A virtue ethics perspective on bioethics

Abstract

The emergence of contemporary forms of virtue ethics in recent decades has challenged familiar Kantian and Utilitarian ethical theories, and its emphasis on moral psychology and human flourishing has led to many innovations in ethical theory. This philosophical work on virtue ethics has led to a corresponding development of virtue ethics approaches to bioethics, in ways which are independent of Kantian and Utilitarian approaches. In this article I outline key distinctive features of virtue ethics, briefly explaining its origins in Aristotle's ethics. I then indicate how virtue ethics has been illuminatingly applied to several issues in bioethics, such as abortion, prebirth testing, euthanasia, and health care practice. I also sketch how virtue ethics might be plausibly extended to the formulation of policy governing the practice of health care.

Resumen

El surgimiento de las formas contemporáneas de la ética de las virtudes en décadas recientes ha presentado un desafío a las bien conocidas teorías éticas kantiana y utilitarista, y su énfasis en la psicología moral y el florecimiento humano ha llevado a muchas innovaciones en la teoría ética. El trabajo filosófico en la ética de las virtudes ha conducido al correspondiente desarrollo de enfoques de esa ética orientados a la bioética, en formas que son independientes de los métodos kantianos y utilitaristas. En este artículo, describo características distintivas fundamentales de la ética de las virtudes, y explico brevemente sus orígenes en la ética de Aristóteles. Luego, señalo cómo la ética de las virtudes se ha aplicado de forma esclarecedora a diversas cuestiones bioéticas, tales como el aborto, los diagnósticos prenatales, la eutanasia y la práctica del cuidado médico. También explico a grandes rasgos cómo la ética de las virtudes podría extenderse de manera admisible a la formulación de políticas que rijan la práctica de la atención médica.

Introduction

The excitement of the renewed focus on virtues in recent normative ethics has generated a corresponding new wave of work applying virtue ethics to issues in bioethics. Many central bioethical concerns, such as abortion, end-of-life decision-making, and truth-telling in patient care, have now been viewed through the lens of virtue ethics, and this approach is now also being fruitfully applied to various emerging issues, such as genetic testing, and the ethics of human enancement.

Of course, traditional discussions of medical ethics before the inauguration of the broad discipline of bioethics in the early 1970s often drew on virtue terms in evaluating how doctors should behave in clinical practice. In 19^th-century America, for example, graduating doctors were urged (commonly by well-known Protestant clergymen) to aspire to ideals of personal integrity and ‘high moral character’, to be worthy of the trust placed in them by patients (see Imber, 2008). Indeed, personal and professional integrity appear then to have been regarded as synonymous, whereas today's doctors tend to see professional integrity as a matter of serving the goals of medicine in their professional roles, whether or not they have high standards of personal integrity outside that professional context.

In this article I outline some key features of Virtue ethics, indicating how it differs from Utilitarian and Kantian approaches to ethics. I then discuss how virtue ethics approaches have been applied in several important areas in bioethics, such as the morality of abortion, prebirth testing, euthanasia, health care practice, and health care policy.

Key features of virtue ethics

The most fundamental claim made by virtue ethics as a theory of right action is that reference to character and virtue are essential in the justification of right action (see Hursthouse, 1999, pp. 28-31). A virtue-ethics-criterion right action can be stated initially in broad terms as holding that an action is right if and only if it is what an agent with a virtuous character would do in the circumstances (see Hursthouse, 1991, p. 225). That is, a right action is one that a virtuous person would do in the circumstances, and what makes the action right is that it is what a person with a virtuous character would do here.

An important qualification was subsequently made to this initial statement of a virtue-ethics-criterion of right action. In responding to concerns that even virtuous agents might occasionally act wrongly when they act contrary to their virtuous characters, Rosalind Hursthouse stipulated that the virtuous exemplar in the above criterion of right action must be understood to be acting in character (Hursthouse, 1999, p. 28). Other variants of virtue ethics have recently been developed that specify the link between virtue and right action somewhat differently from that mentioned above. For example, Christine Swanton (2003) advocates what she calls a ‘target-centered’ approach, whereby virtuous actions are those that hit the target – realize the proper goal – of the virtue relevant to the context, and right actions are those that are overall virtuous in the circumstances in which the actual agent finds themselves (pp. 228-40). Nevertheless, the primacy given to character in both of these versions helps to distinguish virtue ethics from standard forms of Kantianism, Utilitarianism, and Consequentialism, whereby actions are justified according to rules or outcomes.

Of course, if virtue ethics is to guide and justify actions, this criterion clearly needs to be supplemented by an account of which character-traits count as virtues. (Similarly, a rule-utilitarian criterion of right action needs to be supplemented by an account of which universally adopted rules maximize utility.) Nevertheless, the above formulations already highlight a key difference between virtue ethics and standard Kantian and Utilitarian approaches, whereby the rightness of an act is determined by whether the act is in accordance with certain rules, or by whether it maximizes expected utility, respectively. For neither of those approaches, as standardly defined, make reference to character essential to the justification of right action. For example, Utilitarians like Henry Sidgwick (1981, p. 227) saw virtues such as generosity, gratitude, and courage as instrumentally valuable, insofar as they help to bring about the pleasure and happiness of sentient beings, or a life of ‘desirable consciousness’ (especially in circumstances where we have insufficient time to deliberate).

It is important to clarify that doing what the virtuous agent would do involves not merely the performance of certain acts, but requires acting from certain dispositions and (in many cases) certain motives. For example, acting as someone with the virtue of benevolence would act involves not only providing assistance to another person but also includes having and acting from a genuine concern for their well-being, and a disposition to have and act from that concern in particular kinds of situations. As Aristotle (1980, VI, 13, 1144b26-9) put it, “It is not merely the state in accordance with the right rule, but the state that implies the presence of the right rule, that is virtue”. Acting as the virtuous agent would act typically involves acting from certain motives – though one can act justly from a variety of motives, so long as one acts from a disposition that incorporates an appropriate sense of justice. Every virtue can be thought to embody a regulative ideal, involving the internalization of a certain conception of excellence such that one is able to adjust one's motivation and conduct so that they conform to that standard. Indeed, Julia Annas (2011) has argued that the nature of virtues must be understood by grasping how virtues are acquired, in the way that skills like piano-playing are acquired. That is, virtues should be viewed as comparable to skills “that exhibit the practical intelligence of the skilled craftsperson or athlete” (Annas, 2011, p. 169). Annas argues that “part of the attraction of an ethics of virtue has always been the point that virtue is familiar and recognizable by all, so it would still be a damaging result if virtue is hopelessly unattainable by all but a few”(p. 173; see also Russell, 2009).

A key difference between virtue ethics and standard Utilitarian and Kantian ethical theories is the close connection typically drawn by virtue ethics between motive and rightness. Most forms of Utilitarianism and Kantianism hold that, generally speaking, one can act rightly, whatever one's motivation – so long as one maximizes expected utility or acts in accordance with duty, one has done the right thing, whether one's motives were praiseworthy, reprehensible, or neutral. However, as we have seen, virtue ethics typically holds that acting rightly (in most situations) requires acting from a particular sort of motivation, since this is part of what is involved in doing what a virtuous person would do in the circumstances. Indeed, Michael Slote (2001, 2007) has developed an ‘agent-based’ virtue ethics, whereby an action is right if and only if it is done from a virtuous motive, such as benevolence. Acting from the virtuous motive of benevolence, in Slote's view, is not simply acting to help another from a warm-hearted feeling towards them, but involves seeking via an active capacity for empathy to understand their plight, and monitoring one's action to see that it is actually helping.

Distinguishing virtue ethics more fully from contemporary versions of Kantian and Utilitarian approaches requires filling in the details about which character-traits count as virtues (see Oakley, 1996). So, just as Kantians and Utilitarians need to detail their general criteria of rightness by specifying which rules we are to act in accordance with, or what expected utility consists of, virtue ethicists must likewise provide details about what the virtues are. For virtue ethics to be capable of guiding action, the criterion of right action outlined above needs to be completed with an account of the virtues. The distinctiveness of virtue ethics compared to other theories is brought out more fully when we consider the ways in which advocates of the approach ground the normative conceptions in the character of the virtuous agent.

Many virtue ethicists hold the Aristotelian view that virtues are character traits that we need to live humanly flourishing lives. In this view, developed principally by Foot (1978, 2001) and Hursthouse (1987, 1999), benevolence and justice are virtues because they are part of an interlocking web of intrinsic goods – which includes friendship, integrity and knowledge – without which we cannot have eudaimonia. According to Aristotle, the characteristic activity of human beings is the exercise of our rational capacity, and only by living virtuously is our rational capacity to guide our lives expressed in an excellent way. Construing virtues as character traits that humans need to flourish, Hursthouse argues that what makes a character trait a virtue in humans is that it serves well the following four ‘naturalistic’ ends: individual survival, individual characteristic enjoyment and freedom from pain, the good functioning of the social group, and the continuance of the species (1999, pp. 200-1, 208, 248). Aristotle argues that each virtue can be understood as involving hitting the mean between two vices – for example, the virtue of courage is the mean between the vices of cowardice and rashness. However, Aristotle realizes that telling us to aim at a mean between excess and defect is vague: “if a man had only this knowledge he would be none the wiser – eg, we should not know what sort of medicines to apply to our body if some were to say ‘all those which the medical art prescribes, and which agree with the practice of one who possesses the art”’ (1980, VI, 1, 1138b29-33). So Aristotle proceeds to develop his account of ethical judgment as practical wisdom (phronesis), as a way of explaining how virtues can guide actions.

A different approach to grounding the virtues, pioneered by Michael Slote (1992), rejects the eudaimonist idea of Aristotle that virtues are found by considering what humans need in order to flourish, and instead derives virtues from our commonsense views about what character traits we typically find admirable – as exemplified in the lives of figures such as Albert Einstein and Mother Teresa – whether or not those traits help an individual to flourish. Swanton (2003) also rejects Aristotelian eudaimonism, and argues that virtues are dispositions to respond to morally significant features of objects in an excellent way, whether or not such dispositions are good for the person who has them. For example, Swanton (2203, pp. 82-3) argues that a great artist's creative drive can be a virtue, even if this drive leads the artist to suffer bipolar disorder – such an artist's creative drive need not bring flourishing, but Swanton argues it is nevertheless an excellent way of responding to value, and can certainly result in a life that is justifiably regarded as successful in some sense.

Applications of virtue ethics to bioethics

Reproductive ethics

A pioneering influence on applications of contemporary virtue ethics to issues in bioethics was Rosalind Hursthouse's early work on the ethics of abortion. In her book Beginning Lives (1987) and her subsequent article ‘Virtue Theory and Abortion’ (1991), Hursthouse argued that the morality of an abortion decision depends importantly on the sort of character a woman expresses in making such a decision in her particular circumstances. For instance, it would be cowardly to have an abortion out of fear of parenthood when one is otherwise well-positioned to become a parent, and having a late abortion in order to avoid postponing an overseas holiday would exhibit a callous and self-centered attitude. However, an adolescent girl who terminates her pregnancy because she does not feel ready for motherhood yet shows an appropriate level of humility about her current level of psychological development. Hursthouse argues that these judgments are justifiable because parenthood and childbearing are intrinsically worthwhile, and are part of a flourishing human life. This does not entail that one cannot flourish without becoming a parent, just as claims about the intrinsic value of, say, artistic accomplishment do not entail that one cannot flourish without being an artist. While humanly flourishing lives are plausibly thought to include certain core intrinsic goods (such as justice, integrity, understanding, and friendship), such a life need not (and indeed, arguably could not) contain all intrinsic goods. Nevertheless, Hursthouse is arguing that parenthood and childbearing can be integral parts of certain flourishing human lives. Hursthouse thereby demonstrates how individuals can exercise their rights virtuously or viciously, and so she suggests that the traditional abortion debate about the competing rights of the mother and the fetus misses what is crucial to the morality of abortion.

Virtue ethics has also been applied to other issues in reproductive ethics, such as embryo selection in preimplantation genetic diagnosis (PGD). Rosalind McDougall (2005, 2007, 2009) argues that decisions to select a particular embryo for implantation on the basis of sex or disability should be evaluated in terms of whether a virtuous parent would make such a decision in the circumstances. According to McDougall's parental virtues approach, “an action is right if and only if it is what a virtuous parent would do in the circumstances” (2005, p. 602). McDougall provides an account of three key parental virtues, which she characterizes as ‘acceptingness’, ‘committedness’, and ‘future-agent-focus’, and she argues that these three traits are also virtues for prospective parents who are considering selective reproduction decisions. In this approach, non-medical sex selection is wrong because it is contrary to the parental virtue of acceptingness (2005, p. 601). McDougall (2007) also uses this framework to evaluate decisions to select for a particular disability, such asdeafness, as American deaf couple Sharon Duchesneau and Candy McCullough did in a much-discussed 2002 case. Selecting an embryo for implantation because one wants a child to be deaf like oneself is, McDougall argues, also contrary to the parental virtue of acceptingness.

Virtue ethics can also illuminate more general questions about the ethics of reproductive decisions. Decisions to reproduce can sometimes express morally questionable motives and attitudes. For instance, someone might decide that they wish to have a child to save a failing relationship, or as a misguided means towards ‘genetic immortality’, or so that they might have someone to provide care for them when they grow old. Virtue ethics could evaluate the overall morality of a decision to have a child not only according to a person's or couple's motivations in reproducing, but also according to the intrinsic goods such decisions enable us to realize. That is, deciding to have a child from morally dubious motives, like wanting to save a failing relationship, does not necessarily make such a decision morally wrong. If procreation and parenthood are themselves correctly regarded as intrinsically good, then once decided upon, their value could be somewhat independent of a person's motives for undertaking to procreate and become a parent in the first place. In any case, clearly people can decide to reproduce and become parents for unselfish reasons, such as deciding to become a parent to develop parental love. Having a child because one wants to love the resulting child is not obviously a self-serving thing to do. (Indeed, the desire to love one's child has been mentioned by many intending and actual parents in studies over the last forty years as one of their strongest and most common reproductive motivations.) Virtue ethics can thus help to bring out what is especially valuable about reproductive liberty generally – that is, reproductive liberty provides us with an opportunity to develop and have parental love.

Health care practice

Virtue ethics has also been constructively applied to a number of issues in health care practice, including truth-telling, medical futility, and whistle-blowing. Because of its teleological structure, Aristotelian virtue ethics provides an apt basis for developing an ethics of professional roles. In this approach, which character traits count as virtues is determined by their connections with eudaimonia, the overarching goal of a good human life. An account of virtues in the context of professional roles can be developed in terms of a similar teleological structure. For example, Justin Oakley and Dean Cocking (2001) argue that good professional roles must be part of a good profession, and a good profession is one that involves a commitment to a key human good, which is necessary for human flourishing. Thus, health is clearly a central goal of medicine – as Aristotle (1980, 1094a7) noted, “the end of the medical art is health” – and because of the importance of health for human flourishing, medicine would clearly count as a good profession in this approach. Which of a doctor's character-traits then count as medical virtues are the character-traits that help them serve the goal of patient health. So, virtue ethics can hold that patients ought to be told the truth about their condition, not because truth-telling maximizes utility, nor because patients have a right to know such information, but because doing so is part of having the virtue of truthfulness, and a disposition to be truthful to patients serves the medical goal of health without breaching the constraint against violating the patients autonomy. Kate Hodkinson (2008) argues that questions about nurses revealing a truthful diagnosis to a terminally ill patient should be addressed by reference to virtues like honesty, amongst others. Similarly, doctors can justifiably refuse to provide futile interventions for a dying patient because doing so would be contrary to the virtues of medical beneficence and professional integrity. A doctor in this situation could justifiably say to a patient requesting such an intervention, “I cannot with my doctor's hat on do this for you”. In addition, a doctor can justifiably report manifestly corrupt behavior by colleagues, because exposing such conduct is an exercise of the virtue of courage in this context (see Bolsin, Faunce, Oakley 2005; Hamric, Arras, and Mohrmann, 2015).

This virtue ethics approach to health professional roles has also been applied to psychiatry, nursing, and social work. For instance, Jennifer Radden and John Sadler (2010) argue that serving the proper psychiatric goals of mental health and healing requires psychiatrists to develop role-constituted virtues like self-knowledge, self-unity, and realism, along with what they call “unselfing”, whereby practitioners demonstrate a “personally effaced yet acutely attentive and affectively attuned attitude toward the patient, the relationship, and its boundaries” (p. 132). These role-specific virtues are especially important in mental health because patients are especially vulnerable to exploitation in this context. Alan Armstrong (2008, pp. 125-56) has argued that compassion, courage, and respectfulness are role virtues in nursing practice (see also Sellman, 2011), and Sarah Banks and Ann Gallagher (2009) argue that justice and courage are crucial virtues enabling practitioners to serve the proper goals of social work.

These applications of virtue ethics to health care built on earlier accounts of virtues in medicine, such as that provided by Edmund Pellegrino and David Thomasma (1993), who developed an account of virtues such as compassion, fortitude, courage, and justice in medical practice, which in turn drew on Alasdair MacIntyre's (1981, p. 178) notion of a virtue as a trait that enables one to achieve the goods internal to a practice. However, those earlier accounts were offered as supplements to rights-based or utilitarian perspectives on medical ethics, rather than as stand-alone virtue ethics approaches to medical practice.

Euthanasia

One of the first contributions to bioethics from a virtue ethics perspective is Philippa Foot's (1977) discussion of euthanasia. Foot employs an Aristotelian account of a good life in terms of human flourishing to explain when death can be a good to the person who dies. Foot argues that life is still a good when it has a minimum of basic goods such as autonomy, relationships with others, moral support, and justice, even if certain bad features, such as significant disability and suffering, are also present. But death is a good when these basic goods are absent: “On any view of the goods and evils that life can contain, it seems that a life with more evil than good could still itself be a good … It is not the mere state of being alive that can determine, or itself count as, a good, but rather life coming up to some standard of normality … Ordinary human lives, even very hard lives, contain a minimum of basic goods, but when these are absent the idea of life is no longer linked to that of good” (1977, pp. 94-5).

Thus, Foot suggests that someone can have a rational desire to die, and yet death could still be a bad for them, insofar as their life still has these basic goods, to some extent. Foot also recognizes that even where these basic goods are missing, a person might still want to live, and so justice would preclude our carrying out the act of killing that charity would normally permit us to perform in such circumstances. In reminding us that euthanasia is death brought about for the good of the person who dies rather than merely at the request of the person who dies, Foot demonstrates the relevance of the virtue of charity to the issue of when acts of euthanasia are ethically justifiable. Another important virtue ethics approach to euthanasia is Liezl van Zyl's (2000) book-length account, which highlights the virtues of compassion, benevolence, and respectfulness, as medical virtues that are especially important in end-of-life decision-making. Van Zyl also provides a set of rules to assist with determining the moral justifiability of deliberately terminating or shortening a patient's life.

Virtue ethics and health policy

Applications of virtue ethics to health care policy are still at an early stage of development. This seems partly due to an assumption that expressions of virtue by health professionals will not be readily detectable by regulators, and also because of a belief that the virtuousness of a practitioner's character (as distinct from, say, dutiful practitioner behavior) is not the proper concern of the state.

One way of developing a distinctively virtue ethics approach to health care policy might be through the links between virtuous character-traits and therapeutic doctor-patient relationships, and the impact that allowing or restricting certain practices evidently has on the proper orientation of doctor-patient relationships. A virtuous doctor's conduct in clinical practice is governed by a regulative ideal of serving the health of their patients, an ideal that a virtuous doctor has internalized as a normative disposition guiding and justifying their clinical decisions and actions, without this ideal necessarily being consciously invoked in their every decision. The governing conditions two people apply to their relationship provide a crucial way of distinguishing between various kinds of relationships, such as friendships and good doctor-patient relationships. For example, a preparedness to terminate one's professional relationship with a patient once they are healed seems perfectly compatible with this counting as a good doctor-patient relationship, whereas being disposed to terminate a personal relationship because one no longer needs assistance from the other person seems to be incompatible with that relationship being a genuine friendship (see Oakley and Cocking, 2001). If one accepts that the nature of a doctor-patient relationship – as therapeutic or otherwise – is importantly determined by the sorts of governing conditions doctors apply to their clinical decision-making about patients, then the nature of that relationship can reveal the presence (or absence) of certain medical virtues because having those virtues itself importantly involves applying certain governing conditions to one's clinical decisions and professional relationships with patients. If, for example, a doctor's prescribing decisions towards a particular patient were governed primarily by the doctor's own financial self-interest rather than by this patient's best health interests, then that clearly counts against any claim that the doctor has and acts on the virtue of medical beneficence – at least in the context of their medication-prescribing decisions regarding this patient.

The state arguably has an obligation to maintain doctors’ medical virtues, because the state already accepts a commitment to help doctors maintain the therapeutic orientation of doctor-patient relationships, and doctors’ medical virtues (or otherwise) are revealed in the nature of the professional relationships they develop and maintain with their patients. Consider, for example, the impact of direct-to-consumer-advertising of prescription pharmaceuticals on doctor-patient relationships. There is evidence that some doctors working in such environments can find it difficult to avoid acquiescing to patients’ brand-specific drug requests, even when a doctor regards the requested drug as clinically inappropriate for the patient's condition. Governments could more strictly regulate pharmaceutical direct-to-consumer advertising and could take steps to strengthen physicians’ virtue of medical beneficence where such advertising is allowed, so as to reduce levels of physician acquiescence to the clinically-inappropriate medication requests often evidently prompted by such advertising, thereby helping preserve therapeutic relationships between physicians and patients (see Oakley, 2015).

Another virtue-based approach to policy, developed by Martha Nussbaum (2006) and others, builds on Aristotle's approach in the Politics. Aristotle argues that “He who would duly inquire about the best form of a State ought first to determine which is the most choiceworthy life – for if this is unclear, the best form of political arrangement must remain unclear also” (1323a14-17). Nussbaum draws on Aristotle's view that “the form of government is best in which every man, whoever he is, can act best and live happily” (Politics 1324a23-5), and argues that the proper goal of a polity is to provide the conditions that give its citizens an equal chance of developing and exercising their capabilities to live flourishing human lives. The capabilities being referred to here include those familiar from the Nicomachean Ethics, such as being able to understand the world, to engage in practical reasoning about our lives, and to form personal relationships with others. Similarly, in developing an account of what constitutes a good family, Rosalind Hursthouse (2008) argues that a good society would support social policies that encourage and sustain good, loving families and would reject policies that tend to create dysfunctional families.

Conclusion

As the above discussion indicates, virtue ethics opens fresh new perspectives on many of the traditional issues in bioethics. Given that bioethics is concerned with some of the most fundamental topics and decisions in our lives, it should be no surprise to find that the depth of analysis provided by virtue ethics lends itself particularly well to the issues raised in this field. Indeed, there is much scope for future applications of virtue ethics to other topics in bioethics, such as public health ethics, health care resource allocation, moral enhancement, and public policy. I hope that the advances made so far stimulate the development of new virtue ethics analyses of these and various emerging issues in bioethics. This promises not only to enrich discussions in bioethics, but is in turn also likely to bring out new dimensions to virtue ethics itself.