By Julian C. Hughes.

Now more than ever, in the midst of the COVID-19 pandemic, we need the virtues and the insights that virtue ethics afford us. We have all read or heard the dilemma: there is a shortage of intensive care staff or beds so that triage must take place and doctors are placed in a terrible position. The older person with comorbidities, over against the younger previously fit person, is likely to lose out. The dilemma is described in terms of the tension between the duty to care for patients and the requirement that health care outcomes, at a population level, are maximized. The consequentialist (public health) argument wins rather than the deontological concern about the person in front of you. The upshot is that healthcare workers experience moral distress.

This scenario is indeed a deeply distressing one. But is it possible that virtue ethics might be helpful? And, if so, it is interesting that the possibility is scarcely mooted. It is sometimes said that virtue ethics is good at describing matters but not much good at prescribing what should be done. In which case, who wants the virtue ethicist to turn up and start telling people the extent to which they do or do not have the virtues? So, how does virtue ethics help?

Well, it does describe what is going on and this can in itself be helpful. In the dilemma we are considering we can formulate the problem in terms of tension between different inner dispositions or virtues. The doctor or nurse wishes to be compassionate and to show fidelity to the patient right here, but practical wisdom tells her that she has to follow the national guidance and the protocol for treatment decisions. This is simply to restate the dilemma in a different form, except that consideration of the virtues is psychologically more subtle than this. For the virtues are not, in reality, exercised one at a time. They reflect moral character, which is made up of numerous dispositions, not just compassion and fidelity versus practical wisdom, but also honesty, justice, steadfastness, humility, courage, integrity and so on. We face these dilemmas as whole people and, moreover, with others and with the virtue of solidarity. There will be a tension that leads to moral distress, but this is in the context of other inner moral characteristics that will be helpful. At least, they might be helpful once they are named and acknowledged.

It is possible to make an analogy with grief. This is a process, which might make it seem different from moral distress. But coming to terms with moral distress is also a process. Just as in grief it might be helpful to learn that people often feel anger or depression as part of a normal grief reaction, so too in moral distress. It is normal that, if you have the virtue of charity, you will feel a deep sadness when you have to allow someone to die because you also have the virtue of prudence. And it might be helpful to be told that you have been just; and that sticking to the guidelines requires a steadfast spirit, which takes courage.

Of course, just as grief can get “stuck” or can become all-consuming, so too moral distress might be overwhelming. In which case, the person needs help. But part of that help might involve discussing the person’s competing inner dispositions.  Understanding the virtues, being aware of them, might prove therapeutic.

In addition, virtue ethics also allows prescription. It suggests we should look to what the virtuous person would do. So, virtue ethics might well say to the doctor or other healthcare practitioner: show compassion, be brave, exhibit some integrity and the like. But, again, it does not do this in a crass way.

Once we are aware of the virtues and the role they play in our lives we can develop the tendency to ask ourselves questions about the decisions we are making. We can do this gently and in a human fashion. It is not an intellectual exercise, as it might be if I asked myself whether what I had just done was going to maximize welfare, or whether it is what I would choose if behind the veil of ignorance. No, the virtues suggest that I might ask myself, ‘Could I have imparted that news in a better way to the relatives?’; or I might pause to check some further details in the notes before I make a particular decision; or I might take a deep breath and tell myself to be brave as I ring someone up with some bad news, which I know I must impart if I am to be truthful. It is often said that virtue ethics is about what you become by what you do. It is how we develop and become better, more flourishing human beings, even in the face of tragedy. We do not avoid the tragedy or moral distress. We cannot metaphorically pat ourselves on the back for having done the right thing at a population level. The virtuous person will feel the distress but understand it as a natural consequence of the tasks he or she is required to carry out.

Finally, the virtue of solidarity also means that we are all in this together and it reminds us that the virtues are in evidence all around us during this crisis. They are seen in the small kindnesses extended by a neighbour, as well as in the sharing of research data in an open and transparent way between institutions and nations. We cannot and should not ignore the virtues. They are ubiquitous, as they should be, and we should laud them. They tell us how to live well as individuals and societies in the face of distress and hardship.

Author: Julian C. Hughes

Affiliations: Consultant for over 20 years and professor in old age psychiatry. He remains honorary professor at the University of Bristol and visiting professor at Newcastle University, UK.

Conflict of Interest: None.