J7ournal ofmedical , 1984, 10, 171-172 J Med Ethics: first published as 10.1136/jme.10.4.171 on 1 December 1984. Downloaded from

Editorial , , and

It is sometimes claimed that 'new fangled' in their textbook on medical ethics Beauchamp and philosophical medical ethics is unnecessary and indeed Childress say: 'In general, conscience is a mode of that it is positively disadvantageous, leading too often thought about one's acts and their rightness or 'to abstract and inconclusive argument - wrongness, goodness or badness' (5). neither conducive to postprandial reflection nor Thus it is immediately clear that claims for the necessarily relevant to the insistent demands on the adequacy of a conscience for medical ethics must busy practitioner throughout his day' (1). Particularly make clear which ofthese two ofconscience is in medical education, as Osler so quaintly put it, 'What intended. If the former, non-thinking, non-rational have bright eyes red blood quick breath and taut faculty of conscience is intended, the problem of muscles to do with ?'(2). Rather, clinicians conflict of conscience, whether intrapersonal or so often claim, all that's needed for medical ethics is a interpersonal, is left unamenable to ; Dr A's sound conscience, good , and integrity. conscience tells him to transfuse the Jehovah's Witness First, and vitally, it is important to affirm that few if regardless of her own views, Dr B's conscience tells any moral , let alone those who are him not to transfuse such a patient. Where standscopyright. specifically interested in medical ethics, would deny medical ethics? Which position is right and why? Is no that sound conscience, good character and integrity are resolution or even attempt at resolution possible or essential to moral life in general and medicomoral life desirable? Perhaps, it might be argued, attempts at in particular. But as soon as attempts are made to such resolution could be made by appealing to the explain what is meant by these claims the need for some two members of the trio, good character and sort of critical philosophical becomes integrity. They are considered below, but it is difficult apparent. to deny the possibility, at least, that Drs A and B are

Conscience, for example, turns out to be an both of good character and both people of integrity. http://jme.bmj.com/ ambiguous . On the one hand is the concept of The obvious way out of such an impasse is to choose an unthinking but morally controlling force within us the other concept of conscience, in which the exercise telling us what we should do and not do. This is the of reason is an essential element. But if that concept of concept corresponding to the Oxford English conscience is chosen the original claim - that moral Dictionary's 'internal conviction . . . the faculty or philosophy can be dispensed with, and medical ethics which pronounces upon the moral quality of be allowed to rest on conscience, good character and one's actions or motives, approving the right and integrity - becomes vacuous. For 'making reasoned condemning the wrong', and corresponding to Freud's judgements about moral questions' and 'thought about on October 2, 2021 by guest. Protected account of the 'ego-' or (later) 'superego' - the one's acts and their rightness or wrongness, goodness faculty of the in which the injunctions and or badness' are among the main constituents of the prohibitions of 'father .. . masters and others in activity of moral philosophy. ... continues in the form of conscience to Perhaps the concept of integrity can rescue the exercise the censorship ofmorals. The tension between claim? Again there is a preliminary problem of the demands of conscience and the actual attainments ambiguity: integrity can mean some morally specified of the ego is experienced as a sense of '(3). and admirable condition such as 'sinlessness ... The second concept ofconscience corresponds to the soundness of moral principle . . . uprightness, OED's 'inward .. . inmost thought . . . honesty, ' or 'the character of uncorrupted internal recognition of the moral quality of one's virtue'; alternatively and quite differently it can mean, motives and actions'. It also corresponds to many more literally, completeness or wholeness. (Dictionary analyses of conscience in the theological and definitions such as these are rarely if ever of any philosophical literature in which conscience is an substantive in philosophical discussion - but essentially rational faculty - in this journal for example they are often exceedingly valuable for showing briefly D'Arcy wrote 'my conscience is simply myself, making and conclusively that one word does in fact have reasoned judgements about moral questions' (4); and different meanings). The usual sense ofintegrity relied 172 Editorial J Med Ethics: first published as 10.1136/jme.10.4.171 on 1 December 1984. Downloaded from on in moral philosophy leans upon the latter more both deontological and utilitarian . literal concept of (moral) wholeness - it is the concept Exemplars of both categories can certainly be of one's own man or woman. It involves construed to be fundamentally concerned with the identifying oneself with a particular moral stance and good for man, and both are able to find room for the sticking to it in adversity and in the face of other , at least as means to that good, and often as temptation to abandon it; it involves a sense of what partly constitutive of that good. Be that as it may, the one can and cannot live with and is thus a fundamental important point in this context is that questions about part of one's and moral identity, one's the centrality or otherwise of the virtues are moral wholeneness. But this sense of integrity - the philosophical questions. Thus even if it were agreed sense roughly ofbeing one's own person, ofdoing one's that moral philosophy is primarily about the virtues it own moral thing - does not seem to obviate the need for would be absurd to suggest that this made it possible for moral criticism, reflection and argument any more medical ethics to do without moral philosophy. than reliance on one's (unreflective) conscience does. Unless of course the claim is that while someone may For people notoriously vary as to what they morally properly be concerned with critical study of the speaking can and cannot live with; and if impasse or virtues, doctors need not be - they only need to be is to be avoided some sort of rational reflection is virtuous, ie of good character. Once again the required. Furthermore, how is one properly to decide problems of such a claim are unpacked along with the what sort of moral agent one ought to be, where one contents. WEat are the virtues of a good doctor (or the must say 'enough, no further', without such reflection components of his good character)? This is a question and criticism? recurrently discussed by medical educators and The writes: 'one who disagreement, as well as a wide variety of proposed displays integrity acts from those dispositions and answers, is characteristic of such discussions (9). The motives which are most deeply his, and has also the idea that this question is not a proper concern of the virtues that enable him to do that' (6). Here we seem to medical profession is hardly likely to appeal to the sorts have a concept of integrity which involves both the of doctors who claim that doctors need not be sense of wholeness and also some specific virtues akin concerned with the critical study of the virtues. Yet to to the second dictionary definition of integrity. Thus answer it without such study - without critical the discussion shifts to the third member of the triad, philosophical study of the moral assumptions and copyright. good character, which is equivalent to, and in our times objectives of medical practice - is somewhat like a more common way of saying, virtuous character. Can specifying the syllabus for therapeutics while claiming reliance on good or virtuous character (in association that neither the medical students nor the doctors laying with good conscience and integrity) be sufficient for down the syllabus need know any pharmacology. Of medical ethics and obviate the need for philosophical course such ignorance used of necessity to be the case medical ethics? There seem to be two senses in which in medical training, and we look back with some regret an affirmative answer might be plausible. The first is at those times. Shall we not equally look back with

the sense in which moral philosophy is claimed to be regret at our contemporary readiness voluntarily to http://jme.bmj.com/ primarily concerned with the virtues and thus study of eschew critical moral philosophy? different sorts of moral philosophy - for instance study of deontological and utilitarian of ethics in the context of medical ethics - is claimed to be inappropriate. The second is the claim that doctors do not have to understand the philosophical underpinnings References and notes of their - they simply have to be good moral (1) Watt J. Conscience and responsibility. British medical agents - doctors of good or virtuous character. journal 1980; 281: 1687-1688. on October 2, 2021 by guest. Protected There is no that virtue theories of ethics are (2) Osler W. A way oflife. Springfield, Illinois: C C Thomas, making a comeback after having been for a long time 1969:3. The central theme of his talk to medical students, out in the philosophical cold. Geach, Foot, Von given in 1913, was that they should learn the habit of Wright, Wiggins, McDowell and Maclntyre are regular work and to live for each day. prominent in this contemporary philosophical (3) Freud S. The ego and the id and other works, 1923-1925. movement, which is largely oriented towards In: Strachey J, Freud A, Strachey A and Tyson A, eds. Aristotelian ethical The standard edition of the works of . development of , especially London: Hogarth Press and Institute of Psychoanalysis, concerning the and of 'practical vol 19: 49. reasoning', the Aristotelian claim that ethics stems (4) D'Arcy E. Conscience. J3ournal of medical ethics 1977; 3: from man's telos or proper end which is or 98-99. in the sense offlourishing, and the claim that (5) Beauchamp T L, Childress J F. of biomedical it is development and exercise of the virtues which ethics (2nd ed). New York and Oxford: Oxford University constitute such . Despite the contrary Press, 1983: 270. arguments of MacIntyre (7) there seems no reason in principle why Aristotelian virtue theory should not be compatible with contemporary moral philosophy (8) of (Continued on page 190) 190 R S Downie J Med Ethics: first published as 10.1136/jme.10.4.171 on 1 December 1984. Downloaded from them, there is still the question which Dr Boughton the setting-up of the Welfare . The idea behind raises of the procedures which it is expedient or even the Welfare State is that a person's health, education, morally permissible to use to curb it (and similar old age, and so on are too important to be left to the cut- activities). Dr Boughton notes that legislation can be and-thrust of market competition or , and that counter-productive and that education is sometimes the State should therefore provide a system more or more effective. This is true, and one could add here less free to all but paid for by graduated taxation. The that even were it the case that legislation might slogan here is: from each according to his ability, to sometimes be effective there is still the question aE to each according to his need. It was assumed by the whether there can be too high a price to pay for the pioneers ofthe Welfare State that it could be grafted on enforcement of principles which might in themselves to the liberal tradition and that economically and be desirable expressions of . Switzerland is morally we could have the best of and sometimes mentioned as a country in which the . It is this assumption that creates the enforcement of morally desirable principles has problem of the right to be unhealthy. The problem produced an undesirable social atmosphere. The arises when, in terms of one tradition, we are general point is that liberalism is not simply about what sympathetic to the right to be unhealthy and, in terms ought or ought not to be enforced but also, as Dr of the other, we have a to care for the unhealth of Boughton illustrates, about ways of proceeding to others, where 'care for' means 'pay for through heavy convince people by education and example (many taxation'. doctors and nurses smoke and drink heavily) as to how Within the tradition ofcollective socialism the terms they ought to behave towards others. 'compulsion' and '' take on a different aspect. The conceptual question of what constitutes harm to Firstly, the sharp distinction in liberalism between others is brought out in a sharp way by one of Dr your selfand its freedom and my selfand its freedom is Boughton's main conclusions, that 'compulsory health minimised; we are 'members one of another'. and safety is a very dangerous notion which may only Secondly, the State is not something alien to the self be justifiable when the public health interest, and not and its essential freedom, but rather the of the its economic interest is at stake'. But is it not true that a State are an expression of the self; as Rousseau puts it, person or a State is harmed when resources which they force us to be free. (Again, there are Christian copyright. might otherwise be used on education, housing, the antecedents for this view - 'In Thy service is perfect arts ... are directed to finance the consequences of freedom'.) What for the liberal is State 'compulsion' or avoidable self-? An answer to this question 'sterile ' constitutes for the socialist an turns on a philosophical analysis of the concept of expression of his true social self. harm, as we can see if we examine another tradition which has a different approach to 'harm' and The theoretical confusions we can find ourselves in 'compulsion' - socialism. are due to the fact that we are almost as much We tend to think of collective socialism in terms of influenced by the collectivist ideas of Christian the Soviet or Chinese varieties, but in fact there is a socialism as we are by the idea ofliberal individualism. http://jme.bmj.com/ native English variety which goes back to the Levellers Nor do I advocate any attempt to impose consistency in of the seventeenth century. Indeed, the origins of this the practicalities of the moral and political sphere. It is form ofsocialism are to be found in , which preferable to take each issue as it comes - seat belts, tells us that we are 'members one ofanother'. Whereas fluoride, boxing . . . on a pragmatic basis. And if a the tradition of liberalism stresses freedom and the preference for the muddle of piecemeal social satisfaction of individual wants, the tradition of engineering over the consistency and purity ofpolitical socialism stresses fraternity and the satisfaction of doctrine ofthe Right or the Left is still liberalism, then individual needs. It is this second tradition which led to so be it. on October 2, 2021 by guest. Protected

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(6) Williams B. Moral luck. Cambridge: Cambridge virtues. For (a these days uncommon) advocacy of University Press, 1981: 49. as a medical virtue see Pappworth M H. A primer (7) MacIntyre A. - a study in moral theory. of . (3rd ed.). London: Butterworth, 1971: 31 London: Duckworth, 1981: 216. and Linzer M. Doing what 'needs' to be done. New (8) See reference (5) 265-268, for an indication of how such England Jrournal of Medicine 1984; 310: 469-470. For a compatibility can be construed. brief non-medical account of the medical virtues see May (9) See for example Crisp A H. Selection ofmedical students W F in: Callahan D, Bok S, eds. Ethics teaching in higher - is enough? A discussion paper. Journal of education. Hastings on Hudson: Hastings Centre, 1980: the Royal of Medicine 1984; 77: 35-39, and the 230-233. authors he cites for advocacy of a wide range of medical