Practical wisdom: Aristotle, Aquinas and contemporary medical ethics

According to Aristotle, the virtue of practical wisdom (phronesis) is the ability to identify and use the right means to accomplish good ends, with ‘good’ being defined within an ethics of virtue.2 It is fundamentally about aligning right means with good ends through an accurate perception of what is required in the practical realities of a particular situation.3 As a virtue, practical wisdom is a character trait that is developed through practice.4 Once acquired, it functions as a disposition that motivates and enables a person to make good choices by responding realistically to a problem through clear perception and deliberation concerning a given set of circumstances. Within an ethics of virtue, practical wisdom is directed towards the ultimate end (telos) of human flourishing (that which makes people thrive as human beings). This ultimate telos provides the criterion or compass by which one navigates through a given set of circumstances. The telos in medicine would be the more proximate goal of health.

Aquinas' virtue of prudence (prudentia) is in large part similar to Aristotle's phronesis. Prudence enables the virtuous person to make right choices by identifying the right means to achieve good ends through deliberation and planning5 and facilitating the application of general moral principles to specific circumstances.6 Aquinas believed that human flourishing requires living within the world as it actually exists, and prudence is preeminent among the virtues simply because an accurate engagement with reality is a necessary step in figuring out what, in a given situation, is good for human beings.7

Given the historical significance of Aristotle's and Aquinas' ideas, it is not surprising that some contemporary bioethicists reflect their thinking. Pellegrino and Thomasma8 draw directly from them for a description of practical wisdom as ‘medicine's indispensible virtue’ that disposes the physician to ‘attain the truth for the sake of action’ and coordinates the expression of all other virtues in medicine to achieve right and good healing actions for patients. Beauchamp and Childress9 advocate the virtue of discernment and recognise its close association with phronesis. They describe the practically wise person as one who knows which ends are valuable, how those ends can best be realised in a particular context, and which virtues and principles of duty are most relevant in a given situation.

Core elements of practical wisdom

Practical wisdom is a crucial virtue because it allows one to perceive clearly and respond well by engaging concrete circumstances through actions that are aligned with goals worth pursuing. Practical wisdom also depends on other moral virtues and general moral principles to ground the process of deliberation within a larger moral framework. Based on the traditions established by Aristotle and Aquinas, I would suggest that practical wisdom includes the following core elements:

1. Pursuit of worthwhile ends (goals) derived from a concept of human flourishing;

2. Accurate perception of concrete circumstances detailing the specific practical situation at hand;

3. Commitment to moral principles and virtues that provide a general normative framework;

4. Deliberation that integrates ends (goals), concrete circumstances, and moral principles and virtues;

5. Motivation to act in order to achieve the conclusions reached by such deliberation.

These elements pose probing questions in a society and profession marked by moral pluralism. The most significant of these pertain to the idea of human flourishing, given metaphysical controversies about the status of human nature and its fulfilment amidst diverse philosophical and theological beliefs and belief systems.10 A second area of concern pertains to the pedagogical challenges of teaching virtues, especially those that bear on morality.11 Regarding the first of these concerns, the medical profession is at a certain advantage for being able to circumnavigate philosophical questions about ultimate human ends in its pursuit of more proximate health-related goals, about which there is broad (though not complete) consensus. The substantial degree of consensus surrounding clinical goals in medicine reflects this advantageous position, and the capacity of goals to facilitate reasoning in clinical practice shows how important these proximate health-related ends are for wise clinical decision making.

Goal-directed decision making in medicine

Goals are relevant to all of clinical medicine, and their relevance is especially clear in areas such as end-of-life care.12 To be meaningful, medical interventions need to be assessed in light of their mediating relationship between a patient's medical status and his or her health-related goals. Goals serve as guiding objectives and are conditioned by a patient's diagnosis, prognosis and treatment wishes. Once defined, goals allow clinicians, patients and families to discuss whether a given intervention makes sense—that is, whether an intervention is likely to accomplish specific objectives. Goals thereby provide an individually defined telos that gives meaning and orientation to a contemplated intervention. Without goals, deciding for or against a possible intervention may feel (and possibly be) directionless—like travelling without a destination—and decisions may be dictated more by immediate circumstances and short-term results than by the prognostic implications of underlying realities. The practical need for goal-directed action in clinical medicine may become particularly apparent when ethical questions or disagreements arise.13

Goals of medicine for policy and goals of care for practice

The Hastings Center convened a group of international scholars to identify a set of justifiable ‘goals of medicine’ that should guide health policy.14 They were motivated in part by concerns about influences that threaten to blur a proper understanding of what medicine's goals should be. After 4 years of deliberation, the participants of the Hastings Center project affirmed a list of four goals of medicine that ought to guide health policy:

1. Prevention of disease and injury, and promotion and maintenance of health;

2. Relief of pain and suffering caused by maladies;

3. Care and cure of those with a malady, and care of those who cannot be cured;

4. Avoidance of premature death, and pursuit of a peaceful death.

It is not my intention to attempt a defence of this list. But I believe these goals are compelling for their concise articulation of the basic ends that have shaped, and by and large continue to guide, Western medicine. This is not to deny the existence of reasoned controversies concerning the best number or specification of such goals, or to neglect the import of philosophical discussions about the meaning of health and disease themselves,15 but it is to suggest that grounds for the validity of these four goals should be available.

In addition to goals that articulate overarching ends for health policy, ‘goals of care’ are cited in the medical literature as a means of guiding communication between clinicians, patients and patients' families about clinical decisions. A structured review of goals of care towards the end of life analysed the content of 116 articles and identified a comprehensive list of six practical goals:16

1. Be cured;

2. Live longer;

3. Improve or maintain function/quality of life/independence;

4. Be comfortable;

5. Achieve life goals;

6. Provide support for family/care giver.

Ranging from cure to comfort, these goals represent a wide scope of possible objectives that can serve as a starting point in discussions to help patients articulate their wishes and guide shared decision making with clinicians. Although drawn from the end-of-life care literature, the generality of these goals makes them applicable to all of medical practice. For some patients, one or more of these goals will capture their desired purposes; in other cases, discussion that begins with these six goals may lead to the identification of other possible objectives.

Challenges associated with goals

Although highly valuable, goals of care are not without challenges and limitations. The more general the goal, the more interpretation it requires, and when more than one goal pertains—which is commonly the case—possible conflicts between goals will require resolution or prioritising. The less certain the prognosis, the greater the challenge of deciding on goals (one of which may be the need to ascertain the prognosis). Goals also shift over time as biological realities, and patient preferences evolve over the course of a disease. One of the greatest skills physicians need is the ability to facilitate modulation from one set of goals to another—such as from the ‘full court press’ of interventional therapy to the ‘comfort measures only’ of palliative care. Such skill requires careful monitoring, anticipation of disease trajectories, and honest and compassionate dialogue.

Disagreements about goals may arise between patients, family members and clinicians. For example, a family may prefer that a patient's life be prolonged by intensive life-supporting means, whereas the physician or nurse believes that continued life support will not advance reasonable goals and will only prolong suffering. Such disagreements remind us that the selection of goals is not only based on biomedical realities and available technology, but also on beliefs about matters as fundamental as the value of prolonging life, the acceptability of suffering, the significance of a given outcome probability, and the financial implications of treatment. As a result, goals may need to be explained or negotiated in the hope that a shared understanding between involved parties will emerge. But even in cases of refractory disagreement, articulation of goals encourages dialogue that may clarify sources of disagreement and lead to creative and mutually satisfactory resolutions amidst lingering differences.

Clinical judgement and practical wisdom: a claim of similarity

Pellegrino and Thomasma17 make a claim related to the central concern of this paper, that clinical judgement requires practical wisdom. I would like to take this claim one step further and suggest that a comparison of clinical judgement and practical wisdom implies that clinical judgement, if integrated with goals of care and ethical reasoning, is actually a form of practical wisdom within the specific context of medicine. For both involve looking at problems truthfully and then deciding how best to respond on the basis of the ends in view, the means best suited to achieve those ends, and an appreciation of the moral principles and virtues necessary to guide and motivate action. To support this suggestion, we need to define clinical judgement and explore its relationship to ethics and goals.

Clinical judgement

Clinical judgement is the basic skill of the physician that solves a medical problem through data collection, development and testing of explanatory hypotheses, and formulation of recommendations for therapy based on those hypotheses. In more detail, clinical judgement is ‘the totality of the mental processes involved in all stages at which the clinician collects and interprets data; formulates a problem statement, confirms and refutes diagnostic hypotheses; considers, plans, and implements possible diagnostic and therapeutic options, tests, and interventions; and evaluates likelihoods and outcomes.’18 Its components are sometimes viewed as the general process of clinical reasoning by which the physician suspects the cause of a patient's symptoms and signs, gathers relevant information, selects necessary tests, and then recommends treatment.19 Clinical judgement is generally considered an explicit cognitive process, although some believe it also entails tacit elements, the latter of which are not susceptible to conscious verbal descriptions but are demonstrable through action.18 Amidst its various articulations, we can summarise by saying clinical judgement is an inductive and iterative process of information processing that transforms a host of data (from the history, physical examination and laboratory) into a differential diagnosis (a manageable list of possible hypotheses that may explain a patient's problem) that is then sifted and further tested in an attempt to identify the most likely explanation for a malady and justify an approach to its treatment.

Clinical judgement in relation to ethics

Some accounts of clinical judgement or reasoning carry modest indication of the ethical values necessary for its execution, presumably because appropriate ethical commitments are taken for granted. This seems to be the case in the sophisticated work of Kassirer and Kopelman.19 They acknowledge that choices about tests and treatments depend on assessments of risks and benefits (as well as the physician's level of diagnostic confidence), but they do not discuss the underlying ethical values that inform those assessments. By contrast, other writers expressly note the intersection of the ethical and biomedical features of clinical judgement, such as the ethical significance of making a wrong diagnosis20 or the generally value-laden nature of clinical judgement deriving from an ethical dimension beyond practical reasoning.21

This ethical dimension of clinical judgement is portrayed by Pellegrino22 as its defining feature, because the ethical dimension of medicine (a right and good healing action) gives clinical judgement its direction and purpose. Pellegrino's dissection of the anatomy of clinical judgement reveals its multiple facets and contrasting modes of reasoning, one of which is ethical reasoning to determine how any and all tests and treatments will serve to advance the interests of a particular patient. Pellegrino's analysis offers a multifaceted portrait of clinical judgement that requires a genuine engagement between the physician and the patient in order to orient the outcome of all reasoning to the patient's good. Pellegrino suggests that the process of clinical judgement can be crystallised by answering three successive questions: What can be wrong? What can be done? What should be done? It is this third question that testifies to the ethically grounded and patient-centred purpose of clinical judgement, as it translates reasoning from the scientific realm of induction and deduction into the moral realm of the patient's good. Thus framed, clinical judgement is a telos-guided endeavour that greatly resembles the virtue of practical wisdom.

Clinical judgement as a form of practical wisdom

The relationship between clinical judgement and practical wisdom is so close because both arise from the same primary moral ground—the good of the patient. While their usual descriptions may emphasise different domains, one can suggest that clinical judgement is a manifestation of practical wisdom within the specific context of medicine, attended by its particular skills of detection and deliberation. For clinical judgement, like practical wisdom, is at heart a matter of looking at the world truthfully and then deciding how best to respond to it on the basis of the ends in view, the means best suited to achieve those ends, and an appreciation of the moral principles and virtues necessary to guide and motivate both diagnostic and therapeutic decisions.

The close relationship between clinical judgement and the virtue of practical wisdom is also suggested by similar requirements for extensive training. Clinical judgement requires repetitive and supervised practice over years of training so that trainees can learn a skill that comes by experience,18 and, like learning to speak a language, it requires participation in a practice rather than learning an abstract theory.20 The close relationship is also suggested by the way clinical judgement is formed within a community of practitioners defined by standards of professionalism that are themselves dependent on virtues.23

Although clinical judgement is routinely framed within a narrower biomedical model, we should consider the benefits of expanding its frame explicitly through an understanding of practical wisdom. This would provide a more complete and ethically grounded view of the work that clinical judgement is intended to accomplish. Developing such a view of clinical judgement would require its explicit integration with goals, ethical values, and motivations necessary to achieve its larger purpose (the patient's good).

To claim that a fuller understanding of clinical judgement requires a broader view is not meant to deny that the narrower biomedical features of clinical judgement cannot be usefully compartmentalised. Sophisticated and informative textbooks on clinical reasoning attest to this reality. But I would suggest that teaching clinical judgement without routinely acknowledging its larger purposes is an incomplete endeavour that risks misleading trainees by not directing them to the communication needs and ethical concerns that require dialogue with patients about their goals in order to achieve outcomes that are truly patient-centred. If we can learn to integrate the biomedical and ethical aspects of clinical judgement, we may help lessen the risk that ‘clinical judgement’ will merely express ‘the clinician's judgement.’

Teaching the components of practical wisdom in medicine can in one sense be seen as a process of encouraging the conceptual integration of clinical judgement, goals of care, and ethical reasoning (see Box 1 for a case example). However, teaching trainees to employ practical wisdom presents pedagogical challenges familiar to educators who attempt to teach virtues (dispositions towards action). I agree with those who hold that virtues—practical wisdom and others—can be taught and learnt by example and experience11 within a community of practice that encourages and supports active deliberation about clinical judgements.24

Practical wisdom and reflection

Practical wisdom as presented in this paper is a cognitive, action-oriented process guided by goal-directed reasoning within a normative ethical framework and spurred on by motivation to act according to the conclusions reached through deliberation. Motivation is a key ingredient of practical wisdom, and, in a virtue-based framework such as Aristotle's, motivation points to the relationship between cognition and desire, as well as to the importance of ethical reflection (developing a conscious understanding of who we are and what we do).3 In medical practice and education, some have suggested that the benefits of reflective practice include the acquisition of wisdom through the development of mental habits that involve ‘thinking about thinking and feeling about feeling.’25 Consistent with such views, I would suggest that reflective habits such as self-monitoring and mindful practice26 can be understood as part of a clinician's attempt to look truthfully at a clinical situation on the assumption that our mental processes and inner experiences have the potential to influence the way we perceive the concrete clinical circumstances we encounter.