ETHICS
http://dx.doi.org/10.17159/2519-0105/2022/v77no5a9

 

Exploring Modern Virtue Ethics in the Context of Oral Healthcare

 

 

HD Miniggio

BDS (UMF, Cluj-Napoca), MScMed (Bioethics and Health Law) (Wits), PGDip (Health Sciences Education) (Wits), Senior Lecturer, Department of Oral & Maxillofacial Pathology, Oral Microbiology & Oral Biology, Sefako Makgatho Health Sciences University, South Africa. ORCID number: 0000-0003-2003-0306

Correspondence

 

 

INTRODUCTION

Virtue ethics is established as one of the dominant ethical theories that has application for healthcare practice, including oral health. Attributed to the ancient Aristotelian concepts of living a deeply fulfilled life, virtue ethics draws attention first and foremost, to the significance of character traits, or virtues in the process of ethical decision-making. This focus on character, contrasts with duty-based ethical theories such as deontological ethics (with a primary concern on duties) the principles of biomedical ethics (with a central focus on the principles and the obligations derived from these) and consequentialist ethics (with a primary focus on the consequences of actions).¹

From a traditional virtue ethics viewpoint, one can evaluate what an appropriate course of action would be in a particular situation. This is achieved by understanding what an individual who has cultivated a virtuous character would be expected to do in a similar situation, coupled with an appreciation of the essential conditions needed to achieve a fulfilled life.^1-4 In recent years, there is increasing interest and regard (in healthcare ethics literature, including oral healthcare) for the types of professional virtues that healthcare practitioners should develop and exercise in their interaction with patients; these professional virtues are also valuable in guiding the ethical decision-making process.^1-3This interest in virtue ethics is further motivated by the realisation that character cannot be detached from ethical discourse in healthcare provision.^5-7

However, it seems that the features that make traditional virtue ethics valuable, have also created the impression that this theory is not as effective at providing action-guidance in resolving ethical dilemmas encountered in healthcare provision, as duty-based ethical theories.^5-8 Motivated by this misguided perception of the lack of action-guidance of traditional virtue ethics approaches, a variety of appealing modern forms of virtue approaches, have been put forward. These modern virtue approaches aim to provide a correlation between considerations of virtue (and related virtuous behaviour), vice (and related vicious behaviour) and considerations of right or wrong actions.^1,8

Given the significance of the development and exercise of virtues in the oral healthcare practitioner-patient relationship, it is surprising that modern virtue approaches do not form an integral component of ethics discourse in oral healthcare. Currently, ethical discourse in the oral healthcare context is still dominated by the four principles of biomedical ethics.

Originally advanced by Tom Beauchamp and James Childress, this approach is appealing as it provides an accessible guide to resolving ethical dilemmas specifically encountered in healthcare provision; these dilemmas are resolved by a process of specifying and balancing the four principles of respect for autonomy, beneficence, non-maleficence, and justice in ethical decision-making.⁹The principle which is determined to carry the greater weight in the particular ethical dilemma, then serves as an action-guiding principle to be followed by the healthcare practitioner.⁹ Although these ethical principles represent useful starting points in ethical deliberations, virtue ethics makes further demands on healthcare practitioners. These demands include the development of practical wisdom¹ and the cultivation and exercise of a set of professional virtues that assist healthcare practitioners to manage the nuances characteristic of ethical decision-making in their interaction with patients.^1,8

In this article, I aim to evaluate whether modern virtue ethics approaches, can provide adequate action guidance in the context of oral healthcare provision and claim that it can. Such an evaluation is significant given that the action-guiding capacity of virtue ethics is not well represented in current ethics literature pertaining to oral healthcare provision.

To achieve this aim, this article is structured as follows. I begin with a brief overview of the modern virtue-based approach that Rosalind Hursthouse and Julia Annas advance, while acknowledging that other authors² also advance modern virtue accounts. To this end, I present the several noteworthy features associated with Hursthouse's virtue approach and show how virtue ethics provides adequate action-guidance through virtue rules. I then present the noteworthy virtue elements put forward by Annas, with specific focus on the relevance of virtue ethics in the context of healthcare practice which is characterised by specific aims from which well-established duties, expected from healthcare practitioners, arise.

I conclude that virtue rules provide adequate demands for right behaviour, virtue ethics accommodates duties and is a helpful action-guiding tool in assisting oral healthcare practitioners in resolving ethical dilemmas encountered in oral healthcare provision. Lastly virtue ethics is valuable in encouraging the development of virtuous character in oral healthcare practitioners.

Modern virtue ethics approaches

Virtue ethics has an interesting history dating back to the Athenian time of Plato and Aristotle, although Aristotle is generally considered the founder of virtue ethics. This theory was overshadowed by the more popular duty-based ethical theories in the 1950's, but has since been restored as a valuable contender to deontology and consequentialism.⁸ As Hursthouse and Pettigrove explain, scholars in the field began to recognise that these popular duty-based theories fail to:

Pay attention to a number of topics that had always figured in the virtue ethics' tradition-the virtues themselves, motives and moral character, moral education, moral wisdom or discernment, friendship and family relationships, a deep concept of happiness, the role of the emotions in our moral life and the fundamentally important questions of what sort of person I should be and how we should live.⁸

A virtue is defined by Edmund Pellegrino as "the most ancient, durable, and ubiquitous concept in the history of ethical theory...because one cannot completely separate the character of a moral agent from his or her acts, the nature of those acts, the circumstances under which they are performed, or their consequences".⁵ In the context of healthcare provision, it is helpful to think of a virtue as a character trait or quality that enables someone to carry out their duties or functions adequately, thereby enabling them to be good in a specific role, for example good in the role of a healthcare practitioner.¹⁰ The professional virtues that have been designated as important in the oral healthcare practitioner-patient relationship are, amongst others, "compassion, trustworthiness, integrity, discernment and conscientiousness".⁹

It is important to note that although the primary focus of virtue ethics is on the virtues that individuals should develop and exercise, this does not suggest that "only virtue ethicists attend to virtues, any more than it is to say that only consequentialists attend to consequences or only deontologists to rules".⁸ This signifies that each of the normative ethical theories will evaluate (as part of the ethical decision-making process) the pertinent aspects associated with the duties within a specific role, the consequences of the various courses of actions as well as the role that character plays in the process; what distinguishes them is the central focus of each theory.^1,8 It comes as no surprise then, that aspects of character and virtues have also been incorporated in modern deontological approaches, the principle-based approach as well as modern consequentialist approaches.⁸ However, proponents of duty-based ethical theories seem to be concerned that by focusing primarily on character or by being agent-based, virtue ethics may lose sight of the more practical aspects of right and wrong action and duties.^1,9 The concern is usually presented as follows:

If virtue ethics is 'agent-centred rather than act-centred, concerned with 'What sort of person should I be' rather than 'What sorts of action should I do?' (with 'Being rather than Doing'), if it concentrates on the good or virtuous agent rather than on right action and what anyone, virtuous or not, has an obligation to do; how can it be a genuine rival to utilitarianism and deontology? Surely ethical theories are supposed to tell us about right action, i.e., about what sorts of act we should do.¹

Several virtue ethicists, amongst others, Rosalind Hursthouse and Julia Annas have provided eloquent counter arguments to the claim that virtue ethics provides insufficient action-guidance and have addressed the concern that virtue ethics may overshadow duties. Hursthouse for example, shows how virtue ethics uses a similar methodology for guiding virtuous behaviour or right action as the rival normative theories. She explains that a specific virtue is useful in providing "a prescription- do what is honest, charitable, generous"; conversely a vice is useful in providing "a prohibition- do not do what is dishonest, uncharitable, mean".¹ In this way, virtue and vice provide virtue-rules, or V-rules as she calls them, and these V-rules in turn, guide behaviours and actions.¹

Hursthouse further illustrates that even though the focus is on virtue and vice in the form of character development, this does not mean that the theory does not take into consideration duties, principles, or consequences.¹ She also points out that the procedure used in the ethical decision-making process in virtue ethics and for example, deontology, is similar.¹ Both normative theories offer an initial indeterminate premise as follows. The first premise offered by deontology starts by considering that "an action is right iff it is in accordance with a correct moral rule or principle"; while the first premise in virtue ethics begins by considering that "an action is right iff it is what a virtuous agent would characteristically (i.e. acting in character) do in the circumstances".¹ Both of these premises do not, at this initial stage, offer sufficient direction for how one should act and both need further supplementation with a second premise.¹ The second premise for deontology is "a correct moral rule (principle) is one that.".¹ At this stage the second premise can be completed by a set of rules that are "laid down for us by God, or is universalizable/ a categorical imperative".¹ Similarly, the second premise provided by virtue ethics is "a virtuous agent is one who has, and exercises, certain character traits, namely, the virtues" and "a virtue is a character trait that.".¹ At this stage the second premise is similarly completed by either a set of possible virtues or by specifying that a virtue is "a character trait that a human being needs for eudaimonia, to flourish or live well".¹

The outcome of this process of supplementation and specification in both normative theories, results in the establishment of a principle or rule for deontology versus the establishment of a virtue-rule in the case of virtue ethics.¹In a similar manner to the action-guidance that emanates from a duty or a principle, virtue-rules make demands that translate into right action or virtuous behaviour.^1,11 For example, from a virtue ethics perspective, the justification for the virtue of honesty is not found in the fact that lying is prohibited by a specific moral duty, but rather that lying would be dishonest and dishonesty is a vice; a virtuous moral agent would identify lying as such, and would refrain from that sort of behaviour.¹ In other words, the virtue of honesty is able to guide action in that it demands that the individual should "respond to this situation honestly, rather than dishonestly or indifferently".¹¹ In this way, virtue ethics answers the question 'what should I do?' and V-rules in the form of virtue and vice place strong demands for correct action and behaviour on individuals.^1,11 Thus the concern that by focusing on character development, virtue ethics is unable to provide adequate action-guidance is unfounded. Regarding the concern that virtue ethics may overshadow duties, Annas shows us that virtues are compatible with duties, particularly those well-established and accepted duties within the context of specific professions¹¹. Some examples of such professions that she offers are, amongst others, law, and healthcare practice.¹¹ She explains that the role of virtue ethics in these contexts can be understood in the following manner:

The field in question (such as law or medicine)⁰ is already established by certain institutions and the roles that these create within them. This is just the point that if I am a judge, for example, I already occupy a role which brings with it certain duties and obligations. Virtues can play more than one role when applied to the field, but it is not called on to create the duties or to serve instead of them: these are already there, as parts of the field within which ethical issues arise, with virtue applied to the field to provide resolution or explanation. The field of law, for example, is already established, with its institutions and its roles, such as that of a judge. It's within this framework that questions can be raised about virtue and vice.¹¹

Virtue ethics is, in this way helpful in assisting individuals within a well-established role, for instance in a role as a healthcare practitioner, in ensuring ethical practice and the achievement of the aims of that profession. Otherwise stated, a healthcare practitioner may perform her basic duties within the specific role that she occupies; while performing her duties she may "be patient and sympathetic, or impatient and unsympathetic, to a patient's account of his symptoms and general problems".¹¹ Annas further states that "one way of putting this point is to say that virtues of a good doctor are not just virtues at the general level, but virtues as specified within the framework of a given profession".¹¹

Lastly, it is interesting to note that "virtue is a matter of degree" and from a virtue-based perspective a distinction is made between what is called a "full or perfect virtue and "continence" or strength of will".¹ In this respect, "the fully virtuous do what they should without a struggle against contrary desires; the continent have to control a desire or temptation to do otherwise".¹ Importantly, an individual or a healthcare practitioner who may not have developed a fully virtuous character as yet, is still able to make decisions and display behaviours that count as virtuous.⁴

Thus, virtue ethics provides adequate action guidance that is comparable to the other ethical theories with the additional benefit of guiding the development of good character in healthcare practitioners.^1,11

Implications for oral healthcare

Within a modern virtue ethics theory, the professional virtues that have been identified as important for healthcare practitioners to acquire and exercise, make strong claims for action in the context of oral healthcare provision. From the various professional virtues, in the remaining section, I limit my focus on the virtue of compassion and integrity in highlighting the value of virtue in the context of oral healthcare.

The virtue of compassion refers to a character strength that is concerned with the wellbeing of others or an "orientation of the self toward the other".¹² Compassion makes a strong claim on the healthcare practitioner to have "an active regard for another's welfare with an imaginative awareness and emotional response of deep sympathy, tenderness and discomfort at another's misfortune or suffering".⁹ The virtue of compassion entails that oral healthcare practitioners are motivated to respond compassionately and not be apathetic to the oral healthcare needs of individual patients and community of patients.

The virtue of integrity is a character trait which presupposes the possession of both the character trait of authenticity as well as honesty.¹² This virtue makes a strong claim on oral healthcare practitioners in respect to speaking "the truth but more broadly presenting oneself in a genuine way and acting in a sincere way; being without pretense; taking responsibility for one's feelings and actions".¹²Acting in a sincere manner is important in maintaining the trust in the oral healthcare practitioner-patient relationship and in respecting the dignity and autonomy of patients. One manner of maintaining authenticity and honesty within the oral healthcare-practitioner patient relationship is by providing truthful information to patients that allows them to make informed decisions regarding their dental treatment. Jorge Garcia considers that "enabling or facilitating (that is, ensuring) a patient's agency by providing her information and securing her consent is a principal mode of the physician's respecting her patient as a person capable of and entitled to self-direction".⁶He further states that "the duty of respecting the particularities of the relationship between each patient-and-physician pairing likewise is a principal way for the physician to treat her patient as unique, unrepeatable, irreplaceable, inexhaustible, infinite, and unfathomable in her personhood".⁶

From a virtue ethics perspective, becoming a good oral healthcare practitioner demands striving for excellence and expertise in technical skills and knowledge; further to that, it requires the development of excellence in character and exercising the specific professional virtues within the relationship with patients and communities of patients. The refinement and the continued exercise of the professional virtues of compassion, trustworthiness, integrity, discernment, and conscientiousness will advance the oral health needs of patients and assists oral healthcare practitioners in fulfilling their duties within the well-established roles within the profession. It follows that, the ethical duties of oral healthcare practitioners, including the duty to provide informed consent to patients, find a natural home in a modern virtue ethics approach.

 

CONCLUSION

The aim of this article was to evaluate whether modern virtue ethics can provide adequate guidance in the context of oral healthcare provision. I have shown that by means of virtue rules or V-rules, this theory provides strong requirement for right action or behaviour and virtue ethics accommodates the various duties of oral healthcare practitioners.^1,11

Importantly, the strength of virtue ethics is that, apart from an evaluation of the various duties, consequences and expected behaviours from oral healthcare practitioners, this theory also calls attention to the development of a virtuous character which requires wisdom and internal motivation and could enrich the ethical discourse in oral healthcare provision.

In conclusion, the value of virtue ethics in oral healthcare can be summarised as follows, being a good oral healthcare practitioner entails being motivated to acquire and sustain excellence in skills and knowledge; this should be coupled with the development of good character and the exercise of professional virtues within the oral healthcare practitioner-patient relationship. This in turn, will advance the oral health needs of each patient as well as communities of patients. Accordingly, a good oral healthcare practitioner "must not only possess skills but be motivated properly to use them".⁶

Acknowledgements

I would like to thank Prof. T. Metz for his valuable contribution in the structuring of the elements of the introduction of this article.

 

REFERENCES

1. Hursthouse, R. On virtue ethics. Oxford: Oxford University Press, 1999.         [ Links ]

2. Pellegrino ED. The internal morality of clinical medicine: a paradigm for the ethics of the helping and healing professions. J. Med. Philos 2001; 26(6): 559- 79.         [ Links ]

3. Gardiner P. A virtue ethics approach to moral dilemmas in medicine. J. Med. Ethics 2003; 29(5): 297-302.         [ Links ]

4. Garcia JLA. Virtues and principles in biomedical ethics. J. Med. Philos: A Forum for Bioethics and Philosophy of Medicine 2020; 45(4-5): 471-503.         [ Links ]

5. Pellegrino ED. Toward a virtue-based normative ethics for the health professions. Kennedy Inst. Ethics J 1995; 5(3): 253-77.         [ Links ]

6. Garcia JLA. The physician-to-patient relationship in virtues-based ethical analysis. Life & Learning XXIII 2017; 225: 41.         [ Links ]

7. Shea M. Principlism's balancing act: why the principles of biomedical ethics need a theory of the good. J. Med. Philos 2020; 45(4-5): 441-70.         [ Links ]

8. Hursthouse R, Pettigrove G. Virtue ethics in E.N. Zalta (ed.) The Stanford Encyclopedia of Philosophy. Stanford: Stanford University, 2018: 1-20.         [ Links ]

9. Beauchamp TL, Childress JF. Principles of Biomedical Ethics. New York: Oxford University Press, 1979.         [ Links ]

10. Spielthenner, G. Virtue-based approaches to professional ethics: a plea for more rigorous use of empirical science. J. Moral Philos 2017; 16(1): 15-34.         [ Links ]

11. Annas, J. Applying virtues to ethics (Society of Applied Philosophy Annual Lecture 2014). J. Appl. Philos, 2015; 32(1):1-14.         [ Links ]

12. Peterson C, Seligman M.E.P. Character strengths and virtues: a handbook and classification. New York: American Psychological Association, 2004.         [ Links ]

 

 

Correspondence:
Hilde D. Miniggio
Department of Oral & Maxillofacial Pathology, Oral Microbiology and Oral Biology, Sefako Makgatho Health Sciences University, South Africa
Email: hilde.miniggio@smu.ac.za

 

 

1 The word practical wisdom is translated from the Latin word phronesls and Is otherwise known as discernment.
2 Modern virtue-based approaches are proposed by the following authors: Michael Slotes's agent-based approach, Linda Zagzebski's exemplirist virtue theory. Christine Swanton and Liezl van Zyl advance similar agent-based virtue accounts.