Bull.lnd. Inst. Hist, Med. Vol. XXVI pp. 75 to 80

ARISTOTLE'S ETHICAL THEORY & MODERN HEALTH CARE

SISIR K. MAJUMDAR*

ABSTRACT

The Greek physician of antiquity - Hippocrates (460 - 356 B.C.) is called theFather of Modern Medicine and the Hippocratic Oath to which doctors of modernmedicine traditionally and formally express their allegiance. forms the basic founda-tion of medical ethics. The tradition of Western ethical philosophy began with theancient Greeks. Form Socrates (469-399 B.C.) and his immediate successors, Plato(427-347 B.C ) and Aristotle (384-322 B.C.), there is a clear line of continuity, throughHellenistic period (from the death of Alexander the Great (323 B.C.) to the end ofPtolemic dynasty (30 B.C.) and the Roman annexation of Egypt - broadly post-Aristotelian) and medieval thought to the present day. But the society has qualita-tively and quantitatively changed since the Industrial Revolution in the late 18th and19th centuries. Society, today, is just a collection of discrete individuals, each withhis or her own purposes and interests. Hence it has become almost imperative toapply the principle of autonomy to issues in the ethics of health care. The aim of thisshort essay is, therefore, an attempt to explore the relevance, if any, of Aristotelianethical theory to the modern health care.

Aristotle's ethical theory, in the main,represents the prevailing opinions of edu-cated and experienced men of his day inAthens and other city-states of Greece.Ethics is derived from the Greek word"Ethos" meaning custom and, in antiquity,it was a systematic account of the prin-ciples by which decent, well-behaved citi-zens would regulate their conduct. Evenin those days, society was not homoge-neous. In the City-state of democratic Ath-ens, the citizens with voting rights num-bered about 50,000 and the slaves havebeen calculated at about 100,000 (Tofallis

1978). This socio-political scenario inGreece of the day reflects the limitationsof Aristotle's ethics and its relevance tothe modern society of today.

Aristotle's concept of justice inhis most famous ethical treat se"NICOMACHEAN ETHICS" is still widelyprevalent (Russell, 1946). He thought thateach thing or person had its or his propersphere, to overstep which is unjust. Somemen, in virtue of their character and apti-tudes, have a wider sphere than others,and there is no injustice if they enjoy agreater share of happiness (eudaimonia).This view is taken for granted in Aristotle.

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In a society, as it is today in most parts ofthe world, particularly in this country, thisconcept of justice has definite relevanceto the distribution or 'availability of re-sources in the health market. Ability topay is the determining factor, discrete in-dividualism rules over everything else inmodern health care.

Autonomy and the principle of re-spect for autonomy is important in con-temporary medical ethics. Autonomy(meaning "self rule") is the capacity to think(autonomy of thought), decide (autonomyof will) and act (autonomy of action) on thebasis of such thought and decision, freelyand independently and without any. hin-drance. Autonomy is, therefore, a sub-class of freedom or liberty, but not all free-dom or liberty is autonomy. According toAristotle, the concept of autonomy maybe termed as man's specific rationality.Thus, the role of doctors is to provide goodexpert advice concerning various availableoptions and then to support the patient'sor his/ her legal guardian's (when thepatient is incapable of exercising his or herautonomy). Coercion or malicious way ofinfluencing in such matters by doctors isnot acceptable. This is the usual norm incurrent medical practice in this country.

Aristotle's "teleology" (Greek-telos,'end', 'purpose') flavours all his work, includ-ing his ethical theory. The "end" of man isto live "well" or "happily" (Eudaimonia); thestate arises naturally as assistinq andworking towards that end; and the variousinstitutions of the state should be judgedby the standard of how far they assist the

Aristotle's Ethical Theory - Majumdar

state to achieve its purpose. Aristotle'scelebrated description of man - a "politikonzoon" - an animal that naturally lives in astate - "Polis". Medical or health caresystem as one of the essential institutionsof the state should also assist that stateto achieve its purpose, in this case, the"happiness" or eudaimonia for the individualcitizen. "Eudaimonia" or "happiness" is"a virtuous activity of the soul".

On "Virtue"(arete}, Aristotle classi-fied human character into five types, rang-ing from the great souled man to the moralmonster. Medicine has a moral traditiondating back to Hippocrates and Galen (131-200 A.D.). Good health of the society de-pends on the good health of the individualmember of the society. Aristotle's con-cept on virtues could be the guiding phi-losophy of modern health care manage-ment.

Modern health care systems are dif-ferent in different countries. In most coun-tries, health care is a purchasable, privatecommodity, depending on the individual'sability to pay. Private medicine, as in theU.S.A. is the classic example of thislaissez fa ire medicine. In Great Britain,the National Health Service (N.H.S.) es-tablished in 1948 is undergoing tremen-dous changes and is slowly and steadilyproceeding towards privatisation. WhenBritain is departing from the socialist healthsystem, the U.S.A. is rushing fast todayto some sort of socialist health system.The Marxist doctrine - "from each accord-ing to his ability to each according to hisneeds" is still lurking in the psyche of those

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who formulate health care systems in dif-ferent countries. This is what is likely tohappen in the U.S.A. in the near futureunder the proposed health care system.

In Great Britain, market economy isguiding every system - health, medical,education, etc. Patients, rather clients(from the Greek word "Klin" meaning 'bed)are consumers in the health market. Trusthospitals are providers. Ability to pay forthe care is the criteria. Individual choicein the selection of doctor or health care orhospital gets priority. The care needs tobe cost-effective. The carers - hospitalmanagers, fund-holding general practitio-ners (G.P.'s) are shopping around in themarket place - the corridors of private andTrust hospitals. It is just? Just or unjust,market forces will regulate accessabilityto hightech modern medicine on the basisof people's ability to pay. All these fit wellinto Aristotle's concept of distributivejus-tice.

Aristotle's concept of doctors is asfoliows (Temkin, 1953) and is still preva-lent in the world of health and medical carein many parts of the world:

1.0rdinary Practitioners (Demiourgos)2.Master of the Craft (Architektonikos)3.Man who studied medicine as part of

general education.The third category of doctors fits into

the making process of modern doctors.Others are self-styled or self-trained orquack doctors/village healers, still preva-lent in many parts ofthe developing world.Doctors of today, in private practice, mayselect their patients or clients according

77to their financial ability to pay, but not ac-cording to social status. It is money andmoney alone which holds the key in se-lection. It fits well into libertarian and utili-tarian theories of justice so long as it isapproved by the individual's purse

Justice is one of the central concer-ns of philosophers and Aristotle's formalprinciple of justice is still widely accepted.The formal principle of justice or equalityattributed to Aristotle is that equals shouldbe treated equally and unequals unequallyin proportion to the relevant inequalities(Aristotle, Politics, Book3,Chapter 9,P.193, Penguin Books, London, 1988). Butthis Aristotelian principle of justice withdemands for equal consideration, fairnessand impartiality is interpreted by differentauthorities in different ways to justify theirown thinking on the matter.

With enormous scientific advance-ment in the 20th century, medical treat-ment has become expensive. Costs pro-hibit the supply of hightech medicine uni-versally. Resources are scarce. There isdisparity between supply and demand.Morality dominates the allocation of rareresources, Inequality in health care is theresult in the end. Private medicine flour-ishes for the rich few and shies away fromthe maximum number of people and thusunequals are treated unequally. On top ofeverything else, market economy or forcesrule the world of modern health care. Inthis respect, privatisation of health servicesseems to be consistent with Aristotle'sethical theory on distributive justice. Butit is in conflict with the prevalent situation

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in modern health care in Briltain and alsoin some West European countries wherethe cradle-to-grave welfare state is consid-ered as a mark of a civilized society. Re-cession and again population threaten tomake it all unaffordable. It is a moral di-lemma for the society and the state. In thissphere, 'Aristotle's concept of distributivejustice is under considerable strain.

Aristotle's concept of good health isquite clear. When health is destroyed bydiseases, the body needs purificationthrough medicines, just as sick souls needpurification through music - Aristotle sawhealth as harmony - proper attunement ofthe body. To him, health was "Summumbonum" ("Eudaimonia","happiness") - itwas identical with happiness, the aim to-wards which all human endeavour shouldbe directed. This is the essence of allhealth care systems globally even today.Aristotle's ethics also dealt with practicalissues in day-to-day medical care, whichdoctors frequently face, even today.

Suicide, according to Aristotle, is acowardly act because it gives in to bodilypain. Aristotelian school condemned sui-cide. The modern stand on suicide re-mains the same and Is expressed as ac-cidental mis-adventure. Aristotle advocatesthat abortion should be performed beforethe foetus attained animal life; after that,he no longer considers abortion compat-ible with holiness (Aristotle, Politics, BookVII, 1335b/19). Abortion is still a contro-

Aristotle's Ethical Theory - Majumdar

versial issue.In modern times, the physician has

become the confidant of the healthy andthe sick, the expert of social agencies, thecounsellor of the judge, the authority towhom even the planners of foreign anddomestic policies look up. To the Greekphilosophers like Plato and Aristotle, thePhysician was no advisor on morals, jus-tice or politics. To them, medicine wasnot another form of education or philoso-phy. However, it needs to be mentionedthat in modern health care, which is morecomplicated and sophisticated than wasprevalent in antiquity, the physician's advi-sory role over many of the above-mentionedmatters is not only acceptable, but essen-tial. Escaping capital punishment for mur-der on grounds of diminished responsibil-ity due to mental insanity diagnosed byrelevant medical experts is a good examplewhich is at variance with the physiciansrole in Greek antiquity.

In Greek antiquity, medicine was notan educational force, nor doctor an educa-tor, though he might have identified withthe ideal of health. According to Aristotle,the physician can tell men how to behealthy; the decision is in their own hands(Aristotle, Topica, II, 2,11 Oa 19). It is aclear expression of respect for autonomyof the patient. This is a very importantaspect of modern health care.

The principle of medical confidential-ity - that doctors must keep their patient's

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secrets - is one of the most venerablemoral obligations of medical ethics. TheHippocratic Oath enjoins:

"Whatever, in connection with myprofessional practice, or not in connectionwith it, I see or hear, in the life of men,which ought not to be spoken of abroad, Iwill not divulge, as reckoninq that all suchshould be kept secret".

Indeed, according to World MedicalAssociation (W.MA) International Codeof Medical Ethics, it is an absolute require-ment, even after the patient's death (B.MA1984). In France, the obligation of medi-cal confidentiality is enshrined in law as

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an absolute medical privilege which no-one,including the patient, is allowed to over-ride, even when to do so would be in thepatient's interest (Havard, 1985).

In a conflict between confidentialityand telling the truth, according to Aristotle"the decision rests with the perception" ofthe doctor (quoted by Ross, 1930). Thatmeans that the final decision in such acontroversy rests with the doctor to makeon the basis of the doctor's understandingof "the greatest balance of right overwrong". This interpretation is broadly con-sistent with both French and W.MA'sposition and also with the basic tenets ofAristotelian ethics.

REFERENCES1. British Medical Association 1984 The Handbook of Medical Ethics, B.MA,

London, P.70-72.

2. Havard J. 1985 Medical confidence, J:Med.Ethics, 11:8-11

3. Ross W.O. 1930 The Right and the Good. Clarendon Press,Oxford, P.22, 41-42.

4. Russell B. 1946 History of Western Philosophy, Routledge,London, P.194.

5. Temkin O. 1953 Greek Medicine as Science and Craft. Isis,44:213-225.

6. Tofallis K. 1978 Socrates -Man and Philosopher. GreekInstitute, London, P.32.

80 Aristotle's Ethical Theory - Majumdar

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