Perspectives in Biology and Medicine

A New Theory of Medical Ethics and Professionalism

The search for "ethical" and "professional" standards in medicine is as old as medicine itself (see Figure 2). Rhodes seeks to contribute to this search with her new theory of medical ethics and professionalism. With honesty and humility, Rhodes identifies three factors that changed her view of ethics in the clinic and her sense of medical professionalism: that medicine mostly gets what it does right; that practices in medicine and medical ethics often don't align; and that the utility of "popular approaches to medical ethics" are limited in the clinic (13). These

Click for larger view
View full resolution

Figure 1.

The medical transaction

[End Page 180]

Click for larger view
View full resolution

Figure 2.

Imperatives of the medical transaction

insights induced her to view medical ethics in a different light. In a late section of her book, she writes:

The ethics of medicine should be understood as a commitment to the distinctive duties of the profession and the development of doctorly character. Doctors need to be sensitive to the complex interrelation of human reason and emotion. They need to understand and accept the scope of their distinctive duties, and they need to make themselves into people who are inclined to fulfill their professional obligations. Those who accomplish both exemplify professionalism, and they are entitled to the trust that patients and society invest in them.

(281)

With this definition from Rhodes in mind, it might be easier to see why she came to view her work as "heresy." Presumably she was committed to understanding her discipline along lines defined by other, earlier ethicists and bioethicists. She specifically contrasts her evolving view with those of Beauchamp and Childress, summarized in four principles (autonomy, beneficence, nonmaleficence, and distributive justice), and of Gert, Culver, and Clouser, summarized in 10 rules of common morality (don't kill, cause pain, disable, deprive of freedom, deprive of pleasure, deceive, cheat; do keep promises, obey laws, and fulfill duties).

Finding these principle- and rules-based theories inadequate to meet all the conditions she ascribes to the clinic, Rhodes pivoted toward privileging of duties to frame her approach to medical ethics and professionalism. It is as if a eureka moment induced in her a new vision for a field marked by traditions and traditionalisms. Here is how she puts it: [End Page 181]

Those insights led me to recognize that a new theory of medical ethics was needed. A new theory would therefore have to challenge the long-standing and widely accepted common morality approaches and have to cohere with both the laudable elements of clinical practice and explain why some accepted behaviors and policies were wrong. Thus, I realized that developing a new theory of medical ethics would be embarking on a project to contest the common morality approaches to medical ethics, something that was likely to be regarded as bioethics heresy.

(13)

After embracing "heresy," Rhodes had to come up with an alternative basis for her theory of medical ethics and professionalism. Duties, as the structural and functional backbone of all clinic work, became the basis of her new theory (see Table 1).

Chapters 2 through 9 of Rhodes's book contain detailed explanations of her chosen duties, coupled with case scenarios that support her judgments. To strengthen her presentation, she groups duties under relevant headings: the distinctive ethics of medicine (duties 1 and 2), medicine's core responsibilities (duties 3–5), the commitment to science (duty 6), duties of behaviors toward patients (duties 7–9), duties to respect patients' autonomy and assess capacity (duties 10 and 11), medicine's commitment to truth (duty 12), commitments to fellow professionals (duties 13–15), and why trustworthy stewardship requires justice (duty 16). She then follows with four additional chapters that address topics like development of a doctorly character, resolving moral dilemmas, problems with the "best interest" standard, and professional responsibility and conscientious objection, before closing with concluding thoughts.

Rhodes also provides examples and references in her footnotes that contribute significant sidebar material that cannot be parsed in this review. Suffice it to say many important qualifying statements appear in the notes. Also helpful is a 30-page appendix replete with oaths, codes, and specialty professional statements germane to medical ethics and professionalism. Even if readers do not come to agree with Rhodes, they will have a resource worthy of space on their bookshelf.

Are Medical Ethics Suis Generis?

A curiosity in Rhodes's new theory is the elasticity of its scope and applicability. She suggests a narrow zone of application. Doctors, engaged in medicine, it is to be inferred, supplied her with the 16 duties of practice she organizes into a new medical ethics theory, and they are the ones to be held accountable to its enumerated obligations: "Doctors are the ones who define the duties of the profession because they are the only ones who can adequately understand what is involved, appreciate the potential risks and benefits of their service, and distinguish competent practice from acceptable performance" (31). [End Page 182]

Click for larger view
View full resolution

Table 1.

Rhodes's duties of medical ethics

Here Rhodes is the observer who organizes what is present and evident in the ethics-praxis nexus. This is accurate to an extent: praxis and ethics do shape and reshape one another continually. But so do morals and laws sourced from outside the profession. Witness the post-Dobbs scramble in medicine to accommodate a new set of abortion limits. Of a sudden, disruption in doctors' understanding about what is legal has shifted what they may considered practical if not ethical, even if no moral shift on the subject has occurred. Change in any of the four domains that define limits on medicine's work—moral, ethical, practical, and legal—induces continuous and inevitable change (see Figure 3). Culturally, traditions fade. Few swear by Apollo anymore. Conversely, traditionalisms persist largely because of who controls the narrative. Medical ethics today, for instance, are less likely to be viewed as the product of physician praxis shaped by Abrahamic morals than the (nonmedical) assertions of Aristotle, Kant, or Hobbes as they have been absorbed into ethics and law. All three philosophers were unknown when Sirach, the author of Ecclesiasticus, averred:

                Honor physicians for their services,for the Lord created them;for their gift of healing comes from the Most High,and they are rewarded by the king.The skill of physicians makes them distinguished,and in the presence of the great they are admired.The Lord created medicines out of the earth,and the sensible will not despise them.

(Ecclesiasticus 38: 1–4)

[End Page 183]

Click for larger view
View full resolution

Figure 3.

Restrictions on the medical transaction

More to the point, nothing in medicine is so cloistered as to miss being influenced by factors outside medicine. Granted, such factors may enter medicine filtered through doctors' experience with them—like the ancient medical wisdom with religious pedigree quoted above—but that does not mean medical ethics are suis generis, as Rhodes suggests in this statement:

the ethics of medicine is internal to the profession in that it … is constructed by the profession for the profession. It is not defined by society, politicians, lawyers, or philosophers. The hallmark of professionalism is, therefore, the commitment to and the internalization of medicine's distinctive ethics. Medical ethics has to be inculcated by the profession, and it has to be enforced and policed by the profession because no one else is in a position to do the job.

(31–32)

In essence, Rhodes asserts doctors and ethics in medicine are in a closed feedback loop, wherein each continuously reinforces and alters the other, presumably for the better. It is for this reason, it would appear, that she emphasizes "inculcation" and development of "doctorly character" as the essence of professionalism. That it should proceed along lines defined by Aristotelian virtues is an important (if ironic) point to be taken up later. Suffice it to say, if I am reading Rhodes accurately, only Aristotelian doctors can be trusted to maintain the mean among the feelings required to fulfill the 16 duties she proscribes in her theory. Common morality is insufficient. Only elite morality will do, and in her view this morality is indistinguishable from medical ethics. [End Page 184]

In her turn toward professionalism, the ethics-praxis nexus closed-loop system looms equally large in Rhodes's project to recreate doctors in the image of her new medical ethics theory:

The critical point that has not been adequately appreciated is that the understanding of professionalism derives from the distinctive ethics of medicine. Professionalism is needed because it involves doctors committing themselves to ethical standards that are different from and more demanding than those of common morality. It requires physicians to understand what distinctive duties of medicine entail, how they apply to medical practice, and why physicians must uphold those duties. It entails doctors embracing their unique obligations, identifying with them, and accepting the responsibility to fulfill them with a sincere commitment. In that sense, it involves developing a character that takes pleasure in fulfilling professional obligations and committing oneself to moderate desires that might interfere with upholding professional duties. In sum, professionalism is doctors' personification of medical ethics. Professionalism involves understanding the obligations of a physician, making oneself into a person who is likely to fulfill those duties, and acting in accordance with the dictates of medical ethics.

(33, original emphasis)

Here, too, a whiff of the suis generis pervades Rhodes's perspective on professionalism: doctors must commit to transforming themselves and being transformed as persons by their profession or they will be subject to accusations of unprofessional behavior. This, for many who do not enter the profession of medicine "pre-professionalized" by example and habits or virtues cultivated since childhood, may be a heavy lift. The pre-med process permits little room for ethical reflection and character development, and the image of "doctorly character" that aspirants to the profession carry is often childish at best. The medical school admissions process privileges self-discipline, stamina, getting good grades, and display of a persona superficially consonant with the profession's sense of itself as willful, wily, and hard-working. Once admitted, med students may persist in the same competitive behaviors and disguises that produced their admissions success, in essence reverting to training when under pressure to master new material, albeit more for a new and elevated purpose.

Here an anecdote may help. While teaching first-year medical students in a "medicine and society" required course, six months into their first semester, when students are quite exhausted, I asked my small group members how they were doing and if they still felt like the same person they were when they were admitted to medical school. After an awkward silence one of the bolder students said, "I'm not sure any of us ever were that person." I was stunned. It was then and there that I decided that the medical school admissions process, at least at my institution, had collapsed under its metrics-driven effort to numericize everything, missing the signals of character and virtue essential to the long-haul project [End Page 185] of being a doctor. And here I also speak of those who remained silent in the first place to my question.

To Whom Do the 16 Duties Apply?

Rhodes fronts another conundrum with her presentation of a new theory of medical ethics and professionalism: to whom do the 16 duties of medical ethics apply? Throughout her explication it seems evident she is talking about learned persons who have been awarded medical degrees, have been licensed by the state to practice medicine, have likely completed a residency in a specialty and been certified by a specialty board, and quite possibly have completed subspeciality training to earn "higher" skills and practice privileges that build on "lesser" foundational skills and privileges. In other words, doctors qua physicians and specialists, as most people understand those words to be used in society in general, and the clinic in particular. And yet, in what seems like an accommodation to medical-industrial complex trends that seek to apply the "medical professional" label to anyone who has donned scrubs, worn a white coat, or used medical terminology in the course of their work, she writes expansively:

Many people, and people in fields such as sociology and history, understand ethics and morality to mean different things. As a philosopher, I take ethics and morality and variations on those terms to be synonymous. Similarly, some people distinguish the terms doctor, physician, and medical professional. I use them as equivalent for the purpose of presenting this theory. Furthermore, even though I primarily discuss doctors, I intend what I say to apply broadly to people in all medically related professions because I consider them all to be medical professionals, and the duties of medical ethics to apply to doctors, nurses, social workers, physician assistants, pharmacists, genetic counselors, physical therapists, bioethicists, and so on.

(41)

Setting aside (for now) the equivalence drawn by Rhodes between morals and ethics, her equation of the duties of, say, a pharmacist or nurse with a physician's is problematic. For instance, if a person hands a pharmacist a prescription, does the pharmacist "assess the patients' decisional capacity" (duty 11) before she fills the prescription? She might ask if the patient prefers a pill or liquid, if a choice exists, or if the patient has any questions, but there an interrogation of decisional capacity might likely cease. On the other hand, pharmacists are permitted to be the commercial source and the persons who give a vaccine based on expanded definitions of scope of practice by law. But this does not mean the pharmacist and the doctor are equivalent in other respects. Similarly, if a nurse seeking to "be mindful in responding to medical needs" (duty 5) as he prepares to enact a physician's chart order, decides that the ordered care is not "based on need" (duty 4) or lacks a "scientific basis" (duty 6), should the nurse then countermand the [End Page 186] physician's order? No matter how well conceived or how far outside the nurse's understanding of his licensed scope of practice the order falls, the nurse who deems it a breach of his "medical professional" duties to complete such an order would be deemed ethical by Rhodes's scheme. And this variance needn't even be a matter of conscience for the nurse: he might just judge that the ordering physician is wrong and decide that his duty is to not complete the order but present a temporizing alternative.

Going a step further into the "and so on" zone, how are perspectives about duties distributed across the broad spectrum of "medical professionals" to be resolved when conflicts arise that cannot be adjudicated inside the circle, so to speak? For example, the "medical professionals" at Theranos, the company founded by Elizabeth Holmes to disrupt blood test technology, persuaded "medical professionals" in major pharmacy and retail outlet chains to install the company's microsample blood test machines to permit patients to bypass other "medical professionals" who might deem larger samples of blood necessary to do lab tests that still other "medical professionals" declare necessary for accurate test results. Such daisy chains composed of "medical professionals" are impossible to hold to Rhodes's 16 duties. By what adjudication process, at a minimum, would their disagreements as "medical professionals" qua "business partners" be resolved? Only one prescribed by law. Law is all that remains when the three other backstops in the clinic (moral, ethical, and practical) fail to stop a wild pitch. Fortunately, it is usual but not universal that law will exercise judgment in deference to science and the physician professionalism encapsulated in the 16 duties. This is especially true when the need to establish causation enhances the assignment of blame that can lead to monetary damages for harms experienced at the hands of "medical professionals," even while fulfilling their 16 duties.

If Rhodes is guilty of too broad an application of the 16 duties across an inchoate spectrum of "medical professionals," she may also be guilty of overlooking similarities in the "learned professions"—medicine, ministry, and law—as operating with duties and codes of ethics that are congruent with those she claims are exclusive to medicine. The specific duties of the learned professions arose from combinations of education, skills, and responsibilities. For instance, in 1652, George Herbert wrote in The Priest to the Temple, or The Countrey Parson His Character, and Rule of Holy Life:

A Pastor is the Deputy of Christ for the reducing of Man to the Obedience of God. This definition is evident, and containes the direct steps of Pastorall Duty and Auctority. … Out of this Chartre of the Priesthood may be plainly gathered both the Dignity thereof, and the Duty: The Dignity, in that a Priest may do that which Christ did, and by his auctority, and as his Vicegerent. The Duty, in that a Priest is to do that which Christ did, and after his manner, both for Doctrine and Life.

(Chapter 1)

[End Page 187] Resonant in Herbert's English is the sense that duty connects to virtue sourced in a divine relationship for a theological purpose with very serious intent. Elsewhere Herbert emmeshes legal and medical duties with ministerial duties, as in Chapter 23:

The Countrey Parson desires to be all to his Parish, and not onely a Pastour, but a Lawyer also, and a Phisician. Therefore hee endures not that any of his Flock should go to Law; but in any Controversie, that they should resort to him as their Judge. … Now as the Parson is in Law, so is he in sicknesse also: if there be any of his flock sick, hee is their Physician. … But if neither himseife, nor his wife have the skil, and his means serve, hee keepes some young practicioner in his house for the benefit of his Parish, whom yet he ever exhorts not to exceed his bounds, but in tickle cases to call in help. If all fail, then he keeps good correspondence with some neighbour Phisician, and entertaines him for the Cure of his Parish.

Here Herbert portrays, in practical terms, ways the three learned professions benefit from consort with each other. In this we may presume affinity among the professionals based on education, skills, and responsibilities in cardinal domains of society. This affinity, I suggest, goes to the level of a sense of duty and the need to be of a character that is grounded in virtues of body, mind, heart and soul—or, if you prefer, a harmony among biophysical, rational, aesthetical, and transcendental inclinations.

For instance, replacement of the words medical and patients with ministerial and parishioners rewrites Rhodes's duty number 2 to read: "Use ministerial knowledge, skill, powers, privileges, and immunities to promote the interests of parishioners and society." Similarly, substitution of medical with legal converts duty 16 to: "Ensure justice in the allocation of legal resources." This is not linguistic legerdemain. Rather, the fungibility of terms used in the two examples suggests that the learned professions could, if they chose to, construct duties and ethics similarly. Further, an individual representative of a learned profession may seek to transcend (or conscientiously object to) his or her profession's self-assigned duties and self-enforced ethics based on a moral sense that is unequal to that indivdual's commitment to the profession's ethics in other ways.

Do Some Virtues Serve Medical Ethics Better Than Others?

As a self-described heretic, Rhodes asserts:

Here I press a case for regarding medical ethics as involving both duty and virtue united in a specific way. For these purposes I use both duty and virtue in a broad sense meant to capture alternative approaches to ethics rather than focusing on particular exemplars of different views. By duty, I mean to indicate [End Page 188] the deontic rules, principles, and obligations that define right action. By virtue, I similarly cast a wide net, without here distinguishing them, to capture the feelings, sentiments, dispositions, inclinations, attitudes, and emotions associated with good character.

(259)

Here I want to return to Rhodes's earlier assertion to explore if ethics and morals equate: "Many people, and people in fields such as sociology and history, understand ethics and morality to mean different things. As a philosopher, I take ethics and morality and variations on those terms to be synonymous" (41). Though I disagree, I must accept Rhodes's assertion to make sense of her subsequent statements about ethics and morality in the clinic. My suspicion is there may have been a time when ethics and morals were equivalent. If so, it was one when the hegemony over behavioral-verbal narratives used to make sense of the world was centralized and enforced by expectations grounded in cultural and class, many of which subsequently became traditions promulgated by elites. Functionally, a heresy would violate such elite traditions, would it not? Ergo, Rhodes's self-declared heresy against the hegemony in bioethics arises from her questioning of its behavioral-verbal narratives underpinning morals and ethics.

Yet, as a physician and priest, I view Rhode's moral-ethics equivalency assertion as a traditionalism of philosophy derived from the traditions around the language and sources philosophers privilege in discourse about ethics. Here I am reminded of a quote from Jaroslav Pelikan's The Vindication of Tradition (1984): "Tradition is the living faith of the dead, traditionalism is the dead faith of the living. And, I suppose I should add, it is traditionalism that gives tradition such a bad name" (65). Recourse to Aristotle's Nicomachean Ethics may be one such traditionalism. Aristotle's writings, the backbone upon which Rhodes bases her consideration of virtue in medicine, gained currency in Western European culture across the 13th century CE. Ever since, his work has been given outsized attention. Unknown to Augustine of Hippo (but perhaps not to earlier moralists) Aristotle's work influenced Thomas Aquinas, a moralist who sought to reconcile the traditionalisms of orthodox Christian theology with the newly discovered elements of Hellenistic philosophy, all without committing heresy. If Plato was good for the Church, why not a little Aristotle? After all, Abrahamic scripture was full of baffling incongruities. God had to be made more orderly than the Bible permitted. Indeed, the project of retrofitting Aristotle into a theology that had already adjudicated and negotiated multiple heresies, schisms, and persecutions was a delicate technical task. This is to say, in part, that our received Aristotelian traditions are hardly "originalist": rather, the light of Aristotle was received as through a lens ground by cultural and class needs. Today that lens has been reground to filter away any contaminants of the Abrahamic traditions against which Aristotle was originally judged.

Yet a question remains: is Aristotle relevant to 21st-century medical ethics and professionalism? That Aristotle, who spoke to a segment of ancient Athenian class [End Page 189] and culture, appealed to similarly constructed cuts of class and culture in subsequent ages may help explain his privileged place in philosophy as a persistent traditionalism. Radical objectivity, however, would suggest Aristotle is interesting but nonessential to medical ethics as now expressed in the ethics-praxis nexus of the clinic. Indeed, if the clinic can politely thank and pat Hippocrates and Galen on the head, certainly the philosophical academy can do the same with Aristotle in medical ethics and professionalism. At a minimum, Aristotle's contribution to contemporary medical ethics and professionalism amounts to a monkey in a suit dancing to someone else's tune—interesting but non-contributory. At best, Aristotle's scheme informs without impelling ethical praxis. Indeed, no doctor I know has ever been queried about Aristotelian virtues at the bedside. Who wants to be treated as the outcome of intersecting means? But ask doctors if they have been asked some version of "Will you care for me with all your mind, heart, soul, and being?" and you will discover that concern about character formed by Abrahamic morals runs deep in the clinic, especially among patients. And doctors (with other medical professionals) are here to serve patients.

It is perhaps in this way that morals and ethics can be differentiated: in the test tube that produces ethics from praxis and duties, morals are a catalyst. Without the catalyst, the chemical reaction toward what is ethical will still occur, by mass effect and under pressure and heat from what is practical and legal. But with morals as a catalyst, the reaction toward the ethical is accelerated. In such a catalytic reaction, morals may be seen as the behavioral-verbal narrative given to the aggregate of a person's natural tropisms and culturally reinforced inclinations needed to organize self qua self in the world; by contrast, ethics constitute a behavioral-verbal narrative used to organize a self among other selves in that same world. And of course, overlap exists, but not equivalency. As has often been said, when you move from is to ought, you move from morals to ethics. Viewed this way, the overlapping behavioral-verbal narratives of selfhood are a self's morals and ethics as these get differentiated by the applicable categories of relationship—in other words, of "self to self" or "self to others." This said, unless organized by some means, the behavioral-verbal narrative of any self qua self can soon become gibberish.

Once organized, though, a self's behavior-verbal narrative gains coherence. With coherence, morals can catalyze reactions that permit other selves to experience intersubjectivity, which is governed by ethics. Virtues provide such order and may do so at the moral and ethical level under the best of circumstances. For Rhodes's purposes, Aristotelian virtues do the job best for doctors, but as I and others have hinted, that may not always be the case. With all the virtues to choose from, where is one to begin?

In the concluding section, I recommend four particular virtues be screened for and sought in candidates for admission to the medical profession: honesty, diligence, curiosity, and compassion. I select these four virtues because they permit [End Page 190] the self qua self to interact as a self among others in the duties that Rhodes construes as essential to medical ethics and professionalism. In this I reference Alasdair MacIntyre's (2007) definition of a virtue as "an acquired human quality the possession and exercise of which tends to enable us to achieve those goods which are internal to practices and the lack of which effectively prevents us from achieving any such goods" (191). When it comes to medicine the four virtues—honesty, curiosity, diligence, and compassion—are integral to both Rhodes's 16 duties and to the project of cultivating radical relational readiness required to convert fear and hope to cure and care through a medical transaction.

The Four "Best" Virtues for Doctors

When interviewing candidates for admission to medical school, I developed a pattern that went something like this: I reviewed the application for the applicants' name, school, major, and where they were from. Upon greeting the candidates, after pleasantries, I told them that I only knew those four things about them but that I would review the rest of their application after we talked, as I wanted to see if what they said in the interview aligned with what they said in their application. After this disclosure I would then ask, "Is there anything in your application you wish to explain to me from the beginning?" The answers provided sorted applicants in various ways: they soon revealed themselves to be honest or dishonest about their reasons for seeking admission to medical school; they showed if they were diligent or not diligent in seeking education and development as a person versus only for the purpose of admission to medical school; they displayed whether they were curious or incurious about testing themselves in novel situations or fields of endeavor and what their risk tolerance might be; and finally, they projected or failed to project compassion toward themselves and others in their reflections about their successes and failures.

Once I ascertained if each of these four virtues was present, I would then move to conversation about other things—a step that might reveal the strength and proportion of each virtue in the character being revealed. In this way the smooth-talking jerk with perfect grades and scores might not fare as well in my evaluation as the late-bloomer candidate who felt called to medicine but hit a rough patch along the way, creating a less than perfect application from a perfectly suited character. For me, at least, how candidates handled adversity was more important than if they had perfect scores. Honesty, diligence, curiosity, and compassion inevitably produce a pre-professionalized candidate whose inclinations will likely strengthen through the habituation processes that arduous medical training circumstances and practices afford. [End Page 191]

Is a Virtue-Based Theory of Ethics in Medicine Possible?

The foregoing musings beg this question, "Is a virtue-based theory of ethics in medicine and the nature of professionalism possible?" My answer is, "No—no more so than a theory based on principles, common law, or duties." The reason is that abstract concepts formulated around principles, laws, duties, and virtues, applied to concrete situations in an over-zealous way, invites Procrustean dogmatism. What doesn't fit gets lopped off or stretched, depending on the need. For instance, what is autonomy—really—to the preemie whose parents have abandoned her to the care of the NICU nurses? Where can common law be applied when a pill tastes bad or the double-effect pattern of morphine use in the hospice business is accepted and rewarded? How can duties proscribed by law in a differential fashion be reconciled by a theory that seeks to blur the margins of professionalism? And last, of all the virtues available to pick from, why settle on four as particularly suited to medicine? [End Page 193]

These and similar questions arise whenever "good, better, best" become the center of a debate. I will end by saying I think Rhodes got this part right:

Because ethics must address the reality of human nature, morality does not end with duty. It extends to the feelings that interfere with people recognizing what their duty requires and meeting their obligations. The ethics of medicine therefore has to address feelings as part of its broad aim of making doctors and the medical professional trustworthy. This includes appreciating that feeling appropriate emotions is a necessary tool for enabling doctors to reliably succeed in doing what they ought to do. That in turn makes doctors duty bound to develop fitting feelings. Such well-habituated constant feelings are the virtues of good doctors and an essential element of medical professionalism.

(275)

To this I say, "Amen." If the clinic plans to survive the medical-industrial complex pressures to turn suffering to profit and actuarial reimbursement to better margins, those who admit people to medicine and allied educational programs need to seek out and find the honest, diligent, curious, and compassionate people Rhodes envisions as being "trusted doctors."