You’re a hot-shot doctor. (Don’t worry, pre-meds, you’ll make it eventually.) Jill, a 19-year-old young lady, comes to the hospital. Despite being only somewhat conscious and slightly delusional, she is complaining about a sharp pain on her lower right side. After a few tests, you diagnose perforated appendicitis. Her appendix has torn from the growing inflammation, and the infection has started to spread throughout her body. Left alone, Jill will probably die. Yet new forms of minimally-invasive, low-risk laparoscopic surgery mean you can help. An emergency surgery can save Jill’s life, leaving her with only a small scar.
Unfortunately, you have not had a meaningful conversation with Jill because of her confusion. Whenever you get close to her bed, she pushes you away and refuses any treatment. She clearly doesn’t understand what is going on. Wanting to help, you wonder whether you should perform the surgery despite her apparent refusal.
Living in a society dedicated to personal autonomy, you understand that liberty rules the public sphere, and medicine is no exception. You are obligated to respect Jill’s wishes unless you determine that she lacks the capacity to make decisions. Fortunately, you remember back to your ethics training. To have “capacity,” the patient must (1) understand the facts of the situation, (2) appreciate the significance of the decision and the risks involved, (3) rationally weigh the options, and (4) communicate a decision based on that reasoning.
You go back into Jill’s room and decide that she fails all four parts of this “decisional capacity” metric. Jill cannot communicate a choice, let alone understand the situation, reason through options, or appreciate the significance of the risks. Because it is an emergency situation, you perform the surgery.
She recovers in three days and thanks you profusely.
The following week, you find yourself in a shockingly similar situation. Jane, also 19, comes to the hospital with the same complaint. Her diagnosis is identical. Fortunately, Jane is lucid and able to communicate. You recommend surgery. To your surprise, Jane tells you that she is in the adult entertainment business, an erotic dancer, and refuses any treatment that will give her a scar.
Unable to convince her, you ask for help. Her nurses, a psychiatrist, and the ethics committee of the hospital all intervene to no avail. The stalemate continues. Jane clearly understands her situation, including the simplicity of the procedure and the small size of the scar. She rationally argues, in multiple conversations, that her physical image and her dancing career are so important that she prefers the risk of refusing surgery.
No scars, she says.
You understand that you cannot perform the surgery against her will, even though you feel it would be in her own best interest. You back down, give her antibiotics, and hope for the best. Tragically, she dies the next day. [Jane’s story represents a real case from a large Midwestern hospital.]
Was the best moral conclusion reached? Certainly not. Yet although the conclusion was tragic, Jane’s right to liberty and self-determination prohibit her doctors from paternalistically performing a forced surgery that would have lead to a better outcome. The US Supreme Court has affirmed the rights of informed refusal in cases like Jane’s: Forced medical treatment legally constitutes battery.
On the other hand, Jane’s conception of her own human good is obviously stunted, leaving her with a half-baked moral system in which she wrongly values her physical appearance and her career over her life. Because she is not morally well-formed, Jane is not fully equipped to make medical decisions about her welfare, even though she fulfills the four criteria for decisional capacity. Weighing the benefits of alternative choices requires both a good system of values and a clear vision of how those values contribute to a flourishing life.
In our society, we raise our children to listen to the dictates of their consciences. Generally, they know what is right and what is wrong. We do not, however, teach them to question how their consciences have been formed or how their moral principles contribute to a good and happy life. As a result, our children grow to become people who have lists of moral principles in their heads, but no systematic understanding of how to balance them or what grounds their values.
Catastrophic situations, such as serious medical crises, can cause us to question our long-held moral precepts and values: Is life still worth living if a certain quality of life has been lost? With only a list of moral principles, and no systematic understanding of the sort of flourishing to which those principles are intended to contribute, we are stuck. We are left unable to determine which principles should be privileged when they come into direct conflict.
Virtue ethics provides one such systematic understanding of the good life and how to attain
happiness. It emphasizes the appropriation of the virtues rather than adherence to lists of precepts. Virtue ethics presents a conception of the good life as one in which moral principles are so deeply internalized that they determine one’s whole posture toward life. Living justly and temperately becomes a matter of habit because one’s desires and sympathies have become ordered to a life of virtue by reason and acculturation.
As Will Durant once summarized Aristotle’s understanding of virtue, “we are what we repeatedly do. Excellence, then, is not an act but a habit.” The formation of good habits requires rigorous discipline, much like the repetition of athletic training. Raising our children this way will at first look like the training of Pavlov’s dog, but it will not be complete until it has lead them to careful reflection on what the good life for man is and how the virtues contribute to it, individually and in concert.
Don’t fool yourself into thinking that these debates are just for philosophers and doctors. It is likely that you will be faced with a difficult decision about critical medical care either for yourself or for a loved one whose wishes are unclear. More crucially, Jane and Jill had parents; parents who, in Jill’s case, formed in her a rightly-ordered attitude to life so that she could express gratitude for a surgery she was incapacitated to choose. Jane’s moral formation went tragically wrong; her lack of the virtues and of a well-formed conception of human flourishing cost her her life. How are you going to raise your children?
Andrew is a second year medical student at Northwestern and Greer is the Events Planning Coordinator at the Notre Dame Center for Ethics and Culture. They can credit the back roads of Ireland for their friendship. There are some things you can’t go through together without becoming the greatest of friends: breaking your arm cycling through Co. Kerry is one of them.