Patients' Responsibilities: II. Virtues of Patients

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Although considerable attention has been given to virtues in medicine (Drane; Pellegrino and Thomasma, 1993), most writings focus on the virtues of caregivers rather than on those of care receivers. Patients writing about their experiences of illness (Abram; Sacks; Scott-Maxwell) often struggle with questions of virtue and character, but they tend not to express those questions in systematic or theoretical form. Little has been written on patients' virtues per se.

Several commentators suggest that virtues of different people involved in medicine have to be correlated with the goals or purposes of the medical encounter (Drane; Pellegrino and Thomasma, 1993). For example, in For the Patient'sGood, Edmund Pellegrino and David Thomasma (1988) suggest that the virtues of a good patient include truthfulness, probity (or an effort to uphold one's end of the healing relationship), justice, tolerance, and trust (which includes some elements of gratitude and friendship). These virtues arise out of the model of obligations appropriate to the internal goods of the practice of medicine. In The Virtues in Medical Practice, Pellegrino and Thomasma add benevolence, humility, and courage. These virtues, which apply to practitioners as well as patients, "dispose both parties to act well in relation to the ends of medicine" (1993, p. 194).

However, Edmund Pincoffs argues that virtues cannot be reduced simply to qualities related to the internal goods of a practice. If virtues are correlative to role-specific duties, as Tom Beauchamp and James Childress suggest, then patients might be expected to exhibit the virtues correlative to their duties of truthfulness, compliance with treatment regimen, and respect. However, such a view would neglect important virtues, such as gratitude, that are not readily identified with action guides.

Both Karen Lebacqz and William F. May address the virtues of patients as qualities that emerge in response to the situation of illness or limitation, but not specifically as qualities having to do with the doctor–patient or caregiver– care receiver relationship and not specifically as correlated with duties. Drawing on both fictional (Solzhenitsyn) and real-life (Abram; Fox; Scott-Maxwell) stories of patients, Lebacqz addresses the virtues of patients generally. May treats the virtues of the elderly within the general context of their confrontation with limitation, adversity, and death.

In line with other commentators (Drane; Hauerwas; Pellegrino and Thomasma, 1988), Lebacqz argues that virtue, which can be defined as a unity of the self, is not the same as specific virtues. Virtues are qualities or traits of character judged to be excellent. They emerge as general stances toward the world or as responses to situations. The situation of patients is generally characterized by bodily change, threats to self-identity and understanding, and the assumption of a new social role—that of "patient," with all its indignities, loss of control, and powerlessness. The virtues of patients are "excellences" in response to these situational changes.

Using classical virtue theory (Pieper), Lebacqz proposes that two "cardinal" virtues and one "theological" virtue are particularly appropriate to the situation of patients. Fortitude, or courage in the face of fear, is the first virtue for patients, who often wonder whether they have the strength to do what is needed. Fortitude includes both endurance and attack: both accepting limits and railing against limitation.

Prudence, or acting in accord with the real, is crucial for patients, who must learn to deal with new realities in their lives. The first aspect of prudence is perception; the second aspect is the willingness to act on what is perceived. Perception includes both listening, or contemplation, and removing hardness from the heart in order to value the little things in life.

Finally, Lebacqz suggests that hope in the sense of trust in the attainment of ends is crucial for patients (cf. Hauerwas, who argues that hope forms every virtue). In the face of despair and even terror, hope keeps patients from falling into despair. Humor is a central component of such hope.

Lebacqz stresses that there is no single pattern of virtue for patients and no one way of expressing relevant virtues. While she follows the Aristotelian pattern of assuming virtue to be a mean between extremes, she notes that virtues are culturally conditioned and, hence, what is considered virtuous in one culture may not be in another. For example, patient waiting might be prized in some cultures while aggressive resistance would be in others. Whereas Pellegrino and Thomasma (1988) note that healthcare providers often consider the "good patient" to be the one who is willing to suffer, Lebacqz rejects long suffering as a central virtue for patients. Similarly, virtues might be assessed differently for men and women in different cultures.

May's treatment of virtues of the elderly stresses several of those noted by Lebacqz. May also puts courage at the head of the list, and includes in it both endurance and attack. He places the virtue of prudence into the broader category of wisdom, and uses traditional categories to propose that prudence includes memoria, or learning from the past; docilitas, or the capacity to be silent and thus to perceive; and solertia, a readiness for the unexpected and an openness to the future. He does not list hope per se, but does include humor or hilaritas ("celestial gaiety") as a virtue related to wisdom.

May also adds some virtues of the elderly in situations of illness. Since patients are "receivers," May argues that humility is a crucial virtue for them. It removes the sting from the humiliations that they must endure. While Lebacqz argues that patience is not always a virtue, May suggests that purposive waiting and taking control of one's own spirit under circumstances of adversity is a virtue. For the elderly, May adds the virtues of benignity, letting go of one's possessions in openhanded love, and simplicity, learning to travel unencumbered. Finally, he suggests that integrity is a virtue that expresses unity of character and implies both uprightness and wholeness. Although May does not list theological virtues per se, he does suggest that integrity points to the transcendent dimension.

These different treatments of patients' virtues suffice to indicate that there is no single list of virtues appropriate to patients and no agreed mechanism for deriving such a list. Nonetheless, using Pincoffs's sorting scheme, we might suggest that patients need both instrumental and noninstrumental virtues.

Instrumental virtues are geared toward the goal of restoring health. These fit best with the view that virtues are qualities intrinsic to the goods of an institution or practice such as medicine. In the case of patients, such instrumental virtues would include complying with appropriate treatment regimens (probity) and telling the truth about one's situation (honesty). These virtues support the goal of working toward the patient's health.

Patients also need noninstrumental virtues. In these, Pincoffs includes: (1) aesthetic qualities such as serenity, which comes close to May's virtue of simplicity; (2) meliorating qualities such as tolerance and tactfulness, which come close to notions of humor utilized by both Lebacqz and May; and (3) moral virtues such as fairness and honesty, akin to virtues urged by Pellegrino and Thomasma.

There is general agreement, then, that virtues are qualities of persons generally admired or praised in a culture, and that certain qualities are particularly important for patients: courage (or fortitude), wisdom (especially prudence), humor, hope, truthfulness, and faithfulness to the task of healing, whether through long-suffering endurance or through attack and resistance. In spite of this agreement, the assessment of what constitutes a virtue will be culturally conditioned and will likely reflect the biases of dominant groups in a culture.

karen lebacqz (1995)

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SEE ALSO: Beneficence; Care; Conscience, Rights of; Death; Healing; Law and Morality; Maternal-Fetal Relationship; Narrative; Pain and Suffering; Patients' Responsibilities: Duties of Patients; Professional-Patient Relationship; Trust; Virtue and Character


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