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Becoming a Good Doctor: The Place of Virtue and Character in Medical Ethics.

Becoming a Good Doctor

The practice of medicine and the study of its ethics, like private clubs and rules of syntax, are gradually becoming more inclusive. Doctors are paying more heed to what patients have been telling them, and the reading of literature has emerged as one means for sensitizing physicians to patients' stories. Ethicists are paying more heed to what clinicians have been telling them, and the study of the doctor's character has helped ethicists to understand better the doctor's actions. Two recent books help to bring these new developments into focus.

In the introduction to his powerful, exciting new book, Patient Encounters, philosopher James H. Buchanan quotes Dr. Jurgen Thorowald: "The status and progress of medicine ought always to be judged primarily from the point of view of the suffering patient and never from the point of view of one who has never been ill." In Patient Encounters, Buchanan succeeds in painting a series of vivid portraits of illness from the patient's perspective. Himself a victim of infectious endocarditis as a child, he writes movingly about his own illness and also describes the death of his mother from lung cancer. He chronicles struggles of famous persons (viz. Thomas Wolfe's demise from tuberculosis, Flannery O'Connor's battle against lupus, Wilder Penfield's fight to save his sister from a malignant brain tumor, Harvey Cushing's crusade against acromegaly) and fictional ones (all of whom are based on actual patients and clinical events).

Each of the sixteen stories deals with a specific disease (for example, porphyria, progeria, Parkinson's syndrome, AIDS). He weaves together, in a smooth and effective manner, the clinical, textbook facts about each illness with the story of a person or a family locked in mortal combat against that illness. The dry coldness of the textbook descriptions is overwhelmed by the warmth and vigor of the patients' stories.

Buchanan captures the key clinical features of each disease and succeeds well in placing the patient's fight against illness into a larger framework of life's struggles. His writing style is vivid and expansive, even flamboyant. He opens his chapter on Alzheimer's disease by querying: "Is it out of malice or is it out of mercy that we are condemned to watch our own death? No other animal is so cursed--or so blessed--as to observe with horrified detachment its own disappearance into the thin envelope of nothingness."

Several of his stories are particularly poignant. In "Just Looking," Buchanan displays a novelist's gift in the depiction of a voyeur's obsession: "Ernest Waltmeyer was a jeweler and had but one testicle. Neither fact, of course, was the cause of the other. It just happened that way. Still it did bother him to be...well, to be...defective in an otherwise perfect world of full-cut carat diamonds and intricate Swiss watch movements."

The book does not always achieve such lofty heights. Buchanan has attempted to discover the particular "signature" of each disease, but one is struck instead by the uniqueness of each person's response to an individual illness, rather than commonality of experience. The unique signature of the person is more evident than a unique signature of disease. He also attempts to link different diseases together. For example, amyotrophic lateral sclerosis (ALS), Alzheimer's disease, and acromegaly are "diseases of the soul" while progeria, AIDS, and carcinoma are "diseases of the heart," and suicide and voyeurism are "diseases of life." Such linkages are puzzling and unexplained. No convincing threads are given to join these illnesses together. Physicians are admonished to "treat each patient as an individual." The author would do well to treat each illness as an individual.

The author's rich descriptions can be repetitious. Lupus, porphyria, and smoking are all "metabolic furnaces." Several illnesses are "caldrons of agony," and his world is replete with objects that are "ocher yellow."

Nevertheless, Patient Encounters is a rewarding and memorable book. Buchanan credits Richard Selzer and Oliver Sacks for their inspiration and help. This book is a worthy addition to any shelf containing their works.

James F. Drane, in his Becoming a Good Doctor: The Place of Virtue and Character in Medical Ethics, also cites Oliver Sacks, whose story of a doctor's agnosia, The Man Who Mistook His Wife for a Hat (New York: Summit Books, 1985), becomes a metaphor for the problems of modern medicine: "Like Dr. P., medicine has refined its abstract categorizations of bodies, but has lost contact with the personal features of patients. Like him, modern medicine functions, but in a diminished and depersonalized world."

Drane believes that modern medical ethics with its emphasis upon principles, theories and rules, has become depersonalized as well, losing its focus on the quintessential medical task of an individual doctor caring for an individual patient. Having worked with the important Spanish philosophers Jose Luis Aranguren and Pedro Lain Entralgo, Drane attempts an ambitious new synthesis between Northern European and American Protestant ethics, to which duties and rights are central, and Southern European Catholic theology, which emphasizes character and virtue.

The author begins by presenting a taxonomy of six dimensions of the doctor-patient relationship: diagnostic and therapeutic acts, verbal communication, doctor and patient decisions, the feelings of doctors and patients for one another, the societal aspects of medical acts, and the priestly or religious functions of the doctor. He then describes, in sequence, the six virtues of benevolence, truthfulness, respect, friendliness, justice, and religion needed by a "good doctor" (one "who treats patients the way they should be treated; one who addresses the needs which patients bring to the doctor; one who fulfills a publicly proclaimed medical vow to help persons who are ill; one who does what the doctor/patient relationship requires") to fulfill the requirements needed for each of these six dimensions of patient care.

The sections on friendliness and religion are of particular interest. Drane notes that friendliness (which, he points out, is actually a form of love) between the doctor and the patient can meet both of their needs by offering the pleasure of one another's company, sharing of confidences, intimacies, and feelings, and exchange of mutual personal and professional benefits. He is also careful to note, of course, some of the dangers of excessive "friendliness."

He outlines quite persuasively the role of the physician as the modern priest, noting that "health has taken the place of salvation and the doctor is the only mediator of this new essential value." He believes that the virtue of religion or "reverence" would assist in meeting this priestly function and defines it as "reflection on the awesome dimensions of his work; recognition of what is 'transcendent' in the patient (the mystery of human life) and commitment to serving patients struggling with life's meaning."

He is careful to outline the relationship between virtue and character, noting Kierkegaard's phrase that the practice of virtue requires "absolute commitment":

Any effort merely to acquire virtues, like piling bricks one upon the other, is obviously an exercise in futility. Deeds repeated one after another lead nowhere and do nothing; but deeds derived from attitudes, informed by a faith and directed toward an ideal can lead to the development of both virtue and character. Virtue practiced without a vision of the good or disconnected from belief about the meaning of life, becomes virtue for its own sake: moral gymnastics or ethical masochism.

Yet his terminology can be confusing. He describes the verbal communication between doctors and patients as being "spiritual" for unclear reasons, and has a tendency to state the obvious. He also tends to present opinions without supportive evidence, as when he asserts that "An absence of attention to doctor virtues and character development has had a negative effect on many aspects of the doctor/patient relationship, but especially on the communication process," or to offer sweeping generalizations without justification. This style of writing can be awkward or even uninterpretable at times.

He criticizes the deontological school of ethics for its excessive analysis of cases, but his own work suffers by not being grounded in actual clinical examples. It has plenty of spirit but not enough flesh.

Thus Becoming a Good Doctor meets only with partial success. The author has attempted a valuable corrective to the deonotological emphasis of modern medical ethics. His book is an attempt to swing the pendulum back so that issues of character and virtue can be discussed alongside duties, responsibilities, and rules. This is a noble enterprise and he has succeeded in moving the pendulum; much more effort will be needed to place the pendulum in the center.

Dale A. Matthews is assistant professor of medicine, University of Connecticut School of Medicine, and George Morris Piersol Teaching and Research Scholar, American College of Physicians.
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Author:Matthews, Dale A.
Publication:The Hastings Center Report
Article Type:Book Review
Date:Nov 1, 1990
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