BackgroundMedical ethics has recently seen a drive away from multiple prescriptive approaches, where physicians are inundated with guidelines and principles, towards alternative, less deontological perspectives. This represents a clear call for theory building that does not produce more guidelines. Phronesis (practical wisdom) offers an alternative approach for ethical decision-making based on an application of accumulated wisdom gained through previous practice dilemmas and decisions experienced by practitioners. Phronesis, as an ‘executive virtue’, offers a way to navigate the practice virtues for any (...) given case to reach a final decision on the way forward. However, very limited empirical data exist to support the theory of phronesis-based medical decision-making, and what does exist tends to focus on individual practitioners rather than practice-based communities of physicians.MethodsThe primary research question was: What does it mean to medical practitioners to make ethically wise decisions for patients and their communities? A three-year ethnographic study explored the practical wisdom of doctors (n = 131) and used their narratives to develop theoretical understanding of the concepts of ethical decision-making. Data collection included narrative interviews and observations with hospital doctors and General Practitioners at all stages in career progression. The analysis draws on neo-Aristotelian, MacIntyrean concepts of practice- based virtue ethics and was supported by an arts-based film production process.ResultsWe found that individually doctors conveyed many different practice virtues and those were consolidated into fifteen virtue continua that convey the participants’ ‘collective practical wisdom’, including the phronesis virtue. This study advances the existing theory and practice on phronesis as a decision-making approach due to the availability of these continua.ConclusionGiven the arguments that doctors feel professionally and personally vulnerable in the context of ethical decision-making, the continua in the form of a video series and app based moral debating resource can support before, during and after decision-making reflection. The potential implications are that these theoretical findings can be used by educators and practitioners as a non-prescriptive alternative to improve ethical decision-making, thereby addressing the call in the literature, and benefit patients and their communities, as well. (shrink)

Physicians participate in several kinds of activities in their professional lives. Clinical care is the core function of the physician. Medical education is overwhelmingly oriented toward this func...

Paramedics encounter ethical dilemmas at work, and while previous research has improved ethics education and practice, more can be learned from the lived experience of paramedics facing ethical challenges. This paper explores the lived experience of two paramedics, one with five years’ experience, the other twenty, presented with comparable cases. The participants, who were interviewed in a broader qualitative study exploring practical wisdom, were asked to select a case involving ethical decision-making from their own practice experience. Semi-structured interviews employed the (...) five-step Critical Decision Method as a framework to explore various aspects of the decision-making process. The two cases were identified as exemplars of prominent themes suitable for discussion. The findings highlighted several factors that influence paramedic ethical decision-making, including practical wisdom, communication and teamwork, clinical support, and education. This case comparison identifies a greater need to focus education on the fostering of practical wisdom, and the development of non-technical skills such as communication and teamwork, supported by interprofessional education endeavours. Furthermore, greater access to support for paramedics must be available to further evolve practical wisdom. The combination of improved education and support will likely cater for the full spectrum of ethical challenges faced by paramedics in their work. (shrink)

BackgroundAs the COVID-19 pandemic develops, healthcare professionals are looking for support with, and guidance to inform, the difficult decisions they face. In the absence of an authoritative national steer in England, professional bodies and local organisations have been developing and disseminating their own ethical guidance. Questions inevitably arise, some of which are particularly pressing during the pandemic, as events are unfolding quickly and the field is becoming crowded. My central question here is: which professional ethical guidance should the professional follow?Main (...) bodyAdopting a working definition of “professional ethical guidance”, I offer three domains for a healthcare professional to consider, and some associated questions to ask, when determining whether – in relation to any guidance document – they should “bin it or pin it”. First, the professional should consider the source of the guidance: is the issuing body authoritative or, if not, at least sufficiently influential that its guidance should be followed? Second, the professional should consider the applicability of the guidance, ascertaining whether the guidance is available and, if so, whether it is pertinent. Pertinence has various dimensions, including whether the guidance applies to this professional, this patient and/or this setting, whether it is up-to-date, and whether the guidance addresses the situation the professional is facing. Third, the professional should consider the methodology and methods by which the guidance was produced. Although the substantive quality of the guidance is important, so too are the methods by which it was produced. Here, the professional should ask whether the guidance is sufficiently inclusive – in terms of who has prepared it and who contributed to its development – and whether it was rigorously developed, and thus utilised appropriate processes, principles and evidence.ConclusionAsking and answering such questions may be challenging, particularly during a pandemic. Furthermore, guidance will not do all the work: professionals will still need to exercise their judgment in deciding what is best in the individual case, whether or not this concerns COVID-19. But such judgments can and should be informed by guidance, and hopefully these preliminary observations will provide some useful pointers for time-pressed professionals. (shrink)

The article by Doernberg and Truog (2023) suggests that five different medical spheres have five distinctive sets of moral norms based on the ends of those spheres, implying that different roles in...

Virtue ethics has long provided fruitful resources for the study of issues in medical ethics. In particular, study of the moral virtues of the good doctor—like kindness, fairness and good judgement—have provided insights into the nature of medical professionalism and the ethical demands on the medical practitioner as a moral person. Today, a substantial literature exists exploring the virtues in medical practice and many commentators advocate an emphasis on the inculcation of the virtues of good medical practice in medical education (...) and throughout the medical career. However, until very recently, no empirical studies have attempted to investigate which virtues, in particular, medical doctors and medical students tend to have or not to have, nor how these virtues influence how they think about or practise medicine. The question of what virtuous medical practice is, is vast and, as we have written elsewhere, the question of how to study doctors’ moral character is fraught with difficulty. In this paper, we report the results of a first-of-a-kind study that attempted to explore these issues at three medical schools in the United Kingdom. We identify which character traits are important in the good doctor in the opinion of medical students and doctors and identify which virtues they say of themselves they possess and do not possess. Moreover, we identify how thinking about the virtues contributes to doctors’ and medical students’ thinking about common moral dilemmas in medicine. In ending, we remark on the implications for medical education. (shrink)

Higher education is seeing renewed calls for strengthening ethics education, yet there remains a dearth of research on the state of ethics education across undergraduate curricula. Research about ethics in higher education tends to be localized and often isolated to fields of graduate study. In contribution to a contemporary, landscape understanding of ethics education, we collected data on the placement and prevalence of ethics instruction within the general education curricula at 507 major U.S. colleges and universities. Our findings suggest that (...) 1) most schools in our study’s population do not explicitly require ethics as a part of their general education curricula; and 2) a school’s religiosity and research status are positively associated with explicitly requiring ethics instruction for its undergraduate student body. (shrink)

There is a claim that clinical ethics support services (CESS) improve healthcare quality within healthcare organisations. However, there is lack of strong evidence supporting this claim. Rather, the current focus is on the quality of CESS themselves or on individual learning outcomes. In response, this article proposes a theoretical framework leading to empirical hypotheses that describe the relationship between a specific type of CESS, moral case deliberation and the quality of care at the organisational level. We combine insights from the (...) literature on CESS, organisational learning and quality improvement and argue that moral case deliberation causes healthcare professionals to acquire practical wisdom. At the organisational level, where improving quality is a continuous and collective endeavour, this practical wisdom can be aggregated into morisprudence, which is an ongoing formulation of moral judgements across cases encountered within the organisation. Focusing on the development of morisprudence enables refined scrutinisation of CESS-related quality claims. (shrink)

Virtue-approaches to medical ethics are becoming ever more influential. Virtue theorists advocate redefining right or good action in medicine in terms of the character of the doctor performing the action. In medical education, too, calls are growing to reconceive medical education as a form of character formation. Empirical studies of doctors’ ethics from a virtue-perspective, however, are few and far between. In this respect, theoretical and empirical study of medical ethics are out of alignment. In this paper, we survey the (...) empirical study of medical ethics and find that most studies of doctors’ ethics are rules- or principles-based and not virtue-based. We outline the challenges that exist for studying medical ethics empirically from a virtue-based perspective and canvas the runners and riders in the effort to find virtue-based assessments of medical ethics. (shrink)

Phronesis has become a buzzword in contemporary medical ethics. Yet, the use of this single term conceals a number of significant conceptual controversies based on divergent philosophical assumptions. This paper explores three of them: on phronesis as universalist or relativist, generalist or particularist, and natural/painless or painful/ambivalent. It also reveals tensions between Alasdair MacIntyre’s take on phronesis, typically drawn upon in professional ethics discourses, and Aristotle’s original concept. The paper offers these four binaries as a possible analytical framework for classifying (...) and evaluating accounts of phronesis in the medical ethics literature. It argues that to make sense of phronesis as a putative ideal in professional medical ethics—for example, with the further aim of crafting interventions to cultivate phronesis in medical ethics education—the preliminary question of which conception of phronesis is most serviceable for the aim in question needs to be answered. The paper identifies considerable lack of clarity in the current discursive field on phronesis and suggests how that shortcoming can be ameliorated. (shrink)

Ethical decision making in medicine has recently seen calls to move towards less prescriptive- based approaches that consider the particularities of each case. The main alternative call from the literature is for better understanding of phronesis concepts applied to decision making. A well-cited phronesis-based approach is Kaldjian’s five-stage theoretical framework: goals, concrete circumstances, virtues, deliberation and motivation to act. We build on Kaldjian’s theory after using his framework to analyse data collected from a three-year empirical study of phronesis and the (...) medical community. The data are a set of narratives collected in response to asking a medical community what making ethically wise decisions means to them. We found that Kaldjian’s five concepts are present in the accounts to some extent but that one of the elements, motivation, is constructed as playing a different, though still crucial role. Rather than being an end-stage of the process as Kaldjian’s framework suggests, motivation was constructed as initiating the process and maintaining the momentum of taking a phronesis-based approach. The implications for medical ethics decision-making education are significant as motivation itself is a highly complex concept. We therefore theorise that motivation is required for leading in, continuing and completing the actions of the ethical decision taken. Appreciating the central importance of motivation through the whole of Kaldjian’s framework has implications for cultivating the virtues of phronesis and courage to take the right course of action. (shrink)

In recent times, daily, ordinary medical practices have incontrovertibly been developing under the condition of complexity. Complexity jeopardizes the moral core of practicing medicine: helping people, with their illnesses and suffering, in a medically competent way. Practical wisdom (a modification of the Aristotelian phronèsis) has been proposed as part of the solution to navigate complexity, aiming at the provision of morally good care. Practical wisdom should help practitioners to maneuver in complexity, where the presupposed linear ways of operating prove to (...) be insufficient. However, this solution is unsatisfactory, because the proposed versions of practical wisdom are too individualistic of nature, while physicians are continuously operating in varying teams, and dealing with complicated technologies and pressing structures. A second point of critique is, that these versions are theory based, and thus insufficiently attuned to the actual context of everyday medical practices. Now, our proposal is to use an approach of practical wisdom that enables medical practices to counter the complexity issue and to re-invent the moral core of medical practicing as well. This implies a practice oriented approach, as thematized by practice theory, qualitative empirical research from the inside, and abduction from actual performed practical wisdom towards an apt understanding of phronèsis. (shrink)

Backround Education in ethics and professionalism should reflect the realities medical students encounter in the hospital and clinic. Method We performed content analyses on Case Observation and Assessments (COAs) written by third-year medical students about ethical and professional issues encountered during their internal medicine and paediatrics clinical clerkships. Results A cohort of 141 third-year medical students wrote 272 COAs. Content analyses identified 35 subcategories of ethical and professional issues within 7 major domains: decisions regarding treatment (31.4%), communication (21.4%), professional duties (...) (18.4%), justice (9.8%), student-specific issues (5.4%), quality of care (3.8%), and miscellaneous (9.8%). Conclusions Students encountered a wide variety of ethical and professional issues that can be used to guide pre-clinical and clinical education. Comparison of our findings with results from similar studies suggests that the wording of an assignment (specifying “ethical” issues, “professional” issues, or both) may influence the kinds of issues students identify in their experience-based clinical narratives. (shrink)

Phronesis is often described as a ‘practical wisdom’ adapted to the matters of everyday human life. Phronesis enables one to judge what is at stake in a situation and what means are required to bring about a good outcome. In medicine, phronesis tends to be called upon to deal with ethical issues and to offer a critique of clinical practice as a straightforward instrumental application of scientific knowledge. There is, however, a paucity of empirical studies of phronesis, including in medicine. (...) Using a hermeneutic and phenomenological approach, this inquiry explores how phronesis is manifest in the stories of clinical practice of eleven exemplary physicians. The findings highlight five overarching themes: ethos (or character) of the physician, clinical habitus revealed in physician know-how, encountering the patient with attentiveness, modes of reasoning amidst complexity, and embodied perceptions (such as intuitions or gut feeling). The findings open a discussion about the contingent nature of clinical situations, a hermeneutic mode of clinical thinking, tacit dimensions of being and doing in clinical practice, the centrality of caring relations with patients, and the elusive quality of some aspects of practice. This study deepens understandings of the nature of phronesis within clinical settings and proposes ‘Clinical phronesis’ as a descriptor for its appearance and role in the daily practice of (exemplary) physicians. (shrink)

Background This study introduces an empirical approach for studying the role of prudence in physician treatment of end-of-life (EOL) decision making.Methods A mixed-methods analysis of transcripts from 88 simulated patient encounters in a multicenter study on EOL decision making. Physicians in internal medicine, emergency medicine, and critical care medicine were asked to evaluate a decompensating, end-stage cancer patient. Transcripts of the encounters were coded for actor, action, and content to capture the concept of Aristotelian prudence, and then quantitatively and qualitatively (...) analyzed to identify actions associated with preference-concordant treatment.Results Focusing on codes that describe characteristics of physician-patient interaction, the code for physicians restating patient preferences was associated with avoiding intubation. Multiple codes were associated with secondary measures of preference-concordant treatment.Conclusions Prudent actions can be identified empirically, and research focused on the virtue of prudence may provide a new avenue for assessment and training in EOL care. (shrink)