Health Care Reform: What History Doesn’t Teach

The paper begins by tracing the historical development of American medicine as practice, profession, and industry from the eighteenth century to the present. This historical outline emphasizes shifting conceptions of physicians and physician ethics. It lays the basis for showing, in the second section, how contemporary controversies about the physician’s role in managed care take root in medicine’s past. In the final two sections, I revisit both the historical analysis and its application to contemporary debates. I argue that historical narratives can function as “master narratives” that suppress or leave out historical facts. I bring to the surface what is covered up by the master narrative approach, and show its relevance to contemporary ethical debates. I conclude by proposing that preserving the integrity of medicine will require modifying the master narratives we tell about physicians. The integrity of medicine also offers new perspectives for thinking about managed care and the broader topic of health care reform.     

Reply to Griswold, <Emphasis Type="Italic">Forgiveness: A Philosophical Exploration</Emphasis>

This paper replies to the account of forgiveness developed in Griswold’s Forgiveness: A Philosophical Exploration. It defends the idea that “unilateral” forgiveness is the paradigm case of the virtue of forgiveness, rejecting Griswold’s claims that forgiveness is essentially a “dyadic” virtue, and that reconciliation of the wronged party with the wrongdoer is a defining element of forgiveness. Forgiveness is fundamentally a matter of being reconciled to the persistence of human wrongdoing, as expressed in particular instances. Reconciliation may well be essential to some attempts at “political apology” for wide-scale wrongdoing. But then, contrary to some of Griswold’s claims, forgiveness will be central to many national projects of bringing about civic reconciliation. The paper also distinguishes between the project of seeking moral reconciliation from the project of seeking and granting political recognition for those who have been denied civic status. Contrary to Griswold’s view, the Vietnam Veterans War Memorial is best understood as a project of seeking and granting recognition, not as an attempt to produce civic reconciliation in response to the Vietnam War.     

The Virtuous Body at Work: The Ethical Life as <Emphasis Type="Italic">Qi</Emphasis> 氣 in Motion

This essay argues that moral self-cultivation as described in the Confucian tradition involves the cultivation of the body. Preparing the body in certain ways, perhaps by making it healthy, is a necessary part of moral self-cultivation. This claim includes: (a) nourishing the body in a proper way is a first step in moral self-cultivation, and the bodily care is instrumentally valuable to one’s flourishing life; (b) making and keeping a healthy body is partly constitutive of a moral well-being and hence bodily care is also intrinsically valuable to a flourishing life. This perspective on embodied virtue is established through a discussion of qi. The body as the storehouse of qi is not only a passive reservoir of knowledge that serves as moral guidance, but also actively plays an indispensable and integral role in activities related to one’s moral transformation. A well-cared for body provides a moral agent with the temporal and spatial possibility for moral refinement and an enhanced good life.     

Virtues,Skills, and Right Action

According to Rosalind Hursthouse’s virtue based account of right action, an act is right if it is what a fully virtuous person would do in that situation. Robert Johnson has criticized the account on the grounds that the actions a non-virtuous person should take are often uncharacteristic of the virtuous person, and thus Hursthouse’s account of right action is too narrow. The non-virtuous need to take steps to improve themselves morally, and the fully virtuous person need not take these steps. So Johnson argues that any virtue based account of right action will have to find a way to ground a moral obligation to improve oneself. This paper argues that there is an account of virtue that can offer a partial solution to Johnson’s challenge, an account where virtue is a type of practical skill and in which the virtuous person is seen as having expertise. The paper references the account of skill acquisition developed by Hubert and Stuart Dreyfus. Their research demonstrates that novices in a skill have to employ different strategies to act well than the strategies used by the experts, and so the ‘virtue as skill’ thesis provides support for Johnson’s claim that the actions of the non-virtuous will differ from the virtuous. On the other hand, their research suggests that there is no separating the commitment to improve yourself from the possession of expertise, and so the ‘virtue as skill’ thesis has the resources for grounding the obligation to improve oneself in an account of virtue.     

Artifice and virtue in the<Emphasis Type="Italic">Xunzi</Emphasis>

Xunzi was chronologically the third of the three great Confucian thinkers of China’s classical period, after Confucius and Mencius. Having produced the most comprehensive philosophical system of that period, he occupies a place in the development of Chinese philosophy comparable to that of Aristotle in the Western philosophical tradition. This essay reveals how Xunzi’s understanding of virtue and moral development dovetailed with his positions on ritual propriety, the attunement of names, the relation betweenli (patterns) andlei (categories), and his view ofdao (the way) in general. I have argued for a “constructivist” understanding of each of these aspects of Xunzi’s philosophy in some detail elsewhere (see Hagen 2000, 2001, 2002, 2003), and so here I will just briefly review a few key points before addressing their relation to moral development.     

Understanding the Trusted Doctor and Constructing a Theory of Bioethics

This paper offers a constructivist account of bioethics as an alternative to previous discussions that explained the ethics of medicine by an extrapolation of principles or virtues from ordinary morality. Taking medicine as a higher and special calling, I argue that the practice of medicine would be impossible without the trust of patients. Because trust is a necessary condition for medical practice, the ethics of the profession must provide the principles for guiding physician behavior and the profession toward promoting trust and being trustworthy. In a phrase, that principle is “seek trust and deserve it.” I sketch out how the concept of trust provides a different justification for common sense principles of bioethics and explain how the concept of trust provides reasonable guidance for resolving moral conflicts within medicine. The trust-seeking approach provides a new and unexpected ordering of some traditional medical values, it reveals the weightiness of previously undervalued bioethical precepts, and illuminates the centrality of some largely ignored obligations of medicine. It also has the power to guide clinical practice and to inform the profession about standards for medical institutions. This revised version was published online in August 2006 with corrections to the Cover Date.     

医学专业精神的初步研究

由于历史和社会文化的差异,中西方对医学专业精神有着不同的理解。在中西不同语境下,分析了“Profession”和“Professionalism”这两个核心概念的涵义,并从中西对比的视角,对中西方医学专业精神所面临的几个共同问题进行了初步研究,包括医学专业核心道德价值观念、利益冲突、行业自治等。在此基础之上,还对我国医学专业精神的发展提出建议。     

Two Senses of Justice: Confucianism,Rawls, and Comparative Political Philosophy

This paper argues that a comparative study of the idea of a sense of justice in the work of John Rawls and the early Chinese philosopher Kongzi is mutually beneficial to our understanding of the thought of both figures. It also aims to provide an example of the relevance of moral psychology for basic questions in political philosophy. The paper offers an analysis of Rawls’s account of a sense of justice and its place within his theory of justice, focusing on the features of this capacity and how it develops. It then provides an account of the sense of justice in Kongzi’s thought as it is seen in the Analects. Finally, it shows how examining the similarities and differences between the two accounts can deepen our understanding of both views, as well as our appreciation for the importance of understanding how a sense of justice develops.     

On the notion of home and the goals of palliative care

The notion of home is well known from our everyday experience, and plays a crucial role in all kinds of narratives about human life, but is hardly ever systematically dealt with in the philosophy of medicine and health care. This paper is based upon the intuitively positive connotation of the term “home.” By metaphorically describing the goal of palliative care as “the patient’s coming home,” it wants to contribute to a medical humanities approach of medicine. It is argued that this metaphor can enrich our understanding of the goals of palliative care and its proper objectives. Four interpretations of “home” and “coming home” are explored: (1) one’s own house or homelike environment, (2) one’s own body, (3) the psychosocial environment, and (4) the spiritual dimension, in particular, the origin of human existence. Thinking in terms of coming home implies a normative point of view. It represents central human values and refers not only to the medical-technical and care aspects of health care, but also to the moral context.     

Expressivism and Moral Dilemmas: A Response to Marino

Simon Blackburn’s expressivist logic of attitudes aims to explain how we can use non-assertoric moral judgements in logically valid arguments. Patricia Marino has recently argued that Blackburn’s logic faces a dilemma: either it cannot account for the place of moral dilemmas in moral reasoning or, if it can, it makes an illicit distinction between two different kinds of moral dilemma. Her target is the logic’s definition of validity as satisfiability, according to which validity requires an avoidance of attitudinal inconsistency. Against Marino’s arguments, I contend that expressivists following Blackburn are able to show how we appreciate the validity of arguments found in dilemma-contexts, and that Marino’s argument concerning the distinction between contingent moral dilemmas and logical moral dilemmas rests on a mistake concerning the logical representation of a contingent dilemma.     

A Royal Road to Consequentialism?

To consequentialise a moral theory means to account for moral phenomena usually described in nonconsequentialist terms, such as rights, duties, and virtues, in a consequentialist framework. This paper seeks to show that all moral theories can be consequentialised. The paper distinguishes between different interpretations of the consequentialiser’s thesis, and emphasises the need for a cardinal ranking of acts. The paper also offers a new answer as to why consequentialising moral theories is important: This yields crucial methodological insights about how to pursue ethical inquires.     

Revisiting the need for virtue in medical practice: a reflection upon the teaching of Edmund Pellegrino

Edmund Pellegrino considered medicine as a skill, art, and perhaps most importantly, a moral enterprise. In this essay, I attempt to exemplify how the legacy and contributions of Edmund Pellegrino, as a teacher and a physician, could allow for a renaissance of medical practice in which physicians engage intellectual and moral virtue to both effect sound care, and do so in a humanitarian way, rather than in simple accordance with a business model of medicine. The virtues are viewed in a renewed light as being key characteristics of physicians, and important to patient centered care.     

An antinomy of political judgment: Kant,Arendt, and the role of purposiveness in reflective judgment

This article builds on Arendt’s development of a Kantian politics from out of the conception of reflective judgment in the Critique of Judgment. Arendt looks to Kant’s analysis of the beautiful to explain how political thought can be conceived. And yet Arendt describes such Kantian reflection as an empirical undertaking that justifies itself only in relation to the abstract principle of the moral law. The problem for such an account is that the autonomy of the moral law appears to be at odds with the social cohesion of Kantian political life. The ensuing contradiction can be deemed the antinomy of political judgment. Kant’s conception of reflective judgment offers such an inquiry considerably more to work with than Arendt uncovers. In particular, the regulative principle of the purposiveness of nature that is shown to direct all reflection can be seen to offer the solution to this antinomy.     

The medical profession and the corporatization of the health sector

This article describes the most important determinant of contemporary American medical practice: the corporatization of the health care delivery system. It argues that there is an urgent need for greater reflection by physicians on the values inherent in profit-based health care and on the implications of such a model of care. Other pressures on the medical profession and several available responses are examined. The article then poses a challenge to the profession to assume a more forthright advocacy for social equity in health care provision.     

Situationism and Confucian Virtue Ethics

Situationist research in social psychology focuses on the situational factors that influence behavior. Doris and Harman argue that this research has powerful implications for ethics, and virtue ethics in particular. First, they claim that situationist research presents an empirical challenge to the moral psychology presumed within virtue ethics. Second, they argue that situationist research supports a theoretical challenge to virtue ethics as a foundation for ethical behavior and moral development. I offer a response from moral psychology using an interpretation of Xunzi—a Confucian virtue ethicist from the Classical period. This Confucian account serves as a foil to the situationist critique in that it uncovers many problematic ontological and normative assumptions at work in this debate regarding the prediction and explanation of behavior, psychological posits, moral development, and moral education. Xunzi’s account of virtue ethics not only responds to the situationist empirical challenge by uncovering problematic assumptions about moral psychology, but also demonstrates that it is not a separate empirical hypothesis. Further, Xunzi’s virtue ethic responds to the theoretical challenge by offering a new account of moral development and a ground for ethical norms that fully attends to situational features while upholding robust character traits.     

Developing the Good Physician: Spirituality affects the development of virtues and moral intuitions in medical students

The Project on the Good Physician is a national longitudinal study of moral and professional formation of American physicians over the course of medical training. The purpose of this paper is to examine the processes by which spirituality influences the development of three virtues (mindfulness, empathic compassion, and generosity) in medical students as mediated by the moral intuition to care/harm, as well as make predictions as to how this type of study could be generalizable to other populations. Study participants were 563 medical students recruited by the University of Chicago from 24 medical schools across the U.S. (54.7% male, 57% white) who completed measures assessing virtue formation 9 months apart. Path analysis of a cascade model showed that spirituality (but not religiousness) was directly and indirectly related to change in the virtue empathic compassion, and also indirectly related to change in the virtue generosity. Moreover, the moral intuition to care/harm partially mediated the association between spirituality and the virtues of empathic compassion and generosity (but not mindfulness).     

Openness with patients: a categorical imperative to correct an imbalance

This paper examines the concept of ‘openness with patients’ from the stand-point of the limitations of biomedical ethics. Initially we review contemporary critiques of bioethics and, in particular, of principlism; we relate how other; somewhat neglected, forms of medical ethics can yield useful information and provide moral guidance. The main section of the paper then shows how a bioethical approach to openness misses the social context in our example, the viewpoints of patients; we present some of the increasing wealth of research evidence which points towards patients wanting more information and a greater degree of openness. Finally we put forward that a principlist’s objection to active encouragement of openness might be based on the risk of infringing upon the ‘right not to know’. We reject this by arguing how rights can be trumped. Dr. Anthony S. Kessel, BSc, MBBS, Mphil, MSc, is a general practitioner, medical ethicist and currently specialist registrar (Barking & Havering Health Authority)/Honorary lecturer in public health medicine in the Epidemiology Unit, London School of Hygiene & Tropical Medicine, London, UK.     

Associative Virtues and Hume's Narrow Circle

This article offers a straightforward reading of Hume's ‘narrow circle’ – the boundary employed to define those with whom we sympathize in assessing an agent's moral character – that follows from a more careful look at his account of virtue. Hume employs a principle that can be understood as a virtue ethical equivalent of associative obligation, which thereby delimits the boundaries of this circle. This reading avoids concerns about unjustified partiality, moral blind spots, and demandingness, and shows a clear path for reaching uniform moral judgments; it also offers a new perspective on virtue of interest for contemporary virtue ethics.