Paper Ideas: MacIntyre and Dependent Relationality

From BrothersBrothers

Main Points

  1. Practical reasoning includes both moral reasoning and clinical reasoning. While we experience these types of problem solving as different, they operate in much the same way, and often are so integrated that it becomes very difficult to discern the difference. The main difference is, perhaps, that we experience the moral as referring back to foundational commitments.
  2. Traditions can be judged against one another in their ability to respond to problems. In RDA, MacIntyre extends Aquinas' account of the development of the ability to be a practical moral reasoner to highlight an element of that development that has gone largely unnoticed: the way that it constitutes us all as dependent.
  3. MacIntyre's method is an empirical one: to explore the experience that we have of our own life and that which we discover in the lives of non-human animals in order to generate an ontological account: what experiences are inherent in our being as an animal and as a human animal. My goal here is to test MacIntyre's account in the setting of clinical conflict, when provider and patient don't agree on a course of action, in order to see (1) whether his ontological account is confirmed in this experience and (2) whether it allows us to discover something helpful in this experience; i.e. whether it helps us deal with this problem.
  4. Our practical reasoning, both moral and clinical, require development. We often assume (as Kohlberg did) that our moral development ends when we are young adults, but that our development in practical clinical reasoning starts when we enter medical school, and perhaps never ends (as Osler says). This account somewhat depends on a model of development that frames development as movement from simpler stages to more complex stages. If we thing about development different, that is, that our practical reasoning is subject to constant life-long refinement as (1) we learn new information (evidence-based medicine) and (2) we discover mistakes in our reasoning, then we can think of the development of our practical reasoning as a life-long task.
  5. The development of practical reasoning requires others to correct us. The lists that we might make about who is important in correcting us depend somewhat on whether we are referring to moral reasoning or clinical reasoning. For moral reasoning, we might list our family, our religious community, and perhaps even our colleagues and coworkers. For clinical reasoning, we usually list our more senior colleagues and those experts with whom we come into contact. Osler would certainly have added our patients to that list. But what if our patients are not just important in our clinical development and as objects of our moral reasoning? What if they are, in fact, important to the development of our practical moral reasoning? If that were the case, our account of what happens when we come into conflict with our patients would be radically reshaped. No longer are we in conflict with our patients as two fully-formed moral agents weighing autonomy vs. autonomy in a power struggle, a struggle we will always win. Rather, we both must understand ourselves as both dependent and rational animals. The patient is the object of my moral reasoning at the same time that I am dependent on him or her to provide me with insight into myself, my reasons and that which I take to be knowledge. this relationship is not exactly reciprocal, for my patient is the object of her own moral reasoning - the conflict is about what will be done to her body. But she dependent on me not just for my expertise or the exercise of my technical skill. She is dependent on me to provide her insight and correction about herself, her reasons and that which she takes to be knowledge.
  6. This description of our relationship, a relational value theory, seems to provide a robust account of bring in relation to one another in the setting of clinical conflict. It also frames this conflict in a way that admits of several advances in dealing with such problems. This include at least: (1) It at least reframes the power issues. (2) It provides an account that integrates both our moral and our clinical practical reasoning. (3) It allows us to understand how it is possible that sometimes we can refuse to do what our patient at first thinks we must do, and also how it is possible that we will sometimes do what we at first thing we must not do. (4) It allows the provider to understand him or herself as having both moral and professional integrity, but not at the expense of responsiveness in a living interaction with another person, the patient. (5) It provides an account of what Sulmasy calls "epistemic humility" - it allows to be tolerant of those who think differently from us by allowing us to remain open to the possibility that we are in need of correction. There is the possibility of a mean here, though, such that our humility does not render us as mere technicians at the whim of our patient's wishes.

Version 2


  1. Few topics have been as hotly debated in the discourse on medical ethics as claims to conscientious objection by providers.
  2. Provider claims to conscientious refusal have usually revolved around reproductive and end-of-life issues, and the discourse within medical ethics has similarly focused on these areas.
  3. The questions that seem to occupy much of the attention within this debate relate primarily to the status of the provider as moral subject:
    1. What is the nature of the conscience of the provider?
    2. What is the relationship between the moral commitments of the provider and the professional responsibilities of the provider?
    3. Do providers have a duty to provide certain services to patients?
  4. Perhaps one of the reasons that this debate has generated so much attention is that these three questions are not limited in scope to the topic of conscientious objection.
  5. In fact, conscientious objection is simply the testing ground for these questions that are really about what it means to be a healthcare provider. It is an apt case study. The practices of physicians, nurses, pharmacists, and nurse-practitioners are all similarly constituted by being in relation to a patient. These practices are meaningless without patients. And because they always take place in relation to patients, conflicts inevitably arise. Conscientious objection with respect to reproductive or end-of-life issues are simply highly polarizing examples of the numerous conflicts that develop in clinical practice. These conflicts are not special occasions, but rather an everyday part of practice. Antibiotics for URIs.
  6. These three questions, then, are in fact about the relationship between provider and patient that provides the context for all healthcare practice and the inevitable conflicts that arise in that context.
  7. If this is true, though, then the focus of these questions seems inadequate. First, while they focus on moral issues, it is clear that the conflict that is inherent in the provider-patient relationship is not just about commitments that we normally label as moral, but also about commitments that we would label as "professional" or even "scientific". Second, they focus on the physician as a moral subject. Because of this, the patient is, by default, cast as the moral object.
  8. If we are to address the question of provider-patient conflict, then, we will need to ask questions and seek answers that account for the full set of commitments of both providers and patients.
  9. Providing such a comprehensive account, along with an examination of the alternative accounts, is a task for generations. I certainly do not intend to address it fully in these pages. But perhaps we can find some movement forward by exploring what resources one tradition may hold in dealing with this problem.
  10. This is the method of Alasdair MacIntyre. In his book After Virtue, and developed more fully in his later books, MacIntyre argued that our contemporary moral disagreements have come to appear incommensurable because our moral discourse has become fragmented among numerous traditions and vocabularies. We simply don't share an external set of standards that would allow us to weigh one account against another.
  11. He has proposed that the only method we can use to determine whether a tradition is successful is to explore whether it is able to provide an account that responds adequately to the problems that arise over time. Traditions that fail to provide a meaningful response to major problems will need either to develop and adapt, or be discarded as irrelevant. The problem of provider-patient conflict is certainly such an important problem.
  12. The focus of this paper, then, is to take MacIntyre up on his challenge to put traditions to the test, in this case, his own adaptation of the Thomistic moral traditon. Does MacIntyre's account of Thomistic moral theory provide us with useful resources? Does it provide an ontological account of relationships that obtains in the setting of the provider-patient relationship? Does this account reveal something that is helpful in dealing with conflict?
  13. I believe it does. I will argue that in his book Dependent Rational Animals, MacIntyre has extended the Thomistic moral tradition by highlighting the importance of dependence in the ontology of human animals and non-human animals. This attention to dependence makes possible an account of provider-patient conflict that is both confirmed in the experience of that conflict, and also reveals new avenues for successfully negotiating such conflicts. I will use the three questions that have framed the conscientious objection debate to structure my discussion. Each question will require revision, and this revision in light of MacIntyre's account will help reveal how his account advances the discussion.

What is the nature of the conscience of the provider?

  1. The meanings attributed to the word "conscience" are so varied that the word seems to cause more problems than it solves. On some accounts, the "conscience" is that faculty through which people are able to apprehend the commands of divine law. To go against conscience, on this account, is to act in such a way that breaks those laws that are readily accessible through this internal faculty.
  2. For Aquinas, moral action does not begin with internally apprehended laws. Rather, moral action is always oriented toward a good, or telos. The goods that people seek through their actions vary from person to person, and vary throughout the lifespan of each person. But the ultimate good of human life for Aquinas is "that state of perfect happiness which is the contemplation of God in the beatific vision" (WJ?WR? 192). Even though humans are limited in their ability to become perfectly oriented toward that goal, humans can seek the goods of human life that approximate that ultimate good. Virtuous action, then, is not action following from laws. It is action that arises from a desire to seek the ultimate good of human life.
  3. Conscience does have a part in this account of moral action, in fact Aquinas' account of conscience is one of the most important in the history of moral theology. However, conscience does not serve as an infallible giver of law. For Aquinas, that which we call conscience is divided into two separate elements: synderesis and conscientia. Synderesis bears some similarity to the common contemporary use of conscience; synderesis is that faculty by which humans are able to apprehend the basic aim which provides the context for all moral reasoning. But recall that this is not an account of morality that depends on moral rules. Rather than providing the apprehension of rules, synderesis allows humans to grasp that actions are oriented toward goods. "Practical reasoning begins with something you want. It takes for granted that this is wanted and deliberates about the means of achieving it. The intellectual grasp of the aim as aim... is synderesis" (Aquinas on Good Sense - McCabe). That orientation toward a telos, "the practical principle of seeking what is in some respect good," (Aquinas on Good Sense - McCabe 346) is the basic orientation that makes moral evaluation possible, including deliberation on which ends should be sought and which means will allow for the attainment of those ends.
  4. Again, synderesis on Aquinas' account does not contain any principles that are so specific they can be applied directly in concrete circumstances. Conscientia is the judgments that we make on the basis of a synthesis of a broad set of information within a particular concrete situation. It is the "application of knowledge to activity" (Summa Theologiae I-II, question 19, articles 5 and 6). Synderesis makes such judgments possible, and practical reasoning is the method by which knowledge is applied.
  5. Unlike the deontological orientation that places the commands of a divine law at the center of morality, Aquinas focuses on practical reasoning.
  6. Practical reasoning is the process by which humans decide what "on particular occasions it is best for them to do" (DRA 67). When a human engages in practical reasoning, she reflects upon the ends or goods she wants to attain, the means which will allow her to attain those ends, and the concrete circumstances that affect whether one action is more likely to attain those goods than another.
  7. Our ability to successfully engage in these three components of practical reasoning develops over time. Infants "direct themselves towards the immediate satisfaction of felt bodily wants: for milk and the breast, for warmth and security, for freedom from this or that discomfort or pain, for sleep" (DRA 68). Their action is clearly oriented toward certain ends, but they lack the ability to reason practically on how to attain those ends. It is only later in life that children learn to ask for a drink, or later move a chair to the sink to get one themselves.
  8. Over time, more means become possible for us and we develop in our understanding of the concrete conditions of the world around us. And as we gain the ability to imagine possible futures for ourselves, the goods that we want to pursue develop. Fulfilling our thirst remains an important good, but we develop an interest in other goods as well. We may even come to desire the good that Aquinas identifies as the ultimate good of human life.
  9. Practical reasoning, then, is not limited to matters of morality. For healthcare providers, practical reasoning in the clinical setting includes both moral reasoning and clinical reasoning. And both must develop over time.
  10. We often assume, though, that while young adults begin to develop the capacity to reason clinically when they enter professional school, their moral development ends at about the same time. This is perhaps true, but only if we envision development as movement from simple states to more complex stages, in the fashion of Kohlberg. But this is not the way Aquinas envisions development. Development with respect to practical reasoning involves discovering new means for attaining our ends, imagining new possible futures for ourselves, and understanding the world around us more deeply. In some cases, we may even develop as we learn that our previous assumptions, medical or moral, were incorrect. In this way, we can think of the development of our practical reasoning as a life-long task.

What is the relationship between the moral commitments of the provider and the professional responsibilities of the provider?

  1. There can be little doubt that providers experience the moral and the professional as distinct dimensions of their life, but while distinct these dimensions are not unrelated. Characteristic of the moral is its relationship to what we would call "foundational commitments". The moral is strongly related to that which we identify as most important in our lives, and perhaps also in our community. The moral is often correlated with the "personal," but for many providers who would articulate their commitments in terms of morality, their professional calling is itself a moral matter. Their professional identity is itself rooted in their "foundational commitments."
  2. On the other hand, decisions that are "purely clinical" or "purely scientific" are often partitioned from those concerns that are considered moral. The example given above of the decision not to prescribe antibiotics for a patient with a URI is thought to be purely professional. But that decisions is not exclusively based on scientific knowledge - it is based on valued interpretations of the meaning of that knowledge. Providers seek to use antibiotics judiciously because they place values on the possible harms and possible benefits that patients may experience from taking them, even patients do not attend to such issues. Providers are also concerned about the impact of resistance on other patients that can result from injudicious antibiotic use. Clinical judgments are value judgments.
  3. The connections do not end there. As I have observed, practical reasoning is the mode by which healthcare provides apply both clinical and scientific information and also moral information. If conscientia is, for Aquinas, the "application of knowledge to activity," then properly speaking conscientia includes both "clinical" and "moral" judgments. Even if we would be unwilling to extend this observation to place both the clinical and the moral within the contemporary understanding of conscience, we can at least acknowledge that moral choices that providers encounter in the clinical setting are never purely moral nor purely clinical. Put differently, clinicians rarely engage in practical reasoning without engaging both moral reasoning and clinical reasoning.
  4. We can imagine, though, that a provider may seek multiple good in her life. She may seek a conception of the "beatific vision" that she shares with her religious community, while at the same time seeking the goals of her profession, which could include healing the sick and alleviating suffering. Would she need to choose between these goods in certain situations? Absolutely she would. But this account rules out the possibility that a provider could simply "set aside her personal morality" in order to enact her "professional responsibility". While providers distinguish between the personal or moral dimension and the professional or clinical dimension, the practical reasoning that takes place in concrete situations necessarily includes both. In situations that seem to place goods at odds with one another, the virtue of prudence would prevent providers from reasoning practically using only a portion of their knowledge or attending to only a subset of their available means.
  5. On the other hand, this account similarly precludes the possibility that conclusions could be drawn in any clinical case, including those identified as "moral" or "ethical," without the process of practical reason. As Aquinas concludes, "Since discourse on moral matters even in their universal aspects is subject to uncertainty and variation it is all the more uncertain if one wishes to descend to bringing doctrine to bear on individual cases in specific detail, for this cannot be dealt with by either art or precedent, because the factors in individual cases are indeterminately variable. Therefore judgment concerning individual cases must be left to the prudentia of each person." (Commentary on the Ethics II, lect. 2) That is, moral actions depends on the prudent reasoning of the provider in concrete clinical situations. I do not mean to imply that Aquinas does not think there are moral rules. He simply argues that beyond the basic level of what synderesis provides, only prudence exercised by the practical reasoner can discern the relevance of such rules.

Must healthcare providers perform services that patients request even when they have strong moral objections to that service?

Discarded Text

  1. Children enter the moral life by first following the rules set by parents and teachers. Although children are rewarded and complimented for following rules, following rules is not itself inherently good. Rather, rules provide the context, the "right direction," for children to develop their understanding of which goods to seek in their actions. "The moral life begins with rules designed to direct the will and the desires toward its and their good by providing a standard of right direction (rectitudo). This rectitude is valued, not for its own sake, but as leading to that perfected will and those perfected desires which happiness requires." (WJ?WR? 194). But rule-following does not "direct the will and the desires" toward "the good" on its own. Rules, which provide "right direction," must be paired with training in the moral virtues.
  2. I will return to the virtues later, but it is important to note at this point that

Version 1


  1. Conflict is often topic of bioethics.
  2. Example is conscientious objection.
  3. However, conflict is often a routine part of medical practice - antibiotics for URIs.
  4. However, that medical care at the end-of-life only generates involvement when conflict occurs points to the fact that conflict between provider and patient is an inherently ethical issue, as much for discontinuation of life-sustaining treatment as when deciding whether to use an antibiotic to treat a URI.
  5. Some physicians have observed that such conflicts have become more common as patients have become active in researching available treatment options. This trend has itself been driven by the movement to empower patients to be more involved in decisions about their medical treatment.
  6. This movement is closely related to the principle of autonomy. This principle, heavily critiqued in our field during recent years, did not originate with Beauchamp and Childress, but is, rather, heavily embedded in the liberal tradition in the US. The rise in patient autonomy during recent decades has not been so much an emerging trend as an American inevitability.
  7. Perhaps also inevitable has been the backlash against the patient autonomy movement that has begun to frame physician-patient conflict as a matter of "autonomy vs. autonomy." If patients are entitled to their autonomy, so the argument goes, providers are also entitled to act autonomously. "Practices on the margins," like discontinuation of artificial hydration or the performance of abortions, fall outside the core of the practice of medicine. Providers, then, are entitled to a significant amount of autonomy in deciding which services they are willing to provide.
  8. The focus of debate on these issues has been the conscience of the physician. Should the provider act consistently with his or her conscience, and thus exert his or her autonomy? Or should should the provider act against his or conscience - and thus allow the patient's autonomy to win.
  9. While rarely discussed using similar language, conflicts over treatments that fall safely in the center of the practice of medicine are equally about "autonomy vs. autonomy." In seemingly increasing numbers, the "autonomy" of providers to offer treatment options on the basis of "best medical opinion" or the "best interest of the patient" has been challenged by patients who have different ideas about what treatments or evaluations are in their best interest.
  10. These types of situations are framed as debates about what is in the best interest of patients, which quickly leads to "who decides" - the focus quickly returns to power.
  11. These ways of framing conflicts between providers and patients (autonomy vs. autonomy, who decides what is in a patient's best interests) are perhaps especially frustrating because they are essentially incommensurable on the basis of the accounts they give. Autonomy vs. autonomy excludes the possibility of a normative claim that would allow us to decide "which autonomy wins". Likewise, when the question becomes not "what is in the patient's best interest" but rather "who decides what is in the patient's best interest", no normative claim dependably agreed upon between provider and patient is available to resolve the conflict.
  12. There are really two irresolvable problems - how do we understand the power issues between autonomy and autonomy, and how do we understand the moral decisionmaking of the provider - on the basis of conscience? If so, how do we understand the conscience?
  13. While the attention to physician's moral (including medical) decision-making seems appropriate, the focus on power, while a highly useful tool for describing what is going on in such situations, fails to perform any work in deciding what should be done. Providers win - as Pellegrino observed in his "6 characteristics of professionals), the desire for help on the part of the patient creates a significant power imbalance. The provider, while perhaps desiring to avoid an uncomfortable confrontation or receive a patient complaint, loses nothing in exerting his or her power. To accept the absolute provenance of the provider's conscience, then, is to regard the power differential between patient and physician as unproblematic.
  14. What is badly needed with respect to the problem of provider-patient conflict, then, are accounts of the two key elements in this problem: the practical moral reasoning of the provider, and the nature of the relationship that exists between the provider and patient.
  15. Alasdair MacIntyre provides not only an answer to both of these questions, but a response that successfully integrates the two. MacIntyre provides a way to reframe the problem of provider-patient conflict that, while not eliminating the power differential between provider and patient, at least provides a meaningful account of the relationship between provider and patient, and the significance of the relationship to the moral reasoning of the provider.

Moral Reasoning of the Provider

Moral Development

  1. Whether you accept the accounts of Kohlberg and Gilligan, there can be little doubt that empirically we experience our moral selves as developing over time.
  2. Conscience is often divided in terms of its direction through time: prospective and retrospective. "Retrospective conscience" (pg. 136, What is Conscience, Sulmasy) is that sense of discomfort or guilt that we experience when we reflect on actions that we performed in the past that we experience now as "wrong."
  3. Retrospective conscience, then, has usually received focus when exploring why we sometimes commit actions that we know in the moment not to be right. But we may be disturbed by our retrospective conscience about an action that we thought to be right in the moment.
  4. How could our conscience be fooled?

Practical Moral Reasoning

The Relationship Between Provider and Patient

Dependent Rational Animals

  1. Empirically derived ontology that frames being as being-in-relation, and being-in-relation as a matter of dependence.
  2. Dependence is tied closely to moral development - we are dependent not only because we are vulnerable when we are babies. We are constantly dependent because we need others to help us discover who we are. We develop in our intellectual capacity, and we are dependent on others for this. We develop in our proficiency in our trade, and we are dependent on others for this. We develop in our ability to reason practically, and we are dependent on others for this. We need other to provide us with correction when we are wrong. We need others to point out our blind spots. (Will need to refer to book to see how he organizes these components of dependence).
  3. Just as our telos is always something "out there" - something that we are continually working with an orientation toward, we are ourselves never "finished products." In our intellectual development, our skill in our trade, and even in our moral development we are also in development. As long as we live and come into contact with ours, we continue to be subject to their correction, to their revealing things about ourselves and that world that we are blind to.

Disagreeing, but not Conflicting

  1. MacIntyre points out in DRA that we are accustomed to dealing with persons such as patients as the objects of our moral thinking. But on this account, patients are never only the objects of or moralizing, we are dependent on them for our moral reasoning. Providers encounter patients as themselves "unfinished products", as practical moral reasoners with a considerable amount of experience, but necessarily open to those relationships within which they will continue to develop.
  2. On this account, the conceptualization of the conscience as a law giver is revealed as seriously flawed. Physicians who claim to have closed the book on their moral law have become unable to exist in relation with their patients. Their refusal to respond to requests for emergency contraception is simply a symptom of a failure to acknowledge their dependence.


  1. Integrity, then, is not always responding to moral challenges in the same way, but rather to acknowledge our dependence on those with whom we are in relation to provide us with correction.
  2. Certainly providers are not exclusively dependent, they are also reasoning. They must enter into conversations with patients with an acknowledgment of dependence, but with a proper confidence in the experience that has provided them with moral development to date.