VanDyke, Virtues and Principles

Journal of Medicine and Philosophy, 45: 471–503, 2020
doi:10.1093/jmp/jhaa013
Virtues and Principles in Biomedical Ethics
Downloaded from https://academic.oup.com/jmp/article-abstract/45/4-5/471/5878078 by 81695661, OUP on 01 August 2020

JORGE L. A. GARCIA*
Boston College, Boston, MA, USA
*Address correspondence to: Jorge L. A. Garcia, PhD. Stokes Hall North Room 229.
Morrissey College of Arts and Sciences. Gasson Hall. Philosophy Department. 140
Commonwealth Avenue. Chestnut hill, MA 02467. E-mail: JLAGarcia@aol.com
In the seventh and most recent edition of their classic book,

Principles of Biomedical Ethics, Tom Beauchamp and James
Childress define a virtue as a character trait that is “socially valu-
able and reliably present” and a moral virtue as such a trait that is
also both “dispositional” and “morally valuable” (2013, 31, 377).
The virtues that they single out as “focal” within biomedical ethics
are compassion, discernment, trustworthiness, integrity, and con-
scientiousness (Beauchamp and Childress, 2013, 37–44). Not all is
well in their treatment of virtue. Beauchamp and Childress seem to
worry that an ethical theory in which virtues are fundamental will
neglect duties, rights, and societal needs. Further, they insist that
there is no reason to think that, within ethical theory, one family
of ethical concepts is the most important, nor that one theoretical
approach is correct, or even superior to others. I will try to show,
that there are (and that we have) strong reasons to see language,
concepts, and matters of virtue as fundamental within normative
ethical theory, both generally and in such specialized subareas as
medical ethics. These reasons reveal themselves when we analyze
concepts at the core of the alternative approaches to theorizing
ethics that Beauchamp and Childress identify.
Keywords: meta-ethics, virtue theory, Beauchamp and Childress
I. BEAUCHAMP AND CHILDRESS ON MORAL VIRTUES
In the seventh and most recent edition of their classic book, Principles of
Biomedical Ethics, Beauchamp and Childress define a virtue as a character
trait that is “socially valuable and reliably present” and a moral virtue as a
trait that is also both “dispositional” and “morally valuable” (2013, 31, 377).
© The Author(s) 2020. Published by Oxford University Press, on behalf of the Journal of Medicine and Philosophy Inc.
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472 Jorge L. A. Garcia
(Hereafter, I use “B&C” to refer to this edition or, sometimes, to its au-
thors.) The virtues that they single out as “focal” within biomedical ethics are
compassion, discernment, trustworthiness, integrity, and conscientiousness
(2013, 37–44).
Their discussions both of the virtues and of their proper place within moral
theory have several significant merits (B&C, 2013, esp., ch. 2 and 9). First,

to their credit, B&C do not insist that biomedical agents should primarily at-
tend to principles, nor do they treat such agents’ following rules as in itself
more important than their cultivating virtues, and thus becoming and being
virtuous. Similarly, it is good that B&C do not insist that ethical theorists treat
virtues as conceptually or normatively derivative from, or inferior to, either
what is intrinsically good or bad or what duties or rights we have. In addition,
B&C are on the right path when they accept Rosalind Hursthouse’s (2002)
claim that virtues give “instruction,” including guidance on how to behave.
Likewise, they avoid familiar criticisms of virtue ethics (better, virtues-
based normative ethical theory) that, for example, such approaches must
scant duty, ignore action, and lack practical guidance, and that virtue
ethics (VE) is antiquarian, culturally relative, unable to resolve conflicts, or
else that it is excessively tied to “ethics” in the narrow sense of a sphere
of evaluation that is self-centered (even egoistic), aspirational, compara-
tive (that is, dealing in what is better or worse), subjective/personal, emo-
tional, and therein detached from “morality” (in the similarly narrow sense
of a sphere of evaluation focused on other persons, obligations, categor-
ical imperatives, and on noncomparative concepts (such as those of what
is obligatory or illicit), rights, practical reason, and dignity). Best of all,
B&C improve even on many advocates of VE in recognizing that the
“ethics (i.e., philosophical theory) of virtue” is not the same thing as an
“ethics of (i.e., centered on) character.” Those two differ because we call
virtuous things other than character traits (and the people they charac-
terize), including actions, choices, and decisions, and (sometimes brief)
emotional responses or reactions. Nor must someone be a V person, i.e.,
a person with V-ness as a trait of her character, for some of her actions,
choices, or reactions to be V. In fact, B&C hold that there are certain kinds
of setting in which agents’ focusing on virtues is especially important.
Among these they specify situations of trust, intimacy, or familiarity.
Nevertheless, not all is well in their treatment of virtue. B&C seem to
worry that an ethical theory in which virtues are fundamental will neglect
duties, rights, and societal needs. Further, they insist that there is no reason
to think that, within ethical theory, one family of ethical concepts—such as
the family of virtues, the family of duties and obligations, or the family of
intrinsically valuable things—is the most important, nor that one theoretical
approach is correct, or even superior to others.
Pace B&C, I try to show that there are (and that we have) strong reasons to
see concepts and matters of virtue as fundamental within normative ethical
Virtues and Principles in Biomedical Ethics 473
theory, both generally and in such specialized subareas as medical ethics.

These reasons reveal themselves when we analyze concepts at the core of
the alternative approaches to theorizing ethics that B&C identify.
Consider utilitarianism and its consequentialist descendants. Such theor-
izing usually begins with and expands from judgments on what states of
affairs are intrinsically good and bad. To say something is thus good or bad,

however, is to say it is (un)desirable and (dis)valuable. That is to say, they
are good or bad for us to desire and value. Thus, such claims are about what
desires in us are good or bad ones and which states of valuing or disvaluing
are good/bad states in us. These, of course, are not good or bad qua desire
or valuing but are morally good or bad in that they tend to make the one
who so desires morally good, that is, someone who is in certain ways a good
R for some relevant R. Better, they count toward her being a good R, good as
an R. For example, they help make her to be a good physician, or a good
nurse, or a good researcher that is, good in one of the roles that constitute
her moral life.
Now let us turn to the theories broadly classed as “Kantian,” including
the deontological pluralism of Ross and his followers, and today’s forms of
contractualism. All these focus on duty and obligation; on laws and rules;
on what is required, permitted, forbidden, or prohibited; and on that which
is morally right or wrong. However, some theorists have recently suggested
that we conceive of duties in such ways that they become “transparent,”
indicating not only that some course is immoral or morally required, say,
but also why it is. Moreover, several philosophers have persuasively urged
us to employ “thick” moral concepts, meaning concepts that have signifi-
cant descriptive content.1 These theoretical claims are very important and
illuminating, and—what has not been noticed—they lend support to a type
of ethical theory that is based on virtue-concepts. For virtue concepts are
themselves paradigms of descriptively rich ethical concepts. Moreover, the
other main group of thick concepts, which includes such action-concepts as
those of stealing, lying, murdering, kidnapping, torture, are all themselves
defined by their opposition to various virtues–in most of these examples,
justice–or indicate and depend on invoking virtue and vice. Nothing counts
as stealing unless it is dishonest, as lying unless it is deceitful, as murder or
kidnapping unless it is unjust, as torture unless it is cruel, and so on. Thus,
norms that rule out certain actions as vicious in these and other ways are
both “transparent” and “thick.”
B&C also treat “rights theory” as an independent approach. Of course,
such a theory looks chiefly to people’s rights, i.e., that to which they are
entitled, and to those rights’ infringement, violation, and honoring. Yet, a
right is defined by the fact that someone’s violating it constitutes her treating
someone else unjustly; and even what some call “infringing” a right, which
supposedly need not be wrong, still involves the prospect and risk of acting
unjustly. Needless to say, justice and injustice are themselves a virtue and
its corresponding vice. In these ways, then, even brief but somewhat close
attention to all three theoretical approaches that B&C present as alternatives
to one in which virtues are basic ultimately leads back to the virtues.2
There is a second path to the same result: that virtues are basic in moral
theory when it is properly understood. For the virtues’ fundamentality is
also revealed when we begin to analyze each of B&C’s four main principles.

Plainly, Beneficence and Non-maleficence derive their importance from their
relationship to benevolence, which B&C acknowledge is a virtue. Just as
clearly, Justice, another of their “principles,” is itself a moral virtue.3 Finally,
Respect for Autonomy is tied to virtue in both of its constitutive concepts.
Respect is of moral import chiefly as respect for persons in virtue of the
person-defining features of their naturally pervasive rationality. One aspect
of this rationality is autonomy, when it is conceived, as by Kant himself, as
rule by reason. Respect for persons in, among other things, their self- direc-
tion–autonomy–is, as Kant and his followers stress, the foundation of justice.
Notably, Justice, as we mentioned, is one of B&C’s key principles.
A third path to the fact that virtues are basic in ethical theory reveals itself
when we look closely at the caring and concern that B&C correctly treat as
central to biomedicine, especially, to its nature and purposes, and thence
also to its ethics. (Hereafter, I call this bioethics.) That is because caring and
concern for someone reduce to a kind of targeted benevolence, and ben-
evolence (or goodwill) is not only a virtue in its own right, but the form of
most of the other chief types of moral virtue. Below, we return to this last
topic and its significance.
II. RETHINKING VIRTUES AND THEIR PLACE IN PHILOSOPHICAL

THEORIES OF MORALITY AND OF BIOETHICS
As their book’s title, retained through many expanded editions, suggests, prin-
ciples are central to the approach to understanding and theorizing bioethics
that Beauchamp and Childress take in their classic text. Their chief tasks are
to understand the four principles of Beneficence, Non-Maleficence, Justice,
and Respect for Autonomy (by, for example, distinguishing them from rules),
to determine their place and role in bioethics (relative to, say, virtue, obliga-
tions, and rights), and to draw out their implications for some of the field’s
issues and controversies, both those that are traditional and those that have
only recently arisen. Figuring out how a biomedical actor should behave in
a situation is, for them, a matter of applying those principles by interpreting
them and weighing their comparative significance in the case, a process they
identify as first specifying and then balancing the principles. Here, in con-
trast, I both sketch and make a case for a conception of the ethical, including
the bioethical, within which concepts of virtue are central and fundamental.
Near the end, I offer some suggestions on how this approach might fruitfully
be applied to some current controversies.
Rather than begin with the moral virtues of persons, that is, with traits of
character, let us start with morally virtuous responses. It is important to re-
member that we predicate virtue-terms (V-terms) of people’s (sometimes mo-
mentary) feelings, desires, and resolutions, of their decisions, actions, and so

on, as well as of character traits and persons. The moral virtues themselves,
that is, virtuous character traits, are lasting and deep-seated dispositions to
complexes of such virtuous forms of mental response. Aristotle thought that
what makes something a virtue is that it makes its bearer good. This is a
little overstated, but largely correct (Aristotle, 2011, Bk. 2, Ch. 5, 1106a15).4 A
brief moment of kindness, say, is admirable and therein virtuous, but it does
not suffice to make someone good (a good person). Rather, that a feature or
mental state is virtuous tends to make someone good in that it counts toward
the person who has it being good in certain ways. (Better, as we shall see, it
counts toward her being a good K, that is, a good instance of a kind K, for
certain values of “K.”) Thus, virtues are good-making, contrary to what B&C
say.5 Virtues are not really themselves good, but having one of them helps
their bearer to be good, i.e., to be a good K.6 Someone’s responding V-ly
is her responding well, having a response that we can call good in a loose
way, because it counts toward her being relevantly good. Some character
traits are virtues because being so disposed tends to make someone good in
a relevant way, counts toward her being a good K.
Some medieval thinkers held the view I endorsed above, that love (good-
will) constitutes the general form of the moral virtues. In a more modern
idiom, we can say that the chief moral virtues are types of goodwill, involving
the subject’s willing and wishing for good things–whether in general or spe-
cific types of good–to some person or persons (including oneself). At the
heart of the virtue of truthfulness, for example, is willing someone the bene-
fits of true belief and knowledge. Central to fidelity is willing this person or
that the benefit of having her trust fulfilled. Likewise, we can understand the
virtue of justice as constituted by willing someone the goods of having both
her personhood and its consequent rights respected by oneself and others’.7
Conscientiousness is commitment to avoiding vicious departures from good-
will, and so on.
III. THE METATHEORY OF MORALS
As we have just indicated, B&C are correct to see other virtues as deriva-
tive “expressions of caring” (2013, 37), and to see compassion, caring (and,
thence, the biomedical phenomena of caring about someone, caring for her,
taking care of her, and providing care to her) as basic, with goodwill consti-
tuting what we can call the general form, shape, or structure of fundamental
moral virtues.8
Now, we can expand on these points to sketch morality’s metatheory.

By the term “metatheory” here, I mean a somewhat systematic account of
the structure, determinants, and interconnection of the various subtheories
within morality, that is, systematized analyses of what is virtuous and vi-
cious; of obligatory, forbidden, permitted, and supererogatory actions; of
the impersonal value and disvalue of states of affairs; of rights and their

violation; and so on. We begin by expanding a little on the point just made.
It is appealing and illuminating to conceive of morality as based on virtue-
concepts in the sense that both deontic claims–that is, claims about what
behavior is either consonant with or violates duty, what is permitted, for-
bidden, wrong, obligatory, etc.–and also claims about which states of affairs
are impersonally good or bad, valuable or undesirable, should be analyzed
in terms of virtue-concepts.
In virtues-based moral theory, virtue-concepts are internal both to deontic
judgments and to those of impersonal value. First, why accept that virtue-
concepts are internal to deontic claims? Consider this: the fact that feature
F is a virtue in Ks, as sharpness is a virtue in knives, implies not only that
good Ks do (tend to) have F, but also that Ks should/ought to have F; that
F is a vice in Ks likewise implies that Ks ought not to/should not have F.
Moreover, something similar also holds in the reverse direction: that this (or,
simply, a) K should/ought, as a K, to have F suggests it is somehow good in
a K to be F, that its having F counts toward its being good as a K, and thus
indicates that its being F is a virtue in it (qua K). In general, that this (or any)
K should not/ought not to have F implies that having F is a vice in Ks. We
can thus simplify the picture by understanding some action’s being required
as its being required for its agent being virtuous in action, for her acting vir-
tuously, or, perhaps better, for her to avoid acting viciously. Thus, roughly,
we identify the deontic concept of permission with someone’s behaving in a
way consistent with her being virtuous–or, at least, not vicious–in her action
and its motivations, and the deontic concept of prohibition or wrongness
with behaving inconsistently with acting virtuously.9
Such virtue-analyses of “should/ought/must not,” forbiddenness, wrong-
doing, etc., have salient theoretic advantages. They helpfully capture (i) the
intuitive (conceptual) link of a duty to a role, (ii) the relativity of “ought”
and “ought not” and our idea (stressed by Michael Thompson) that signifi-
cant wrongdoing is (at least often, and even usually) victimizing someone,
(iii) the (claimed) theoretic desiderata, already mentioned, of “thickness”
and “transparency” for the notions of duty that are usually taken as paradig-
matically “thin,” (iv) the scalarity and comparativity of wrongness, and they
offer (v) enhanced theoretic simplicity by integrating the concepts of duty
and “ought not” with that of an action’s being relevantly bad or vicious.10
Second, why think that virtue-concepts are internal to judgments of im-
personal value? One strong reason lies in the fact that the most promising
accounts of states of affairs’ impersonal value analyze it in terms of responses
that are fitting or required. Mere psychological disposition is obviously inad-

equate for capturing impersonal value. We know that what is good in a way
not merely personal–good for Jack, his needs and goals, say, but perhaps
also, bad for Jill and hers–is not merely what people are inclined to like or
want, but must be something about their liking or wanting which is in some
suitable way justified or warranted. This leads many philosophers, learning

from Franz Brentano’s understanding of the good as what is richtig (correct,
right) for someone to “love,” to theorize that something’s being good im-
personally consists in its being fitting, suitable, appropriate, apt, correct, or
required for someone to want, approve of, endorse, or strive for it.
Analyzing being impersonally valuable in terms of virtue marks theoretic
improvement over fittingness and requirement approaches in several ways.
It captures these concepts’ scalarity and comparativity, since something can
be virtuous to a certain extent (scalarity) and less virtuous (comparability)
than is something else. It replaces philosophers’ strange and supposedly
irreducible concepts of Richtigkeit, suitability, and so on, with familiar con-
cepts of virtue and vice, which have been long and well theorized. It also
retains Brentano’s insight that there are two normative concepts in operation
here. For him, what is good is not only correct to love but also incorrect
(unrichtig) to hate, as the bad is incorrect to love as well as correct to hate.
As understood here, what is impersonally valuable and desirable is therein
both virtuous to value and also vicious desideratively or affectively to op-
pose; for something to be undesirable and disvaluable, in an impersonal
way, is for it to be both vicious to favor and also virtuous to disfavor and to
want not to be.11
In addition, such an analysis helpfully captures forms of Amartya Sen’s
(1982) “position-relativity” of impersonal value and avoids difficulties in irre-
ducible and “intrinsic” value, and yields an appealing and intuitive account
of being better as being what it is more virtuous of someone to favor.
There is much more to be said about Virtues Basing, but it is more effi-
cient for our purposes here to move on to another metatheoretic possibility.
Let us call it Role Relativity. I propose that we adapt Aristotle’s insight about
the nature of virtue and its relation to being good in the following way. Its
virtues tend to make a thing of a certain kind, K, to be a good K, a good
instance of K, and tend to make that thing do well the work that is internal
to its being a K. (We can call that work its “function,” using the term in a
somewhat technical and rather broad sense.) Now, let us specify this general
account of virtue to the narrower sphere of morality and moral virtue, as we
usually understand it, and, especially, to the still narrower field of biomed-
ical ethics. A person’s having a moral virtue tends to make someone a good
K, for example, a good nurse, or good physician, or a good biomedical re-
searcher. (Henceforth, I shift from “K” for “kind” to R for the more specific
type, person-to-person “role-relationship.”) Her being virtuous to someone S
tends to make her a good R to S. What being virtuous in her role demands
is what moral virtue–that is, what morality, what avoiding moral vice–de-
mands and requires of her.12 This, then, constitutes her duty within the role.
When she acts contrary to what being virtuous in action, acting virtuously
as an R, demands of her, she cannot but act badly (as an R).13 Any role, of
course, is always a role in something, whether it is a play, a game, a plan,
or some other undertaking. As suggested above, the roles that are central

and, I think, definitive of morality, however, are role-relationships, and thus
relationships. They are roles that constitute ways of standing connected to
some person, playing a part in, as we might say, the narrative that is her
life’s story.14
Thus conceived, someone’s duties are relative and internal to certain roles
she occupies in some person’s life. This solves by a kind of reverse reduc-
tionism the problem of duties of partiality and their relation to what are
taken to be universal duties, with the latter duties seen here as deriving from
the former.15 What I mean is that what philosophers have taken to be your
duty not to tell lies, your obligation not to cheat or steal, your responsibility
not to kill or harm people willy-nilly, and so on, are all of them better the-
orized in terms of your role-relationships with others. You fail me in some
pertinent role-relationship in which you stand relative to me, by acting in a
way sharply opposed to that role’s virtues, when you lie to me, cheat or steal
from me, kill or harm me with no adequate excuse, and so on. Likewise,
you mistreat any of these other people, fail them in the role(s) that you
play in their lives, when you treat one of them in such ways. Thus, the sug-
gested account captures these moral duties’ universality without accepting
that they are independent of roles, owed to no-one. Rather, they are owed
each person and always within some role-relationship between that person
and the agent.16
Of course, for this account to be plausible, we must allow that you stand
in such a relationship with everyone. This would still yield universal duties
in the sense of duties violated any time you treat anybody in relevant ways.
However, a role-relationship gives us this without assuming a universal base-
line impartiality across persons. Quite the opposite. On this account, in lying
to me you violate your duty of veracity to me, since your doing that would
treat me viciously, your duplicity standing in stark opposition to the truth-
fulness that is a virtue in any caring, person-to-person relationship. In just
the same way, your lying to that person over there violates your duty to
her, treating her viciously in your relationship with her, and so on for each
person. Each duty then is owed to someone, since your acting in a contrary
way means you are being vicious to someone, a bad R in relation to her. All
duties being relative to role-relationships, no question arises of whether role-
duties are reducible to, or derive from, general relationship-independent
duties not to tell lies, kill wantonly, cheat, steal, etc. We have no relationship-
independent duties, though we can rightly talk of our duties, owed to each
person, that we violate whenever we fail her, treat her viciously, by lying to
her, or killing her for no reason, or cheating her, or stealing her property.
That is the truth behind the claims that, morally, we must not kill willy-nilly,
may never lie, are not permitted to cheat anyone, and so on.
Any wrongdoing is a wronging of someone, i.e., treating her badly as
her R and therein failing her in the agent’s role as her R, for example, vic-
timizing her as her physician or nurse (or as her spouse, or her brother,

or her partner, and so on). Which role-relationships are the ones such that
someone’s being good within them constitutes her moral virtues, moreover,
virtues whose requisites constitute her moral duties? Of course, these are
critical and difficult questions for such a view of morality. They are too deep,
complicated, and far afield for me to answer here, even if in principle I were
able to do so in a convincing way. Let me first offer a tentative proposal on
them and say a few words in its support. Afterwards, I suggest a way around
this controversy for our purposes here.
My suggestion is that the role-relationships within which we have our
virtues and duties and live our moral lives must be ones such that some
subject’s, S1’s, filling one of them in the life of a person, S2, contributes to
(or partially constitutes) S2’s flourishing as a human being, i.e., S2’s living a
life in which she fares well, one that fulfills her as a rational and social animal
of a certain sort, while at the same time S1’s occupying it at least does not
detract from S1’s own human flourishing. Whatever the underlying theoretic
details, we can easily identify some roles that, intuitively, morally constitute
a person’s life for purposes of moral evaluation. These include the relation-
ships of friend, spouse, parent, daughter or son, sibling, co-citizen, certain
kinds of partner (such as business), and “neighbor” in the broad sense, used
in Christian scripture, of being a fellow traveler along life’s way and another
child of God. It is salient and critical that each such role is a sort of office in
that it provides standards for evaluating how well or poorly anyone occu-
pies it. (Note, first, that our term “office” derives from a Latin word, officium,
that can be translated as “duty,” as in the title of Cicero’s classic work, and
second, that we intuitively associate duties with roles, talking of duties of,
and as, say, a physician or a nurse, a student or a teacher.)
As just suggested, however, I think that, for purposes of theorizing bio-
ethics, we do best here to duck the difficult theoretical questions about just
what such a role-relationship is, which ones are morally constitutive, with
whom someone can be so related, what are the entry and exit conditions
for each role, and so on. Let us instead just count for theoretic-practical pur-
poses such professional roles as physician, nurse, and researcher as, each of
them itself, a morally determinative role.17 For now, that can be a stipulation.
Properly understood, I hold, virtues-basing and role-relativity lead to
what I call Patient Focus. The factors that make actions, their motives, and
a wider range of non-cognitive mental phenomena good, bad, right, and
wrong, among other normative features, are the agent’s stance toward rele-
vant aspects of the welfare of specific moral patients.18 It is these that count
toward her being a good nurse to S1, a bad doctor to S2, a poor, vicious
researcher for us in the biomedical inquiry that she wrongly undertakes or
pursues. That implies that what chiefly counts towards an action’s being vir-
tuous or vicious (and therein wrong, duty-violating) is, in the first instance,
its connection not to a categorical imperative (pace Kant), nor to the greater
happiness (pace traditional utilitarians), nor to the best available outcome

or possible world (pace recent consequentialists), nor to the agent’s own
flourishing (pace Aristotle), nor even to divine imperatives (contrary to such
divine command theories as Adams’s), but rather to how, in its motivational
input, its agent stands to certain relevant aspects of the welfare of particular
persons.19 It is the well-being of the agent’s other (her respondent) within
a relevant role that is focal in shaping her action’s moral status.20 Further, in
thus leading to ethical theory that is Virtues Based, Role Relative, and Patient
Focused, such a theory also supports a further metatheoretic feature and op-
tion, which we can call Input Drive. Virtues, as dispositions to want and feel
certain things and to perform related actions, are mental phenomena, so it
is motivational input that drives any action’s being virtuous or vicious, and
thence right or wrong, i.e., its conforming with duty (understood as what is
requisite for virtue or, minimally, for non-viciousness) or its violation of duty
(i.e., its being significantly vice-ridden, vicious).21
Though many of these ideas and my terminology are unfamiliar, they are
not wholly without precedent. We can think of Virtues Basing as a form of
what the philosopher of social science Brian Epstein calls “anchoring,” which
is a kind of deep (or meta-) grounding, because it claims to provide grounds
for such facts as that this act’s being torture grounds its being morally wrong,
and that a certain state of affairs’ consisting in your being healthy grounds
its being valuable impersonally.22 As conceived here, it is torture’s inher-
ently expressing vicious motivation and it being normally virtuous of me
and others to want you to be healthy that grounds each of these grounding
relations. Virtues Based ethical theory is similar to what Michael Slote calls
“agent-based virtue ethics” and Linda Zagzebski “motivation basing.” Where
both of them focus on virtue and vice as internal to wrongdoing, however,
and thus on what is here called Input Drive, Virtues Basing is broader,
claiming also that the aretaic is internal to the impersonal value attributed
to the state of affairs.23 Role Centering would satisfy something very close
to a form of morality consisting in what Samuel Scheffler calls “relationship-
based reasons,” a conception of the moral that intrigues him but for which
he has searched the literature in vain and to whose investigation he inspired
others.24 Patient Focus can be seen as a kind of middle ground, situating
moral “ought”-judgments between Kant’s “hypothetical imperatives,” which
comprise “ought”-judgments rooted in the agent’s own interest and desires,
and his “categorical imperatives,” which are supposed to derive from pure
reason and be largely independent of anyone’s wants, needs, or interest.
Rather, focusing on morality’s patients, our actions’ victims, and beneficiaries
reveals what is already intuitively true: that what is morally virtuous and
even necessary derives from what benefits the patient, advancing her needs
and welfare, unlike categorical imperatives, rather than from what serves the
agent’s. In addition, Patient Focus theorizes that the idea of morally wronging
someone–an important topic that Elizabeth Anscombe, Thompson, and a
few others have begun to explore–is central to all wrongdoing.

Finally, let me highlight as rubrics some locutions that may offer clues and
insight into this approach to understanding the realm of moral features the-
oretically. As seen here, such expressions as “It’s V of S to do A,” “S is being
V in doing A,” “S's doing A is V (of her)” are the most revealing formulations
and, as far as they go, should be treated as canonical. Since the virtues are
features that make someone good as belonging to a kind and, in morality,
good as occupying a certain role-relationship in someone’s life, each of
these formulae needs to be understood as implicitly relativized to such roles.
Thus, it is not just V of S to do A, but V of S, within role R, and to someone,
S*, whose R our subject S is.
Likewise, we do well to replace Kant’s common but misleading question,
“What ought I to do?,” with the more illuminative and revelatory formulation,
“How should I conduct myself?” We do well to gloss this last as inquiring
how, in what way, from what motives, I should act as R to someone S*.
Again, we can reformulate that question this way: “Which modes of conduct
in me cannot but be vicious to S* insofar as I am R to S*, that is, insofar as I
am S*’s R?.”25
IV. SOME CONTRASTS BETWEEN B&C’S BIOETHICAL PRINCIPLISM

AND THE VIEW OF ETHICAL FOUNDATIONS HERE PRESENTED
An Internal Medical Ethics. As viewed here, virtues and their various vices
provide the advantage of continuity between the biomedical professions’
“ideals” and their “duties.”26 Virtue is aspirational, an ideal, while duties are
defined in terms of such distance from virtuous motivation as to constitute
vice. Someone can fall short of an ideal without violating her duty, but there
is nonetheless strong continuity between ideals, which engage what is good,
and duties, which involve what is bad. These are not concepts from different
parts of ethics; to the contrary, they have a common source. Moreover, this
approach allows us to dispense with B&C’s (very odd) notion of a separate
“virtue of nonmalevolence” (2013, 31) and, more broadly, with the (equally
odd) concepts of both “negative duties” (2013, 365) and “negative rights”
(2013, 370f).
Rather, we can say that malevolent actions are vicious because they stand
opposed to the virtue of benevolence. Murder, for example, is vicious in
violating our virtue-based requirement to care for anyone’s life by revering
it and, when feasible, striving to protect and preserve it, and therein it is
contrary to what virtue requires of anyone in her relationships with another.

For that reason, we can also say that it violates duty, and is wrong (a word
from the same root as “wrung” and that indicates being twisted) in that it
skews far away from the “right” (etymologically, the straight) path of hewing
to virtue. We may express this in a largely non-literal way by calling some
conduct “prohibited” or “forbidden,” not because there are real acts of pro-

hibition at morality’s foundation, but as a way of communicating that such
behavior is unacceptable, “wrong” in the sense of skewing away from the
“right”/straight path of virtue, in that it is normally vicious of anyone so to
conduct herself, or to allow such behavior to be done, or to stand, without
opposing it.27 Similarly, lying to someone is treating her viciously because
it stands egregiously opposed to our virtues-based requirement to will an-
other the good of true belief, and we can and do often express that fact
by saying that it is not only vicious but also wrong, prohibited, forbidden.
Such expressions I take to be quite legitimate, but highlight here because
they have often misled ethical theorists. Thus, proper moral theory has no
need of negative virtues, negative obligations, or negative rights. (Contrast
B&C, 2013, 371, where four of ten “basic obligations” and four of ten corres-
ponding “basic rights” are formulated as negative.)
As mentioned above, the way we conceive it here, all the principal
types of ethical features–virtues, duties, rights–are “internal” to certain
role-relationships, including the moral features deployed within bioethics.
General ethical principles, as we suggested, can be illuminatingly viewed
largely as mere generalizations about the implication of those virtues that
are internal to morally constitutive roles, including those of fellow travelers
through life (what Christians mean by “neighbor”), or friend, or co-citizen.
More to the point here, the virtues and obligations crucial to bioethics are all
of them role-relative virtues and similarly role-relative duties that derive from
those virtues. It is not so much that general ethical principles are “applied”
to medicine, but that the general/abstract form of interpersonal role-virtue,
which is reverential and respectful goodwill, gets clarified with respect to
which are the goods that it is especially important for the role-occupant to
will her role-other (role-opposite, role-respondent), and what special forms
that willing takes in this role. That is not to say there is no place for talk
of principles or rules. First, as just mentioned, the discourse of moral rules
and principles can be understood as helpful generalizations about what is
needed not to act viciously. Second, the virtuous person will be inclined
to do some things, and to avoid others, “on principle,” as we say. She will
“make it a rule (for her)” so to behave. Third, there may be genuine rules
enacted by people, and principles so adopted, that then bind those within
certain role-relationships as matters of virtue and vices. (That is, on pain of
vice, as we might put it.) Various codes of professional ethics are perhaps
best viewed in this light. Fourth, of course, many of us also believe that there
really is a divine Law-giver, who underscores some behavior’s viciousness
with commands that add the vice of disobedience to those actions’ ante-
cedent vice and wrongness.28
Recall our point above, that each of B&C’s own four major principles of
biomedical ethics are, in fact, best understood as pointing back to some
virtue as foundational. Beneficence, doing good, takes on moral import from
its connection to the virtue of benevolence, willing well by willing what is

good, which normally motivates it.29 Failures of goodwill can offend against
this virtue, violating it. Maleficence is morally important because its motiv-
ation often lies in some–oftentimes, a categorically more egregious–failure
of the goodwill that properly makes us reluctant to cause someone harm.30
Justice is, of course, a virtue in its own right. Below I suggest an account of it
in term of personal respect. Relatedly, what is most important in B&C’s prin-
ciple of respect for autonomy is (virtuous) respect as a response to persons,
whose dignity both grounds the importance of a measure of autonomy and
limits it by excluding acts directed against, or callously indifferent to, the life
and well-being of the one who possesses that dignity.
Profession, as act and institution. The various types of medicine, of
nursing, and arguably also of medical research can all be understood as
ways of professionalizing (that is, of solemnizing in official and public acts
of professing, and governed by special ethical codes) something that is an
aspect of most morally determinative roles: as care-giving is a manifestation
of caring. (This is also true of the profession of teaching, and some other
professions may similarly be professionalizations of more basic and natural
person-to-person role-relationships.) Let us look a little more closely at the
topic of profession, which is of central importance within medical ethics.
Though his view is flawed, there are insights in Talcott Parsons’ under-
standing of a profession as “a cluster of occupational roles [whose] incum-
bents perform certain functions valued in the society in general” (quoted in
B&C, 2013, 7). The “function” provides standards of evaluation in virtues
(and the duties that derive therefrom). However, contra Parsons, what mat-
ters more is that those in the role serve (take care of) certain individuals (cli-
ents or patients, not society) who value them within their role. Now consider
B&C’s conception of professionals as “distinguished by their specialized
knowledge,” having organizations that “control entry,” undergoing “closely
supervised training,” and being “committed to providing a service to others”
(2013, 7). The medical professional, we need to remember, commits her-
self to certain specific ends and means, especially in the oath she takes (or
should take). Pace B&C, it is the role-virtues, not obligations, that ultimately
“comprise the ‘ethics’ of the profession.”
As Thomas Cavanaugh (2017) has recently reminded us, oath-taking was,
and largely should remain, a solemn pronouncement (“before all the gods and
goddesses” and before members of the community as well in Hippocrates’
tradition), committing oneself to certain goals, especially to caring for the
health of each patient by advising her on, and striving after her, health’s
promotion, maintenance, and restoration. This oath is unlike a promise, or

even a vow, to someone, because it allows no room for any party to release
the oath-taker from her obligation. This observation captures and provides
justification and theoretical framework for Edmund Pellegrino’s vision of an
internal conception of medicine’s ethics, and it contrasts with a conception
in which medical ethics constitutes an imposition/application of what are

presumed to be external, role-independent moral principles.32 Remember,
I have argued that such general principles are already best understood as
expressing virtue-claims about what is internal to being a good nurse or
physician. The reverse does not hold. It is not, that is, that the ethics internal
to medical and healthcare roles stems from and depends on a prior set of
relationship-independent moral norms or principles.
Justice. I think these considerations indicate that B&C may misunderstand
the scope and nature of justice when they concentrate their account on
issues of how a society distributes its benefits and burdens, redresses dis-
ability and racial and sexual injustices, and addresses problems of public and
global health (2013, ch. 7). Their treatment neglects what are traditionally
seen as retributive and commutative forms or spheres of justice, in addition
to the distributive. More importantly, it neglects the more modern insight
that respect is central to responding justly to people, their status, needs,
and rights.
On the contrasting approach here advanced, justice seems best under-
stood as a personal moral virtue of having and showing respect (which is
a complex state of mind) for another person in recognition of her status,
and by both deferring to her status, needs, or will, within one’s own will,
and also by protecting and restoring what is endangered or taken from her
through others’ disrespect. When so conceived, the questions of society’s
distribution and allocation of burdens and benefits, on which B&C lavish at-
tention, appear as but one sphere among many in which people do (or do
not) manifest respect for others by treating them with (or without) virtuous
concern for their well-being and deference to their personhood. Patterns
or sets of holdings (“distributions”) involve injustice only indirectly and in-
sofar as people’s aiming at them, knowingly allowing them, or tolerating
their continuation, shows disrespect to those disadvantaged. It is neither
someone’s having this or that set of benefits and burdens, nor even in com-
parison with what some other person has, that is itself unjust. Instead, what
is callous, malicious, or otherwise disrespectful is these people’s letting–or
perhaps worse, causing–other people to have so little when the first group
could without great cost remedy the second group’s predicament. A state of
affairs, including a pattern of holdings, is properly called unjust only in that
it is (or would be) pro tanto unjust, and therein vicious, of people to cause
or allow it to come to be or to continue, because we presume such action or
omission to manifest the agent’s contempt for the patient(s).
That justice depends on respect can be supported in two ways. First, the
justification of our injustice-claims is best understood as invoking respect.
We often think of need as a ground for claims of justice and injustice, and
the approach here advocated can well accommodate this by noting that our
egregiously neglecting your basic needs often manifests our lack of respect
for you in your personhood. My thus leaving your basic needs unmet is pro

tanto unjust in that it indicates my insolence before (i.e., lack of respect for)
both your dignity and the concern for your welfare that your dignity de-
mands of me. Likewise, when we cite someone’s deserving or meriting some
good thing as a demand in justice, we can understand this as our claiming
that, in failing to provide her with it, we treat her unjustly, fail to show ad-
equate respect for the person she is. My denying you a benefit that you de-
serve is unjust in that I show disrespect for you as having a claim. For similar
reasons, too is my imposing on you an undeserved penalty unjust.33
Equality. In contrast, consideration of utility, well-being, or capabilities are
plausible as claims of justice only insofar as they are, or can be, elucidated in
terms of need, merit, or rights, and thus as appeals to that to which someone
is entitled as a matter of treating her respectfully. People also sometimes ap-
peal to equality to support claims of justice. Again, in general, this can be
accommodated insofar as it is an appeal to the disrespect we show people in
tolerating their poverty in a context where we have so much that we could
easily alleviate their burden. Here, notice, it is not equality as such that mat-
ters morally but, rather, one person’s having so little that another, who has
much more, manifests contempt or disdain by failing to act in order to ameli-
orate the latter’s plight.
Equality, however, plays a different role in some recent bioethical contro-
versies, one that warrants a bit more discussion. We are all “equally” persons
in that we are simply persons, a status that allows no degrees. As persons,
our lives and well-being have special import in that it is vicious of someone
not to value, desire, and pursue another’s (or, for that matter, her own) sur-
vival and health. Thus, aside from cases where my own vicious wrongdoing
lessens my claim to people’s goodwill, it is inherently unjust of you or others
to aim at my death and often even unjust of you not to strive to preserve
it.34 You thereby mistreat me, treat me viciously. More specifically, you act
unjustly toward me. So, equality takes on its main import within bioethics
from the fact that we are all equally persons–that is, individuals of a rational
nature, as Boethius insightfully wrote–and therefore no one’s life is so in-
considerable that she has no claim in justice to her care-givers’ preserving
it.35 Because both of us are persons, your life is no more and no less worthy
of preservation and protection than mine is, your or my illness, health, etc.,
notwithstanding. In deliberately putting me to death, you attack my life and
therein also my health, since health is a matter of bodily and mental func-
tioning and death is the state of complete cessation of any genuinely organic
function.36 It is, however, precisely my life and my health that, as my medical

care-giver, it is virtuous of you to cherish in your heart and to protect and
preserve by your behavior.
Viewed from this perspective, much of today’s biomedicine, all too open
to homicide, and much of the bioethics that rationalizes what (adapting,
as I have before, Jules Feiffer’s incisive phrase) we can call our society’s

“little murders” and presumes to proffer it reason’s imprimatur, both ap-
pear as caricatures, grotesque and degraded travesties of a biomedicine
and a bioethics genuinely devoted to bios and an ethos of preserving and
revering it. To believe that you show me mercy in euthanasia only shows
the insight in Hebrew Scripture’s assertion, “the tender mercies of the
wicked are cruel” (Proverbs 12:10). By the same token, I wrong myself, in
suicide, whether assisted or do-it-yourself, and in giving up on life. Thus,
to abandon my role of self-stewardship, and its attendant virtues and
duties, is flagrantly vicious, even if its perpetrators often merit pity more
than condemnation. (Whether we do or should call this unjust seems to
me a technical matter, irrelevant to the moral substance.)37 My being just
to you demands I recognize your equality in that I must respect you as
being the same as, equal to, everyone else in fundamental personhood
and humanity.
Second, several of the theories of justice that B&C discuss can be seen as
requiring respect.38 Consider what B&C regard as an egalitarian theory of
justice. As I just suggested, moral equality is equality not in holding goods
but in our inherent equality as persons, especially, as sites of reason. As for
the libertarian justice theory, libertarians stress rights, which are best under-
stood mainly to be demands on our respectful response to personhood.
Quite recently, some have proposed what B&C classify as a capabilities
theory. This approach to justice begins from the idea that “opportunity to
reach states of proper functioning” has “basic” import. However, this import
can and should be explained not as “basic” but as deriving from the dignity
of the persons whose functioning (especially, function of the types peculiar
to them as persons) is at issue and, thence, from the respect due them as
such (B&C, 2013, 259).
B&C see virtue as failing and faltering in situations “when strangers meet,”
wherein they think we instead need to focus on rights and obligations (2013,
382). This poses a real problem, especially when, as in the account I offer
here, virtues are seen as making their bearers good within relationships. Still,
the Christian conception of others as “neighbors” linked to us as fellows
(that is, as other travelers viewed as accompanying us along life’s journey),
sharing a common fate, and as mutually vulnerable, gives a helpful model
for a philosophical theory that sees even strangers as related to us in ways
that allow us to excel or fail and that therein both impose duties and ground
people’s rights against one another.
V. VIRTUES IN MEDICINE: SOME VIRTUES AND DERIVATIVE DUTIES

OF PHYSICIANS, NURSES, RESEARCHERS
B&C wisely place caring for someone at the heart of health care. What
physicians and nurses do in providing care to some patient is to take care
of her and to care for her, and all these derive from the more fundamental

phenomenon of caring about her. Caring about someone in the sense rele-
vant here chiefly consists in wanting, wishing, and willing good things for
her.39 The principal ways of caring about a person include: striving for her
good by seeking to preserve, restore, or advance it; being truthful with her;
respecting her in the elevated status internal to her personhood; being dis-
posed to defer to her self-governance.40 We should note another essential
part of genuine caring, especially in health care. When I care for you in the
relevant way, that is, substantially, permanently, and for your own sake,
I make it a point never to turn against you and never to abandon you. Since
caring for you is realized in caring for your welfare, striving that you live and
live well, I ought to recognize a floor of good-will in regard to you beneath
which I should never fall. That means that unless you first rupture our rela-
tionship through some evil-doing, my relationship with you, my being your
R, requires that I not give up on you or your life or ever strive (intend) to
end them. Our medical tradition has long captured and codified this moral
essential in the doctrine that a physician may neither abandon her patient to
die or wither away, nor act to kill her. The latter, of course, lies behind the
Hippocratic injunction first to do no harm. We should add at this point that
my caring about you as your physician must also entail my maintaining my
own integrity as a care-giver (that is, as a member of a caring profession)
and therein upholding the professions’ nature and historical traditions in my
own conduct.41
I should say a little more about, and in support of, these assertions. We
can proceed stepwise. To care about someone is to care about her welfare
and status (or dignity). Someone’s welfare is what is comprehensively good
for her, that is, as the term implies, what makes her fare well, either causally
or constitutively. Moreover, she fares well when she has what contributes to,
or partly constitutes, her having a good life in the sense of a life that suits
and fits her as a human person. That means our caring about her having,
among others, the goods peculiar to rational beings, including a measure of
self-governance.42 Such deference to someone’s self-governance is one part
of respecting her. So too, however, and more fundamental is reverence for
someone in her personhood. It is the latter that is inconsistent with aiming
at her death, whether through commission or omission, for the sake of such
lesser goals as increased comfort. Caring about someone in a positive way,
however, is wanting, and wishing, and willing, and taking pleasure in her
doing well through having certain things good for her in light of the kind
of being that she is. Thus, we can properly understand the caring relevant
to medicine as goodwill, which is, roughly, the secular counterpart to what

Christians call the moral (and theological) virtue of charity. Note, though,
that the goodwill that is morally virtuous has a special quality and qualifica-
tion. It necessarily includes respect, because the goods it is virtuous to will a
human being include certain goods peculiar to persons in that they respond
to, suit, or enhance the rationality that naturally pervades a person’s way of

living. If my love for a person is identical to the kind of “love” that I may feel
for my pets, farm animals, or trees, then that is not the interpersonal moral
virtue. It does not do what moral virtues do, which, as we noted above, is to
count toward my being good in certain role-relationships that we occupy in
this or that person’s life. Rather, the moral virtue of goodwill is respectful,
that is, respect-filled, love for persons as persons, and in their personhood.43
This applies at least as much to nurses, often viewed as the providers of
care who are most personally involved with patients, as it does to phys-
icians. As for biomedical researchers, respectful caring involves respect for
each person’s life, which in turn means, as we just mentioned, not falling
below a suitable floor of good-will with regard to anyone. Below we show
the important implications of this last point.
We should perhaps address here a problem for our approach, which
understands duty as derivative from virtue by understanding violating duty
as acting viciously. Standardly, philosophers think of duty and obligation
as among the deontic concepts that also include not only right and wrong,
but also the licit and illicit, the permitted and prohibited, the allowed and
forbidden. These last few, however, raise a conceptual difficulty. For we
think of vice as admitting of comparison and degrees: I, my attitudes, and
my actions, can be more vicious than you and yours, or less, and they can
also be very vicious, or only just barely vicious. Not so, it may seem, with
the licit and illicit. Whether both my actions and yours are licit, permitted,
and allowed illicit, or both are illicit, prohibited, and forbidden, that seems
to be the end of the matter. We cannot go on to ask or answer whose ac-
tions are more licit or illicit, etc., nor whether this licit action is only slightly
or extremely permitted, nor claim that this prohibited action is but a little
forbidden while that other one is very forbidden indeed. So, how can the re-
duced feature–duty–thus differ from the one to which it is reduced–vicious-
ness–with the latter, but not former, being scalar and comparative?
It is a thorny difficulty for such a reduction of deontic concepts to aretaic
ones as is here proposed. In response, I tentatively offer three suggestions,
none of which excludes the others. First, the reduction I propose is some-
what corrective, not entirely descriptive and neutral. I hold that shifting
to aretaic concepts marks a theoretic and classificatory improvement over
using the explicitly deontic, so we should not expect them exactly to coin-
cide. Second, there may be an unnoticed asymmetry here in the realm of
the morally deontic. Although we do not think any actions are more or less
permitted or prohibited than are others, we do allow that some may be more
wrong, and others less.44 In fact, it may be revealing that we freely shift here
from the deontic to explicitly evaluative talk, as when we say, for example,
that stealing is wrong but teaching children to steal is worse, meaning it is
even more wrong. Third, we can adapt proposals from Slote and Zagzebski
and treat the morally licit/permitted/allowed those actions by doing which,
in her circumstances, the agent treats no one in a way that is flatly, finally,

vicious within any of the roles she plays in people’s lives. In keeping with
our second suggestion, this move would rule out any action being less or
more permitted than another, while still allowing some forbidden actions
that are, in their motivational structure, further from duty and virtue than are
others and therein “worse,” where by the latter term we mean that they de-
viate more sharply than the others from the right/straight course of relevant
virtues.
VI. DEALING WITH APPARENT MORAL CONFLICTS IN B&C AND IN A

MEDICAL ETHICS THAT IS VIRTUES BASED, ROLE RELATIVE, PATIENT
FOCUSED, AND INPUT DRIVEN
B&C endorse a two-step method for addressing conflicts between valid

moral principles. This principlist model includes, first,“specifying” each nor-
mative principle’s point and content and, second, then “balancing” (better,
weighing) each against the other (B&C, 2013, 17–24). This account seems
to me problematic in several ways. First, it lacks needed depth in that it
is limited to principles of action, while the morality of acts needs to be
grounded in the deeper morality of their underlying motivation and atti-
tudes. There are different ways of responding to various patients’ needs,
and the modes of response that may conflict are not always limited to the
behavioral. Second, as Henry Richardson (1990) has complained, B&C’s ap-
proach threatens to collapse into mere subjective preference, masked as a
supposedly rational intuition that in fact reason can neither articulate nor
defend. Third, again following Richardson, the approach’s reliance on pur-
ported balancing misconstrues a process that is qualitative and interpretive
as something that is largely quantitative, a comparison of moral “weights.”45
In contrast, a Virtues-Based approach that incorporates Patient Focus, Role
Relativity, and Input Drive strives to clarify both the manner in which and
the extent to which each proposed course of action’s motivational input
diverges from the relevant role-virtue and also to specify each virtue’s con-
tent, its realization in (implications for) practice, and its place (especially,
whether it is central) within its role. We can call that process elaboration of
each role-virtue or its prospective and deliberative actuation in the agent’s
circumstances. We should treat many of our ordinary generalizations (e.g.,
“causing [her] death is malicious [to her],” “not giving her the medicine she
needs, and therein allowing her to die, is inconsiderate [of the agent to
her], callous,” “lying to her is duplicitous, and two-faced, a kind of double
dealing”) as judgments about what holds pro tanto. These may not survive
full consideration of the situation since, for example, my giving the medicine
you need to her, who also needs it, is not genuinely inconsiderate of you in
these circumstances. Sometimes, however, the pro tanto judgment survives.
Lying to someone is still duplicitous (of you in regard to her), after all, even
if done to help her (or someone else). Further, this virtues-based approach

helpfully rules out genuine and egregious departures from virtue as ineli-
gible, i.e., as beneath justifiable choice. They are inferior to, and therein less
eligible than, lesser deviations.46
Thus conceived, real or prospective moral failures of action or omission
are always instances of failing some person or persons (focus on patients),
within certain role-relationships (relativity to roles) in the agent’s motivations
and decision-making (actions’ moral status driven by their motivational in-
puts).47 B&C borrow the concept of norm-specification from Richardson,
and the different approach I suggest here helps retain Richardson’s own
view of specifying principles as both “interpretive” and “qualitative.” Rather
than optimizing the world’s condition or, what might be different, bringing
about the greatest amount of good, a virtues-based approach that con-
ceives the principal virtues as forms of love will stress the importance of
the agent’s minimizing the extent to which she departs from goodwill in
regard to anyone in any role she occupies or, perhaps better, to her ac-
knowledging and observing the floor beneath which her motivational depar-
tures from goodwill will not go in regard to anyone. Such a floor can help
justify exceptionless norms against the medical killing of patients, at least,
intentionally.
VII. SOME PRACTICAL APPLICATIONS, BRIEFLY SKETCHED
Ethical method and metatheory matter chiefly for their implications for our
moral judgments. In my view, however, we need to supplement bioethical
method with a philosophy of medicine in order adequately to justify such
judgments. Space does not permit me to supply and defend such a phil-
osophy here. Instead, let me indicate what more is needed, and how I think
the relevant questions should be answered, before I propose some applica-
tions. As I understand virtues, they are features that, in certain ways, help
make someone a good physician, good as a nurse, or that help her do her
medical research well. What is it to be or do these things? It should be largely
uncontroversial that a physician is as such a healer, that is, someone who
works to restore or maintain her patient’s health. To deny that a physician is
to heal is like saying a teacher need not instruct or construction has nothing to
do with building. Beyond that conceptual point, though, are there additional
goals and tasks internal to medicine and nursing? What is it to be healthy?
Who and what is the patient? Some conceptions of health are so broad that
almost every problem becomes a medical one. That should be rejected, as it

seems inaccurate, counterintuitive, and poses obvious sociopolitical dangers.
More promising is conceiving health in terms of integrated organic function,
a conception with which B&C seem sympathetic (2013, 257). We can extend
that as needed to allow for mental health and, thence, illness. Given the links
between poor function and discomfort, the physician’s knowledge of human

anatomy, and her grasp of pharmacology, it makes sense for medical profes-
sionals also to take on alleviation of patients’ pain, and that has long been
one of their important, if subordinate, goals and tasks. As for the patient, what
separates physicians from, say, veterinarians, is that the former take persons,
rather than lower animals, as their patients.48 The topic of personhood has
wasted a lot of ink the past few decades, mainly as thinkers struggle to deny
its status to various kinds of people they hold in low regard, such as those
hopelessly ill, the unborn, infants, people with badly damaged brains, and
so on. My own view is that no one has really improved on Boethius’ classic
account of a person as an individual rational by her nature. Such rationality
is someone’s by nature, as an inherent potency even when physical obstacles
block its realization, and it tends to pervade her life and mind in such a way
that it becomes possible and important to ask how rational are not only her
reasoning and beliefs, but also her decisions, preferences, wants and aver-
sions, likes and dislikes, sentiments, and emotions.
All this seems to me pretty straightforward and in little need of defense,
but I am aware that all these claims are all controverted, that alternative an-
swers are available, and that a full presentation would involve clarification,
elaboration, support, and arguments against rival positions and reasoning.
As I said, I can offer none of that here. My metatheoretic proposals in pre-
vious sections are, I think, somewhat innovative and creative. Mere novelty,
however, is a meager virtue. My next task is to sketch how these methodo-
logical innovations, when combined with a philosophy of medicine along
the lines just indicated, can be put to use reviving, defending, and reinvig-
orating some venerable but now widely neglected traditional positions on
some current controversies in bioethics.
Truth-telling
A healthcare professional’s lying to her patient is, as such, manipulative of
that patient, mendacious to her, deceitful, prevaricating, tergiversate, and,
especially, is unavoidably duplicitous. These are normally vicious, because
they are opposed to the virtues of truthfulness, openness, forthrightness,
candor, etc. Of them, I think duplicity (double-dealing, being two-faced,
mendacious, and fraudulent) gets a kind of (negative) pride of place be-
cause of the way the liar as such both presents herself as doing one thing
and then acts in a way that is, in its motivational structure, diametrically
opposed to that.49 The lying medical professional does not merely mislead
(and therein behave in ways that are deceptive and mendacious) but, in
asserting, offers as care-giver a solemn (even if implicit) assurance to her

audience (whom I take to be her patient or that patient’s family), perhaps
even a promise, but then violates that assurance. Unlike other forms of de-
ception, which need not always be vicious, this is a grave and egregious
betrayal of the other person, especially her patient, that is both deep and
violative of that other and the liar’s relationship with her. For that reason,

unlike some other kinds of deception, which sometimes are not flatly vi-
cious in their circumstances, lying is inherently vicious and therein imper-
missible. It seems to be worse, more vicious, than is merely being dishonest,
deceptive, prevaricating, and so on.50
Truth is even more plainly central to research than it is within clinical
healthcare practice. Note that we call both Ph.D.s and M.D.s “doctor,” which
originally means teacher. It is plainly diametrically opposed to the nature
of teaching, in publishing (that is, making public) research results and
methods, for someone intentionally to give others false instruction, misin-
formation. In our age of (sometimes excessive or misguided) deference to
autonomy, it should be easier for us to discern the central part of the bio-
ethical professional’s role that consists in advising, correcting, counseling,
reassuring, warning, and otherwise informing the patient about her situation,
options, and prospects. Still more, it is as contrary to the nature of one’s role
of researcher for her to lie about what she found or how she investigated as
it would be for her to strive only to find out what is not the case, instead of
seeking truths, in the first place.
A virtues-based bioethical theory that is also role relative, patient focused,
and input driven in the ways sketched above allows for a medical ethics
that is both reformist in regard to recent and current bioethics and critical
in that it poses challenges to societal norms in our increasingly anti-life cul-
ture, where the latter stresses patient autonomy to the neglect and detriment
of respect, thereby weaponizing autonomy against the very lives of those
who possess it. Today’s (debased) bioethics also misconstrues respect itself,
seeing it as directed to a person’s mere preferences, therein missing Kant’s
insight that what warrants respect is grounded in each human being’s ra-
tional nature and consequent dignity. Further, as we saw, these misunder-
standings lead such thinkers as B&C also to misunderstand justice, which is
a personal moral virtue of having and showing respect (which is a complex
state of mind) to another in recognition of her status and by both deferring
to her status, needs, or will in one’s own will and also by protecting and
restoring what is endangered or taken from her through others’ disrespect.
Life and death

Homicidal supposedly medical interventions such as assisted suicide, euthan-
asia, infanticide, abortion, and the types of biomedical research that destroy
human embryos (better, embryonic human beings), are all counter-medical
and essentially vicious, because each is diametrically opposed to medicine

as healing (i.e., restoring and maintaining human health). On the virtues-
based view taken here, none of these interventions is genuinely a medical
procedure, as not one of them really heals a body, although such healing is
the goal (that is, the “good internal to the practice,” in Alasdair MacIntyre’s
terminology) that shapes the biomedical professional’s role-virtues.51

People often defend these counter-medical interventions by invoking the
patient’s autonomy. That move, however, is a mistake, for the main reason
that a human person’s preferences and will matter morally is that limited
deference is a principal way of honoring her personhood, its preciousness/
sanctity and dignity. That means her preferences matter only because, and
insofar as, they reflect her personhood, especially, insofar as they are in-
formed by her reason. As her mere likes and velleities do not seriously
count, neither should an agent hide behind the rhetoric of autonomy to jus-
tify treating someone in ways that run counter to her dignity and precious-
ness as a human being; that would get things upside down.52
Beyond medicine’s limits

It is important to note, likewise, that such interventions as we just men-
tioned–execution, assisted suicide, abortion, and, we can add, torture and the
mutilation involved in, for example, so-called “sex reassignment” surgery–
are not genuinely medical on the virtues-based account here presented.53
Rather, as I suggested above they are properly designated counter-medical
in that they direct the physician’s knowledge (of anatomy, function and dys-
function, pharmacology, etc.) and her conduct not to promoting a patient’s
health, as in (the healing profession of) authentic medicine, but to its reduc-
tion or, in death, elimination. Nowadays, some will worry that physicians’
refusal to participate in these communally endorsed or permitted practices
will strip people of choices. However, those who deem it important to pro-
vide such choices should remember that counter-medical interventions can
be accommodated in ways that do not compromise and debase medicine. If
a(n anti-life) society wishes to, they can devote resources to training special
technicians who practice as executioner’s aides, suicide-assistants, abortion-
ists, mutilators, torturer’s helpers, etc., etc., without thereby deforming the
honorable professions of medicine and nursing, as happens when those in
health care stoop to these practices.
Relatedly, this conception of biomedical ethics views some interventions–
e.g., merely elective (non-restorative) plastic surgery, vasectomy, and some
other forms of contraception–as more properly classified as extra-medical ra-
ther than properly medical themselves. That is because they do not heal, nor
in any way promote health, though they need not inherently oppose health.54
Again, societies eager to have these practices available can train cadres of
new (but non-medical) specialists and technicians. These procedures have
nothing to do with physicians and nurses qua physicians and nurses. Rather,
they involve dangerous distortion of their professional self-understanding.
There is no reason grounded in genuine respect for persons to “respect”
(that is, to defer to) a person’s preference except insofar as that preference
itself shows appreciation of and respect for her own (and others’) dignity as
persons. Someone’s suicidal death wish, e.g., cannot reflect due respect for

personhood, because it aims to destroy a person in the name (not of dignity
properly understood but) of despair, comfort, vanity (in a prideful refusal to
accept dependent living), self-pity, and so on. For this reason, the proper
sphere of dignity-based autonomy comprises a certain wide discretion about
how to live, but never extends explicitly to the question of whether (nor how
long) to live.
Integrity
Pace B&C, what is called integrity is not simply, or even chiefly, a self- regarding
virtue. For in acting in regard to a given patient in a way contrary to medicine’s
nature, the physician fails (in her role-relationship with) that patient. Conscience
protection is misconceived in much current discussion: acting from conscience
in many controversial cases is merely insisting on acting in accord with (vir-
tuously within) one’s role as an M.D., nurse, researcher, and consistently with
medicine’s (and nursing’s) nature(s). At least, such protection is needed in order
to limit the healthcare professional’s departure from her role’s inherent tasks.
Being conscientious here is not, as some assume, a private, internal affair, even
a kind of self-indulgence. Rather, it is a matter of keeping faith with what one
has solemnly and quite publicly professed herself to do and to be for others.
All this makes for a bold, contrarian, and much needed bioethics, one
that, by speaking truth to power, challenges the community of bioethicists,
the biomedical professions and institutions, and the larger society to reform
themselves. In some earlier writing, I contrasted this with what I called a
“biophobic” bioethics, meaning an approach that is averse to human life,
denigrating and depreciating it, treating it as merely a means to various
ends. That remains an accurate characterization, but here I prefer to put
the point more positively and call for a life-friendly bioethics, one that con-
sistently cares for and affirms the life of human persons. Such a renewed
and reformed biomedical ethics would spurn today’s nightmares of the
posthuman, and strive instead to be proudly human, deeply humane, and
pervasively humanist.
VII. CONCLUSION
My suspicion is that the approach here advanced can illuminate many other
fields of practical health care as well, including public health, hospital ad-
ministration, medical and nursing education, pharmacology, epidemiology,
and others. As a child of parents who both worked blue-collar service jobs
in a hospital and grew up in a nearby slum building that the same hos-
pital owned for a while, let me add that I think badly neglected aspects
of healthcare ethics concern the roles of the healthcare institution as em-
ployer, as landlord, and as neighbor. Recognition of the various persons
in whose lives these institutions play crucial parts might illuminate and de-

mand modifying the ways they conduct themselves. This would help us to
evaluate healthcare institutions in their role-relationships with a variety of
stakeholders. Those, however, must be topics for another thinker and an-
other day. They take us too far afield from our topic here: the seminal work
that Beauchamp and Childress have done in biomedical ethics and how we
now need to build on, correct, and move beyond it.
NOTES
1. On “thickness,” see Scheffler (2002, Ch. 11). On “transparency,” see Richardson (1990).
2. I think this is not true in the reverse direction. That is, I do not believe that consideration of the
nature or logic of virtues must likewise lead us to the intrinsic value and disvalue of states of affairs, nor
to duty, nor to rights. However, I do not try to show that asymmetry here.
3. Some argue that justice is fundamentally a feature of states of affairs and that a just person is just
only in a derivative way, being someone disposed to act so as to bring about or maintain such states of
affairs (see Williams, 1981, Ch. 6). I think the reverse true. Any mere state of affairs is just only either
metaphorically, as bitterly cold weather may be called cruel or otherwise vicious, or because it is a state
of affairs of the sort that someone’s justice will incline her to endorse it or, a little differently, of the sort
that it will be just of someone to endorse.
This approach has the advantages of keeping justice closely tied to respect, and thus to persons,
whose dignity merits them alone full moral respect, and also of capturing the essence of injustice as a
kind of arrogance wherein the agent disrespectfully arrogates to herself what is owed to another.
4. Also see Thomson (2008, Ch. 5).
5. “A virtue is a dispositional trait that is socially valuable and reliably present in a person, and a
moral virtue is a dispositional trait of character that is morally valuable and reliably present” (2013, 31).
This, I maintain, does not go deep enough. A moral virtue is valuable in that it counts toward the person
having it being a morally good person in some more specific way, e.g., being a good friend in that she
is a devoted one or a good neighbor in that she is considerate. Further, to analyze virtue in terms of the
valuable (or the desirable), as B&C here do, gets things backwards. For something to be valuable is for
someone’s valuing or desiring it to be virtuous of and in her.
6. Thus, we here repudiate the claim, variously made in Slote (2003), Adams (2006), Hurka (2000),
and Zagzebski (1996), among others, that virtues are “intrinsically good” in the ways that philosophers
use that term.
7. We have more to say on some of these below, especially on truthfulness and justice, which latter
figures quite prominently in B&C’s account.
8. Contrary to B&C, goodwill is not quite the same as the sentiments of “compassion” or “sympathy”
(2013, 37). The first, as its name indicates, is a state of the will and of related desires, while the latter two
are matters of feeling, emotional occurrences or states.
9. A little more precisely, we should say that a permitted action is one whose agent is not vicious
in performing it, a prohibited one is an action whose agent therein acts viciously. Note that we think of
some actions as morally necessary, that is, obligatory, and others as morally impossible, that is, forbidden.
Adopting our understandings thus brings the moral use of these concepts into accord with Aristotle’s
definition of the necessary as that without which some evil–here, the action itself–cannot be avoided
(Aristotle, 1924, Bk. V, Ch. 5).
10. On wrongdoing as victimization, see Thompson (2008); on “thick” and “thin” moral terms and
concepts, see Scheffler (2002); on transparent norms, see Richardson (1990).
Perhaps some of her wrongdoing, especially such self-regarding actions as wasting time or eating
imprudently, would more intuitively be classed as failing oneself, letting oneself down, than “victimizing”
oneself. (I owe this point to Anthony McCarthy.) However, this difference seems to me largely termino-
logical, because we can still identify a victim, oneself, who is the person whom the agent failed, let down,
and therein wronged in her behavior.
Let me add a remark or two in support of some of my claims about the content, implications, and

benefits of a virtues-based account of the deontic. We intuitively judge some actions worse and more
wrong than others. Yet this commonplace is unavailable when we adopt a law-conception of morality.
For, as we see clearly in the realms of civil and criminal law, no illegal action is any more illegal, nor any
less, than is another. Moreover, nothing is simply morally wrong, but only wrong in a fairly specific way,
unjust or cruel, for example. In fact, to say it is wrong is to say it is wrong in some respect, some way. If
it is wrong, then there is something specific wrong with or in it. Moreover, when we mistreat someone,
our act wrongs her because there is something in our treatment of her that makes it mistreatment, that is,
behavior that is wrongful in some way that can be identified. It is wrong of us so to conduct ourselves
in that we are being vicious in behaving like that. It is this “thickness” that enables people to challenge
and defend evaluative classifications. Because the relevant “thick” terms are, either immediately or indir-
ectly, virtue terms, however, and since a virtue-concept is a mental concept, it follows that the respect in
which the action is wrong must make reference to some state of mind, and the logic of our evaluative
classifications makes it clear that it is the agent’s mind that matters here. Thus, we say that your action is
wrong, immoral, because it is, say, disrespectful or cruel, where that means you are being disrespectful
or cruel in behaving as you are. You are, in other words, acting disrespectfully or cruelly. This helps us
to see actions as they properly appear in moral assessment: as exercises of agency, events pregnant with
significance they derive from the attitudes that they express. We might say that what really matters is less
Kant’s famous question, “What should I do?” than the deeper inquiry, “How, that is, in what way and
from what mindset, should I act?”
11. Slote (2003) and Zabzebski (1996) are among those who also analyze the deontic in terms of
the aretaic, but neither extends such analysis, as I suggest, to concepts of impersonal value. Moreover,
Zagzebski allows their usual effects to impact what kinds of actions are virtuous and vicious, meaning
her account is not fully input-driven.
12. We can then understand supererogatory actions as expressing virtue, which is what makes them
admirable, without being demanded by virtue in the sense that omitting them is as such vicious. (The
same, mutatis mutandis, for supererogatory omissions: they express virtue but acting contrary to them
need not be vicious.)
13. That she acts badly as an R in this instance, even as (if) a bad R, need not entail that she is
simply a bad R. Probably, being a bad R involves more. Maybe a bad R is an R who frequently acts in this
(or some similar) way. Or perhaps a bad R is an R who performs an action of this type in an egregious
fashion. Note here an important, if familiar, asymmetry between good and bad. A virtue in an instance of
kind K is a feature that counts towards its being a good K, but its lacking other, similarly “good-making”
features may keep this virtue from making a K be a good K. In contrast, its having a single serious de-
ficiency may by itself suffice to make a certain K into a bad K. Aquinas and Foot make this point in
different ways. See, for example, Aquinas (1920, S.T., 1a2ae, q. 19, art. 6, ad 1) and Foot (1977, Ch.
1) Thomas Cavanaugh drew my attention to a related passage in Boethius. In correspondence with me,
Cavanaugh glosses Boethius, in accordance with Dionysius, this way, “Goodness comes from an integ-
rity/unity or wholeness, while badness comes from any defect/lack” (Dionysius the Areopagite, 1897, bk.
IV, sec. xxx, column 729c).
14. Comprehensive role-relativity implies that relationships between persons and, thence, being par-
tial to some people, are fundamental within morality. This contrasts with the more standard assumption
that morality must be basically impartial and partiality therefore problematic and in need of special justi-
fication. Mendus is notable for also claiming to ground impartiality in a deeper partiality. If I understand
her, however, she views this grounding as nonmoral and motivational, whereas I think any legitimate
impartiality’s dependence on an underlying partiality to be a matter of moral justification (Mendus, 2002).
15. The problem mentioned has drawn considerable attention lately. (See Mendus’s [2002] and
Seglow’s [2013] monographs and most of the essays in Feltham and Cottingham [2010].)
16. Role-centering captures and supports a central insight of input drive: being virtuous in acting,
and avoiding viciousness therein, demands that an agent act as, act in a certain way because she is, an R
to someone S. This view is at some distance from the view usually attributed to Aristotle, but notice that,
if we emphasize his famous claim that we are social animals, and interpret this as meaning that, fully to
thrive, we need to be in certain kinds of relationships with various persons, then we come to the idea
that an agent’s acting so as to fulfill her humanity may reduce to her acting in ways consistent with her
living up to and fulfilling each of those relationships.
17. Here I prescind from the sometimes important differences between being a registered nurse, a
licensed practical nurse, and a licensed nurse practitioner; and also between being a primary care doctor,
a specialist of one or another kind, a surgeon, and so on. Their fundamental virtues, and consequent

duties, seem to me largely the same, at least in broad outline. Each targets one or another aspect of cer-
tain persons’ health.
We should acknowledge an issue that arises about fitting medical researchers into the scheme pro-
posed here. In the clinical setting, a nurse or physician normally has specific patients, each of whom
stands to her as the one whose nurse or physician she is. This is not clearly so with (pure) researchers,
who do not as such have patients. If someone, call her researcher R*, however, has no one to whom she
stands in the role of researcher, then no question can arise of whether she acts virtuously in her role vis-
a-vis that person, nor, derivatively, whether she has violated any duties to someone that her being that
person’s researcher imposes on R*. That would exempt issues of their morality from consideration within
the ethical theoretic model here proposed. How should the theorist who is sympathetic to the view that
I advance here respond to this challenge? One suggestion that occurs to me is that insofar as someone
is engaged in specifically medical research, her work and goal remain, like those of the nurse and phys-
ician, targeted on individuals because it is directed to maintaining, improving, or restoring the health of
each person whose health is already compromised or stands under possible threat. That person, then,
can be the researcher’s role-respondent, role-other, and thus the beneficiary of her virtuous behavior and
victim of her vicious conduct.
Here is one further complication we should mention, at least in passing. In today’s economy, at least,
almost anyone who is, say, my nurse or doctor will also be an employee of a government, not-for-profit
institution, or company. On the one hand, that fact makes it easier to identify her relationships and her
role-others, the parties to whom she is R. On the other hand, that fact means that possibilities for conflicts
could be frequent. I make some remarks on resolving apparent moral conflicts in section VI.
18. I borrow this convenient term, with its helpful contrast with that of the moral agent, from
Warnock (1971, 148). Also: “The condition of being a proper ‘beneficiary’ [or, we should add, victim,
or more generally, a moral patient] of moral action is capability of suffering the ills of the predicament”
(Warnock, 1971, 151).
19. Insightfully, Anthony McCarthy (2016) has asked how such an account of moral duty accommo-
dates what we usually think of as general duties to contribute to charity, which do not relate the agent
to any specific individual. Kant calls these duties “imperfect” and “other-regarding.” My short answer is
that (i) such duties are very difficult to identify, and (ii) I doubt they exist. On the first point, recall only
that Kant thinks such imperfect duties allow the agent broad discretion, whereas “perfect duties” sup-
posedly do not. But, pace Kant, any duty allows infinite discretion. Even a duty to repay you five dollars
today around noon allows me to give you cash or a check (and, if cash, with these bills or those, and, if
a check, with this top check or the one beneath it, etc.) and is fulfilled if I pay you at the stroke of noon,
at a second before or after, or at any of the infinite number of moments between noon and a second
past noon. So, breadth of discretion cannot serve to distinguish imperfect from perfect duties. On the
latter, perhaps what we should say is that someone whose charity never leads or even inclines her to do
more than the minimum required is meager in her charity. Robust, full charity would in fact dispose her
always to do more for everyone. This deficiency may show up in her relationship with anyone and we
can see this unwillingness to help any needy person, even conditionally, as distorting her relationship
with everyone.
20. I borrow the term “role-respondent” from Sarah Harper (2007).
21. Of course, the view taken here, that what is morally important, including wrong-making, in ac-
tions lies on their input side rather than in their output, runs counter to the “consequence-dependence”
that some believe is indispensable to moral status. See Sen (1985). Of course, even a thoroughgoing form
of input drive still allows that an action’s intended and expected results can matter, since they directly
involve the virtue of goodwill. (That I do A expecting it to harm you indicates a limit to the extent to
which I will you the good of your escaping such harm.) An action’s actual and objectively probable bad
results, however, matter only insofar as they give evidence of your mental stance toward that bad result,
and that evidence is likely to be both poor and easily defeated.
22. See, especially, Epstein (2018, Ch. 6). Epstein frames his discussion in terms of grounding and
anchoring “principles,” but I think it better to think of these as relations holding between facts and prop-
erty instantiations of various categories.
23. This might seem to be what Slote (2003) calls “hyper agent-basing,” which treats virtue as
more basic than being good. However, Virtues Basing claims only that virtue is internal to the way in
which, for example your being healthy is impersonally good–good, that is, in a way that goes beyond
its being good for you and your intimates–and your being sick impersonally bad, not that it is internal
to all forms of being good. In fact, the latter suggestion is viciously circular if, as I think we should, we

follow Aquinas’s Aristotelian view that virtues are features that tend to make something a good instance
of its kind.
24. See Scheffler (2002), Mendus (2002), and Seglow (2013), among other recent inquiries.
25. In treating apparent conflicts below, I also suggest we substitute for Prichard’s famous inquiry,
“Which is the greater obligation?”, the deeper and more revealing question, “Whom would the agent treat
more viciously, in relation to whom would she more deeply depart from virtue, in acting this way or
that?” (Prichard, 1912, 30). Again, both the deliberating agent and the theorist examining apparent moral
conflicts should centrally investigate the question: “How distant from the relevant virtue is this way of
acting as compared with that one?” and “How central to its role is this virtue, which problematizes this
way of acting as compared with the centrality of the virtue that problematizes that one?”
26. Contrast B&C (2013, 6) where they assert that “[by] definition, moral ideals such as charitable
beneficence are not required of all persons; indeed, they are not required of any person. Persons who
fail to fulfill their ideals cannot be blamed or criticized by others.” That is largely true, but it overlooks
the close connection among ideals, virtues, and duties. Ideals reflect virtues, which are traits that tend to
make the one who has them a good K, for some relevant kind K. Duties, however, are also relativized
to virtues. Whatever is required of someone is what is required of her to avoid her acting viciously and
therein contrary to some virtue. “Charitable beneficence,” for example, is an ideal because it shows a
high level of the virtue of charity. Also, B&C’s talk of “their ideals” suggests the dubious thesis that ideals
are simply invented by individuals. There are, however, objective ideals: what an ideal medical doctor,
nurse, or researcher would be like is not just up to each person. What is up to me is whether I do or do
not make this objective ideal my personal goal, not what it would in fact take to be an ideal nurse.
27. Adams’ (2006) conception of virtue as persistent excellence in being for the good helpfully lends
itself to distinguishing such forms of vice as (i) merely not being for some good, (ii) being against a good,
as well as (iii) being for a good so weakly or (iv) in such a deranged way as to be so far removed from
excellence as to constitute vice. My point here is that the first form of opposition to virtue is not only
different from the second but also less grave, because less opposed to the relevant form of willing the
good (goodwill).
One advantage of seeing all wrong acts as vicious is that, once we acknowledge goodwill as pro-
viding the principal virtues’ core virtue, it supports classifying acts of ill-will as inherently worse and less
eligible than forms of action problematic merely because, in performing them, the agent does not will
someone a particular good. Of course, this consideration lends important support to the type of moral
reasoning (DER) misleadingly called the principle or doctrine of double effect, which stresses the imper-
missibility of acting with the intent of achieving certain bad results. I will not pursue this topic, though
it is crucially important for seriously addressing many moral conflicts and dilemmas. For more, see,
among many other works, Cavanaugh (2006), and articles in a special issue on double effect reasoning,
American Catholic Philosophical Quarterly, vol. 89, No. 3 (Summer 2015). For a summary and expansion
of arguments opposed to DER, see DiNucci (2014).
Of course, many religious people hold that there really are authoritative acts of permitting and for-
bidding, as in the Decalogue that People of the Book believe. My point is twofold. First, this further claim
is not a conceptual part of moral duty, and that being morally allowed, forbidden, and so can be rather
well conceptualized and understood without it. Second, what it adds, in a literal way of some acts being
permitted or forbidden, itself needs explication in terms of more basic concepts of virtue and vice in that
the way in which acts of disobedience to divine commands are wrong is that they are disobedient and
rebellious, and therein viciously opposed to the virtues of grateful obedience and fidelity to our divine
Creator.
28. As mentioned earlier, “right” is another word for straight, and “wrong” for bent or deviant, so
the approach here taken can readily accept those descriptions, clarifying that it is virtue that defines the
straight/”right” path and wrong action an egregious (i.e., in some way vicious) departure therefrom.
29. It is worth remarking that beneficence for each does not necessarily require aggregating bene-
fits and harms across persons, although utilitarians insist on such aggregation. Further, willingness to
harm, some in order to benefit others, threatens injustice. V-BMT, in insisting that an agent abandon no
one when she strives to help, captures an insight gleaned when we take seriously the experience of op-
pressed minority groups. (See Garcia, 2017a)
30. Early utilitarians were on to something important when they stressed benevolence in action.
Some of them may have wanted to stress utilitarians’ (to my mind, confused) continuation of the Christian
moral tradition of love and goodwill. Acts of maleficence are morally objectionable chiefly for their motiv-

ation in failures of goodwill. The more recent fixation on beneficence and non-maleficence, which may
owe to W. D. Ross’s desire to differentiate his ethical views from the utilitarians’, is probably designed to
stress the view of both Rossian deontologists and consequentialists that morality is about what an agent
causes, not what she does or does not will. I think that gets morality exactly wrong. Treating each person
well, fulfilling one’s morally determinative roles in her life, is at the core of morality as here conceived.
Pace Singer, that is the key and substance of anyone’s “living an ethical life,” which has nothing to do
with bringing about the best overall state of the world, still less with doing that with maximum efficiency.
31. See Cavanaugh (2006) and Pellegrino and Thomasma (1993).
32. Thus understanding justice in terms of respect for persons has the advantage of meeting our
intuitions in restricting justice and injustice (and, with them, moral rights), to persons. This contrasts with
some recent theories, according to which subhuman animals have rights and can be treated unjustly.
Since I agree with Boethius that human beings are rational by nature, it follows that every human being
is a person, having what are now widely and correctly called “human rights.” That every human being
has rationality in her nature does not, of course, that it is operational in everyone. Obviously, someone’s
age, medical condition, and other things affect her reasoning.
Rooting human dignity in personhood and, thence, in natural rationality helps unite the secular,
Ciceronian tradition on dignity with the Christian, which relies on the human being as imago Dei. That is
so because God, in that tradition, is bodiless, without sensuous appetites, and identical with the Godself’s
rationality, which extends to reason-informed preference and will. Such an approach can also help illu-
minate the demands of and proper response to human beings’ personal dignity. It is not our depraved
or perverted urges, nor even what Rawlsians call a “conception of the good,” to which we need to defer
but chiefly such wants, self-understanding, and projects (especially, commitments to self-cultivation and
self-control) as are shaped by rational inquiry and survive its critical scrutiny. Below I point out some
implications of this for some bioethical controversies.
33. Of course, that does not mean that you have to do everything possible to keep me alive, lest
you be unjust to me in your conduct. However, it does mean that you need a strong reason rooted in
responding to someone else’s need not to do something you could do to keep me alive, when I am
otherwise at risk, and it rules out as categorically unjust your taking action aimed at my death.
34. Contrast B&C on personhood (2013, 68–69). Of course, my life may be more limited than yours
and have much less prospect to last longer. Still, it needs to be shown why that makes it less valu-
able morally, let alone, unworthy of and beneath consideration and extension. See also Beckwith and
Thornton’s (2020) contribution to this special issue.
35. Those with an especially broad conception of what counts as organic function can qualify this
to read that death is “the almost complete cessation of organic functioning.” Such breadth strikes me as
implausible, but I will not pursue that dispute here.
Oddly, the index to B&C’s book contains no entry for “health.” They do, however, mention without
objection Daniels’ influential account which is framed in terms of “adequate or ‘species-typical’ levels of
functioning” (2013, 257).
36. B&C chiefly discuss physician-assisted suicide (and “hastening of death”) and euthanasia (2013,
168–181).
37. In part for reasons of space, my discussion here ignores what Beauchamp and Childress call
“utilitarian,” “communitarian,” and “well-being” theories of justice.
38. Matthew Shea pointed out to me that, in the bioethics literature, emphasis on emotion,
need, partiality and special relationship, and dependency characterizes the so-called ethics of care.
That seems fine to me so long as we recognize that these also play an important role in all genuine
compassion and goodwill. After all, compassion and goodwill are passional (i.e., emotional) and
volitional states of mind, respectively. We consider it a more important kind of goodwill to secure
a necessity for someone (need) than merely to increase her pleasure or cheerfulness. A response
that offends against the virtue of goodwill if I take it toward my intimate seems OK when I take it
in regard to a stranger. (This helps illuminate the centrality of partiality and relationships, including
what are called “special relationships,” within morality.) And, forms of goodwill that are often mor-
ally optional for me may become mandatory in certain situations where the other person is especially
dependent on my assistance.
By the way, there may also be a sense in which we can say that you care about me–you are not
indifferent to me–if you hate me and wish me ill. However, that is not the sense or sort of caring about
someone that is closely related to providing someone care, taking care of her, and caring for her. The
latter sense and sort of caring are what concern us here.

39. An anonymous referee asked me to clarify my V-BMT’s relation to the ethics of care. Since there
are many versions of care-ethics, let me affirm that I join some familiar forms of care ethics in accentu-
ating some of the agent’s relationships, stressing her motivation (since what determines whether I am
being caring in my action is what is in my mind), concentrating on the actions’ patients, esp. their needs
and interests. Unlike some within that movement, however, here we emphasize the agent’s being con-
sistent with her relationship in the way she acts, rather than her actions’ effect on preserving or restoring
a relationship. Likewise, the position taken here depends on no claims about female psychology or its dif-
ference from males’, nor on feminist theory, and it restricts the key type of caring to the mind, excluding
issues of competence or effectiveness.
One of the most important recent texts in care-ethics is Slote (2007), which explicitly articulates its
care-ethics as a type of virtue ethics. Briefly to differentiate my V-BMT from what Slote calls his own
“agent-based virtue ethics” allow me to point out that, while both analyze duty through virtue, prioritize
actions’ input over their output, and stress (sometimes short-lived) motives and attitudes over character
traits, my V-BMT bears resemblance to what Slote calls “hyper agent based,” in that it also reduces a
central kind of value judgment, viz., judgments about what states of affairs are impersonally valuable,
to judgments of moral virtue. In addition, it relativizes virtues and all moral features to roles, and articu-
lates patient focus, which last more greatly distances my position from both consequence-dependence
(let alone consequentialism, either direct or indirect) and from cross-personal aggregation.
40. See Cavanaugh (2006) on Hippocrates’ tradition and its superiority to its ancient competitors.
Contrast B&C (2013, 41–42).
41. I think that is best understood as comprising broad discretion over how she lives, how her future
life goes. That is a sphere that affects but, importantly, does not as such include, whether she continues
to live. This shows both the grounds and limits of autonomy. I cannot sensibly respect you as a person
by deferring to your autonomy over your life, while also treating your life or death as a mere means to
your own or others’ comfort. Above, I gave some reasons for this limitation and will not here elaborate
on them further.
42. Here I agree with Christian theologian Margaret Farley, although not with all that she sees as the
implications and applications of what she calls “just love.” See Farley (2008).
43. Urmson observed this phenomenon decades ago: “It is surely more wrong to hit a benefactor
over the head than merely to fail to show gratitude” (1969, 93).
44. See Richardson (1990).
45. Since virtues are mental states and chiefly connect to actions as motivational inputs, virtues-
basing and input-drive support one important component of the form of reasoning in practical ethics
often called the principle of double effect. That is, these metatheoretic features indicate that it matters
to whether an action is morally acceptable/permissible, that its agent does or does not intend something
bad in performing it. For such input is normally vicious and serves to corrupt the action. Of course, more
than that needs to be established in order to ground double effect reasoning in principle, let alone its
more controversial applications.
46. Of course, not every occasion on which a healthcare professional does not help someone in a
particular way is an instance of failing her patient morally. You are not vicious to me if you give a medi-
cine to, or spend time treating, someone else who also needs it, instead of me. We call omissions of care
provision morally vicious and wrong pro tanto but, in various situations, the agent can be acquitted of
suspicion that her omissive conduct stems from her being insufficiently caring to one patient by pointing
out that she acted from virtuous concern for another patient.
47. See Ramsey’s (1970) classic discussion.
48. That every lie is wrong, of course, implies that every lie is equally wrong only if wrongdoing
does not really admit of degrees and comparisons. That would be true if morality really fit the legal
model, because no illegal act is any more or less illegal than another. It is an advantage of understanding
wrongdoing as acting viciously (rather than as acting against an irreducible moral law) that it allows some
wrong acts to be “more wrong”–to put it better, it allows them to be more vicious–than are others, be-
cause more distant in their motivational input from the relevant virtue.
49. See B&C’s chief discussion of deception that comes under the rubric veracity and its obligations
(2013, Ch. 8, 301–311). Thomas Cavanaugh kindly cited to me the famous verse, “What a tangled web
we weave when first we practice to deceive.” (Walter Scott, “Marmion,” Canto VI, stanza xvii). That can
assist us in keeping in mind the snarl of complication in which our lies often implicate ourselves.
50. Contrast B&C on healing. “When, in the patient’s assessment, the burdens of continued attempts
to cure outweigh their probable benefits, the caring physician should redirect the course of treatment so

that its primary focus is the relief of pain and suffering . . . For [some] patients, relief of intolerable suf-
fering will come only with death, which some will seek to hasten . . . Principles of respect for autonomy
and beneficence and virtues of care and compassion all offer strong reasons for recognizing the legit-
imacy of physician-assisted death” (2013, 185).
Let us separate some of these contentions better to evaluate them. First, the patient, no less than
anyone else, has an obvious right to make her own assessment of whether her treatment’s continuation
brings more burden than its benefits justify. At the same time, for that assessment to deserve serious con-
sideration, in making it she must make it in a serious way, including exerting strong effort to eliminate
prejudices, whim, self-indulgence, and other unworthy factors. That does not mean that, even if respon-
sibly reached, the patient’s assessment is necessarily correct or better than anyone else’s. Second, the
patient does have a moral right to have the decision on treatment she makes on the basis of her own re-
sponsibly reached assessment be treated as dispositive. It is her body, and she has broad, though not un-
limited, jurisdiction over it. Third, there is no reason for the medical staff to accord relieving the patient’s
discomfort precedence over their pursuing the goals to which their profession commits them, viz., pro-
moting her health. Fourth, the patient’s health and life are themselves central and thence unconditional
goals of medicine, goods internal to it, and thus superior ends to relief from discomfort. Fifth, ending
someone’s suffering by ending her existence, i.e., her life, is not really relieving her discomfort, which
latter is good in that it insofar as it accords her a better existence. That is a genuine benefit, whether or
not medical; killing her is not. Sixth, respect for the patient in the dignity of her personhood takes prece-
dence over acquiescence to her decisions, since it grounds respect for autonomy, and autonomy itself is
only morally meaningful as informed by the patient’s reason in a good faith effort to discern the objective
truth about her welfare. So, pace B&C, neither the moral virtue of respect, nor that corresponding to “ben-
eficence” (viz., the virtue of benevolence), nor morally significant compassion and care militate in favor
of death, let alone “physician-assisted death.” To the contrary, the latter is, on the account offered here,
properly regarded as a counter- medical intervention, that is, one inherently contrary to any practice that
is genuinely medical rather than part of it.
51. Sometimes people defend these measures as in the patient’s best interest, rather than as required
for respecting her autonomy. Death, mutilation, and the like, however, can never be in anyone’s med-
ical interest because they diminish her health, which, I contend, it is medicine’s point to advance. More
important, such interventions attack her dignity as a person, treating her life and bodily integrity as mere
obstacles to achieving other goals.
52. On sex reassignment surgery, I should clarify that my concern here is not about how to treat
those who are biologically “intersexed” (e.g., whose DNA is non-standard or does not match their
anatomy, or whose anatomy mixes or lacks female and male reproductive organs) Rather, my remarks
deal only with surgery on people unhappy, uncomfortable, distressed, or the like with their biological
sex, what the American Psychiatric Association now calls “gender dysphoria.” This is a tragic state of
mind, but the problem to be addressed does lie in the subject’s mind; altering her body to try to make it
match her erroneous self-image is misguided. It is her beliefs and feelings that need modification, not her
body that needs mutilation. (I also have doubts about chemical–esp. hormonal–treatments, but I do not
here touch on that topic.) For a discussion of this matter that is rare for being both sensitive and sensible,
see Anderson (2018).
53. I say “perhaps” because some forms of contraception and, still more, permanent sterilization can
damage someone’s health. I am grateful to Anthony McCarthy for this point.
54. That is not to say that patients cannot get things wrong and make incorrect decisions to which
healthcare professionals need to defer. Such a professional serves at the patient’s pleasure and has no
moral right to impose treatments on a patient against the latter’s will. That is the sort of unwanted physical
interference that in the law is called “battery” and is a moral offense as well. Above, I briefly discussed
autonomy and some of its limits. What matters here is that deference to the patient’s right to decline, how-
ever unjustified, others’ touching her body in certain ways does not extend to a right that they intervene
in ways of her choosing, let alone a right that they act on her body so as to kill her. That it is largely up
to me to decide how I will live, and up to you to decide how you will, does not at all entail that either
of us has domain over whether to live.
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Journal of Medicine and Philosophy, 45: 471–503, 2020

Virtues and Principles in Biomedical Ethics

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In the seventh and most recent edition of their classic book,

I. BEAUCHAMP AND CHILDRESS ON MORAL VIRTUES

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theory, both generally and in such specialized subareas as medical ethics.

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II. RETHINKING VIRTUES AND THEIR PLACE IN PHILOSOPHICAL

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III. THE METATHEORY OF MORALS

Now, we can expand on these points to sketch morality’s metatheory.

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that are fitting or required. Mere psychological disposition is obviously inad-

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IV. SOME CONTRASTS BETWEEN B&C’S BIOETHICAL PRINCIPLISM

contrary to what virtue requires of anyone in her relationships with another.

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promotion, maintenance, and restoration. This oath is unlike a promise, or

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function.36 It is, however, precisely my life and my health that, as my medical

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V. VIRTUES IN MEDICINE: SOME VIRTUES AND DERIVATIVE DUTIES

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to medicine as goodwill, which is, roughly, the secular counterpart to what

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VI. DEALING WITH APPARENT MORAL CONFLICTS IN B&C AND IN A

B&C endorse a two-step method for addressing conflicts between valid

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VII. SOME PRACTICAL APPLICATIONS, BRIEFLY SKETCHED

almost every problem becomes a medical one. That should be rejected, as it

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asserting, offers as care-giver a solemn (even if implicit) assurance to her

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Life and death

and essentially vicious, because each is diametrically opposed to medicine

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Beyond medicine’s limits

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