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JME Online First, published on March 6, 2014 as 10.1136/medethics-2013-101861 Clinical ethics
PAPER
The duty to do the best for one’s patient Roger Crisp Correspondence to Professor Roger Crisp, St Anne’s College, Oxford OX2 6HS, USA; [email protected] Received 2 October 2013 Revised 3 January 2014 Accepted 3 February 2014
ABSTRACT This paper is a discussion of the duty of doctors to do what is best for their patients. What is required by this duty is shown to depend on the circumstances, including any financial constraints on the doctor. The duty to do the best is a duty of benevolence, and this virtue itself has to be understood as bounded by other virtues, including justice and professional responsibility. An Aristotelian account of medical benevolence is developed, and the issues of supererogation and individual judgement are discussed within this framework. The paper ends with the claim that the patient-centred conception of benevolence defended in the paper is in line with consequentialist and deontological ethical traditions.
Most of us believe that doctors should have the best interests of their patients at heart, care genuinely for and about them, and—within the limits of informed consent—do what is best for them. But there appear to be practical, often resource-based constraints and indeed moral constraints which can make it difficult to do what is best. Consider first the following case.
considerably, the issue arises of whether D should ignore her instructions or at least take the matter further with her employer. I suggest that cases of the latter type probably occur quite frequently, and here D need not inform P of what she is doing, so as to avoid disappointment. The former type of case is conceivable, though far less common, if only for reasons of feasibility (doctors who consistently ignore their employer’s instructions will have their contracts terminated). In most cases, however, we shall probably hold that by prescribing t2 D is doing the best for her patient in the circumstances. But how, P might complain, can this be so? Given that she would be better off with t1, and that D is aware of this, D is knowingly doing what is worse for her. We must conclude that doing the best for one’s patient in the circumstances is sometimes not the same as doing the best possible for one’s patient. We cannot expect unlimited care from our medical practitioners. There are temporal and financial constraints within which they have to work, and it is within these constraints that they will do what is best for us. Now consider the following, more problematic case: Request. The best drug for patient P is t1, and the second-best t2. The latter is cheaper, and the doctor D has been asked, if she thinks it appropriate, to prescribe t2 in preference to t1.
Instruction. The best drug for patient P is t1, and the second-best t2. The latter is cheaper, and the doctor D has been strictly instructed by senior management to prescribe t2 in preference to t1.
To cite: Crisp R. J Med Ethics Published Online First: [please include Day Month Year] doi:10.1136/ medethics-2013-101861
This case might appear quite straightforward. But in fact it does raise some questions. First, is D required to tell P the situation regarding the drugs? This might be thought to be necessary for P to give autonomous, informed consent to being treated with t2. For one very significant characteristic of t2 is that it is inferior to t1, and since this characteristic is clearly relevant to P’s decision about her treatment it is plausible to suggest that she should know about it. One can imagine various scenarios in which the information might affect that decision. P might, for example, choose to increase her own co-payment for her treatment to cover the cost differential between t1 and t2. Or she might seek to lobby her healthcare provider or insurance company. I suggest that doctors should operate on a presumption of transparency in such cases, though there may be unusual cases in which it is advisable not to provide the patient with the information (a case, eg, in which the price differential is huge, the difference in effectiveness small, and the patient highly anxious, perhaps even to the extent that informing her would worsen her condition). Second, if the price differential is not excessive and/or the effectiveness of the two drugs varies
Crisp R. J Med Ethics 2014;0:1–4. doi:10.1136/medethics-2013-101861 Copyright Article author (or their employer)
This is a common situation, in the UK at least. How will the virtuous doctor behave in such a case? What P expects (among other things, of course) is benevolence. The benevolence in question is ‘patient-centred’ and not broadly or even narrowly impartial. So D should not take the position that she is required impartially to promote the wellbeing or health of all patients, all of the patients covered by this particular healthcare provider, or all of her own patients. The virtues bound one another.i Consider the following case, adapted from Philippa Foot (p. 72):1 Research. A medical researcher is close to finding a cure for some extremely painful condition. She is motivated by a desire to benefit humanity, and in the final stages of her research she inflicts this condition deliberately on certain people without their knowledge, so that she can test the drug she has created on them.
i
My account will be offered largely within the framework of an Aristotelian ethics of virtue. But since the most influential ethical traditions, including consequentialism and Kantian deontology, make room for virtue, my arguments will in general be applicable within these other traditions. See the final paragraph of the paper, below.
2014. Produced by BMJ Publishing Group Ltd under licence.
1
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Clinical ethics Even if her experiment is successful, we would not describe this researcher as benevolent. In this case, justice and respect for autonomy put limits on what can be done to benefit humanity as a whole. If, in Request, D were, without further thought, to prescribe t2 on the ground that she was doing what is best for patients as a whole, again, I suggest, we would not describe her behaviour as benevolent. Her duty to her patient here and now requires her to give that patient some priority over others. At this point, it may be useful to offer a brief account of what a virtue is. Aristotle has, I suggest, provided us with an excellent framework for this—his so-called ‘doctrine of the mean’. In the core statement of that doctrine, Aristotle says that virtue is concerned with feelings and actions, and that we find in these excess, deficiency and the mean. He goes on: For example, fear, confidence, appetite, anger, pity, and in general pleasure and pain can be experienced too much or too little, and in both ways not well. But to have them at the right time, about the right things, towards the right people, for the right end, and in the right way, is the mean and best; and this is the business of virtue. Similarly, there is an excess, a deficiency and a mean in actions. (ref. 2, 1106b18–24)
What Aristotle has noticed is that human life can be seen as consisting in certain ‘spheres’. Some of these spheres involve core human feelings—fear, anger and so on. Others concern actions, such as the giving away of money. Consider, then, eleutheria, generosity, the sphere of which includes the giving of money (and, confusingly, the taking of it, but we can ignore that).ii The generous person, in Aristotle’s schema, will give away money at the right time, in relation to the right things, to the right people, for the right end and in the right way. The stingy person—that is, the person with the ‘deficient’ vice—will fail to give money away at the right time, in relation to the right things and so on; while the person with the ‘excessive’ vice in this sphere—wastefulness— will benefit the wrong people, at the wrong time and so on. (Any particular individual, of course, could have both vices, as Aristotle notes) (ref. 2, 1121a30–2). Return now to the doctrine of the mean, as stated above. The word Aristotle uses for ‘right’ here is dei, an impersonal verb, which can also be, and very often is, well translated as ‘one ought’. So we now have our account of generosity: the generosity of an action consists in its being the giving away of money at the time one ought, in relation to the things one ought to be giving money away in relation to, to the people one ought, and so on. Further, the analysis extends to any virtue whatsoever. Any action is virtuous to the extent that it is the performing of an action, within the sphere of a virtue, at the right time, in relation to the right things, and so on. And any feeling is virtuous in the same way, mutatis mutandis. How will benevolence—and in particular patient-centred benevolence—fit into this framework? Benevolence is not a central virtue for Aristotle himself, but an analysis of it can be given in terms of the doctrine of the mean. Benevolence is what we might call a ‘dual aspect’ virtue. It involves a characteristic feeling— concern for another, or compassion—and characteristic action— helping that other. The notion of ‘caring’ in fact covers both of these aspects. The benevolent person will feel compassion for the right people, at the right time, in the right way and so on, and likewise respond to the needs of the right others, at the right time, in the right way and so on. As John McDowell puts it: ‘A kind person
ii
See esp.[2] (bk. 4, ch. 1).
2
has a reliable sensitivity to a certain sort of requirement which situations impose on behaviour’ (p. 142).3 And again we find benevolence as a mean between two vices. The most common, of course, is the deficient vice—the failure to care for the right people, at the right time, in the right way and so on. We might call that callousness. But one can also care for the wrong people, at the wrong time, in the wrong way and so on. We might call this vice excessive care. Some people find it hard to see how caring for others could ever be excessive. Surely, given how short of care for others we are, the more the better? But consider someone who shows condescending and inappropriate pity for people with disabilities; she feels compassion at the wrong time and towards the wrong people. In a case in which compassion for some disabled person is called for, but where the onlooker is feeling sorry for the person merely because of how they look (rather than because of the burdens imposed on them by how they look), then compassion is being felt for the wrong things and in the wrong way. Someone might feel compassion at the right time, for the right things, for the right people and to the right degree, but do so because she enjoys the self-satisfaction she achieves through reflection on how kind she is being. So her compassion is felt for the wrong end or the wrong reason. Now return to Request. What might provide the boundaries for patient-centred benevolence in such a case? One virtue that might plausibly be thought relevant is that of professional responsibility. In most cases, a doctor is required to work within the framework established by her employer and to take seriously any request issued by that employer in connection with her practice. Another, I suggest, is justice. Given that resources are scarce, and allocation procedures are reasonably fair, a doctor who ignores any suggestion to economise where possible is potentially committing an injustice in violating the rights of other patients to healthcare. We sometimes speak of a person’s being ‘too generous’ or ‘too kind’. For Aristotle, this language makes no sense. As he puts it, ‘with regard to what is best and good (virtue) is an extreme’ (ref. 2, 1107a7–8): you can’t go beyond it. This has an interesting implication, which is brought out in the following case: Instruction 2. The best drug for patient P is t1, and the second-best t2. There is not much difference, however, between the effectiveness of each. t2 is cheaper, and the doctor D has been strictly instructed to prescribe t2 in preference to t1. She entirely ignores this request, and prescribes t1.
On one common view of the virtues, in this case D’s kindness leads her to act in a potentially irresponsible and unjust way. Her kindness, demonstrated by her care, motivational and active, for her patient is beyond reproach, though she is to be criticised for ignoring the demands of professional responsibility and justice, and (we may assume) making the wrong overall decision. On the Aristotelian view, this position on the virtues ignores the fact that motivations and actions are admirable only in so far as they are constitutive of the exercise of virtue, and this requires that they be correct and guided by practical wisdom. According to the Aristotelian, D in Instruction 2 is to be criticised for getting things wrong in the spheres of responsibility and justice, and in the sphere of benevolence or kindness. Hers is an excellent example of excessive care. It might now begin to appear as if the Aristotelian doctor has turned out to be somewhat callous. Rather than caring passionately about her patient, she coolly responds to the rational Crisp R. J Med Ethics 2014;0:1–4. doi:10.1136/medethics-2013-101861
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Clinical ethics demands on her and does what the situation—rather than her heart, as we might say—calls for. This need not be the case, however. The Aristotelian doctor can care passionately for her patient; but she will also care passionately about certain other considerations and virtues, and will not allow her patient-centred concern to override her commitment to these other virtues. Further, it seems to me not inconsistent with the Aristotelian view to allow for a certain conception of priority to the patient to emerge as part of the virtue of patient-centred benevolence. Consider, then, the following case: Request 2. The best drug for patient P is t1, and the second-best t2. The difference in effectiveness between the two is not great, but it is not insignificant either. t2 is cheaper, and again the difference in price is not great, but not insignificant either. The doctor D has been asked, if she thinks it appropriate, to prescribe t2 in preference to t1.
In this case, it is quite plausible to suggest that—as far as the questions of whether t1 is sufficiently more effective than t2, and not too expensive, to justify its prescription—D has some leeway to decide between prescribing t1 and t2. As Aristotle is careful to point out, at several points, the subject-matter of ethics—real, particular, human decisions about what to do—is, to some extent, vague: The spheres of what is noble and what is just … admit of a good deal of diversity and variation…. We must … not look for the same precision in everything, but in each case whatever is in line with the subject-matter. … How far and to what extent someone must deviate before becoming blameworthy it is not easy to determine by reason, because nothing perceived by our senses is easily determined; such things are particulars, and judgement about them lies in perception. (ref. 2, 1094b14–16; 1098a26–7; 1109b20–23)
Does that mean that D can decide either way in Request 2? I suggest not: there would be something lacking in any doctor who was not, in such cases, inclined to give priority to the interests of the patient in front of her. This suggests, in fact, that this is not after all a case of vagueness. The considerations directly relevant to professional responsibility and justice may well be indeterminate; but in such cases, patient-centred benevolence requires the doctor to give priority to the patient in front of her. Here is a further puzzle arising out of the Aristotelian conception of virtue. Consider the following case: Companionship. Doctor D has, over the years, developed a fairly close relationship with patient P, whom she is currently treating for depression. P’s partner has recently died and P is lonely, especially at weekends. It is Saturday evening. D has no conflicting commitments, and could choose to visit P.
Now were D really committed to doing the best for P, she would visit her. But most of us believe that, though it would be highly commendable of D to make this visit, she is not required to do so and would not be blameworthy in the slightest for failing to do so. This is because we believe in the Christian notion of supererogation—the idea that it is possible to go, meritoriously, beyond the call of duty. In Aristotelian ethics, there is no room for supererogation. One’s duty is to act as the virtuous person would act, and, if the virtuous person would make the visit, that is D’s duty and she will be blameworthy for failing to do so. And this conception of ethics is reflected in modern thinking. We find it hard to accept that a ‘truly moral’ person might say to herself, as Sidgwick puts it: “This is the best thing on the whole for me to do, but yet it Crisp R. J Med Ethics 2014;0:1–4. doi:10.1136/medethics-2013-101861
is not my duty to do it though it is in my power.” ( p. 220).4 This seems to common sense an ‘immoral paradox’. How should a modern virtue ethicist deal with supererogation? One option, of course, would be to accept the Aristotelian position in which supererogation plays no theoretical role. A second option would be allow for different levels of virtue. ‘Basic virtue’ might be performing one’s duty and no more, while ‘ideal virtue’ would be going beyond duty (see eg, (ref. 5, p. 149)). This is likely to seem unattractive to the majority of virtue ethicists, who will prefer not to describe as virtuous the kind of agent of whom Sidgwick’s ‘immoral paradox’ is true. A final option would be to retain supererogation, and give up the idea that duty is to be defined by reference to what a virtuous person would do. Given the emphasis on modern virtue ethics on such accounts, this may seem too radical a suggestion. But in fact such accounts appear unlikely to succeed.6 Even if one is virtuous it is no reason to do an action that people like oneself characteristically act in that way. So here the thought would be that the virtuous person will do her duty and go beyond it when appropriate. But a doctor who merely does her duty is not thereby vicious. Above, we saw that Aristotle suggests that, in real decisions, judgement about them often depends on ‘perception’. The same is true for the decision-maker herself. She has to have that capacity to see things in the right way that Aristotle calls ‘practical wisdom’. This is acquired through experience of particular cases, which is why we do not find young people who are practically wise (ref. 2, 1142a11–16). Medical judgement is, of course, similar, which is why junior doctors will often defer to their seniors in diagnosing a patient. The judgements required in the kinds of case I have been discussing are not entirely medical. This is to some extent true even of judgements of effectiveness, which will require a sympathetic understanding of the impact of certain conditions on the quality of life of a particular patient. It is certainly true of judgements of cost-effectiveness, since medicine in itself tells us nothing about what treatments should cost. Should we leave these decisions entirely up to the judgement of individual doctors, informed by their experience as much as possible? This is sometimes how people seem to read Aristotle’s views on ethics, as if all the work will be done through the sensitivity of the virtuous person and none by the application of principle. In fact, however, Aristotle does allow room for principles, even in the case of the virtuous (who presumably do not need to keep reminding themselves of the need to be just, generous, even-tempered and so on). In 9.2 of the Ethics, Aristotle is discussing, in the context of a general discussion of philia or ‘interpersonal relations’, the question of different levels of obligation corresponding to different degrees of relationship with others. Aristotle claims that, in general, we should return a benefit instead of doing a favour for our friends, but notes that this isn’t always so. Consider a case in which some villain, for whatever reason, has ransomed you from kidnappers. Are you required to ransom him in return, if he is kidnapped? Or imagine that he hasn’t been kidnapped, and asks for his money back. Unfortunately, your father does require ransoming, and surely in this case you should pay the ransom rather than repay the debt. And so on. In each case we have to give to each ‘what is appropriate and fitting’. In this chapter, Aristotle comes up with various quite substantive ethical principles. You should ransom your father in preference to yourself. You should honour your parents appropriately, as well as older people in general, by giving up your seat to them, and so on. With friends and brothers you should be plain-speaking and share everything. These principles are not, we must assume, absolute. 3
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Clinical ethics That would be inconsistent with Aristotle’s stress on the unpredictability, complexity and indeterminacy of human decision-making. But they are very helpful rules of thumb. This implies that doctors might reasonably seek some rules of thumb to help them in deciding cases such as those we have been discussing. Indeed, it could be that healthcare providers themselves might provide such principles. For example—and this is only an example—it might be thought appropriate to use information about the cost-per-QALY of certain treatments to make certain pro tanto judgements about their appropriateness or inappropriateness in certain cases. Further, we should recognise that the capacity to make such practical judgements can also develop through consideration of hypothetical as well as actual cases, and this suggests an important role in medical education for consideration of such cases, articulated to some reasonable extent. In other words, it is likely to assist doctors in their moral decision-making to consider and reflect upon the real cases they have faced and are facing of conflict between a patient’s interests and other considerations, and possible cases that may arise in their practice in future. Moral judgement can be honed through the imagination as well as through reason. I can imagine a methodological objection to my overall argumentative strategy above—namely that it is excessively reliant on common-sense morality and its deliverances. This morality is quite contingent, and relying on it in this way is likely to lead to an unjustified conservatism in decision-making, even if it is made somewhat more philosophical through being developed as a form of Aristotelian virtue ethics. Perhaps, some toughminded health manager may say, doctors should be seen as mere technicians, providing the best care for patients within the financial constraints available. In the light of the ethical traditions available to us, this objection seems to me to misfire. First, broadly consequentialist or
4
utilitarian accounts will see the value in patient-centred beneficence—in the doctor-patient relationship itself, and the trust engendered by it, and indeed in the incentives it provides to the doctor to make medical decisions with care and attention to the medical condition of the patient as well as her wishes and needs. Second, deontological positions are also likely to allow room for a principle of patient-centred beneficence which requires the giving of appropriate priority to the interests of the patient. Would such a principle pass Kant’s ‘categorical imperative’ test? I see no reason why it should not. It could be argued that a rational person would want medical resources used as efficiently as possible, and so wish to avoid any person-relative moral obligations. But if that person were real, my guess is that she would much prefer a world in which doctors do care for their own patients in particular as opposed to maximising the health of some population. Acknowledgements This paper was presented in February 2011 at the Harvard University Program in Ethics and Health. I wish to thank my audience for extremely helpful comments and discussion. Competing interests None. Provenance and peer review Not commissioned; externally peer reviewed.
REFERENCES 1 2 3 4 5
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Foot P. Utilitarianism and the virtues. Repr. Moral dilemmas. Oxford: Clarendon Press, 2002:59–77. Aristotle. Ethica Nicomachea. Bywater I, ed. Oxford: Clarendon Press, 1894. McDowell J. Virtue and Reason. Repr. In: Crisp R, Slote M, eds. Virtue ethics. Oxford: Oxford University Press, 1997:141–62. Sidgwick H. The methods of ethics. 7th edn. London: Macmillan, 1907. Dreier J. Why ethical satisficing makes sense and rational satisficing doesn’t. In: Byron M, ed. Satisficing and maximizing: moral theorists on practical reason. Cambridge: Cambridge University Press, 2004:131–54. Crisp R. A Third Method of Ethics? Philos Phenomenol Res Published Online First: 25 Jul 2012. doi:10.1111/j.1933-1592.2012.00607.x
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JME Online First, published on March 6, 2014 as 10.1136/medethics-2013-101861 Clinical ethics
PAPER
The duty to do the best for one’s patient Roger Crisp Correspondence to Professor Roger Crisp, St Anne’s College, Oxford OX2 6HS, USA; [email protected] Received 2 October 2013 Revised 3 January 2014 Accepted 3 February 2014
ABSTRACT This paper is a discussion of the duty of doctors to do what is best for their patients. What is required by this duty is shown to depend on the circumstances, including any financial constraints on the doctor. The duty to do the best is a duty of benevolence, and this virtue itself has to be understood as bounded by other virtues, including justice and professional responsibility. An Aristotelian account of medical benevolence is developed, and the issues of supererogation and individual judgement are discussed within this framework. The paper ends with the claim that the patient-centred conception of benevolence defended in the paper is in line with consequentialist and deontological ethical traditions.
Most of us believe that doctors should have the best interests of their patients at heart, care genuinely for and about them, and—within the limits of informed consent—do what is best for them. But there appear to be practical, often resource-based constraints and indeed moral constraints which can make it difficult to do what is best. Consider first the following case.
considerably, the issue arises of whether D should ignore her instructions or at least take the matter further with her employer. I suggest that cases of the latter type probably occur quite frequently, and here D need not inform P of what she is doing, so as to avoid disappointment. The former type of case is conceivable, though far less common, if only for reasons of feasibility (doctors who consistently ignore their employer’s instructions will have their contracts terminated). In most cases, however, we shall probably hold that by prescribing t2 D is doing the best for her patient in the circumstances. But how, P might complain, can this be so? Given that she would be better off with t1, and that D is aware of this, D is knowingly doing what is worse for her. We must conclude that doing the best for one’s patient in the circumstances is sometimes not the same as doing the best possible for one’s patient. We cannot expect unlimited care from our medical practitioners. There are temporal and financial constraints within which they have to work, and it is within these constraints that they will do what is best for us. Now consider the following, more problematic case: Request. The best drug for patient P is t1, and the second-best t2. The latter is cheaper, and the doctor D has been asked, if she thinks it appropriate, to prescribe t2 in preference to t1.
Instruction. The best drug for patient P is t1, and the second-best t2. The latter is cheaper, and the doctor D has been strictly instructed by senior management to prescribe t2 in preference to t1.
To cite: Crisp R. J Med Ethics Published Online First: [please include Day Month Year] doi:10.1136/ medethics-2013-101861
This case might appear quite straightforward. But in fact it does raise some questions. First, is D required to tell P the situation regarding the drugs? This might be thought to be necessary for P to give autonomous, informed consent to being treated with t2. For one very significant characteristic of t2 is that it is inferior to t1, and since this characteristic is clearly relevant to P’s decision about her treatment it is plausible to suggest that she should know about it. One can imagine various scenarios in which the information might affect that decision. P might, for example, choose to increase her own co-payment for her treatment to cover the cost differential between t1 and t2. Or she might seek to lobby her healthcare provider or insurance company. I suggest that doctors should operate on a presumption of transparency in such cases, though there may be unusual cases in which it is advisable not to provide the patient with the information (a case, eg, in which the price differential is huge, the difference in effectiveness small, and the patient highly anxious, perhaps even to the extent that informing her would worsen her condition). Second, if the price differential is not excessive and/or the effectiveness of the two drugs varies
Crisp R. J Med Ethics 2014;0:1–4. doi:10.1136/medethics-2013-101861 Copyright Article author (or their employer)
This is a common situation, in the UK at least. How will the virtuous doctor behave in such a case? What P expects (among other things, of course) is benevolence. The benevolence in question is ‘patient-centred’ and not broadly or even narrowly impartial. So D should not take the position that she is required impartially to promote the wellbeing or health of all patients, all of the patients covered by this particular healthcare provider, or all of her own patients. The virtues bound one another.i Consider the following case, adapted from Philippa Foot (p. 72):1 Research. A medical researcher is close to finding a cure for some extremely painful condition. She is motivated by a desire to benefit humanity, and in the final stages of her research she inflicts this condition deliberately on certain people without their knowledge, so that she can test the drug she has created on them.
i
My account will be offered largely within the framework of an Aristotelian ethics of virtue. But since the most influential ethical traditions, including consequentialism and Kantian deontology, make room for virtue, my arguments will in general be applicable within these other traditions. See the final paragraph of the paper, below.
2014. Produced by BMJ Publishing Group Ltd under licence.
1
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Clinical ethics Even if her experiment is successful, we would not describe this researcher as benevolent. In this case, justice and respect for autonomy put limits on what can be done to benefit humanity as a whole. If, in Request, D were, without further thought, to prescribe t2 on the ground that she was doing what is best for patients as a whole, again, I suggest, we would not describe her behaviour as benevolent. Her duty to her patient here and now requires her to give that patient some priority over others. At this point, it may be useful to offer a brief account of what a virtue is. Aristotle has, I suggest, provided us with an excellent framework for this—his so-called ‘doctrine of the mean’. In the core statement of that doctrine, Aristotle says that virtue is concerned with feelings and actions, and that we find in these excess, deficiency and the mean. He goes on: For example, fear, confidence, appetite, anger, pity, and in general pleasure and pain can be experienced too much or too little, and in both ways not well. But to have them at the right time, about the right things, towards the right people, for the right end, and in the right way, is the mean and best; and this is the business of virtue. Similarly, there is an excess, a deficiency and a mean in actions. (ref. 2, 1106b18–24)
What Aristotle has noticed is that human life can be seen as consisting in certain ‘spheres’. Some of these spheres involve core human feelings—fear, anger and so on. Others concern actions, such as the giving away of money. Consider, then, eleutheria, generosity, the sphere of which includes the giving of money (and, confusingly, the taking of it, but we can ignore that).ii The generous person, in Aristotle’s schema, will give away money at the right time, in relation to the right things, to the right people, for the right end and in the right way. The stingy person—that is, the person with the ‘deficient’ vice—will fail to give money away at the right time, in relation to the right things and so on; while the person with the ‘excessive’ vice in this sphere—wastefulness— will benefit the wrong people, at the wrong time and so on. (Any particular individual, of course, could have both vices, as Aristotle notes) (ref. 2, 1121a30–2). Return now to the doctrine of the mean, as stated above. The word Aristotle uses for ‘right’ here is dei, an impersonal verb, which can also be, and very often is, well translated as ‘one ought’. So we now have our account of generosity: the generosity of an action consists in its being the giving away of money at the time one ought, in relation to the things one ought to be giving money away in relation to, to the people one ought, and so on. Further, the analysis extends to any virtue whatsoever. Any action is virtuous to the extent that it is the performing of an action, within the sphere of a virtue, at the right time, in relation to the right things, and so on. And any feeling is virtuous in the same way, mutatis mutandis. How will benevolence—and in particular patient-centred benevolence—fit into this framework? Benevolence is not a central virtue for Aristotle himself, but an analysis of it can be given in terms of the doctrine of the mean. Benevolence is what we might call a ‘dual aspect’ virtue. It involves a characteristic feeling— concern for another, or compassion—and characteristic action— helping that other. The notion of ‘caring’ in fact covers both of these aspects. The benevolent person will feel compassion for the right people, at the right time, in the right way and so on, and likewise respond to the needs of the right others, at the right time, in the right way and so on. As John McDowell puts it: ‘A kind person
ii
See esp.[2] (bk. 4, ch. 1).
2
has a reliable sensitivity to a certain sort of requirement which situations impose on behaviour’ (p. 142).3 And again we find benevolence as a mean between two vices. The most common, of course, is the deficient vice—the failure to care for the right people, at the right time, in the right way and so on. We might call that callousness. But one can also care for the wrong people, at the wrong time, in the wrong way and so on. We might call this vice excessive care. Some people find it hard to see how caring for others could ever be excessive. Surely, given how short of care for others we are, the more the better? But consider someone who shows condescending and inappropriate pity for people with disabilities; she feels compassion at the wrong time and towards the wrong people. In a case in which compassion for some disabled person is called for, but where the onlooker is feeling sorry for the person merely because of how they look (rather than because of the burdens imposed on them by how they look), then compassion is being felt for the wrong things and in the wrong way. Someone might feel compassion at the right time, for the right things, for the right people and to the right degree, but do so because she enjoys the self-satisfaction she achieves through reflection on how kind she is being. So her compassion is felt for the wrong end or the wrong reason. Now return to Request. What might provide the boundaries for patient-centred benevolence in such a case? One virtue that might plausibly be thought relevant is that of professional responsibility. In most cases, a doctor is required to work within the framework established by her employer and to take seriously any request issued by that employer in connection with her practice. Another, I suggest, is justice. Given that resources are scarce, and allocation procedures are reasonably fair, a doctor who ignores any suggestion to economise where possible is potentially committing an injustice in violating the rights of other patients to healthcare. We sometimes speak of a person’s being ‘too generous’ or ‘too kind’. For Aristotle, this language makes no sense. As he puts it, ‘with regard to what is best and good (virtue) is an extreme’ (ref. 2, 1107a7–8): you can’t go beyond it. This has an interesting implication, which is brought out in the following case: Instruction 2. The best drug for patient P is t1, and the second-best t2. There is not much difference, however, between the effectiveness of each. t2 is cheaper, and the doctor D has been strictly instructed to prescribe t2 in preference to t1. She entirely ignores this request, and prescribes t1.
On one common view of the virtues, in this case D’s kindness leads her to act in a potentially irresponsible and unjust way. Her kindness, demonstrated by her care, motivational and active, for her patient is beyond reproach, though she is to be criticised for ignoring the demands of professional responsibility and justice, and (we may assume) making the wrong overall decision. On the Aristotelian view, this position on the virtues ignores the fact that motivations and actions are admirable only in so far as they are constitutive of the exercise of virtue, and this requires that they be correct and guided by practical wisdom. According to the Aristotelian, D in Instruction 2 is to be criticised for getting things wrong in the spheres of responsibility and justice, and in the sphere of benevolence or kindness. Hers is an excellent example of excessive care. It might now begin to appear as if the Aristotelian doctor has turned out to be somewhat callous. Rather than caring passionately about her patient, she coolly responds to the rational Crisp R. J Med Ethics 2014;0:1–4. doi:10.1136/medethics-2013-101861
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Clinical ethics demands on her and does what the situation—rather than her heart, as we might say—calls for. This need not be the case, however. The Aristotelian doctor can care passionately for her patient; but she will also care passionately about certain other considerations and virtues, and will not allow her patient-centred concern to override her commitment to these other virtues. Further, it seems to me not inconsistent with the Aristotelian view to allow for a certain conception of priority to the patient to emerge as part of the virtue of patient-centred benevolence. Consider, then, the following case: Request 2. The best drug for patient P is t1, and the second-best t2. The difference in effectiveness between the two is not great, but it is not insignificant either. t2 is cheaper, and again the difference in price is not great, but not insignificant either. The doctor D has been asked, if she thinks it appropriate, to prescribe t2 in preference to t1.
In this case, it is quite plausible to suggest that—as far as the questions of whether t1 is sufficiently more effective than t2, and not too expensive, to justify its prescription—D has some leeway to decide between prescribing t1 and t2. As Aristotle is careful to point out, at several points, the subject-matter of ethics—real, particular, human decisions about what to do—is, to some extent, vague: The spheres of what is noble and what is just … admit of a good deal of diversity and variation…. We must … not look for the same precision in everything, but in each case whatever is in line with the subject-matter. … How far and to what extent someone must deviate before becoming blameworthy it is not easy to determine by reason, because nothing perceived by our senses is easily determined; such things are particulars, and judgement about them lies in perception. (ref. 2, 1094b14–16; 1098a26–7; 1109b20–23)
Does that mean that D can decide either way in Request 2? I suggest not: there would be something lacking in any doctor who was not, in such cases, inclined to give priority to the interests of the patient in front of her. This suggests, in fact, that this is not after all a case of vagueness. The considerations directly relevant to professional responsibility and justice may well be indeterminate; but in such cases, patient-centred benevolence requires the doctor to give priority to the patient in front of her. Here is a further puzzle arising out of the Aristotelian conception of virtue. Consider the following case: Companionship. Doctor D has, over the years, developed a fairly close relationship with patient P, whom she is currently treating for depression. P’s partner has recently died and P is lonely, especially at weekends. It is Saturday evening. D has no conflicting commitments, and could choose to visit P.
Now were D really committed to doing the best for P, she would visit her. But most of us believe that, though it would be highly commendable of D to make this visit, she is not required to do so and would not be blameworthy in the slightest for failing to do so. This is because we believe in the Christian notion of supererogation—the idea that it is possible to go, meritoriously, beyond the call of duty. In Aristotelian ethics, there is no room for supererogation. One’s duty is to act as the virtuous person would act, and, if the virtuous person would make the visit, that is D’s duty and she will be blameworthy for failing to do so. And this conception of ethics is reflected in modern thinking. We find it hard to accept that a ‘truly moral’ person might say to herself, as Sidgwick puts it: “This is the best thing on the whole for me to do, but yet it Crisp R. J Med Ethics 2014;0:1–4. doi:10.1136/medethics-2013-101861
is not my duty to do it though it is in my power.” ( p. 220).4 This seems to common sense an ‘immoral paradox’. How should a modern virtue ethicist deal with supererogation? One option, of course, would be to accept the Aristotelian position in which supererogation plays no theoretical role. A second option would be allow for different levels of virtue. ‘Basic virtue’ might be performing one’s duty and no more, while ‘ideal virtue’ would be going beyond duty (see eg, (ref. 5, p. 149)). This is likely to seem unattractive to the majority of virtue ethicists, who will prefer not to describe as virtuous the kind of agent of whom Sidgwick’s ‘immoral paradox’ is true. A final option would be to retain supererogation, and give up the idea that duty is to be defined by reference to what a virtuous person would do. Given the emphasis on modern virtue ethics on such accounts, this may seem too radical a suggestion. But in fact such accounts appear unlikely to succeed.6 Even if one is virtuous it is no reason to do an action that people like oneself characteristically act in that way. So here the thought would be that the virtuous person will do her duty and go beyond it when appropriate. But a doctor who merely does her duty is not thereby vicious. Above, we saw that Aristotle suggests that, in real decisions, judgement about them often depends on ‘perception’. The same is true for the decision-maker herself. She has to have that capacity to see things in the right way that Aristotle calls ‘practical wisdom’. This is acquired through experience of particular cases, which is why we do not find young people who are practically wise (ref. 2, 1142a11–16). Medical judgement is, of course, similar, which is why junior doctors will often defer to their seniors in diagnosing a patient. The judgements required in the kinds of case I have been discussing are not entirely medical. This is to some extent true even of judgements of effectiveness, which will require a sympathetic understanding of the impact of certain conditions on the quality of life of a particular patient. It is certainly true of judgements of cost-effectiveness, since medicine in itself tells us nothing about what treatments should cost. Should we leave these decisions entirely up to the judgement of individual doctors, informed by their experience as much as possible? This is sometimes how people seem to read Aristotle’s views on ethics, as if all the work will be done through the sensitivity of the virtuous person and none by the application of principle. In fact, however, Aristotle does allow room for principles, even in the case of the virtuous (who presumably do not need to keep reminding themselves of the need to be just, generous, even-tempered and so on). In 9.2 of the Ethics, Aristotle is discussing, in the context of a general discussion of philia or ‘interpersonal relations’, the question of different levels of obligation corresponding to different degrees of relationship with others. Aristotle claims that, in general, we should return a benefit instead of doing a favour for our friends, but notes that this isn’t always so. Consider a case in which some villain, for whatever reason, has ransomed you from kidnappers. Are you required to ransom him in return, if he is kidnapped? Or imagine that he hasn’t been kidnapped, and asks for his money back. Unfortunately, your father does require ransoming, and surely in this case you should pay the ransom rather than repay the debt. And so on. In each case we have to give to each ‘what is appropriate and fitting’. In this chapter, Aristotle comes up with various quite substantive ethical principles. You should ransom your father in preference to yourself. You should honour your parents appropriately, as well as older people in general, by giving up your seat to them, and so on. With friends and brothers you should be plain-speaking and share everything. These principles are not, we must assume, absolute. 3
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Clinical ethics That would be inconsistent with Aristotle’s stress on the unpredictability, complexity and indeterminacy of human decision-making. But they are very helpful rules of thumb. This implies that doctors might reasonably seek some rules of thumb to help them in deciding cases such as those we have been discussing. Indeed, it could be that healthcare providers themselves might provide such principles. For example—and this is only an example—it might be thought appropriate to use information about the cost-per-QALY of certain treatments to make certain pro tanto judgements about their appropriateness or inappropriateness in certain cases. Further, we should recognise that the capacity to make such practical judgements can also develop through consideration of hypothetical as well as actual cases, and this suggests an important role in medical education for consideration of such cases, articulated to some reasonable extent. In other words, it is likely to assist doctors in their moral decision-making to consider and reflect upon the real cases they have faced and are facing of conflict between a patient’s interests and other considerations, and possible cases that may arise in their practice in future. Moral judgement can be honed through the imagination as well as through reason. I can imagine a methodological objection to my overall argumentative strategy above—namely that it is excessively reliant on common-sense morality and its deliverances. This morality is quite contingent, and relying on it in this way is likely to lead to an unjustified conservatism in decision-making, even if it is made somewhat more philosophical through being developed as a form of Aristotelian virtue ethics. Perhaps, some toughminded health manager may say, doctors should be seen as mere technicians, providing the best care for patients within the financial constraints available. In the light of the ethical traditions available to us, this objection seems to me to misfire. First, broadly consequentialist or
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utilitarian accounts will see the value in patient-centred beneficence—in the doctor-patient relationship itself, and the trust engendered by it, and indeed in the incentives it provides to the doctor to make medical decisions with care and attention to the medical condition of the patient as well as her wishes and needs. Second, deontological positions are also likely to allow room for a principle of patient-centred beneficence which requires the giving of appropriate priority to the interests of the patient. Would such a principle pass Kant’s ‘categorical imperative’ test? I see no reason why it should not. It could be argued that a rational person would want medical resources used as efficiently as possible, and so wish to avoid any person-relative moral obligations. But if that person were real, my guess is that she would much prefer a world in which doctors do care for their own patients in particular as opposed to maximising the health of some population. Acknowledgements This paper was presented in February 2011 at the Harvard University Program in Ethics and Health. I wish to thank my audience for extremely helpful comments and discussion. Competing interests None. Provenance and peer review Not commissioned; externally peer reviewed.
REFERENCES 1 2 3 4 5
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Foot P. Utilitarianism and the virtues. Repr. Moral dilemmas. Oxford: Clarendon Press, 2002:59–77. Aristotle. Ethica Nicomachea. Bywater I, ed. Oxford: Clarendon Press, 1894. McDowell J. Virtue and Reason. Repr. In: Crisp R, Slote M, eds. Virtue ethics. Oxford: Oxford University Press, 1997:141–62. Sidgwick H. The methods of ethics. 7th edn. London: Macmillan, 1907. Dreier J. Why ethical satisficing makes sense and rational satisficing doesn’t. In: Byron M, ed. Satisficing and maximizing: moral theorists on practical reason. Cambridge: Cambridge University Press, 2004:131–54. Crisp R. A Third Method of Ethics? Philos Phenomenol Res Published Online First: 25 Jul 2012. doi:10.1111/j.1933-1592.2012.00607.x
Crisp R. J Med Ethics 2014;0:1–4. doi:10.1136/medethics-2013-101861
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The duty to do the best for one's patient Roger Crisp J Med Ethics published online March 6, 2014
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