entity. It is important to distinguish this misconception. The technician, who has learned the trade, is a member of the business community of medicine. The healer, who always keeps the patient as the center of his focus “knows the art.” Physicians are often challenged to choose what is best for the patient versus what is best for the corporate bottom line. Pellegrino notes that healthcare cannot be a commodity, given the special nature of illness and healing.3 Pellegrino rightfully recognizes that we have tacitly entered into a contract with society to use the knowledge we acquire from these allowances for the benefit of those who are sick.
We are urged to refrain from substituting the word “consumers” for patients or “providers” for doctors. We are urged to remain physicians and to be concerned with healing and not moneymaking. Pellegrino ends his discussion on medicine as a commodity with another quote by Plato, suggesting the ethical path for all physicians, namely, Can we deny, then, said I, that neither does any physicians, insofar as he is a physician, seek to enjoin the advantage of the physician but that of the patient?5
The Moral Agent
If by reading this article your aspiration is to be best healer you can be, then as a philosopher of medicine, medical ethicist, and clinician–educator, Pellegrino would have said that you must also recognize your role as a moral agent. On a regular basis, healers must contend with certain morally questionable practices and determine how they will respond.
Pellegrino adds: To me, the most important thing in a relationship is that the heart of the relationship is a moral enterprise that occurs between not only the doctor and his patient, but the lawyer and his client, the minister and his confessor, and the teacher and his student. All of these relationships have a dependent person who needs help, who goes to another person who professes to be able to help. They enter into a fiduciary relationship.6
We are urged to be virtuous. Plato listed 4 cardinal virtues: fortitude, temperance, justice, and wisdom. Pellegrino, in writing of the virtues in medical practice, has extended this list to include fidelity to trust, compassion, integrity, self-effacement, and phronesis. Phronesis is a term used by Aristotle to denote practical wisdom or the capacity for moral insight.7 In discussing virtue within the context of practicing medicine, Pellegrino writes that virtue is aligned with excellence in living the good life. This excellence depends upon knowledge of good, evil, and self. It is not specialized knowledge directed to any one activity but rather to living one’s whole life well. It must, like an art, be perfected through practice.8
A Virtuous Person
The virtuous physician must also be a virtuous person. This physician has character traits that define him as such and can be seen following his life according to a moral law. The virtuous physician is someone we can trust to do the right thing and to act courageously, honestly, justly, wisely, and temperately, according to Pellegrino. The virtuous physician will act well and with decent moral code even when others are not watching. While not defining the virtuous physician in specific detail, Pellegrino gives us some hints as to how he or she may be recognized. The virtuous physician is:
- A person of character. Someone who can be predictably trusted to act well in most circumstances and who does not yield to the allures of power, pleasure, or self interest.
- Someone who follows the internal morality of the (medical) profession. Profession is defined by Pellegrino as “a declaration of a way of life that is specific, a way of life in which expert knowledge is used not primarily for personal gain but for the benefit of those who need that knowledge.”8
- Someone who practices altruistic beneficence. This implies “not only taking the interests of others into account but doing so in such fashion that our intentions and acts give some degree of preference to the intentions of others.”8
- The virtuous physician is one who acts with the “right reason,” which Aristotle and Aquinas considered essential.7 He or she realizes that they may easily be pulled in many directions by all different facets of life, but through thoughtful judgment, is able to balance these opposing forces in order to achieve success in all areas. Clearly, in order to be a great healer, one must also strive to be a virtuous healer.
The Physician–Patient Relationship
When I asked which of his many scholarly publications he considered most effective in communicating the importance of the physician–patient relationship to today’s doctor, who strives to be the best he or she can be with regard to the art of medicine, Pellegrino quickly cited A Philosophical Reconstruction of Medical Morality and the Caring Ethic.9 In this publication, Pellegrino first describes how there exists a philosophical foundation for the obligations that bind those who profess to practice medicine, “better still, all who profess to heal.”9 He notes that today fewer physicians follow a religious foundation of ethics or remain faithful to the Hippocratic Oath. Pellegrino proposes a philosophy of the physician–patient relationship beginning with the tenet that the physician is in all aspects of life a good man or woman. Second, he explains that the nature of medicine itself is a profession—a vocation—based on healing; further, that this raises certain expectations and implies particular requirements on the part of the physician. Commiseration and humaneness are cited as unique virtues to our profession, just as truth is to a judge. The third source of a professional basis of ethics is the physician–patient relationship itself. Efforts to optimize this was a factor in drafting of the 1847 Oath of the American Medical Association (AMA).6 The AMA has a long history of recognizing the ethical basis of medical practice and identifies responsibility to the patient as foremost.10 The Table outlines the Principles of Medical Ethics—standards of conduct adopted by the AMA’s House of Delegates on June 17, 2001.
Humanism in Medicine
Pellegrino closes with a discussion defining humanistic characteristics of the medical profession. As physicians, when we are sought out to help our patients, we are professing to be competent and moreover that we will strive to use this competency to improve their total health, in all aspects of social, emotional, and physiological life. This is “a promise that we will not place our own interest first, that we will not exploit the vulnerability of those we serve, that we will honor the trust that illness forces upon those who are ill.”9
Pellegrino challenges the professed healer, the “one who declares aloud” to be mindful of and faithful to the fact that this role dictates a moral responsibility to uphold ethics in the practice of his or her art. He reminds us that the profession of medicine has its own unique philosophy that unites those who are called to this vocation and moreover that these accepted medical ethics are based upon the unique relationship between the physician and patient.
Richard Colgan, MD, is the vice chair of medical student education and clinical operations, as well as a professor at the University of Maryland School of Medicine, Department of Family and Community Medicine in Baltimore, MD. He is the author of Advice to the Healer: On the Art of Caring.
References:
1. Plato, Sachs J (translator). Plato: Theaetetus. Newburyport, MA: Focus Publishing/R Pullins Co.; 2004.
2. Hippocrates. The Oath. In: Adams F (translator). The Genuine Works of Hippocrates. Baltimore, MD: Williams and Wilkins; 1939.
3. Pellegrino ED. The commodification of medical and health care: the moral consequences of a paradigm shift from a professional to a market shift. In: Engelhardt H Jr, Jotterand F (eds). The Philosophy of Medicine Reborn A Pellegrino Reader. Notre Dame, IN: University of Notre Dame Press, 2008:101.
4. Plato. The Republic. 360 BC: 341c.
5. Plato. The Republic. 360 BC: 342c.
6. Personal communications with Dr Edmund Pellegrino, July 2008.
7. Pellegrino ED. The Virtues in Medical Practice. Oxford: Oxford University Press, 1983.
8.Pellegrino ED. Character, virtue and self interest in the ethics of the profession. In: Engelhardt H Jr, Jotterand F (eds). The Philosophy of Medicine Reborn A Pellegrino Reader. Indiana: University of Notre Dame Press; 2008:135.
9. Pellegrino ED, Thomasma DC. A Philosophical Basis of Medical Practice, A Philosophical Reconstruction of Medical Morality. Oxford: Oxford University Press; 1981.
10. American Medical Association. Principles of medical ethics. 2001. www.ama-assn.org/ama/pub/physician-resources/medical-ethics/ama-code-med…. Accessed July 1, 2014.