A very interesting paper in Academic Medicine entitled ‘A Humble Task: Restoring Virtue in an Age of Conflicted Interests’ (1) comments on the increasing replacement of relying on physician virtue by external regulation as a safeguard for patient care. The authors define virtue as ‘how we behave when no one else is watching.’ Accordingly, they argue, virtue serves as bedrock for professional self-regulation, particularly at the level of the individual physician. From the time of William Osler through to the end of the 20th century, physician virtue was viewed as an important protection for patients and research participants. More recently policy groups relying on social science data indicate that ethical decisions often result from unconscious and biased mental processes, particularly in the face of financial conflicts of interest. As a result external regulatory processes have increasingly replaced physician virtue as the main way to safeguard patients in the medical systems of many countries.
The authors argue that virtue is still needed in medicine – at least as a supplement to regulatory frameworks. For example, although rarely treated as a reportable conflict of interest, standard fee-for-service medicine can result in temptation to prioritise self-interest or institutional interests over patient interests. Because conflicts of interest are ubiquitous, physician self-regulation (professional virtue) is still needed. They further argue that humility must serve as the crowning virtue; that is a courageous willingness to recognize one’s own limitations. A contemporary understanding of humility has been offered by Coulehan2 , who proposes that humility requires three qualities:
“Unflinching self-awareness”; an ability to know your own strengths as well as a willingness to confront your weaknesses.
“Empathetic openness to others”; manifested by good listening skills and the ability to be present to the needs of others.
“A keen appreciation of, and gratitude for, the privilege of caring for sick”.
PRIME agrees with this, and would point to the example of Jesus, the Great Physician, who was unfailingly present to others and cared consistently for the sick during His time on earth. The authors say, ‘The first two of these qualities clearly support the very habits we recommend as a remedy for the self-serving bias that has called the very possibility of virtue into question: acknowledging our tendency toward biased decision making, practicing reflection, and soliciting input from respected others precisely in order to ensure that we protect our commitment to serving patients before ourselves.’ (This is strikingly similar to the Christian discipline of confessing our sins.) ‘The third quality suggests an even more fundamental habit: recalling the fundamental goals of medicine’.
The paper concludes by saying that, ‘educational programs for physicians, residents and medical students need to remind people of the primary goals of medicine. Physicians and institutions need to model decisions that prioritise patient interests. And medical ethics courses need to go beyond lecturing on rules and highlighting problems with conflicts of interest, by teaching the skills and habits that enable physicians to act in accordance with the goals of medicine, even when confronted with fatigue, strong personal rewards, and other challenges to integrity.’
Are you a virtuous physician, humbly aware of your own limitations, willing to be empathetically present to others and grateful for your privileged calling of caring for the sick? Are you concerned to role-model and teach these things to your students and juniors? It is PRIME’s vision that, with God’s help, we all should be so.
Huw Morgan Senior PRIME Tutor
Dubois JM, et al. A Humble Task: Restoring Virtue in an Age of Conflicted Interests. Academic Medicine.2013; 88:00-00. (published online)
Coulehan J. On humility. Ann Intern Med. 2010; 153:200–201.