Excerpts from the Second Annual Jack W. Provonsha Lecture

By Edmund D. Pellegrino, MD, Director, Center for the Advanced Study of Ethics, and John Carroll, Professor of Medicine and Medical Humanities, Georgetown University, Washington, D.C.

February 15, 1989

The professions today are afflicted with a species of moral malaise that may prove fatal to their moral identities and perilous to our whole society as well. This malaise is manifest in a growing conviction even among conscientious doctors, lawyers and ministers that it is no longer possible to practice their professions within traditional ethical constraints. More specifically, the belief is taking hold that unless he looks out for his own self interest, the professional will be crushed by the forces of commercialization, competition, government regulations, malpractice, advertising, public and media hostility and a host of other inimical socioeconomic forces.

This line of reasoning leads to the conclusion that the self-interest of the professional justifies the compromises in, and even the rejection of, obligations imposed by traditional concepts of professional ethics.

I take strong exception to this line of reasoning both in its foundations and in its conclusions. I argue to the contrary: 1) that what deficiencies there are in professional morality are, as they have always been, deficiencies in character and virtue, 2) that a firm philosophical foundation exists for altruism and fidelity to trust in the ethics of the professions, 3) that professional ethics must at times be independent of conventional morality, and 4) that the professions are moral communities with enormous moral power which, properly used, can sustain the moral integrity of the practitioner and the professions. Moreover, if they use their moral power well, the professions can become paradigms of disinterested service that can raise the level of conventional morality.

This is an ambitious set of assertions. To speak of character and virtue in today's moral climate is to be suspected of sanctimoniousness or hypocrisy. We must admit that the concepts of virtue and character are two of the oldest and slipperiest in moral philosophy. Also, the proper place of self-interest in virtue ethics has never been satisfactorily settled. Finally, we still lack a coherent moral philosophy of the professions in which to locate the concepts of character, altruism and self-interest and to define the relationships between them. These difficulties not withstanding, we cannot avoid engagement with what I take to be the central crisis in the professions today -- the confusion about who and what we are, and what we should be.

Each of our professions has its own list of morally questionable practices that its members would justify on the grounds of threatened self-interest. All such practices have three features in common: First, they are based on the use of privilege and power for the personal gain of the professional. Second, they reflect a failure to take certain risks required for the well being of those whom the profession serves. Finally, in the case of both of these features, justification is sought on the grounds of legitimate self-interest. It is my conviction that these practices and the justification sought for them derive from the de-emphasis on character and virtue in the three professions we are examining.

In what follows, I examine three questions about the current moral malaise of the professions: 1) What are the reasons for the erosion of virtue ethics and the moral legitimation of self-interest in the ethics of the professions? 2) Is there a philosophical basis for restoring virtue ethics to the professions? 3) What are the practical and theoretical implications of such a return of virtue ethics?

Despite numerous efforts since then, no one has improved on Aristotle's imperfect, but still useful, definition of virtue. Aristotle identifies moral virtues as states of character, by which he means "...the things in virtue of which we stand well or badly with reference to the passions."(1) Virtue is a particular state of character, one which "...both brings into good condition the thing of which it is the excellence and makes the work of that thing be done well."(2) And further, "the virtue of a man also will be the state of character which makes a man good and which makes him do his work well."(3)

By "ethics of the professions," I do not mean the norms actually followed by professionals, or the professional codes they espouse, but rather the moral obligations deducible from the kinds of activity in which they are engaged. The ethics of the professions, therefore, consists in a rational and systematic ordering of the principles, rules, duties and virtues intrinsic to achieving the ends to which a profession is dedicated. This is the "internal morality" of a profession.(4)

"Self-interest", too, has several meanings. There is a legitimate self-interest which pertains to the duties we owe to ourselves -- duties which guard health, life, some measure of material well-being, the good of our families, friends, etc.(5)

Given the nature of professional relationships, some degree of effacement of self-interest -- which I shall take to mean the same as beneficent altruism -- is morally obligatory for health professionals.

What Accounts for the Erosion of Virtue and the Rise of Self-interest?

Let me turn now to the first of my three questions: What accounts for the erosion of virtue ethics? I would select four factors: a) the unresolved conceptual tension between virtue and self-interest, b) the conceptual difficulties of virtue ethics itself, c) the modern turn in ethics from the character of the moral agent to the resolution of dilemmas, and d) the shift in economic and political values in the last decade.

The tension between self-interest and virtue was recognized at the beginning of western moral philosophy. Plato has Socrates confront this dilemma in the Republic when Thrasymachus asserts that "justice is nothing but the interest of the stronger."(6) Glaucon for his part contends that man by nature pursues self-interest and is deflected only by law -- an idea also advanced by other ethical "relativists" like Thucydides and Gorgias. Callicles goes further and insists that virtue consists in acting selfishly and tyrannically. W. K. C. Guthrie shows how persistent the idea of self-interest and self love was in the thought of the Sophists.(7)

Aristotle too had difficulties with the reality of self-interest and its reconciliation with his doctrine of moral virtue. He asks if one should love one's self primarily, or one's neighbor.(8) At one point, he tries to show, like so many philosophers after, that acting to benefit others contributes to happiness and therefore is in one's own self-interest.(9) But this is a weak argument because Aristotle also asserts that the truly virtuous person ought to practice altruism for its own sake.(10) In his interesting analysis of this problem in Books VIII and IX of the Eudemian Ethics, Engberg Pedersen concludes that Aristotle's position is that justice is the basis of all the virtues. The virtuous person assigns no more of natural goods to himself than to others. In this way he encompasses altruism, places restraints on inordinate self-interest and serves legitimate self-interest.(11)

Despite the unresolved difficulties of dealing with the reality of self-interest, the ethics of Aristotle, Plato and the Stoics placed the emphasis squarely on virtues. Virtue ethics dominated classical and Hellenistic moral philosophy. It came to its highest development in the moral philosophy of Aquinas who joined the supernatural to the natural virtues. Thus the classical and medieval philosophies of virtue constituted a continuum.

This continuum centered on a conception of the virtuous person as one who exhibited the traits of character essential to human flourishing and to optimal fulfillment of the capabilities inherent in human nature. For such a person, self-interest was recognized as a responsibility but it was to be submerged to varying degrees by noble acts in the interests of others. The good life called for a rational balance between personal good and the good of others.(12) But the cardinal virtues -- temperance, justice, courage and prudence -- all implied some degree of effacement of self-interest as a mark of the virtuous person. At a minimum the virtuous person was not to take advantage of the vulnerability of others. As examples: Socrates chose death to teach a moral lesson to his fellow Athenians; Plato distinguished the art of making money from the art of healing;(13) Cicero admonishes the corn merchant not to raise prices when the crop is small;(14) Hippocrates makes beneficent concern for the welfare of his patients the first principle of medical ethics.(15) Thus, while they recognized the reality of self-interest, the ancient and medieval moral philosophers held firmly to virtue as the touchstone of the moral life.

In the post medieval period two philosophical assaults were launched on virtue ethics, one by Machiavelli and the other by Thomas Hobbes. Both are conceptual descendants of Thrasymachus, Callicles and the anti-virtue pre-Socratics. Both replaced the optimistic view of human nature with moral pessimism. Both found the traditional concepts of virtue antithetical to human nature and self-interest. Machiavelli simply converted the traditional virtues into vices, while Hobbes psychologized them as a form of self-interest. The Machiavellian and Hobbesian strains are the heart of today's moral malaise and cynicism which seeks to give moral legitimacy to the professionals' self-interest.

Machiavelli (1469-1527) was too well educated in classical humanism to deny totally the value of virtue as an ideal in human conduct. But his observation of the real world in which men lived -- in warfare, tyranny and political upheaval -- convinced him that there was no survival value in living virtuously. The good man simply could not thrive in a world in which so many others were not good.(16) And so Machiavelli advised the Prince who would be successful to use whatever means would ensure his survival and the continuance of his power. The classical cardinal virtues of temperance, justice, even at times fortitude and prudence, could be impediments when dealing with those who ignored these constraints on self-interest. In these circumstances the virtues thus became vices. Moreover, on the Machiavellian view, virtue itself became an instrumental notion, a power to effect a given end rather than a behavioral ideal. Indeed, for Machiavelli virtue became virtu, "manliness" -- an expression of power rather than a disposition to act well as it was understood in the classical medieval continuum.

Bernard Mandeville (1670 1773), a physician, went further than Machiavelli in some ways. Not only did he think the virtues were impractical, but he held them to be vices -- destructive not only for personal but social good. It is through greed, the desire for luxury, pleasure, and power that society prospers and things get done. The satisfaction of acquisitiveness, intemperance, and gluttony makes for jobs, puts money into the economy and provides a livelihood for many.(17) Mandeville's "Fable of the Bees," whether tongue in cheek or not, has been influential in encouraging an anti-virtue bias which has always found supporters and has many today.

Nietzsche's (1844-1900) anti-virtue stance was of a different kind but still in the Machiavellian spirit. For Nietzsche's "ubermensch", the traditional virtues were meaningless. They were simply impediments to the achievement of greatness. The virtues were for lesser mortals. For the superman, virtues like temperance or justice would be vices.(18)

A more modern exponent of a similar moral viewpoint is Ayn Rand. Her ideas, though far less well argued than those of Machiavelli, Mandeville or Nietzsche, are a current compound of all three. Rand's novels of the successful architect or industrialist extol the "virtues" of individualism, ruthlessness, power, and uninhibited pursuit of wealth and self-interest.(19) Her ideas have had a considerable influence on those who seek moral justification for their acquisitive instincts. In this regard it is interesting to note that the slogan of Regardie's magazine is "money, power, greed."

Moral Machiavellianism -- whether in its original version or its later varieties in Mandeville, Nietzsche, or Rand -- is very much alive today. We see it in the medical entrepreneurs who own hospitals or nursing homes, the lawyer power broker who sells influence or leveraged buy outs, in the multi-million dollar ministries. Indeed, all who hold that virtue simply does not pay and that it is a fool's enterprise are moral Machiavellians.

Machiavelli made the virtues into vices. Thomas Hobbes (1588 -1679), on the other hand, tried to maintain some idea of virtue which was reconcilable with self-interest. His was a formal philosophical break with the medieval tradition. His aim was to establish ethics on purely naturalistic grounds, free of the theological spirit that characterized the medieval synthesis. He built his moral philosophy on a pessimistic view of human nature that departed sharply from the essentially optimistic classical- medieval view.

Aristotle opens his Politics by asserting that man is a social animal. Man, Hobbes said, was unsocial by nature. He enters society only to satisfy his most fundamental urges. His selfishness is primary and is expressed in a desire to preserve his own life, enhance pleasure, avoid pain, and become secure from attack by others. Hobbes does not make the virtues into vices, rather he puts them at the service of self-interest. We pity others because we see the possibility of being in the position of those we pity. We are benevolent either because it gives us power or it will assure us benevolence in return. "All society" he said, "is for gain or glory."(20) We obey society's rules only because we feel if we do not, others will threaten our security. On Hobbes' view, effacement of self-interest is unnatural, because it makes us the victims of others. Self-interest determines what is good and bad. But self-interest alone will not secure a peaceable society. That must finally be secured by an absolute sovereign, or society will be torn apart by competing self-interests.

Hobbes' view on self-interest was coupled with a scorn for the good which had been vital to classical and medieval philosophy. If the good is reducible to what we like or dislike, as Hobbes suggested, then virtues and vices are also matters of preference. Hobbes' powerful assertions shaped much of English moral philosophy. His successors tried either to rebut the primacy of self-interest or reconcile it with some more altruistic principle.

John Locke (1632 1704), for example, agreed with Hobbes that good and evil are determined by pain or pleasure or conformity to some law. He did assert that we ought to help others but only if it did not endanger our own self-interest. Shaftesbury (1671 1713) tried hard to show that self-interest and service to others were synonymous. Virtues, he said, "pay off" in self-interest because of the pleasure we get from benevolent acts. The vices like anger, intemperance, and covetousness, on the other hand, bring pain. Shaftesbury thought that we ought to embrace virtue because we have an obligation to protect self-interest, so that affection for virtue is really affection for self-interest. Hutcheson (1694 1746) developed Shaftesbury's moral sense theory more fully, as did Hume (1711 1776). They identified virtue as that which gives the spectator of virtuous acts a feeling of approbation, while vicious acts elicit disapproval. They took some of the bluntness out of Hobbes' emphasis in self-interest. But they end up agreeing that we have no ultimate obligation to virtue other than its bearing on our self-interest or happiness. Adam Smith (1723 1790), too, holds that virtues are those traits of character that are useful or agreeable to the moral sentiment of the agent or others. Bentham (1748 1832) argued that whatever is conducive to the general happiness always conduces to the happiness of the agent. In this way his utilitarianism reconciles self regarding and other regarding interests by subsuming all of these interests under the principle of greatest happiness. J. S. Mill (1806 1873) went further than Bentham positing that the greatest good of all is the source of one's own happiness. One's own self-interest, therefore, is best served by acting for the good of all. On this view, consciously doing without happiness to achieve the greatest good of all is paradoxically a source of happiness.(21)

In contrast with the moral sentiment, theorists and the utilitarians, the Cambridge intuitionists like Cudworth (1617 1688), Henry More (1614 -1687), and Cumberland (1631 1718) tried to show that there were reasons for virtuous acts even if they conflicted with self-interest. More even postulated a "Boniform faculty", a virtue that gives us mastery over our baser impulses to serve selfish interests first.(22)

Bishop Joseph Butler (1692 1752) took issue with both Shaftesbury and Hobbes. Neither self love nor benevolence were the only affections involved in human behavior. Altruism and self-interest do not completely exclude other desires and motivations. Nor are benevolence and self-interest mutually exclusive. Man has a conscience which enables him to order his passions so that he can do what is good not just for self. By conscience man can know how much benevolence will advance and how much will damage his self-interest. Butler was a cleric and looked to God to implant conscience in humans to point out what action is most in conformity with human nature. Thus conscience enables us to know that some things are inherently good and some inherently bad. Butler thus invoked theology implicitly if not always explicitly, though he tried, as did Hobbes, to extract his moral philosophy from reason.(23)

Enough has been said to demonstrate how the question of altruism and self-interest arose in Hobbes and Machiavelli and established two powerful strains of thought with which moral philosophy has been occupied ever since. As I pointed out earlier, the problem arose in ancient philosophy as well. In Christian moral philosophy as enunciated by Aquinas, self preservation was built into natural law. What is owed to self and what is owed to others was ordered by the virtue of charity. Indeed, it may be that this is the only way in which the inherent tensions between self-interest and altruism can ever be finally resolved.

These tensions certainly have not been resolved in twentieth century moral philosophy. The subjectivism and emotivism of Ayer, the prescriptivism of Hare, the existentialism of Sartre -- all make moral judgment matters of approval or disapproval, preference, or self determination. The metaethical emphasis on language and logic of moral discourse rather than the content of moral judgments further weakened the classical notions of virtue so that the definition of virtue has become either so vague as to be meaningless or so encompassing as to include every conceivable likable trait.(24)

Twentieth century moralists have refined the eighteenth century notion of moral sentiment and further psychologized ethics. In the light of the psychologies of Freud or the behaviorism of Watson or Skinner, today many moralists look to modern psychology to define the virtues and to close the gap between knowing the good and being motivated to do the good. Others look to genetics, culture or social organization to explain altruism and self-interest.(25) Nagel, on the other hand, presents a Kantian challenge to this trend and argues for the rationality of altruism. In doing so, he rejects the Humean subordination of reason to desire or emotion.(26) Philippa Foot tried unsuccessfully to link virtue and self-interest in her work Virtues and Vices.

The disarray of normative ethics, including the destruction of virtue ethics, has occasioned a spate of recent attempts to resuscitate the classical and especially the Aristotelian idea of virtue. This move was initiated by Anscombe (27) and Macintyre.(28) Their success varies, and the extent to which they can reverse the dominance of self-interest in ethics begun by Hobbes is highly problematic.

The second major factor in the erosion of virtue ethics is the philosophical difficulty inherent in the concept of virtue itself. First, is its lack of specificity. Virtue ethics does not tell us how to resolve specific moral dilemmas. It de-emphasizes principles, rules, duties and concrete prescriptions. It only says that the virtuous person will be disposed to act in accord with the virtue appropriate to the situation. This lack of specificity leads to a distressing circularity in reasoning. The right and the good is that which the virtuous person would do, and the virtuous person is one who would do the right and the good. We must define either the right and the good or the virtuous person if we are to break out of this logical impasse.

Furthermore, virtue theory cannot stand apart from some theory of human nature and the good. The more vague our definitions of human nature and its telos, the more difficult it is to keep virtue from becoming vice and vice virtue. Since virtue ethics puts its emphasis on the character of the agent, it requires a consistent philosophical anthropology, otherwise, it easily becomes subjectivist, emotivist, relativist and self destructive.

Further difficulties include the relations of intent to outward behavior. Is good intention a criterion of a virtuous person? How do we determine intention? Can a good intention absolve the agent of responsibility for an act which ends in harm -- a physician telling a patient the truth out of the virtue of honesty, and thereby precipitating a serious depression or even suicide? Few are virtuous all the time. How many lapses move us from the virtuous to the continent, incontinent, or vicious category? How does virtue ethics connect with duty and principle based ethics which give the objectivity virtue ethics seems to lack?

Classical ethics in the East and the West have usually eschewed systems of rules or principles or at least subordinated them to the notion of moral character. Where do virtue and supererogation meet? Are virtues synonymous with duties? Is supererogation merely a higher degree of virtue? Why are some people virtuous and others not? Must we turn to sociobiology for the answer as some suggest?(29) Are virtues genetically ingrained, mere survival mechanisms designed to propagate the gene pool?

In spite of its ancient lineage, these fundamental questions are yet to be answered. Because they have not been answered to everyone's satisfaction, moralists have turned to something more probable -- to the question, what shall I do? How do I solve this dilemma before me now?

This brings me to the third point I want to mention with regard to the erosion of virtue ethics, namely the turn -- particularly in professional ethics -- toward quandary and dilemma solving. This is the result of a number of factors operating in the last two decades. One is the concreteness and urgency of the new ethical issues arising in scientific advance and sociopolitical change. Medical and biological progress, for example, challenges traditional ethics. Yet these developments must be confronted without the ethical compass points of a consensus on values or common religious beliefs. We are now a morally heterogeneous society, divided on the most fundamental ethical issues, particularly about the meaning of life and death. Without a common conception of human nature we cannot agree on what constitutes a good life and the virtues that ought to characterize it. As a result, the ethics of the professions, especially of the medical profession, has turned to the analysis of dilemmas and of the process of ethical decision making. For many, ethics consists primarily in a balancing of rights, duties and prima facie principles and the resolution of conflicts among them. Procedural ethics has replaced normative ethics. This avoids the impasses generated when patients, clients and professionals hold fundamentally opposing moral viewpoints.

But analysis cannot substitute for character and virtue even though it provides conceptual clarity. Moral acts are the acts of human agents. Their quality is determined by the characters of the persons doing the analysis. Character shapes the way we define a moral problem, selects what we think is an ethical issue, and decides which principles, values and technical details are determinative.

It makes a very great difference, therefore, whether a professional is motivated by self-interest or altruism. Given the realities of professional relationships, the character of the professional cannot be eliminated from its central position and that is why virtue ethics must be restored as the keystone of the ethics of the professions.

A fourth and final factor eroding a virtue approach in the medical profession is the legitimation in public attitude and tolerance of self-interest. In response to the economic imperatives acting so forcefully on the health care system, physicians and other providers have been encouraged to compete with each other. The availability, cost, and quality of health services have been turned over increasingly to market forces. The Federal Trade Commission has classified the professions (yours and mine) as businesses and made them subject to one ordering principle -- the preservation of competition.(30) Health providers have been encouraged to become entrepreneurs, to invest in health care facilities and technologies, to be offered bonuses for keeping utilization of health care resources to a minimum. Without these incentives, it is argued, the best will not enter medicine, or will retire early. Medical progress would stop and new services would cease to be available. For the first time in medical history, self-interest has been given legal and moral legitimation, and profit has been turned into a professional virtue. These trends are making the physician into a businessman, an entrepreneur, a proletarian, a gatekeeper, a bureaucrat. Never has there been more confusion about who and what it is to be a physician.

Is There A Philosophical Basis for Restoring Virtue Ethics?

This brings me to my second major question: Is there a sound philosophical foundation in the nature of professional activity for resolving the tension between altruism and self-interest in favor of virtue and character? I believe there is, and I would ground my proposal in six characteristics of the relationship of professionals with those who seek their help. Individually, none of these phenomena is unique in kind or degree. They may exist individually in other human relationships and occupations. But, as a moral cluster, they are, in fact, unique and generate a kind of "internal morality" -- a grounding for the ethics of the professions that is in some way impervious to vacillations in philosophical fashions, as well as social, economic or political change. This internal morality explains why the ethics of medicine, for example, remained until two decades ago firmly rooted in the ethics of character and virtue. This was true of the medical ethics of the Hippocratic school and the Stoics. It is found in the seminal texts of Moslem, Jewish and Christian medical moralists. It persisted in the 18th century in the writings of John Gregory, Thomas Percival and Samuel Bard, who, although cognizant of the philosophies of Hobbes, Adam Smith and Hume, nonetheless maintained the traditional dedication of the profession to the welfare of the patient and to a certain set of virtues. Only in the last two decades has there been (to use Hume's terms) a "sentiment of approbation" regarding self-interest.

The first distinguishing characteristic of professional relationships is the dependence, vulnerability and eminent exploitability of the person who seeks the help of a physician, lawyer at clergyman. The person in need of help to restore health, receive justice or rectify his relationships with God is anxious, in distress and driven by fear. To avoid death, damnation, or incarceration, he is impelled to seek help, though he wishes he could avoid it. He is not free to peruse life's other goals until help is forthcoming.

The second characteristic of professional relationships is their inherent inequality. The professional possesses the knowledge that the patient or client needs. This places the preponderance of power in his hands. He can use it well or poorly, for good or evil, for service or self-interest. How can we speak, as some do, of the professional relationship as a "contract" when one party is so dependent upon the other's services?

The third characteristic of professional relationships is their special fiduciary character. In a state of vulnerability(31) and inequality, we are forced to trust our physicians, lawyers or ministers. We are ill equipped to evaluate their competence. We are forced to reveal our intimate selves -- baring our bodies, our personal lives, our souls and our failings to another person who is a stranger. Without these invasions of our privacy, we cannot be healed or helped. Moreover, the professional invites our trust. Professionals begin their relationship with us with the question: How can I help you? Implicitly they are saying, "I have the knowledge you need; trust me to have it and to use it in your best interests." In the case of medicine, that promise is made in a public oath at the time of graduation when the graduate announces to all present that, henceforth, he can be trusted to serve interests other than his own. It is repeated in the codes of medicine and other professions and the ordination rites of clergymen.

Indeed, it is this public declaration that defines a true "profession" and separates it from other occupations. The very word comes from the Latin profiteri, to declare aloud, to accept publicly a special way of life, one that promises that the profession can be trusted to act in other than its own interest. Businessmen and craftsmen ask to be trusted, but not at cost to themselves. Caveat emptor can never be the first principle of a profession.

Fourth, the knowledge of true professionals, as I have just defined them, cannot be wholly proprietary. Their knowledge is ordained to a practical end, to meeting certain fundamental human needs. Professional knowledge does not exist for its own sake. This is clearest in medicine where society permits invasions of privacy that would otherwise be criminal in order that physicians may be trained. Thus, medical students, who are not fully skilled are permitted to dissect human bodies, attend and assist at autopsies and operations, and participate in the care of sick people. They are allowed literally to practice, albeit under supervision. Surgeons in training take many years to develop their skills. Their first operations are hardly as proficient as those which follow. Attending patients involves delays, diffusion of responsibility and accountability, and discomfort and even physical risk for the patient. Society permits these invasions of privacy and the risks attached to them, not primarily so physicians can make a living but because society needs an uninterrupted supply of doctors. Medical knowledge, and analogously, legal and clerical knowledge, are held in trust for those who need them. They can never be solely dispensed for the profit of the professional or on terms unilaterally set by him or her. That is why lawyers are officers of the court, and clergymen are ordained to minister in the name of God or their churches.

The fifth feature of the professional relationship is that the professional is the final common pathway through which help and harm must pass. The final decisions, actions, and recommendations must be made by one person, the professional, with whom the patient or client has a covenantal relationship of trust.

The sixth distinguishing characteristic feature of professional relationships is that the professional is a member of a moral community, that is, a collective human association whose members share the privileges of special knowledge and together pledge their dedication to use it to advance health, justice or salvation. Together the members of the moral community make the same promises and elicit the same trust they do as individuals. They are bound by the same fidelity to the promise they have collectively made and the trust they have collectively elicited. The professional is, therefore, not a moral island. He belongs to a group which has been given a monopoly on special knowledge and holds it in trust for all who need it. Each professional is responsible to his colleagues, and they are together responsible for him. Collectively they are responsible for fidelity to the trust they have solicited from society. This is what the privilege of self-regulation means -- not that each professional is his own judge of what is ethically permissible.

These features regarding human relationships are the components of the "internal morality" of the professions, the immediate moral ground for their obligations, and the source of definition of their virtues. To use Aristotle's terminology, those virtues make the work of the professions "be well done."

The virtues of professional life are many, but I believe they are reducible, primarily to two -- fidelity to trust and beneficence, which follows from the virtue of fidelity to trust. These two traits of character are the ethical foundations upon which the other virtues and principles of professional ethics depend. Clearly, they are incompatible with the Machiavellian and Hobbesian doctrines of self-interest. Their reality and irreducibility provide the most powerful argument for the restoration of virtue ethics in professional morality.(32)

What Are the Practical Implications of Virtue Ethics?

If there is validity in the philosophical foundations of professional morality as I have argued, a number of practical implications follow which are pertinent to healing the moral malaise and confusion of today's professionals.

First, professionals cannot displace the moral failings of the professions on others -- on society, other professions, government, economics, the market place, etc. No one can make the conscientious professional do what he thinks is not in the interests of his patient or client. Can anyone force doctors to follow a policy damaging to their interests? The fact that the professional is the final common pathway for all policies and decisions and actions forces him to be the guardian of the interests of his patient or client. Indeed he invited that responsibility when he invited the patient or client to trust him.

As a result, individual practitioners must be very careful in exonerating themselves from morally dubious practices on the basis of survival. Professional ethics will have no future only if it is gradually suffocated by the moral compromises of individual professionals. There will be times when, as guardians of the patients' welfare, physicians will have a moral obligation to refuse: they will refuse to "dump" the patient who cannot pay; they will refuse to discharge the patient before he is ready; they will refuse to act as society's fiscal agents; they will refuse to be seduced by the profits of investments and ownership of health facilities or bonuses for denying or delaying needed care; they will refuse to be gatekeepers, except to protect their patients from unnecessary medical interventions or procedures.(33) The physician of character will be the one who can reliably be expected to exhibit the virtues of fidelity to trust and effacement of self-interest.(34)

The second practical implication is that the individual professional must not be expected to stand by when the well being of his patient or client is threatened. It is an obligation of the professions as moral communities to be advocates for those they serve and to take collective action to assure that their services are available and accessible to all, to protect those in need of healing, justice or salvation against public legislation or institutional policies that may harm them.

The professions as moral communities must also take the responsibility for each member's ethical behavior seriously enough to monitor, discipline and even remove each other when the canons of professional morality are violated. Think of the enormous moral power the professions could exert if they were truly the advocates of those they serve. Suppose that, in addition, all the helping professions were to join their efforts. Could any society resist? Can they do less? In the face of this power, can any of the three great professions blame society for their own moral lassitude?(35)

A third implication is that the formation of character is as important in the education of professionals as their technical education. Although this was a major concern of professional education in the past, it has now been forsaken. People have asked ever since Plato raised the question in the Meno: Can virtue be taught? I believe it can. Obviously, the whole task of character formation cannot be left to the professional schools. Families, churches, and schools, all shape the character of students long before they enter professional schools. But these schools must also teach what it is to be a good physician, lawyer or clergyman -- what kind of person the good professional ought to be. Much can be done in character formation when a student is motivated by his desire to be a good professional even if his education prior to medical, law school, or seminary was morally neutral or deficient.

The most effective instruments of character formation are the professionals who teach in medical and law schools and seminaries. But they must be able to demonstrate that competence and character are inseparable, and that fidelity to trust and self effacement can be, and must be, indispensable traits of the authentic profession. Unfortunately not enough professional school faculty members are convinced of this; nor are enough morally equipped to serve as models of virtue.

Paradigm cases of ethically sensitive professionals drawn from the history and tradition of each profession are also helpful. They are more effective than is generally realized. One of the tragedies of medical history is its depreciation of the lives of the great physicians. While biographies may not have much fascination for sophisticated medical historians, they still have inspirational value for aspirants to medicine. Other professions have their morally paradigmatic biographies as well. Most professional students enter with some ideal of service in mind which the professional school has a responsibility to reinforce.

A fourth implication is that cure of the moral malaise of the professions requires something more than reordering the social organization, or tailoring the semantic and semiotic feature of professional codes as Kultgen rather naively supposes.(36) What failings there are in the professions are failings in character and not in the language of our codes. If character and virtue are restored, the appropriate social reorganizations will follow -- not the other way around.

Finally, there are theoretical reasons as well for a restoration of virtue, both in general and professional ethics. Happily a renaissance of interest among moral philosophers in this subject is very much in evidence. But virtue ethics must not be seen as self- sufficient or as antithetical to principle or duty based systems of the analysis of ethical dilemmas. The theoretical challenge is to develop the logical connections between analytical and virtue ethics, between principles and character, to close the gap between cognition of the right and good and the motivation to do it, and in the light of my whole discussion, to strike the morally defensible balance between self-interest and its effacement which recognizes the primacy of altruistic beneficence.

The theoretical challenges will be complicated because virtue and duty based ethics are today isolated from a more comprehensive moral philosophy which could tell us why we must be moral and what we define as the moral life. We need to reconnect ethics to some notion of the good and to a coherent philosophical anthropology. To this end, it might be well to reexamine the classical medieval synthesis before ethics was torn from its roots in moral philosophy. That synthesis, amplified by our newer knowledge of human nature, derived from the biological and social sciences and reflected upon theologically, might provide the new resuscitation that an effective virtue ethics demands.

For the time being, a reflection on the nature of professional relationships can be fruitful even in the absence of a comprehensive moral philosophy of which it might be a part. The internal morality of the professions based on the realities of professional relationships is clear enough to help us repair the ozone hole opened in the fabric of professional ethics, even if we cannot repair the whole moral atmosphere on which our society depends for its survival.

I have emphasized what I believe to be some of the elements common to the moral philosophy of our three professions of medicine, law and ministry. Many of these same features are shared by other professions. I must leave them to decide how the virtues of fidelity to trust and effacement of self-interest apply to them. Suppose all the professions were to acknowledge virtue as a ground for moral accountability. Would this not be the leaven for raising the standards of conventional morality as well?

Endnotes

1. Aristotle, Nichomachean Ethics 11056, pp. 25 26.

2. Ibid at 1106a, pp. 16 17.

3. Ibid. at 1106a, pp. 22 24.

4. Ladd, "The Internal Morality of Medicine: An Essential Dimension of the Patient Physician Relationship" in The Clinical Encounter (E. E. Shelp, ed., 1983).

5. Aristotle, supra Bk. 9, Ch. 8. In this chapter, Aristotle distinguishes two types of self love: reproachful and virtuous. Reproachful self love is self love that arises not according to a rational principle but according to passion. The person who loves self in this way desires what is advantageous, not what is noble 1169a 4-6). The person of reproachful self love assigns to himself the greater share of wealth, honor, and bodily pleasure. The person who demonstrates virtuous self love is inspired by the rational principles to secure for self the most noble goods. The actions of this person will benefit both himself and others.

6. Plato, Republic, 338C.

7. W. K. C. Guthrie, The Sophists (1971). This is a thorough and detailed examination of the idea of self interest and its relationship to justice in the Republic. It is particularly helpful in its discussion of how Hobbesian and Machiavellian strains were prefigured in the thinking of the Sophists.

8. Aristotle, supra, note 6.

9. See J. M. Cooper, Reason and Human Good in Aristotle (1986) for a consideration of Aristotle's view on love of self and of others.

10. Aristotle, Nichomachean Ethics, 1155b, p. 31; 1156b, pp. 9 10; 1159a, pp. 6 12, 28 33. See also, Hardie Aristotle's Ethical Theory (1968) at 326.

11. See, T. Engberg Pedersen, Aristotle's Theory of Moral Insight (1983), pp. 237 262 for a penetrating analysis of Eudemian Ethics, Bks. 8 and 9.

12. Hardie supra note 11 says that for Aristotle, "the end of the state is Îgreater and more perfect' than the end of the individual and thus, the activities of the statesman are aimed at Îhappiness' for himself and his fellow citizens." Ibid, p. 216.

13. Plato, Republic, pp. 341e 347a.

14. Cicero, De Officiis, Bk. 3, Ch 13.

15. Hippocrates, Oath.

16. N. Machiavelli, The Prince (1970): "This is because, taking everything into account [the prince] will find that some of the things that appear to be virtues, if he practices them will ruin him, and some of the things that appear to be wicked will bring him security and prosperity." Ibid., p.87.

17. B. Mandeville, The Fable of the Bees (1962).

18. F. Nietzsche, The Genealogy of Morals ( 1967).

19. Ayn Rand, The Fountainhead (1971).

20. T. Hobbes, Leviathan (1968); See also Sidgwick, Outlines of the History of Ethics (1988). Sidgwick neatly summarizes Hobbes' paradoxical view of social duty thus: "a view of social duty in which the only fixed positions were selfishness everywhere and unlimited power somewhere could not but appear offensively paradoxical." Ibid., pp. 165 169.

21. J. S. Mill, Utilitarianism (1979), Ch. 2.

22. H. More, Enchiridion Ethicum (1978)

23. J. Butler, Three Sermons on Human Nature (1897).

24. E. Pincoffs, Quandaries and Virtues (1986).

25. E. O. Wilson, Sociobiology: The New Synthesis (1975).

26. T. Nagel, The Possibility of Altruism (1978).

27. G. E. Anscombe, "Modern Moral Philosophy" 33, Philosophy (1958).

28. A. Macintyre, After Virtue: A Study in Moral Theory (1958).

29. Wilson supra, note 26.

30. E. D. Pellegrino, "What is a Profession? The Ethical Implications of the F.T.C. Order and Some Supreme Court Decisions," Survey of Ophthalmology 1 15 (1984).

31. See R.E. Goodin, Protecting the Vulnerable (1985). This author proposes vulnerability as a source of moral obligation in his analysis of our social responsibilities.

32. E. D. Pellegrino and D.C. Thomasma, For the Patient's Good: The Restoration of Beneficence in Health Care (1988).

33. See Ansberry, "Dumping the Poor", Wall Street Journal (Nov. 29,1988), p. 1.

34. H. T. Engelhardt and H. Rie, "Morality for the Medical Industrial Complex", p. 319, New England Journal of Medicine pp. 1086 1089 (1988). These authors argue against the thesis that I am presenting particularly in their view that traditional standards must be tailored to conform to institutional and third party payer's requirements.

35. J. Callahan, Ethics and the Professional Life (1988). This is an anthology dealing with the relationships between professional and ordinary morality with contributions by philosophers and professionals in law, medicine and business.

36. J. Kultgen, Ethics and Professionalism (1988), p. 4.


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