Summary
David Thomasma (1939–2002) was an American philosopher and bioethicist who, in a decades-long collaboration with Edmund Pellegrino, developed one of the most systematic defenses of virtue-based medical ethics in the twentieth century. Their joint project, spanning at least three major books and numerous articles, argued that medical ethics should be grounded not in externally applied principles but in the internal morality of medicine itself, derived from the nature of the healing relationship and the vulnerability of the sick person. Thomasma brought to the partnership a particular focus on the practical linkage between virtue and principle, proposing a typology of how the two interact in clinical moral reasoning.
Life and Career
Thomasma spent most of his career at Loyola University Chicago, where he directed the Medical Humanities Program. His philosophical formation, like Pellegrino’s, was Thomistic, and the two men shared the conviction that the Aristotelian-Thomist tradition offered resources for medical ethics that modern principlism lacked. The collaboration was genuine: their co-authored works bear the marks of two minds working the same problems from slightly different angles, with Thomasma often developing the more technical philosophical distinctions while Pellegrino supplied the clinical grounding.
He died in 2002, before the full reception of their work had played out, leaving Pellegrino to continue the project alone for another decade.
Methodology
Pellegrino and Thomasma occupied a self-consciously positioned methodological stance in twentieth-century moral philosophy. They adopted a realist Thomist position as their primary framework while drawing selectively on other thinkers, deliberately situating themselves midway between abstract ethical theory and the practical demands of clinical life (Pellegrino, 1993). This was neither pure casuistry nor pure theory but an attempt to ground clinical decision-making in a coherent account of human nature and the ends of medical practice. Their Thomist commitments, particularly the insistence that virtues must be referred to real ends, not merely to social conventions, separated them from both the contractarian and the pragmatist currents that were also at work in bioethics during the same period.
Intellectual Contributions
Three Modes of Virtue-Principle Linkage
Thomasma’s most distinctive independent contribution was a typology of how virtues relate to principles in moral reasoning. He distinguished three methods: “tacking on,” where motivation is added after determining what is right; mediation, where the virtuous agent resolves conflicts between competing principles; and substitution, where internalized virtue renders explicit rules unnecessary (Pellegrino, 1993). This typology addressed a central objection to virtue ethics, that it cannot guide action without collapsing back into rules, by showing that the relationship between character and principle admits of degrees.
[GAP: Underlying this typology is a tighter structural claim: virtues, principles, and duties are linked through the ends of medicine rather than operating as separate normative registers.] [GAP: In this account, principles state what is right; duties are obligations assumed by those entering medicine.] Virtues dispose the agent to choices that actually attain those ends (Pellegrino, 1993). [GAP: The three therefore form an integrated normative structure rather than competing frameworks, a point that differentiates the Pellegrino-Thomasma approach from both Kantian deontology and from virtue ethics treated as a complete and self-sufficient alternative.]
The Ends of Medicine
With Pellegrino, Thomasma argued that the ends of medicine are the restoration or improvement of health and, more proximately, healing; curing illness and disease or caring for the patient living with residual suffering (Pellegrino, 1993). This was not a casual definition. The entire virtue-ethics program depended on identifying the telos of medicine, because virtues are dispositions that facilitate the attainment of ends. If medicine’s ends cannot be specified, the virtues specific to medicine cannot be derived (Pellegrino, 1993).
Their approach was teleological in the Aristotelian and Thomistic sense: relating the virtues of medicine as a practice to its ends, and requiring a philosophy of medicine to define those ends (Pellegrino, 1993). They adopted the classical definitions of Aristotle and Aquinas (Pellegrino, 1993).
The Internal Morality of Medicine
Thomasma and Pellegrino jointly developed the argument that three features of medical activity constitute its “internal morality”: the nature of illness (which creates vulnerability), the nonproprietary character of medical knowledge, and the oath of fidelity (Pellegrino, 1993). Medical knowledge, they argued, is held in trust for the good of the sick; by accepting medical education, physicians enter a covenant with society that cannot be dissolved unilaterally (Pellegrino, 1993).
The internal morality analysis was developed further into a five-feature account of why medicine requires the effacement of self-interest. Those features are: the inherent inequality and vulnerability that illness creates between physician and patient; the fiduciary nature of the relationship; the moral character of the decisions that physicians must make; the nature of medical knowledge itself (specialized, asymmetrically held, not reducible to market exchange); and the physician’s moral complicity in outcomes, given that patients cannot easily evaluate the advice they receive and act on it (Pellegrino, 1993). This five-part elaboration provided a structural basis for the specific virtues the book subsequently examined, since each feature generates corresponding obligations that only virtue can reliably fulfill.
They derived the four principles of biomedical ethics not from external philosophical systems but from internal obligations arising from the physician-patient relationship itself (Pellegrino, 1993), ordering them under the concept of beneficence in trust; encompassing the patient’s complete well-being, not simply medical well-being (Pellegrino, 1993).
Compassion as Epistemic Virtue
Thomasma and Pellegrino treated compassion not as a sentiment but as a moral virtue in the classical sense: a habitual disposition to act that facilitates the telos of healing (Pellegrino, 1993). Their analysis gave compassion an intellectual component that distinguished it from mere fellow-feeling. The compassionate physician must achieve a paradoxical epoché, a phenomenological suspension of affective attachment, to objectively assess the patient’s predicament while remaining engaged with it (Pellegrino, 1993). Compassion, they argued, has both a moral and an intellectual component: morally indispensable because healing requires attending to the patient’s values, and intellectually consisting in the habitual disposition to comprehend the uniqueness of each patient’s predicament (Pellegrino, 1993).
Clinical Judgment as Prudence
Pellegrino and Thomasma gave sustained attention to the practical intellectual virtue of prudence (phronesis) and its relation to clinical judgment. They argued that clinical judgment is not merely a technical competence but is essentially an exercise of prudence: the right way of acting in a complex situation fraught with uncertainties, requiring the physician to discern appropriate means and to balance benefits against harms across the full particularity of the individual case (Pellegrino, 1993). This meant that the good clinician is not simply a well-informed technician but a morally formed agent, since prudence in the Aristotelian-Thomist tradition cannot be separated from the rest of virtue. The person who lacks justice or compassion will also lack the discernment to judge rightly in clinical situations, because those situations are saturated with moral as well as technical complexity. This position had the effect of making the intellectual virtues and the moral virtues interdependent in a way that challenged both technocratic and purely principlist accounts of good medical practice.
Temperance and Technology
Thomasma expanded the classical virtue of temperance beyond its traditional domain of bodily appetites to cover the temptations of modern professionalism; particularly the inappropriate use of medical technology and the appetite for professional power (Pellegrino, 1993). This was a characteristic move: taking a classical concept and showing that its logic extends naturally to problems its originators could not have anticipated.
Integrity over Autonomy
Thomasma and Pellegrino challenged the dominance of autonomy in American bioethics by arguing that integrity is the more fundamental concept. The moral claim to autonomy, they maintained, rests on the deeper moral claim of all humans to integrity of the person (Pellegrino, 1993). Integrity operates in two senses in medical ethics: integrity of the person (a moral claim belonging to every human) and being a person of integrity (a virtue, a moral habitus acquired through constant practice) (Pellegrino, 1993).
The Seven Theses
The book propounds seven theses: virtue is irreducible in medical ethics; virtue ethics must incorporate analytical ethics; physician virtues fuse general and special virtue; medical virtues derive from the nature of medicine; deriving virtues from medicine’s ends escapes free-standing virtue problems; principle and virtue ethics must be linked; and moral philosophy must connect with moral psychology (Pellegrino, 1993).
The specific virtues examined in The Virtues in Medical Practice arise from two sources: the caring bond among healing, caring, and curing on one side, and the public trust implied by the physician’s commitment to care on the other. The virtues named are faith, trust, hope, compassion, courage, and fidelity (Pellegrino, 1993). This inventory is not arbitrary; each virtue corresponds to a structural feature of the physician-patient encounter as Pellegrino and Thomasma analyzed it. Fidelity, for instance, tracks the fiduciary character of the relationship; hope tracks the asymmetry between the knowledgeable clinician and the vulnerable patient who must trust in outcomes neither can fully control; and compassion tracks the requirement to attend to the patient as a person rather than as a bearer of pathology.
Cassell and the Parallel Project on Suffering
The Pellegrino-Thomasma program was not the only systematic attempt of its era to reconstruct medical ethics around the patient’s experience rather than around principles or rights. Eric Cassell’s parallel work on suffering and the goals of medicine converged with their project from a phenomenological rather than a strictly Thomist direction. Cassell argued that the doctor-patient relationship is not merely a social or economic arrangement but a foundational therapeutic factor with its own healing power, operating independently of specific treatments, and recognizable across all cultures and throughout the history of medicine (Cassell, 1991). This claim reinforces the Pellegrino-Thomasma premise that the relationship itself is morally and therapeutically primary, not a mere delivery mechanism for interventions.
Cassell also addressed the tension between the scientific and the personal dimensions of medicine that Pellegrino and Thomasma approached through the virtue of prudence. In Cassell’s formulation, the art and science of medicine are not opposed but concerned with two different objects: science is the instrument for treating disease according to its mechanisms, while art is the instrument for treating sick persons as the persons they are (Cassell, 1991). This distinction parallels the Pellegrino-Thomasma insistence that the ends of medicine include more than the correction of biological malfunction, and that virtue, not merely technical skill, is required to address the patient as a whole person. Read together, Cassell and Pellegrino-Thomasma represent a sustained convergent critique, from different philosophical starting points, of the reduction of medicine to applied biology.
Scholarly Assessment
The Pellegrino-Thomasma project occupies a distinctive and contested position in twentieth-century medical ethics. It emerged in conscious opposition to principlism, the framework associated with Tom Beauchamp and James Childress, whose Principles of Biomedical Ethics (first edition 1979) had by the 1980s become the dominant analytical idiom of the field. Principlism organized medical ethics around four mid-level principles, autonomy, beneficence, nonmaleficence, and justice, derived from common morality rather than from any single philosophical tradition. Pellegrino and Thomasma accepted the practical utility of those principles while insisting that they are insufficient as a complete moral framework: principles state what is right, but they cannot by themselves motivate, guide, or sustain the physician’s conduct in the concrete particularity of clinical life. The virtues are not optional additions to principle-following but the conditions that make reliable principle-following possible.
This argument encountered predictable objections. Critics from the principlist side questioned whether virtue ethics could provide the kind of determinate guidance that clinical decision-making requires, especially in cases where reasonable persons disagree. Critics from other directions questioned whether the Aristotelian-Thomist framework, however sophisticated, could avoid importing metaphysical commitments that would be unacceptable to physicians and patients outside that tradition. Pellegrino and Thomasma’s response, visible especially in Virtues in Medical Practice, was to argue that the internal morality of medicine itself, not any external philosophical tradition, generates the specific virtues, so that any physician who accepts medicine’s ends is committed to the virtues regardless of metaphysical background.
The project’s relationship to narrative ethics is less adversarial but also less fully worked out. Writers such as Arthur Kleinman and Rita Charon argued during the same period that attentiveness to patients’ illness narratives was both ethically and clinically indispensable. This claim is compatible with the Pellegrino-Thomasma position and in some respects extends it, since narrative competence might be understood as one component of the compassion and prudence they describe. However, Pellegrino and Thomasma did not develop narrative ethics as a distinct strand within their framework, and the integration of virtue-based and narrative approaches remains a largely incomplete project in medical humanities.
The lasting contribution of the Pellegrino-Thomasma collaboration is not any single argument but the recovery of the physician’s character as a legitimate object of ethical inquiry. By demonstrating that virtue ethics is not a vague supplement to principle-based reasoning but a philosophically rigorous and practically indispensable dimension of medical ethics, they reopened questions about moral formation, professional education, and the nature of clinical excellence that a decade of principlist dominance had largely set aside. The specific Thomist commitments may be more debated than the diagnostic claim that principles without virtuous agents are insufficient; and that diagnostic claim has proven durable across a range of subsequent frameworks.
See Also
- Edmund Pellegrino
- Virtue Ethics
- Philosophy of Medicine
- Physician-Patient Relationship
- Phronesis
- Autonomy
- Compassion
- Medical Ethics
Sources
- Pellegrino, E. D. & Thomasma, D. C. (1993). The Virtues in Medical Practice. Oxford University Press. [pellegrino-thomasma-virtues-1993]. Lead authority
- Cassell, E. J. (1991). The Nature of Suffering and the Goals of Medicine. Oxford University Press. [cassell-nature-of-suffering-1991]