Introduction

There has been significant debate about whether the moral norms of medical practice arise from some feature or set of features internal to the discipline of medicine. Several bioethicists have contributed to the discussion in recent years, offering different and often conflicting views on the issue. Certain figures in the debate maintain that medicine is a practice that has both a fixed essence and immutable goals. The essence and goals of medicine give rise to unique professional norms that guide the practice of clinicians. Others suggest that the morality guiding medical practice arises from sources external to the discipline. The latter typically argue that a common morality or prevailing social norms should be used as a guide for the ethical practice of medicine. A large part of the motivation behind the debate is didactic—some theorists want physicians to realize that they are part of a moral community and, furthermore, hope to develop a moral code that is accessible to clinicians and provides a useful guide for action. More broadly, scholars appear to be concerned about practices that some believe are moral but that nevertheless arguably contravene medical ethics (euthanasia and physician-assisted suicide being perhaps the most salient contemporary examples). A moral framework is needed for dealing with these conflicts.

In this essay, I analyze Edmund Pellegrino’s conception of the internal morality of medicine, situating it in the context of Alasdair MacIntyre’s influential account of “practice.” Pellegrino’s work draws heavily upon Aristotelian normative theory as well as MacIntyre’s post-Marxist critique of modern moral philosophy. Building upon MacIntyre, Pellegrino argues that medicine is a social practice with its own unique goals—namely, the medical, human, and spiritual good of the patient—and that the moral norms that govern medical practice are derived from these goals. After providing an overview of Pellegrino’s work, I discuss some forceful objections to his theory—specifically, that it is too rigid and incapable of entering into dialogue with contemporary values systems; that it is dependent on an external conception of human flourishing; and that it is incompatible with the rapidly changing nature of modern medicine. In the final section of this essay, I consider how theorists working in the Hippocratic tradition might respond to these objections against essentialism by drawing upon MacIntyre’s historico-cultural method as well as what he labels “Aristotle’s ‘metaphysical biology’” [2, p. x].

It is my hope that this article will stimulate further research into the core elements of an internalist, essentialist account of the nature of good medical practice. This essay is also intended to continue an ongoing and important dialogue between traditional medico-ethical theory and contemporary liberal and utilitarian approaches to bioethics.

MacIntyre on practices and professional morality

Much of the recent literature on professional morality draws upon Alasdair MacIntyre’s Aristotelian account of practice. MacIntyre’s early work is concerned with the overlap between a society’s sociocultural practices and its conception of morality. MacIntyre argues that our social and professional practices and our understanding of morality have a teleological structure—that is to say, our professional, social, and moral lives are both defined by and ordered toward particular goods or ends. Medicine, for example, is ordered toward the good of healing, and statesmanship to the good of governing a polis or nation. The goods or ends of specific practices inform the way that moral concepts like “excellence” and “virtue” are understood. In the context of medical practice, excellence and virtue refer to the provision of humane and effective treatment for patients. In statesmanship, by contrast, excellence refers to the effective government of a polis through exercise of the virtues of a good leader (good judgment, justice, fortitude, and so forth).

Importantly, the goods or ends of cultural and professional practices are neither exclusively moral nor exclusively technical—this dichotomy between technical and moral excellence is, for MacIntyre, an artifact of modern moral philosophy. Drawing upon Aristotle, MacIntyre suggests that the moral good and the technical good overlap, such that every practice has a eudaimonic dimension to it. That is to say, every practice relates in some way to human flourishing. Medicine contributes to human flourishing insofar as it restores patients to health and allows them to engage in the sort of activities that are constitutive of flourishing. It also fulfills the medical practitioner insofar as she is actualizing her skills as a physician. Education contributes to flourishing insofar as it develops the rational and affective capacities of human beings. Similarly, the fine arts satisfy the human desire for aesthetic experience.

In his 1981 book After Virtue, MacIntyre offers an explanation for why rival conceptions of virtue have developed in the course of Western intellectual history [1]. According to MacIntyre, society’s understanding of the virtues has evolved as a result of profound shifts in the nature and goals of its social practices. From the valorization of warriors and political advisors in Homeric Greece, virtue was transformed by the Judeo-Christian exultation of humility and charity and then again by the development of modern science and the modern nation state. In these different contexts, the virtues track different goals or goods. The conclusion that MacIntyre draws from his historical study is that virtues cannot be understood in isolation from the social contexts in which they are exercised. MacIntyre tentatively accepts the historico-cultural critique of the universalist pretensions of modern moral philosophy [1, pp. 211–236].

Interestingly, MacIntyre’s view evolved over the course of his intellectual career, and he eventually recognized a profound tension between developing a sociohistorical account of practices and eschewing a “metaphysical biology” [2, p. x]. In his 1999 book Dependent Rational Animals, MacIntyre acknowledges the “error in supposing an ethics independent of biology to be possible” [2, p. x]. He suggests that “no account of the goods, rules and virtues that are definitive of our moral life can be adequate that does not explain … how that form of life is possible for beings who are biologically constituted as we are, by providing us with an account of our development towards and into that form of life” [2, p. x]. Instead, MacIntyre develops an account of what he calls “the virtues of acknowledged dependence” [2, pp. 119–128]. Rather than being grounded in a particular social practice, these virtues arise from the embodied nature of human beings. Our vulnerability and mutual dependency require of us that we show unconditional care for those who are injured or experiencing disability.

Pellegrino on the internal morality of medicine

Pellegrino’s account of the morality of clinical medicine leans heavily in the direction of the writings of Aristotle and MacIntyre [3].Footnote 1 Pellegrino begins by identifying excellence in medicine as the pursuit of the good. He quotes Aristotle, who in the Nicomachean Ethics states that “every art and every inquiry, and similarly every action and choice, is thought to aim at some good; and for this reason the good has rightly been declared to be that at which all things aim” (Nic. Eth. 1094a1–3, in [4, p. 1729]). Medicine, according to Pellegrino, is directed toward the good of healing and the health of the patient: “the well being of the patient is the good end of medicine and of the physician’s art and action” [3, p. 566]. When a doctor interacts with a patient in a manner befitting a doctor, she is of necessity acting for the sake of the good of the patient.

Pellegrino references MacIntyre’s definition of practice and—while distancing himself from the anti-essentialism of After Virtue—states that the goods toward which clinical medicine is directed are internal to the practice itself. That is to say, the excellence of healing is something internal to and definitive of the practice of medicine (and, indeed, the other helping and healing professions). The idea of being a healer does not have its origins in some external moral code or system, but rather has developed from the seminal encounter of doctor and patient—something that is a fixed constant in medicine regardless of the historical and cultural context. In another essay, Pellegrino describes the doctor–patient encounter as a meeting of “life-worlds” in which the vulnerable patient, sick or injured, seeks help from the doctor, who professes to be a healer [5]. In this encounter, the doctor commits to act for the good of the patient and seeks, where possible, to restore the patient to health.

The purpose of the internal–external distinction may seem obscure to those unfamiliar with Pellegrino’s work. But the ultimate motivation is to suggest that medicine has a fixed essence that does not change with the contingencies of culture and history. Regardless of whether we live in a pluralist society or one that is economically or morally libertarian, the role of the doctor remains to seek the good of the patient [6].

In the most immediate sense, seeking the good of the patient means restoring the patient to physical or psychological health. Importantly, Pellegrino develops a manifold conception of the good of the patient according to which patient wellbeing is much more than mere physical or psychological equilibrium. This conception also has built into it an account of the human good that is Aristotelean in form:

At this level, we are concerned with the good peculiar to humans, like preservation of dignity of the human person, respect for his rationality as a creature who is an end in himself and not a mere means, whose value is inherent and not determined by wealth, education, position in life, etc. The patient is a fellow human with the physician to whom he is bound by solidarity and mutual respect. [3, p. 570]

Pellegrino even includes an idea of the spiritual good in his conception of patient welfare: “The highest level of good which must be served in the clinical encounter is the good of the patient as a spiritual being, i.e., as one who, in his own way, acknowledges some end to life beyond material well-being” [3, p. 570].

Controversially, Pellegrino suggests that the internal morality of medicine is incompatible with an ethic of autonomy according to which the preferences of the patient override all other ethical considerations. He states, “to give supremacy to the patient’s definition of his own good over the other levels of good is to absolutize the patient’s autonomy and to violate the autonomy of the physician. … The existence of complexities cannot be used to justify a utilitarian, legalistic, or libertarian definition of the ends of medicine or the physician’s or patient’s good” [3, p. 572]. Pellegrino also suggests that certain forms of ostensibly harmful medical practice—self-mutilation, embryo research, or euthanasia—are incompatible with the discipline’s enduring moral code: “What the patient describes as good for himself … may violate the good for humans or the spiritual good” [3, p. 572].

Recent criticisms of Pellegrino’s internalist account

While several criticisms have been levelled against Pellegrino’s internalist theory [7], one can identify three dominant themes in the extant commentaries. First, critics like Miller and Brody [8] argue that an account of medical morality needs to be responsive to changes in sociocultural values. Second, critics like Veatch [9] argue that a substantive conception of human flourishing must be built into any theory of medical morality and that such a notion of flourishing is necessarily external to the ends of medical practice. Third, several other commentators (e.g., [10]) observe that radical technological and economic changes in the provision of medical care in recent years may require revision to a medical ethics centered on an outdated model of doctor–patient interaction. I will briefly review each of these three kinds of objections before considering how a contemporary scholar sympathetic to Pellegrino’s work might attempt to respond to them.

In contrast to Pellegrino’s essentialist conception of clinical medicine, Miller and Brody describe medicine as an “evolving tradition” [8, p. 598]. The practice of medicine has its own set of norms, they suggest, but these norms are in continual dialogue with the evolving values of society. They advocate for “an interpretive and responsive process of accommodating and balancing values and norms proper to medicine with the common morality external to medicine in light of changing conditions of social life,” arguing that “the debate over medical morality calls for continuity and adaptation” [8, p. 598]. They reject Pellegrino’s assessment that controversial practices like physician-assisted death are incompatible with the internal morality of medicine, while at the same time maintaining that “participation in capital punishment … clearly contravenes the IMM” [8, p. 595]. Physician-assisted death is something that can potentially be squared with at least some goals of medicine—such as “the relief of suffering and assisting the terminal patient toward a reasonably comfortable death” [8, p. 595]—whereas capital punishment is totally incompatible with the ends of medical practice.

Veatch flatly rejects Pellegrino’s internalist thesis, arguing that the goals of medicine are plural and evolving; therefore, to make ethical assessments about which goals to pursue, one must look to standards external to medicine [9]. Veatch observes that physicians can perform a variety of distinct roles—such as those performed by pediatricians, psychiatrists, emergency room doctors, and other specialists. These roles may involve regular extended interactions with a small number of patients or isolated brief interactions with a large number of patients; or they may even involve no interactions with any patients at all—as where a doctor has ended up in an administrative or public-health role. Veatch also argues that the goals of medical interventions necessarily supervene on some underlying conception of human flourishing. He argues:

It is impossible to know whether it is appropriate to maintain permanently vegetative life or relieve potentially character-building suffering or promote new disease-resistant genetic make-up of humans without turning outside the naked notion of medicine to a more fundamental set of beliefs and values that tell us what the end of life is. [9, p. 636]

The morality of medicine, then, would appear to be grounded in a set of values external to clinical practice.

Finally, Nuala Kenny has observed that the way in which medical care is provided has changed dramatically since Pellegrino first attempted to rebuild medical ethics and medical morality. In contrast to a previous era in which medical care was largely confined to the interactions between doctors and their patients, modern medicine has evolved into a technologically and economically complex enterprise. Kenny states that “the doctor–patient relationship has changed with different models of interaction across primary care and specialties, and the requirements of informed consent and respect for patient autonomy” [10, pp. 79–80]. She notes that “the organization and delivery of care have changed from the domains of physician and families to complex systems of delivery with care provided by teams” [10, p. 80]. Furthermore, funding has changed from a payment direct to the doctor to “a wide range of public and private insurance schemes that insulate doctors and patients from the direct resource consequences of decisions but involve shared risk and common resources” [10, p. 80]. Kenny questions whether Pellegrino’s ethical framework, grounded in an account of the unique nature of the doctor–patient encounter—the moment of clinical truth, so to speak—has the resources to deal with the complex and diversified nature of twenty-first-century medical practice.

Responding to challenges, old and new

These criticisms represent a significant challenge for any practitioner sympathetic to an essentialist and internalist account of medical ethics. While I believe that some of the aforementioned commentators have misconstrued specific details of Pellegrino’s ethical theory,Footnote 2 I do nevertheless believe that each criticism points to an aspect of Pellegrino’s professional ethics that is in need of scholarly attention. There is certainly work to be done to clarify what precisely Pellegrino means by “internal” in his internalist account of medical morality [3]. It would also be useful for scholars to elaborate on Pellegrino’s Aristotelian-Thomistic appeal to the human good: to what extent is the human good something that transcends medicine as a social practice, relating rather to fundamental features of our shared ethical lives? Furthermore, the diversification and bureaucratization of modern medicine has eroded a collective awareness of the importance of personalized, patient-centered care. If the idea of the doctor–patient relationship as providing the ethical rule for medical practice is not to be abandoned, then must scholars rail against the depersonalization of twenty-first-century medicine? Or rather, should an alternative ethical framework be developed for what is an increasingly bureaucratic approach to health and healing? Rather than attempting to answer these deep and multifaceted questions, I wish to conclude with a modest methodological suggestion, drawing again on MacIntyre’s ethical theory, which may assist scholars in meeting the challenge posed by contemporary, anti-essentialist bioethics. As noted earlier, MacIntyre recognized in his later works the need to reconcile a sociological account of human practices with the underlying embodied, animal nature of human beings. What is needed in a holistic account of ethics is both close attention to the historical and cultural milieu in which ethical theories arise and a detailed account of the mutual vulnerability and dependency of human beings as dependent rational animals. Ethics, on this account, is not solely an artifact of human history, nor does it completely transcend our historico-cultural milieu.

This, I would suggest, is the goal at which contemporary medical ethicists following an internalist account should aim. Ethicists who want to argue that modern medicine is of a piece with traditional medical practice also need to acknowledge that in certain inessential, though nonetheless profound, respects, the nature of medical practice has changed. While the ends of medicine, strictly speaking, have not changed, the provision of medicine today is far more diversified and team-based than it was: countless new specialties have emerged with their own unique philosophy of care; decision-making between doctors and other health professionals is less hierarchical than it once was; and medicine has become increasingly interdisciplinary, drawing upon the resources of areas like psychology, Eastern medicine, and social work. There is also far more plurality in the value-systems of patients than there was when Western societies were more religiously incorporated and socially conservative. Ethicists working in the same tradition as Pellegrino and others must show that they are sensitive to the rapidly changing nature of contemporary medical practice; and furthermore, they must demonstrate that their ethical framework is nuanced enough to accommodate the new technological and cultural milieu in which we now find ourselves.

At the same time, such theorists must clarify and defend the link between their essentialist, internalist framework and a trans-historical conception of human nature and the human good. As policymakers increasingly base ethical guidelines on political exigencies and consensus, ethicists operating within this framework must continue to defend the necessary connection between professional ethics and a substantive conception of human nature. One obvious contender for a rigorous account of the intersection of ethics and anthropology is New Natural Law Theory (see, e.g., [11]). Yet the reception of New Natural Law Theory has been mixed, and those working in this tradition run the risk of balkanizing the discipline of bioethics.

Perhaps in the context of medicine, it may be profitable for medico-ethical theorists to place the work of scholars like Pellegrino into dialogue with the account of human vulnerability and dependency advanced in MacIntyre’s Dependent Rational Animals [2]. MacIntyre argues that there are certain virtues of “acknowledged dependence” that manifest themselves in actions of unconditional care between members of society [2, pp. 119–128]. Parenthood, social solidarity, Christian charity, and so forth are predicated on the vulnerability and sense of neediness that all human beings experience. At different stages in our life, we all find ourselves disabled or vulnerable to a greater or lesser extent, at which point we require that other human beings care for us even though we may not be in a position to directly reciprocate that care. Just as MacIntyre’s account of the vulnerability inherent in our animal nature serves as the ground for an ethics of vulnerability and dependency, so too could it serve as the foundation for medical ethics rooted in Aristotelian biology. Perhaps a theorist sympathetic to an Aristotelian conception of practice might find it productive to adopt this Aristotelian conception of our shared human nature as well. It would, at least, allow one to respond to those who want to relativize medical ethics to one’s sociocultural milieu.

Conclusion

In this paper I have discussed Edmund Pellegrino’s account of the internal morality of medicine, situating it in the context of Aristotelian normative theory as well as the writings of Pellegrino’s contemporary Alasdair MacIntyre. I have discussed some of the main criticisms that have been levelled against Pellegrino’s essentialist framework for medical ethics. I then concluded by suggesting that ethicists of the Pellegrino-ilk must be sensitive to the historico-cultural nuances of contemporary medical practice; they must seek to make traditional medical ethics amenable to individuals in contemporary pluralist societies. While this does not mean abandoning an account of the essential goals of medicine, it does mean humbly acknowledging that patients and doctors alike may have radically different perspectives on medical ethics. Essentialist bioethics, in this sense, must be proposed but not imposed. In addition, I have alluded to the need to preserve a link between Aristotelian ethics and a teleological conception of the human person and the human good. I have suggested that the later work of Alasdair MacIntyre may provide a particularly fruitful avenue for future research in this respect.

Theorists defending an essentialist conception of medical practice have a difficult task—particularly considering the radically fractured nature of contemporary liberal democracies. A robust philosophical method, however, can facilitate productive dialogue between traditional medico-ethical thought and contemporary streams of bioethical thought (such as Anglophone utilitarianism and continental philosophical approaches to bioethics). The writings of Edmund Pellegrino offer a good example of how to engage in such productive and respectful dialogue.