Anthony T. Vernillo, DDS, PhD, MBE (Bioethics) Professor, Department of Oral & Maxillofacial Pathology, Radiology & Medicine

While on sabbatical leave from NYUCD during the 2004-05 academic year, Dr. Vernillo earned a Master's degree in bioethics from the University of Pennsylvania School of Medicine and Center for Bioethics.

If a patient asks a doctor for a procedure that, after careful evaluation, the doctor determines to be unsuitable, unnecessary or not in the best interests of the patient, but which the patient insists on having, what is an ethical response on the doctor’s part? Is there a limit on what procedures a patient can expect a doctor to perform? Where do the patient’s rights end and the doctor’s moral and social responsibility begin? These are questions of ethics and integrity, areas in which we still have much to learn from the ancient Greeks.

Ethics Is Not Arbitrary

Aristotle saw the ability to reason as the key to understanding ethics. According to Aristotle, “All people seek the good, not the way of their ancestors.” This means that people by nature are motivated to think and reason about what is necessary to achieve a good life, rather than mindlessly to adopt the ready-made moral judgments and traditions of previous generations.

Ethics is a generic term for various ways of understanding and examining the moral life. Ethicists and moral philosophers disagree on what might serve as the normative basis of moral judgment, but they do not disagree on the need for something normative. Ethics is a form of inquiry that attempts to answer the question, “Which general norms for the guidance and evaluation of conduct should we accept and why?” Ethical theories attempt to identify and justify these norms. The fact that a person believes something is right or wrong is not enough; the moral philosopher insists that those beliefs must be justified by something normative, and the exploration of what is normative is the work of ethics.

Norms provide a set of guidelines for behavior. In the area of health professional ethics, norms include respect for autonomy (a norm of respecting the decision-making capacities of autonomous persons); nonmaleficence (a norm of avoiding the causation of harm); beneficence (a group of norms for providing benefits and balancing benefits against risks and costs); and justice (a group of norms for distributing benefits, risks and costs fairly).

But do these norms provide answers for the ethical dilemmas we face today? After all, we are the first generation to have to deal with such issues as brain imaging and brain privacy (neuroethics); artificial organs, including hippocampal brain implants and what it means to be human; facial transplantation, identity and self; stem cells, cloning and genetic engineering.

Given these issues, the debate can seem intractable, with all sides convinced of the validity of their position. For some, the solution is to believe that there are no absolute truths, and, therefore, that ethics is arbitrary. But if there are no absolute truths, there are no consequences, and hence no morality, leaving us adrift in a meaningless universe. By definition, ethicists and moral philosophers reject such thinking.

Dr. Paul Wolpe, a bioethicist at the University of Pennsylvania’s Center for Bioethics, notes that there is in fact widespread consensus on a number of ethical issues, including those involved in science policy. Current health professional norms may not answer all ethical questions arising from advances in science and technology, but he argues that they do demonstrate that consensus is possible. For example, Dr. Wolpe cites agreed-upon guidelines for the conduct of research and universal standards of informed consent, risk/benefit analyses, ethics review committees and subjects’ rights to participate or refuse to participate in research investigations. These guidelines lay the foundation for reasoning together, and hence for ethical debate.

Character, Wisdom and Virtue

Ethics is also about character. In fact, the ancient tradition of thinking about ethics gave character centrality. The ancient Greek word ethos, from which we derive our term ethics, did not mean rules or norms; it meant, simply, character. Character is determined by how much wisdom (an understanding of how we ought to live) and virtue (a habit of acting in accordance with wisdom) one has in one’s life.

And how is character shaped? We learn from our teachers, who teach by example. Socrates taught Plato. Plato taught Aristotle. Aristotle taught Alexander the Great, even when Alexander wasn’t so great. Alexander, however, became great through association with the great man, Aristotle. That’s how it works. We become like the people we are around—not because of what they say, but because of what we see them do. Goethe stated it best, “Character calls forth character.”

Still, the character tradition in ethics holds that the core of morality is not about good actions, but is rather about good people, the idea being that good people will do good things. Character therefore is not first and foremost about what we do, but is rather who we are, as manifested in what we do. It is about settled habits of attitude and action. If we become wise and virtuous people, we perform wise and virtuous actions.

Virtues are understood to be characteristics, attitudes, habits or dispositions of character — integrity, trustworthiness, honesty — that aid us in living well together, in making a positive difference, in becoming the best people that we can be, and thus are foundations of human flourishing (Aristotle’s eudaimonia). Morality is that domain of human endeavor concerned with identifying, cultivating and encouraging those virtues, or qualities, that facilitate ultimate human flourishing. For Aristotle, these ancient virtues included, but were not necessarily limited to, justice, truthfulness, honor and shame.

Aristotle maintained that we acquire virtues much as we do skills. Aristotelian ethical theory has long insisted that moral excellence is closely connected to virtues and moral ideals. Still, the Aristotelian model does not expect perfection, only that a person continually strive toward perfection. Whenever a person is on the continuum of developing character, there will be a goal of moral excellence that exceeds what he or she has already achieved. According to Aristotle, human beings ought to follow a moving target of excellence as a fundamental way of leading one’s life, including one’s professional life.

Integrity

In Aristotelian logic, to pursue virtue is to behave ethically, and integrity is the sum of that ethical behavior. Given this background, let’s return to the questions that began this essay, questions concerning the role of ethics and integrity in the doctor-patient relationship.

Integrity, considered by some to be the primary virtue in health care, can be defined as consistently upholding and standing firm on one’s values. Two contemporary ethicists, Beauchamp and Childress, argue that problems in maintaining integrity sometimes arise not from straightforward moral conflict, but from demands that people abandon personal goals. People can feel violated if they feel they are being asked to abandon their commitments in order to pursue goals set by others.

Healthcare professionals sometimes confront this kind of situation when they refuse to comply with the requests of patients or with the decisions of their colleagues on the grounds that to do so would compromise or sacrifice their core beliefs. To put it another way, to compromise below the threshold of integrity is simply to lose it. We justify any actions or refusals to act on the grounds that if we acted otherwise, we would sacrifice our integrity.

People also sacrifice their integrity through manipulation and mendacity, inflicting harm on others, or treating other people as they would treat physical objects, as mere means to their own ends. According to Kant, we treat others as a mere means to an end when we force them to do something, or when we obtain their consent through coercion (overt or subtle), or dishonesty. The injunction against such behavior is absolute. A clinician who places his or her own interests above the well-being of the patient, by persuading a patient to have an unnecessary procedure, for example, is violating that injunction. A clinician is acting ethically and with integrity when his or her first question is: “Does the patient really need that procedure?”

Integrity is above all about an approach to life that does not vary depending on the situation. Ethics is about evaluation of a situation based on agreed-upon guidelines. Ethics inevitably employs determinations and judgments about values. It also means being brutally honest with ourselves and about the standards we set in our profession to benefit our patients and protect them from harm. Ultimately, it comes down to each of us. If we have the moral character to act virtuously, that is, ethically, we will influence others to do the same.

"Sometimes when students feel pressured to complete their requirements in a narrow time frame, there’s a tendency to perform too many procedures in one visit, resulting in inadequate patient care. This is something we all have to deal with because of the pressures of meeting our requirements for graduation, and it’s a challenge."