Medicine, Health Care and Philosophy

, Volume 18, Issue 1, pp 129–137 | Cite as

The nature of epistemic virtues in the practice of medicine

Scientific Contribution

Abstract

There is an assumption in virtue epistemology that epistemic virtues are the same in different times and places. In this paper, however, I examine this assumption in the practice of medicine as a paradigm example. I identify two different paradigms of medical practice, one before and the other after the rise of bioethics in 1960s. I discuss the socially defined role and function of physicians and the epistemic goals of medical practice in these two periods to see how these elements affect the necessary epistemic virtues for physicians. I conclude that epistemic virtues of medical practice differ in these two periods according to the differing epistemic goals and the socially defined function of physicians. In the end, I respond to the possible objections to my thesis based on the distinction between skill and virtue.

Keywords

Epistemic/intellectual virtue Practice of medicine Bioethics Epistemic goal Skill 

Introduction and historical background

Medicine is probably one of the oldest practices in human societies. During its long history, medicine has been associated with a sense of right and the good. Practice of medicine has always been regarded as beneficial, good, and praiseworthy. At the same time, practitioners of medicine in different times and places were required to exhibit certain character traits and skills that were deemed necessary for the fulfillment of the goals of the practice. In this sense, ethics has always been part of both the practice of medicine and theoretical discussions over the nature and goals of medicine. In a very broad sense of the term, there was a traditional ethics of medicine, in which the concepts of a good doctor, the bond of trust between the physician and the patient, and the principle of beneficence were the most important notions in medical ethics. This long tradition starts back in the antiquity, continues in the Middle Ages, and continued to have a strong influence in the modern medicine. In this context, the emergence of bioethics indicates a major transformation of the practice of medicine.

Bioethics has developed out of the old discipline of medical ethics in the second half of the 20th century. Traditionally, medical ethics was mainly about the character traits of a good doctor. The main ethical principle ruling the doctor-patient relationship was beneficence. In other words, the main criterion for a good doctor was acting in a way that serves the best interest of her patient. In that paradigm of the physician-patient relationship, the physician was the party in charge of medical decision-making, and the patient had no significant role in decisions about her health. The bond of trust was the most important characteristic of a good physician-patient relationship. Another notable aspect of the old paradigm of medical practice was that mostly physicians were thinking and writing about the ethics of medical practice and the traits of a good physician. As Rothman summarizes, “Well into the post-World War II period, decisions at the bedside were the almost exclusive concern of the individual physician, even when they raised fundamental ethical and social issues. It was mainly doctors who wrote and read about the morality of withholding a course of antibiotics and letting pneumonia serve as the old man’s best friend” (Rothman 1991, p. 1). It was only a physician’s medical expertise that would determine what is best for the patient to do for her health condition. And physicians’ trustworthiness for doing this job was clearly based on their presumed virtues.

Starting in the 1960s in the United States of America, there was a fundamental change in the long-standing paradigm of medical practice (Callahan 1990, p. 3; Rothman 1991; Jonsen 1998). Physicians were no longer considered as the ultimate decision-makers in medicine. Instead, patients are now assumed to have the moral and legal right to decide about their medical condition. This breakthrough in the practice of medicine was the result of certain historical and social developments, including the crimes of Nazi doctors, unethical practice of physicians in medical research, and a number of rights movements such as women’s rights, gay rights, civil rights, and children’s rights (Rothman 2001, p. 266). In other words, the patients’ rights movement in the field of medicine played the same role as other rights movements: it tried to limit the authority of those in power to strengthen the voice of the oppressed and marginalized classes. This challenge to the long-held authority of physicians in medical decision-making was championed by a group of “outsiders” including theologians, philosophers, lawyers and social scientists. The common theme of the contributions made by this diverse group of scholars has been the emergence of an interdisciplinary field of study that was later called bioethics.

With different degrees of importance, in both the old and the new paradigms of medical practice there are different virtues for a good physician. Another common feature of the two paradigms is that in both, virtues of medical practice are mainly considered to be moral virtues; there is little reference to intellectual or epistemic virtues in the ethics of medical practice. There are a variety of lists of intellectual virtues in different works by virtue epistemologists and in the classic works of philosophy. There seems to be an assumption that the lists include “the intellectual virtues” i.e. a complete and unchanging set of virtues. Even someone like Zagzebski who emphasizes the social aspect of virtues identifies them as those deep traits that are mentioned “on the greatest number of lists of the virtues in different places and at different times in history” (Zagzebski 1996, p. 89). In other words, it is assumed that virtues, including the intellectual virtues, are the same in different times and places. While I do not intend to make a hard and fast distinction between epistemic and moral virtues, intellectual virtues are those excellences, habits, and dispositions of the mind that help us in being a better thinker. In contrast, moral virtues are those excellences, habits, and dispositions of character that make us a better human being. In this paper, however, I will argue that due to the social aspect of the intellectual virtues in a practice, epistemic virtues vary in different times and places based on the epistemic goals of the practice and the socially defined function of the practitioners.

To explain this thesis, I shall consider the ethics of medical practice as a paradigm example. In this context, I shall look at the ethics of medical practice in two different periods. I consider intellectual virtues in the practice of medicine before the rise of bioethics in the 1960s, and compare them with the intellectual virtues that are deemed necessary after the rise of bioethics. Based on this comparison, I conclude that there are different sets of intellectual virtues that correspond to different periods in the history of a single practice, i.e. medicine. I then explain these differences based on the differing functions and roles of clinicians in the two periods. I also argue that intellectual virtues will depend on the epistemic goals of the practice, and with different emphasis on various epistemic goods the required intellectual virtues will change. Finally, I conclude that intellectual virtues in medical practice are defined by the changing role and function of the clinicians. Medical practice, in various times and places based on its defined social and professional roles and also depending upon its assumed epistemic goals, has different set of necessary intellectual virtues.

The old paradigm of medical practice

There are a variety of traditions in the history of Western medicine with the two prominent figures whose influence lasted for centuries after their death: Hippocrates and Galen. However, the mainstream and dominant tradition in medicine for centuries has been the Galenic tradition and even the works of Hippocrates were understood and interpreted in the light of Galen and his commentaries on Hippocrates. Hence, in what follows, the old paradigm in medicine basically corresponds to the dominant Galenic tradition.

In what I call the old paradigm of medical practice, which may also be called the paternalistic model, physicians had the exclusive authority over decision-making in medicine. This authority was considered legitimate because of the physicians’ professional knowledge, the virtues of physicians, and the strong bond of trust that was a defining characteristic of medical practice. In this paradigm, a good patient was considered to be the one who follows all the recommendations made by her physician. All the communications between physician and patient were about the things the patient needs to do for her improvement and the prevention of further complications. The epistemic goal of medicine in this paradigm was medical knowledge, which consisted of the diagnosis of disease condition, its nature and causes, and the best available medical or surgical treatment for the restoration of health, to the extent that is possible. To attain this goal and do their job, physicians were required to have certain excellences. Since the ancient times, it was assumed that human nature is healthy and perfect as long as its constituent elements are in a state of harmony. It was based on such an understanding of the nature of health and disease that the job of physicians and their required character traits were all defined. As Magner says:

One of the important and characteristic expressions of Hippocratic medicine is found in the text known as On Ancient Medicine. A major thesis of this work is that nature itself has strong healing forces. The purpose of the physician, therefore, was to cultivate techniques that would work in harmony with natural healing forces to restore the body to a harmonious balance. (Magner 2005, p. 95).

In other words, it was assumed that the best a physician can do is to assist natural healing forces within the human body to work properly and bring about health, which was considered a previous state of balance and harmony. Another aspect of the ancient medicine was its emphasis on the concept of harmony. Health and disease were both defined based on the concept of a naturally existing balance. Health was the (default) state of nature resulting from the harmony among the four humors (Carrick 1985, p. 16). Correspondingly, disease was the state of an imbalance among the humors: “The humoral doctrine explains health as the result of the harmonious balance and blending of the four humors. An excess of one of the humors results in a dyscrasia or abnormal mixture” (Magner 2005, p. 99). It was based on these ideas of the nature of health and disease that physicians were relying on the analysis of bodily excretions and secretions for the diagnosis of original imbalance as the cause of disease. The most important excellences that were deemed necessary for being a good physician were faculty traits such as good eyesight (Adams 1894, p. 474). Magner provides a good explanation for this phenomenon:

Until very recent times, the only ‘analytic laboratory’ available to the physician was that made up of the five senses. In other words, the nose and tongue served as the first analytical chemists. Thus, to understand the nature of the patient’s disease, all excretions, secretions, and effluvia had to be analyzed directly in terms of sense perceptions. (Magner 2005, p. 99).

In other words, physicians, as part of their everyday job for the diagnosis of diseases were using their taste and smell faculties for the analysis of human body fluids such as blood and urine as the main sources of getting information about the nature of imbalance in the humors. Hence, among the main epistemic virtues for a physician were certain types of reliabilist faculty traits of good taste, smell, and eyesight to be able to differentiate among various changes in body fluids that are characteristic of different disease conditions. As the main diagnostic tools for physicians during their whole career, these excellences were stable and deeply seated traits that defined the most important epistemic virtues necessary for good physicians. A related question is the expected roles and functions of a physician regarding which diagnosis was a necessary element.

In addition to the crucial role in the diagnosis of disease conditions, physicians were generally deemed responsible for finding the prognosis of diseases, providing the best available therapies, and ways of preventing disease. Especially important in this context is the issue of prognosis. Because in a time that available therapy for many diseases was limited, prognostication gained a prominent place in medicine (Demaitre 2003, p. 787–788). The resources necessary for prognostication were gathered from a wide variety of sources ranging “from Hippocratic semiology to Galenic chronology and to Arabic (as it is sometimes characterized) astrology” (Demaitre 2003, p. 788). All these measures were taken “in the hope for achieving certainty” and “to establish prognostication as a science” (Demaitre 2003, p. 788).

This quest for certainty was not limited to the ancient and medieval doctors, however, and even contemporary physicians seem to share the same attitude. “It seems that the myth of scientific certainty carries the day. The more sophisticated among them know that certainty in the sense of ‘knowing for sure’ has been replaced with probabilistic terms. But even this change has made no difference in the view physicians hold of scientific certainty” (Sassower and Grodin 1987, p. 230). For the purpose of fulfilling all these goals, physicians needed to portray the picture of their knowledge in a way that rejects the chance of fallibility. This notion of perfection is especially prominent in the element of prognosis. Being able to predict future events in the course of disease gave physicians’ knowledge a tone of certainty that one might say was not warranted. However, this notion of certainty had a very important impact on the social status of physicians, and medical profession in general, during most of its history (Demaitre 2003, p. 803). Hence, medical knowledge in most periods of the history of medicine has been considered as a kind of knowledge with high degree of certainty, and physician’s social status was partly influenced by this quality of their knowledge. This understanding of the epistemic goal of medicine influenced the epistemic virtues that were deemed necessary for a good practitioner of medicine.

In addition to faculty traits, physicians were generally expected to be perfect in their diagnosis and prognosis of disease. This perfectionist attitude towards the process of diagnosis, treatment, and prognosis of disease was both expected as a public need and as a defining feature of a good physician. As a matter of clarification, if a doctor, in the old paradigm of the practice of medicine, after doing the necessary diagnostic exams was speaking in the language of probability and possibilities about the nature or cause of the disease and its prognosis she was not probably regarded as a virtuous physician. While the theoretical foundations of ancient medicine, owing to the influence of different epistemological contributions, might have not supported the dogmatism, but the dominant social role of physicians was defined in a way that presupposed the certainty. In other words, the epistemic goal of certainty of knowledge as a social element necessitated a kind of dogmatism regarding the processes, methods, and the final recommendations in medical practice. This notion is reflected in the fact that a good patient was considered to be the one who totally complies with the prescribed medications or medical and dietary recommendations. In other words, what I call a social expectation of “medical dogmatism” regarding the science and practice of medicine has survived well into the modern times.

Another aspect of the old paradigm of medical practice that contributed to what I describe as the social expectation of “medical dogmatism” was the unquestioned authority of physicians in medical decision-making. Probably based on the presupposed high epistemic status of medical knowledge, it was the normal practice in almost all periods of the history of medicine that decisions at the bedside should be made by the physician. In the process of decision-making, the individual patient and her particular goals and values in life were not discussed or addressed. Medical knowledge was about the diagnosis, treatment, and prognosis of disease and to further the goal of a healthy and flourishing life, which indicates that, in fact, the patient’s goals and values in life were actually considered. The point is that ancient medicine was mostly practiced in societies that, because of the critical role played by traditions, enjoyed a shared understanding of values and goals and a common interpretation of human flourishing. Hence, the patient’s goals and values were implicitly factored in the medical decision making through the shared values and goals between the physician and the patient. However, in the modern context and in the absence of a commonly shared source of goals and values that define human flourishing, physicians under the new paradigm are expected to explicitly consider the patient’s particular goals and values. In this process, the patient and her particular goals and values attain a certain level of power in medical decision making that, for the reasons discussed above, was absent in the old times. Instead, there was a greater emphasis on other values, such as not harming the patient, and giving bad news was considered as against the value. Hence, in the old paradigm of medical practice, there was a power and authority imbalance between physician and patient that was ultimately justified as a social phenomenon based on the difference in knowledge about health and disease that the physician had and the patient lacked.

Another epistemic side of an earlier paradigm of medical practice was its grounding on the concept of the patient’s best interest. This interest was mostly defined in medical terms and, consequently, the physician was the one who had access to it. The best interest was an objective criterion of a good practice of medicine. The only thing a physician needed to be justified in his decisions was the mastery of current medical knowledge and practice. Hence, epistemic virtues of a good physician included only those excellences that were necessary for achieving that presumed objective knowledge. In other words, the epistemic good of the knowledge of the best interest provided the theoretical foundation for the set of intellectual virtues necessary for the practice of medicine.

The new paradigm of medical practice

Starting in 1960s and under the influence of certain right movements, the norms of medical practice started to change in a fundamental way. There seems to be a consensus among the historians of medical ethics that the 1960s demarcate the beginning of a new era in the history of medical practice (Callahan 1990, p. 3; Rothman 1991, pp. 1–4; Jonsen 1998, pp. 4–5). For the first time in the history of medical practice, the concept of a patient’s rights in decision-making about her medical condition appeared in the debates. The central concept in all these developments has been what is generally referred to as the principle of respect for autonomy (McLean 2010, p. 6). According to this new concept, the patient's wishes and preferences, and her particular goals and values in life should be considered in medical decision-making. According to a stronger version of this principle, patients should be the ultimate decision-makers about their health condition. Physicians are obligated to provide patients with facts about their medical condition including the nature of disease, various possible alternatives for treatment and their respective pros and cons, and the prognosis of disease. This fundamental change was the result of certain social developments.

Before the rise of bioethics in 1960s, a group of rights movements developed mainly in the United States. As Rothman summarizes “Civil rights, women’s rights, gay rights, and…patient rights, all rose to prominence in the 60s and 70s, and all shared a similar mind set. It was characterized, in the first instance, by a profound suspicion and distrust of constituted authority-whether in familial, educational, community, political, or medical institutions” (Rothman 2001, p. 226). A set of norms is derived from the principle of respect for the autonomy.

As a moral norm, respect for autonomy has been the basis for the justification of a cluster of rules, which together with the original norm of autonomy provide the content for most arguments and counter-arguments in the ethics of biomedical practice. All the various rules derived from the concept of autonomy such as informed consent, confidentiality, the right to privacy, and truth-telling are now incorporated into the body of various professional codes of medical practice and into the body of existing laws and regulations governing biomedicine. The most important norm that entered the practice of medicine in all its various fields has been the requirement for informed consent. Physicians and clinical researchers are expected to inform patients about the nature of medical condition, various available treatments and their respective pros and cons, the prognosis of disease condition, and the consequences of no treatment option. In both clinical medicine and biomedical research nothing can be done without the previous approval of the patient and her informed consent. The net result of all these normative changes has been a paradigm shift in the practice of medicine with fundamental transformation of the role and function of physicians and what is expected from a good physician.

As a prominent aspect of the new paradigm in medical practice, medical standards are no longer a sufficient justification for a course of action or a medical decision. Under the new paradigm of medical practice, a good physician is the one who is able to effectively communicate with her patient about the nature of disease, available medical and surgical options and their pros and cons, and the prognosis of disease condition. This should be done in a way that is correct and based on the best available medical evidence and understandable to the patient and/or family. Telling patient the facts about her disease condition is a requirement based on both the professional codes and laws and regulations pertaining to medical practice. At the same time, the physician is expected to listen to the patient's story and incorporate the patient's values and goals in life into the process of medical decision-making. However, under the old paradigm a tradition acted as the common source of values and goals and defined the meaning of human good in a way that there was no need for the explicit conversation about such matters at the bedside. In other words, a virtuous physician should be able to listen carefully to her patient’s particular narrative of life and illness and use that as a source of information for making a whole picture of the patient as a person. The important point is that the contemporary emphasis on narratives and history taking, in addition to be a re-emergence of an old theme in medical tradition, is intended to give the patient certain level of authority in medical diagnosis and treatment, because the physician is no longer assumed to share or know the values and goals of the particular patient. Accordingly, the physicians under the current paradigm are required to share epistemic and decisional authority with their patients. In the absence of tradition as a shared source of values and goals, medical standards which were supposed to give the physician his authority, are no longer sufficient for a warranted medical decision. Consequently, grasping the best available medical knowledge no longer guarantees making a virtuous physician.

There is a more recent development that is distinctive of the current practice of medicine. Compared to the biologism of an earlier period, contemporary medicine is cognizant of the influence of factors beyond simple biological mechanisms in the pathogenesis and treatment of disease conditions. Hence, the epistemic goals of medicine are no longer defined only in biological terms. Current framework of medical knowledge includes notions from psychology, biology, sociology and spirituality. Consequently, medicine is becoming increasingly dependent upon the results of various kinds of clinical, biomedical, epidemiological, psychological, pharmacological, and sociological studies. The results of this wide array of research have a tremendous level of impact on daily medical practice. New drugs and methods of treatment, new findings about the causal mechanisms of diseases, the effect of various genes on virtually all fields of medical practice, and the impact of various social and psychological factors are discovered and discussed in the language peculiar to different contexts of scientific research. Hence, an epistemically virtuous physician should be able to understand the implications of this wide set of research studies for his daily medical practice. A good physician should also be able to identify different kinds of limitations and biases in the results of scientific studies. Without these excellences, physicians are vulnerable at two extremes of either not having access to the best available knowledge-in case he does not update his knowledge with the newly found evidence- or using the untrustworthy sources of information and being unable to identify the limitations and biases of the studies. The cause of all these various possible scenarios is the lack of certain necessary excellences that results in a quality of medical practice that is below the accepted norms.

Another implication of the fundamental social and professional changes that occurred in medical practice is a change in physicians understanding of the epistemic status of medical knowledge. With the introduction of a variety of possible influences from the part of biological, social, psychological, and spiritual factors and their interactions on the state of health and disease, the older model of “medical dogmatism” that was characteristic of medicine of an earlier period becomes inappropriate for current medical practice. In addition, if we consider the fact that what the physician knows about the nature of disease, its course, available treatment options, and prognosis is ultimately based on the result of previous research and has its own limitations, the best can be said is that current medical knowledge probably comes to be useful in some patients and inappropriate for others. This whole notion of the probabilistic nature of medical science and the possibility of various kinds of errors creates a situation that is called “medical fallibility” by MacIntyre (MacIntyre 1976, pp. 51–71). This notion of medical fallibility has important epistemic implications for the practice of medicine.

While it is true that the notion of fallibility and uncertainty of medical knowledge could be inferred from the ancient theories and philosophies of medicine but, as I emphasized before, practitioners of the dominant Galenic tradition understood and practiced medicine in a way that was based on the assumption of the certainty of medical knowledge. Hence, while the notion of medical fallibility might not be completely new in the theoretical sense of the term, but regarding the long lasting tradition of medical dogmatism it appears as something new.

Medical fallibility is in contrast to the old notion of medical dogmatism and perfectionism, which required physicians and their medical knowledge to be perfect. If the status of medical knowledge is what MacIntyre describes as medical fallibility, then the epistemic goal of certainty in medical knowledge is unwarranted. Even if the physician could know all the relevant facts about a disease process, it would not be sufficient to provide certainty that was implied in the notion of (dogmatic) medical knowledge. The reason is that there is always a patient side of the story that in a critical way determines the meaning of health and disease and a good or bad course of action in bedside decisions. The epistemic goal in the new paradigm of the practice of medicine, then, is a kind of understanding about various kinds of factors that are interacting in a disease process, and that is informed by patient’s narrative in each particular case. As Zagzebski says, understanding has three features “It is acquired through mastering a techne; its object is not a discrete proposition but involves the grasp of part/whole relations; and it involves representing some portion of the world non-propositionally” (Zagzebski 2001, p. 242). In the case of medical practice, the relevant techne is mastering the best available evidence in medicine. The fact that an appropriate model of medical practice cannot always be expressed in a propositional form is reflected in the new trend in medical education that increasingly relies on the use of literary works, narratives, movies, works of art and other non-propositional forms of communication. This new epistemic goal necessitates a different set of virtues for physicians.

Mastering the techne of modern medicine requires first and foremost the virtue of epistemic humility. In accordance with the more humble status of medical knowledge as understanding, a good physician considers himself and his knowledge of the medical evidence in a way that is contrary to the arrogant attitude of a physician in the old paradigm who knows all the things about the disease and is expected to tell the patient what she needs to do. This virtue of epistemic humility, as Roberts and Wood say, is characterized by the absence of a set of epistemic vices such as arrogance, pride, domination, and superciliousness, which were basically intended for being highly praised and regarded for the purposes of social status and dominating others (Robert and Wood 2007, p. 77). Under the new paradigm, this virtue of epistemic humility enables physicians to be always aware of the limits of their epistemic power, and be open to different and especially opposing views. This virtue is especially necessary for physicians to seek the patient’s side of the story and be willing to listen to the patient's narrative as a source of relevant and valuable information for medical decision-making.

A review

I started with the current assumption that epistemic virtues are the same in different times and places. To examine this assumption, I used medicine as a paradigm example and reviewed the practice of medicine in two different periods. I argued that based on the different epistemic goals of the practice and also owing to the different socially defined function and role of the medical professional, there are differing sets of necessary epistemic virtues for the practice of medicine. In the next section, I will review possible objections to my thesis and respond them. In this regard, the most notable objection is that what I described as the changing character of virtues in two different periods has nothing to do with epistemic virtues; what I have counted as epistemic virtues are, in fact, skills that are necessary for virtues but are not virtues themselves. This objection is based on a distinction between virtue and skill that I will address and analyze below.

These are skills not intellectual virtues

As I stated earlier, my objective in this paper is to demonstrate the dependence of epistemic virtues on functions and social roles and that virtues may vary based on the differing epistemic goals of the practice. The theoretical underpinning of the most important possible objection to my thesis is a hard and fast distinction between virtues and skills, according to which virtues may still be considered to be the same while some necessary skills may vary. In other words, what I counted above as virtues, in fact, are skills not virtues. Since Zagzebski’s work is well-known in virtue epistemology literature, and regarding the fact that she has reviewed the arguments for making the distinction and defended the idea in her work, I use her writings as representing an example of the pro-distinction work and respond to the possible objections. Let’s start with Zagzebski’s account of a virtue.

Zagzebski says “A virtue, then, can be defined as a deep and enduring acquired excellence of a person, involving a characteristic motivation to produce a certain desired end and reliable success in bringing about that end” (Zagzebski, 1996 p. 137). In Zagzebski’s account, then, virtues have two components: reliable success, and proper motivation. This notion of virtue has provided Zagzebski with resources to make the first distinction between a virtue and a skill.

First argument for the distinction

Zagzebski formulates the first distinction between a virtue and a skill as “A vice is the contrary of a virtue, not its contradictory, but a skill has no contrary. The only candidate for the contrary of a skill is the lack of the skill, but surely, a vice is not simply the lack of a virtue. This is because vice, like virtue, is acquired by habituation” (Zagzebski 1996, p. 112). My response to this idea is that all intellectual vices can be explained as instances of the lack of one or more intellectual virtues, exactly in the same way that skills may be lacking. As an example consider the intellectual virtue of courage. The opposite of intellectual courage can best be explained by the lack of what having intellectual courage implies. This notion seems to be congruent with the metaphysical assumption of the monotheistic Abarhamaic traditions, according to which all that exists is good and an evil is defined as the lack of a good. In the same way, we have just virtues and skills; their contraries simply signify their absence. With this understanding of the nature of virtues and vices in mind, there is no distinction between a virtue and a skill.

Second argument for the distinction

As the second argument for making a distinction between a virtue and a skill, Zagzebski appeals to the distinction between intrinsic and extrinsic value. “If a skill has value, that is because of features of the situation in which it is used extrinsic to the skill itself. On the other hand, a virtue is intrinsically valuable” (Zagzebski 1996, p. 113). It seems that the argument contradicts my examples of virtues in the practice of medicine as being really virtues because they were relative to the features of the situation. My response is based on a traditional Aristotelian view of virtues as being function- and role-dependent. Everything has its own virtues that are defined based on its function. As an example, the virtue of a knife is to cut objects conveniently. In the same way, the virtues of a good physician are defined by her function. If the function of the physician changes, as I demonstrated it does, then the virtues may change accordingly. In other words, the value of virtues is dependent upon the socially defined function and role. For example, truthfulness is currently a highly valuable virtue for medical practice but in the old paradigm, there was less emphasis on truth-telling as a valuable character trait for physicians. Zagzebski, in response, might say that truthfulness was still a virtue even if it did not lead to better sum of goods, as she argued in the cases of courageous Nazi and compassionate judge (Zagzebski 1996, pp. 91–101). My response to Zagzebski’s hypothetical comment is that the same thing can be said about all skills: In some instances they might not add to the sum of goods and actually lead to more negative results but this does not devalue having skills.

Third argument for the distinction

The third point that helps in making a distinction between virtue and skill is the service relationship between skill and virtue. As Zagzebski says “Skills serve virtues by allowing a person who is virtuously motivated to be effective in action” (Zagzebski 1996, p. 113). For the purpose of clarification, Zagzebski mentions examples of skills that are associated with and serve certain virtues:
  • Compassion skills: knowing what to say to the bereaved

  • Moral wisdom skills: being able to talk a young person into staying in school or getting out of a street gang

  • Fairness skills: knowing how to fairly evaluate student papers or papers submitted to a professional journal

  • Skills of self-improvement: knowing how to develop a certain talent

  • Skills of generosity: being effective in giving to others (e.g., in a way that does not embarrass them)

  • Skills of courage: knowing how to stand up to a tormentor” (Zagzebski 1996, p. 113). It is clear that in Zagzebski’s account, virtues have accompanying skills. But a closer look at the examples provided by her reveals that in all cases epistemic content of the virtues are considered to be skills. In other words, what she calls skills are the contents and meanings of those virtues. In all of the above examples, we can consider those skills as the answers to the question of what is that virtue or what does having that virtue mean. Skills, in this account, guarantee the reliable success part of the meaning of a virtue. In this way, skills are not something different from virtues: they are, in fact, the core meanings of the virtues.

Zagzebski might respond by saying that there is still a difference between a virtue and its accompanying skill: a virtue has a proper motivation component, while a skill at best enables its possessor in reliable success. In other words, skills have something less than virtues. In response to this hypothetical comment I start with a question: how can we know that proper motivation is there? In my view, the best answer is by looking at the reliable success component, i.e., skill in Zagzebski’s account. If, for example, someone persistently and consistently expresses honesty, then she is honest: reliable success indicates proper motivation. Hence, there is no difference between a virtue and a skill with regard to proper motivation: both require proper motivation, which can be ascertained by the reliable success component that both skills and virtues share. At the very least, we can say that the virtue and the skill are indistinguishable.

To further clarify the distinction between virtues and skills, Zagzebski provides some examples of skills and tries to explain their importance for virtues. As she says “Spatial reasoning skills, mathematical skills, and mechanical skills are important for effectiveness in many of life’s roles, and a person who is virtuous in such roles would be ineffective without the associated skills” (Zagzebski 1996, p. 115). If we consider Zagzebski’s own definition, a virtuous person should have two things to be considered virtuous: reliable success and proper motivation. How can one who does not show reliable success and is not effective in attaining the goals of the virtue be considered virtuous in that role? It seems paradoxical to say that someone is virtuous in a role and at the same time is not reliably successful in bringing about the goals of the virtue. A hard and fast distinction between skills and virtues is unnecessary and leads to implausible conclusions as the above example indicates. The question arises as if having skill is so important for achieving the goal of virtue, why Zagzebski insists on separating virtue and skill?

A possible answer to the above question might be that Zagzebski’s virtue theory is modeled after virtue ethics, and in virtue ethics having the proper motivation has an important role in the definition of a moral virtue. In other words, this tendency to make a hard and fast distinction between skill and virtue serves the function of justifying a responsibilist account of intellectual virtue. This distinction also helps Zagzebski in denying faculty traits the position of a virtue, because it is hard to explain a proper motivation component for such faculty excellences as good eyesight.

Concluding remarks

I began with an assumption regarding the constancy of the list of epistemic virtues in different times and places. My objective in this paper was to examine that assumption by using the practice of medicine as an example. Then, I reviewed the two paradigms of medical practice and their respective epistemic goals, the socially defined function of and the epistemic virtues necessary for the physicians. I concluded that virtues of medical practice vary according to its epistemic goals and the defined function of physicians. This change may mean different things. Sometimes, as in the case of the intellectual virtues of good smell and taste, the virtues have lost their place in medical practice. In the case of truthfulness, something that was not considered a central virtue in medical practice is now, under a different paradigm, considered to be one of the most important virtues. And in cases such as the ability to interpret and handle different sets of published research data in a proper way, something new is now added to the list of virtues. In the end, I responded to the possible objections based on the distinction between a virtue and a skill.

References

  1. Rothman, D.J. 1991. Strangers at the bedside: A history of how law and bioethics transformed medical decision making. New York: Aldine de Gruyter.Google Scholar
  2. Callahan, D. 1990. Religion and the secularization of bioethics. Hastings Center Report 20(4): 2–4.CrossRefGoogle Scholar
  3. Jonsen, A.R. 1998. The birth of bioethics. New York: Oxford University Press.Google Scholar
  4. Rothman, D.J. 2001. The origins and consequences of patient autonomy: A 25-year retrospective. Health Care Analysis 9: 255–264.CrossRefGoogle Scholar
  5. Zagzebski, L.T. 1996. Virtues of the mind: An inquiry into the nature of virtue and the ethical foundations of knowledge. Cambridge: Cambridge University Press.CrossRefGoogle Scholar
  6. Magner, L.N. 2005. A history of medicine. Boca Raton: Taylor and Francis Group.Google Scholar
  7. Carrick, P. 1985. Medical ethics in antiquity: Philosophical perspectives on abortion and euthanasia. Dordrecht: D. Reidel Publishing Company.CrossRefGoogle Scholar
  8. Adams, F. 1894. The genuine works of hippocrates. London: Sydenham Society.Google Scholar
  9. Demaitre, L.E. 2003. The art and science of prognostication in early university medicine. Bulletin of the History of Medicine 77(4): 765–788.CrossRefGoogle Scholar
  10. Sassower, R., and M.A. Grodin. 1987. Scientific uncertainty and medical responsibility. Theoretical Medicine 8(2): 221–234.CrossRefGoogle Scholar
  11. McLean, S. 2010. Autonomy, consent, and the law. New York: Routledge-Cavendish.Google Scholar
  12. MacIntyre, A. 1976. Toward a theory of medical fallibility. The Journal of Medicine and Philosophy 1(1): 51–71.CrossRefGoogle Scholar
  13. Zagzebski, L.T. 2001. Recovering understanding. In Knowledge, truth and duty: Essays on epistemic justification, responsibility, and virtue, ed. Mattias Steup. New York: Oxford University Press.Google Scholar
  14. Roberts, C.R., and W.J. Wood. 2007. Intellectual virtues: An essay in regulative epistemology. New York: Oxford University Press.CrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media Dordrecht 2014

Authors and Affiliations

  1. 1.Albert Gnaegi Center for Health Care Ethics, Saint Louis UniversitySt. LouisUSA

Personalised recommendations