Virtue Ethics and Moral Character Related to Medical Profession

Abstract

Although moral values are universal, their application varies in different cultures. To Aristotle moral values are the result of habitual adherence to them. They become second nature. Galen combined the innate nature and temperaments. Al-Mawardi divided the origin of morality into two main branches: (a) The innate ones, (b) The voluntary character, which emanates from the training and using our faculties. Muslim philosophers tried to combine Aristotle and Galen; Miskawaih defined morality as being innate, controlled by instincts and humors, but definitely can be changed by training, cultivation, and culture. The motive and intention play an important role in the formation of moral character. In Islam, Prophet Muhammad (PBUH) taught that acts will be judged in accordance with the intention. If the motive is good and the act is good, the person will be rewarded by God; however, if the act is good and the motive is bad, the person will be punished for it.

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Although moral values are universal, their application varies in different cultures. In this study we are inclined to choose the following:

• (1) Moral values are the result of habitual adherence to them. They become second nature as a consequence of habitually doing what one considers is right. This is what Aristotle maintained in his famous Nicomachian Ethics [1]. According to him all moral values and characters can be changed. Some Muslim writers on ethics accept such view (with some alterations). Tahanooni in his Kashaf Istilahat alFanoon wa alOloom “the lexicon of the terminologies of Arts and Sciences” says that morality “Khulq” is a habituation and nature, which is affected and directed by religion [2].

• (2) Others say morality is innate and emanates from within the self, and cannot be changed (except with great effort) (al-Jurjani [3], Miskawayh (Tahzib Al-aKhalaq).

• (3) Galen [4] combined the innate nature and temperaments, e.g., sanguineous temperament, which usually appears at young age and youth, but those of sanguineous temperament continue until their old age. All dictators, conquerors, and despots from Nimrod, Pharoes till Hitler, and Stalin have had this bloody temperament. Others have bilious temperament, some have melancholy, and at old age usually the temperament is phlegmatic. The theory of humors, which he proclaimed, controls the temperament and affects the character. These humors are four: the blood, the bile from the gall bladder, the black bile from the spleen, and the phlegm from the brain and lungs. The theory is obsolete, and instead of these four humors, the new sciences replace them with hormones, genes, and myriads of smaller factors from within the body and from outside the body, i.e., environment, which displays the effect of nature and nurture on our characters and morality.

• (4) Al-Mawardi [5] divided the origin of morality into two main branches:

  • (a) The innate ones, which are part of our nature, which may be good or bad, and is controlled by instincts and humors (of Galen)

  • (b) The voluntary character, which emanates from the training and using our faculties. It is of course influenced by one’s education and community.

It seems that he is combining both Aristotle and Galen, with a strong inclination to Islamic ethos developed by the Qur’an and Prophet Muhammad (PBUH). Other Muslim philosophers tried to combine Aristotle and Galen, e.g., alFarabi in his book “AlJama’ bain al Hakimain [6]” (Combining the two philosophers, i.e., Aristotle and Galen). Similarly, Miskawaih in his book Tahzib Al-akhalaq [7] defined morality as being innate, controlled by instincts and humors, but definitely can be changed by training, cultivation, and culture.

Tom Beauchamp and James Childress in their book “Principles of Biomedical Ethics [8] considered virtue as “a trait of character that is socially valuable; a moral virtue is a morally valuable trait of character … communities sometimes disvalue persons who act virtuously or admire persons for their meanness and churlishness.” This occurs when the innate good nature of human beings is changed by a system of life that extols power and wealth, which become the most important aspiration for the whole nation.

It happened in Pre-Islamic Arabia (Jahiliyyah). The poets of that epoch extolled the character of doing injustice to others, killing the men, enslaving the women, children and the weak, and appropriating their wealth (herds, money, jewelry, or land). The poet (Zuhair Ibn AbiSalma, a Jahyiliah) said:

Injustice is innate in all persons …

If you find one who refrains from injustice then he has a serious malady.

It seems that many in the present-day civilization have returned to this old PreIslamic morality, which Beauchamp and Childress deplored.

The Motive

Motive and intention play an important role in the formation of moral character. Hence, the act may appear virtuous, even when the intent and motive are bad. According to some ethicists, such acts are to be classified as immoral (Beauchamp and Childress).

In Islam, Prophet Muhammad (PBUH) taught that acts will in accord be with the intention of God. If the motive is good and the act is good, the person will be rewarded by God; however, if the act is good and the motive is bad, the person will be punished for it. There are many traditions to this effect. “Deeds and acts will be judged by the intention and motive” [9].

In another tradition the Prophet is reported to have said that the one who taught the Qur’an and religion would be dragged to Hell. He would exclaim and say: “O God I have taught people your book and your religion, for your sake.” God will say: “Nay you did it to be called a scholar (alim) and they did call you so.” The other example is of a wealthy person, who donated a lot of money to the poor and needy, but his intention was not for the sake of God, but to be called generous and benevolent by the people, and it was said.

The third tradition is about a person fought for the cause of religion against infidels, but his intention was to show off his bravery and courage, and not for the sake of God. Though he was slain in the war, and the people called him martyr, God ordered him to be dragged into Hellfire, because his intent and motive was people saying that he was brave and courageous [10].

These traditions show how important is the motive and intent in Islam in considering the deeds and acts of humans, which will only be judged by God according to their intent and motive.

On the other hand, a number of philosophers consider a person disposed by a good character with good motives to be more important than another person who acts only because of the strong sense of duty. The right motives and character tell us more about moral worth than do right actions performed under the prod of obligation [11]. The friend who acts only from obligation lacks the virtue of friendliness and the relation lacks moral merit [12].

The obligation-oriented theories which replaced the virtuous judgment of healthcare professionals with rules, codes, or procedures will not produce better decisions or actions. The most reliable protection of subjects in research is by an informed conscientious compassionate researcher [13]. From this perspective, character is more important than conformity to rules, and virtues should be inculcated and cultivated over time through educational interactions, role models, and the like [14]. Nevertheless, rules and regulations are very important to regulate research and health professionals, as only few will reach the high standards of innate benevolent character of the well-informed conscientious compassionate researcher or health provider. Many have to be controlled by rules, regulations, by-laws, and laws.

The person worthy of trust and praise is one who has ingrained motivation with a burning desire to perform the right action, and possessing a caring compassionate sympathetic generous character [8].

The action must also be appropriately done, according to the state of the art (of medicine), and conforming with the relevant principles and rules [8]. If the physician or nurse acts incompetently, he or she will not be praiseworthy, and has to improve himself/herself to the required standard.

Prophet Muhammad (PBUH) said: “Any person who practices medicine without due knowledge of medicine (or that specialty of medicine) is liable” [13].

He also said, “No person is wise without experience [14].” Islamic jurists for more than 1,200 years put the regulation that no one is allowed to practice medicine unless he is given a certificate from the Muhtasib (the controller of physicians) that he is competent. The practitioner has to get consent from those he is going to treat, or get the consent of the guardian if the patient is a child or mentally incompetent [15].

Roles and practices in medicine and nursing embody standard obligations and virtues. The important virtues in medicine and nursing are:

• (1) Compassion: showing active regard for the welfare of the patient. It involves both sympathy and empathy with deep mercy and actions of beneficence that attempt to alleviate the misfortunes and sufferings of others [8].

Physicians and nurses who express no emotions in their behavior toward their patients have a moral weakness. The compassion and emotions of the health provider should not cloud his judgment and his rational and effective response. If the patient is his own relative, he/she should abstain from medical management if his/her decision is going to be affected by the natural emotions.

Spinoza and Kant have advanced cautious approach to compassion, fearing that compassion will blind reason and proper action. This need not be true, if the person is balanced, and the patient is not his near relative or spouse, or close friend.

Contemporary medical and nursing education inculcates detachment of the health provider, in order to avoid emotional involvement that blurs common reason and proper action. There should be a balance struck between the psychological detachment and sympathy and even empathy shown by the health provider to the patient and/or his family.

• (2) Discernment: The virtue of discernment brings sensitive insight, acute judgment, and understanding of action [8]. It is related to the above-mentioned discussion of the effect of compassion and psychological detachment.

A discerning physician or nurse will see when a despairing patient needs comfort rather than privacy or vice versa, or when he needs a spiritual support for which the hospital should provide the spiritual healer, if possible. For Muslims, a religious advisor may be a member of the staff of the hospital. Otherwise the patient or his relatives may provide their own advisor and instructor.

• (3) Trustworthiness [ 8 ]

The physician/nurse should be trustworthy. It emanates from the belief of the patient that his physician/nurse have both technical competence, the required knowledge, and good moral character. Trust is the most important ingredient in the relation between the patient and the health providers. Many of the allegations and litigations against health providers are rooted in mistrust. The media exposing and magnifying physicians’ mistakes erodes the trust of the public with the medical profession. In Arab countries the mushrooming private hospitals, run for business and profit, with some graphic and horrific mistakes published in the media (one surgeon alleged to have killed 20 patients in operations to treat obesity), caused public consternation and loss of trust in the medical profession as a whole [16]. The government hospitals are notorious for being overcrowded with long waiting lists unless you have a friend (crony) of some authority in one of these hospitals, or you are of some status and influence to harness any difficulty.

It is unfortunate that “trust is a fading ideal in contemporary healthcare institutions” as Beauchamp and Childress have noted in their textbook: Principles of Biomedical Ethics [8].” For centuries healthcare professionals managed to keep trust at the center stage of their practice, even when they had far less effective treatments to offer patients than today’s professionals do. Recently, the centrality of trust had declined, as is evidenced by the dramatic rise in medical malpractice suits and adversarial relations between healthcare professionals and the public. Overt distrust has been engendered by mechanisms of managed care, and by the incentives some healthcare organizations (health insurance companies in USA) create for physicians to limit the expenses and kind of care provided [8].” The loss of intimate contact between physicians and patients, the increased use of specialists, the growth of impersonal medical institutions, and the loss of good communication are all contributing causes to the erosion of trust.

Physicians, on the other hand, also mistrust their patients, and feel that they will be sued if there is any suspicion of any mistake, and hence they take defensive medicine, and ask for investigations (expensive and laborious) in order to ward off any charge of suspected negligence. The expense of medical care is sky rocketing because of these unrequired investigations, and because of the expensive drugs and machinery of modern medicine.

Integrity

Some healthcare professionals refuse to comply with the requests of their patients or with the decisions of their colleagues on grounds that to do so would compromise their core belief. The physician may refuse to do abortion, on grounds of religious beliefs, or he/she may refuse to change the gender of his patient (transsex), which he/she insists to do.

The current system of medical rules allows the physician to abstain from such managements, but he is required to transfer the patient to another physician who will comply with the patient’s requests of such operations. The value of moral integrity is beyond dispute. It means soundness, reliability, wholeness, and integrations of moral character and being faithful to moral values and standing up in their defense if necessary. The medical profession and its constant demands may deprive us of the liberty to structure and integrate our lives as we see fit, and that will affect our integrity. Persons may lose their integrity if they lack sincerity and steadfastness in keeping their fundamental moral convictions, especially if the exigencies of their ever-demanding job enforce them to practice things which they do not believe. Such exigencies may be rare in Western countries, but they are not so rare in third world countries. A gynecologist in a third world private hospital may be sacked from his job if he adamantly refuses to perform any abortion, not indicated medically. Such a person usually believes in the sanctity of life and, hence, he may also stand against do not resuscitate (DNR) policy agreed upon in certain codes where any further management becomes futile. The question of euthanasia is definitely beyond these boundaries, as it is still being considered a type of homicide by all governments except Holland, Belgium, and a few states in the USA.

The situations that compromise integrity can be avoided by an institutional policy that realizes the convictions of its staff, and delegates the work that is against the conviction of one physician to another who accepts it. There should be no retribution for such act of conviction, but that does not rule out incitement for those who perform the act. The medical profession nowadays requires that the physician should not in any way impose or even propose any judgment to the patient’s beliefs or indulgences. If the patient, for example, drinks alcohol or takes drugs of addiction, or has multiple sexual relations or is homosexual, the physician cannot even advise him against this perilous behavior. This is considered an intrusion in the patient’s lifestyle, for which he/she, the physician is not even allowed to advise against.

However, the physician is allowed to advise against smoking and obesity, but the decision of course should be taken by the patient without any instigation or prodding. But why the physician cannot advise against fornication, adultery, sodomy, drugs of addiction and alcohol is beyond our comprehension in the Muslim world. The physician should be a sincere advisor to the patient in matters that would affect his/her health, and if he fails to advise accordingly, he is failing in fulfillment of his duty.

This attitude is considered paternalistic in modern medical ethics and interfering with autonomy. Let us agree that enforcing a certain point of view is definitely encroaching on autonomy, but there is no point in allowing the physician to strongly advise against smoking and obesity and provide the means to help the patient overcome these problems, and at the same time refusing to allow the physician to strongly advise against sodomy, adultery, fornication, drug addiction, and alcohol drinking.

Conscientiousness

“An individual acts conscientiously if he or she is motivated to do what is right because it is right, has tried with diligence to determine what is right, intends to do what is right, and exert an appropriate level of effort to do so [8].” In a nation where 50 million citizens have no medical insurance, the duty of all conscientious persons is to strive hard to remove that injustice. It is not right to condone the prevailing system and relegating such an issue to the politicians and congress.

Beauchamp and Chiildress in “Principles of Biomedical Ethics” fifth edition stressed the fact that Afro Americans were without medical insurance and found to suffer from hypertension when they attend Casualty Department, should not be treated, as many researchers found that such poor patients will not be able to continue medication or follow-up, as they have no family physician nor medical insurance, and hence consider treating them as a waste of time, effort, and money. In fact, Beauchamp and Childress in the seventh edition (2013) of their book criticized the American health system and considered it unjust to all those citizens without any health insurance or health coverage; without saying it, they agree to let them suffer and die with their hypertension and its sequelae , e.g., strokes, heart attacks, heart failure, and kidney failure [17].

It is unbelievable to find that neighboring Cuba, which suffers from poverty and American sanctions have better health indices, e.g., infant mortality rate, 5 years mortality rate of children, longevity. Cuba provides free health services not only to its citizens, but even to the visitors of Cuba. Definitely the standard of health of Cubans is much higher than the 50 million US American citizens without any health insurance.

The authors praised the ethical moral stance of a recent Ph.D graduate in chemistry, who refused to take a job in a laboratory that pursues research in chemical and biological warfare, though he is in dire need for the job to support himself and his family. If this chemist refuses this job, it will be taken by another young man who will pursue the research with greater vigor. Despite all these circumstances, George, the chemist, refused this job and accepted all the sufferings to himself and his family because his conscience stood in the way of accepting it [8].

There is no doubt that George’s decision is praiseworthy from an ethical and moral stance. But if the suffering of his family is great, and the wife with the children might leave him, the decision of George needs reconsidering. The research will go on in chemical warfare with or without George; the sequelae (consequences) may be worse with another chemist. The family of George will disintegrate and the harm is so great that he should reconsider his position. An Islamic point of view would advise George to balance the two evils, and accept the lesser one, which is in this case working in the chemical laboratory. His refusal in not going to change anything in the lab research of chemical warfare will definitely result in disintegration of his family and great suffering to all its members. The axiom in Islamic jurisprudence of accepting the lesser evil when faced with two evils will solve the dilemma of George or anyone in a similar situation.

This shows the pragmatic sequential Islamic point of view, which agrees in this case with utilitarian consequentialist philosophy.

In other situations, where a clear cut encroachment on Islamic dogma or laws occurs, the consequentialist utilitarian philosophy will be refuted. For example, opening of a brewery or wine factory may benefit the owners, the workers, their families, and the vendors and make the consumers happy. Nevertheless, it will not be allowed by Islamic Law (Sha’riah), as there is clear prohibition both in the Qur’an and the Tradition. The cumulative harm to the society may be much more than the apparent benefit. The Qur’an says: “They ask you about wine and gambling. In them is a great sin and some benefit for people. But their sin is greater than their benefit” (The Qur’an 2:219).

People with conscience feel that they are obliged to take a certain action even if harm is going to befall them or their family. Such a person will resist the temptation to set aside what he or she believes to be right. Prophet Muhammad (PBUH) when he started to preach against idolatry in Makkah, the elders of his tribe tried their best to dissuade him from this course. They offered to make him their chief, collect money for him to be the wealthiest person in Quraish (his tribe), and to marry him with the most beautiful girls. He refused all these offers and said to his uncle: “I swear by God, if they put the sun in my right hand and the moon in my left hand, to leave this message, I will not leave it” [18] .

The physician should not contravene his conscience and will not be lured by temptation or by threats. Prophet Muhammad said: “You should not obey whoever may be, if he orders you to disobey God’s commanments and laws” [19]. The physician can withdraw from any action that contradicts his conscience, e.g., gender selection in gynecological practice, both prior to conception as in test tube babies, or after conception by chorionic villus sampling or amniocentesis. If the conceptus proves to be a girl, the parents may ask for abortion. The physician may refuse certain operations as sex transfer or beauty operations or hymnography (closing the hymen of a girl in order to marry as a virgin). These objections should be respected and the conscientious physician should be allowed to withdraw from such management. The hospital may direct the client to another health provider. If the country upholds the Sha’riah, such practices should not be allowed by law. The principle of autonomy entails respecting the others, their decisions, and their free will, which needs veracity (truthfulness), fidelity (faithfulness), respecting the privacy of others, and confidentiality. There are a lot of virtues required in the health provider, such as compassion, concern, caring, sympathy (and sometimes empathy), modesty, patience, and courage. All these virtues and many others have no norms of obligation.

Moral Ideals [8]

There are two levels of moral standards: ordinary and extraordinary moral standards. The ordinary form requires adhering to the minimum moral requirement, which include honesty, trustworthiness, and faithfulness. Others of high standard will include self-sacrifice in certain situations, e.g., saving a person from drowning, or from fire or in a battlefield to save his comrades and exposing himself to real danger and even loss of life. Such a person feels that he is only doing his duty, and nothing more. These actions however are supererogatory and praiseworthy.

In Islam it is incumbent on every Muslim to give 2.5 % of his wealth annually to the poor and needy. That is obligatory, but if a person gives much more than that fixed amount, then it is supererogatory. Similarly, if a physician or nurse does much more than his/her obligatory duty, then he/she is performing a supererogatory action which is praiseworthy.

Any action or even intent in Islam will be under one of the following moral categories:

• (1) Actions that are right and obligatory (wajib), e.g., truth telling.

• (2) Actions that are wrong and prohibited, e.g., lying, cheating, and the most heinous, killing an innocent person.

• (3) Actions that are allowed and are optional. They include normal activities of eating, drinking, wearing clothes, habits, and working. They are usually neither wrong nor obligatory and hence called Mubah, e.g., allowed, and the person can choose to do or not to do.

• (4) Supererogatory: which include actions commendable, praiseworthy but they are not obligatory. In Islam it is called Mandub or Nafil.

• (5) Actions which are not obligatory nor prevented, but is recommended to avoid, for example, wasting time without any good effect. This is called Makrooh in Islam, and if it is done no punishment is expected, and if it is avoided, reward from God is expected.

Many duties in the medial practice and nursing are profession-related rather than obligation. A physician or nurse who cheers his patient and brings hope to him is doing an obligation in certain situations or a supererogatory action in other situations. To care for patients with communicable diseases, e.g., Ebola virus, tuberculosis, typhoid, typhus fever, plague, and even severe influenza epidemic is definitely an obligatory moral action for health providers. If the health provider exceeds his duty then it is supererogatory. HIV patients and Hepatitis B and C patients are not infectious except by contact of blood, blood products, body fluids, and sexual contact. The health providers and lab technicians should be careful not to come into direct contact with blood and body fluids. They should wear gloves and be careful with needles.

As John Stuart Mill said: “The contented man, or the contented family who have no ambition to make any one else happier, to promote the good of their country or their neighborhood, or to improve themselves in moral excellence, excite in us neither admiration or approval” [20]. Virtues beyond obligations are needed for the whole community, but more so for health providers. The virtues of courage, patience, hospitality and tactfulness, and so forth are needed to give example of moral excellence. Morally exemplary lives guide and inspire us to higher goals and morally better lives.

Each individual should aspire to a level as his or her ability permits. Persons vary in their moral life, as they differ in their athletic performance or their academic performance, but there should be a level that no one goes below it. This is the obligatory level, but there are those who excel and are exemplary models in moral performance. The best of these are the Messengers of God, e.g., Abraham, Moses, Jesus, and Muhammad. They are the shining stars which every human should aspire to emulate.

Aristotle maintained that we acquire virtues as much as we do skills. Surely virtues can be built up by training and by exemplary characters, but persons differ by their innate nature. Some are easily trained to build up moral values and virtues, while others are less fortunate. The important thing is that whatever their abilities are, they should not go beyond the standard minimum of morals and virtues through self-cultivation, guidance, and aspiration. Everyone should aspire to improve and strive to climb up the ladder of virtues and morality.

The Aristotelian model does not expect perfection, on that persons strive toward perfection … the ideals motivate us in a way that basic obligations may not set out a path we can climb in stages, with a renewable sense of progress and achievement [18]