The perspective of Virtue Ethics regarding the process of medical decision-making

Many doctors understand bioethics as the discipline that should substantiate decisions and conduct in dilemmatic cases, indicating rational and universal rules of action. In this scenario, the perspective of Virtue Ethics proposes the modification of the question “what to do” to “how to be” and, how to constitute one’s own character in order to take wise and prudent decisions in life, including professional ones. This theoretical essay will present the Aristotelian Ethics perspective, its contemporary authors, the answers to the main criticisms and will underline the advantages this framework offers to medical decision-making processes its evaluative, particularistic and teleological characteristics. It will lead to a conclusion that more than proclaiming an autonomous patient and a profefssional who seeks externally established rules, Virtue Ethics recognizes that both patient and professional are integrated in communities, traditions and cultures, respecting values and virtues, in the pursuit of a particular purpose for their practices and lives.

The perspective of Virtue Ethics regarding the process of medical decision-making http://dx.doi.org/10.1590/1983-80422016242124 The formal study of bioethics as ethics applied to life, and specifically to medicine, began in the 1970s and was mainly guided by the theory of principlism 1 .Since then, professionals have become used to this lingo and a few of them acknowledged the existence of other theoretical references in this area of study.
According to Childress and Beauchamp's theory of principlism 2 , everyday practical decisions or discussions of dilemmatic cases and professional relations must be based on observation and respect to four prima facie principles (non-absolute): Beneficence, nonmaleficence, autonomy and justice.Although there is no hierarchy between them, and because nonmaleficence (primum non nocere) is intuitive to professionals, having originated with the Hippocratic Oath, the theory focuses especially on the principles of respect for autonomy and beneficence, the latter as a concept to do good to others, both in relations and, especially, in professional conduct.
But what exactly are principles?We could try to define principles as rules and duties, universal norms to guide human conduct.For van Hooft 3 , principles were generalizations formulated by induction of past moral decisions of exemplary individuals.Thus, it is important to stress that principles come from outside, that is, they are exogenous.As a principle, beneficence is the moral obligation of physicians and other health care professionals to do good, or, yet, to do what is best for patients.But another possibility is "to do good for the patient" not on principle, but by virtue of benevolence.If we consider virtues as something internal to decision-makers, benevolence (referring to the constitutive characteristic of agents, rather than to action and behavior) in this context would be how inclined individuals, health care professionals, are to act to promote the good, to do good to others, patients.
Virtue derives from the Latin "virtus", but the Greek term "areté" gives meaning to excellencefulfillment of the purpose or function to which individuals are destined -, accomplishing essence itself, finally referring to the capabilities and abilities which make those have them good 4.According to Rachels, virtue is a trait of character, expressed by habitual patterns of behavior that are good for a person to have 5 .Actually, the concepts of virtue and principle are not too far apart, as they are both linked to values we formulate in social and cultural contexts.As these very valuations make us define our actions and conduct, our moral life, either in accordance with rules accepted in the community or based on the inclination to act and constitute oneself in a virtuous way.
Considering this brief introduction, rather than establishing differences between principles and virtue, the purpose of this work is to emphasize the possibility of another ethical approach to bioethics, which is also based on notions of well-being and alterity, not as an obligation, rule or duty, but as an ability and construction of a specific character which is pursued voluntarily by individuals in their personal lives as well as in professional activities, with practical purpose.

The ethics of duty
By understanding ethics as a field of knowledge which deals with behavior, actions and relationships between individuals, bioethics, specifically when it comes to medicine, can be the discipline that seeks to substantiate the answer to the question "what should I do?" in a given situation 6 .This is the approach to the theory of the ethics of duty, also known as "deontological ethics", which is that which aims to establish rules of action.
Philosopher Immanuel Kant 7 established that the universal rules should be followed by individuals independently of their desires or intentions, and should aim the general interest.For him, there was only one moral principle on which all moral duties should be based: The categorical imperative, whose maxim is that individuals' actions must be taken in a way that such actions can become universal laws, applicable to all.
Principalist bioethics 2 is based on Kantian ethics, more specifically on a deontological proposal.However, fixed and rigid principles, which do not admit exceptions or considerations of specific cases, limit the reach and depth of conducts.Sometimes the application of these principles or rules is complex and are found to be conflicting (in the case of principlism).Another major criticism is extreme rationalism, as it does not consider the participation of emotions, needs and desires in the decision-making process, even though they are part of human nature.For Kant, reason itself has a purpose 7 .
Another ethical approach in modern times is utilitarianism, which targets consequences, rather than means.It is not exactly an ethics of duty, but it also established rules which limit individual interests in favor of the interest of others, that is, general interests 8 .In this theory, the answer to the question "what should I do?" lies in the best consequence for a larger number of people, which is referred to as the maximization of pleasure and utility.With

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The perspective of Virtue Ethics regarding the process of medical decision-making http://dx.doi.org/10.1590/1983-80422016242124indications of good consequences, action rules are established, regardless of the motivation 5,9 .However, the procedure involved in practical decisions, to weigh pleasures and pains, seems simplistic and is criticized as a cold calculation algorithm, which does not even define exactly what would the best be.As in the Kantian reference, for utilitarianists moral decisions must be impartial and universal.
Therefore, utilitarianism fails to respect individual rights.This is the main criticism on which even Kant was based when he started his theoretical body on the intrinsic value of individuals, who must always be respected 5,8,9 .Utilitarianism also fails when it does not add values and preferences, which is described as an egalitarian and neutral concept 9 , despite John Stuart Mills adaptations of Bentham's original theory.

Aristotle and the ethics of good
Rules which do not allow exceptions, general analysis which does not consider specificities, rational decisions which do not go through evaluative reflection and actions in favor of indefinite greater happiness are found to be insufficient to deal with contemporary problems, including those which are health-related.A timeless consideration is that perhaps this set of inflexible actions is not really the best way to guide conducts and decisions.The current moral debate is characterized by the plurality of values and principles, which make this debate immeasurable.Apparently, there is not a single school of thought likely to become unanimously accepted and, thus, become the sole response to the question of how to act in a given situation 10 .
In this case, a plausible proposal is returning to Aristotelian ethics 11 , converting the question on how to act or what to do in each situation into a question on how to constitute oneself, how to form one's own character and, associated with this, being capable of making decisions related to life with wisdom and prudence.This is so because Aristotelian ethics, or the ethics of well-being, starts with the broad and inclusive question of how human beings should live a moral life (rather than the non-moral), the so-called dialectics of well-being.Thus, in contrast to the ethics of duty (of doing what had been established to be conventionally right), this approach is referred to as the "ethics of the good", of acting for the good 8 , which is the determined purpose of life as well as of human activities.So, it is a teleological ethics.
For Aristotle, man's ultimate end -that towards which all of his activities converge, mainly those related to his function in the communityis Good, in the search for eudaimonia -from the Greek eu (well/good) and daimon (spirit).The term has been translated as "happiness" or "flourishing", but is not related to temporal feelings, but rather to the notion of full realization of life.Eudaimonia also translates soul activities according to forms of excellence or virtues.Then, another denomination of the Aristotelian ethical referential appears, the "ethics of virtues".Thus, virtues are characteristics of moral agents which lead them to act towards the good, pursuing certain ends -ultimate human ends or their practice.Aristotle divides virtues into intellectual and moral ones, and explains that the acquisition of such virtues, provided there is effort, happens by instruction and practice, respectively.Finally, Aristotle stresses the effort to acquire virtues or perform virtuous actions, given that the will to do so is a manifestation of the soul, as well as emotions and faculties.In this case, the vocation to moral virtues leads to good choices, improving the appetitive part (will) of the soul, which leads it to pursue certain ends.For him, the moral virtue of prudence (from the Greek phronesis) is the most important one.
Prudence, however, is not associated with neutrality -distortion in the meaning of the word which happened throughout time 12 -but it proposes a careful analysis of the circumstance aiming to act with the best result.It favors the calculation of what is best in human beings when it comes to things which can be affected by action; hence its imminently practical nature.Above all, the calculation is adequate, correct and wise.Prudence is precisely practical wisdom, perception of the will according to the right desire, which culminates in a good choice.
The right choice in medicine is directly approached by Aristotle in his "Nicomachean Ethics" 11 .What is adequate depends on the considerations related to each specific case -rather than to generalizations.Deliberations are given on the means, but seek the ends, which, in medicine, refers to the health of patients.And as medicine does not have an end in itself, for Aristotle, contrary to popular belief, it is not considered art.The philosopher does not make additional comments, but we may contemplate that medicine is science and ethics, as ethics itself deals with conducts in interpersonal relations and with the character of decision-makers.

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The perspective of Virtue Ethics regarding the process of medical decision-making http://dx.doi.org/10.1590/1983-80422016242124

Neo-Aristotelian Ethics
Several contemporary philosophers recover elements of Aristotelian ethics, mainly when it comes to its teleological characteristic, focused on moral agents which are constituted in a virtuous way.Among them were Elizabeth Anscombe 13 and her husband Peter Geach, Philippa Foot 14 , Rosalind Hursthouse 15 and Alasdair MacIntyre 10 .US-based Scottish philosopher Alasdair MacIntyre was the one who described the conceptual immeasurability of rival arguments and the ethical relativism which accompany the plurality of possible moral conducts of our time 10 .Above all, Maclntyre criticizes the modern illuminist project as well as that of emotivism, a movement which, according to him, transforms evaluative and moral judgments into expressions of preference, feelings and subjective desires, of individuals that constitute themselves apart from social relations.In opposition to this liberal individualism of our time, it appropriates the epistemological concept of paradigm provided by Thomas Kuhn 16 .
In Kuhnian historicist vision, science evolves when theoretical currents with different explanations for a phenomenon acknowledge one of them to be the best one, the paradigm.However, in an ethics in which different currents express individual preferences, there will never be one single paradigm, says MacIntyre, who believes in a return to Aristotle and to the dialectics of well-being, in which there is no separation between being and duty.That would be a return to the finalist or teleological vision of the being, in its practical functions.
MacIntyre defends the formation of moral individuals implicated in specific practical questions of their time, responsible for their own development, based on the construction of a proper narrative and in relation to practices which have internal ends.This is a second point that stands out in his work, the concept of a subject narrative, with its history, culture and insertion in communities.The third point refers to the ontological aspect of human beings as social beings, beings who are, above all, rational, and yet also inherently dependent and who assume their independence as they mature without denying the nature of their mutual needs 17 .

The ethics of virtues -advantages in relation to medicine
The great advantage of using this theoretical framework for medical deliberation is its evaluative nature.Value judgments are considerations about what is important, in specific cases, for proper or prudent decisions 18 .It seems there will be no rule applicable to all cases as the best and only correct option, as supposed in deontological ethics.On the other hand, a certain purpose is what we seek in each situation.Recalling Aristotle, the ultimate purpose of medicine is the health of patients 11 .This teleological aspect of the ethics of virtues is, then, another important advantage presented by the theoretical referential to the medical decision-making process.What is sought is the good of the patient, the good of others.In this respect, it differs from the utilitarianist approach, which is characterized for being consequentialist.In utilitarianism, we do not seek good, but rather the maximization of pleasure and utility 19 .When actions favor greater happiness for a greater number of people, the universal sphere becomes more important than the private one, and the intrinsic value of individuals or patients, with their history and desires, perhaps even their dignity, is lost.Thus, we return to the evaluative question.
If a moral agent evaluates a situation, judging what the best decision is, and is willing to act well, according to what is required in each case, then professional motivation is a third advantage of the perspective of the ethics of virtues 20 .Acting well, for the greater good, and constitute yourself in a virtuous way, is an internal inclination of the moral agent.It requires awareness of the responsibility in the constitution, and this awareness is an advantage in relation to decisions which follow rules or principles established externally, decisions which are not necessarily made by the agent.Well-trained professionals, who keep their techniques updated, and whose character is well-constituted and virtuous, also have the advantage of making prudent decisions in scenarios which do not allow for a lot of deliberation, such as decisions concerning critical patients and which are made in real time.
Good practice and the motivation which precedes it are also part of the notion of professionalism, which is important to be rescued 21 .Professionalism currently counteracts the so-called "consumerism in medicine", in which the respect to patient autonomy became the most important value in the decision-making process, leading professionals to lose independence in relation to other patients to which, ultimately, they render services 22 .Considering the perspective of the ethics of virtues, this return of professionalism is a consequence of the focus on character constitution and motivation

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The perspective of Virtue Ethics regarding the process of medical decision-making http://dx.doi.org/10.1590/1983-80422016242124 on the part of the physician.Excessive focus on patient autonomy may be interpreted as something inconvenient in regard to the perspective of principialist bioethics.
Even without excesses, the theoretical focus on the defense of patient autonomy seems to be a simplistic and nearly elusive vision, as it does not free professionals of their responsibility in regard to decisions made in each case.This professional responsibility related to decisions versus patient autonomy is especially important in pediatrics, as it is a field which deals mostly with individuals who do not have autonomy.The current consensus (accepted even by the America Academy of Pediatrics) is that of the so-called "shared decisions" between parents and physicians 23 .And the ethics of virtues is the perspective which better underlies this concept, rather than the classical perspective of principlism.After all, how can we better consider the interests of a child whose future -and disease prognosis -is unpredictable? 24MacIntyre 25 understands that child autonomy is not what is important, as presupposes the moral of Illuminism -people as rational moral individual agents whose objective is the search of their own interests and preferences.For him, we, as people, are part of a moral community whose purpose is to jointly seek the good life, and children are dependent members of these communities.
Finally, physicians that take their role in the decision-making process not only evaluate the technical aspects, but also do not make purely rational choices.The ethics of virtue approach also has the advantage of giving way to emotions, even with all the rationalism involved in it 3,20 .Emotions are part of moral and constitutive perceptions of value judgments 20,26 , and, according to Aristotle, moral education in virtues depends on feelings as reactions of our own actions.

Ethics of virtues -fighting the criticism
Nevertheless, there is some criticism to the theory 15 .The first one comes from those who expect ethics to dictate norms and guidelines of conduct and correct behavior suitable in several different situations, especially conflicting ones: If Aristotelian ethics does not make available a behavior guide, then, how can we employ it in practice?Ethical behavior could be observed through the identification of virtuous people, that is, knowing what a certain virtuous individual would do in a given situation.To fight this criticism, Elizabeth Anscombe 13 promptly clarified that there is no suggestion regarding the alleged identification of virtuous individuals, but rather the understanding of how it would be to act using one virtue or another, as opposed to vices.What the virtuous thing to do is in a given situation, what it means to act with courage or benevolence or compassion, etc. 15 .
That is where the second criticism arises: how can we require that someone act virtuously?It would not be possible to force someone to want to be virtuous, but it would be possible to create rules to be followed.One answer to this question seems to be that it is not possible to make someone follow rules either, or to act guided by principles and values contrary to one's own inclination or will.Thus, specifically when it comes to this aspect, the theory of virtues prevails as it focuses precisely the inclination of a moral agent to act for the good, given that the theory is based on the good.
As noted, this inclination and the understanding of one's own responsibility bring advantages to the theory of virtues 5 .The grounds of ethical theories show concern in relation to what leads people to act (well), as internal motivations, rather than that which they are obliged to do as a result of external impositions or out of respect for one's duties -which makes the issue of substantiation ontological.Considering this perspective, individuals are moral agents, and their motivation leads them to act in search of what matters the most to them 27 .
However, even if we leave aside the matter of motivation in the second criticism, there are still advantages in the proposal involving the ethics of virtue, which conceives the possibility of moral education.Recalling Aristotle: intellectual virtues can be taught, and moral virtues can be acquired by the habit of virtuous practice 11 .It is important to stress that habit, here, must not be interpreted either as an addiction of those who have settled or as non-creative repetition and considered without due assessment of each case.Habit makes those who experience similar situations related to the correct choice of virtues to be employed experienced.
When it comes to virtues as part of factors which explain the theory, we can contextualize two other criticisms.The first one is called "cultural relativism" -virtues valued in each time period and environment may vary; therefore, how or which ones to apply?This criticism also affects other ethical perspectives and seems to be a bigger problem to them.For instance, principles are also historical and culture-related.On the other hand, even though virtues may vary in application, their concept is not

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The perspective of Virtue Ethics regarding the process of medical decision-making http://dx.doi.org/10.1590/1983-80422016242124changeable or relative.The same holds true for their opposing vices, which are never longed for.Humility is a good example: It was considered a virtue in the religious context and seen as a vice opposing magnanimity for the Greek.On the dictionary, these concepts are stable -humility can be defined as the quality of not projecting oneself, or acting with simplicity, whereas magnanimity is defined as the quality to project oneself and live up to one's attributions.
Another criticism regards the conflict which can be established regarding the use of different virtues in a given situation.And this problem also seems to be shared by other perspectives.For instance, in principlism principles are often conflicting, and that is precisely why the theory is based on a vision of non-absolute principles, so-called prima facie principles; this makes principlism different even from Kantian ethics, in which principles are absolute.Nonetheless, in the ethics of virtues, theory is not explained based on virtues, but rather on teleology, the notion that moral agents aim at a specific end and use practical wisdom to perform virtuous acts which culminate in this end.
However, the search for a single end, eudaimonia, involving the entire community, referred to as polis, generates another criticism worth mentioning: It would be impossible to return to Aristotle in times of exalted individuality, predominant since the Illuminism.In MacIntyre's criticism, it is precisely because of this inaccurate and slippery limit between individualism and emotivism that there should be a return to the perspective of Aristotelian virtues.Being grounded in teleological conception of life appears to supersede the individual pursuit for satisfaction of interests and wishes.

Final considerations
Modernity has proclaimed autonomous individuals, who are also free and endowed with equal rights, seeking to pursue their interests.The role of ethics would be to solve conflicts resulting from the relationships between individuals.In this case, the question that must be made is: "how to act?".For Aristotle, men are social and political beings by nature and have a telos -human beings feel accomplished in the search of an end, in their practices, and being part of a community, with established culture and values that are reachable through effort and desire.In the Neo-Aristotelian vision, the first position of the being, voluntarist, opposes the narrative and teleological concept.Michael Sandel 28 says that, just like other professional practices in general, medicine can benefit from a new place for morality: And that is not the place to dictate rules to be followed, but to internalize our own project for ourselves as well as our concern for others.In practice, the ethics of virtues presents itself as a proposal to the challenges involving conduct and decision-making in medicine.Solutions for dilemmatic cases do not involve conflicting principles or rules, but rather the exercise of virtues in judging situations and the choice of suitable means to the ends established in a way to ensure that the best decisions are made.To that effect, professionals' responsibility lies in the formation of their own character, facing professional needs, as well as what these professionals' ends in medicine are and also those in their personal lives in general.