A trifocal perspective on medicine as a moral enterprise: towards an authentic philosophy of medicine.

Journal of Medicine and Philosophy, 40: 8–25, 2015 doi:10.1093/jmp/jhu044 Advance Access publication December 10, 2014

A Trifocal Perspective on Medicine as a Moral Enterprise: Towards an Authentic Philosophy of Medicine

*Address correspondence to: Gerald M. Ssebunnya, MB ChB, PhD, Padre Pio Medical Centre, Plot 16739 Depenqa Road, Gaborone-West, PO Box 601977 Gaborone, Botswana. E-mail: [email protected]

The fundamental claim that the practice of medicine is essentially a moral enterprise remains highly contentious, not least among the dominant traditional moral theories. The medical profession itself is today characterized by multicultural pluralism and moral relativism that have left the Hippocratic moral tradition largely in disarray. In this paper, I attempt to clarify the ambiguity about practicing medicine as a moral enterprise and echo Pellegrino’s call for a phenomenologically and teleologically derived philosophy of medicine. I proffer a realistic trifocal matrix in which the virtuous moral agency and the teleologically derived moral imperative of the physician are comprehensively integrated with an action-guiding practical analytical framework for the resolution of ethical dilemmas in medicine. I argue that this trifocal perspective points us towards an authentic philosophy of medicine that is not only verifiable through Lonerganian self-appropriation, but also authentically objective through the possible moral self-transcendence of the good physician. Keywords: moral agency, moral imperative, moral self-transcendence, practical analytical framework I. Introduction The fiducious interpersonal relationship between the physician and the patient is indisputably the basis of the fundamental claim that the practice of medicine in the Hippocratic tradition is essentially a moral enterprise. To paraphrase Pellegrino (2008d, 81): the physician as a medical professional © The Author 2014. Published by Oxford University Press, on behalf of the Journal of Medicine and Philosophy Inc. All rights reserved. For permissions, please e-mail: [email protected]

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Gerald M. Ssebunnya* Padre Pio Medical Centre, Gaborone, Botswana

Authentic Philosophy of Medicine

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II. The Urgent Need for Clarity about the Claim of Medicine as a Moral Enterprise The claim of medicine as a moral enterprise remains the subject of contentious debates among the dominant traditional moral theories such as virtuebased ethics, Kantianism, utilitarianism, rights theory, and communitarianism (Pellegrino, 2008b, 50; Beauchamp and Childress, 2009, 333). There is no doubt that each of these traditional theories gives us invaluable insights into the ethical practice of medicine. The problem that arises, however,


characteristically deals with fellow humans in a vulnerable state; confronts the most personal, intimate recesses of the lives of other humans; is permitted access to the inner life of another human being; promises to help and invites trust; and is judged by the degree to which the good of the patient is attained by his/her professional activities. However, it is evident that, more than in Hippocrates’ days,1 the medical profession today is characterized by extensive multicultural pluralism and moral relativism that has left the Hippocratic moral tradition largely in disarray (Engelhardt and Jotterand, 2008, 12). In my paper, I highlight the urgent need to clarify today’s conceptual ambiguity surrounding the fundamental claim that the practice of medicine is essentially a moral enterprise. In the concreteness of the clinical encounter, the good physician is the express moral agent whose moral imperative is the unitary good of the patient. Therefore, I proffer a trifocal perspective of (a) the moral agency and (b) the moral imperative of the good physician, together with (c) an integrated action-guiding practical analytical framework as the necessary and arguably sufficient matrix for the ethical practice of medicine today. I also explore the rich heritage of virtue-based ethics in medicine and echo Pellegrino’s call for a phenomenologically and teleologically derived philosophy of medicine.2 I argue that an authentic philosophy of medicine needs to be anchored in the authentic subjectivity and possible moral self-transcendence of the good physician. In this regard, I highlight Lonergan’s insight into our normative invariant dynamic structure of cognitive consciousness and deliberative value judgment,3 which underpins the authentic objectivity of the good physician as a moral agent. The key here is that, because of our universal, invariant, and normative dynamic interior operations for cognition and value judgment, our moral agency and moral imperative are verifiable through methodical self-appropriation. Hence, the trifocal perspective on medicine as a moral enterprise becomes a realistic objective proposition, which points us towards an authentic philosophy of medicine. Before we explore the basic tenets of this trifocal proposition, let me first underline the urgent need today to clarify the fundamental claim of medicine as a moral enterprise.

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is that each moral tradition tends to claim moral universality (Beauchamp and Childress, 2009, 5–6), with a corresponding reductionist exegesis on morality in medicine. Yet, realistically, each of these dominant moral theories can only give us a limited view on morality in medicine, which view is necessarily limited to the scope of that particular theory (MacIntyre, 2007, 10; Pellegrino, 2008e, 25). Moreover, as MacIntyre (2007, 6–22) ably argues, there is the inherent problem of internal historical incommensurability within each traditional moral theory (such as the historical erosion of virtue-based ethics), besides the conceptual incommensurability among the various moral theories. The point to note is that the demands of practicing medicine as a moral enterprise today clearly transcend the essentially compromised scope of a single traditional moral theory. For instance, although virtue-based ethics may illuminate the character of the good physician, it would fall short as a practical action-guiding framework for the resolution of ethical conflict in today’s morally pluralistic clinical encounter (Pellegrino, 2002, 381). Similarly, although Kantianism may pledge a rational categorical moral imperative for medical practice, it would be of little help in evaluating the physician as a motivated compassionate moral agent (Gardiner, 2003, 298). Moreover, the Kantian ideal of treating patients always as ends in themselves may be unattainable, given the inevitable learning curves in medical education and practice (Le Morvan and Stock, 2005, 513). Particularizing theories like moral psychology and hermeneutics, on the other hand, focus on analyzing and interpreting the particularities of the moral situation that make it unique, such as socio-cultural and personal circumstances (Pellegrino, 2008c, 275–6). However, since they basically focus on concrete situations where they are essentially analytical, explanatory, and heuristic, particularizing theories necessarily lack normative force (Pellegrino, 2008c, 276). Meanwhile, consequentialist theories such as utilitarianism focus on the outcome of moral action and are linked to the nature and circumstances of the act, and generally do not take into account the moral agent’s intentions (Pellegrino, 2008c, 276). As Pellegrino (2008b, 50) rightly surmises, the key area of contention among the dominant moral theories today is about a consensual comprehensive account of the human good in which a realistic medical ethics may be grounded. Indeed, the crisis in medical ethics today is that there is lack of consensus on an intrinsic medical morality that can firmly cultivate and ground the requisite professional virtues and values (Kinghorn et al., 2007, 44). Consequently, there is a critical problem of lack of conceptual clarity about the fundamental claim of medicine as a moral enterprise. Hence, in order to sustain this fundamental and indisputable claim, it becomes imperative that we take a fresh outlook towards an authentic philosophy of medicine that focuses beyond the polarizing mono-focal viewpoints of the dominant traditional moral theories.


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III. The Basic Tenets of the Trifocal Perspective on Medicine as a Moral Enterprise Let me hasten to state that the trifocal perspective (of moral agency, the moral imperative, and the practical analytical framework) is not being presented as a fully worked-out ethical theory, but simply as a comprehensively integrated essential matrix that is pivotal to the practice of medicine as a moral enterprise. Nonetheless, it reflects various degrees of the eight criteria for theory construction (coherence, comprehensiveness, practicability, clarity, simplicity, explanatory power, justificatory power, and output power) as outlined by Beauchamp and Childress (2009, 334–36) and is thus a realistic foundation that invites further research towards the construction of a viable medical ethics and an authentic theory of medicine. I am also alert to the cynicism and hostility towards “comprehensive accounts”—especially if deemed to be of a nonsecular character (Neuhaus, 2008, 223)—in today’s bioethics discourse that is dominated by abstracted principlism.4 Nonetheless, as Pellegrino (2008e, 30) rightly points out, there is a critical need today to define the philosophy of medicine not as a school of philosophical thought but rather as a realistic philosophy derived from the end of medicine in the concrete reality of the clinical encounter. In fact, the key “is not how to demonstrate the superiority of one normative theory over the other, but rather how to relate each to the other in a matrix that does justice to each and assigns to each its proper normative force” (Pellegrino, 2008c, 276). Hence, there is a need for a conceptually comprehensive philosophy of medicine that is informed by such foundational theories as virtuebased ethics (Engelhardt and Jotterand, 2008, 3).


O’Rourke (2000, 11–12) summarizes the polarizing mono-focal viewpoints in health care ethics today as: emotivism; legalism; cultural relativism; and fideism or religious faith. He then rightly exalts “reasoned analysis”—its difficulty and intricacy notwithstanding—as a plausible approach to a viable health care ethics (O’Rourke, 2000, 12–13). Reasoned analysis is particularly concerned with clarifying the normative concepts and discerning the various values at play in a given concrete situation (O’Rourke, 2000, 12–13). It is on this view of acknowledging moral pluralism through reasoned analysis that the internal morality of medicine must necessarily—as a matter of rational exigency—be derived from the reality and concreteness of the clinical encounter. In other words, the claim of medicine as a moral enterprise needs to be realistically located in the context whereby “both [the physician and the patient] are pursuing an end in which they are joined by the realities of being ill, being healed, and professing to heal. The moral pursuit of these relationships is what determines what is right and good” (Pellegrino, 2008b, 53). It is within the reality and concreteness of the physician–patient relationship, therefore, that I identify the three necessary and probably sufficient conditions for the ethical practice of medicine.

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Indeed, as I discuss below, my conceptualization of the moral agency and the moral imperative of the good physician is particularly informed by both Kant’s and Aquinas’s foundational moral accounts, which dominate the two main strands of ethical thought—the ethics of obligation and the ethics of the good (or virtue-based ethics), respectively (Devettere, 2000, 9). So, let us take a conceptually comprehensive look, respectively, at: the moral agency of the physician (and of the patient); the moral imperative that compels the physician to act in a morally responsible manner; and the practical analytical framework that concretizes the physician’s moral responsibility during the clinical encounter.

The physician–patient relationship denotes a deliberate interpersonal interaction between a patient who seeks medical care and healing, and a physician who professes to care and heal with competency and discernment. By moral agency in medicine, therefore, I refer to the properly interpersonal human act of the physician in his/her endeavor to competently care for and heal the patient, as well as the properly interpersonal human act on the part of the patient who seeks and accepts, or rejects, the physician’s assistance. Evidently, because of the fiducious nature of the relationship, the preponderance of the moral responsibility is on the part of the physician. Nevertheless, the moral agency of the patient is equally at play and has become increasingly recognized in contemporary bioethics through the ethical principle of respect for the autonomy of the patient. The key point to note is that the practice of medicine involves properly human acts in a concrete interpersonal encounter occasioned by the universal reality of illness. According to Aquinas (1948, Summa Theologica [hereafter, ST] 1-2.1.1), properly human acts are what constitutes moral agency and are always intended towards an end. In other words, human acts are specified by their end (Aquinas, ST 1-2.1.3), which is the happiness and fulfillment of the moral agent. As morality is concerned with the pursuit of the good and the avoidance of evil (Aquinas, ST 1-2.94.2), moral agency is intended towards the true human good as its end. Thus, the notion of moral agency is necessarily rooted in a theory of the human good and of goodness in general (Porter, 1990, 69). And because properly human acts are essentially voluntary, the will becomes central to moral agency. Accordingly, in order to consistently act well, the will—and hence the moral agent—requires a habitual right disposition, which is the due ordering of the will to the human good (Aquinas, ST 1-2.5.7). This habitual right disposition is what constitutes virtue (Aquinas, ST 1-2.55.4), which denotes the right way in which the moral agent voluntarily acts towards the attainment of the human good. Meanwhile—in arguably the most influential theory of moral agency in history (Beauchamp and Childress, 2009, 74)—Kant grounds the whole of


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moral agency in the autonomy of the will. He extols a good will as being of absolute value and probably constituting “the indispensable condition of our very worthiness to be happy” (Kant, 1964, 61–62). In fact, he places the attainment of the good will as the ultimate end of practical reason. Through his formulation of the categorical imperative, Kant proposes a selflegislating moral agency whereby the moral agent must act only from pure reason on a maxim, which at the same time can become a universal law. This self-imposed moral law is universal, mandatory for all moral agents, and becomes Kant’s basis for autonomous moral agency (Coons and Brennan, 1999, 118). Most remarkably, however, Kant dismisses all traces of self-interest, emotions, or natural inclinations from being motivations that enable practical reason to dutifully attain its ultimate end. He thus leaves us with only the duty to act from disinterested volition as the marker of moral agency (Kant, 1964, 68). Kant’s stance is certainly contrary to the fact that “emotions are part of our creaturely nature and therefore good in themselves, [and] the key moral challenge they present lies in their proper ordering rather than their repression” (Pope, 2002, 33). Kant’s conception of moral agency becomes particularly problematic in medical practice, whose end is the holistic good of the patient—emotions inclusive. Nonetheless, his conception of autonomous moral agency remains highly influential in bioethics today, particularly in the formulation of the prominent principle of respect for personal autonomy. Remarkably, it is Aquinas’s holistic conception of virtuous moral agency— rather than Kant’s unemotional categorical imperative—that has traditionally shaped the practice of Western medicine. It is notable that Aquinas’s system of thought, which is rooted in a comprehensive theory of the human good and of goodness in general (Porter, 1990, 31–32), affords us arguably the most formidable integrated account of reality (Clarke, 2001, 3–4). Moreover, he gives us a comprehensive treatise—which is characterized by “rational precision” (Pinckaers, 2002, 25)—on specific normative concepts like human dignity, human happiness, human personhood, and human nature. Above all, as Porter surmises, “Aquinas’ permanent significance lies precisely in the fact that his thought contains the seeds of its own transcendence” (1990, 172). Hence, his regenerative holistic conceptualization of moral agency remains particularly insightful in contemporary bioethics discourse. As Jotterand points out, the practice of medicine is essentially a holistic human activity with a moral end, which is the good of the patient (2003). Hence, the virtuous character of the physician as a moral agent becomes pivotal, as the good physician “has to use moral and interpretative discernment during the consultation in order to finalize a diagnosis for the best interest of the patient” (Jotterand, 2003). In other words, “the medical relationship depends on the doctor’s ability to implement scientific knowledge according to moral values inherent in his or herself” (Jotterand, 2003). In fact, according to Senn (2004), two particular attributes characterize the good physician, namely, competency in technical medical skills, and

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skillfulness in moral discernment and interpersonal relationships. In essence, therefore, what the virtues of the good physician denote are the character qualities required of the physician as a moral agent to achieve the good of the patient as a human person (Pellegrino, 2008c, 273). Thus, the good physician is a motivated virtuous moral agent with the right “disposition of character to act in the best interests of the ill; . . . to appreciate the sufferings, needs and interests of the sick person” (Senn, 2004, 3). So, let us examine what actually motivates the good physician.

Connatural with moral agency, as I have indicated above, is the intentional pursuit of the good as the end of properly human acts. As Aquinas (ST 1.5.1; 1-2.94.2) explains, every human being participates in a particular way in a moral imperative that lies behind all human acts: the good. By moral imperative in medicine, therefore, I refer to the particular set of internalized moral values that compel a physician to practice medicine as an intentional properly human act in pursuit of the good. A moral value is the transcendental notion of the good that is intended and affirmed through a process of deliberation (Lonergan, 1972, 34). Notably, the moral imperative is concerned not with something abstract but rather with the concrete good (Lonergan, 1972, 36). It is also vital to note that the internalized moral values that underpin the moral imperative may be inherent or acquired, and are functionally synergistic. By inherent moral values I refer to those values of right and wrong that arise by virtue of our human nature and are therefore universal. According to Coopersmith (2013), the moral imperative or concepts of right and wrong are universal values inherent in all human beings as rational creatures and, therefore, transcend personal or societal construct. So, in the case of natural law theory, inherent moral values are dictated by practical reason and are self-evidently derived from the normative natural inclinations possessed by all (Aquinas, ST 1-2.94.2). Our natural inclinations are essentially good for our human existence and include: self-preservation as beings of a human nature (by preserving human life); attending to our biological and social needs as members of the animal kingdom; and, because we are rational beings, the pursuit of truth and the good (Aquinas, ST 1-2.94.2). It is vital to note that our practical reason apprehends good as its end since “good is that which all things seek after” (Aquinas, ST 1-2.94.2). In fact, according to Aquinas (ST 1-2.94.2), the underpinning precept for our natural inclinations, and the source of our inherent moral imperative, is to do and pursue good and avoid evil. Thus, in line with our natural inclinations, all properly human actions are naturally directed towards what is deemed to be good.


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As O’Rourke (2000, 17) explains, our natural inclinations are normative and give rise to the four categories of universal human needs and corresponding human functions, namely, the biological or physiological; the psychological; the social; and the spiritual or creative. Although each function is largely distinct and may predominate at a given time, all four of them are interrelated and are actively present in each human act (O’Rourke, 2000, 17). Satisfying our universal human needs in the right way, therefore, is the basis for our inherent moral values. In Kantian thought, on the other hand, although natural inclinations are categorically disowned, inherent moral values are still derived from the universal a priori principle of rationality. Thus pure reason, uninfluenced by natural inclinations, becomes the practical power to produce a good will— thereby making pure reason the supreme law that gives the person practical freedom and from which other laws may be derived. Kant (1964, 69–70, 88) determines that what pure reason requires as a categorical imperative is to act on a principle, a maxim, which at the same time can become a universal law. In Kant’s worldview, therefore, practical freedom or the moral life is not in doing what the human person’s natural inclination dictates, but in doing what pure reason wills. Hence, for Kant, the moral imperative becomes simply an unemotional duty, which “is the necessity to act out of reverence for the law” (1964, 68). As for acquired moral values, I refer to those values of right and wrong that are internalized through education and the very experience of human living. In this regard, the education may be formal, as that structured in schools and religious institutions, or informal, as that acquired from social interactions within the family and society at large. Thus, the idea of acquired moral values highlights the reality that, firstly, in the pursuit of the moral life, appropriate moral education is vital. Secondly, socialization becomes a critical determinant in the development of moral values. This reality proves particularly vital when considering the notion of the “hidden curriculum” in medical education.5 The point to note is that, because of our inherent and acquired moral values, the moral imperative becomes a function not only of our inherent common humanity, but also of our right moral formation and development. As Grundstein-Amado (1995, 175) points out, the diverse values—inherent and acquired—need to be integrated into a comprehensive and integrated functional value system aimed at the pursuit of the good. Hence, the functionality of the moral imperative is necessarily rooted in the concept of the human good and goodness in general. In his remarkable comprehensive theory of the human good and goodness in general, Aquinas locates the notion of goodness in “being” itself as one of its transcendental properties (Porter, 1990, 36–37).6 However, as Rhonheimer (2011, xi–xii) cautions, it is critical that we avoid a moral realism that reduces the moral good simply to the metaphysical or ontological good.

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It is only God in whom the ontological good equates with the moral good (2011, xii). Thus properly understood, the fact: [t]hat being and good are convertible, that every form of the good is also a form of being (and vice versa), does not in any way necessitate the reduction of the moral being and the moral good of … [the human person] to ontological structures and natural teleologies, nor does it call for an attempt simply to derive good from being, without any further mediation on the part of reason. (Rhonheimer, 2011, xii)

VI. The Action-guiding Practical Analytical Framework Simply put, the practical analytical framework refers to a set of ethical principles that forms an objective standard aimed at analyzing ethical action and resolving situational ethical dilemmas. An integrated practical analytical framework, therefore, is what concretizes the teleologically derived internal morality of medicine, as it translates the moral agency and the moral imperative of the physician into specific concrete action (Tangwa, 2004, 63). Indeed,


Accordingly, the moral imperative in medicine is concerned with the physician’s intentional pursuit of the good through reasoned analysis of the operative value systems actualized in the concreteness of the physician–patient relationship (O’Rourke, 2000, 11–12). Now, the underlying moral imperative for the physician’s due reasoned analysis and, indeed, “[t]he first principle of medical ethics, the end to which it is directed, is the good of the patient” (Pellegrino, 2008d, 69). Pellegrino (2008d, 75) elaborates that the good of the patient is essentially unitary, being a hierarchical summation of four levels, in ascending order: the medical good, the patient’s perception of the good, the human good, and the spiritual good. This hierarchy of the unitary good of the patient is morally construed in that a truly authentic moral imperative of the good physician requires conceptual consistency of the medical good with the patient’s perceived good, the good for humans as humans, and the spiritual or ultimate good (2008d, 74). Fundamentally, therefore, the moral imperative in medicine is inextricably aimed at the reaffirmation of the dignity of—and the prevention of indignity to—the patient as a human person. As Sulmasy (2008, 478) surmises, medicine as a profession owes its existence to “our moral response to those of our kind who are suffering from disease and injury … [and] it is because of the intrinsic value of the sick that health care professionals [ought to] serve them”. Now, given today’s multicultural and morally pluralistic society, upholding the dignity of the patient as a human person demands objective action-guidance. Moreover, the practice of medicine today is characterized by biomedical uncertainties and multifaceted ethical dilemmas. It becomes imperative, therefore, to establish an objective practical analytical framework for the situational interpretation and concretization of moral principles in the reality of the clinical encounter (Pellegrino, 2008a, 243).


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VII. The Rich Heritage of Virtue-based Ethics in Medicine Virtue-based ethics, which is rooted in a comprehensive theory of the good, is arguably the foundational and most resilient ethical system of practically all major Western and Oriental civilizations (Pellegrino, 2002, 380). It is not surprising, therefore, that a virtue-based ethic became the cornerstone of


such an action-guiding framework becomes an objective antidote to moral relativism and emotivism in translating ethical theory into practical application (Jonsen, 1998, 211). A prototype of a practical analytical framework, and evidently the dominant one in contemporary bioethics, is principlism, which is premised on the prima facie ethical principles of beneficence, nonmaleficence, justice, and autonomy. It is critical to note that the practical analytical framework must not be conceived of as a mechanical substitute for the authentic moral agency of the physician. In their comprehensive account, the Principles of Biomedical Ethics, Beauchamp and Childress (2009, 45–46) highlight the desirable integration of virtuous moral agency with action-guiding principlism. As I have already indicated above, moral agency and an integrated moral imperative are ineradicable in the properly ethical action of practicing medicine. Hence, an abstracted practical analytical framework per se would consequently eclipse the notion of the good physician as a virtuous moral agent and thus impoverish the practice of medicine as a moral enterprise. Without authentic moral agency, as Beauchamp and Childress (2009, 31) rightly point out, one may simply “be disposed to do what is right, intend to do it, and do it, while simultaneously yearning to avoid doing it.” Moreover, the practical analytical framework is distinct from medical oaths or codes of medical ethics. Useful as they may be, codes are neither modes of concretizing methodological ethical analysis, nor are they necessarily rooted in any robust ethical theory (Pellegrino, 2010, 93). As Pellegrino (2010, 93) points out, “the Hippocratic code and its historical congeners are [merely] assertions of moral precepts presented as self-evident and selfjustifying prima facie obligations.” A medical oath or code per se, therefore, does not constitute a practical analytical framework. To reiterate, the argument for a trifocal perspective on medicine as a moral enterprise is a realistic and comprehensive proposition: it focuses on an objective concrete situational response to the universal reality of illness that hinges on the virtuous moral agency of the good physician, who is morally motivated to heal and to uphold the dignity of the patient as a human person. Hence, even in today’s morally pluralistic society, virtuous moral agency that is integrated with the good of the patient as its moral imperative remains indispensable to the concrete practice of medicine as a moral enterprise. In this regard, the rich heritage of virtue-based ethics in medicine remains vital.

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the medical profession not only in the Hippocratic tradition, but also in the Confucian, Hindu, and other schools of thought (Pellegrino, 2002, 380). The notion of personal virtue is specifically encapsulated in the brief passage of the Hippocratic Oath: “And in a pure and holy way I will guard my life and my techne” (Miles, 2004, xiv). As Miles (2004, 97) explains, this vow is an acknowledgement of the physician’s commitment to a moral self-reflective personal and professional life. Notably, the dominant conception of virtue in the ethics of the health professions is the Classical-Medieval synthesis, which has been comprehensively developed in Thomas Aquinas’s extensive account (Pellegrino, 2002, 257). It is a synthesis of the Classical Aristotelian and the Medieval Judeo-Christian worldviews and remains the premise for the intensive debate on virtues in bioethics discourse today (Pellegrino, 2002, 380; Pellegrino, 2008c, 256–57). The connatural consonance of medicine with virtue-based ethics is unmistakable. Fundamentally, medicine is both scientific as well as an art. Being scientific, medicine entails the speculative intellectual virtues7 of intuitive insight, science, and wisdom in the pursuit and apprehension of medical scientific truth. As an art, it entails the practical intellectual virtue of art, which is concerned with the correct judgment about things to be made. It then requires the overarching virtue of prudence (which is both a practical intellectual virtue and a cardinal moral virtue8) that fuses the truth-seeking intellectual virtues with the cardinal moral virtues of justice, courage, and temperance that are teleologically aimed at the good (Pellegrino, 2008c, 259). In other words, authentic moral agency necessitates prudence as the overarching virtue to rectify the will towards the moral good or virtuous moral choice (Reichberg, 2002, 139). Besides the intellectual and cardinal moral virtues, the practice of medicine requires the physician as a moral agent to possess certain specific moral virtues so as to overcome self-interest for the sake of the unitary good of the patient. These specific virtues include caring, trustworthiness, compassion, and empathy, among others. Above all, it is the integrating theological virtue of charity, or love of friendship, that orders and activates all the other virtues in medicine towards authentic beneficence, nonmaleficence, justice, and respect for personal autonomy, which are the fundamental ethical principles in the practice of medicine. Evidently, however, there has been a sustained conceptual erosion of virtue that was prompted by the post-Medieval and post-Enlightenment scepticism (Pellegrino, 2008c, 261). Indeed, as Pellegrino (2008c, 255) rightly observes, there is an apparent affirmation of Alasdair MacIntyre’s view in After Virtue “that virtue-based ethics has lost its normative force because the moral philosophy on which it was based for so long is no longer intact in either general or professional ethics”. Nonetheless, the conceptual erosion of virtue notwithstanding, virtue-based ethics in medicine remains a vital matrix in which virtuous moral agency, a teleologically


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VIII. Towards an authentic philosophy of medicine Pellegrino (2008e, 36) ably argues for a philosophy of medicine that is teleologically and phenomenologically derived. He accordingly expounds a philosophy of medicine that is not simply a sum total of the philosophies of the various branches of knowledge upon which it draws, but rather one that is rooted “in the unifying perspective and integrative aspects of the conceptions of helping and healing that are specific to medicine and not to any of the contributing sciences” (2008e, 40). He thus surmises: Philosophy of medicine makes the specific method and matter of medicine the subject of study by the method of philosophy. Philosophy of medicine seeks philosophical knowledge of medicine itself. It seeks to understand what medicine is and what sets it apart from other disciplines, and from philosophy itself. … The philosophy of any discipline is a search for ultimacy, for a grasp of the reality of the things studied beyond what is discernible by the discipline studied. (Pellegrino, 2008e, 36)

Pellegrino’s treatise on the philosophy of medicine is particularly insightful because it points us towards an authentic search for the ultimate in medicine. However, I argue that his account does not seem to articulate how this search for the ultimate in medicine becomes objectively imperative. In other words, although his argument for a phenomenologically and teleologically derived philosophy of medicine is certainly plausible, it does not adequately and objectively answer the questions as to why and how the physician is normatively compelled towards the good of the patient. Besides, there is the echoing question that if we are to sustain the claim that medicine is essentially a moral enterprise, whose morality should it actually enterprise in our morally pluralistic society? There is a need, therefore, to locate and articulate the objectivity of the moral imperative of the good physician who is the express moral agent in the philosophy of medicine. I submit that the notion of the trifocal perspective I have outlined above affords us the key to this crucial authentic objectivity.


derived moral imperative, and a practical analytical framework underpin the practice of medicine as an altruistic moral enterprise (Pellegrino, 2008a, 251). In this regard, Pellegrino (2008c, 269) argues for the restoration of normative virtue-based ethics in the health profession, albeit re-formulated towards an integrated comprehensive philosophy of medicine. Such a philosophy of medicine must be rooted, not in ideologies and absolutism, but rather in critical reflections on the particularities of the lived experiences of the physician–patient relationship that is characterized by moral choices and dilemmas, caring, compassion, suffering, healing, dying, and finitude (Pellegrino, 2008e, 26). In short, there is a need for an authentic philosophy of medicine.

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IX. Authentic Objectivity in the Trifocal Perspective


The key to authentic objectivity in the practice of medicine as a moral enterprise is in the nature of the fundamental physician–patient relationship itself, which is characteristically a value-laden relationship (Cooper and Tauber, 2005, 322). As we have already noted, by “value” we mean the transcendental notion of the good that is intended and affirmed through a process of deliberation (Lonergan, 1972, 34). Medicine essentially deals with disease and illness, “which are defined and treated as part of a complex web of human values” (Tauber, 2008, 456). Thus, clinical decision making involves a series of interpretative analyses of a diverse assortment of professional, societal, and personal values (Tauber, 2008, 457). It is within this value system that both physicians and patients are necessarily faced with a complexity of moral choices (Tauber, 2008, 454). Consequently, the attending physician, as a moral agent, is required to make a diverse range of objective value judgments in each encounter with a patient (Tauber, 2008, 450). Now, to get an insight into the authenticity and objectivity of the physician’s value judgments, we need to refer to Lonergan’s normative structure of our interior cognitive and value judgment operations, and his concept of self-appropriation. Self-appropriation is essentially the methodical “appropriation of one’s own intellectual and rational self-consciousness” (Lonergan, 2008, 22). As Walmsley (2008, 7) explains, self-appropriation is “a way of grasping what really goes on as we come to know … [and] involves sustained self-attention … [and] heightened self-awareness”. In addition, it requires a “sufficiently cultured consciousness [that] is aware of the complexity of human knowing and is willing to tackle this problem” (Walmsley, 2008, 9). It is critical to note, therefore, that self-appropriation is characteristically distinct from self-reflection or introspection (Walmsley, 2008, 13) and is only achievable with considerable sustained methodical effort (Walmsley, 2008, 10, 16). The reward for this sustained personal effort is a clear insight into the normative structure and interior operations of our cognitive and moral agency and “the discovery of the human person as a self-transcending being” (Walmsley, 2008, 14–15). A detailed exposition of Lonergan’s monumental cognitive theory is certainly beyond the scope of this paper. Nonetheless, the key point to note is that each value judgment one makes signifies an end of an interior normative process of cognitional and deliberative operations that involve four levels: experiencing, understanding, judging, and deliberation, value judgment and decision that is followed by responsible action (Sullivan, 2005, 146). Notably, there are four corresponding a priori “transcendental precepts” that motivate our inherent cognitional and volitional normative dynamism, and these are: to be attentive, to be intelligent, to be reasonable, and to be responsible (Lonergan, 1972, 11–14, 231).


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Each level of consciousness is accordingly prompted by the transcendental precept at that level to sublate9 the insights accumulated from the previous level in a cumulative and expansive mode that generates further insights, culminating in a judgment of value. Thus, the questions for value arise from the transcendental precept to be responsible: “Is it good? Is it worthwhile? Is it right?” (Cronin, 2004, 28). Moreover, as a value judgment sublates a judgment of truth, our moral imperative to apprehend value is not only responsible but rational as well (Sullivan, 2005, 155). In fact, our moral imperative to apprehend value essentially arises from the transcendental intention of value that characterizes our invariant and normative cognitional structure. In this regard, the physician’s transcendental intending of value is specified in the categorial good of the patient, which forms the specific moral imperative in the practice of medicine. What is critical to note here, as Sullivan (2005, 155) points out, is that the four invariant transcendental precepts are the basis for intellectual and moral authenticity. Therefore, the moral agent becomes subjectively authentic when he/she is attentive, intelligent, reasonable, and responsible. This essentially means that genuine objective knowing and valuing proceeds from the authentic subjectivity of the moral agent (2005, 127). In other words, as Lonergan puts it, “objectivity is simply the consequence of authentic subjectivity, of genuine attention, genuine reasonableness, genuine responsibility” (1972, 265). It is also vital to note that this invariant interior normative cognitive and value judgment process is verifiable—with due diligence—by each one of us through the above-mentioned methodical process of self-appropriation. Furthermore, authentic moral agency in the judgment of value is exercised in freedom, which actually means the freedom to terminate a deliberation by deciding responsibly on a particular value judgment and executing it (Sullivan, 2005, 195). Indeed, as Sullivan (2005, 195) rightly points out, “[t]he key issue with regard to freedom is to use it responsibly by regularly opting not merely for the apparent good, but the true good”. What this means, therefore, is that the moral agent attains moral self-transcendence when he/she authentically, freely, and responsibly exercises his/her moral agency to originate and execute personal and societal value judgments (Sullivan, 2005, 195). According to Lonergan (1972, 35), moral self-transcendence is rooted in our immanent unrestricted desire to apprehend the true good.10 Therefore, the good physician can actually achieve the state of moral self-transcendence by authentically exercising his/her personal and professional freedom in the self-reflective discernment of values in the concreteness of the clinical encounter. Consequently, it is the subjective invariant internal normative process of value judgments that essentially becomes the key to objective moral agency—and hence to sustaining the possibility of an authentic philosophy of medicine. And because this interior normative process of moral agency is verifiable through self-appropriation, the trifocal perspective on medicine as a moral enterprise becomes a verifiable realistic proposition. As Cronin (2006, 1) rightly observes, in seeking ethical certainty and objectivity,

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ethical absolutes are to be found, not in formulated laws, not in lists of virtues and vices, not in systems of moral philosophy, not in authority figures dictating to us, but in the ethical norms immanent and operative in each one of us and unfolding in an invariant pattern of cognitional and volitional activities by which we know moral values, we decide for and implement these values.

X. Conclusion I have attempted to clarify the fundamental claim that the practice of medicine is essentially a moral enterprise and echoed Pellegrino’s call for a phenomenologically and teleologically derived philosophy of medicine. I have proffered a trifocal perspective in which the virtuous moral agency and the teleologically derived moral imperative of the physician are comprehensively integrated with an action-guiding practical analytical framework for the resolution of ethical dilemmas in the practice of medicine. I have argued that this trifocal approach is realistic because it is derived from the realities of the clinical encounter. It is also constructive and comprehensive because it consists in synergistically harnessing invaluable insights from relevant normative concepts. I have indicated that, above all, it points us towards an authentic philosophy of medicine that is not only verifiable through Lonerganian self-appropriation, but also authentically objective through the possible moral self-transcendence of the good physician. As I pointed out, however, the trifocal perspective on medicine as a moral enterprise is certainly a work in progress that invites further research. It must still overcome, among others, the pivotal hurdles of achieving functional consensus on what constitutes the unitary good of the patient, and of effectively demonstrating its objectivity, given the demanding method of self-appropriation that underpins its conceptualization.


Hence, the authentic subjectivity and moral self-transcendence of the physician as a moral agent become pivotal to the objectivity of the trifocal perspective on medicine as a moral enterprise, and thus to an authentic philosophy of medicine. By being genuinely attentive, intelligent, reasonable, and responsible, the good physician exercises authentic subjectivity and thereby achieves moral self-transcendence. Indeed, the good physician is an authentic moral agent with freedom to originate moral value judgments and execute them responsibly in the concrete reality of the clinical encounter. Accordingly, the authentic subjectivity of the physician becomes the key to the desirable clinical ethical approach of reasoned analysis (O’Rourke, 2000, 11–12). It emerges, therefore, that the conceivable authentic subjectivity and moral self-transcendence of the physician as a moral agent is what underpins the trifocal perspective on medicine as a moral enterprise, rendering it realistic, normative, verifiable, and authentically objective.


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Notes

Acknowledgment This paper is part of the author’s doctoral thesis, The Eclipse of the Good Physician: A Trifocal Perspective on Medicine as a Moral Enterprise, presented to St. Augustine College of South Africa in 2013.

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1. It is vital to note that there was no moral consensus in medicine even during Hippocrates’ days. As a matter of fact, “[r]ather than reflecting prevailing mores of the time, the Hippocratic Oath was a protest document, condemning prevalent activities such as abortion and euthanasia” (Kao and Parsi, 2004, 882). 2. See Engelhardt and Jotterand, 2008. 3. See Lonergan, 1972; Crowe and Doran, 1992; and Lonergan, 2008. 4. The term “principlism” was originally coined by Bernard Gert and H. Danner Clouser in the late 1980’s “to refer to all accounts of ethics comprised of a plurality of potentially conflicting prima facie principles” (Beauchamp and Childress, 2009, 371). 5. The concept of the “hidden curriculum” in medical ethics education was first formally described by Hafferty and Franks in 1994 and refers to “a set of influences that function at the level of organizational structure and culture [through role modelling and socialisation]” (Hafferty and Franks, 1994, 864). 6. A transcendental property of being is “a positive attribute that can be predicated of every being, so that it is convertible with being itself” (Clarke, 2001, 290–91). 7. See Reichberg, 2002, 135–36. 8. Like art, prudence is a practical intellectual virtue, whereby “art is the right reason of things to be made; whereas prudence is the right reason of things to be done” (Aquinas, ST 1-2.57.4). Prudence is at the same time a cardinal moral virtue as it guides moral choice, which is the inner act of the will—hence its overarching role. 9. Sublation is a critical operation in Lonergan’s intentionality analysis whereby “each successive level sublates previous levels by going beyond them, by setting up a higher principle, by introducing new operations, and by preserving the integrity of previous levels, while extending enormously their range and their significance” (Lonergan, 1972, 340). 10. In fact, moral self-transcendence is analogous to cognitional self-transcendence, which is rooted in our immanent unrestricted desire to know (Lonergan, 2008, 659). Cognitional self-transcendence and moral self-transcendence are achieved through the underlying dynamic operations in human consciousness proper to the levels of consciousness for judgment of truth and judgment of value, respectively (Walmsley, 2008, 17).

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