pellegrino 2006

Target Article

Toward a Reconstructionof Medical MoralityEdmund D. Pellegrino, Georgetown University

At the center of medical morality is the healing relationship. It is defined by three phenomena:the fact of illness, the act of profession, and the act of medicine. The first puts the patient in avulnerable and dependent position; it results in an unequal relationship. The second impliesa promise to help. The third involves those actions that will lead to a medically competenthealing decision. But it must also be good for the patient in the fullest possible sense. Thephysician cannot fully heal without giving the patient an understanding of alternatives suchthat he or she can freely arrivetogether with the physicianat a decision in keeping with hisor her personal morality and values. In todays pluralistic society, universal agreement on moralissues between physicians and patients is no longer possible. Nevertheless, a reconstruction ofprofessional ethics based on a new appreciation of what makes for a true healing relationshipbetween patient and physician is both possible and necessary.

Open PeerCommentaries

Robert M. Veatch, p. 72

Denise M. Dudzinskiand Wylie Burke, p. 75

Rosamond Rhodes, p. 76

Nuala Kenny, p. 78

Joel D. Howell, p. 80

Gail Geller, p. 82

Loretta M. Kopelman, p. 85

Angelo E. Volandesand Elmer D. Abbo, p. 88

Katherine Wassonand E. David Cook, p. 90

One of my major concerns, in recent years, has beenwhat I perceive as the need to rebuild a basis for med-ical ethics and medical morality. This was in factthe central theme of my recent book, A Philosophi-cal Basis of Medical Practice. To establish such a basisin some philosophical conception of the physicianpatient interaction is necessary, I believe, for a num-ber of reasons. The first is that if you look at the his-tory of medical ethics and medical morality you willfind, by and large that it consists of a series of a pri-ori statements of what ought to be done, statementsof moral principles. Nowhere, however, in the firstdocuments, the scripture so to speak, of medicalethicsthe Hippocratic corpus or collections those70-plus books, the Hippocratic Oath includeddoyou find an attempt to put a philosophical, rationaljustification under the obligations that are deduced.

Now you might say, What difference does thatmake? I think it makes a very significant differ-ence if you look at what has been happening to theinterpretations of the physicianpatient encounterover the past several hundred years. What is uniqueabout the medical encounter is the interaction be-tween someone who is ill, on the one hand, andsomeone who professes to heal, on the other. Whatwe think about that relationship in large measuredetermines what we regard as the obligations pa-

Originally published in The Journal of Medical Humani-ties, 8(1), Spring/Summer 1987. Reprinted with permis-sion from Springer Science and Business Media.

tients and physicians owe each other. In short, med-ical ethics is based in our philosophy of the healingrelationship.

Medicine is a moral enterprise, and has been soregarded since Hippocratic times: that is to say, ithas been conducted in accordance with a definiteset of beliefs about what is right and wrong medicalbehavior. Only in recent years, however, has it beenethical in the strict sense of that term.

Let me clarify that point. Ethics is a branch ofphilosophy; it is not a set of visceral sensations aris-ing somewhere in the solar plexus and suffusingthe frontal lobes with good or bad feelings.Ethics is a formal, rational, systematic examina-tion of the rightness and wrongness of human ac-tions. It comes into existence only when a moral sys-tem becomes problematic and is challenged. Ethicswas born when Socrates began to raise those per-plexing questions which so vexed his contempo-raries that they offered him the cup of hemlock.He passed onto the next world as a consequencewith his irritating questions still unanswered. Itis when the claims of morality put forward in anygiven time are made problematic subjects for criti-cal inquiry that ethics begins. And if you examinethe history of medical morality, you will find thatmost of it is the history of moral statements with-out very much in the way of formal philosophicaljustification.

Why is that of concern? For one thing, the2,500-year-old image which emerges from the

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The American Journal of Bioethics

Hippocratic corpus and which still has wideuncritical acceptance today, is the very image beingmost seriously questioned in our democratic, plu-ralistic society in which more and more people arebeing educated about matters of bodily and mentalhealth. That image is of the physician as a benign,benevolent, all-knowing authoritarian figure whodecides what is best for his patients. That concep-tion served humanity well in a time that was sim-pler and when medical decisions did not involve, asthey do increasingly today, a host of new questionsof values and morality it more easily fulfilled ex-pectations in a society in which there were very feweducated people who would say, Just a momentIwould like to understand what is happening! I wantto have a say in what you are going to do.

Today the traditional image is being fractured.It is being challenged and drastically revised in someof the more recently proposed professional codes.That great canon of medical morality, the Hippo-cratic Oath is being honored more in the breachthan in the observance. Each one of its prescriptionshas been questioned by some physicians and vio-lated by others. Thus, it is almost impossible todayto define a common set of medical moral principlesto which all physicians subscribe.

A further point is that we have competing in-terpretations of the physicianpatient interactionto contend with. The first, as I have said, was apaternalistic one, the Hippocratic notion of the be-nign, all-knowing physician. The second is basedon the philosophy of John Locke: the idea of twoautonomous individuals entering a contract for ser-vice. Then a third model is the commercial one be-ing eagerly propounded by some of my colleaguestoday. In this model, medical knowledge is heldto be a proprietary possession of the physician.He makes it available, as the baker would makebread available, when he pleases, in what mannerhe pleases, for those who can purchase it if theyplease. If they dont like the bread they can go onto another baker.

Another viewpoint is that there is no real differ-ence between the medical transaction and the trans-action between you and your auto mechanic, dis-cussing the health of your automobilewhether heshould or should not operate on the carburetor. Thisanalogy may seem fanciful, but it is seriously andboldly argued. Other modelsthe hieratic, holis-tic, psychosociobiologic, and biological modelsall have an effect upon some facet or facets of thephysicianpatient relationship. Each, when appliedlogically and completely, results in a different kind

of ethics and practice and a different educationalschema.

It seems self-evidently important whether youthink the physicianpatient relationship is a con-tractual relationship between two autonomous indi-viduals, whether you think one individual has pro-prietary right over the knowledge he has and canpurvey it for a price on his own terms, or whetheryou prefer some other model. A philosophical un-derstanding of that relationship therefore becomesthe first step in any reconstruction of medical moral-ity. The obligations of physician as physician, thefirst step in medical morality, must depend on whatwe think of the healing relationship.

Personally, I would reject all of the notions I havecited and would rather put forward another one. Itis of interest to know that what I am proposing wasattempted a long time ago. This was the attemptto derive the obligations of a physician from thenature of medicine, made in the first century AD, bythe physician to the Emperor Claudius, ScriboniusLargus. In a rather brief disquisition on medications,Scribonius put forward the notion that we shoulddetermine the responsibilities of the physician byexamining the nature of medicine itself. He saidthat the aim of the physician, the end of medicine,was humanitas.

That was the first time, as far as we know,that a word with that precise meaning was usedin this connection. Humanitashumanity, a loveof mankind, was not the same as philanthropia, theGreek concept which expressed rather a kindlinesstowards the patient that would enable the physicianto have a good practice and a good reputation. Scri-bonius Largus also used the word misericordia, mercy.Misericordia and humanitas, in his conception, werethe aims of the physician in the same way that justicewas the end and aim of the judge and the lawyer.

There has been no real attempt since Scriboniusto build a concept of medical practice on such aphilosophic foundation. I propose to make such anattemptto examine the nature of the physicianpatient relationship, and to draw from this some ofthe obligations of the physician.

It is important to note that while I am speak-ing of the physician the same approach is applicableto the nurse, dentist, psychologistany of the pro-fessions that offer themselves as healers. There arethree phenomena that we must consider: the first isthe fact of illness; the second is the act of profession;the third is the act of medicine.

Consider first the fact of illness. When one be-comes ill, one undergoes a change in existential

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states. Lets say that one experiences a sudden painin the chest. Most people today are well enough ed-ucated to know that this could be the beginning ofa heart attack. That realization leads very quicklyto the conclusion that one is no longer healthy, butis ill. Illness is a subjective definition made by thepatient, not solely by the physician. The latter de-termines what is a disease, which is not the sameas illness. It is the patient who determines that hisor her customary balance the sense of wellness hasbeen disturbed to the point where it is necessary toconsult someone else for assistance. Recognition ofthat disturbed balance initiates the state of illness.

What happens to someone who is in that state ofillness? First of all, some of the things we associatemost closely with being human involve the capac-ity to use our bodies for transbodily and outwardlydirected purposes. In a state of illness the body is nolonger our ready instrument; it becomes, instead,the center of our concern. It begins to tyrannize, tomake demands; it has to be listened to, taken some-where for help. In a sense, theres a split between theself and the body: one steps back, as it were, and be-gins to look at ones body; the unity of body and selfthat had previously existed is fractured somewhat.

Secondly, the person who is ill has lost some ofhis freedom. He does not have the knowledge per-sonally to discern the answers to three fundamentalquestions that occur to anyone in a state of illness:Whats wrong? What can be done? and What ought tobe done? Since the patient cannot make his own de-cision unaided, he must put himself in the handsof another person. He becomes dependent upon theperson and therefore vulnerable.

Being ill is a radically different state of affairsfrom being well. To those who argue for the auto me-chanic version of the healing relationship, I wouldsuggest that, as distressed as we may be with thecarburetor and the perverse things automobiles doto us in cold weather, the illness of our autos doesnthave the kind of impact on our very existence thatillness does. The underlying thought in illness formost persons, even with trivial and certainly withimportant symptoms, is: Is this the beginning of theend of my existence?

The fragility of our human existence comes be-fore us bluntly when we experience illness. We havetherefore, in the fact of illness, a wounded state ofhumanity. We havent changed human nature on-tologically, but the operations we usually regard ashuman are impaired.

In that particularly vulnerable state we confrontthe second fact of the physicianpatient relation-

ship: the act of profession. The word profession comesfrom the Latin word, profiteri, which means to de-clare aloud. But how do we declare aloud? Whenyou come to a physician, his question is, How can Ihelp you? Implied in that question is his promise,the promise to help. Thus, in the presence of onevulnerable human being who is ill we have anotherhuman being who promises to help, to heal, to re-store the balance insofar as scientific knowledge willallow.

Implicit in the act of profession are two things.The first implication is that the physician possessesthe necessary knowledgethat he is competent.The second is that he will use that competence in thepatients interest and not his own, for the patientsgood. What we mean by the patients good today in-creasingly raises questions about values, about whatis the good life. To act in the patients interests im-plies the promise that the physician will act in sucha way that the patients interpretation of the goodlife will be protected and that he will have an op-portunity to make the value choices that so oftenunderlie the decisions about what should be done.

The relationship between someone who is ill andsomeone who promises to help is perforce a relation-ship of inequality. I am not justifying the inequality.I am defining what is, not what ought to be. Thephysicianpatient healing relationship is of its na-ture an unequal relationship built on vulnerabilityand on a promise.

The third element of the physicianpatient rela-tionship is the act of medicine. The act of medicineinvolves those actions on the part of the physicianthat will lead to a correct healing decision. A heal-ing decision is one that will make the patient wholeagain, restore bodily harmony if that is possible, andperhaps even make it better than before the illnessoccurred. A healing decision is consistent with theknowledge that we have of scientific medicineinother words, a medically competent decision.

But it must also be a good decision. A good de-cision will fit this particular person, at this age andsituation in life, with this persons aspirations, ex-pectations, and values. We are all closely identifiedwith our values; they are the things we think areimportant, the things that define us as persons. Thecontemporary emphasis on holistic or whole-personmedicine derives from the notion that to protect thewhole person we must not only heal the organapoint so obvious that we dont need to make it anymore, even though it is violated time and againbut we must also make the decision that is good forthis person in the fullest sense.

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The choice of how we want to live our liveswhen we face serious illness, whether we want toreject the indicated treatment or run substantialrisks of discomfort for even a small chance of benefit,are value decisions no one can make for us. Thecomplexities of a good decision are such that wecannot deduce them automatically from what maybe a scientifically correct decision.

It is in the moment when physician and patienttogether decide what should be done that medicineas medicine comes into being. This is the momentof clinical truthan exercise in practical judgment,in prudence, and ultimately in ethics. Indeed, itis in the relationships involved in the triad of thefact of illness, the fact of profession, and the act ofmedicine that the obligations of the physician andthe patient to each other are born. A few examplesof the way these obligations derive from the natureof the healing relationship are in order. But theymust be limited for want of time.

One of the realities of illness is the gap in infor-mation that separates the patient and the physician.Certainly one of the physicians obligations is toclose that gap, to enhance the patients capability toact and make truly human decisions. Therefore, thepatient needs to understand the nature of the illnessand the alternatives being offeredto understandthem well enough to be able to make an authenticpersonal decision. There are, in truth, very few com-plex and abstruse notions in medicine that cant becommunicated in plain English terms. Physiciansneed to be reminded that whats required is the in-formation and the understanding to make this deci-sion, not all decisions in medicine. There is no ques-tion that the person who is ill has the most exquisiteinterest in that decision. Disclosure of medical factbecomes a first moral imperative: the physician can-not really heal unless he enhances the patients moralagency, his capacity to make his own moral and valuedecisions based on a knowledge of alternatives.

Consent then, becomes not a legal but a moralnotion. Set aside the question of whether a piece ofpaper has been signed or not. All too frequently asigned permission is testimony of a superficial trans-action. True consent (the word comes from the Latincon and sentire, meaning both to know and to feel to-gether) implies that the patient and the physiciantogether must know what they are dealing with,and what the alternatives are. They have come to aconclusion together about what it is they wish to do.We cannot have a morally valid consent when infor-mation is withheld or manipulated, when freedom islacking, when there is insufficient reflection on the

values at issue. The physician has a responsibility tounderscore the moral questions so that the patientcan act in a way consistent with his or her beliefsystems. Clearly he must avoid imposing his ownvalues on the patient.

In this view the ancient and traditional notionof the benign, authoritarian physician who decideswhat is best for the patient needs revision. Instead,we must think of two moral agents, the patient andthe physician, interacting over the value questions.The medical decision very frequently reflects an in-tersection of value decisions. So when a patient whois a Jehovahs Witness says he or she does not wanta transfusion and regards that value as overridingoverriding life itselfthe physician has to respectthat decision. The same is true of the Catholic forwhom abortion is anathema. Remember, however,that the physician too is a moral agent. Therefore,the patient cannot ask the physician to override hisvalues. To respect the patients moral agency doesnot mean submitting to whatever he wishes if itviolates the physicians moral beliefs.

It is obvious that we are talking about a muchmore mature, open relationship than has existed inthe past: a relationship in which two individualsinteract as moral agents, recognizing that one isin a more vulnerable position than the other. Theweight of the obligations therefore rests on the per-son with the greater degree of power and authority,and the one who has made a promise to help. In thisview we have an ethics of responsibility, imposedupon the physician by virtue of his own freely madepromise to the one who is ill. The emphasis is onobligations and responsibilities mutually incurredby both physician and patient and not on their mu-tual rights.

A serious question today for conscientiousphysicians is how to deal with conflicts betweenwhat is good for the patient and what is good forsocietybetween individual and social obligations.Take the cost of medical care. Should the physi-cian act as an instrument of social and economicpolicy and decide who shall receive care and whoshall not? Should the physician enter into quality-of-life determinations or even raise the questions?Here, I would hold, the patient has to express hisor her view, the physician his or hers. If they arein concordance they can move ahead together. Theoptimal decision is one which arises between themrather than too directly from either the doctor orthe patient. This kind of interaction takes time. In-evitably there is the objection: But we dont havetime! Nevertheless, we cannot so easily escape the



fact that moral considerations take precedence overall others. Unless delay means a positive danger forthe patient, we are obliged to take the time neededfor a morally defensible decision-making process.

We have in the medical relationship two inter-acting moral agents, each of whom most respectthe dignity and values of the other. A logical con-sequence is that at times the physician is morallyimpelled to remove himself or herself from the rela-tionship when he or she differs on a matter of moralprinciple with the values the patient expresses. Weare very likely to see the emergence, in the not-too-distant future, of the expectation that physicianswill announce in advance their positions on the morecrucial human life decisions. These decisions mayinvolve such things as abortion, artificial insemi-nation, withholding of treatment prolonging life,or using socioeconomic determinants in allocatingscarce medical resources.

It is abundantly clear that in a morally plu-ralistic society universal agreement between physi-cians and patients on fundamental moral issues isno longer possible. It is more than ever impera-tive, then, that patients and physicians recognizewhere their value systems coincide and where theydiverge. In the vulnerable state of illness, patientsmust be protected against submersion of their valuesystems without, on the other hand, expecting thephysician to sacrifice his own. The triad of phe-nomena inherent in the healing relationshipthefact of illness, the act of profession, and the act ofmedicineprovides a sound foundation for defin-ing relationships of physicians and patients neces-sary to preserve the moral agency of each.

These concerns raise some interesting questionsabout the education of physicians. A remarkablething has happened in medical schools in the pasttwo decades. In 1963 the number of medical schoolsthat taught medical ethics was perhaps a dozen. To-day in a national survey we have just concluded wehave found that of the nations 126 medical schools,114 teach medical ethics. I would not imply thatmedicine has become more ethical by virtue of thatstatistic; but at the very least, ethical questions arebeing examined in a critical fashion. What is moreimportant in a pluralistic society is that medicalstudents and young physicians today are being edu-cated in some of the skills of ethical discourse. Theyare learning how to analyze ethical dilemmashowto recognize, analyze, and understand their ownvalue systems and those of their patients, and howto resolve conflicts in values. Moreover, these ques-tions are occurring in medical rounds at the bedside

and in the clinic. This would have been unthinkabletwenty years ago.

The capacity to recognize, analyze, and resolveethical issues at the bedside is just as important asknowledge of the basic and clinical sciences. Thisjudgment follows inescapably if you accept the ideathat the end of medicine is a right and good healingaction for a particular human being. This capac-ity is at least one of the more tangible elements ofcompassion. Compassion has a moral quality; it isnot just a fine bedside manner or a capacity to havea physiological or psychological empathy with thepatient. These are not to be deprecated. But com-passion is something more. It means (to go backonce more to the Latin) feeling with, sufferingwith, the patient.

Every human experience is unique, especiallythe experience of illness. No one can fully experienceanother persons experience of illness. Nevertheless,if we are to arrive at a medical decision that fits asclosely as possible a patients experience, we mustpenetrate that unique experience to some degree.Thats what compassion means. To feel somethingof what it is to be ill: not in general, not in society,not in ones family, but in this person here and now.Compassion becomes a moral requirement becausea truly healing action requires some comprehensionof what this illness means to this person. Objectiv-ity required by medical science is a stepping back,which is absolutely necessary for the technical de-cision. But with compassion we step back into thepatients experience in order to make a good, morallydefensible decision.

To summarize, I think we need to reconstructmedical morality on a sound philosophical basethe base that is unique to medicine: the physicianpatient relationship. It makes a great deal of differ-ence whether you look at it as a healing relationshipin the terms I have been describing, as a contractbetween two persons who are on an equal footing,or as a commercial transaction. We are now in anera in which competition may become a new salva-tion theme in medicine: unleashing the competitivespirit, it is ventured, will save us all by driving costsdown. Well, even if it does reduce costs, what willit do to the healing relationship?

Ask yourself, as you all must eventually, asphysicians must: is there something about illnessthat is unique and that puts it into a different cat-egory of human relationships from that of yourrelationship with our auto mechanic or grocer? Ithink our answer must be, Yes. If we can establishthat point we may hope for fairly wide agreement



amongst us on what constitutes an ethical relation-ship between the healer and those who are ill.

Even with this agreement there remain broadareas in which there is no consensus. A philoso-phy of the physicianpatient relationship is not thewhole of medical morality. One cannot have a com-plete medical morality unless one has taken a standon several levels of medicalmoral discourse. First,the one I have been talking about: What are theobligations of a professed healer, simply by virtueof making that profession? We can come to a com-mon agreement at this level because the phenomenaof illness, medicine, and the act of medicine havefoundations we can observe.

This will not tell us how we should act in theface of specific medical moral dilemmaswhat todo in the case of abortion, euthanasia, the prolon-gation of life, the care of the infant with multipledeformities, behavior control, genetic engineering,and all the other medicalmoral problems of theday. On these important issues we are not likely toagree unless we are in agreement at two deeper lev-els. One level has to do with what we think man is,what his nature isour philosophy of man: Is hegenetically determined in a certain way?; are ethicsand science the same thing?; is ethics swallowed byscience, by neurology? The other level has to do withour opinions about a source of morality outside ofman, a transcendental source, that stands over andbeyond man. Do we believe in God?; what do webelieve about Him?

Most of the difficulty and emotion in ethicaldiscourse arises from the great differences of opin-ion at the last two levels: the philosophical and thetheological. In a pluralistic society we cannot expectuniformity on these last two levels.

But I do think agreement is both possible andnecessary at the first level, at the level of a phi-losophy of the physician-patient relationship, thefocus of my remarks. I and some others are workingtoward a reconstruction of medical morality thatmight extend what Scribonius Largus started in thefirst century AD. We certainly have the insights to-day to go somewhat further, in a somewhat moresophisticated way, and to develop a viable profes-sional code that will fit the requirements of ourtimes better than some of the older ones do. Weare trying to challenge both physicians and patientsto ponder these issues because professional medicalethics is no longer an enterprise to be pursued solelyby physicians, for physicians.

Finally, I believe, the elements of the healing re-lationship and the obligations derivable from them

are common to all health professionals. We musttherefore look towards the reconstruction of not justmedical ethics but an ethics for the health profes-sions, for all who profess to heal. There will be someclashes arising from the differences between, let ussay, the act of medicine and the act of nursing, butthese will be minor and subsidiary to those thingsthat are common to all of us.

Difficult as a reconstruction of professionalethics will be in a pluralistic society, with so manyhealth professions vying with each other, I think theconstruction of a common ethic is possible and nec-essary. But for it to be successful we must start withthe phenomena we all sharepatients, physicians,nurses and all professed healers: the phenomena ofthe healing relationship.

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