Virtue in Emergency Medicine

Authors


  • Previously published in Acad Emerg Med 1996; 3:961–6. Originally received April 9, 1996; accepted April 12, 1996; updated April 29, 1996.

  • A related commentary appears on page 63.

Address for correspondence and reprints: Gregory Luke Larkin, MD, MSPH; e-mail: gluke.larkin@yale.edu.

Abstract

At a time in which the integrity of the medical profession is perceptibly challenged, emergency physicians (EPs) have an opportunity to reaffirm their commitment to both their patients and their practice through acceptance of a virtue-based ethic. The virtue-based ethic transcends legalistic rule following and the blind application of principles. Instead, virtue honors the humanity of patients and the high standards of the profession. Recognizing historical roots that are relevant to the modern context, this article describes 10 core virtues important for EPs. In addition to the long-recognized virtues of prudence, courage, temperance, and justice, 6 additional virtues are offered unconditional positive regard, charity, compassion, trustworthiness, vigilance, and agility. These virtues might serve as ideals to which all EPs can strive. Through these, the honor of the profession will be maintained, the trust of patients will be preserved, and the integrity of the specialty will be promoted.

What constitutes a truly good physician? Modern conceptions of the “good doctor” are often linked to malpractice claims, outcome data, economic profiling, and, even more recently, the ability to follow practice guidelines. Although following rules and optimizing technical outcomes are important, they say little about the physician’s character. Character, or virtue, is an ancient concept that is often not well articulated in our modern conception of the complete emergency physician (EP). We assert that virtue is central to the practice of emergency medicine (EM) and that there are specific, identifiable virtues that the practitioner should possess.

Character And Virtue

Ethike, the Greek word for “character,” forms the etymological root and philosophical basis of the classical Western notion of ethics. For the ancients, character and virtue were inextricably intertwined. Homer’s Iliad contains an early depiction of character (ethike) and virtue (arete). In it, the heroes of the Trojan War are animated by their quest for virtue, or attempts to achieve perfection. Homer used the Greek word arete to describe not only virtue, but all characteristics that enable an individual to achieve excellence in the performance of their duties.

The ancient Greek notion of character and virtue was most highly developed by Aristotle around 330 BC. In The Nichomachean Ethics, Aristotle states that the exercise of virtue is necessary to live a good and happy life.1 Virtues are dispositions to be good. They include not only good actions, but also good thoughts and good feelings. Aristotle further described virtue or character as the golden mean between deficiency and excess. Courage, e.g., was described as the mean between foolhardiness and cowardice. Like Socrates and Plato before him, Aristotle regarded courage, justice, prudence, and temperance to be the four cardinal virtues. The struggle for optimal balance in one’s life was the struggle for virtue. His concept was that virtue must be practiced to find the balance; it must be cultivated for moral behavior to become a habit.2,3

Virtue-based ethical concepts remained important long after Aristotle’s death. In the medieval period, 1,500 years after Aristotle, virtue-based ethics reached its height under the teachings of St. Thomas Aquinas. Aquinas taught the importance of the four primary virtues, but added the theological virtues of faith, hope, and charity. To this list of four virtues, Aquinas contrasted the seven deadly sins, or vices (pride, avarice, lust, anger, envy, gluttony, and sloth).4,5

Other influential traditions offer remarkably similar moral guidance. The prayer of Maimonides is probably second only to the Hippocratic Oath in its influence on Western medical ethics. Traditionally ascribed to Moses Maimonides (1135–1204), the great philosopher and codifier of Talmudic law, it says, in part, “inspire me with love for my art and for Thy creatures. Do not allow thirst for profit, ambition for renown and admiration, to interfere with my profession, for these are the enemies of truth and of love for mankind and they can lead astray in the great task of attending to the welfare of Thy creatures. Preserve the strength of my body and of my soul that they ever be ready cheerfully to help and support rich and poor, good and bad, enemy as well as friend. In the sufferer let me see only the human being.”6

Although the most ancient literatures, Hittite, Babylonian, Assyrian, and Egyptian, have no available evidence of influential moral codes for physicians, there were laws to protect the patient from abuse and maltreatment.7 In the ancient Moslem tradition, no ethic specific to medicine is noted since behavior was guided by broad religious precepts based on the Qur’an, the holy book, and sunnah, prophetic influences. Ethical writings in Islam are under the rubric adab, which means “proper manners,”“good etiquette,”“correct procedure.” This literature emphasizes practical piety and high character because these virtues are said to aid in the general trust and acceptance of professional advice (al-Ghazali). One of the earliest endorsements of professional virtue (c. 875 AD) is from Ali al-Ruhavi’s Adab al-Tabib (“The Ethics of the Physician”): “The philosophers can only improve the soul, but the virtuous physician can improve both body and soul.”8 Al-Ruhavi further insisted that before a physician could treat the patient as a whole, the physician should become whole. In Islam, medicine is viewed as much as a vocation as a profession. The spiritual component is integral. More recent Islamic writings provide insight into moral expectations of physicians. The International Organization of Islamic Medicine recently published a code of ethics.9,10 The physician is expected to “protect human life in all stages, under all circumstances, doing my utmost to rescue it from death, malady, pain, and anxiety; to keep people’s dignity, cover their privacies and lock up their secrets, extending my medical care to near and far, virtuous and sinner, friend and enemy; to strive in the pursuit of knowledge and harnessing it for the benefit but not the harm of mankind.”

In other cultures, ancient writings describe specific virtues and moral precepts. In ancient Hindu medicine, e.g., there is clear evidence of a virtue-based medical ethic: “You must put behind your desire, anger, greed, folly, pride, egotism, jealousy, harshness, calumny, falsehood, sloth, and improper conduct.”11 Hindu tradition provides a highly developed virtue-based ethic that remains influential. The Chinese have a code of medical ethics that originated in the seventh-century writings of Sun Ssu-miao who is frequently called the father of Chinese medicine. A translation of his work notes, in part: “A great doctor, when treating a patient, should make himself quiet and determined. He should not have covetous desire. He should have bowels of mercy on the sick and pledge himself to relieve suffering among all classes. Aristocrat or commoner, poor or rich, aged or young, beautiful or ugly, enemy or friend, native or foreigner, and educated or uneducated, all are to be treated equally. He should look upon the misery of the patient as if it were his own and be anxious to relieve the distress, disregarding his own inconveniences such as night call, bad weather, hunger, and tiredness. Even foul cases should be treated without the slightest antipathy. One who follows this is a great doctor, otherwise he is a great thief.”12

Character And Virtue In Modern Medical Practice

Moral precepts have directed physicians throughout the ages, throughout diverse cultures. In modern times, virtue-based philosophies have been steadily assaulted by influential Western philosophers.13 Virtue-based theories have steadily fallen out of favor and have been largely rejected with the advent of the industrial revolution and the development of modern science.14–16 The current application of business principles threatens to further erode virtue-based theories, as moral requirements give way to rule following and as behaviors are determined only by the law.17,18 Medicine is in danger “of becoming less of a moral enterprise, a mere commodity to be bought and sold, the virtue of its practitioners defined by the success of the bottom line.”

Modern medicine has become steeped in the tradition of rules, laws, scientific principles, and utilitarian practice guidelines. Although following rules and optimizing outcomes are important, we believe that the classic and widely based notions of character and virtue are equally important to the successful physician.19

Our assertion that virtue is essential to the practice of EM demands that we accept as a starting premise that there are ideal qualities that should guide EPs’ behavior. Aristotle described this as our telos, or natural end. We assert that the telos of an EP is not merely to work within the rules, but also to be a moral professional who cares for and about patients. This notion transcends corporate and contractual requirements. While the recognition of virtue does not prevent the sound application of business principles to the practice and management of medicine, it does prevent finances from becoming the solitary driving force. It injects morality into evaluation of the bottom line.

The injection of virtue into the EP–patient relationship also does not abolish the need for ethical rules and principles. Certainly, principle-based concepts of professional ethics have been most influential and important in modern medicine. The four ethical principles of beneficence, nonmaleficence, autonomy, and justice focus primarily on duties and obligations, not requirements for personal virtue.20 Subscription to the importance of virtue does not denigrate principalism, but buttresses it. If principles and duties are the letter of the law, virtue is the spirit of the law.21 Virtues are the foundation on which the principles are chosen, interpreted, ordered, and applied. While virtues have been recognized for centuries, the 4 principles are as young as the specialty of EM, having gained widespread influence in the 1970s. Furthermore, principles, laws, rules, and guidelines may change. Virtues should not.22,23

We look, then, to the classic virtues of Western philosophy and to the contributions of many cultures to describe virtues important to modern EPs. They are offered for individual consideration, presented to inspire personal analysis. In our modern practice, we often look to external sources to measure adherence to the “right” and to the “good,” but we must ultimately act according to personal beliefs, guided by our own counsel. We must establish personal standards by which we can live, work, and hold ourselves accountable. These virtues are offered, then, for personal reflection, to be translated into action according to the values of the individual EP.

Virtues

The virtues detailed in this section cannot be all-inclusive, and certain virtues, such as humility, are aligned so closely with others they are not mentioned separately. As Plato and Aristotle noted, there is considerable overlap between many important virtues. This reflects both their compatibility and their interdependence. In this analysis, we recognize the timelessness of classic virtues of Western thought, so we examine these four first: prudence, courage, temperance, and justice. To them we add others, drawn from widespread influences that are important in the practice of EM: unconditional positive regard, charity, compassion, trustworthiness, vigilance, and agility.

Prudence

Prudence connotes discernment, judiciousness, and proper discrimination. It is from the Greek word phronesis, or “practical wisdom.” Phronesis was considered by Aristotle to be a necessary prerequisite because it is needed to weigh justice, courage, temperance, and other virtues and vices. In modern EM, it forms a similar strong foundation. It is both basic common sense and the ability to reach sound conclusions. The benefit of insight, discretion, and good judgment belongs to one who is prudent. It is the skill, developed with practice and experience, of deciding what is important, applying appropriate weight to important facts, integrating information, realizing that there may be facts not yet available, and coming to a reasoned, sound decision. Knowing the right action, the right interaction, demonstrating the right behavior, and making the right decision require prudence, or practical wisdom.

Courage

The EP is routinely required to put aside fear, confront distasteful situations, resolve uncomfortable challenges, and deal with unpleasant circumstances. Mahatma Gandhi said that “Fearlessness is the first requisite of spirituality…Cowards can never be moral.”24 Patients with potentially violent behavior, communicable disease, unpleasant demeanor, malodor, and other frightening or unattractive features challenge all EPs, but especially those who lack courage. Moral courage is fortitude to do what is required, what is right, in the face of unpleasant or aversive conditions. Described as the Aristotelian mean between cowardice and foolhardiness, it does not require EPs to place themselves in grave danger. It does demand that the physician not evade unpleasant conditions, not run from difficulties, and not avoid doing what is right for the sake of ease. It may require confrontation with those who would interfere with important care or those who endanger patients through incompetence or impairment. It may require bravery to do what is required. It may also require kindness and gentleness, showing support to those who are hostile, whether patient or health care worker. The challenges that require courage may be physical or emotional. Sometimes the emotional courage to be patient and understanding is more difficult. Perhaps kindness in the face of hostility is even a higher form of courage. Austrian poet Rainier Maria Rilke (1875–1926) offers insight into this: “Perhaps all the dragons in our lives are princesses who are only waiting to see us act, just once, with beauty and courage. Perhaps everything that frightens us is, in its deepest essence, something helpless that wants our love.”25

Temperance

Temperance reflects imperturbability, poise, composure, and self-control. This is grace under pressure, manifested as calm in the face of chaos and a confident presence despite massive stimuli. It is the ability to act, knowingly and deliberately, rather than react impulsively. Disciplined emotion and restrained passions allow objectivity and reason during times of critical decision-making. It inspires the trust of others.

Aristotle’s golden mean between deficiency and excess requires that extremes of behavior be avoided. Unrestrained anger and frustration or profound passivity and apathy must be avoided in the practice of EM. In addition to our behavior, even our medical decisions require temperance. Unbridled enthusiasm for or rejection of technology, arrogant proclamation, or condemnation of new ideas, or too quick a rush to judgment of any sort, serves neither the patient, the physician, nor the profession. Temperance requires humility, as the physician recognizes there is a vast amount of information not yet known and, although recognizing this, is still able to remain composed and steer a reasoned course. Temperance is self-control, without which EM could not be effectively practiced.

Justice

Justice is fairness. It is required to ensure that medical decisions are made with reason and honesty. Selfish or biased influences must be recognized and avoided. EPs, confronted by medical and management decisions, must ensure fairness and consistency in patient care. We must ensure that high standards are met for all emergency patients. This recalls the ancient Chinese requirement to treat all equally. Emergency decisions, then, must be based on careful and objective assessments of medical need; therefore, justice, fairness, and elimination of bias are particularly required.

Unconditional Positive Regard

Closely aligned with justice is the imperative to treat each patient with unconditional positive regard. If we are to treat all fairly, we must approach each patient with recognition of his or her worth as a human being. We are required to view each person as one of value, one worthy of high standards of care, one who deserves our best efforts. Individual practitioners do not have to morally agree with an individual’s behaviors, nor should we avoid counseling for fear of intruding on individual values, but we must never view the individual as unworthy of conscientious care. Relating to patients, even difficult patients, with a demeanor of caring and human acceptance furthers the relationship and the therapeutic goal. Despite low social standing, poor temperament, intoxication, illegal actions, or other unpleasant characteristics, each patient must be encountered with common courtesy, sincerity, and willingness to help. Individual judgments of worthiness should be avoided; they interfere with the relationship, are contrary to effective care, and fail to serve virtuous ends.

Charity

Effacement of self-interest, or altruism, is perhaps the highest level of virtue. Charity goes beyond the mandates of nonmaleficence and even beneficence. Charity denotes the cheerful giver, one not self-seeking, but willing to do more than that minimally required to serve a person in need, even if it interferes with self-interest. Aquinas first introduced charity as a cardinal virtue in the Middle Ages, but it remains noble, even in modern secular society, because it denotes self-sacrifice, applying free will to serve another in need. Generosity to patients and colleagues, recognizing the needs of others and addressing them, can be simple yet powerful demonstrations of charity. In an era where physicians perceive threats to their autonomy and to their financial status, charity remains the pinnacle of virtue, because, at the root, it is about genuine caring and selfless giving.

For one human being to love another human

being: that is perhaps the most difficult

task that has been entrusted to us,

the ultimate task, the final test and proof,

the work for which all other work is merely

preparation. (Rainier Maria Rilke)25

Compassion

Compassion combines elements of understanding, humility, empathy, sympathy, sensitivity, tact, and even gentleness. Compassion is a part of professional competence and is perhaps as important as technical competence, because both are required to effect meaningful healing. We care for people in crisis who are exceedingly vulnerable to humiliation and harm at the hands of caregivers who lack compassion. As with the Aristotelian virtues, compassion is a mean between indifference and involvement to the point of ineffectiveness. It is possible to overidentify with the suffering and become overly involved. Perhaps the more common problem is cold indifference. In a time of crisis, patients need to feel as though they are cared for and about. Only then can they trust. Patient satisfaction probably depends more on these feelings than on the technical skills of the physician. High standards of compassion must be demonstrated consistently, modeled by academic faculty, nurtured in residents, and expected as a critical core quality of a successful EP.

Trustworthiness

Trustworthiness and integrity are moral prerequisites for the practice of medicine. They are essential to all human relationships and equally critical for EM. Integrity allows one to integrate all other virtues and adhere to principles. The patient must trust the physician to reveal information, submit to examination, accept therapy, and feel confident in the care offered. There is no other reliable way to protect patient interests. In obtaining informed consent, e.g., the physician decides what and how much information to reveal; the patient considers the information, but also considers the source. There must be honesty, fidelity, and trust in the belief of information accuracy, in the comprehensiveness, and finally, in the skill of the practitioner. This relationship can never be reduced to a legalistic, financial service contract. In such a scenario, the therapeutic alliance weakens and the physician’s personal and professional commitment to the well-being of the patient may be questioned. Health care is an intensely personal, fundamentally human interaction that, in the final analysis, requires trust.

In scientific and research activities, similar demands for integrity, for trust, are important. The medical community in general and patients in particular must trust that they will not be exploited for power, profit, or prestige. Intellectual honesty is a basic requirement for the success of the profession and the well-being of patients. Trustworthiness extends broadly to encompass the requirement that each practitioner knows personal limits. Physicians must possess integrity to call for consultation, for assistance, or for referral. It serves no good end to imagine oneself as all-wise and all-knowing. Competence, even power, comes from the humility of knowing our limits and knowing when to access additional information or others with different technical abilities. Being trustworthy in all aspects of professional life gives anxious, anonymous, and vulnerable patients reassurance and confidence when they need it most.

Vigilance

EPs remain ready at all times to care for patients in need. We are close to the community, ready to receive any person in crisis. We are ready for victims of violence, disaster, or disease, ready to patiently and thoroughly provide care. This guardianship, 24 hours a day, does not weaken during holidays, weekends, or nights; in fact, most emergency care occurs during nontraditional work hours. Demands are uncontrollable, defined only by patients’ illnesses. Yet alertness and preparedness are required, despite the circadian disharmony that threatens personal wellness. High standards can never weaken; all care must be of the same thorough nature. No matter what the illness, no matter what the medical crisis, someone stands ready in the ED to help. Always responsive, EPs must be acutely aware that they are medical guardians, the fabric of the safety net of American society.

Agility

Perhaps more a technical requirement than a moral one, agility requires that the practitioner possess mental, physical, and personal dexterity. It does not exclude those with physical disabilities, but emphasizes the requirement to meet the needs of patients and the department. This agility is adroitness, which means being skillful and adept under pressing conditions. The requirement also includes resilience, the ability to rebound from emotional and physical challenges, while avoiding cynicism and resignation. The need for agility and resilience transcends the more basic requirement of competence, augmenting it with physical and intellectual features.

In a setting where much is demanded physically, emotionally, and intellectually, one needs the ability to confront difficulties, giving freely while avoiding impulsive reactions, apathy and professional burnout. The EP must have a nimbleness of mind, responsiveness, endurance, and broad technical and ethical abilities. Added flexibility and adaptability allow one to emerge undaunted from difficulty, from change, from misfortune, even from insult, while successfully meeting unpredictable challenges and uncontrollable workloads. This conception is similar to the excellence, or arete, exemplified by the Homeric heroes Hector and Achilles. It is also the request for strength of body and of soul in the prayer of Maimonides. It is echoed in the ancient Chinese requirement that one overcome physical discomforts to provide care. In modern EM, the requirement for agility is physical, interpersonal, intellectual, and even emotional.

A Plan For Eps

If one accepts that there are ideal qualities that should govern EPs’ behavior, then EPs should strive to acquire certain virtues. These virtues neither depend on nor minimize religious or cultural beliefs. Indeed, they enhance such beliefs by promoting a respect for patients, effective care, high standards of conduct, and society’s trust. Striving to achieve the ideal virtues should guide the behavior of both individual practitioners and their professional organizations. Endeavoring to reach these ideals represents a lofty goal, yet is fundamental to the moral well-being of our professional community.

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