I now want to consider if and how far the traditional medical virtues have turned to vices. I want to begin by considering three social presuppositions of the practice of the traditional medical virtues. The first is technological. The practice of medicine has for most of its history been carried on in societies where human life is immensely fragile and vulnerable and where the technical means to safeguard it have been very limited. High infantile mortality rates, low expectations of life for surviving adults, extremely limited predictive powers in framing prognoses, all underlie the ordering of medical priorities embodied in different versions of the Hippocratic Oath. Medicine would have been a quite different form of social practice if either life was to be preserved only if health could be restored or life was to be preserved only if grave pain and suffering were to be avoided or health was to be restored only if in so doing pain and suffering were not to be increased That ordering of medical priorities which places a supreme value on life is made more intelligible by considering the social background which it originally presupposed.
A second presupposition of the practice of the traditional medical virtues was the existence of a shared and socially established morality. The physician could assume that the patients’ attitudes towards life and death would be roughly the same as his own, and vice versa. Hence the patient in putting him or herself into the hands of his or her physician could feel that he or she was not relinquishing his or her moral autonomy.
A third presupposition of the practice of the traditional medical virtues was that the activities of the physician or surgeon took place within a given social order, but were not themselves able to shape or be responsible for shaping that order. Medicine could not be understood in its traditional perspective as a social practice competing with other social practices for scarce resources and offering debatable criteria for their distribution.
None of these presuppositions is now warranted and it is social change that has destroyed their warranty. Technological change has made of the preservation of human life a very different issue. Moral change has made of the trust which the patient ought to express in the physician a very different issue. Changes in the scale and the cost of medical care as well as political and economic change in society at large have made the distribution of medical care into a very different issue. In each case what was a virtue has become at best problematic, at worst a vice. Consider once more the ways in which virtues become vices.
There is first the case where the effects of a practice change so that the character of the relevant actions change. This is what happened to the medical practice of making the preservation of human life an overriding goal. Consider two kinds of change. It is now the case, as it used not to be, that this goal involves the systematic preservation of the old long after they can function as genuine human beings. It is now the case, as it used not to be, that this goal involves systematically increasing the proportion of hopelessly crippled infants and helplessly decaying old people to healthy adults and children. Any agent who knowingly participates in producing such effects systematically, as many physicians do, does great harm and wrong. What was a virtue has become a vice, but not an unproblematic vice. For the physician now finds himself in a tragic dilemma.
Consider the case of recently born crippled infants where heroic efforts may preserve either a needless bundle of distorted and suffering nerves and tissues or – sometimes against all probable calculation – a human child, physically imperfect but with real potential, perhaps even a Helen Keller. (I consider the case of infants rather than of the old, because the collapse of the extended family has left most of us with a deep inability even to approach the problems of the old, an inability institutionalized in the way we, as a society as well as individuals, treat them.) Any rule which relieves the physician of the burden of extending suffering uselessly imposes on him the burden of taking innocent life wantonly; and no rule would be worst of all.
What has happened to place physicians in this dilemma is the result of the coincidence of two distinct histories of moral change. In the society at large our fragmented inheritance has resulted in abandoning us to a secular, liberal pluralism which leaves us resourceless in the face of moral problems; in the history of medical practice a change in its presuppositions has rendered what was virtuous vicious and what was unproblematic problematic. Thus parts of medical practice became morally problematic precisely at a time when we have minimal resources for the solution of moral problems.
As with the first of the three traditional medical values, so also with the other two. The trust which defines the relationship of patient to physician was based upon the presupposition of a shared, established morality. The physician could have a reasonable assurance that his patients’ beliefs about suffering, death and human dignity were much the same as his own; the patient could have a reasonable assurance that his beliefs would be respected But in a liberal, pluralist moral culture the patient knows, not only that the traditional basis for this assurance is now missing, but that the physician has no special resources for the solution of the moral problems which arise in the course of a relationship to a patient The parent of a helplessly ill child or a helplessly old person cannot know that the physician wills their good, because they cannot know what his conception of good is. Once again the physician is in a tragic dilemma: the invitation to trust which was once a sign of virtue becomes a sign of something else. The change in the structure of roleplaying has changed the quality of the actions. A virtue has in a characteristic way become a vice. But the physician has no easy way out. The whole nature of medical care is almost unimaginable without a context of mutual trust; to simply abandon that mutual trust, because it is no longer warranted, would be destructive. To try to maintain it in its traditional forms is equally dangerous.
It is of course in this situation that market relations become significantly obtrusive in medical practice. Differential treatment is offered for differential reward; access to medical care is radically unequal. Here again the physician is, like everyone else, in a situation which he cannot escape. The demands of social justice and the demands of the physician for autonomy are in radical conflict If members of the medical profession choose certain forms of specialization in research or in practice, they thereby determine the availability of certain patterns of medical care. If the freedom of physicians is safeguarded, the equal rights of citizens will be flouted So the autonomy of the medical profession becomes a social vice, while the freedom of the physician remains an important value. Once again we have a dilemma which is almost intolerable.