Virtuous leadership: Ambiguities, challenges, and precedents

Virtuous leadership is the focus of a growing body of academic literature but is little discussed by contemporary philosophers. Current treatments tend to over-generalisation: assimilating diverse features to a few broad categories and applying simplified ethical theories. This essay argues that virtue and character education need to be keyed to specific activities, that “virtuous leadership” is in danger of being confused with extrinsic activism, and that the history of ethics in health care provides an instructive example of thinking ethically about practice. Questions commonly posed in the literature—What specific virtues are required for leadership? How may these be formed?—are unduly simple and often rest on faulty assumptions about the nature of leadership and of the structure of virtuous action. Philosophers engaged in advising professionals about the virtues of leadership would do well to consider how the relevant points apply to their own practice.

The topics of virtuous leadership and of the place within it of ethical character and its formation have become the focus of a growing body both of profession-oriented and of academic literature.The academic literature is contributed to mainly by practitioners in the fields of business, management and organisational studies, psychology, and educational theory. 1 While this literature introduces serious issues, much of it is derivative, simplistic, and formulaic: listing qualities of accountability, collaboration, integrity, judgement, and so on, without adequate specification of what these might actually amount to, not taking account of different forms and contexts of leadership and of the incommensurability of some values and virtues, or considering whether the very notion of leadership is uniform or polymorphous and whether it is an essentially contested concept: evaluative, complex, ambiguous, and persistently indeterminate (Gallie 1956).These are philosophical questions, yet notwithstanding that leadership is an issue addressed by major philosophical writers from the classical and medieval periods-most notably Plato (Republic), Aristotle (Ethics), Cicero (On Duties), and Aquinas (On Princely Government 1: On Kingship)-it has received little attention from contemporary philosophers, with most of what has been published being exposition and commentary on historical figures. 2  Leadership is a multi-faceted phenomenon, and it may be considered in a variety of ways from within several broad perspectives: anthropological, cultural, historical, psychological, and sociological as well as ethical.So far as ethics is concerned, and with reference to virtuous leadership, the subject may usefully be approached in three ways: (1) via the problems posed by inadequate or worse leadership; (2) by way of the solutions offered through the formation of good character by the cultivation of relevant virtues; and (3) by considering historical examples of the role of ethics in professional practice.My discussion here explores all three, giving greatest attention to historical examples, arguing (a) that virtue and character education need to be keyed to the nature of specific activities, (b) that "virtuous leadership" is currently in danger of being confused with extrinsic activism, and (c) that the history of health care provides a helpful example with which to approach the issue of virtuous leadership as involving serious reflection on the ultimate point of the specific activity in question.As Aquinas writes in relation to political leadership: "[W]e should consider that to govern is to lead the thing governed in a suitable way towards its proper end [convenienter ad debitum finem perducere]" (Aquinas 1959, 73).In addition, I suggest that philosophers engaged in advising professionals about the virtues of leadership would do well to consider how the relevant points apply to their own practice.
From the perspective of this overall position, the questions commonly posed in the kind of literature referred to at the outset-What specific virtues are required for leadership?How may these be formed?-areat best unduly simple and at worst rest on faulty assumptions about the nature of leadership and of the structure of virtuous action.A better approach is to recognise the specificity of the different domains in which leadership is at issue, attending to the nature of the practices involved, their proximal and distal aims and purposes, and their internal as well as external goods; and also looking at the characteristic forms of authority, responsibility, co-operation, and mutuality and of the institutions within which they occur.This requires appreciating the specific ways of thinking and acting in terms of which these various matters are understood by practitioners themselves.Academics, actors, artists, bankers, engineers, farmers, fishers, lawyers, military personnel, musicians, politicians, those in religious life, schoolteachers, and so on, arrange and conceive of their different activities in different 1 Indicative are the facts that the chapter "The Philosophy of Leadership" in Bryman et al. 2011 is co-written by business school specialists in organization studies; that the guest editors of two 2017 special issues on "Philosophical Contributions to Leadership Ethics" of the prominent journal Business Ethics Quarterly all come from business, management, and organisational studies, and that of the thirty-two contributors to a recent collection on virtuous leadership (Newstead and Riggio 2023), only one is a member of a philosophy department.ways. 3Different concepts are often deployed, and even where there are broad similarities, different conceptions (be they analogically related) may be in play.In this connection it is important to recognise that notions featuring in a practice may not be applications of generic concepts but instead be ones that have emerged out of it, as ways of framing and dealing with recurrent issues.Some of these matters are illustrated and discussed in the following sections, but the general point is akin to that made by Wittgenstein in the epigraph above: the importance of resisting the temptation to think that things which look different (here diverse forms and cases of leadership) are really the same, and to be alert to the possibility that things which look the same (illustrations of leadership) are really different.

| A M ET HODOLOGICA L PR E L I M I NA RY
In thinking philosophically about ethical issues, there is a tendency to over-generalise.This has two aspects: first, assimilating quite diverse and often highly specific features and situations to a few broad categories and, second, approaching themes and topics through the lens of general and highly abstract ethical theories.The latter is particularly marked in a conception of applied ethics that, though now largely disavowed among moral philosophers, remains prominent in courses and publications concerned with ethical aspects of leadership, management, and professional practice across a wide range of fields.This involves the application of an existing theory as in utilitarian, deontological, and virtue approaches to some practical matter, analogous to the procedures involved in applied mathematics or applied chemistry. 4 Accordingly, for the applied ethicist the specificity and particularities of an issue are relevant only in so far as they can be described in terms of some predetermined classification, as, for example, promoting or diminishing welfare, or respecting or violating rights.
Advocates of "virtue ethics" are apt to congratulate themselves on avoiding the abstracting and simplifying tendencies of consequentialism and deontology, but they are not themselves free of the problematic generalising and theorising orientations.It is a mistake even to think of a turn to "virtue" in terms of the adoption of a competitor theory, rather than an emphasis on the evaluation of character and motive (see Haldane 2019), and even when that impulse is avoided there remains the issue of oversimplification.In the Nicomachean Ethics (V, I), Aristotle observes that there are two ways of speaking about actions as "just" or "unjust": one ("complete justice") meaning something akin to "right" or "wrong," which applies across the full range of virtues and vices; the other ("particular justice") relating to a specific field of action concerning what is due to others.But within this latter field of action he further distinguishes between distributive and corrective justice; and in his commentary on Aristotle's text (Sententia Libri Ethicorum) Aquinas draws additional distinctions, including commutative and retributive justice.Still in the same tradition later scholastics distinguished further orders and classes of domain-specific principles of justice and of other virtues. 53 Here it would be profitable to consider Alasdair MacIntyre's insightful account of the relationship between practices, traditions, institutions, internal goods, and virtues (MacIntyre 2014, chap.14, "The Nature of the Virtues," esp.187-203).So far as I am aware, MacIntyre nowhere discusses the virtues of leadership, but he does discuss the vices of certain conceptions of management (MacIntyre 2014, 74), and others have begun to apply his thinking to the issue of business leadership (Sinnicks 2018).For an exploration of one kind of leadership within a specific field of tradition-constituted practice, that of visual art, and the changing conceptions of this, passing from exemplar, to master, to critical-advocate, see Haldane 2024a. 4So conceived, "applied ethics" began as an instance of "applied philosophy" (Stevenson 1970).This conception deployed in By way of illustration, consider two spheres: those of economics and of warfare.Reflecting on the requirements of justice in connection with economics is apt to bring to mind such matters as fair pricing, fair trading, and fair wages.But much more fundamental so far as the structure of capitalism is concerned is the matter of the accumulation and investment of monetary wealth.Historically, money was seen as a unit of exchange abstracted (unlike barter) from the character of the goods and services purchased by it.But by stages money came to be regarded as itself a kind of commodity that could be traded privately or in a public marketplace.One form of that trade was the renting out of money, more familiar as cost-bearing loans.What does the virtue of justice, characterised as giving what is owing to others, have to say about this?At that level of abstraction it is apt to be silent, or more accurately dumfounded, since the general formula "giving to others what is their due" is too remote from the specificity of the practice, the parties, their roles, and their relationships.If it seems otherwise, that is because the relevant subject-and context-specific determinations are implicitly assumed.It takes a good deal of serious thinking about the issue to come up with ethical positions, and that needs to be done not deductively but abductively: that is, not as applying a prior formula but as arriving at principles from consideration of the specificities of the practice, taking account of such matters as opportunity costs, the difference between loans and investments, and the difference between the rights and responsibilities of individuals and of agents of common resources.Thus, following Aquinas (Summa Theologiae, Secundum Secundae q.78), the scholastics distinguished between usury (making a charge for the use of the money additional to the return of the principal sum provided) and legitimate interest.The latter is a charge additional to the loan itself, an "extrinsic title" of which six varieties were identified: damnum emergens (cost incurred to the lender), lucrum cessans (loss of income to the lender), poena conventialis (compensation for late payment), periculum sortis (risk of default by the borrower), and praemium legale (incentive for useful lending). 6n the case of warfare, it seems obvious to us that there is a significant moral difference between soldiers on the battlefield, directly engaged in the fighting, and others associated with, but not members of, the immediately warring parties.Today we are apt to describe this in terms of a distinction between "combatants" and "non-combatants."But if that is presumed to be an ethically relevant difference, then it is not one that was always recognised even among "high" civilisations.For the Greeks and Romans, warfare was directed to conquering entire populations, and the norms of war ("common customs"-koina nomima for the Hellenes, bellum Romanum for the Romans) allowed that defeated populations might be massacred, enslaved, or held for ransom (see Green 1998).Nor is it universally held by contemporary philosophers that killing non-combatants is worse than killing combatants (Tadros 2018).Again, the general principle that justice requires giving to others what is their due is too abstract to settle the question of right conduct in war.There is, however, a notion developed within the just-war tradition of "non-combatant community," but this was not identified by the application of some pre-existing general principle of "innocence"; rather it was arrived at by thinking about the specificities of conflict and then produced inductively as a principle of justice in warfare ( jus in bello).Here, as in the case of "money ethics," the relevant principles are specific and diverse and not consequences of a highly generalised virtue of justice.So, in thinking about virtuous leadership in relation to banking and financial services, or the military and other fields, one would do well to avoid the formulaic approach of trying to apply some general ethical theory to a wide range of cases.One should begin instead with specific spheres in which authority and leadership are, and need to be, exercised and think about the justifying conditions and ethical dimensions of these, distinguishing between the authority of appointed office (institutionally warranted), of directive role (practically warranted), and of expertise (epistemically warranted).

| R E A L PROBL EM S
Having been cautioned against simplistic ethical thinking, it does not take much sophistication to recognise the kinds of gross failures of leadership that have occurred in recent times in the spheres of banking, commerce, entertainment, health care, military action, policing, politics, religion, and therapeutic services.To these should be added the domains of academia, broadcasting and journalism, the charity sector, and schooling.There is a lengthy and substantial tally of charges we could lay at the feet of sector leaders who have ignored, overseen, and in some cases facilitated and even practised cynical appeals to racism and xenophobia, financial and reputational aggrandisement, sexual exploitation, hypocritical espousals of virtue by corrupt moral and "spiritual" figures, deployment of academic position in the service of political advocacy, political displacement of intellectual excellence in favour of ethnic, sexual, and other identities as criteria of appointment and promotion, systematic mis-selling of goods and services, and so on.
The question: What principles of leadership or character traits would prevent or limit such faults and failures?though well intentioned, is not well conceived.First, different contexts often provide different kinds of opportunities and temptations and call for different sets of personal qualities.Second, the role of virtue is not primarily as a counterforce to vice but as an orientation towards the good.Third, the nature of leadership is complex and variable: sometimes it is highly specified and defined in terms of tasks, roles, and responsibilities; at other times it is loosely indicated.Fourth, there is an ambiguity in the notion of a virtuous leader that is often blurred, between leaders who are personally virtuous and lead, and ones who have leadership qualities but have unethical aspects to their personal lives.Fifth, and very importantly, there is an asymmetry between acting well and acting badly.In general terms, acting well requires doing well in respect of different evaluative criteria: doing (1) the right kind of thing, (2) for the right reason, (3) in the right way, (4) towards the right end.Failure in respect of any one of these constitutes acting badly (see Haldane 2011).Whether that is serious depends on the specifcs of the case, and we have a range of evaluative terms for expressing such kinds and degrees of assessment: "well-intentioned but misconceived," "well meant but short-sighted," "procedurely correct but inappropriately handled," "appropriate but self-serving," and so on.Given that, in the sense indicated, it is easier to act badly than to act well, do we want to maintain this general logic of evaluation in contexts of leadership or restrict the dimensions of assessment in number or in kind-making them only role, or task, specific?

| PU R PORT E D SOLU T IONS
A common response to the exposure of failings of leadership of the kinds listed above is to introduce policies and procedures designed to identify faults and active wrongdoing.Beyond this, however, are efforts to put in place ethics codes and training programmes.These efforts entail two kinds of ethical approaches.The first involves a package of policies including forms of self-regulation, codes of conduct, standards of practice, and confidential reporting of violations.In general, this might be termed an ethic of vigilant requirement.This was the main approach in the early phases of modern professional ethics.The second approach looks instead to moral formation seeking to inculcate habits of self-examination and benevolent intent, and it might therefore be termed an ethic of virtuous character.So 14679973, 0, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/meta.12704 by NHS Education for Scotland NES, Edinburgh Central Office, Wiley Online Library on [09/09/2024].See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions)on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License described, however, and in reality, both sorts of approaches tend to be both formalistic and atomistic.The formalism is that of procedures and aims conceived in general and not in domain-specific terms.Indicative of this is the commonality of the policies in which if any reference is made to a sphere of practice, it is in terms that allow for substitution of one sphere for another.The atomism is marked by the fact that the recommended policies of vigilant requirement or virtuous character formation view these matters in isolation from broader aspects of moral requirement and virtuous character.It is as if they are deemed only to apply to the context under consideration and are indifferent to how parties act in other contexts.
Consider in this connection the issue of political leadership.Until the point of Joe Biden reluctantly yielding to the pressure on him to withdraw from the race, both of the leading nominees in the 2024 U.S. presidential election were burdened by questions of competence, probity, and integrity.The case of Donald Trump is obviously far more weighty and farreaching in regard to wrongdoing and disregard for principles of probity than that of Joe Biden.Trump has been the subject of several civil actions and criminal charges since leaving office in January 2021.Biden, however, was evidently in serious mental decline even before the election debate that led to his withdrawal.He has also faced questions about overlaps between his past Senate committee assignments and later legislative priorities, and about his son Hunter's financial interests and manner of advancing them.In Israel, Prime Minister Benjamin Netanyahu has been indicted on bribery and fraud charges in three different cases, and the criminal trial is ongoing even as he oversees a military campaign against Hamas that appears to violate more than one of the conditions of just ( jus in bello) warfare. 7Meanwhile, Netanyahu's strongest supporter among European leaders, Hungarian prime minister Victor Orban, is accused of having established a form of kleptocracy: channelling public funds to political associates and restricting the freedom of the judiciary, the central bank, and the press.It is not hard to find other problematic figures in democratic leadership positions in recent times, such as the two former French presidents Jacques Chirac and Nicolas Sarkozy, each convicted of crimes committed in relation to political activity, embezzlement, and corruption, respectively, and the former Italian prime minister Silvio Berlusconi, to whom Trump has often been compared.
Whether the current political leadership situation is worse than has prevailed in past decades is a moot point, but the fact remains that there is a perceived problem regarding the moral character of contemporary political leaders in major democratic states (to say nothing of other settings).What is to be done about this?One answer is to find ways of forming strong moral character in aspiring politicians (Swaine 2013).This immediately raises several questions: What constitutes moral character?Is it a general, topic-neutral quality or something defined in respect of particular spheres of activity without reference to others?There is a familiar issue highlighted by Machiavelli, emphasised by political realists and acknowledged by more holistically minded moral thinkers: the unavoidability in the pursuit of legitimate and even obligatory political ends of acting in ways that would be deemed unvirtuous in the sphere of personal life. 8 In his essay "Politics and Moral Character" Bernard Williams begins by asking, "What sorts of person do we want and need to be politicians?"Restricting the scope to the sphere of such persons' political actions, he goes on to observe: 7 In particular, that the goods to be achieved must be greater than the probable evil effects of waging war and that the means must not themselves be evil: either by being such as to cause gratuitous injuries or deaths or by involving the intentional killing of innocent civilians (see Haldane 1989). 8See Machiavelli 1995, 48: "Anyone who wants to act the part of a good man in all circumstances will bring about his own ruin, for those he has to deal with will not all be good.So it is necessary for a ruler, if he wants to hold on to power, to learn how not to be good, and to know when it is and when it is not necessary to use this knowledge."For more recent and less extreme but nonetheless pragmatic discussions of the limits of virtue see Kennan 1985 andNagel 1978.It is a predictable and probable hazard of public life that there will be situations in which something morally disagreeable is clearly required.To refuse on moral grounds ever to do anything of that sort is more than likely to mean that one cannot seriously pursue even the moral ends of politics.… If [the space of decent political existence] is to have any hope of being occupied, we need to hold on to the idea, and find some politicians who will hold on to the idea, that there are actions which remain morally disagreeable even when politically justified.… The point-and this is basic to my argument-is that only those who are reluctant or disinclined to the morally disagreeable when it is really necessary have much chance of not doing it when it is not necessary.(Williams 1978, 60, 62) In light of the real and intractable problems facing politicians (and others in leadership in other spheres where requirements may be in conflict), there is something Pollyannaish about the suggestion that cultivating virtue is the solution to the issue of leadership.No doubt virtue is part of the answer, but if one is to take seriously the fact of the different demands arising in diverse departments of life or spheres of activity, and consider the possibility of an incommensurable plurality of goods (and evils) and the fact of genuine dilemmas, then a more serious investigation is required of the specifics and particularities of different domains, and of the relation between virtutes simpliciter (virtues unqualifiedly) and virtutes secundum quid (virtues with respect to particular activities).

| L E A DER SH I P A BUSED
With that purpose in view, I turn shortly to consideration of a particular sphere: health care, looking at historical developments of ethical thought and leadership within it.Before that, however, it is appropriate to note one recently and continuingly prominent form of self-avowedly ethical leadership: that in which senior figures in private and public corporations and institutions associate themselves and their organisations with contemporary social causes.Often this seems a form of self-promotion, motivated by a wish to demonstrate one's own or one's institution's virtuous character in order to secure approbation and thereby personal or institutional advantage, or at least to escape criticism of some aspect of one's history, policies, or activities.Apart from the familiar distaste at displays of self-righteousness, this practice is increasingly inclined to induce scepticism and even cynicism among observers, leading to accusations of some sort of "washing": "green" (environmental), "pink" (LGBT), "blue" (U.N. related), and "social" (diversity, equality, gender, and so on) (see, e.g., Berliner and Prakash 2015).Beyond that, corporate socio-political activism is increasingly meeting with client/consumer opposition and inclining to alienate rather than to persuade.Recent U.S. examples of this include Budweiser, Chick-fil-A, Disney, and Nike (Hou and Poliquin 2023) and the corporate, including major bank funding of the Australian "yes campaign" regarding the Indigenous Voice to Parliament referendum (see Hutchinson 2024 and, on the broader issues, Haldane 2024b).
There, is, however, a different criticism, which focuses not on the motives but on the appropriateness of such activity.Organisations such as schools, colleges, and universities, public bodies such as hospitals, security forces, and military forces, institutions such as banks and businesses, and commercial manufacturers of goods and providers of services exist for specific purposes and are organised and led so as to achieve their purposes efficiently and effectively.Virtuous leadership in these various fields and operations has three relevant aspects: one regarding the quality and manner of delivery of the goods or services in question, another concerning the procedures by which the goods or services are produced, and a third relating to the conditions of those employed within the organisation.It is not the responsibility or the privilege of such leaders to involve their organisations in the promotion of extrinsic projects or campaigns, other perhaps than relevant charitable and philanthropic support.Corporate social responsibility is likewise a proper concern, but extrinsic activism in the form of advocacy for (or opposition to) causes in contested social and political fields is an abuse of leadership.It is liable to be contrary to its proper exercise because it implicitly associates employees with the character and substance of the intervention and is thereby a form of disrespect of their autonomy, in some cases a form of coercive co-option.Again, the idea of virtue secundum quid is relevant, for the business of virtuous leadership pertains to its proper sphere of operation, and that is defined by the character of the organisation and its purposes.

| A N H I STOR ICA L EX A M PLE
At this point I shift from the present to the past, and from leadership in the domains of politics and business to a sphere more obviously and immediately concerned with the human good.Long before it became fashionable to speak of "professional ethics" and "leadership formation," professional practitioners often combined the pursuit of a career with a serious interest in moral questions arising specifically in the area of their practice.One such was the English physician Thomas Percival, who in 1794, in response to a request for a code of conduct from the Trustees of the Manchester Infirmary, circulated a privately printed text entitled Medical Jurisprudence containing an ethical code for doctors.This was met with much interest among his colleagues encouraging him to develop it further, and nine years later he published a revised and expanded version introducing for the first time the now familiar expression "medical ethics" (Percival 1803).
Others have likewise recognised that while modern medicine provides historically unparalleled means and opportunities for securing human goods, it also poses challenges and temptations that may lead to moral harms.Most obvious is the abuse of medical standing and skills, an issue brought to British public attention through the case of the general practitioner Harold Shipman, who before his arrest in 1998 murdered 250 of his elderly patients by administering or prescribing fatal overdoses of medications.The general issue, however, is ancient and adverted to by Plato in the Republic (333e) when Socrates asks, "And isn't it the person who knows how to give protection from a disease who is also the expert at secretly inducing the disease?" (Plato 1998, 12).There is also the less obvious but nonetheless harmful tendency to view the human body in mechanistic and materialist terms and thereby to lose sight of the higher-order realities of the person and of personal value, notions historically linked to the idea of the sacred.
The year following the publication of Percival's work, Pope Pius VII was in Paris for the coronation of Napoleon, and at a reception in the Grand Hall of the Louvre a group of French medical students, members of the group Auxilium christianorum, was presented to him.It included two who would later become famous: Gaspard Bayle, the inventor of the stethoscope, and the cancer pathologist René Laennec.The pope is said to have remarked with surprise and a smile "Medicus pius, res miranda!" ("A pious doctor, what a wonder!").The point and force of his remark relates to the fact that during the eighteenth century medicine had become associated with a "de-sacralisation" of the human body and with a growing "philosophical" materialism.
Six months previously, Pius VII had granted a dispensation to the normal process of considering candidates for beatification in order to accelerate the recognition of the renowned moral philosopher and theologian Alphonsus Liguori (1696Liguori ( -1787)).In his Theologia Moralis, volume IV, of 1755 and in his Praxis Confessarii of 1771 (Liguori 1905(Liguori -1912) ) he addresses the duties and culpable failings of physicians.These relate to the requirement to be properly trained, to be responsible in treating patients, to be available, attentive, and diligent, to follow established 14679973, 0, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/meta.12704 by NHS Education for Scotland NES, Edinburgh Central Office, Wiley Online Library on [09/09/2024].See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions)on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License practice, to be cautious, to avoid harm, to attend to needy paupers, and so on.Beyond these aspects of ethical conduct, Liguori addresses the obligations not to facilitate wrongdoing by patients and to observe spiritual responsibilities.Principal among the latter he identifies the duty to alert patients to the need to make confession lest they die in a state of serious sin.

Liguori writes:
How terrible it is to see so many of the ill brought to the extremity of death … when they can hardly speak, barely hear, scarcely grasp the state of their own conscience … and this is entirely the fault of those physicians who, lest they displease patients or their relatives, do not make them certain about their danger, but rather go on deluding them up to the point that they themselves despair entirely of their patients' lives.… [T]he spiritual health not only of the physician but also of all patients who are under his care depends upon this matter.
(Qtd. in Amundsen 2008, 225) While the concern for patients' spiritual welfare is specified in relation to a particular religious conception of life, death, and judgement, the sense of the duty of a doctor to alert patients to the risk or discerned prospect of death in order that they should make preparation for it was a widely discussed issue of the time and remains an issue today.In 2013 the British Medical Journal published under its "Head to Head" feature two articles addressed to the question "Do patients need to know they are terminally ill?"This is answered "yes" by the London-based, palliative-medicine practitioners Emily Collis and Katherine Sleeman, who argue: "Patients have the right to make informed decisions about their healthcare … [and this] is no less relevant for a patient with terminal illness, for whom an awareness of the incurable and life limiting nature of their underlying condition is essential to decision making" (Collis and Sleeman 2013, 20).
Two contrasts with Liguori may be noted: first, the obligation is specified in terms of the rights of patients rather than directly by reference to the duties of doctors (and without mention of any duties upon patients to make preparations); and, second, the interests towards which the rights are directed are non-spiritual ones.That said, there is no reason to think that the authors would mean to exclude spiritual interests.
In an article answering "no" to whether patients need to know they are terminally ill, Leslie Blackhall, head of the palliative care section of the University of Virginia School of Medicine, argues: "[Telling patients they are terminally ill is a failed model for medical decision making that creates more suffering than it relieves," and "patients with advanced cancer and poor functional status do not need to know that they are terminally ill so that they can 'refuse' chemotherapy or cardiopulmonary resuscitation.In most cases they should not be given these treatments exactly because they are terminally ill" (Blackhall 2013, 20).This, however, seems neglectful of the idea that there may be a need (whether or not there is a preference), and perhaps a duty, to prepare for death.The focus on minimising suffering is intelligible, but it addresses only the hedonic aspect of the quantitative quality in life, neglecting autonomy and duties to self, and entirely omits consideration of the idea of the nonquantitative quality of life (see Haldane 2009c), let alone the possible interest in an afterlife.In this case it seems that the "spiritual" is not merely overlooked but is implicitly denied.Here there appears to be an expression of the outlook that Pius VII associated with the influence among French physicians of the materialism advanced by La Mettrie in L'homme machine (1747).
The code Duties of a Doctor Registered with the General Medical Council (which registers doctors to practise medicine in the United Kingdom) echoes aspects of Liguori's skill, performance, and safety duties, and goes on to tell doctors they must "[t]reat patients as individuals and respect their dignity.… Give patients the information they want or need in a way they can understand.Respect patients' right to reach decisions with you about their treatment and care.… Be honest and open and act with integrity.Never abuse your patients' trust in you or the public's trust in the profession." 9 Meanwhile, the American Medical Association's Code of Medical Ethics includes among its "Principles": "A physician shall uphold the standards of professionalism, be honest in all professional interactions … make relevant information available to patients … shall, while caring for a patient, regard responsibility to the patient as paramount."And in its list of "Ethics Opinions" further states: "The patient has the right to receive information from physicians" and: "The patient has the right to courtesy, respect, dignity, responsiveness, and timely attention to his or her needs." 10 The wording and intent of these codes have to be interpreted, but it would be reasonable to say that they prescribe no "deception."Against this, however, it has been observed that the original version of the AMA code adopted at the meeting of the National Medical Association in Philadelphia in 1847, which declares itself, like most then existing U.S. codes, to be based on Thomas Percival's 1803 Medical Ethics, was used "to support and explain the recommendation against disclosure" (see Sokol 2006).Chapter 1.4 of the 1847 code states: A physician should not be forward to make gloomy prognostications because they savour of empiricism, by magnifying the importance of his services in the treatment or cure of the disease.But he should not fail, on proper occasions, to give to the friends of the patient timely notice of danger, when it really occurs; and even to the patient himself, if absolutely necessary.This office, however, is so peculiarly alarming when executed by him, that it ought to be declined whenever it can be assigned to any other person of sufficient judgment and delicacy.For, the physician should be the minister of hope and comfort to the sick; that, by such cordials to the drooping spirit, he may smooth the bed of death, revive expiring life, and counteract the depressing influence of those maladies which often disturb the tranquillity of the most resigned, in their last moments.The life of a sick person can be shortened not only by the acts, but also by the words or the manner of a physician.It is, therefore, a sacred duty to guard himself carefully in this respect, and to avoid all things which have a tendency to discourage the patient and to depress his spirits. 11  Given a desire to avoid telling patients that they are approaching or are at serious risk of death, one might well invoke the idea that doing so would discomfort them, and even hasten their demise; but it is disingenuous to interpret the code, and Percival's original, as intending to warrant general non-disclosure, let alone strict deception.Not worsening patients' mental or physical state is compatible with telling them that death is approaching, and more to the original point the code(s) speak of "not fail[ing], on proper occasions, to give to the friends of the patient timely notice of danger, when it really occurs; and even to the patient himself, if absolutely necessary," be it that the disclosure to the patient may be mediated by another.
"Proper occasions" and what is "absolutely necessary" are not specified, but they could hardly exclude circumstances in which patients have only a limited opportunity and a practical (let alone existential) need to attend to their affairs and to the state of their "soul."Consideration of their soul, on any account, be it religious, metaphysical, or moral, is a no less and a presumptively more profound basis than, say, the disposition of material property.Of 9 See http:// www.gmc-uk.org/ guida nce/ good_ medic al_ pract ice/ duties_ of_a_ doctor.asp. 10 See https:// code-medic al-ethics.ama-assn.org/ princ iples and https:// code-medic al-ethics.ama-assn.org/ ethic s-opini ons/ patie nt-rights (accessed 15 August 2024).11 https:// www.ama-assn.org/ sites/ ama-assn.org/ files/ corp/ media -brows er/ public/ ethics/ 1847c ode_0.pdf (accessed 15 August 2024).
14679973, 0, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/meta.12704 by NHS Education for Scotland NES, Edinburgh Central Office, Wiley Online Library on [09/09/2024].See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions)on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License course, someone may deny that there is any such ground, but this returns us to the scientific materialism that concerned Pius VII, which is increasingly common among medical practitioners today (see Saba andTagliagambe 2023 andShelley 2019).
Analogous concerns about such associations and the threat they present to traditional medical values and principles, as well as to the good and dignity of patients and to the condition of society at large, have encouraged Christian, Jewish, and Islamic medics to make provision for practising physicians to come together to consider and discuss ethical issues in the light of theological conceptions of human persons and their destiny.It is also common for such people to speak of the obligations attaching to their vocation as well as to their profession.It is in the nature of these attributes, however, that as well as being merely conjoined they can also qualify one another.One may profess a vocation, and a profession may itself be a calling.This raises the question of how profession and vocation may be aligned so that profession may be a source of discernment and deepening of vocation, and not only in the case of health care but across the range of practices that are commonly characterised as professions.This issue is particularly pressing in relation to those holding positions of leadership, who are thereby able to influence others through direction, education, and example.

| PROF E S SIONS , PROF E S SIONA L ET H IC S , A N D PROF E S SIONA L E DUCAT ION
When reflecting on these matters it is important to note that practitioners within the medical, nursing, and broader health care professions, like those in other fields, have for most of their history managed to go about their business without the aid of professional academic analysis and commentary.This is not to say that their practice has been unreflective or without ethical or philosophical assumptions.Health care practitioners have deployed their particular forms of occupational knowledge in order to serve the interests of their clients, of themselves, of their profession, and of society at large.Failure in any one of these regards might then be expected to occasion failure in others.Ineffective, inefficient, or incompetent medics-or architects, or engineers, or lawyers-would soon be without patients or clients, at least if the patients and clients had knowledge and choice in the matter, and the former's bad reputations would quickly secure sanction from their peers, in part for reasons of "guild pride" but also for fear of bringing the profession into disrepute within society.
In all of this, medical and health care practitioners, and professionals in other fields, were guided by an appreciation of the specific values and qualities intrinsic to their professions (virtutes secundum quid), and by a sense of collective professional interest (communis cura).In addition, they recognised that, as members of groups that were viewed with respect as providing responsible, skilled expertise in areas important to the ongoing of life, they had broad societal responsibilities.None of these matters needed to be identified or emphasised by philosophers or professional ethicists, for they were part of common-sense knowledge acquired in the process of training.Indeed, since professions often ran in families, an understanding of the values and interests that shape professional practice could begin to be shaped from early childhood.
Here it is apt to recall that while "professional ethics" and even "medical ethics" as we have them today are relatively recent creations, the idea of professional codes of practice is an ancient one, often embedded in broader cultural and religious traditions.In Hebrew scripture the Pentateuch sets out ordinances concerning (a) the pricing and sale of goods, (b) periods during which someone may redeem items sold in time of poverty, (c) duties to hired servants, (d) the valuation of property, and so on (Leviticus 25 and 26); later it describes rules for the appointment of judges and the administration of justice (Deuteronomy 16).
A thousand years after the Pentateuch was written and more than two thousand years before Percival wrote his Medical Ethics, Hippocrates or one of his company wrote Of the Epidemics and observed the following: "The physician must be able to tell the antecedents, diagnose the present, and foretell the future, practice these things, and have two special objects in view with regard to disease, namely, to do good or at least to do no harm.The art consists in three things: the disease, the patient, and the physician.The physician is the servant of the art, and the patient must co-operate with the physician in combatting the disease" (Hippocrates 1849, I, II,5,365).In Of Prognostics the same author offers advice to his fellow medics on the value of developing skills of prognosis: By foreseeing and foretelling, in the presence of the sick, the present, the past, and the future, and explaining the omissions which patients have been guilty of, [a physician] will be the more readily believed to be acquainted with the circumstances of the sick; so that men will have confidence to intrust themselves to such a physician.… Thus a man will be the more esteemed to be a good physician, for he will be the better able to treat those aright who can be saved, having long anticipated everything; and by seeing and announcing beforehand those who will live and those who will die, he will thus escape censure.
(Hippocrates, 1849, I, 234) These commands and directions lay down regulations and prescribe duties and virtues for certain classes of agents and certain forms of goods and services, and to that extent they constitute part of the foundation of professional ethics.Given current interest in palliative care, it is relevant to note the ancient development of infirmaries, specifically for those with lifelimiting illness.Subsequent to the Council of Nicea (325 C.E.), the task was begun of establishing a hospital in every town in which a bishop presided, that being the centre of authority of a local church.Among the earliest of these was the Basilias, built circa 372 by Basil of Caesarea, Cappadocia (present-day Kayserai).A decade later Gregory of Nazianzus, the archbishop of Constantinople, wrote to the Cappadocians: A noble thing is philanthropy, and the support of the poor, and the assistance of human weakness.… [Basil] did not therefore disdain to honour those with this disease [leprosy], noble and of noble ancestry and brilliant reputation though he was, but saluted them as brethren … taking the lead in approaching to tend them, as a consequence of his philosophy, and so giving not only a speaking, but also a silent, instruction.The effect produced is to be seen not only in the city, but in the country and beyond, and even the leaders of society have vied with one another in their philanthropy and magnanimity towards them.
(Gregory of Nazianzus 1894, 43) Basil's hospice and related "corporal works of mercy" (Matthew 25:34-36) were innovatory, not a continuation of pre-existing pagan practice.In 362, fifty years after the conversion of Constantine and the start of the Christianisation of the empire, his nephew Julian the Apostate, who had rejected Christianity, sought to reverse his uncle's policy but encountered a difficulty.Writing to Arsacius, the high priest of Galatia, he complained: "The Hellenic religion does not yet prosper as I desire [though] … the worship of the gods is on a splendid and magnificent scale.Why, then, do we think that this is enough, why do we not observe that it is [the Galileans'] benevolence to strangers, their care for the graves of the dead and the pretended holiness of their lives that have done most to increase atheism [i.e., Christianity]?I believe that we ought really and truly to practise every one of these virtues" (Julian 1923, 68).
Basil and the Christians of Galacia were leaders in creating a new "profession" informed by a new ethic.This ethic emphasised that the offices of care were vocations defined in relation to the example of Christ and his disciples, and to the theological virtues of faith, hope, and charity.These roles, like the ancient codes of conduct, are, save in the case of Hippocrates, religious in source, and all were addressed to particular groups, whereas contemporary professional codes justify themselves in terms of secular reasoning and aspire to universal application.Because of the familiarity and seeming ahistoricity of the contemporary codes, it is easy to miss the fact that they form but one structure relating virtue, profession, and leadership in one conception of those categories.
Looking to history (and contemporaneously to different cultures) one can see other patterns in some ways analogous to but in other ways different from the familiar, noting also that one form of leadership consists in the creation or transformation of a profession: such was the virtuous leadership of Hippocrates, Basil, and Thomas Percival.This bears on several issues introduced and emphasised earlier: first, Wittgenstein's general point about attending to differences; second, that of the ways in which practices are informed by conceptions that are shaped by (and themselves shape and reshape) traditions and associated institutions; and, third, the fact that proper leadership requires focussing on the goods internal to specific practices, and beyond that, in so far as the leadership is more broadly virtuous, having some thought for the relation between these and more extensive human goods.

| CONC LUSION
Among the causes of the emergence of contemporary professional ethics and the focus on leadership, two are salient.First, from the 1960s various professions found themselves objects of suspicion.Some of this suspicion related to scandals, in which architects, doctors, engineers, lawyers, and teachers were accused of acting corruptly, either in their own interest or in that of colleagues or clients.Second, and more important from an academic perspective, was the approach to social institutions that viewed them as being at best unreflective about their own nature, ends, and activities, and at worst bastions of privilege and agents of injustice.
So far as the professions were concerned, this latter indictment held that the notion of a profession was a social construct designed to add the mystification of status to a set of competences, to secure exclusivity of entry and continuing membership, a method of protectionism, and an entrenchment of social inequality.So conceived, professions were accused of being service monopolies, unanswerable to general societal norms.In response, the professions themselves began to revise or formulate codes of ethics and practice.Some defenders of professional roles also claimed that their primary goal was not to advance any particular conception of life in its various departments, let alone overall, but to serve the interests of their clients by presenting impartial and disinterested analyses of required action, with designs for how the latter might then be implemented.Inevitably, these defences met with a further round of criticism.Professional codes were charged with being no more than efforts to limit the risk of litigation; claims of objectivity were challenged as concealing implicit values; and talk of serving society was accused of being a cover for asserting one set of values over others.
One upshot of these exchanges was a trend among academics to rein in their accusations, and for the professions to allow some external assistance of the sort that philosophy could provide.So was born the field of academic professional ethics, and the more recent development of ethical leadership formation.In many ways these have been positive developments.They have, however, also served the interests of other professional fields: those of "applied ethicists" and of "ethical leadership experts," whether practising under those titles or some others.For, the same period as saw self-questioning among the professions also witnessed the massive expansion of higher education in Europe and North America.With more students enrolled in colleges and universities, there was an occasion for hitherto select disciplines to expand; and philosophers and others saw their opportunity.
First came service courses, then textbooks and journals, then conferences and societies, then anthologies, encyclopaedia entries, and handbooks.New branches of academic subjects were conceived, born, and rapidly developed.Quite apart from their capacity to sustain a population of members of traditional departments, these new fields created opportunities within professional schools.Between them these two groups have generated interesting material, but for the reasons considered earlier, including over-generalisation, they stand somewhat apart from the practical realities of professional practice and also removed from the intellectual core of philosophy and related theoretical disciplines.
Thus, while philosophers of a particular professional field carry out the useful task of pointing to some of the complexities involved in understanding the distinctive practices of that profession, and explore the complex network of obligations to clients, to colleagues, to the professions per se, and to the general public, certain broader questions remain unanswered.Yet these include matters more important than the details of professional codes, since they bear very powerfully and very directly on whether those codes amount to anything substantial and effective.The recent turn to the cultivation of character and virtue is a valuable development, but it is best pursued when approached with real knowledge of the history and specificity of the domains and practices it seeks to serve, and with attention to the pre-existing modes of ethical reflection associated with professional practice and leadership.

AC K NOW L E DGM E N T S
The present text derives from a presentation at the University of Birmingham Jubilee Centre for Character and Virtues conference entitled Virtuous Leadership and Character held at Magdalen and Oriel Colleges, Oxford, in Juanuary 2024.I am grateful to an anonymous reviewer for constructive comments and suggestions that have helped me improve the paper.

R E F E R E NC E S
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