Book Review
The Moral Physician
Practicing Medicine and Ethics: Integrating Wisdom, Conscience, and Goals of Care
by Lauris Christopher Kaldjian
Cambridge University Press, 2014
(304 pages, $90.00, hardcover)
reviewed by Christopher Tollefsen
Lauris Kaldjian, a practicing physician and director of the Program in Bioethics and Humanities at the University of Iowa, has written a book of crucial importance to health care practitioners concerned with the protection of conscience as well as the protection of patients. The conjoined emphasis is important: increasingly, the assertion of patient autonomy is viewed as a trump against physician conscience. Where physicians have moral objections to patient requests, those objections, it is said, should be considered private. Thus, the medical profession effects the same separation characteristic of political liberalism: that between public and private reason and reasons.
At the same time, physician pushback and the attempt to affirm a place for conscience in the medical profession are often seen as efforts by the physician to impose his values on others. The extreme result of the effort to marginalize physician conscience is apparent in a famous essay by Oxford bioethicist Julian Savulescu. Where a medical procedure is legal, he writes, physicians "who compromise the delivery of [such] services on conscience grounds must be punished through removal of license to practice and other legal mechanisms."
Practical Wisdom
Kaldjian promises an "integrated framework" for resolving the tension between physician conscience and obligation to patients, and he is largely successful in delivering on that promise. The starting points are a recovery of the idea of medicine as an end-directed profession by its nature, and the idea of virtue as a set of character traits necessary for achieving worthwhile ends.
Prudence, or practical wisdom, is the master virtue that an agent needs to recognize both legitimate ends and morally upright means to achieve those ends. Prudence also enables an agent to deliberate well, and to identify the morally salient aspects of the circumstances. The practically wise agent acts from the right kind of motivation; practical wisdom is not a form of cleverness or self-interested cunning.
Given the concept of medicine as an end-directed practice, with goods internal to its pursuit, this ideal of practical wisdom can be recognized in its application as the essence of good clinical judgment. Such judgment is not neutral as to ends, nor is it mere instrumental cleverness. And while it is clearly other-regarding, in its virtuous concern for patient well-being, it is also self-regarding in being a virtue of the physician, and directed to that physician's own human flourishing.
Conscience as a Resource
This last thought gives us the link to the related concepts of integrity and conscience. On a plausible Thomistic account of conscience, which Kaldjian clearly finds attractive, judgments of conscience are judgments of reason directing an agent towards upright action in service of real goods. Such judgments can go astray, of course, but they are always an agent's final determination of what it is right to do.
In chapter 9, Kaldjian argues that it is thus folly to think conscience can be detached from a physician's professional life of service. He identifies the need to shift the discussion's focus "from conscientious objection to conscientious practice." Conscience should be seen as a resource and not an obstacle for medical practitioners, even if the value of conscience requires that certain physician-protecting negative rights be acknowledged by the state, society, and the medical profession.
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