Virtue, progress and practice

Abstract

The reasonable man adapts himself to the world; the unreasonable one persists in trying to adapt the world to himself. Therefore, all progress depends on the unreasonable man. (G.B. Shaw) [1] There are questions so resistant to easy resolution that we tend to ignore them for as long as we can, but so fundamental that they keep returning whenever we try to discuss anything that really matters with any degree of seriousness. Such questions are often deemed ‘philosophical’ in nature,1 and questions of this sort in clinical practice include: what is good practice in medicine and health care? What do we mean by progress in these areas? How do we recognize virtue when we see it? How do we support and promote it? How do I become a more virtuous practitioner? One problem with these questions is that we do not know precisely how to go about resolving them. We lack a clear and agreed method for producing answers that all rational parties will accept, and that are sufficiently full and detailed to be of any practical use – meaning, answers that can guide our decisions in specific cases. We can translate this problem into yet another question, but it is similarly philosophical in form: in terms of which methods, and with recourse to which sources of knowledge and evidence, can we aspire, rationally to reach sound conclusions on the nature of progress, virtue and good practice? This further, methodological question cannot credibly be avoided. It would be bizarre indeed if empirical evidence had no bearing on these vital questions, but how precisely we use evidence to answer them, and which evidence we use, is by no means obvious. It is not as though there were some missing piece of information that we could one day just find, that would reveal the answers in much the same manner as Douglas Adams's imagined ‘Deep Thought’ computer revealed that the answer to the question ‘what is the meaning of life, the universe and everything?’ was in fact ‘42’[2]. Certainly, there are texts, articles and published guidelines telling us how to practice more ‘ethically’[3,4], use evidence more effectively [5,6] and frame policies that will guarantee that quality and excellence become the ‘hallmarks’ of our respective organizations [7,8]. Unfortunately, such guidelines, handbooks and ‘how-to’ texts rarely have anything to say that is at once substantive (that goes beyond the platitudinous) and is also supported by a clear and rigorous account of the reasoning linking their premises to their conclusions [4,6,9,10]. Authors purporting to offer ‘practical’ advice too often recognize no requirement to supply convincing, explicit argumentation in support of the conclusions they invite their readers to accept [8,11] and are likely to regard the request for supporting arguments as unreasonable. Like the Deep Thought computer, they supply an answer, but not the working out. Their background assumptions and underlying conceptual framework – the implicit premises and normative structures that shaped their answers, that determined these answers as opposed to other possible ones – are apparently not worth discussing, of no interest to ‘busy practitioners’[5] and those ‘employed in the more mundane processes of what is called real life’[12]. The current climate is, and has for some time been, one of ‘moderate anti-intellectualism’[11]. It is considered reasonable for human beings – at least, those deemed responsible professionals – to apply their intellectual capacities to the learning of sometimes complex techniques, to know and follow conventions for good practice in their areas of work: ‘how-to’ questions are the legitimate preoccupations of the rational, professional mind. But it is deemed ‘intellectual’ in a derisory sense – somehow strange, bolshy or ‘other worldly’[5,12]– for a professional to want to understand the reasons behind the current conventions and to contribute to the debate about their appropriateness and sustainability. The characteristically philosophical attitude, once thought definitive of the professional outlook [11], of asking ‘why?’ questions – why does that follow? why these goals, rules and assumptions as opposed to others? – is met with suspicion in many contemporary organizations [13–16]. Far from being genuinely unreasonable, such an attitude is, as Shaw notes [1], a permanent prerequisite for progress. The point of Adams's Deep Thought story is not simply the absurdity of hoping to answer questions that are in fact philosophical in nature with recourse to a quasi-scientific calculation. There is an inherent absurdity in the idea of simply accepting an answer on a fundamental matter relevant to the conduct of one's own life, while showing no desire to scrutinize or even comprehend the thinking behind it. Such an answer is in an obvious sense ‘meaningless’ to those who purport to ‘just accept’ or ‘work with’ it, in much the same way that ‘42’ is meaningless as an answer to the question ‘what is the meaning of life, the universe and everything?’ To practice ‘on the basis’ of an answer one has no real understanding of is, in just as obvious a way, to act thoughtlessly. Whatever we mean by a rational, responsible practitioner, the person who ‘never thought of thinking for himself at all’[11] would not seem to be it. We need to think carefully and for ourselves about how to formulate the questions, and about the types of argument we might employ to address them. We cannot rule out the possibility (and indeed there are strong arguments in favour of the view) that ‘doing the working out’ with regard to such fundamental matters is part and parcel of being a virtuous practitioner, and that only a community made up of such persons can make real progress [1,8,11]. Fortunately, despite anti-intellectual influences and the (truly unreasonable) pressures upon practitioners' time and energy in the contemporary world [17], there are still many ‘unreasonable’ men and women who want to understand and control their practices, to question the basis for their activities and who are prepared to subject dominant ideas and assumptions to critical scrutiny. The pages of this journal have for many years supplied ample illustration of the fact that penetrating, intellectually serious discussion of pressing questions facing researchers, clinicians and policy makers is not only possible but necessary, if we are to secure improvements and avoid the pitfalls of dogmatism and the spurious triumphalism that has characterized much of the mainstream debate about progress, evidence, policy and practice in medicine and health care [18–24]. In 2010, the journal presented its first ever philosophy thematic edition, including papers by some of the most original and incisive thinkers the discipline has to offer on a vast range of subjects of urgent practical import [11]. This, the second thematic edition of the Journal of Evaluation in Clinical Practice to focus specifically on the application of philosophical methods and argumentation to medicine and health care, provides an even greater range of papers [25–60] on the themes of progress in medicine, virtue in practice, and evidence and methodology in research and evaluation. Articles bring fresh and challenging analyses of the relationship between progress in the science and the practice of medicine, the role and limitations of statistical reasoning in medical research, patient involvement, autonomy and rationality, the relationship between reason and emotional engagement in the life of the good practitioner, the role and value of uncertainty in health care and how to promote virtue in practice. Authors raise urgent methodological and epistemological questions about cultural bias in the generation of evidence and its implications for technological and scientific advances in medicine; medical knowledge and reductionism; epistemic biases in the researching of patient involvement in health care practices; the relationship between experience, narrative and evidence in the formation of arguments with practical conclusions; person-centred and patient-centred approaches to medicine and the increasingly important role of medical humanities in developing new conceptions of practice and new directions in medical research. The edition incorporates a section on empirical research and philosophy, which includes articles and commentaries on the nature and status of tacit knowledge, virtuous actions and practice, evidence-based decision making and the relationship between context and good practice. In addition, there is a section on values-based practice (VBP); a debates section incorporating responses to articles in the previous philosophy thematic (on questions as divergent as the relationship between evidence-based medicine [EBM] and the philosophy of science, the epistemic claims of homeopathic practitioners and the ethics of conscience clauses for practitioners in the issue of referrals for abortion); detailed, critical reviews of two extremely significant new publications on statistical research and EBM, and a conference report. A key goal of the philosophy thematic edition is to promote interdisciplinary discussion, between philosophy and allied humanities disciplines on the one hand and medical practitioners and researchers on the other. The report on the workshops in the philosophy of medicine and health care at King's College, London, is a fine illustration of the mutually beneficial nature of such interdisciplinary dialogue [60]. Part of our goal is to show not only that philosophy (along with allied humanities disciplines) has an indispensible contribution to make to the discussion of practice, but that the problems of practice provide the proper context for real progress in philosophy. The idea that ‘proper’ philosophy is somehow detached from the ‘mundane’ concerns of ordinary life is an aberration, and the philosophers of today need to relearn the skills of Socrates in engaging, attentively, with the claims and the thinking of the broader populace, in particular those engaged in practices vital to our collective well-being. Applied philosophy is not an ‘offshoot’ of the subject but a return to its roots, in the rigorous questioning and systematic analysis of human thought about the concerns we face in the processes of real life. The attempt to address these concerns helps us to think more carefully about what philosophy is, to challenge and refine our ideas about proper methodology in the subject [8]. The edition opens with a series of original papers on the nature of progress in medicine. We can perhaps agree easily enough that progress in medicine is significantly associated with progress in the biological sciences and in clinical research, but determining the nature of the relationship and its implications for practice is less straightforward. While we may have a good intuitive sense of what we mean by ‘progress in science’, agreeing a formal account that can settle real controversies has proved a more challenging prospect [16,61–66] and even if we had a shared account of progress in science, this may not translate easily into a shared conception of progress in medical practice [59,67–69]. Jeremy Simon achieves an impressive balance of accessibility and intellectual weight in a fascinating paper, introducing readers to underlying theoretical arguments about the metaphysics of medicine, and of diseases in particular [25]. Simon presents a new account of the nature of diseases, by appealing to the most persuasive features of rival realist and constructivist positions in the philosophy of science, and an insight into what progress in medicine looks like if we understand diseases in this way. Another insightful contribution, that of Leen De Vreese [26], takes as its starting point the important distinction between what scientific progress means for a particular domain, such as medicine, and the question of scientific progress in general. The paper rigorously outlines the methodological differences this distinction implies, based on the goals of the distinct areas being subjected to analysis, and applies these arguments to the proper goals of research in the medical sciences and to EBM in particular – showing how critically thinking about EBM from the point of view of progress can help us to put its favoured methodologies in the right perspective [26]. Approaching the issue of progress in medicine from a radically different angle, Ignaas Devisch looks at the debate about autonomy in medicine, and a traditional way of construing that debate that equates autonomy with progress and its opposite, ‘heteronomy’– the determination of behaviour by ‘outside’ influences – with (an implicitly regressive) medical paternalism [27]. With detailed reference to the debate about why autonomous people make unhealthy choices, Devisch demonstrates that debates about progress that appeal to such oppositions are based on unrealistic conceptions of choice and the human condition, proposing instead the concepts of ‘oughtonomy’ and ‘nudging’ as the basis for solutions to the problems inherent in influencing individual health choices without being offensively paternalistic [27]. James Penston's work [28,70] presents a significant and comprehensive challenge to contemporary orthodoxy regarding rationality and progress. It addresses reasoning and progress in medicine specifically, but has implications for the way we discuss policy and practice that extend far beyond this area. His contribution to this edition [28] outlines his attack on statistical methods in medical research, in particular the use of epidemiological studies and large-scale randomized controlled trials (RCTs). Presenting arguments which he recognizes will be regarded by many as heretical, he questions the benefits of these methods and attacks the products of what some regard as ‘the very paradigm of modern medical research’ as a ‘pig in a poke’. (These rigorous and important arguments, and their implications for the future direction of medical research, are taken up again in the reviews section of this edition [58] by an author whose own rather different views on statistical research [71] are similarly subjected to incisive critical attention [59].) The section concludes with a provocative and challenging discussion of EBM and ‘epistemological imperialism’[29]. Helen Crowther et al. provide the powerful illustration of haematology to raise serious concerns about the claims of EBM to provide a method for determining the safety and efficacy of medical therapies and public health interventions. Drawing on research which suggests that EBM may be riven through with cultural bias, both in the generation of evidence and in its translation, the authors argue that technological and scientific advances in medicine accentuate and entrench these cultural biases, to the extent that they may invalidate the evidence we have about disease and its treatment. They note that this creates a significant ethical, epistemological and ontological challenge for medicine and our thinking about medical progress. Populist contributions to the debate about rationality and professional practice accept implicitly certain contemporary dichotomies, most obviously between ‘reason’ and ‘emotion’, and as a consequence are likely to dismiss traditional conceptions of ‘virtue’ as outdated and irrelevant to ‘our’ modern (or indeed post-modern [47]) world. Our intellectual forefathers were by no means ignorant of the distinction between reason and emotion, but had the wisdom to regard reasoning as an activity of the whole person, a human organism with dispositions and attachments, engaged in the project of making sense of the world and capable of functioning more or less well with respect to others [8,67,72]. They may, perhaps, have been better placed than some contemporary commentators to appreciate the significance of the fact that practitioners are persons, and that ‘the clinical encounter is an encounter between persons’[73]. Discussion of the virtues – the dispositions and responses relevant to functioning well as a whole person in a given social context – provides not only a realistic approach to discussing good practice. A consideration of virtue also restores the idea of judgement to a central place in this discussion, its having been displaced to the sidelines and relegated to something akin to ‘opinion’– a form of ‘low-grade evidence’ in some contemporary quarters [74]. Stephen Buetow notes that in the current intellectual climate, uncertainty is more likely to be cast as a problem for evidence-based care to minimize than as a virtue. But viewed from the perspective that practice is a human activity, certainty is frequently unrealistic and unwise while uncertainty, he argues, is often natural and wise, promoting hope, creativity and a critical attitude, nurturing safety and protecting against excess [30]. Bolstering his argument with reference to Karl Popper's work on fallibilism in the philosophy of science [75], he argues refreshingly for a discussion of uncertainty that is open and positive, treating it and the fact that practitioners are persons as something to highlight, not as some regrettable if ineliminable flaw. A stimulating and important paper by James Marcum examines the role of ‘the compound virtue, of prudent love’ in the practice of clinical medicine [31]. Explaining the conceptual links between the ideas of the wise person, the wise action and the virtuous practitioner, Marcum argues convincingly for the need to incorporate the ethical and intellectual virtues into the medical curriculum, defending the ‘virtues’ approach against other possible positions in moral epistemology and outlining methods of teaching virtue– to create environments that cultivate professional virtue in our schools and practice settings. The ideas of both Marcum and Buetow are nicely complemented by the highly inventive approach of Petra Gelhaus, whose paper on ‘Robot Decisions’ utilizes the science fiction of Isaac Asimov to highlight the role of human emotions in rational decision making, contrasting even the best-designed ‘infallibly rule-oriented’ robot doctor to the sort of human agency required for virtuous practice in a complex and often inherently uncertain world. Her work brings out the indispensible nature of the emotional virtues in any credible account of rational human agency and thus in any defensible notion of good practice [32]. In a tightly argued and much needed paper on the application of virtue ethics to public health policy, Karen Meagher cautions against the tendency in contemporary bioethics research to develop distinct branches of ‘ethics’, as though curative medicine and public health were incompatible ‘domains’ governed by different ethical paradigms [33]. She shows that the ‘agent-centred’ approach of virtue ethics offers a different point of entry to the problems faced by public health professionals than more standard, ‘action-centred’ approaches, and offers insightful criticisms of the tendency to assess the ethics of policy formation as though in a vacuum from any thoughts about the moral character of those framing and acting upon the policies. In the final paper in this section, Stephen Buetow and Vikki Entwistle point out that the ‘pay for performance’ schemes that are used in many health systems with the intention of improving and rewarding good-quality care downplay and potentially undermine the value of virtue in clinicians [34]. Buetow and Entwistle acknowledge the difficulties of assessing and rewarding good character, but offer some concrete proposals for keeping virtuous practice on the agenda in the context of attempts to develop policies and organizational systems that reward good clinical practice. They speculate that paying for virtue in the short term could ultimately strengthen the intrinsic motivation of clinicians for good practice. As noted in our opening comments, the question of how, precisely, to approach the debate about the fundamental questions of progress, virtue and good practice is itself philosophically contentious. How should we go about applying philosophical analyses of knowledge, reason and good practice to these substantive controversies? What is the right underlying conceptual framework for guiding practice and evaluating policy? How do we frame the questions so that we can go about finding the right answers? Derek Mitchell [35] employs ideas from four diverse thinkers: Martin Heidegger, W.G. Sebald, Gaston Bachelard and Hans-Georg Gadamer, to argue for the importance of a broadly anti-reductionist perspective to understanding knowledge in clinical practice. In this essay, he selects suggestive metaphors for knowing that he argues more adequately ground the encounter between patient and practitioner. He suggests that these authors can help to illuminate the tacit dimensions of knowing relevant to clinical practice. In the accompanying commentary [36], Ross Upshur endorses the need for such perspectives from the humanities, and calls on humanities scholars to provide means to include such ideas in clinical teaching. Sara Donetto and Alan Cribb conduct an extensive review of the literature on ‘patient involvement’[37], noting that the framework or methodological ‘lens’ dominant in much ‘involvement research’– shaping how research questions are framed, how research is conducted and its findings interpreted – contains an epistemic bias. They argue that this biomedical framework tends to normalize and arguably trivialize intrinsically problematic and contentious concepts such as ‘patient preferences’ and, at the same time, to obscure the full range of possibilities for reciprocity in the exchanges between the medical world of the professional and the experiential and narrative world of the patient. Richer conceptualizations of collaboration in clinical work are both possible and very much needed, and the authors call for more attention to the idea of ‘epistemic involvement’ and much greater cross-fertilization between different epistemological paradigms in this area of research. In a paper that complements these concerns, Leah McClimans et al. note the lack of a coherent theoretical framework for discussions of ‘patient-centred care’, and the subsequent compatibility of the rhetoric of patient-centred care with distinct, mutually incompatible agendas and construals of proper policy and practice in health care. Examining two accounts of ‘patient-centredness’ in the context of both US and UK health policy, they argue that neither takes seriously the inherently moral nature of such terms as ‘respect’ and ‘dignity’, and they argue for the need for a more rigorous application of clinical ethics in the theoretical justification of patient-centred care [38]. Recent trends in medicine have emphasized the importance of RCTs, in part because they allow information to be gathered from a much broader range of patients than individual physicians can see in the course of their practice. By contrast, anecdotes, including the stories of individual patients, are held to provide a much lower form of evidence. Robin Nunn [39] sets this received wisdom on its head, pointing out that RCTs, too, are stories and that, in fact all types of evidence are ultimately narratives. He provides a thoughtful examination of what stories are, and what purposes they can serve in clinical research and practice, arguing for the importance of ‘mere anecdote’. The section concludes with the timely and important contribution of Jane Macnaughton, writing on the challenge medical humanities presents to medicine [40]. In line with other contributions in this section [37,38], Macnaughton notes the constraints that dominant medical conceptual frameworks, heavily influenced by the historical dominance of logical positivism, have placed upon the discussion of medical practice. Utilizing approaches based on phenomenology and pragmatism, and illustrated with compelling narrative accounts of the reality of illness, the author argues persuasively for a much broader epistemological perspective in our understanding of medicine, one that can help practitioners and patients by appealing to the rich and diverse sources of knowledge that form our intellectual heritage. What is the role of empirical data in philosophical debate? On the one hand, philosophical work that is oblivious to evidence and the facts is unlikely to make a serious contribution to any substantial enquiry [8,9,48]. On the other hand, there are compelling logical considerations which suggest that philosophical questions cannot be settled by appeal to the evidence – at least, if we mean by ‘evidence’ the discoveries of empirical research. The most famous arguments on this point are in the field of ethics [76], but similar problems apply to deducing epistemological conclusions from factual data [8]. Arguably, the sciences seek to give us adequate descriptions of the world2– and the term ‘sciences’ here includes social sciences and psychology, which seek to give us descriptions of the social world and the human psyche. Philosophical enquiry is, in contrast, typically normative in nature [48], addressing in a very immediate way questions phrased most appropriately in the first person: what should I/we think about issue X? The question of what people in a given time or place do, as a matter of fact, think is part of the subject matter of psychology, but no amount of knowledge about this question can tell us what we should think about the matter. Even Shaw's ‘reasonable man’ needs to adopt some normative framework – the belief that ‘I should believe whatever most people in my time and place believe’ is not an empirical but a normative belief. So while it is widely accepted that empirical research should inform the philosophical process, how precisely its discoveries should ‘inform’ philosophy remains a contentious issue, as illustrated by the exchanges in this section. The section contains original papers that adopt an empirical approach to philosophical questions, plus commissioned commentaries addressing methodological questions raised by this approach. Stephen Henry et al. examine the relationship between tacit clues and clinical judgement, presenting a qualitative analysis of video elicitation interview transcripts to explore ‘whether physicians and patients identify information likely to be tacit clues or judgments based on tacit clues during health maintenance exams’[41]. The article develops ideas and arguments presented in the previous thematic philosophy issue, where Henry applied Polanyi's theory of tacit knowing to the clinical context [73]. Two commentaries explore the philosophical implications and presuppositions of the exercise, about the nature of tacit knowledge and clinical judgement. Hillel Braude welcomes what he regards as a timely and relatively novel contribution to a challenging task, that of providing a concrete evaluation of tacit knowing in the doctor–patient encounter. This task involves translating ‘the unspecifiable in clinical practice’ into rational terms, thus distinguishing tacit clues from ‘what may otherwise be deemed magical or mystical’[42]. Phil Hutchinson and Rupert Read take a more sceptical view [43]. Referring to a commentary in the previous philosophy thematic [72] on Henry's paper in the same issue [73], they note that this commentary, while broadly sympathetic, did have some misgivings which they feel have been ignored by the authors of the study [41]. On the one hand, there is an important, epistemologically and scientifically credible usage of the concept of ‘tacit knowledge’ which takes seriously the implications of ‘human embodiment’ for knowledge in practice, while on the other there is a usage which ‘trades in a sort of mysticism’[43]. In contrast to Braude, these critics do not feel that Henry et al. have entirely expunged all trace of the more ‘mystical’ version of the term. Furthermore, they argue that the move from ‘tacit knowledge’ to ‘tacit clues’ is far more problematic than Henry and colleagues acknowledge [43]. They conclude by noting that the conceptual framework employed by the study colours the presentation of its findings, such that the philosophical issues are not addressed by work of this sort [43]. Both commentaries use the study as a starting point for some very sophisticated argumentation on the philosophical matter, so while Henry and his colleagues may not have settled the underlying questions,3 their empirical work has generated much in terms of philosophical controversy and analysis – perhaps confirming our earlier comments that attention to practice can provide a fertile ground for serious philosophical inquiry. Miles Little and colleagues conducted a study involving 19 medical practitioners associated with the Sydney Medical School, using semi-structured narrative interviews [44]. The goals of the study were ‘to examine the nature, scope and significance of virtues in the biographies of medical practitioners’ and ‘to determine what kind of virtues are at play in their ethical behaviour and reflection’. Narrative data were analysed using dialectical empiricism, constant comparison and iterative reformulation of research questions. They conclude that a particular version of virtue ethics emerged as the most ‘natural’ ethical approach for practitioners in the study. Gideon Calder's commentary [45] looks at why work of this sort, which combines a case study with direct consideration of normative ethics (so ‘bridging the gap’ between empirical and theoretical work) is still quite rare. He notes both the need for social science to take normativity properly into account, if it is to furnish us with an adequate understanding of everyday interactions, and for normative ethics to base its reasoning less on artificial thought experiments, and more on how people actually do make decisions when p