One of the features of personal dignity described above is the dimension of activities. The kinds of activities in which individuals engage is a significant component of their dignity. There is one special way to think about the activities in which individuals engage which needs more focused consideration when talking about the human condition and personal dignity. This dimension is commonly referred to as the practice of the virtues. Particular attention needs to be paid to this area of personal dignity if we are to appreciate fully the human context for the Patient Self-Determination Act and its role in the clinical setting. What will be undertaken in this section is an exploration of the role of the virtues in general and an identification of some of the specific virtues which play an central role in the clinical setting. These specific virtues will be examined in light of the opportunities which the Patient Self-Determination Act presents for their practice.

    Virtues represent states of character possessed by a moral agent. They also represent habits of behavior of a moral agent.⁽¹⁾ In combination these two features of virtue offer a powerful portrait of individuals as they interact with others. These states or habits do not come by chance to individuals. Rather they are chosen as dispositions toward actions as a result of personal deliberations. Individuals choose the virtues they plan to practice.⁽²⁾ The choice takes place over a period of time. Just as one does not "fall into" a virtuous life, so also one action does not constitute a virtuous disposition.⁽³⁾

    Individuals choose the virtues which will be practiced within a context of the human goods which they wish to pursue and the ends or purposes which they wish to accomplish. The virtues are always directed toward some end.⁽⁴⁾ Since the ends of human life are multiple in a pluralistic society, the virtues which will be practiced and the priorities among them will vary widely. It is difficult to identify one virtue or set of virtues or priority of virtues which will or should be practiced in a pluralistic society.⁽⁵⁾ As opposed to a society in which all individuals agree about the ends to be achieved, in a pluralistic society there is no general agreements on ends.⁽⁶⁾ If there is no agreement about the ends there can be no agreement about the means to achieve the ends.

    In order to develop a society which will allow individuals to interact with a reasonable degree of tranquility, the various individuals must develop attitudes and practices which will allow each other to achieve their goals with some measure of latitude. The attitude which is fundamental to a democratic pluralistic society is that of tolerance and this may be the only candidate for a common virtue.⁽⁷⁾ While everything is not possible in such a society, nonetheless many variations in goals and purposes are possible. When disagreements between individuals arise as to the ends to be accomplished or the virtues to be practiced to achieve those ends, then the process of negotiation becomes the fundamental practice.⁽⁸⁾ In negotiating differences, some compromises will need to be made about goals as well as the manner of achieving them. Individuals engaged in virtuous practices will not always be able to practice their virtues to the maximum extent they wish. Negotiation becomes the standard behavior rather than a forceful imposition of one person's will on another.

    The right to self-determination is a good example of the dynamics of the practice of virtue in a society which promotes tolerance of differences. There can never be total self-determination for individuals who must live in a social context.⁽⁹⁾ There will always be limits on one's behaviors. While the limits are placed on individuals for the general good of all, there remain spheres of actions where it is appropriate for individuals to exercise their self-determination.⁽¹⁰⁾ The boundaries between the self-determination of individuals and the general good of society or the welfare of others are continually shifting. The virtues come upon the scene as the good of self-determination and the good of society are being tested.

    The virtues, then, represent a dynamic flow of personal dignity according to which individuals carve out their places in the world as they encounter a variety of circumstances. Aristotle viewed a virtue as a mean between two extremes.⁽¹¹⁾ The virtuous person will find herself in a diversity of circumstances which could all be approached from different extremes. Since the extremes shift so also the mean will shift. Each individual must figure out how the virtues are to be practiced in different situations.⁽¹²⁾ Thus, the practice of the virtues is not just a matter of negotiating with others who may see the situation and the appropriate virtuous practice differently. There must be an inner dialogue and negotiation which occurs in each moral agent to determine the precise practice pattern for the virtue in various situations.

    Because of the wide variety of practices possible for individuals in a pluralistic society, the Patient Self-Determination Act can never apply automatically and non-reflectively. A simple signature on a piece of paper will never suffice. Any decision, whether it is symbolized by a signature or not, must be made against a backdrop of the virtues which individuals have chosen to practice. While the virtue narrative of patients is often tacit and seemingly casual,⁽¹³⁾ it still represents, in a significant way, the background which a patient brings to any individual decision. This background must be explored with a patient before any decision exhibiting self-determination can be made with any degree of credibility. Decisions cannot be made without some reflection on their historical background and the choices leading to the practice of the virtues which direct patients to their desired goals.

    Thus far we have identified and explored several facets of the life of virtue in the human condition as it applies in the clinical setting. (1) Virtues are states of character or habits which guide us toward the accomplishment of the goals which we have chosen to pursue.⁽¹⁴⁾ (2) The virtue history or narrative constitutes a major part of what makes us individuals.⁽¹⁵⁾ (3) Negotiation is often necessary as different individuals choose to practice different sets of virtues or similar virtues but in substantially different ways.⁽¹⁶⁾ (4) The Patient Self-Determination Act brings into focus the importance of understanding the role of the virtues in the clinical setting.

    No presentation of the human context of the Patient Self-Determination Act would be complete without some detailed study of the virtues which surface in the clinical setting and the way they interface with the Patient Self-Determination Act. And so we now turn to an investigation of some of the various virtues which are key ingredients for decision-making in the clinical setting. There are many more virtues than can be examined here but the following analyses should provide some guidance for identifying virtues which may figure into clinical decisions and ways of addressing the issues which those virtues raise. Since the Patient Self-Determination Act is primarily patient-centered, the virtues to be practiced by patients are the focal point of this discussion. However, there will be some exploration of the virtues of the professional as well, in so far as they directly impact on the decisions of patients to consent to or refuse treatment and draft advance directives.

    Patients come to the clinical setting with a history of the virtues which they have consciously or unconsciously chosen to practice. This history provides a significant backdrop for understanding the patient which cannot be ignored. Clinicians who would ignore this virtue history of the patient do so at great risk to the clinical encounter. To disregard the virtue history of the patient would be tantamount to saying that what the patient has done up to the point of the clinical encounter is of no value. But clinicians know this is not the case. The medical history of the patient is one of the most important factors to consider in attempting to address the patient's healthcare problem. But this only reveals clues to the symptomatology of the patient's presentation. It does not give a picture of the whole patient. The virtue history of the patient adds significant information for the clinician if she is to treat the patient as a capable decision-maker rather than simply a bundle of symptoms.

    A few tactical observations may be helpful in addressing the practice of the virtues in the clinical setting. Sometimes patients will come to the clinical encounter with a full range of virtues already in place. In these instances the clinician needs to do three things: (1) identify the virtues which the patient possesses, (2) foster the virtues already present, and (3) create no obstacles to the practice of the virtues. Sometimes patients will be somewhat tentative in suggesting they might want to practice some of the virtues. In this case the practice should be encouraged so that the patient will be able to be an active participant in decision-making.⁽¹⁷⁾ In other situations patients may not have the prerequisite virtues for collaborating in clinical decisions. When this occurs patients may be pointed in the direction of those virtues which they may have failed to develop prior to the clinical encounter.⁽¹⁸⁾ They should be given the opportunity, encouragement, and assistance to develop those virtues. However they cannot be forced to do so because such coercion could violate their liberty and, hence, their dignity.⁽¹⁹⁾

    When patients make it clear that they simply do not want to practice a particular virtue they should probably be let alone unless they later send clues to the caregivers that they might be interested in developing a particular virtue. Caregivers should always be sensitive to the clues which patients might send to them in a variety of disguises. This responsibility is implicit in the codes of ethics which identify an obligation on caregivers to respect the dignity of patients.⁽²⁰⁾ For, as we have seen, developing and practicing virtues is an essential component of personal dignity.

    Caregivers and patients are not immune from the plurality of the practice of virtue and the priorities among the virtues which is a common feature of the human context. Not only will they have to negotiate about which virtue is appropriate in a particular circumstance, but they will often have to negotiate about the manner in which individual virtues are to be practiced. We have seen how this disparity calls for negotiation with particular virtues. As they encounter each other in the conversations attendant to the implementation of the Patient Self-Determination Act, curiosity, responsibility, acceptance, and detachment may require special attention on the part of patients, while the virtues of tolerance, compassion, integrity, and empathy will have special significance for the professional.⁽²¹⁾

    Among the virtues which first surface in the clinical setting is the virtue of curiosity. This is a common virtue which is practiced in daily life. It allows us to make our way in the world where we are constantly bombarded by a variety of stimuli. It allows us to gain understanding of stimuli and facts and lay the foundation for selecting courses of action which will enable us to accomplish our goals. Curiosity functions in a similar way in the clinical setting. It is a virtue which enables patients to acquire the information and understanding necessary to make their decisions about approaches to treatment.⁽²²⁾ It is this virtue which informed consent attempts to address and which the Patient Self-Determination Act can foster.

    Unfortunately it can happen that some patients do not utilize this virtue in the clinical setting. While they may bring it to the encounter they may think that it is inappropriate to make inquiries of their caregivers. If the Patient Self-Determination Act is to be effective patients will have to be encouraged to practice this virtue. This virtue is a good example of a virtue which may be practiced in different ways by the patient and the clinician. The patient may be so curious that the clinician might become uncomfortable in providing all the information which is requested. In cases such as these, the interested parties will have to negotiate the limits of the practice of curiosity so that both can work effectively in the decisional process.

   Hope is a virtue which is generally considered to be essential in the clinical setting. It is the virtue which leaves us open to possibilities and propels us to pursue goals when they become difficult to accomplish. It is hope which causes individuals to fight a disease even when the odds for victory seem to be quite small. But in the clinical setting it must be a hope which is grounded in a realistic assessment of one's situation. False hope, i.e., a hope that no chance of being realized, only creates an illusion for the patient and ultimately creates great harm without producing significant benefits.

    While it is true that everyone has something for which to hope, the problem is that the parameters of hope are continually readjusting themselves in our lives. One cannot hope for the same things in old age that she could hope for when she was young. So those embarked upon a process of disease with accompanying inevitable deterioration and disability cannot have the same hopes as one who may be facing an acute episode but is otherwise vigorously healthy. Our hopes must be adapted to the real, rather than simply desirable, boundaries of our circumstances. But there are no circumstances without some measure of hope, even if the hope is limited to a "gentle" death, care and comfort from one's caregivers, family, and friends, and the companionship needed to overcome the feelings of isolation which so often accompany the process of dying.⁽²³⁾

    The Patient Self-Determination Act presents the possibility of practicing this virtue by allowing the patient to make the relevant inquiries about the boundary conditions regarding her healthcare situation, and whether those conditions can be adjusted. She can clearly define what she will consider to be her reasonable hopes within the confines of her situation and make healthcare decisions accordingly, even to the point of refusing treatments.

    Pressure from caregivers to continue aggressive treatments when cure or decent recovery is not possible often indicates that they are uncomfortable with patients who seem to have abandoned hope for a cure. But patients may be well aware that while it may be unreasonable to hope for a cure, it is not unreasonable to hope for a comfortable passage through the dying process. In this instance as in many others, the patient and the caregiver will have to negotiate the parameters of hope. However, the patient's practice of the virtues will be the deciding factor because it is primarily the patient's virtues which will help her with the reality of her dying and preserve her dignity.

   Courage and risk-taking are virtues which play an important role in making decisions about treatment refusals and advance directives. It is often easy to surrender to fear and simply say "do everything" even though "everything" may be totally inappropriate. It is an act of courage to discriminate among healthcare alternatives when one has to weigh medical probabilities and burdens against benefits. Moreover courage and the acceptance of risks is essential to anticipating the future and giving directions for healthcare interventions when one may not be in the position to make decisions at the time, as is the case with advance directives.

    Some patients are simply better risk-takers than others and often they are better risk-takers than their caregivers. Frequently caregivers would like patients to pursue treatments with low probabilities even though the patients may not be disposed to do so. This attitude on the part of caregivers often leads to the utilization of futile care.⁽²⁴⁾ Acknowledgement of the legitimacy of the virtue of risk-taking may be an important approach to avoiding the initiation or continuation of futile care. The Patient Self-Determination Act acknowledges the moral integrity of patients by giving them the opportunity to exercise these important virtues of courage and risk-taking which lie at the very heart of their personal dignity.

   Responsibility is a key virtue in human life and lies at the foundation of all moral behavior. Without the practice of this virtue all of our moral imperatives would be hollow. Actions would be undertaken simply because they are required by some external source and not because they flow from some internal conviction and appropriation. They would be "an action" rather than "my action."
    There is a strong tendency in human life to attempt to escape from responsibility.⁽²⁵⁾ When undesirable consequences result from our actions they are frequently considered to be the result of someone else's behaviors or other circumstances beyond our control. This phenomenon occurs particularly in healthcare settings where patients already feel overwhelmed by the disease process. It is a recurrent theme to find healthcare professionals blamed for therapeutic outcomes which are the result of therapies which should not have been chosen in the first place and had been chosen because patients evaded their responsibility to take an active part in the decision-making process.

    The Patient Self-Determination Act reinforces the virtue of responsibility in patients. It clearly places the responsibility for healthcare decisions on the patient's shoulders.⁽²⁶⁾ It is the patient who can and should make the decisions to consent to or to refuse treatment and to anticipate her healthcare needs in the future by considering an advance directive.⁽²⁷⁾

    Some caregivers may wish to derail the patient's practice of the virtue of responsibility. This has the effect of producing a compliant patient who follows directions and causes no friction in the clinical setting. Unfortunately this approach also displaces responsibility away from the one who must bear the consequences of the decisions which have been made.⁽²⁸⁾ Compliance frequently violates rather than affirms the personal dignity of the patient. If the outcomes are ultimately seen as undesirable, the patient has every right to complain and may do so with grave consequences for the caregiver and the healthcare facility.

    By encouraging the practice of the virtue of responsibility, caregivers not only protect themselves but help their patients develop their distinctively human side. This may be one of the most positive outcomes of the clinical encounter. But before the patient can act responsibly she must be given all the tools for the practice of the virtue. She must have appropriate information and be clear about her values and goals. Then the necessary connections can be made and the appropriate therapeutic pathways chosen. But even with all of these precautions, undesirable outcomes may still result. Such are the contingencies and uncertainties that are an inevitable part of exercising the virtue of responsibility.

   Prudence is an important virtue to be fostered in the life of all individuals, particularly patients. This virtue encourages them to weigh the various elements of a situation and to approach creatively the uncertainties and probabilities of life in general, and medical practice in particular. Weighing the role of each intervention against the condition which it attempts to address and assessing its possible risks, as well as benefits, requires a great deal of practical wisdom on the part of the patient.

    The practice of prudence requires not only careful judgments on the part of the patient but considerable tolerance on the part of the caregiver. For it is practically certain that the patient will weigh the various elements in the clinical situation in ways somewhat differently from the caregivers. Negotiation between caregivers and patients in the practice of this virtue is essential. Each will have to be open in their conversations about what they see to be the benefits and risks or burdens of particular approaches to treatment. They will also have to communicate about how those possible clinical outcomes may fit into their own value priorities. Finally, each will have to acknowledge the legitimacy and integrity of the value priorities of the other and generally deference will have to be given to the patient because she will bear the consequences of the prudential judgments.⁽²⁹⁾

    The conversations which can result from the implementation of the Patient Self-Determination Act will certainly afford ample opportunity for patients to practice prudence. The acquiring of relevant information as well as determining how it fits into the total healthcare picture and the patient's value life will make it possible for patients to practice this virtue as a central part of their decision-making power.

   Trust is the virtue which lies at the heart of the clinical fiduciary relationship. Without trust the relationship would always be open to suspicion. But this virtue enables both caregiver and patient to view the other with confidence in the other's ability to fulfill her appropriate role in the clinical encounter. Trust also facilitates the viewing of the parties in the relationship as moral equals who are both worthy of respect. It protects both the autonomy of the patient and the integrity of the caregiver.

    The Patient Self-Determination Act casts a new light on the virtue of trust. It encourages conversations in the clinical relationship which go far beyond the discussion of symptoms and treatments. It allows individuals to penetrate behind the wall of decisions to the reasons which underlie them and the values which drive them. And, in the case of advance directives, it encourages discussions about the contingencies of human life which are most difficult to confront.

    Both caregivers and patients must practice this virtue and set the groundwork for it early in the relationship. If there is a lack of trust, the relationship is bound to deteriorate. Negotiations will be necessary about the parameters and expectations of trust.⁽³⁰⁾ Without the understanding which can result from these discussions, the autonomy of the patient will be placed in jeopardy and the integrity of the caregiver will be severely compromised.

   Assertiveness, communicativeness, and decisiveness are virtues directly related to the process of entering into conversations with caregivers, resisting coercion in the discussions, and making clear and unambiguous decisions.⁽³¹⁾ If patients do not actively enter into the exchange with their caregivers and provide clear messages to the caregivers of their wishes, the patients and caregivers will be at a great disadvantage. The caregivers will have to either guess about what patients want or they will do everything possible for the patients in order to protect themselves from liability exposure.

    Because of the legal requirement, the Patient Self-Determination Act makes it possible for patients, in an open and empathic atmosphere, to communicate openly with caregivers and to receive enough information to begin the process of making clear decisions. For patients who find it difficult to begin these conversations and practice these virtues, the law provides the impetus. If the practice of these virtues by patients disturbs some caregivers, nevertheless, they will have a better chance of realizing their advantages for informed consent along with the practice of the virtue of responsibility on the part of patients. Adjustments in the quality of their conversations will have many positive outcomes for the quality of patient care.

   Acceptance is an important virtue in our daily lives when we encounter obstacles or situations which we cannot change. It helps us to define the boundaries for our activities and keeps us from expending our energies in fruitless behaviors which are often productive of great anxiety with no change in the problems we face.

    In the healthcare setting we most dramatically face the limitations of our finitude which require acceptance. Because of the frequent success of medical interventions we are often seduced into thinking that healthcare interventions will always be successful. This is not the case and it is important for patients to realize this fact. Because the Patient Self-Determination Act opens the door to an enriched discussion involving the communication of information leading to consent or refusal of treatment, patients can acquire a more complete understanding of their healthcare conditions and what realistic possibilities of treatment are available for them. Patients can then accept their conditions if they are impervious to medical interventions instead of pursuing futile treatments.

    Frequently there will be a disparity between caregivers, patients, and families around the practice of acceptance. Sometimes the caregivers are more prone to its practice than patients. Many times patients understand their situations very readily and wish to practice the virtue long before caregivers or family members. This is one of the most striking examples of a situation where negotiation about the practice of the virtues needs to occur in an open and honest fashion. The reality, however harsh, of the clinical situation must be outlined and the practice of the virtue which mostly closely reflects that situation must be pursued. The conversations prompted by the Patient Self-Determination Act and subsequent conversations within that context will promote the practice of this virtue in ways which will promote the well-being of the patient.

    Finally, the virtue of detachment, somewhat related to the virtue of acceptance as its foundation, plays a major role in the lives of patients. This virtue allows us to enjoy our lives and special events in them without clinging to them in some dysfunctional fashion. Detachment allows us to "let go" when that is the appropriate and prudent thing to do. This virtue keeps patients from attempting every possible intervention no matter how remote the probability of minimal success merely to extract out of life its last possible moment. Detachment is the virtue which allows us to surrender to natural processes or to a greater wisdom.

    The Patient Self-Determination Act provides the arena for patients to play out the virtue of detachment. It confirms the legitimacy of the virtue by calling to patients' attention that they have the right to refuse treatment, the right to designate an end to the use of therapies when they are no longer capable of making those decisions, and the right to authorize someone else to make those decisions for them if they cannot do it for themselves. This law indicates that it is no longer the role of caregivers to impose their view of the clinical setting on the patient's circumstances. It legitimizes, in a very significant way, the ability of patients to yield to the forces struggling within them.

    There are many other virtues which patients can practice but the above seem to play the most significant roles in health care decision-making and the new role for the Patient Self-Determination Act in that process. It is apparent that, while the focus has been upon the way in which these virtues are applied by patients in the healthcare setting, these are virtues which apply to the broad spectrum of human life beyond healthcare.

    For this reason it must be emphasized that patients are not the only individuals in the clinical setting who have an interest in practicing the virtues. Caregivers have an equal claim to a virtuous life.⁽³²⁾ Caregivers have their own set of virtues and priorities.⁽³³⁾ This feature of the clinical encounter must also be respected. Caregivers cannot be asked to surrender the practice of the virtues which they have cultivated throughout their lives simply to satisfy the whim of patients or social forces.⁽³⁴⁾ But their professional lives must also be driven by a set of virtues which reflect their professional commitments.

    While the healthcare professional may possess and practice all of the above virtues on a personal level as part of the human encounter between the professional and the patient, there are additional virtues which she should possess and practice as a professional. As in the case of patients, professionals may cluster their virtues in different configurations and with different priorities. The Patient Self-Determination Act provides the professional with the opportunity to reemphasize the practice of her virtues. The law may also direct the professional toward enhanced ways of their practice. No list of professional virtues can be complete but the following have been selected to complement the examination of patient virtues which are an integral part of the human context of the Patient Self-Determination Act.

    Professionals are expected to be benevolent toward their patients. This is the most comprehensive of the virtues of the professional. Benevolence propels the professional to perform acts of beneficence which will be directed to the best interests of the patient. Often times benevolence takes the form of self-effacement, i.e., placing the good of the patient above the preferences which the professional espouses.⁽³⁵⁾ Thus, in consenting to or refusing treatment, patients may move in a direction which the caregiver may not prefer, but which the patient considers to be in her best interest. Such decisions by patients may call upon the professional to behave with self-restraint.

    As a comprehensive virtue, benevolence can take various forms in medical practice. Fidelity is the virtue which professionals practice in keeping their promises to their patients as they carry out their mutual obligations in the fiduciary relationship.⁽³⁶⁾ This involves both an element of mutual trust and the dedication to be faithful to the professional obligations to which one is committed. Thus, if the professional is committed to patient self-determination, fidelity requires actions in the decisional process which will enhance this aspect of the patient's value life.

   Compassion is another form of benevolence. Etymologically the word means "to suffer with." This virtue calls upon the professional to view disease, injury, disability, and pain as the patient views it, rather than as a disinterested observer. Compassion helps the professional see the world through the value eyes of the patient. The result is that professionals would explore the patient's values along with the patient and would attempt to enter into that world as a "friend" rather than as a total "stranger."⁽³⁷⁾ Compassion also moves the professional to do everything possible to reduce the distress of the patient's malady. In being compassionate, the caregiver will attempt to understand the values which prompt patients to select or refuse treatment or decide to develop advance directives.

    The virtue of respect is another form of benevolence. In practicing this virtue, the professional recognizes that the patient is her own center of valuing. The patient is seen, not as an object to be used to satisfy the selfish aims of the professional, but rather as a subject who has ultimate worth in herself. Respect is directed toward preserving the dignity of the patient in its most profound sense. This virtue will prompt the professional to honor the patient's agenda for healthcare, whenever this can be done within the boundaries of acceptable medical practice, rather than impose the professional's agenda on the patient.

    Caregivers who exercise benevolence are also going to practice the virtue of honesty. They will give to patients the information necessary for patients to make wise decisions in directing their healthcare. They will also provide candid assessments of the patient's condition, including the prognosis and the probabilities for successful therapies. Honest caregivers will not distort information to make it easier to converse with patients, nor will they hold out false hopes to patients. It requires courage to face patients with grim news about the future which they may face. Honesty is the foundation for helping patients make sound decisions regarding consents to and refusals of treatments. It will also help patients reflect effectively on any advance directive project in which they might wish to engage.

    In the process of interacting with patients, caregivers must exercise their integrity. They must be true to themselves and their professional duties as well as to the patients for whom they care. Patients may make demands on caregivers which require them to go beyond yielding to the patient to respect the patient's autonomy. Some demands may require caregivers to betray their fundamental professional obligations or their deeply held moral convictions.⁽³⁸⁾ Integrity requires the practice of courage because of the difficulty required in telling patients that the caregiver cannot accede to their demands. The practice of courage in pursuing personal and professional integrity may be particularly difficult when patients select futile treatments or refuse life-saving treatments. These virtues also manifest themselves in particularly poignant ways when the caregiver is required to honor an advance directive when the patient's family may demand otherwise.

    The person with integrity will also exercise prudence in making recommendations to patients and in sharing the decision-making process with them. Since there are so many ways in which the art of medicine can be practiced in applying scientific information to a particular patient's condition, there can be no strict algorithms that can be applied to a particular clinical situation. The variables are often different from patient to patient and each variable must be weighed against the others. All of these judgments are matters of prudence or "practical wisdom."⁽³⁹⁾ The person of prudence will not only make prudential recommendations and decisions but she will also communicate to the patient that the judgment is a prudential one. Prudence come strongly into play when discussing decisions to consent to or refuse treatments. But it may be even more required when patients set down stipulations in their advance directives.⁽⁴⁰⁾

    "Tolerance is the primary cardinal virtue in the morality of mutual respect."⁽⁴¹⁾ In our secular society which admits of a plethora of views of the good life, no one person is recognized as having a special claim to wisdom about how the good life should be led. For this reason, we bear the burden of allowing many different views to flourish, and of tolerating a great many which are at variance with our own. To respect another is to tolerate behaviors which may be viewed as disadvantageous, deviant, and, even bizarre. Of course, society draws some limits around these behaviors when they harm another.⁽⁴²⁾ But in a democratic society which values liberty, a great many behaviors are tolerated.

    And so, in healthcare, professionals are often required to tolerate and implement patients' decisions with which they do not agree. This can take the form of ordering treatments which patients desire but which go against the better judgment of the practitioner or ending treatments at the request of the patient or authorized surrogate when the practitioner thinks that the treatments might benefit the patient. The same issues may surface in conversations about advance directives. Caregivers will always have to balance the practice of tolerance against the practice of integrity and respect. The only guidance upon which they can rely is the practice of a reflectively structure virtue of benevolence.

    It is because of the extraordinary complexity of the intersection of the personal virtues of the patient and the personal and professional virtues of the caregiver, described in this section on the virtues, that negotiation is essential in the clinical setting. Ideally, the outcome of the negotiation would be a respect for the virtue life of all the parties involved keeping in mind the goals and purposes of the clinical encounter.

    When disagreements occur one overriding consideration should be kept in mind. The clinical encounter is designed for the welfare of the patient and it is generally the patient who is the best judge of what is in her best interest. Additionally, patients have probably developed a set a virtues which have allowed them to cope with the various exigencies of life. The caregiver's role as clinician does not generally give her selection of virtues and forms of their practice any privileged position in the clinical setting. Therefore, the caregiver at most should make recommendations and provide guidance. In the final analysis, however, the caregiver very often must defer to the patient because it is the patient's virtue life which is primarily at stake in coping with disease, injury, or disability. If things go awry in the clinical setting, it is the patient who must bear the consequences of her own decision.

    If patients and caregivers view themselves, and are viewed by others in the clinical setting, as virtue narratives which are unfolding in time and interacting in space, the richness of their lives as they have practiced their virtues will take on ever increasing significance in healthcare decision-making. Not only will the well-being of patients be promoted but the integrity of caregivers will be optimized because they will look at patients as more than a cluster of symptoms but as an integrated whole worthy of respect as moral equals.

    The practice of the virtues provides an insightful and transparent approach to understanding the dignity of the patient. To know the virtues which a patient has chosen to practice, and to understand the virtues to which the professional is committed, is to come a long way to understanding the foundations of the patient's dignity and how it presents itself in the clinical setting. To appreciate those foundations will inevitably prompt respect for the patient. For, in the patient's desire to select and practice a cluster of virtues to achieve her goals, reflective caregivers will unavoidably see a mirror image of their own struggles in practicing virtues and aspirations for the good life.

1. Aristotle. Nichomachean ethics. Irwin T (trans). Indianapolis, IN: Hackett Publishing Co., Inc. 1985, page 33.
2. Pellegrino ED, Thomasma DC. The virtues in medical practice. New York: Oxford University Press, 1993, page 5.
3. Aristotle puts this feature in a more poetic way when he says that "one swallow does not make a spring time." (Cf. Aristotle. Nichomachean ethics. Irwin T (trans). Indianapolis, IN: Hackett Publishing Co., Inc. 1985, page 7.)
4. Aristotle identifies this over all end as "happiness . . . that which all men seek." (Cf. Ibid. page 1.)
5. Engelhardt HT. The foundation of bioethics. 2nd edition. New York: Oxford University Press, 1996, pages 74-83.
6. Ibid.
7. Ibid., pages 80-81.
8. Engelhardt HT. Bioethics and secular humanism: the search for a common morality. London: SCM Press, 1991, page 121.
9. Thomas Hobbes understood this in the 17th century and devoted much of his major treatise, Leviathan, to the major issues involved in the limitation of self-determination. (Cf. Hobbes T. Leviathan. London: J.M. Dent and Sons, 1937, pages 66-74.)
10. John Stuart Mill identified these special spheres of action as those actions which are "self-regarding," those which have an impact only upon the agent or which have only a remote impact on others. (Cf. Mill JS. On liberty. Buffalo, NY: Prometheus Books, 1986, page 18.) What counts as "remote" is often in need of reflective discussion.
11. Aristotle. Nichomachean ethics. Irwin T (trans). Indianapolis, IN: Hackett Publishing Co., Inc. 1985, pages 42-43.
12. Drane JF. Becoming a good doctor: the place of virtue and character in medical ethics. Kansas City, MO: Sheed & Ward, 1988, page 157.
13. Polanyi M. Personal knowledge: towards a post-critical philosophy. New York: Harper and Row, 1964, pages 299-303.
14. Pellegrino ED, Thomasma DC. The virtues in medical practice. New York: Oxford University Press, 1993, page 21.
15. Brody BA, Engelhardt HT. Bioethics: readings and cases. Englewood Cliffs, NJ: Prentice-Hall, Inc., 1987, page 27.
16. Engelhardt HT. The foundations of bioethics. 2nd edition. New York: Oxford University Press, 1996, page 289.
17. For example, a patient may be hesitant about being decisive in determining the course of treatment. But this virtue is often essential and must be encouraged and supported if the patient is to empower the caregiver to practice her art. It may also be necessary if the patient is to stay the course of therapy, especially if the therapy is lengthy.
18. For example, a patient may come to the clinical setting without the virtue of curiosity because she had been previously encouraged to play only a passive role in her healthcare encounters. The importance of curiosity can be pointed out to her as an essential ingredient for the gathering of information to empower her to make treatment decisions which will help her accomplish her goals.
19. John Stuart Mill may have put this matter best when he said: ". . . the only purpose for which power can be rightfully exercised over any member of a civilized community, against his will, is to prevent harm to others. His own good, either physical or moral, is not a sufficient warrant. He cannot rightfully be compelled to do or forbear because it will be better for him to do so, because it will make him happier, because, in the opinions of others, to do so would be wise, or even right. These are good reasons for remonstrating with him, or reasoning with him, or persuading him, or entreating him, but not for compelling him, or visiting him with any evil, in case he do otherwise. (Cf. Mill JS. On liberty. Buffalo, NY: Prometheus Books, 1986, page 16.)
20. American College of Physicians. Ethics manual. 3rd edition. Philadelphia, PA: American College of Physicians, 1993, page 4. Cf. also Council on Ethical and Judicial Affairs, AMA. Code of medical ethics: current opinions with annotations. Chicago: American Medical Association, 1996, page xiv.
21. Engelhardt HT. The foundations of bioethics. 2nd edition. New York: Oxford University Press, 1996, pages 419-420.
22. President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research. Making health care decisions: the ethical and legal implications of informed consent in the patient-practitioner relationship. Washington, D.C.: U.S. Government Printing Office, 1982, pages 70-77.
23. Levine S. Healing into life and death. New York: Anchor Books, 1987, pages 252-255.
24. This matter will be discussed in detail in chapter 6, section 7.
25. Yalom ID. Existential psychotherapy. New York: Basic Books, 1980, pages 276-280.
26. This is not to say that the observations of the President's Commission related to "shared decision-making" as the idea structure for informed consent have been nullified by the Patient Self-Determination Act. (Cf. President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research. Making health care decisions: the ethical and legal implications of informed consent in the patient-practitioner relationship. Washington, D.C.: U.S. Government Printing Office, 1982, pages 15-39) The Patient Self-Determination Act reinforces the patient's role in participating in this process stipulates some significant signposts for the physician-patient interaction.
27. The issue of patient responsibility will be extensively explored in chapter 9.
28. President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research. Making health care decisions: the ethical and legal implications of informed consent in the patient-practitioner relationship. Washington, D.C.: US Government Printing Office, 1982. The Commission takes the position that compliance is not truly an exercise of patient autonomy and, by implication, responsibility. True autonomy is exercised only when the patient has received information and made a conscious and deliberate choice based upon that information.
29. At least one notable exception has been extensively debated in contemporary medical practice, i.e., physician-assisted suicide. The medical community has been heard with strong voices that they should not defer to patients' wishes for physician-assisted suicide no matter how grounded in virtue the patients' wishes may be. (Cf. Callahan D. When self-determination runs amok. Hast Cent Rep March/April 1992;22:52-55.) These voices have been reinforced by the recent decision of the US Supreme Court. (Cf. Vacco v. Quill. 117 S.Ct. 2293 (1997).)
30. Lidz CW et al. Two models of implementing informed consent. Arch Intern Med 1988;148:1385-1389. The authors here address this matter by talking about the necessity of both patients and physicians clarifying their role expectations of each other early in the clinical encounter.
31. Loewy EH. Changing one's mind: when is Odysseus to be believed. J Gen Intern Med 1988;3:54-58.
32. Pellegrino ED. Toward a reconstruction of medical morality: the primacy of the act of profession and the fact of illness. J Med Phil March, 1979;4:32-56.
33. Drane JE. Becoming a good doctor: the place of virtue and character in medical ethics. Kansas City MO: Sheed & Ward, 1988, page 14-19. Throughout this work (pages 32-133) there is a catalogue of what the author considers to be the major virtues to be practiced by physicians: benevolence, truthfulness, respect, friendliness, justice, and religion. Another such catalogue is found in Pellegrino ED, Thomasma DC. The virtues in medical practice. New York: Oxford University Press, 1993, pages 65-164. Their catalogue includes trust, fidelity, compassion, phronesis (prudence), justice, fortitude, temperance, integrity, self-effacement. A similar, but shorter, catalogue is found in Brody BA, Engelhardt HT. Bioethics: readings and cases. Englewood Cliffs, NJ: Prentice-Hall, Inc., 1987, pages 23-27. They identify compassion, courage, honesty, and integrity.
34. Pellegrino ED. The virtuous physician and the ethics of medicine. In Shelp EE (ed). Virtue and medicine: explorations in the character of medicine. Dordrecht-Holland: D. Reidel Publishing Co., 1985, pages 243-255.
35. Pellegrino ED, Thomasma DC. The virtues in medical practice. New York: Oxford University Press, 1993, page 144.
36. Cf. chapter 3, section 2 for an examination of this relationship.
37. Engelhardt, HT. The foundations of bioethics. 2nd edition. New York: Oxford University Press, 1996, pages 74-78.
38. President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research. Making health care decisions: the ethical and legal implications of informed consent in the patient-practitioner relationship. Washington, D.C.: U.S. Government Printing Office, 1982, page 3. "Patients are not entitled to insist that health care practitioners furnish them services when to do so would violate either the bounds of acceptable practice or a professional's own deeply held moral beliefs or would draw on a limited resource on which the patient has no binding claim." The most recently debated public issue which falls into these restricted areas is physician-assisted suicide.
39. Aristotle. Nichomachean ethics. Irwin T (trans). Indianapolis, IN: Hackett Publishing Co., Inc. 1985, page 44.
40. The difficulty in making these stipulations and exercising prudence in this process will be closely examined in chapter 7, sections 5 and 6.
41. Engelhardt HT. The foundations of bioethics. 2nd edition. New York: Oxford University Press, 1996, page 419.
42. Mill JS. On liberty. Buffalo, NY: Prometheus Books, 1986, page 16. ". . . the sole end for which mankind is warranted, individually or collectively in interfering with the liberty of action of any of their number, is self-protection. . . . the only purpose for which power can be rightfully exercised over any member of a civilized community, against his will, is to prevent harm to others."