Ethical Issues in Medicine

Physician virtues can help them navigate potential ethical dilemmas posed by the COVID-19 pandemic BY DAVID J. ALFANDRE, MD, MSPH

Approximately 2000 years ago, the ancient Greek rhetorician and grammarian Athenaeus observed that “goodness does not consist in greatness but greatness in goodness.” This has new relevance today during the COVID-19 pandemic. This public health crisis has sparked much talk of ethics, with the most intense discussions related to the prospect of demand for healthcare resources outstripping the supply. What would physicians and other healthcare providers do, for example, if the number of COVID-19 infections and hospitalizations rose so fast and so high that there were insufficient intensive care unit beds or mechanical ventilators to care for patients, forcing them to ration those life-saving resources to those most likely to survive?

The Common Good Such extreme conditions (which have thus far been avoided in the United States) necessitate a shift in the standard of care so that treatment decisions are based not on what is best for an individual patient, but on what is best for the community. Such a fundamental shift in usual clinical decision-making must rest on strong moral foundations, which in this case is on the principle of utility: achieving the greatest good for the greatest number. Principlism is another form of moral reasoning familiar to most medical school graduates. The principles of autonomy, beneficence, nonmaleficence, and justice are simple, straightforward, and accessible, but they are often unhelpful to the practicing clinician. But there is another method of moral reasoning that could have practical value today: virtue ethics. Virtue ethics “explores how individuals can learn by habitual practice how to develop good characteristics that will enable them to behave well.”1 It focuses on the actor — in this case, the physician — and is less about how one acts than the character traits one possesses and cultivates to enable the preferred behavior. Virtues are “a disposition that enables us to perceive, feel, want, and act in certain ways”2 — ways that physicians recognize, see in their colleagues, and commit to during their graduation oaths. Virtues include courage, prudence, justice, honesty, integrity, generosity, and empathy, among others, and serve as a center point between its natural extremes. For example, neither lying nor “truth dumping” are acceptable ways of promoting the virtue of honesty with patients.

Reflection and Reasoning In cultivating these virtues, one rationally and voluntarily chooses to exercise them, and creates space for the virtues to grow within oneself. Practicing this process is expected to lead to a desire (not necessarily a sense of duty) to meet one’s obligations, leading to a life that “flourishes.” Virtue ethics also demands that the individual recognize the importance of reflection and reasoning in applying these virtues thoughtfully and in context, with an appreciation for how emotion

Virtue ethics can enable physicians to manage such dilemmas as patients refusing to wear face masks despite rules requiring them to do so.

influences these virtues. In short, when confronted with an ethical challenge, this method of moral reasoning asks, “What would a virtuous doctor do?”3

Using virtue ethics can assist us in managing a modern-day ethical dilemma, such as encounters with patients who decline to wear a face mask during the current COVID pandemic. If you practice in a state or a health care system that requires masking, then from a rulesbased perspective the “right” answer is for the patient to simply follow the rules.

The COVID-19 pandemic may put physicians in a position of deciding who gets an ICU bed.

This concern grows more complicated if the patient is severely short of breath and needs urgent medical care. From a principle-based perspective, framing the problem as one of autonomy vs justice does not necessarily help us decide which principle to prioritize in a given situation. However, from a virtue ethics perspective, we can ask ourselves, “What would a good doctor do in this situation?”3

Consider Patients’ Viewpoint A virtuous physician would show character traits like equanimity, compassion, integrity, and resolve. While the physician would expect and demand patients abide by the state laws that are designed to protect others from infection, they would also demonstrate compassion by appreciating what might lead someone to make a choice that violates the law. Such empathy allows for brainstorming to open one’s mind up to unconventional solutions.

A virtuous physician might also recognize how their emotional responses and those of the patient provide important clinical data that can illuminate how to address the conflict. The patient might be feeling unheard, marginalized, and frightened, while the physician might be feeling frustrated, angry, and worried about viral transmission. Finally, even when there is a supposedly “right” answer based on a rule or law, the virtuous physician may conclude that a rulesbased approach may be oversimplifying. An appreciation of the virtues one wishes to embody can help to navigate the complexity. In responding in this way, and doing so over time with reflection and thoughtfulness, the physician can develop the virtues needed to flourish and provide good medical care. ■

David J. Alfandre, MD, MSPH, is a healthcare ethicist for the National Center for Ethics in Health Care (NCEHC) at the Department of Veterans Affairs (VA) and an Associate Professor in the Department of Medicine and the Department of Population Health at the NYU School of Medicine in New York. The views expressed in this article are those of the author and do not necessarily reflect the position or policy of the NCEHC or the VA.

REFERENCES 1. Gardiner P. A virtue ethics approach to moral dilemmas in medicine. J Med Ethics. 2003;29:297-302. doi:10.1136/jme.29.5.297 2. Bellazzi F, Boyneburgk KV. COVID-19 calls for virtue ethics. J Law Biosci. 2020;7:lsaa056. doi:10.1093/ jlb/lsaa056 3. Pellegrino ED. Professionalism, profession and the virtues of the good physician. Mt Sinai J Med. 2002

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