Professional Values in Modern Clinical Practice

How are professional values defined and applied in the actual practice of modern medicine? Let me begin to answer that question by reviewing the virtues that a number of scholars regard as central professional values in medicine. James Drane considers beneficience, that is, the good work a doctor does for persons who are ill, to be medicine's "fundamental ethical standard," and benevolence to be the virtue that disposes doctors to provide medical help.[1] He also includes as cardinal virtues for physicians respect and concern for patients, truthfulness, friendliness, and justice. Pellegrino and Thomasma take medicine to be a human activity with a specific telos or goal: "a right and good healing action for a particular patient."[2] Drawing on the Aristotelian concept of phronesis, often defined as practical wisdom or prudence, they take clinical judgment to be "medicine's indispensable virtue."[3] Pellegrino and Thomasma relate phronesis, "the state of character which makes a person good and which makes a person do his or her work well," to the ethical principle of beneficence, a principle that they believe to be "at the heart of the medical relationship" and the physician's "primary obligation to patients" (p. 53). Although they identify other essential virtues--including trustworthiness, respect for persons, compassion, justice, integrity, and self-effacement--they stress that in the clinical context of healing relationships these traits should be subsumed within the pivotal virtue of phronesis or prudence. Pellegrino, moreover, has argued that a principle-based and virtue-based medical ethics should be closely linked to "the universality of the phenomena of illness and healing" and should be "grounded in the reality of the physician-patient relationship."[4] Clinical Medical Ethics How do physicians move between the realms of values and philosophical theories, on the one hand, and the clinical realities of medical practice, on the other? Pellegrino has argued that the discipline of clinical bioethics--"clinical medical ethics" as I prefer to call it[5]--represents one approach for linking professional and ethical values with practice. It is a field that "focuses on the clinical realities of moral choices as they are confronted in day-to-day health and medical care."[6] Clinical medical ethics is a practical and applied discipline that aims to improve patient care and patient outcomes by focusing on reaching a right and good decision in individual cases. It does so by identifying, analyzing, and contributing to the resolution of ethical problems that arise in the practice of medicine. It focuses on the doctor-patient relationship and takes account of the ethical and legal issues that patients, doctors, and hospitals must address to reach good decisions for individual patients. Clinical ethics emphasizes that in practicing good clinical medicine, physicians must combine scientific and technical abilities with ethical concerns for the personal values of the patients who seek their help. The content of clinical ethics includes specific issues such as truth-telling, informed consent, end of life care, palliative care, allocation of clinical resources, and the ethics of medical research. Clinical ethics also includes at its core the study of the doctor-patient relationship, including such issues as honesty, competence, integrity, and respect for persons. Thus clinical ethics includes a focus on the ethos of the professional and on the character and virtues of the physician, whom the public expects to demonstrate these qualities. Albert Jonsen, William Winslade, and I have suggested that in the analysis of any ethical issues the following factors must be considered: the medical and scientific facts; the preferences, values, and goals of both the physician and the patient; and the external constraints, such as cost, limited resources, and legal duties, that may shape or limit choices. …