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Building Character: A Model for Reflective Practice

Bryan, Charles S., MD; Babelay, Allison M.

doi: 10.1097/ACM.0b013e3181b6a79c
Ethics
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In 1950, Harrison and colleagues proposed that the physician’s ultimate and sufficient destiny should be to “build an enduring edifice of character.” Recent work in philosophy underscores the importance of character ethics (virtue ethics) as a complement to ethical systems based on duty (deontology) or results (consequentialism). Recent work in psychology suggests that virtues and character strengths can, to at least some extent, be analyzed and taught. Building character might be enhanced by promoting among students, residents, and faculty a four-step method of reflective practice that includes (1) the details of a situation, (2) the relevant virtues, (3) the relevant principles, values, and ethical frameworks, and (4) the range of acceptable courses of action. Exercises using such a model bring together the major goals of ethics education in U.S. medical schools—teaching the set of skills needed for resolving ethical dilemmas and promoting virtue and professionalism among physicians.

Dr. Bryan recently retired as professor, Department of Medicine, School of Medicine, and director, Center for Bioethics and Medical Humanities, The University of South Carolina, Columbia, South Carolina.

Ms. Babelay is a third-year medical student, The University of South Carolina School of Medicine, Columbia, South Carolina.

Correspondence should be addressed to Dr. Bryan, Providence Hospitals, 2435 Forest Drive, Columbia, SC 29203; telephone: (803) 256-5359; e-mail: (charles.bryan@providencehospitals.com).

Thousands of medical students and young physicians have taken inspiration from the opening words to the first nine editions of Harrison’s Principles of Internal Medicine,1 a book first published in 1950:

No greater opportunity, responsibility, or obligation can fall to the lot of a human being than to become a physician. In the care of the suffering, he needs technical skill, scientific knowledge, and human understanding. He who uses these with courage, with humility, and with wisdom will provide a unique service for his fellow man and will build an enduring edifice of character within himself. The physician should ask of his destiny no more than this; he should be content with no less.

These words presaged an era now perceived as the height of physicians’ power, prestige, and prosperity. Indeed, the rise and fall of the American medical profession in the period since 1950 may be the most extreme example of the ascendancy and decline of some professions throughout the Western democracies in the post-World War II era.2 The burgeoning literature on medical professionalism echoes this concern.

There is increasing, if subtle, emphasis on character building as a central task for medical educators.3 A recent review of ethics education in U.S. medical schools suggests two prevalent goals: (1) the inculcation of the set of skills needed for resolving ethical dilemmas and (2) the promotion of virtue among physicians.4 However, many students express dissatisfaction with ethics curricula, and the reactions of students toward efforts to promote professionalism have become “distinctly negative and hostile.”5,6 Perceiving a double standard between what is taught and how their seniors sometimes behave in the wards and clinics, students have suggested, “Central to being a professional is the ability to give and receive constructive feedback.”6

We propose a simple conceptual model in which third-year medical students’ essays and small-group discussions enhance reflection on ethics and professionalism among the students and, moreover, provide a rich database for discussions among residents and faculty of individual departments. This model builds on a growing literature on reflective and mindful practice7,8 and offers another tool for use in striving toward building that “enduring edifice of character” so eloquently articulated by Harrison and colleagues.1

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What Do We Mean by “Character” and “Virtue”?

Harrison and colleagues implied that character building is a highly individual, lifelong project that requires participation in one or another line of work (or what the philosopher Alasdair MacIntyre9 called a “practice” and what is also commonly called a “vocation”); they also implied that character building constitutes the ultimate aim of education and should suffice for happiness and contentment. Today’s health care environment, with its heavy emphasis on patient autonomy, places greater emphasis on patients’ rights and physicians’ duties than on such abstractions as “character” and “virtue.” However, within general philosophy, renewed interest in virtue began in 1954 when the British philosopher Elizabeth Anscombe10 pointed out the limitations of ethical theories based on either duty and rules (deontology, or Kantianism) or results (consequentialism, including utilitarianism). She called for renewed focus on such ancient concepts as virtue and character. Numerous philosophers now debate the substance and meaning of virtue, often from the perspective of Aristotle, Kant, Nietzsche, or others. An emerging consensus holds that virtue-based ethics should complement rules- and results-based ethics, in that we should consider not only the rightness of an action but also the character of the actor. The actor, in turn, should prize the value of what MacIntyre9 called “inner goods”—that is, the satisfaction gleaned from behaving virtuously—as opposed to the value of “external goods”—such as money, fame, and power. These opinions reinforce the emphasis placed on character by Harrison and colleagues and subsequent medical educators.

“Character” might be best defined as “the propensity to do the right thing in difficult circumstances.” As such, character is an integral part of ethics, which is understood as the process of choosing how best to act in difficult or morally ambiguous circumstances. Definitions of “virtue” and “character” are often reciprocal. The Oxford English Dictionary includes among its definitions of virtue “conformity of life and conduct with the principles of morality” and among those of character “moral qualities strongly developed or strikingly displayed.” Thus, virtues are the components of character, and character consists of being virtuous and/or consistently acting virtuously. “Virtues” are the stuff of “goodness” separate from any stipulation of values, principles, or moral rules. To illustrate: Mark Twain’s Huckleberry Finn, who believes that he is a bad boy for failing to return the slave Jim to his rightful owner, nevertheless acts virtuously, despite his contextually mistaken notion of morality.11 Character and virtues are essential to what constitutes a good person, the definition of which, however, is little agreed upon in today’s pluralistic society. What, then, are the virtues, and are they few or many (as famously argued, millennia ago, in Plato’s The Meno)? Can professions claim specific sets of virtues, such as the “medical virtues” reviewed recently in Academic Medicine?12 Can one invent virtues du jour, such as “the virtue of antiperfectionism,” “the virtue of love of life,” and “the virtue of making the most of one’s situation and life in general,” which were listed in a recent article on the possibility of altruism?13 Our emphasis will be on the seven classical virtues of antiquity—the four cardinal virtues14 named by Plato in The Republic and elsewhere (i.e., wisdom, justice, temperance, and courage) and the three transcendent virtues15 named by Saint Paul in 1 Corinthians 13:13 (i.e., faith, hope, and love—the latter of which is rendered in some translations as “charity”). Focusing on these virtues and their “subvirtues” (Table 1) simplifies what McCloskey16 called “virtue talk” and offers a starting point for the project of building character.

Table 1

Table 1

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Can Character and Virtue Be Taught?

There is general agreement that character is largely acquired, with childhood influences and later role models being especially important, and that it reflects the cumulative effect of difficult choices. Thus, the wise headmaster of Hogwarts School of Witchcraft and Wizardry tells the young Harry Potter, “It is our choices, Harry, that show us what we truly are, far more than our abilities.”17 Aristotle,18 who considered virtue to be “a state of character concerned with choice, lying in a mean,” taught that wise choices bring pleasure, which fosters additional wise choices. Mention of Aristotle’s position on the pleasurable nature of wise choices (in philosophy, known as the eudaemonist restraint) usually prompts mention of Kant’s assertion that virtue ultimately derives from an unchanging sense of duty or “fortitude,” a comparison that introduces many complexities.19 These philosophical positions aside, the question arises whether virtues and character traits can be observed, analyzed, and corrected. To put it differently, were those pre-Socratic philosophers known as Sophists correct in claiming that virtue can be taught? The short answer is yes, at least to some extent, according to ongoing research within the today’s “positive psychology” movement.20–25

The positive psychology movement began in 1998 when a group of American psychologists agreed that their discipline had spent most of the 20th century focusing on what is wrong with people rather than on what is right with people. They formed the Values in Action Classification Project to study and classify virtues and character strengths. They concluded that, throughout history, nearly all cultures have endorsed six clusters of character strengths: wisdom and knowledge, justice, temperance, courage, transcendence, and humanity.20 Note that these correspond precisely to the seven classical virtues, except that knowledge is added to wisdom, faith and hope are combined under “strengths of transcendence,” and love falls under “humanity.” The ultimate aim of the Values in Action Classification Project is to produce a body of work analogous to the Diagnostic and Statistical Manual of Mental Disorders that would, in turn, serve as a foundation for refining various diagnostic instruments and behavioral interventions. Our proposal is more modest: to promote the habit of reflective practice through exercises based on actual situations.

At the University of South Carolina School of Medicine, third-year students have, since 2003, been required to write a one-page essay describing an experience pertaining to ethics and professionalism; this essay is to be discussed in a small-group setting with no more than five students and one or two faculty facilitators. Ground rules include maintaining anonymity for all persons and places. These essays, condensed and categorized, now provide a rich database for discussions among faculty and residents about ways to enhance professionalism in the clinical environment. Specific examples, carefully selected from essays presented by now-graduated students, serve as springboards for discussing the details of a specific situation; the relevant virtues; the principles, values, and ethical frameworks; and the options for how one might behave in the future. Such discussions allow for a diversity of viewpoints, which is healthy, because many—perhaps, most—ethical dilemmas seldom have one “right” answer.26–27

The framework for analysis of the students’ essays and also the details of a specific problem and its discussion are shown in List 1. On a first reading, many might interpret the facts in List 1 as representing an egregious failure to tell the truth. However, on further reflection, the scenario could be taken as an example of a higher level of professionalism (Table 2) on the part of the attending surgeon (who worked long and hard to save the patient’s life, in all likelihood with no prospect for remuneration) and of the institution (which expended enormous resources, including a large fraction of its blood supply, on this patient, despite a bleak prognosis from the outset). Students are told that the major goal of the small-group discussions is to encourage ethical reflection as a lifelong habit. Residents and faculty are told that the major goal of the conferences or grand rounds using the students’ essays is to encourage in residents and faculty the habit of talking with students one-on-one to explain why one chose to act in a certain way and to allow questions. When residents or faculty members ask, “How might I do it better the next time?” all participants are engaged in the challenging work of building character—that is, in developing the propensity to do the right thing in difficult or morally ambiguous circumstances.

Table 2

Table 2

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Does Character Suffice for Happiness?

Harrison and colleagues did indeed posit that character is a source of and is sufficient for happiness. However, we would add three caveats to this position. First, the idea that a physician should be content with character as his or her destiny, as expressed by Harrison and colleagues, is for most of us synonymous with Stoicism. The Stoics took their lead in this regard from Socrates. Plato, Aristotle, and others in ancient Greece made the more modest claim that, all else being equal, the virtuous person is happier than the nonvirtuous person. However, even early Stoics Zeno and Chrysippus believed that such advantages as health and wealth are naturally preferable to their opposites and make a significant contribution to happiness.28 Physicians, to earn their livelihoods, must necessarily consider “external goods” as well as the “inner goods” pertaining to virtue and character (Table 2).

Second, character and its component virtues are sensitive to environments and situations.29 It is more difficult to be virtuous in an environment that does not honor or promote virtue than in one that does. Many physicians would maintain that the project of building character is made increasingly difficult by the conditions of medical practice. These include excruciating time pressures, demands of third-party payers, and inadequate reimbursement for time spent listening to patients as opposed to doing things to them. The claim by various philosophers that emotional responses affect the extent to which people act virtuously finds support in a body of experimental evidence, such as the examples that follow. Users of a pay telephone who unexpectedly received a dime when they hung up the receiver were more likely to help a passerby in moderate distress than were users who did not receive the dime.30 Seminarians who were told they were running ahead of schedule to their next appointment were more likely to help a stranger in severe distress than were those who were told they were running a bit late.31 We are not alone in believing that efforts to promote character and professionalism must address the entire learning environment.

Third, the habit of developing character is crucially dependent on the early years of training. Benjamin Franklin famously honed his character as a young man by recording in his diary the extent to which he observed the various virtues.32 We hypothesize that such a habit of systematic reflection, using a template such as that shown in List 1, might similarly assist today’s medical students and residents toward the goals of providing a unique service for one’s fellow humans and building an edifice of character.

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Acknowledgments

This article is based in part on the Nicholas E. Davies Memorial Scholar Award Lecture presented by C.S.B. at the American College of Physicians meeting, San Diego, California, April 20, 2007. The authors thank Linda L. Blank for her comments on the manuscript. The authors also thank students and colleagues too numerous to mention for points made during discussions of the issues dealt with here.

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