Tim Hoff: Welcome to Ethics Talk, the American Medical Association Journal of Ethics podcast on ethics in health and health care. I'm your host, Tim Hoff. This episode is an audio version of a video created by the Journal's editor in chief, Dr Audiey Kao, in which he presents an interview he conducted with the late Dr Edmund Pellegrino 20 years ago. To watch the full video interview, head to our site, JournalOfEthics.org, or visit our YouTube channel.
Dr Audiey Kao: Before his passing in 2013, Dr Pellegrino was Professor Emeritus of Medicine and Medical Ethics at the Kennedy Institute of Ethics and Founding Director of the Center for Clinical Bioethics at Georgetown University. Considered one of the founders of American bioethics, he was the author or coauthor of more than 600 articles and 23 books, including The Virtues in Medical Practice with David Thomasma and African-American Bioethics: Culture, Race and Identity with Lawrence Prograis. Dr Pellegrino's body of scholarship is expansive, to say the least. But what I believe is important here is that his life's work as a physician ethicist has enduring relevance to contemporary issues, including what makes a good leader during a crisis and how to think about the common good. Probably most known for his writings on virtue ethics, Dr Pellegrino emphasized the centrality of moral character in ethical behavior in contrast to deontology that specified duties or rules or consequentialism that emphasized the outcomes of actions.
While Dr Pellegrino wrote and spoke extensively about the virtuous physician, his insights can aptly apply to any person who aspires to be or is in a position of authority. A position that is capable of doing enormous good, but if poorly executed, can intend great harm, especially during times of danger and turmoil.
Dr Edmund Pellegrino: The kind of person the physician ought to be, that's what virtue ethics concerns itself with. What kind of person should the physician be, rather than what rules should he follow, what obligations, what duties? Those are important, but they're secondary to the kind of person the physician should be. So, I talk about the virtuous physician.
The virtues I've been talking about, namely fidelity to trust, compassion, intellectual honesty, courage, benevolence, for example, are necessary because without those personal characteristics, the physician cannot truly heal, cannot make whole again.
Socrates was asked, “Can you teach virtue, Socrates?” And Socrates went on at great length. He didn't really answer the question very satisfactorily, but he explored it beautifully. But Aristotle did answer it, and he said, “Yes, you teach virtue by the practice of virtue.” Young people, despite their cynicism about us older people, are looking for models. They want to see us act with consistency, to behave as we speak. And they have a wonderful nose for hypocrisy. They'll catch you right away. When you turn your back at the wrong time to the patient, you are not a virtuous physician.
I think for the young person contemplating medicine today, they should step back and ask themselves what kind of life they want to lead in a general way. But more important than that, ask themselves if they want to do something which is more challenging than they can ever meet fully in their whole lives. Something which will lead them to a body of information which is bigger than they can encompass, which will bring them into duties and obligations which are larger than most people in this world face. Are they willing, do they want to enter a field in which they can do enormous good and enormous harm, and they have the responsibility of keeping those in balance? If they can say yes to those things, they ought to think about medicine.
Kao: Whether it's an individual who chooses a career in medicine and takes the Hippocratic Oath, or it's an elected official who swears to protect and defend the Constitution of the United States, the public act of professing your duties and obligations is a solemn expression for which the public expects you to uphold. Compared to the medical school days of Dr Pellegrino, and myself for that matter, today's medical students take an oath during their first days in school as part of white coat ceremonies. In 2001, the American Medical Association House of Delegates adopted an oath that articulates the professional duties of physicians worldwide. Among the nine articulated duties in the AMA's declaration of professional responsibility, three are worth noting, given the times that we live in today. They are to treat the sick and injured with competence and compassion and without prejudice; apply our knowledge and skills when needed, though doing so may put us at risk; and advocate for social, economic, educational, and political changes that ameliorate suffering and contribute to human well-being.
Pellegrino: We enter the profession of medicine, not when we get the degree of medicine. That's only a certificate of exposure to an education. We enter the profession when we take an oath. We say, I declare to everyone here that I am committed to the ideals of medicine.
Medicine, along with ministry, law, and teaching, is a helping profession. They all confront human beings in states of need, universal states of need. They all require that something extra, something special in the dedication of one human being to another because of the fact that they're dealing with other human beings in a state of vulnerability. To satisfy those requirements, one must be more than one perhaps feels one can be. One needs to strive for perfection, realizing we're not going to reach perfection. But I think it's extremely important to set an ideal, an ideal which you know you're never going to satisfy perfectly. Because one thing is clear: you're going to fall below the ideal, being human. But if you set the ideal high enough, when you fall from it, you're in a much better level than if you set it low and you fall from it. You're way down here.
Kao: Considered by many to be the father of wildlife ecology, Aldo Leopold said, “Ethical behavior is doing the right thing when no one else is watching, even when doing the wrong thing is legal.” Legendary UCLA basketball coach John Wooden is quoted as saying, “The true test of a man's character is what he does when no one is watching.” On the other hand, British writer and author of The Chronicles of Narnia, C.S. Lewis, has falsely been attributed with saying, “Integrity is doing the right thing even when no one is watching.” Like Leopold and Wooden, Dr Pellegrino also subscribed to what he described as the moment of truth.
Pellegrino: The question is often asked, what's the most important thing in the ethics of medicine? And I always say it's the character of the physician, the kind of person she is or he is. And I say that because there's the moment of truth. The moment of truth may come at 3:00 in the morning when no one is watching, how you behave. By behavior, I mean, how you act in the interests of that patient. And what you do when no one is watching is the measure of the kind of person you are.
Kao: It's worth noting that Dr Pellegrino, Aldo Leopold, John Wooden, and C.S. Lewis are all men, more specifically, White men. White men have long held positions of authority in nearly all aspects of American life. And the field of bioethics is not immune to this historical reality. While his race and gender doesn't and shouldn't invalidate Dr Pellegrino's ethics expertise and wisdom, it is essential that bioethical deliberation and scholarship reflect an authentic diversity of voices and perspectives. In keeping with this aspirational imperative, the Association of Bioethics Program Directors recently issued a statement on violence, COVID, and structural racism in American society.
The statement reads in part that, “As directors and faculty of bioethics programs and centers across the United States and Canada, we have dedicated our careers to promoting equitable access to the health care system and the fair and ethical delivery of health care services. Yet, for too long, we in these bioethics communities have failed to forcefully confront the structural racism embedded in our society. We have not adequately spoken out as a profession about the profound impact of racism on medicine, on public health, on clinical care, and on medical research, despite the centrality of justice as a guiding principle for our field. Today, we commit to changing that, both individually and collectively, through concrete actions to change our field….
Bioethics [also] sees itself as a profession which champions the disenfranchised. However, we have not done nearly enough to champion them within our ranks. We commit now to doing so for our Black colleagues, as well as all underrepresented voices.”
Finally, as we near the end of this episode of Ethics Talk, I want to share this final interview segment of Dr Pellegrino.
Pellegrino: There is a great conflict today, as there always has been, between the timeless values of the ethics of medicine, which is devoted to the good of the patient and requires something more than acting in my own self-interest, and the profit motive. And that's due to the fact that we are today regarding health care as a commodity and saying that its price, its quality, its availability, its accessibility are determined by the forces of the marketplace.
The physician faces a challenge to his character in today's social media particularly, because of the change in the way we've looked at medicine and what it is. In the commercialized, entrepreneurial world, in the market ethos, health care is a commodity. So, why don't you pursue it as a business? I've been challenged by physicians that say, “Dr Pellegrino, you're a fool.” I've been called that publicly, and that's not unusual. “You're an idealistic fool. You know it's a business. Why don't you call it such and stop all of this blather about ethics and virtue?” That's a challenge. [chuckles] And that is a significant number of physicians feel that way. I'm happy to say a large number do not and still want to do the right thing. They are the hope for the future.
Kao: The COVID-19 pandemic has exposed many fractures in American society, including that universal health care coverage is not a guarantee for all. For Dr Pellegrino, who saw the caring profession as a moral enterprise, health care should not be a commodity driven by the forces of the marketplace. Rather, he championed health care as a human right and as a public good.
Thank you for joining us today on this special episode of Ethics Talk. We'll see you next time. [bright theme music plays]
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