Challenges Facing the Appeal to Practical Wisdom in Medicine and Beyond

Practical wisdom is considered a multidimensional virtue of enduring relevance to medicine. Though it has received increasing attention in recent years, proposed frameworks for practical wisdom can differ, and little is known about how medical students and physicians describe its dimensions and relevance. We used structured interviews, employing open-ended and closed-ended questions, to describe how medical students and physicians understand practical wisdom and identify the kinds of clinical situations they believe require practical wisdom. We interviewed 102 participants at two US medical schools in 2021, comprising a voluntary response sample of 40 pre-clinical medical students and 40 clinical medical students and a purposive sample of 22 nominated physicians. Interviews were conducted by videoconference using a structured interview guide. Open-ended responses were coded using qualitative content analysis (directed and conventional) and tabulated; closed-ended responses were tabulated. Quotations provided qualitative illustrations, and frequencies were used for summative results. Participants considered practical wisdom clinically meaningful, broadly relevant and multidimensional. Most described it as deliberative, goal-directed, context-sensitive, integrated with ethics and marked by integrity and motivation to act. Many described it as experience-based, person-centred or problem-solving. Participants also selected an average of 15.6 (SD = 4.9) additional virtues as being essential for practical wisdom in medicine and described a broad range of clinical situations that require practical wisdom in medicine. Participants described practical wisdom as a multidimensional capacity that entails deliberation, depends on a constellation of other virtues and is broadly applicable to medicine. Most agreed it is goal-directed and context-sensitive and involves ethics, integrity and motivation. Efforts to teach practical wisdom in medical education should clarify its dimensions and highlight its relationship to virtue ethics, professionalism, clinical judgement and the individualised care of patients as persons.

Clinical decision making is a challenging task that requires practical wisdom—the practised ability to help patients choose wisely among available diagnostic and treatment options. But practical wisdom is not a...

Decision-making in health care is often challenging and therefore requires practical wisdom. The domains of such wisdom involve goals, perception, ethics, deliberation, and motivation. For Christian patients, there is a need for practical wisdom founded on Christian commitments that shape and guide these domains according to a Christian understanding of life, health, technology, illness, suffering, and death. In this essay, I outline a Christian approach to practical wisdom in health care by infusing Christian beliefs and values into a general framework for practical wisdom in medicine I have described previously. I organize this approach by referring to Christian purpose, vision, ethics, piety, and practice. The result is a framework that intends to integrate faith and reason so that what we believe as Christians forms how we think about health and guides what we choose or decline when considering the possibilities that come before us in health care.

Practical wisdom in medicine and health care

Practical Wisdom in Medicine

To practice medicine and ethics, physicians need wisdom and integrity to integrate scientific knowledge, patient preferences, their own moral commitments, and society's expectations. This work of integration requires a physician to pursue certain goals of care, determine moral priorities, and understand that conscience or integrity require harmony among a person's beliefs, values, reasoning, actions, and identity. But the moral and religious pluralism of contemporary society makes this integration challenging and uncertain. How physicians treat patients will depend on the particular beliefs and values they and other health professionals bring to each instance of shared decision making. This book offers a framework for practical wisdom in medicine that addresses the need for integrity in the life of each health professional. In doing so, it acknowledges the challenge of moral pluralism and the need for moral dialogue and humility as professionals fulfil their obligations to patients, themselves, and society.

How are professional values defined and applied in actual practice of modern medicine? Let me begin to answer that question by reviewing virtues that number of scholars regard as central professional values in medicine. James Drane considers beneficience, that is, good work doctor does for persons who are ill, to be fundamental ethical standard, and benevolence to be virtue that disposes doctors to provide medical help.[1] He also includes as cardinal virtues for physicians respect and concern for patients, truthfulness, friendliness, and justice. Pellegrino and Thomasma take medicine to be human activity with specific telos or goal: a right and good action for particular patient.[2] Drawing on Aristotelian concept of phronesis, often defined as practical wisdom or prudence, they take clinical judgment to be medicine's indispensable virtue.[3] Pellegrino and Thomasma relate phronesis, the state of character which makes person good and which makes person do his or her work well, to ethical principle of beneficence, principle that they believe to be heart of medical and physician's primary obligation to (p. 53). Although they identify other essential virtues--including trustworthiness, respect for persons, compassion, justice, integrity, and self-effacement--they stress that in clinical context of relationships these traits should be subsumed within pivotal virtue of phronesis or prudence. Pellegrino, moreover, has argued that principle-based and virtue-based medical should be closely linked to the universality of phenomena of illness and healing and should be grounded in reality of physician-patient relationship.[4] Clinical Medical Ethics How do physicians move between realms of values and philosophical theories, on one hand, and clinical realities of medical practice, on other? Pellegrino has argued that discipline of clinical bioethics--clinical medical ethics as I prefer to call it[5]--represents one approach for linking professional and ethical values with practice. It is field that on clinical realities of moral choices as they are confronted in day-to-day health and medical care.[6] Clinical medical is practical and applied discipline that aims to improve patient care and patient outcomes by focusing on reaching right and good decision in individual cases. It does so by identifying, analyzing, and contributing to resolution of ethical problems that arise in practice of medicine. It focuses on doctor-patient relationship and takes account of ethical and legal issues that patients, doctors, and hospitals must address to reach good decisions for individual patients. Clinical emphasizes that in practicing good clinical medicine, physicians must combine scientific and technical abilities with ethical concerns for personal values of patients who seek their help. The content of clinical includes specific issues such as truth-telling, informed consent, end of life care, palliative care, allocation of clinical resources, and of medical research. Clinical also includes at its core study of doctor-patient relationship, including such issues as honesty, competence, integrity, and respect for persons. Thus clinical includes focus on ethos of professional and on character and virtues of physician, whom public expects to demonstrate these qualities. Albert Jonsen, William Winslade, and I have suggested that in analysis of any ethical issues following factors must be considered: medical and scientific facts; preferences, values, and goals of both physician and patient; and external constraints, such as cost, limited resources, and legal duties, that may shape or limit choices. …

Stephen Toulmin: Having been, I suppose, the only living person to have studied at the feet of both Dirac and Wittgenstein, I retain a strong sense of the spirit of Aristotle's account of practical wisdom. That is, true progress in practical wisdom can only follow if one goes into a particular field and analyzes the nature of the problems that arise. Only in that way can one begin to understand what is mysterious, what needs explaining, and what needs investigating in the terms that are appropriate for that particular field. The idea that there is a single method for attacking scientific problems for scientists of all kinds does not get us much further than the notion that there is a single set of medical principles that will apply to all cases a physician may encounter, or a single set of moral principles that can give us answers to the human problems with which we find ourselves confronted. There is probably no one method appropriate even to inquiries in a given scientific field at different stages in its development. The recurrence of this case approach or pluralistic approach to practical wisdom as a motif in the history of philosophy is striking. Albert Jonsen of the University of California Medical School has pointed out that Thomas Aquinas, in the Summa Theologica, draws a telling comparison between the tasks that a wise confessor and a prudent physician face when they seek to arrive at some moral or medical diagnosis. Aquinas says that the wise confessor, like the prudent physician, will suspend judgment until he has satisfied himself that he knows all about a particular case with which he is concerned. He will go astray if he goes into a situation with fixed ideas about what the case is and what he said about it. I find the Aquinas point of view linking moral judgment and technical (or clinical) judgment is still very much on the mark. In medicine, the question of how a physician sees a case and manages it, even in its technical aspects, requires that the human implications involved in following one course of treatment rather than another be weighed. So the practice of medicine, even in a technical sense, becomes a moral exercise. And the line between its moral and technical aspects becomes progressively blurred. I want to explore with you today how such considerations bear on differing concepts of scientific progress, why those concepts affect the question of social responsibility, and how they carry over into the activities you support at the National Science Foundation. I have been thinking about the intellectual foundations of science policy at least since Edward Shils commissioned and published a seminal series of articles in Minerva in the early 1960s.1 My concerns are not simply a by product of my interests in the philosophical aspect of the theory of science. For the question of scientific choice and the respective roles of the scientist, the administration, the electorate, and the electorates' representatives in Congress, is very much bound up with different ideas about the nature of scientific progress, and is therefore central to the mission and operation of the NSF. To understand something about how and why concepts of scientific progress have changed over the past 300 years, it is useful to reflect on some of the implications of the vast expansion in the scope of scientific inquiry since Laplace asserted at the end of the 18th century that natural philosophers could aspire to become omniscient cal-

When professionals learn what it is to be a professional, they are already involved in a reflexive and reflective process which brings daily challenges to their sense of Self. In asking how doctors think, Montgomery (How doctors think: clinical judgement and the practice of medicine. New York: Oxford University Press, 2006) unearths an Aristotelian phronesis – a practical wisdom – which drives increasingly efficacious judgments, in clinical cases. This chapter will explore the conceptual basis for such workplace experiences, analysing their emergent quality, their perceptual intensity (‘paying attention’ as Luntley, a Wittgensteinian, puts it), their reliance on embodiment, and, throughout, their holism (following Dewey). Thus, the chapter will establish a solid conceptual basis for ontological and epistemological relationality, such that our professional identities can be both found in, and developed by, meaningful workplace learning. We learn to be, by doing

Reviewed by: How Doctors Think: Clinical Judgment and the Practice of Medicine James Lindemann Nelson How Doctors Think: Clinical Judgment and the Practice of Medicine. By Kathryn Montgomery. New York: Oxford Univ. Press, 2006. Pp. 256. $39.95 (hardcover). Throughout her distinguished career as a medical humanist and medical educator, Kathryn Montgomery has drawn on her keen understanding of the ways in which narrative shapes human understanding and on her close acquaintance with how physicians are formed to make the case that medicine is significantly misunderstood when it is thought of as a science (Montgomery 1993). In How Doctors Think, she treats this idea not as a view to be argued against, but as an illusion that needs to be dispelled. Rather than providing a linear, cumulative argument—breaking down the sub-tasks that need to be achieved if the main thesis is to be supported, and proceeding to knock them down in proper sequence—her book circles its target, looking for the sources of the illusion's tenacity and mobilizing various solvents against the sticky places. Indeed, Montgomery allows her target to drift about a bit. Her "official" point is that medicine is not science as the logical positivists conceived science to be—an enterprise that provides access to "an exact and unmediated representation of reality" (p. 10). But that, of course, doesn't take much showing these days: physics isn't science as the logical positivists conceived science to be. Montgomery's real concern is to account for why such a caricature continues to haunt both thought and practice, how it both helps and harms us, and why the harms outweigh the helps. At times, however, the book's case against the medicine-as-science thesis seems mounted in a way that doesn't depend on such a dusty impression of what science is. The case against this version of the view seems to involve fairly technical points about different styles of inference that characterize clinical versus actual scientific reasoning, as if to say that even sophisticated accounts of science won't capture what is so distinctive and significant about how doctors think. Here readers may find a bit more to cavil about. For example, Montgomery claims that clinicians, unlike scientists, typically reason "abductively"—in other words, they start "from a particular phenomenon, and, using preliminary evidence, hypothesize its possible causes; those hypotheses are tested against details revealed by closer examination" (p. 47). Yet an abductive strategy—"inference to the best explanation"—is widely invoked as a staple of scientific reasoning. So perhaps her remarks here are directed against the official target, a positivist-flavored, yet still socially influential fantasy about what science is, rather than the real thing. What seems most revelatory about the book's "therapeutic" agenda is the powerful and poignant story that unifies many of its chapters and all its major themes: the story of her struggles with her daughter's breast cancer. That recurring narrative thread is the heart of the book, and it starkly and sensitively poses [End Page 633] a painful question that faces patients, those they love, and even doctors. If our lives include the kind of absurd irruption that confronts Montgomery, and if, like her, we are clear-sighted, we cannot pretend that medical understanding isn't severely limited—that its surest source of knowledge, abstract and general, misfits its domain of practice: individual, concrete, particular, anomalous people. Why, and to what extent, then, does it make sense for us to put ourselves into doctors' hands, to suffer interventions we don't fully understand and that will often harm us? What kind of understanding of medicine can sustain us when our children are very ill? Debunking the medicine-as-science thesis doesn't solve this problem; if anything, it sharpens it. What is needed is an account of how doctors think, a version that accommodates what is really plain—that doctors aren't positivist scientists—but that they have powerful, authoritative, healing knowledge and the trustworthy values to direct it properly. Montgomery provides an account of clinical judgment that is inspired by Aristotle's notion of phronesis, or practical wisdom, and this strikes me as exactly the place to...

The history of the practice of medicine is littered with many selfless acts of courage in the face of dire circumstances: Edward Jenner and smallpox vaccinations, Father Damien and leprosy, women nurses during yellow fever epidemic in Memphis, and most recently medical trainees and nurses during the COVID-19 pandemic. The teaching and practice of medicine invariably deals with moral distress and ethical dilemmas in the management of patients, healthcare teams and critical life or death situations. Medicine is a field with deeply entrenched professional hierarchies and significant racial disparities. How does one choose to respond to a morally challenging situation with courage in the face of such hierarchies and disparities when the consequences could potentially harm oneself? How should medical educators shape the integration of the moral self of trainees with the motivation to do the right thing and the practical wisdom (phronesis) of when and how to respond to ethically challenging situations? This chapter discusses historical aspects of courage in the practice of medicine as well as current concepts in professional ethics that guide decision making in situations of moral distress. We discuss the critical role of medical educators in shaping the development of professional identities of future practitioners through mindfulness, reflective writing, and role modeling as mentors. As concerns of professional burn out and depression among healthcare professionals are hotly discussed, empowering practitioners to choose a moral and courageous way to respond when faced with ethical dilemmas thereby maintain their sense of self remains essential for flourishing.

An Integrity-Centered Framework for Practical Wisdom in Medicine

Lorand Gaspar was a doctor of many talents (poet, essayist, translator, photographer, etc.), but beyond this simply accumulative vision, my “return” to Gasparian poetics seeks to perceive how these different activities contributed to the implementation of a commitment to perception and practical wisdom, based on the idea of knowledge that is fundamentally open to successive questioning and different forms of otherness. Taking as a starting point his notes on the practices of medicine in Feuilles d’Hôpital (2023), as well as his intermedial discourse in Carnets de Patmos (1998), my aim is to explore the ways of what I call Lorand Gaspar’s “poethics of translation”, which enabled him to anticipate the hermeneutic horizon of solicitude (or “care”) that has in the meantime established itself as a real turning point in the various fields of thought and art alike.

The practice of medicine is a complex endeavor requiring high levels of knowledge and technical capability, and the capacity to apply the skills and knowledge to do the right thing in the right way, for the right reason, in a particular context. The orchestration of the virtues, managing uncertainty, applying knowledge and technical skills to a particular individual in a particular circumstance, and exercising the virtues in challenging circumstances, are the tasks of practical wisdom. Centuries ago, Aristotle suggested that capacities for wise action are developed through practice, experience, and reflection. Neuroscience and cognitive psychology are now beginning to contribute to our understanding of the complex interplay between emotion, cognition, and behavior that is necessary for wise action, and how this capacity for wise action can be developed. In this paper, I propose that wisdom offers an appropriate true north for medical education. Wisdom shifts the focus beyond the simple acquisition of knowledge and technical skills and integrates essential virtues like compassion, trustworthiness, humility, and the balancing of the virtues, into the professional formation for medical students. Informed by the humanities, the neurosciences, and the social sciences, we must now integrate the skills and practices necessary to the development of practical wisdom into medical education at all levels.

In the Nicomachean Ethics, Aristotle places the art of medicine alongside other examples of technē. According to Gadamer, however, medicine is different because in medicine the physician does not, properly speaking, produce anything. In The Enigma of Health, rather than introducing Aristotle’s intellectual virtue of phronēsis (practical wisdom) as a way of understanding medical practice, Gadamer focuses on how medicine is a technē “with a difference”. In this paper, I argue that, despite the richness of his insights, this focus prevents Gadamer from reaching an adequate account of health and the practice of medicine, and I demonstrate how making phronēsis central via a phenomenological description furthers our understanding of the art of healing in important ways. The paper begins with an exploration of Gadamer’s understanding of phronēsis and technē (via Heidegger) to provide a foundation for a phenomenological analysis of the art of healing. After considering the shortcomings of Gadamer’s analyses, I introduce a working definition of “health” that both captures the spirit of Gadamer’s insights and prepares the ground for a phenomenological description. Finally, I introduce concepts from Merleau-Ponty in order to establish an adequate account of the relation between technē and phronēsis and a more nuanced understanding of experience as unfolding within the expressive trajectories forged by bodies that are subject to the weight of the past and the weight of the ideal. The art of medicine, I argue, needs to be understood as expressive behavior in the context of historically and socially situated individuals, institutions, and open trajectories of sense.