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South African Dental Journal

On-line version ISSN 0375-1562
Print version ISSN 0011-8516

S. Afr. dent. j. vol.75 n.6 Johannesburg Jul. 2020 



The renaissance of virtue ethics and its application in dentistry



HD MiniggioI; PD MotlobaII; CS WarehamIII

IBDS (UMF, Cluj-Napoca), MScMed (Bioethics and Health Law) (Wits), PGDip (Health Sciences Education) (Wits) Senior Lecturer, Department of Oral Pathology and Oral Biology, Sefako Makgatho Health Sciences University, South Africa
IIBDS, MPH (Epid), MDent (Comm. Dent), MBL, Head, Department of Community Dentistry, School of Oral Health Sciences, Sefako Makgatho Health Sciences University, South Africa ORCID Number: 0000-0003-1379-7576
IIIBA Hons (Rhodes), MA (Rhodes), PhD (Milan), Senior Lecturer, Steve Biko Centre for Bioethics, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, South Africa





Virtue ethics, an ethical theory that focuses on concepts of how to live a good life and the characteristic traits or virtues of individuals, has enjoyed increasing popularity and considerable re-emergence in ethical assessment in various healthcare disciplines.
This popularity is, in part, attributable to its contrasting approach to the more formalized rule-based approaches to ethical assessment in healthcare practice.
The formalization of ethical healthcare practice (presented as the four principles of autonomy, beneficence, non-maleficence and justice) coupled with various codes of ethics, has led to a considerable focus and reliance on rules and obligations.
A significant limitation of this type of approach arises from the difficulty in choosing which principle takes greater priority, in cases in which two or more principles are in conflict. What is more, in this rule-oriented approach, motivations of individuals, characteristic traits and relationships, which are important aspects in ethical deliberations, have taken a back seat.
Against this background we describe and propose the incorporation of a virtue ethics approach, with a focus on the character and motivations of the individual or agent, as part of ethical deliberations in the practice of dentistry.




Traditionally, ethical analysis in the practice of medicine has been approached from a rule-based viewpoint. This has encouraged an action-oriented ethical analysis, often to the detriment of character, professional conduct and judgement of healthcare practitioners.

It is now widely acknowledged that not everything that is important in professional life can be captured by codes of conduct and that professionalism goes beyond ethical principles.1

Similarly, the prevailing approach in discussions pertaining to ethical issues that arise in the context of dental practice is principle-based, otherwise known as rule-based.

The principle-based approach guides ethical reasoning by focusing on what actions a moral agent should take. Aspects of internal motivations, character of the healthcare practitioner and professional judgement do not form part of this rule-based approach.

This is a shortcoming since these aspects assist the healthcare practitioner to "[interpret] the principles, [select] the ones to apply or ignore, [put] them in order of priority, and [shape] them in accord to his life history and current life situation".2 Furthermore, virtue ethics also makes room for the incorporation of emotions as an "integral and important part of our moral perception".3

Given the essential role of these aspects in the moral decision-making process, it is surprising that so little attention focuses on these in dental ethics literature. We propose the incorporation of virtue ethics, as part of ethical reflections in the practice of dentistry in conjunction with the four principles. Dental practitioners would, in this way, be better equipped to address ethical issues pertinent to dental practice.

For the purpose of this article, we limit our discussion to aspects of virtue ethics advanced by Aristotle, Alasdair Maclntyre and Edmund Pellegrino. Similarly, from the several virtues which have been proposed as being important in the healthcare context, we restrict our focus to the virtues advanced by Beauchamp and Childress; we argue that these virtues have significant application to the dentist-patient relationship and assist in furthering the goals of the practice of dentistry.

We begin with an exploration of Aristotle's notions of virtue ethics and Alasdair MacIntyre's concept of a practice with goods specific to it. We then briefly explore how virtues are linked to those goods. We also evaluate Edmund Pellegrino's concepts of a morality that is inherent to healthcare practice with a focus on the goals specific to healthcare practice. An exploration of these concepts is significant in understanding virtue ethics theory as it was originally intended, and understanding how these original concepts have subsequently been applied in ethical deliberations in healthcare.

Virtue ethics

"When it comes to moral theories, virtue ethics is the old new kid on the block".4 Our exploration of virtue ethics begins with the 'old' or original concepts of eudaimonia, doctrine of the mean and phronésis. For Aristotle, all human beings have a final purpose; not only, do all human beings have a final purpose but in fact, all human beings strive to achieve this final purpose.5 For Aristotle, this final purpose is to achieve a state of eudaimonia, generally translated as happiness or fulfillment.5

Aristotle proposes that eudaimonia or fulfillment is the highest good for human beings, and as such, it is chosen as an end in itself.5 He further considers that living a fulfilled life requires specific human excellences which he differentiates into intellectual excellences or wisdom (sophia) and practical excellences or wisdom (phronésis).5

A fulfilled life, in turn, is achieved by habitually exercising certain moral virtues. A moral virtue is an "acquired habit or disposition to do what is morally right or praiseworthy".6

Aristotle suggests that virtues can be taught and that exercising a virtue occasionally does not make a virtuous agent, thus virtues must be exercised routinely throughout one's life.5 For Aristotle, a moral virtue is a praiseworthy character trait that is found between two extremes which can be explained by his concept of the doctrine of the mean.5 If we apply the doctrine of the mean to, for example the virtue of courage, we see that the virtue can be found between the two extremes; that of rashness (too much courage) and that of cowardice (too little courage).5 Practical wisdom (phronésis) then, is the virtue which assists the moral agent in choosing the appropriate action at the appropriate time.5 This virtue is often translated as prudence.

But how can a virtue theory developed 2400 years ago, have applicability in ethical assessment in modern day dentistry? We will attempt to answer this question by exploring notions of virtue ethics related to the practice of medicine as advanced by a couple of contemporary ethicists writing on the topic in the field.

Virtue in practice

A virtue in the context of a practice, such as the practice of medicine, can be described as an "acquired human quality, the possession and exercise of which tends to enable us to achieve those goods which are internal to practices and the lack of which effectively prevents us from achieving any such goods".7

According to MacIntyre, a practice can be defined as "any coherent and complex form of socially established cooperative human activity, through which goods internal to that form of activity are realised in the course of trying to achieve those standards of excellence which are appropriate to, and partially definitive of, that form of activity, with the result that human powers to achieve excellence (virtue) and human conceptions of the ends and goods involved, are systematically extended".7

Internal goods are in turn "defined by each particular practice and recognized by the experience of participating in the practice in question".7,8 The concept of internal goods, refers to those goods which can only be achieved as part of being directly involved in that particular practice; the concept of external goods, refers to those goods that can be achieved within the practice as well as outside of the practice or in many other types of practices or activities.7

Examples of external goods, are financial benefit and a certain standing in society.7 The internal goods in the practice of medicine are considered to be the doctor-patient relationship and technical competence.7 MacIntyre considers that the internal goods in a practice can only be achieved through the exercise of certain virtues which lead to the attainment of those internal goods, specific to the practice.7

Pellegrino similarly applies the concept of practices to medicine in the particular sense that MacIntyre proposes, and considers that the practice of medicine is guided by specific goals that are particular to the practice. Pellegrino deems both principled-based ethics and virtue-based ethics as being inadequate, on their own, for ethical deliberations in healthcare and advances the integration of both principles and character in such deliberations.2

Furthermore, he considers that the doctor-patient relationship is unique as it "centres on a vulnerable, anxious, dependent, often suffering individual person".2 This relationship embodies a certain inherent morality to the practice of medicine and through this unique relationship the goals of medical practice are determined and achieved.2 For Pellegrino, the practice of medicine is a moral practice due to the "nature of illness, the non-proprietary nature of medical knowledge, and the nature and circumstances of a professional oath".2 Pellegrino suggests that the goal of medical practice is "the good of the patient" and considers that both the doctor and the patient must jointly work towards this goal and that virtues lead to the realization of that goal.2

The practice of medicine, thus, flourishes most when virtue is pursued by a community of practitioners.2

Amongst the chief virtues, which date back to the time of Socrates, Aristotle and Plato and traditional Christian theology are temperance, courage, justice and prudence.

From these virtues, of particular relevance is the virtue of prudence which "emphasizes long term goals, good judgement in the face of uncertainty, and overcoming shortsighted choices" which "not only provides order for the principles, but also provides order for other virtues".9

While there is no specific nor exhaustive list of virtues applicable in healthcare practice, and several virtues have been proposed, the virtues that have particular relevance in healthcare practice have been designated by Beauchamp and Childress as, compassion, trustworthiness, integrity, discernment and conscientiousness.10

The continuous exercise of these virtues in the relationship with patients leads to the development of a virtuous character; a virtuous character is characterized by Meara et al. as one who:

is motivated to do what is good.

possesses vision and discernment.

realizes the role of affect or emotion in assessing or judging proper conduct.

has a high degree of self-understanding and awareness.

is connected with and understands the mores of his or her community and the importance of community in moral decision making.11

Importantly, "virtuous agents are motivated to do what is right and have developed traits or dispositions or motivations to act in accordance with high ethical standards or ideals".11 Virtue ethics thus teaches us that we are all capable of becoming virtuous, by learning and routinely practicing virtues, which will ultimately define our moral character.

We now apply Maclntyre's concept of a practice and Pellegrino's view of medical practice, which aims at a specific goal, in the context of dentistry. We also propose that the virtues identified by Beauchamp and Childress as being essential in medical practice, are valuable in ethical decision making in dentistry.

Virtue ethics in dentistry

At this point we would like to point out that certain characteristic traits, or virtues, such as compassion and integrity, are mentioned in the ethics literature as being "core values of dentistry" and these are considered to "serve as the foundation of dental ethics".12 However, these virtues are not presented, nor discussed within the broader context of a virtue ethics theory and as such, lose their intended meaning and application.

We now turn our attention to discuss dentistry as a practice as advanced by Maclntyre. Dentistry corresponds well with MacIntyre's definition of a practice, namely "a coherent and complex form of socially established cooperative human activity" which leads to the attainment of certain goods internal to the practice.7

If we consider dentistry as a practice in the sense defined by MacIntyre and the goal of dental practice as being in line with the goal of medical practice, then the goal of dental practice can be considered as the good of the patient in relation to promoting, maintaining and restoring oral health. Furthermore, as a practice, dentistry has internal goods, through which the goals of the practice are achieved. We suggest that the internal goods in the practice of dentistry in the sense that MacIntyre proposes, are technical competence and the dentist-patient relationship.

Patients are dependent on the technical expertise of dental practitioners for reasons ranging from pain relief to oral health rehabilitation and disease prevention.12 The dentist-patient relationship is a significant internal good of dental practice which hinges on trust. Trust is essential in this relationship, as patients accept certain physical intrusions by having portions of their bodies examined and treated by dental practitioners.12

They allow such intrusion "because they trust their dentists to act in their best interests".12 In other words, they trust the motivations of dental practitioners. Furthermore, as part of the consultation process, patients often disclose personal and private information to the dental practitioner, and trust that this sensitive information will not be divulged to others.12

All these aspects render patients vulnerable and dependent on the character and motivations of the dental practitioners. Additionally, trust is important in the patient-dentist relationship as dentists usually make use of their technical skills to earn a livelihood, thus there can be a "potential tension" between the commercial interest of dentists and the best interest of the patient.12 The character of the dental practitioner safeguards against the possible exploitation of vulnerable patients.

We argue that a compassionate and trustworthy dental practitioner, who displays high levels of integrity, discernment and conscientiousness, will safeguard the trust that patients place in the dental practitioner as well as in the dental profession, and advance the good of the patient in relation to promoting, maintaining and restoring oral health.

In the sections to follow we explore these virtues in more detail and provide an overview of certain contexts in which these virtues can assist dental practitioners in the decision-making process.

Let us now consider how virtue ethics, could assist dental practitioners when faced with ethical challenges that arise in those cases where patients make inappropriate treatment choices; choices which are clearly not in their best interest. Such inappropriate treatment choices may be less costly and less procedurally cumbersome in the short term, to the detriment of the oral health of the patient and increase in cost in the long term.

This can cause a difficult ethical dilemma and considerable frustration for the dental practitioner. In such cases, the application of the principle-based approach offers insufficient guidance. In trying to apply the principled-approach to this scenario, we remark that the principle of autonomy (in this case, the right of the patient to make informed decisions regarding their oral healthcare) is in conflict with the principle of beneficence (in this case, acting for the good of the patient). The question arises, should the dental practitioner choose to respect the patient's autonomy or are considerations of beneficence more important? We note that, when faced with ethical dilemmas that arise from the conflict of two or more principles, the principle-based approach does not offer clear guidance as to how the conflict should be solved. In such cases, the dental practitioner is then further required to make use of either intuition or reach out to other ethical theories in order to come to a resolution.

In such an ethical dilemma, in which principles are at odds and the dental practitioner is uncertain which principle has greater importance, virtue ethics is helpful by encouraging a broader and more flexible evaluation of the situation.

From a virtue ethics standpoint, the virtue of compassion is one which refers to "an active regard for another's welfare with an imaginative awareness and emotional response of deep sympathy, tenderness and discomfort at another's misfortune or suffering".10 In this scenario, the dental practitioner has an emotional response to the situation, seeing that the inappropriate treatment choice might negatively affect the oral health of the patient in the long term. Applying the virtue of compassion in this case assists the dental practitioner to respond with sympathy and active regard for the particular circumstances of this case.

The virtue of compassion compels the dental practitioner to understand that, while it is ultimately the right of the patient to make informed decisions regarding their oral treatment, the patient may at times have difficulty with the treatment decision. Such treatment decisions might be, for example, based on irrational fears regarding certain procedures or previous bad experiences with similar procedures, or misconceptions regarding the consequences thereof. If the inappropriate treatment decisions are made due to such external factors, the dental practitioner is in a position to help in alleviating such fears and misconceptions.

On the other hand, if the treatment choice is based solely on financial concerns, the virtue of compassion would compel the dental practitioner to have regard for the welfare of the patient and attempt to And creative solutions to balance the financial constraints with the good of the patient.

Compassion thus compels the dental practitioner to create a conducive environment in which a comprehensive discussion and collaboration can take place. A compassionate response to this dilemma would also entail affording the patient time to reflect on his or her decision regarding treatment options. Such a compassionate response leads to a holistic interaction between the dental practitioner and the patient, in which the collaborative decision can be made and the goals of the practice achieved.

The virtue of trustworthiness is also valuable in this scenario. Trustworthiness is considered the "cornerstone of the doctor-patient relationship".12 In this case building trust with the patient allows for meaningful collaboration in regards to common decision making that serves in the best interest of the patient.

Integrity refers to the "quality of being honest and fair".13 Honesty and fairness represent essential components of the dental practitioner-patient relationship as patients are dependent on the dental practitioner and in this vulnerable position, patients become easily exploitable.

Honesty in this case would go a long way in managing patient expectations and being forthright about the outcomes and possible complications of the various treatment options.

The virtue of conscientiousness is "governed by or conforming to the dictates of conscience".13 In this case, conscientiousness leads to a concern regarding the consequences to the oral health of the patient as treatment options chosen by the patient might not in his or her best interest.

Discernment is the virtue that "brings sensitive insight, understanding and wise judgement to the situation".13 Wise judgement and sensitive insight are important aspects that sensitizes the dental practitioner to the predicament that some patients might And themselves in when their oral healthcare choices are influenced by external factors.

The virtues of compassion, trustworthiness, integrity, discernment and conscientiousness in this case can assist the dental practitioner in solving the conflict between the principles of autonomy and beneficence. Once the dilemma is viewed from a holistic standpoint which takes into account the individual needs of the patient coupled with the motivation to improve the oral health of the patient, a decision can be made in regards to which principle is more significant.

For instance, if the treatment decision is made out of fear of the treatment procedure, the compassionate dental practitioner can take steps to alleviate any unfounded fears, thereby acting in the interest of beneficence. If, however, the treatment option is chosen in the absence of external influences, and after ensuring that the patient understands the consequences thereof, the principle of autonomy takes preference.

The application of these aforementioned virtues can similarly be of value when, for example, dealing with ethical issues that may arise from patient non-compliance and difficult patients, which can negatively impact on the oral health of these patients and thus on the goal of dental practice.

The development and continued exercise of these virtues advances the goals of dental practice and encourages professional judgement in the moral decision making process. Furthermore, these virtues can assist in balancing and choosing between competing principles in ethical issues that arise in dental practice. These virtues are significant in understanding the needs of individual patients and making use of sensible judgement when faced with conflicting ethical interests in dental practice.

A virtuous dental practitioner is able to identify and be sensitive to the various oral healthcare needs and circumstances of individual patients, which goes a long way in improving patient satisfaction and treatment compliance thereby advancing the goals of dental practice.

ln sum, virtue ethics is helpful in providing a more holistic and varied approach to ethical dilemmas encountered in dental practice. This is because the whole character of the dental practitioner takes center stage in this type of approach including the internal motivations.

Such an approach means that the dental practitioner "is not simply an inanimate observer in the process of ethical deliberation" but rather the "living body of ethical practice".4 Ultimately it is the character and motivations of the dental practitioner that guides the ethical decision-making process.

Virtue ethics provides dental practitioners with an additional tool that assists them when solving ethical dilemmas for which the principle-based ethical approach canot provide an answer.



"Virtue ethics calls upon individuals to aspire towards ideals and to develop virtues or traits of character that enable them to achieve these ideals".10 Virtue ethics recognizes the importance of the development of healthcare practitioners' character, which provides the foundation for professional judgement and ethical behavior.

Through an effective dentist-patient relationship based on trust and mutual collaboration, coupled with competence in technical expertise, the goals of the practice of dentistry can be achieved. The incorporation of a virtue ethics approach provides dental practitioners an additional tool for solving ethical issues in dentistry in conjunction with the four principles.

When faced with ethical dilemmas, dental practitioners can make use of the virtue ethics approach which highlights the importance of character in the decision making process and incorporates the question, what type of dental practitioner should l be, as part of the ethical assessment. Such an approach makes room for the incorporation of virtues as part of the ethical assessment of issues pertaining to dental practice, which has, for many years been overlooked.



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Hilde D Miniggio
Department of Oral Pathology and Oral Biology Sefako Makgatho Health Sciences University
South Africa



Author contributions:
1 . Hilde D Miniggio: Conceptualization, first draft, revision, final write-up and final approval - 60%
2 . Pagollang D Motloba: First draft, revision, final write-up and final approval - 20%
3 . Christopher S Wareham: First draft, revision, final write-up and final approval - 20%

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