How Good Do you have to be?

Palliative care is based on a philosophy that acknowledges the inherent worth and dignity of each person and most practitioners will have an ethical framework to base this on – commonly in Western practice this would be autonomy, beneficence, non-maleficence and justice. However, many of the ancient codes of medical ethics were virtue based. Pellegrino and Thomasma identified the importance of refocusing medical ethics on the personhood of the physician and the patient [1] this is particularly relevant for palliative care and medicine. For the purposes of this paper, a virtue is a trait of character that is socially valued and perceived to be morally good. So what kind of virtues might be useful in clinical practice?


Editorial
Palliative care is based on a philosophy that acknowledges the inherent worth and dignity of each person and most practitioners will have an ethical framework to base this on -commonly in Western practice this would be autonomy, beneficence, non-maleficence and justice.However, many of the ancient codes of medical ethics were virtue based.Pellegrino and Thomasma identified the importance of refocusing medical ethics on the personhood of the physician and the patient [1] this is particularly relevant for palliative care and medicine.For the purposes of this paper, a virtue is a trait of character that is socially valued and perceived to be morally good.So what kind of virtues might be useful in clinical practice?

Fidelity to trust
Trust is essential in human relationships.Trust is a confident belief in and reliance upon the ability and moral character of another person.Trust entails a confidence that another will act with the right motives on your behalf.In many ways we are forced to trust professionals, we depend on trust and the professional's desire to protect us rather than to exploit our vulnerability.
Examples of trust include truth telling and honesty.Unskilled attempts to inform patients have created a practice best described as the "assault of truth" [2].An example of this is the often quoted phrase "there is nothing more we can do".This sort of approach serves to induce helplessness, hopelessness and despair in the patient and family.As Elizabeth Latimer puts it "the door to any creative future is slammed shut and the patient has nowhere to look except death" [2].Among the contributing causes for the erosion of trust are the loss of intimate contact between clinicians and patients and the growth of large, impersonal and bureaucratic medical institutions.People who are dying have lost so many elements of their being that it is essential that they can maintain trust in their medical attendants.Without this they may be condemned to a dying filled with hopelessness, fear and uncertainty.

Compassion
The virtue of compassion suggests an active desire to alleviate another's suffering; an active regard for another's welfare with an emotional response of deep sympathy, tenderness and discomfort at the other person's misfortune.Compassion presupposes sympathy, has affinities with mercy and is expressed in acts of generosity of spirit that attempt to alleviate the suffering of the other person.Compassion could be described as suffering together with another, participation in suffering.It is important though to distinguish compassion from mercy, empathy, sympathy and pity [3].Mercy is compassion shown to someone who is in one's power and has no need to necessarily be kind.
Empathy is the capacity to imagine oneself as another; to feel and understand another's feelings; to enter into the emotional world of another.It is not simply an intellectual identification it must be accompanied by feeling.Sympathy is a sharing of feelings and fellowship, "I want to help you" but empathy brings emotion and the feeling that "I might be you" or "I am you".Compassion can however stem from empathy.Pity comes from inequality; it is easier perhaps to pity people who are sick or dying rather than to identify with them.In order to display compassion it is essential to remain engaged with the patient.

Phronesis/Discernment
Phronesis, or to be more readily understood, 'practical wisdom' accounts for knowledge that emerges and exists within the context of practice [4,5].Thus it includes the ability to make judgments and reach decisions without being unduly influenced by unnecessary considerations, fears or personal attachments.In Aristotle's model the discerning person (the practically wise) understands how to act with the right intensity of feeling, in just the right way, at just the right time and with the right balance of reason and desire.Socrates is known to have considered phronesis to be the same as being a virtuous person.Practical wisdom (phronesis) involves understanding what needs to be done for people, understanding how to do it and then acting with caring and sensitive responses.

Justice
"The strict habit of rendering what is due to others" [1].It can also be thought of as fairness or equity.There can be a tension between autonomy and justice.Autonomy exists when people act intentionally with understanding and without controlling influences.Autonomous actions however, may lead harm for others.For example, a person with HIV refusing to disclose information, an airline pilot or a doctor who is a substance abuser.Justice also requires that people are not put down or labelled in any way.Such labels can determine how people are cared for in the future and they may often have arisen from isolated encounters.So often, labels can imply intolerance -this in turn can lead to an expectation that there is a particular "right" way to live or a "right" way to die.

Fortitude
This virtue is co-extensive with courage; it implies the determination to keep on going.It implies temperance, that is, restraint or humility [1] the resistance to retreat from the right thing to do in the face of adversity.The virtues of courage or fortitude concern feelings of fear or confidence.It can require fortitude to help a person to decline an invasive form of treatment.It requires fortitude to stand with a family to obtain the treatment which should be their due in a health system with limited funds.
The decision to opt for palliative care rather than a futile search for a cure can require considerable fortitude on the part of the clinician if they truly believe that option is right.

Temperance
Temperance implies restraint or control in one's business or affairs.It can be synonymous with virtue itself.It is the virtue of doing well of knowing what we know and do not know and of modesty and selfcontrol.In many ways this virtue is closely allied to beneficence.Beneficence implies positive acts and includes all the interpersonal and clinical strategies that health care professionals use to reduce suffering and promote well-being.Temperance may need to be employed to a greater extent as our resources become more and more stretched.The balance between benefits, effectiveness and burdens of all forms and manner of treatments are what is implied in the application of temperance.

Integrity
The virtue of integrity represents two aspects of an individual.Firstly, an integration of aspects of the self-emotions, aspirations, knowledge etc. and secondly the trait of being faithful to moral values and standing up in their defence when they are threatened.Integrity defines who we are and it also integrates all the virtues.A person with integrity is someone who can judge the relative importance in each situation of principles, rules and guidelines and so on in reaching a decision.It is a balanced relationship between physical, psychosocial, spiritual and intellectual elements of our lives.This could be a definition of what palliative care should be about.
The clinician/patient relationship relies on integrity and trust.Neither party must impose their values on the other.This virtue goes back to the ethics of personal responsibility, the most ancient branch of medicine, the ethic of character and virtue.
All of these virtues however need to be used in a balanced way.Ideally clinicians would attempt to utilise some or all of these virtues in order to provide an effective and caring service not just for people who are dying but for all those who seek the help of health care professionals.