Edmund Pellegrino

Summary

Edmund Pellegrino (1920–2013) was an American physician and philosopher who spent four decades arguing that medicine is not a business, not a science, and not a social service — it is a moral enterprise whose ethics must be derived from the nature of the healing relationship itself. Working primarily with his co-author David Thomasma, Pellegrino built the most sustained case in twentieth-century bioethics for grounding medical ethics in virtue rather than in principles alone. His central claim was that the vulnerability of the sick person creates moral obligations that cannot be captured by rule-following; they require physicians of good character, disposed by habit to act well under conditions of uncertainty and power asymmetry.

Life and Career

Pellegrino trained as an internist and spent his career moving between clinical practice, medical education, and philosophy. He held deanships and directorships at multiple medical schools and founded the Center for Clinical Bioethics at Georgetown University. His career coincided with — and helped shape — the emergence of bioethics as a distinct field in America. When the first Trans-Disciplinary Symposium on Philosophy and Medicine convened in Galveston in 1974, the organizers noted that few areas of social concern were as pervasive as medicine and yet as underexamined by philosophy (Carson_Burns_eds, 1997). Pellegrino became one of the figures who changed that.

His philosophical orientation was Aristotelian and Thomistic. He and Thomasma adopted what they called a realist Thomist position — one that positioned itself midway between theory and practice, refusing both pure metaphysical speculation and the pragmatist dissolution of philosophy into disciplinary consensus.(Pellegrino, 1993) They drew selectively on other thinkers but returned always to Aristotle’s concept of virtue as a habitual disposition to act well under the guidance of reason (Pellegrino, 1993) and Aquinas’s enrichment of that concept by giving special place to prudence as the bridge between intellectual and moral virtues (Pellegrino, 1993). They explicitly opted for the classical Aristotelian-Thomist definitions, judging that subsequent philosophical accounts had not improved on the essential notion (Pellegrino, 1993). This was not a casual philosophical allegiance. It structured their entire program: the virtues of medicine, they argued, could only be identified by first establishing the ends (telos) of medicine, and establishing those ends required a philosophy of medicine — not an ethics applied to medicine from outside (Pellegrino, 1993). The book propounded seven theses that together constitute a systematic argument: that virtue is irreducible in medical ethics; that virtue ethics must incorporate analytical ethics; that physician virtues fuse general and special virtue; that medical virtues derive from the nature of medicine; that deriving virtues from medicine’s ends escapes free-standing virtue problems; that principle and virtue ethics must be linked; and that moral philosophy must connect with moral psychology (Pellegrino, 1993).

The Internal Morality of Medicine

Pellegrino argued that the most consequential dilemmas of medical ethics arise not primarily from scientific progress but from the tension within professional ethics itself — the conflict between the physician’s covenant with patients and the pull of self-interest (Pellegrino, 1993). The Hippocratic Oath represented the first explicit model of medicine as a moral community, but Pellegrino judged it morally defective because it was designed to protect the guild rather than those the guild serves (Pellegrino, 1993).

His most distinctive contribution was the argument that medicine possesses an internal morality — that certain ethical obligations arise not from external philosophical systems but from the nature of medical activity itself. Three features of medicine, he argued, make it irreducibly a moral enterprise: the vulnerability created by illness, the nonproprietary character of medical knowledge, and the oath of fidelity that entering the profession entails (Pellegrino, 1993).

The argument about vulnerability is the load-bearing one. When a person falls ill, the ordinary asymmetries of the human situation are drastically amplified. The patient needs what the physician has, cannot fully evaluate it, and is in a position of enforced trust. Medical knowledge, meanwhile, is not private property; it is held in trust for the good of the sick, and by accepting medical education, physicians enter a covenant with society that cannot be dissolved unilaterally (Pellegrino, 1993). The physician, Pellegrino argued, is the “final common pathway” through whom all things medical must pass, making the physician inescapably a moral accomplice in whatever is done for good or ill to patients (Pellegrino, 1993).

From these features Pellegrino derived five elements requiring the effacement of self-interest: the inequality and vulnerability of the medical relationship, its fiduciary nature, the moral character of medical decisions, the nature of medical knowledge, and the physician’s ineradicable moral complicity in outcomes (Pellegrino, 1993). Health care, on this account, cannot be treated as a commodity governed by market forces; the metaphors of business and industry signal a downward moral drift incompatible with a moral community (Pellegrino, 1993). In the capstone chapter of The Virtues in Medical Practice, Pellegrino gave the internal morality a compact formulation: it consists of principles, duties, obligations, and moral character arising from two interlocking triads — three ends of medicine (health, cure, and a right healing decision) and three phenomena of the medical relationship (vulnerability, inequality, and trust) (Pellegrino, 1993).

Virtue, Principles, and Their Linkage

Pellegrino entered a bioethics field dominated by principlism — the four-principle framework of autonomy, nonmaleficence, beneficence, and justice codified by Beauchamp and Childress in Principles of Biomedical Ethics, which had by the 1990s become the dominant framework for clinical ethics in the United States (Carson_Burns_eds, 1997). He did not reject principles. His position was that virtue and principle are both necessary and that neither alone suffices: a skilled ethicist may have dubious character, while a good person may lack articulate principles (Pellegrino, 1993). Virtue-based ethics alone is insufficient for medical ethics because without an agreed-upon account of the telos toward which virtues dispose the agent, that telos remains vague (Pellegrino, 1993). The Nazi physician atrocities offer the starkest historical demonstration: neither virtue training alone nor principle-based ethics alone can guarantee good behavior — both are necessary, coupled with self-critical examination (Pellegrino, 1993).

Beauchamp and Childress in Principles of Biomedical Ethics — the most influential biomedical ethics work of the twentieth century — made a serious attempt to incorporate virtue, but Pellegrino faulted it for largely concentrating on principles and for failing to move through the virtue of prudence to link virtue theory with the nature of medicine (Pellegrino, 1993). More fundamentally, their four-principle framework, though valuable, lacks grounding in the phenomena of the physician-patient relationship and its application to clinical realities reveals mounting shortcomings (Pellegrino, 1993). He also identified three modes by which virtues and principles can be connected: “tacking on” (adding motivation after determining rightness), mediation (where the virtuous agent resolves conflicts between principles), and substitution (where internalized virtue renders explicit rules unnecessary) (Pellegrino, 1993).

The linkage between the two, he argued, runs through the ends of medicine. Principles state what is right; duties are obligations assumed by those entering medicine; virtues dispose the agent to choices that attain those ends (Pellegrino, 1993). Phronesis is the master virtue because it enables the physician to order both principles and particulars correctly in each unique clinical situation — not applying a universal rule mechanically, but perceiving what the individual case requires.(Pellegrino, 1993) The master virtue enabling this linkage is phronesis — practical wisdom, or what Aquinas called prudence (recta ratio agibilium, a right way of acting). In the classical Aristotelian account, phronesis is the intellectual virtue that disposes us habitually to attain truth for the sake of action rather than truth for its own sake, occupying a special place as the link between intellectual virtues and those that dispose to good character (Pellegrino, 1993). Aquinas enriched this into the concept of prudence, extending its discerning capacity beyond Aristotle’s moral and intellectual virtues to include the theological virtues of faith, hope, and charity (Pellegrino, 1993). As the capstone virtue, phronesis bridges abstract moral law and lived clinical experience, ordering principles and particulars correctly in each unique situation (Pellegrino, 1993). Clinical judgment, Pellegrino maintained, is essentially an exercise of prudence: the right way of acting in a complex situation fraught with uncertainties (Pellegrino, 1993). Prudence, he emphasized, is not synonymous with casuistry: casuistry is a method that depends on the proper use of prudence, but a casuist without the virtue of prudence may reach seriously erroneous conclusions (Pellegrino, 1993). Prudence mediates the tension between compassion and objectivity in clinical practice; there is no formula for determining where to strike the balance, and the point of balance is never the same for any series of patients (Pellegrino, 1993). Prudence also cannot be reduced to probability calculus, stochastic reasoning, or game theory; at every junction in clinical decision-making, some prudential assessment of competing values must be made, and the moral quality of the decision depends on the quality of that virtue (Pellegrino, 1993). Pellegrino added a further observation about the relationship between virtue and human flourishing: a physician who habitually exhibits prudence in medical practice moves toward happiness and fulfillment, because to pursue medicine virtuously is to move toward a good life in at least one sector of life (Pellegrino, 1993).

The virtuous physician, on this account, has internalized principle into character and is habitually disposed to pursue it with what Pellegrino called perfection-seeking diligence, especially at the “moral margin” — those situations where right and wrong are not starkly obvious and where mere compliance with rules is insufficient (Pellegrino, 1993). Pellegrino observed that no matter what theory of ethics one espouses — principle-based, duty-based, casuistical, emotivist, situational, or intuitionist — the moral agent is a constant factor in the implementation of the moral act, making virtue an unavoidable conception (Pellegrino, 1993).

Beneficence in Trust

Pellegrino’s teleological approach understood the ends of medicine as 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). He reordered the standard four principles by deriving them not from general philosophical theory but from the internal obligations of the physician-patient relationship (Pellegrino, 1993). The result was a distinctive concept: beneficence in trust, which he made the primary and ordering principle of medical ethics. This encompassed the patient’s complete well-being — not simply their medical well-being — and subordinated the other principles to its guidance (Pellegrino, 1993).

He further specified that the patient’s good is a hierarchical compound of four ascending levels: the medically indicated good, the patient’s own perception of good, the good for humans as humans, and the good for humans as spiritual beings (Pellegrino, 1993). Decisions about what is beneficial must integrate all four levels, not merely the lowest.

The distinction from mere beneficence mattered. Pellegrino insisted that beneficence and paternalism are not synonymous: paternalism violates the patient’s own perception of welfare and is diametrically opposed to both beneficence and nonmaleficence (Pellegrino, 1993). Autonomy-based models of the physician-patient relationship — the consumer model, negotiated contract — are destructive in a different way because they make the relationship instrumental and legalistic, ignoring the inescapable vulnerability of illness (Pellegrino, 1993). They are also deceptive because they fail to reckon with what Pellegrino called “Aesculapian power” — the physician’s power arising from illness itself, from personal charisma, and from a social monopoly of knowledge — which means there is no way to circumvent the physician’s character in actual practice (Pellegrino, 1993). At the same time, Pellegrino argued that integrity is more fundamental than autonomy — the moral claim to autonomy rests on the deeper moral claim of all humans to integrity of the person (Pellegrino, 1993). Integrity in this framework has two senses that must be kept distinct: the integrity of the person (a moral claim belonging to every human by virtue of their humanity) and being a person of integrity (a virtue, a moral habitus acquired through practice and reliable in action).(Pellegrino, 1993) Illness and disease are themselves forms of dis-integration — disruptions of the wholeness that constitutes healthy existence — and healing, on this reading, means restoring that wholeness, not merely removing symptoms.(Pellegrino, 1993) Autonomy, accordingly, cannot be absolute; it must be balanced against the physician’s own integrity, which means neither party may impose values on the other.(Pellegrino, 1993) The ultimate practical safeguard of patient integrity, in Pellegrino’s account, is not a contract, a law, or an abstract principle, but the physician’s fidelity to the fiduciary nature of the healing relationship itself.(Pellegrino, 1993)

Compassion and the Medical Virtues

The virtues Pellegrino and Thomasma selected for examination arose from the caring bond and the public trust implied by the commitment to care: faith, trust, hope, compassion, courage, fidelity, and related virtues (Pellegrino, 1993).

Compassion received particular attention. Its name derives from the Latin com (together) and pati (to suffer), signaling cosuffering as its essential character — a fellowship in the experience of illness (Pellegrino, 1993). Pellegrino defined it as a moral virtue in the classical sense: a habitual disposition to act that facilitates the telos of healing by shaping cognitive care to fit the unique predicament of the patient (Pellegrino, 1993). It has both a moral and an intellectual component. Morally, compassion is indispensable to healing because violating a patient’s values creates disharmony that defeats the healing relationship. Intellectually, it consists in the habitual disposition to comprehend the uniqueness of each patient’s predicament (Pellegrino, 1993). The intellectual component requires a paradoxical epoché — a suspension of affective attachment so the physician can objectively assess the patient’s predicament using the tools of medical diagnosis (Pellegrino, 1993).

Compassion as a virtue strives for a mean: excessive cosuffering causes the physician to lose objectivity, may paralyze action, and risks imposing the physician’s own values — a form of paternalism born of empathy (Pellegrino, 1993). Pellegrino also carefully distinguished compassion from adjacent affective states. Empathy is a broader identification with another’s experience; sympathy is shared fellowship without specificity to suffering; mercy implies condescension toward an inferior; pity carries connotations of inequality. None of these properly characterizes the medical relationship, where the patient is a vulnerable fellow human being with a legitimate claim through the covenant of trust, not an inferior seeking condescension (Pellegrino, 1993). The compassionate physician differs from a compassionate friend by bringing a technical and scientific component that places the patient’s story within a clinical context shaped by others with the same illness; competence and compassion must coexist as mutually reinforcing virtues (Pellegrino, 1993). The monitoring virtue that maintains the proper balance between them is prudence (Pellegrino, 1993). Without compassion, Pellegrino argued, only objective medical good — the lowest order of patient good — is obtainable (Pellegrino, 1993).

The Ecumenical Model of Bioethics

Later in his career, Pellegrino turned his attention to the methodological structure of bioethics as a discipline. He perceived in its evolution a growing and troubling imbalance between the “disciplines of particularity” — literature, history, and the behavioral sciences, with their emphasis on individual experience and cultural context — and philosophical ethics proper, which he saw being displaced by a general trend from objectivity toward subjectivity in ethical analysis (Carson_Burns_eds, 1997). He identified three categories of challenge to philosophical ethics within bioethics: external challenges from humanistic disciplines emphasizing particularity and experiential richness; internal challenges from within philosophy itself (hermeneutics, postmodernism, antifoundationalism); and internal challenges from within bioethics (virtue ethics, casuistry, feminist ethics) (Carson_Burns_eds, 1997).

His response was to propose an “ecumenical model” in which philosophy retains its foundational role for analytical and normative ethics while other disciplines perform descriptive ethics (Carson_Burns_eds, 1997). He distinguished descriptive ethics (the province of humanities, law, biology, and social sciences) from normative and analytical ethics (the specific task of philosophical ethics), insisting that each discipline maintain its distinctive formal object (Carson_Burns_eds, 1997). Pellegrino rejected the idea that foundationalist accounts have been discredited in principle and insisted that practice without metaphysical underpinnings is condemned to circularity (Carson_Burns_eds, 1997).

Reception and Legacy

Pellegrino’s virtue-based approach entered a field that had largely set virtue aside. As he and Thomasma observed, until very recently ethics in general and biomedical ethics in particular had been largely principle-based, despite the fact that for most of its history the emphasis of ethics had been on living a good life and becoming a good person (Pellegrino, 1993). The ancient codes of medical ethics — Greek, Indian, and Chinese — had been virtue-based, looking to the character of the physician as the final guarantee of patient well-being (Pellegrino, 1993). The history of virtue theory itself, as Pellegrino surveyed it, divides into four periods: classical-medieval centrality, postmedieval reshaping, positivist-analytical decline, and contemporary resuscitation (Pellegrino, 1993).

The revival was part of a broader philosophical movement initiated by Elizabeth Anscombe and Alasdair MacIntyre (Pellegrino, 1993). MacIntyre’s After Virtue was the most influential work in this revival, defining virtues as dispositions necessary to attain goods internal to communal practices (Pellegrino, 1993). MacIntyre had also shown, however, that the metaphysical consensus required by virtue theories is irretrievable: virtue ethics alone does not provide sufficiently clear action-guides, as it is too private and prone to individual definitions (Pellegrino, 1993).

Beauchamp and Childress, in their own textbook, proposed a correspondence between principles and virtues, but Pellegrino criticized this as merely renaming action guides as subjective states (Pellegrino, 1993). In the seventh edition of Principles of Biomedical Ethics, Beauchamp and Childress themselves identified five focal virtues for health professionals — compassion, discernment, trustworthiness, integrity, and conscientiousness — acknowledging that what often matters most in health care interactions is not adherence to moral rules but reliable character and appropriate emotional responsiveness (Tom L. Beauchamp, James F. Childress, 2013). This convergence suggests that the virtue-principle debate has moved toward the complementary synthesis Pellegrino had argued for, even if the precise philosophical grounding remains contested.

His insistence that medicine is a moral community — not a trade, not a marketplace — placed him in direct opposition to trends in healthcare delivery that accelerated after his most productive decades. Whether his vision of physician virtue can survive the institutional pressures he diagnosed remains an open question.

Fidelity to Trust

The philosopher Annette Baier defined trust as reliance on another’s competence and willingness to look after what one cares about.(Pellegrino, 1993) Trust is ineradicable in human relationships and especially in professional relationships, where the vulnerability of illness forces patients to depend on the good will of physicians.(Pellegrino, 1993) Trust in physicians differs qualitatively from “system trust” (as one might trust an airline pilot) because the intimacy and personal nature of medical relationships compel concern with character, not just competence.(Pellegrino, 1993)

Against proposals to replace trust with contracts and monitored compliance, Pellegrino argued that an ethics of distrust is both empirically impossible and conceptually self-defeating: every substitute mechanism itself depends on trust to function (Pellegrino, 1993). Advance directives and living wills, for example, cannot specify every contingency their execution will encounter; their practical force depends on the trustworthiness of those charged with honoring them (Pellegrino, 1993). The ineradicability of trust is, for Pellegrino, a source of obligation rather than of privilege. Professionals must earn trust through performance and fidelity to what trust implies; that fidelity cannot be dissolved when it becomes costly (Pellegrino, 1993).

Justice, Fortitude, and Temperance

The three remaining cardinal virtues each received dedicated treatment in The Virtues in Medical Practice, with Pellegrino arguing in each case that classical philosophical accounts required extension to address the specific conditions of modern medical practice.

Justice. Unlike the other virtues, justice has no mean: since all persons possess fundamental dignity and human affairs are imperfect, there is no sense in which one can be “too just,” making defects in rendering what is due the central moral problem (Pellegrino, 1993). Aristotle had distinguished distributive, commutative, and rectificatory justice (Pellegrino, 1993). For Pellegrino, justice in the virtue framework has its deepest roots in love rather than in prudential calculation: not to do justice would be to relapse from love of the other into love of self (Pellegrino, 1993). Justice, Pellegrino argued, is the only bioethical principle that functions simultaneously as both a virtue (a habitual disposition to render what is due) and a principle (an ordinance to treat like cases alike), giving it a prior status in determining the right and the good (Pellegrino, 1993). This priority means justice can limit the absolutization of individual autonomy: when a patient’s autonomous choices cause serious identifiable harm to third parties, justice has a trumping function (Pellegrino, 1993). At the same time, Pellegrino insisted that the physician’s moral autonomy deserves equal respect, and that justice requires that neither impose values on the other (Pellegrino, 1993). Against libertarian ethics, he rejected construals that frame selective treatment of only paying patients as a “virtue,” arguing that such views are fatally flawed from the standpoint of community-based ethics (Pellegrino, 1993). The healing relationship motivated by just concern requires a higher degree of self-effacement: the vulnerability of the sick person imposes a special responsibility not to exploit (Pellegrino, 1993).

Fortitude. Moral courage, Pellegrino argued, must be distinguished from physical bravery. Fortitude is sustained moral courage: the willingness to suffer personal harm for the sake of a moral good, with a note of constancy that singular courageous acts may lack (Pellegrino, 1993). Aristotle’s account frames the mean between cowardice (not stirring the waters, leaving patients without advocacy) and rashness (stirring too much and too publicly, becoming counterproductive) (Pellegrino, 1993). The conditions of corporate medicine make fortitude especially difficult: managed care structures and the demand for physicians to be “team players” diminish the likelihood that individual physicians will speak out against inequities or advocate effectively for patients (Pellegrino, 1993). Pellegrino defined medical fortitude as the virtue that inspires confidence that physicians will resist the temptation to diminish the patient’s good through their own fears or through social and bureaucratic pressure (Pellegrino, 1993). Against libertarian individualism, he insisted that to act out of virtue is not supererogation: all persons are called to live virtuously, and choosing to enter a medical profession affirms that commitment (Pellegrino, 1993).

Temperance. Pellegrino and Thomasma expanded the traditional scope of temperance beyond the appetites for food, drink, and sex to cover the temptations of modern professionalism: the inappropriate use of medical technology and the lust for professional power (Pellegrino, 1993). Medical technology creates a distinctive temptation to “play God,” a paternalism in which physicians come to believe they know best what is good for another person by employing the powers technology now invests in them (Pellegrino, 1993). The practical expression of medical temperance is “therapeutic parsimony”: using only interventions that achieve a reasonable ordering of effectiveness, benefit, and burdens, avoiding both the overuse of technology and its pusillanimous underuse (Pellegrino, 1993). Overuse of technology without evaluation of efficacy, often without the patient’s consent or over the patient’s objections, increases suffering and wastes resources (Pellegrino, 1993). There is also what Pellegrino called the “technological fix”: the temptation to employ technology rather than give oneself as a person in the healing process, a default that training and institutional culture strongly reinforce (Pellegrino, 1993).

The Act of Profession and Self-Effacement

Among the most philosophically precise contributions in The Virtues in Medical Practice is Pellegrino’s analysis of the etymology and moral structure of professional life. The word “profession” derives from the Latin profiteri, meaning to declare aloud, to accept publicly a special way of life. A profession promises that its members can be trusted to act in other than their own interest. Caveat emptor can therefore never be a profession’s first principle, as it can be for commerce (Pellegrino, 1993). The voluntary entry into medical practice constitutes what might be called an act of profession: a public assumption of moral obligations that cannot be dissolved simply because fulfilling them becomes costly or inconvenient.

This analysis grounds the virtue Pellegrino called self-effacement: not selflessness in the sense of self-destruction, but the habitual disposition to take the patient’s interests into account with some degree of preference over one’s own (Pellegrino, 1993). The professions are currently afflicted, in his view, with a moral malaise in which even conscientious practitioners come to believe it is no longer possible to practice within traditional ethical constraints, generating a growing philosophical legitimation of self-interest (Pellegrino, 1993). Pellegrino traced this legitimation to a recognizable genealogy: Machiavelli, who argued that the good person simply could not thrive in a world where others were not good, inaugurating a strain of thought that gives self-interest a survival justification (Pellegrino, 1993); followed by Hobbes, who retained some idea of virtue but placed it entirely at the service of self-interest (Pellegrino, 1993). The practical trajectory of this tradition runs toward a professional ethics constituted solely by quandary-solving and procedural rules, in which analysis is substituted for character despite the fact that it is the agent’s character that shapes how moral problems are defined and which principles are selected (Pellegrino, 1993).

Six characteristics of professional relationships, Pellegrino argued, generate an internal morality that is impervious to changing philosophical fashions: the dependency and vulnerability of the client, the inherent inequality of the relationship, its fiduciary character, the nonproprietary nature of professional knowledge, the professional as the “final common pathway” for outcomes, and the profession as a moral community with obligations to those it serves (Pellegrino, 1993). The virtues of professional life reduce ultimately to two (fidelity to trust and beneficence) from which the other professional virtues follow, and which are incompatible with the Machiavellian and Hobbesian doctrines of self-interest (Pellegrino, 1993). Professions as moral communities also have a collective obligation: to be advocates for those they serve and to monitor, discipline, and remove members who violate professional morality (Pellegrino, 1993).

How Virtue Makes a Practical Difference

The question of whether virtue-based ethics produces decisions that differ from those principle-based ethics would produce receives its fullest answer in the penultimate chapter of the book. Virtue-based ethics, Pellegrino argued, entails three features that principle-based ethics cannot replicate: the pursuit of moral excellence (arete), purity of intention, and sensitivity to moral complicity (Pellegrino, 1993). These features matter most at the “moral margin,” those clinical situations where following the rule is insufficient but not yet prohibited.

Regarding excellence: the virtuous physician accepts as duty what others do not require of themselves, redefining the threshold between duty and supererogation (Pellegrino, 1993). Regarding intention: Aquinas provides the richest account of intentionality; the virtuous person strives for maximal congruence between interior intention and exterior action, choosing means that are themselves as excellent as circumstances allow (Pellegrino, 1993). Regarding moral complicity: prudence functions as an early warning device against morally intolerable cooperation with evil, enabling physicians in dual-agency roles to discern acceptable degrees of complicity when they serve two principals with potentially conflicting interests (Pellegrino, 1993). Virtue-based ethics is also incompatible with a contract model of the physician-patient relationship on structural grounds: contracts presume equal bargaining, are based on an assumption of mistrust, and are minimalistic instruments, insufficient if moral excellence is a goal (Pellegrino, 1993).

For the virtuous physician, treating those in need of help without moralizing or retributive attitudes is a moral obligation (Pellegrino, 1993). Principles and duties of medical ethics tell physicians what they must do, but it remains to virtue to live according to the spirit of medical ethics (Pellegrino, 1993). As Pellegrino put it in the book’s final line: “Principles and duties enable physicians to do good, but virtues enable them to be good, to make the difference that can make a competent professional a noble one.” (Pellegrino, 1993)

The practical force of these arguments is reinforced by complementary analyses from writers Pellegrino influenced and engaged. Eric Cassell, whose account of suffering was a persistent reference point in debates about medicine’s moral responsibilities, 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 evident across all cultures throughout the history of medicine (Cassell, 1991). Cassell also observed that the art and science of medicine are not opposed: science is essential if you want to treat sick persons based on the mechanisms of disease; art is essential if you want to treat sick persons as the persons they are (Cassell, 1991). These convergences suggest that Pellegrino’s virtue framework has traction beyond the formal philosophical argument: the ethics of practice that the physician’s character sustains is not optional decoration but a condition of medicine’s healing function. Kathryn Montgomery, writing on clinical judgment, put the practical force of this point directly: the ethics of practice — the physician’s duty to respond to patient need — consistently overrides epistemological concerns about the limits of medical knowledge in clinical situations, with the physician’s assurances arising not from biomedical facts alone but from the fiduciary relationship with the patient (Montgomery, 2006).

Medical Education and Character Formation

A persistent question in Pellegrino’s program was whether the virtues he described could actually be taught. Against the skeptical view that character is fixed before medical training begins, he argued that the virtues appropriate to the physician qua physician can be taught, even if general moral virtues are not within a medical school’s reach (Pellegrino, 1993). The aim is not to alter fundamental religious beliefs but to form the specific dispositions that make for a right and good healing action in a particular patient encounter.

Faculty modeling, in his account, is the most powerful influence on moral formation, far exceeding the power of lectures or courses in ethics (Pellegrino, 1993). Whether faculty wish it or not, they teach virtue or vice in everything they say or do, and medical school training sometimes works systematically in the wrong direction, breeding aggressiveness and undermining the altruism students brought to it (Pellegrino, 1993). The deeper structural problem is that failure of virtue invites the very external regulation that diminishes professional life: when virtue is not practiced internally, external rules will be imposed, shrinking professional latitude and foreclosing the opportunity for moral growth (Pellegrino, 1993). The patient’s final safety at some point in every clinical encounter depends on the physician’s character, because the physician is the pathway through which all orders pass and is often the final safeguard for patients who cannot speak for themselves (Pellegrino, 1993). This is why the teaching of virtue is not optional. The methodological difficulty of measuring character formation does not render attempts useless; many valued components of medical education also resist easy measurement (Pellegrino, 1993).

The Origins of Bioethics and Pellegrino’s Ecumenical Model

In his 1997 essay in the Carson and Burns volume, Pellegrino offered one of his sharpest accounts of the intellectual field he had spent decades engaging. He began by noting the historical arc: the Hippocratic ethic had remained essentially unchanged for approximately 2,500 years as a taken-for-granted moral mosaic of Pythagorean, Stoic, and later religious elements, coming under critical examination only in the mid-1960s as part of a broader upheaval in American moral values (Pellegrino, 1993). The result was a rapid turn toward principle-based analysis that, in Pellegrino’s view, both answered real needs and foreclosed important questions.

Following Warren Reich’s analysis, he acknowledged two near-simultaneous origin points for the term “bioethics” in 1971: Van Rensselaer Potter’s ecology-based, globally oriented approach at Wisconsin, and the narrower normative-ethics-applied-to-dilemmas approach associated with Georgetown (Carson_Burns_eds, 1997). Pellegrino argued, however, for a neglected third tradition: the “Humanistic Vision” pursued by the Society for Health and Human Values before 1971, in which philosophical ethics played an interdisciplinary and cooperative role with the humanities while retaining its philosophical identity (Carson_Burns_eds, 1997).

The essay distinguished two broad categories within medical ethics. The first is the “ethics of medicine,” concerning the conduct of the healing relationship and amenable to praxis-based analysis. The second is the “ethics in medicine,” addressing deeper biomedical questions about abortion, euthanasia, personhood, and embryo research that require metaphysical foundations beyond what practice alone can provide (Carson_Burns_eds, 1997). Pellegrino’s position was that the turn toward practice-based and constructivist ethics (represented in that volume by Toulmin and Wartofsky) could handle the first category but not the second, and that practice without metaphysical underpinnings is condemned to circularity (Carson_Burns_eds, 1997). He welcomed dialogue with the humanities and social sciences (Carson_Burns_eds, 1997). He insisted that descriptive ethics, which is their proper province, cannot substitute for normative ethics (Carson_Burns_eds, 1997). This was the ecumenical model: philosophy retains its analytical and normative primacy while remaining in genuine dialogue with disciplines of the particular (Carson_Burns_eds, 1997).

See Also

• David Thomasma
• Virtue Ethics
• Philosophy of Medicine
• Physician-Patient Relationship
• Phronesis
• Autonomy
• Beneficence
• Medical Ethics
• Alasdair MacIntyre
• Compassion

Sources

• Pellegrino, E. D. & Thomasma, D. C. (1993). The Virtues in Medical Practice. Oxford University Press. [pellegrino-thomasma-virtues-1993] — Lead authority
• Carson, R. A. & Burns, C. R., eds. (1997). Philosophy of Medicine and Bioethics: A Twenty-Year Retrospective and Critical Appraisal. Kluwer. [carson-burns-philosophy-medicine-bioethics-1997]
• Beauchamp, T. L. & Childress, J. F. (2013). Principles of Biomedical Ethics, 7th ed. Oxford University Press. [beauchamp-childress-principles-of-biomedical-2013]
• Montgomery, K. (2006). How Doctors Think: Clinical Judgment and the Practice of Medicine. Oxford University Press. [montgomery-how-doctors-think-2006]
• Cassell, E. J. (1991). The Nature of Suffering and the Goals of Medicine. Oxford University Press. [cassell-nature-of-suffering-1991]