Practical Wisdom, Clinical Judgments, and the Agential View

Abstract

I. INTRODUCTION

Medicine is a complex intellectual and moral practice. Physicians must develop a healthy and resilient professional identity to thrive in this practice and consistently make both scientifically and morally defensible decisions. The daily work of physicians involves almost constant high stakes decision-making in the process of helping patients retain or regain their health or maintain their integrity in the face of loss of health. Yet, in the United States, our education and practice systems are increasingly fragmented and challenging environments leading to moral distress, moral injury, burnout, and even suicide (Dzeng and Wachter, 2020; Rosen, Cahill, and Dugdale, 2022). In addition, major shifts in the organization and delivery of health care, and the cultural and moral norms of modern society have already eroded some aspects of medical professionalism and threaten to deprofessionalize physicians and cause moral distress and injury to them. This set of circumstances jeopardizes the integrity of the medical profession and the health of the public. In this paper, we argue that practical wisdom (phronesis) represents a useful framework for understanding the synthesis of the scientific, technical, and moral dimensions of medical practice. This framework can guide meaningful integration of concepts of character and excellence into the education and support of both the technical and moral agency of medical professionals, protecting against these threats. Consider the following scenario:

Mr. S was recovering in the cardiac intensive care unit after his third myocardial infarction (heart attack) which left him with very limited exercise tolerance, on many medications to manage congestive heart failure. He was alert, awake, oriented, and in no pain. Although as a recent residency graduate, she was enjoying managing this challenging and complex medical case, Dr. P, Mr. S’s primary care physician, understood full well that the prognosis was poor and treatment options were very limited. After extensive reading and consultation with the hospital’s transplant team, she was excited to conclude that Mr. S was an ideal candidate and eligible for a heart transplant. Armed with her research, she presented this option to the patient.

Mr. S refused to “take someone else’s heart” making it clear that his family could not “afford” for him to have “fancy medical care”. Mr. S asked Dr. P not to talk with his family about his decision. Flummoxed by his response, despite feeling very empathetic with what she presumed were his very reasonable fears, Dr. P was at a loss for words. She acknowledged his choice and left the bedside. When Mr. S’s wife and high-school-aged children questioned Dr. P about his options, Dr. P deferred them to Mr. S, who waved them off, refusing to discuss the issues.

Dr. P was angry with the patient for “giving up.” She felt strongly as a physician that it was her obligation to do “everything possible” to save Mr. S’s life, and she was confident she could get the patient’s wife and adult children to convince him to accept advanced care, although she also understood the perioperative care might cause a significant burden to them. She understood that she was expected to document and follow Mr. S’s wishes, but it bothered her that Mr. S seemed to be choosing to die when he had a chance of living. Dr. P ruminated about the case and was losing sleep over it. When she discussed her feelings with a colleague, he told her to “get over yourself! Mr. S has the right to make the wrong choice.”

Despite the increasing dependence on powerful and enabling technologies (e.g., organ transplantation, extracorporeal membrane oxygenation, genomics, artificial intelligence), medicine remains inherently a complex human activity. Scientific knowledge and technological expertise do not reduce the clinical encounter to mere technical skills, scientific knowledge, or a mechanistic view of the cognitive processes that lead to decisions (Ackerknecht, 1982; Jotterand and Bosco, 2020, 2021). The intrinsic humanistic dimension of medicine requires a careful consideration of the nature of the physician-patient relationship (Pellegrino and Thomasma, 1981, 1988). That is, the clinical interaction cannot simply rely on verifiable scientific knowledge or technical skills but must be tailored to the condition and context of the patient. The motive (compassion), purpose (“individualized satisfactory state of well-being”), and structure (“a relationship of friendship”) of the encounter (Pellegrino and Thomasma, 1981, 65), coupled with scientific and technical expertise, constitute the building blocks of the artful practice of medicine. In the context of this paper, art is understood according to the ancient Greek concept of technē, which until the nineteenth century meant “knowing what to do, how to do it, and why one does it” and encompassed a range of activities such as rhetoric, carpentry, sculpture, and medicine (Pellegrino and Thomasma, 1981, 147; Wiesing, 2018). Nowadays, because technē has become equated to “fine arts,” the term has lost its ability to convey the relationship between knowledge and practice, and is often “associated with inaccuracy, intuition, emotion and communication, or with uncertain therapeutic decisions” in contrast to science characterized by its predictability, precision, and “greater mechanistic understanding of health, disease and treatment” (Wiesing, 2018, 460).

The contrast between the ancient and the contemporary understandings of technē goes beyond a semantic dispute in the philosophy of medicine. Edmund Pellegrino and David Thomasma, in their examination of the philosophical foundation of medicine, stress the importance of maintaining unity among three inherent dimensions of medicine including art (in its pre-nineteenth-century understanding), science, and virtue. They argue that to disarticulate one of this triad is to dismember medicine (Pellegrino and Thomasma, 1981). Unfortunately, in medical education, the artful dimensions of medicine and virtue often are marginalized on behalf of scientific and technical skills. In what follows we examine closely the intellectual virtue of practical wisdom and its importance for implementing scientific knowledge in three domains: (1) aiming for deliberation in clinical judgments; (2) helping clinicians flourish by making wise decisions in light of the moral and emotional challenges they face in their practice; and (3) helping physicians navigate between the rights of patients, physicians’ own moral good, and the objective good intrinsic to medicine.

To this end, we propose a philosophical position, the agential view. In our analysis, we go beyond Pellegrino and Thomasma’s essentialist view that there is an internal morality of medicine and suggest an approach that encompasses the moral and professional identity formation of physicians. We assert that indeed there are internal goods intrinsic to the practice of medicine, but also emphasize that the individual physician must develop a personal moral philosophy of clinical practice that integrates the physician’s own good in the professional context, which should be contrasted, but not opposed to the good of the patient in the doctor-patient relationship (Jotterand, 2002, 2005). This means that in this paper we adopt a relational notion of the good in medicine, which constitutes “a prominent value for both patient and physician in relation to one another... a good that arises within a human relationship” (Pellegrino and Thomasma, 1988, 60). Hence, we examine the conditions necessary for protecting the physician’s agency and promoting his or her good as a person within complex relationships with patients, healthcare institutions, communities, and the broader society.¹ But first we turn to the definition of practical wisdom and its role in moral agency.

II. PRACTICAL WISDOM AND MORAL AGENCY

The term practical wisdom was first elaborated by Aristotle² and comes from the Greek word phronesis. It denotes what Julia Annas calls a “developed intelligent disposition” for making right judgments, reliably and correctly (Annas, 1993, 73, 2011). While it is difficult to render phronesis accurately, since the term can be translated as prudence, practical wisdom, or practical intelligence, we use the term practical wisdom to denote “the art of deliberating well.”... “to make the appropriate choice and to establish the right means through a specific action to achieve a particular moral end” (Jotterand, 2011, 2022, 66). Practical wisdom should be contrasted to deinotes (shrewdness); whereas phronesis always concerns moral matters, deinotes need not. Practical wisdom also should be distinguished from theoretical wisdom (sophia). Sophia and phronesis both refer to rightness, but the former focuses on theoretical and intellectual wisdom, whereas the latter is concerned with deliberating on particular things, actions, or practices oriented toward specific ends that require right (moral) action.

In the case above, the physician might have a theoretical and intellectual understanding of the moral issues at hand, but the issues cut more deeply than that, as the loss of sleep may indicate. The physician may want to achieve an outcome that she has deemed best for reasons of extension of life, usual practice, or even institutional need for a minimum number of transplantations to continue to rank highly as a transplant center. The patient’s refusal challenges the physician’s authority and the patient’s request for confidentiality; keeping vital information from the family on such an important issue, for the physician challenges usual communication standards that envision the patient in a complex web of family and community. This young physician may not yet have advanced in the necessary professional and personal character traits of self-regulation, judgment, and courage. She may not be considering how these virtues need to be incorporated into the moral framework for her role in caring for this patient. These and other challenges should engage the physician to consider these issues more deeply.

Key to our understanding of practical wisdom is that the being, the knowing, and the doing constitute the moral identity of the virtuous person in that practical wisdom is “an intellectual meta-virtue of holistic, integrative, contextual, practical reflection and adjudication about moral issues, motivating moral action” (Kristjánsson et al., 2021, 8). In their analysis, Jubilee Center authors equate phronesis metaphorically to “the conductor of a large orchestra” that imposes harmony in decision-making (Kristjánsson et al., 2021).³ The idea that phronesis functions as a conductor is crucial in our construct of moral agency because phronesis is not like any other virtue for two reasons. First, it is an intellectual virtue (like the pursuit of truth, critical thinking, intellectual curiosity, etc.) that guides moral virtues (such as behavior in society, temperance, generosity, compassion, etc.). Second, it is a meta-virtue with a mediating role that brings unity to the virtues and cohesion between competing obligations and actions (Kristjánsson, 2015). Importantly, it should be noted that while in this paper we focus on practical wisdom in the context of clinical decisions, the manifestation of practical wisdom does not require extensive formal education. Individuals with less formal schooling can be as wise in their endeavors as highly trained physicians. To continue to care well for Mr. S, Dr. P needs to enact an exquisite level of practical wisdom, which includes expertly communicating with the patient and the family, seeking the counsel of others regarding ethical dilemmas, clarifying, and taking into account the costs of care, and negotiating the patient’s changing goals of care and family dynamics as his clinical situation evolves.

Practical wisdom refers to an individual’s capacity to link knowledge with action under complex conditions, the ability to form beliefs (i.e., a worldview), motivations, and a moral identity to act consistently and wisely as illustrated in Figure 1. It requires human agency and the ability to act freely and independently, in two ways. First, practical wisdom requires a rational capacity, understood as the human ability to bring together knowledge of the universal and the specific context. The ability to unify the universal and the particular requires good deliberation that harmonizes how particular beliefs about the world shape desires, passions, and pleasures, and must meet the requirement of moral reasoning or the ability to reason and respond morally (i.e., moral capacity). Second, human agency requires that the physician accept the responsibility to undergo this deliberation and assumes that the social context provides guidance around norms, values, and notions of the good, the right, and the just (i.e., moral content) (Jotterand, 2022).

Fig. 1.

Personal moral philosophy of clinical practice.

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In the case presented, a physician might simply accede to the patient’s requests based on longstanding laws that require confidentiality and allow patients with decision-making capacity to refuse any medical intervention. She could also consider two alternatives. First, she could engage with the patient in an attempt to understand his reasoning and to change his mind. Second, she could disclose the patient’s refusal to family and invite them to attempt to do the same. If the physician does not accept her responsibility to engage in moral deliberation, then her choice becomes merely one of selecting the rule to follow that she finds most convenient or otherwise desirable. The latter choice is essentially what the colleague in whom she confided recommends.

Figure 1 reflects an integrative approach to moral agency not only with regard to how reason and motivation (i.e., moral emotions) interact but also how moral philosophy and moral psychology offer synergetic insights in the formation of a wise person (Jotterand, 2011, 2022; Jotterand and Levin, 2017).

III. THE ART OF GOOD DELIBERATION IN CLINICAL JUDGMENTS

Four Dimensions of Clinical Judgments

Aristotle points out that “... the most characteristic function of a man of practical wisdom is to deliberate well: no one deliberates about things that cannot be other than they are, nor about things that are not directed to some end, an end that is a good attainable by action. In an unqualified sense, that man is good at deliberating who, by reasoning, can aim at and hit the best thing attainable to man by action” (Aristotle, 1984, 1141b 8-13). This definition of practical wisdom suggests four concrete dimensions of clinical judgments: (1) truth, (2) the good, (3) ends, and (4) action. First, Aristotle states that the facts under deliberation must correspond to a reality that can be known by the observer. The quest for truth is a precondition for any deliberation. In the medical context, the acquisition of scientific-clinical facts grounded on empirical evidence is essential for formulating a diagnosis, determining treatment options, and establishing a prognosis. As an intellectual virtue, practical wisdom provides, ideally, the integrity necessary to seek truth, clinical, or otherwise. Furthermore, a physician’s deliberation is not simply an individualistic intellectual exercise. There are standards of excellence and goods inherent to the practice of medicine.

There are different goods that are central to medicine, such as the good of the patient, the good of the physician, and, importantly in the context of our analysis, the relational good that arises between the physician and the patient (or their surrogates), which should lead to an action that fulfills the ends determined by both (Pellegrino and Thomasma, 1988). In the clinical setting, the physician seeks to partner with the patient to make a wise decision that promotes the well-being of the patient based on the information at hand. In some circumstances, the best course of action is curing, while in other cases supportive care is the best path. These consequential decisions are so ubiquitous in daily practice that cultivating practical wisdom is an essential dimension in the moral identity formation of physicians, and yet this cultivation is poorly understood, and the educational process around it is fragmented and largely tacit (Kaldjian, 2010; Bontemps‐Hommen, Vosman, and Baart, 2019)^.

The Nature of Clinical Judgments

In its most idealistic, elemental form—one physician and one patient—medical practice is a discipline in which the physician seeks, insofar as possible, to restore to the patient physical integrity and mental well-being lost through illness. What this suggests is that the physician, when deeply engaged with the patient, interprets clinical reality and articulates a plan of action while displaying good character. This process requires practical wisdom to discern the appropriate means to achieve a good end in a particular context. The art of medicine is the ability to deliberate about and join each domain of concern (i.e., medical facts, concepts of the good, moral norms and values, and professional standards) into the specific context in which the physician–patient partnership takes place (Cutter, 1993).

As we outline in more detail later in the paper, we contend that because medical practice is intrinsically a human activity that entails both clinical expertise and particular moral commitments—what is often referred to as the “internal morality of medicine”—practitioners need models for understanding, studying, and teaching this practice that integrate the moral and clinical actions holistically and pragmatically (Ladd, 1983; Pellegrino, 1998, 2001; Kinghorn et al., 2007; Kaldjian, 2010; Ben-Moshe, 2019). The close connection between the agency of the physician and the act of interpreting medical facts requires particular skills that are most commonly acquired through clinical experience with patients. Patients present physicians with problems embedded in the particularities of their life contexts, in which the patient may intuit a particular underlying disease. Faced with this unique “illness experience,” the physician must assess the problems and context, taking into consideration the patient’s health beliefs, and make a diagnosis, often associated with substantial uncertainty. This “working diagnosis” serves as a starting point for subsequent actions such as additional diagnostic investigations and implementing treatments to see what will happen, and it therefore represents a cognitive process, rather than a definitive decision. The physician must be constantly monitoring, adjusting, and reassessing and must be open to a change of mind to ensure the best interest of the patient. Medical decision-making requires good judgment or, in philosophical language, practical wisdom, because of the “inductive and iterative process of information processing” involved (Jotterand, 2005; Kaldjian, 2010, 560) Dr. P may feel constrained by two clear but opposed choices, but a physician who embraces her moral agency and her own good should continually adjust and reassess, while keeping an open mind about the best interests of the patient.

It should be noted that because there is a wide range in the quality of all types of art, including the art of deliberation in clinical judgments, so too can there be a wide range in a physician’s capacity for synthesizing biomedical information with values and other human aspects of medical decision-making in the interest of a particular patient. As Rudolf Gross asserts and many agree, most diagnoses are formed by clinical judgments experienced as intuitions (Gross, 1993)—or unconscious and automatic reasoning—what Kahneman and others (e.g., Croskerry) (Croskerry, 2009; Kahneman, 2013) have called “fast thinking.” He distinguishes three significant features of these intuitions: (1) usual associations of new and already-recognized sense impressions (pattern recognition); (2) unusual and uncommon associations of impressions and thoughts (uncommon presentations of the common, or common presentations of the rare); and (3) unique associations of connections between new and earlier apperceptions (adding subtleties to existing schema/scripts or key feature patterns). While a detailed discussion of the cognitive science of clinical reasoning is beyond the scope of this paper (see Norman, 2005; Kassirer, 2010), we point out that Gross’ characterization of intuitions as the building of new impressions largely on past impressions indicates that clinical intuitions are partly rational. That is, they are the outcome of what Ray Moseley calls “inferential reasoning” (Moseley, 1993). On the one hand, these past impressions or intuitions reflect accumulated explicit prior knowledge and experience. On the other hand, intuitions often reflect an individual’s ability both rapidly and unconsciously to incorporate new impressions or facts that modify one’s understanding. Therefore, the knower seamlessly adapts intuitions to new knowledge, maximizing the decision-making process for the sake of the patient.

Second, if we understand Gross’ conception of intuitions as inferential reasoning, we can define the art of medicine as the ability to examine and assess medical reality by making wise clinical judgments about the nature of disease and illness (disease being the objective and illness the subjective dimensions or experience of medical reality; see Carel, 2016). How the physician combines the various factors that determine a diagnosis requires practical wisdom, which manifests in creative and critical thinking. A wise physician is one who, relying on intuition forged by experience, not only is able to synthesize medical facts into a diagnosis for the good of the patient, but also acknowledges the role of biases and error in decision-making. Interestingly, to counteract the destructive effects of biases and discrimination, Plews-Ogan et al. propose a framework based on wisdom (Plews-Ogan et al., 2020; Plews-Ogan and Sharpe, 2022). All of this activity is, of course, in the context of an ever-increasing complexity in healthcare delivery. For instance, the need for individual physicians to conduct their professional activities as part of a single, or more commonly, a series of interprofessional teams has arisen.

We should also point out that absolutes in medical decision-making are rare. The physician must sometimes choose actions with inherent risks, such as diagnostic tests (e.g., biopsies, invasive studies) or treatments with known side effects, and do so without certainty of the diagnosis. A skilled clinician, therefore, understands the conditional and compounded probabilistic nature of clinical reasoning and can readjust decisions in the light of new information. Good clinical practice requires courage and tolerance for uncertainty, but more importantly, it requires practical wisdom. Those virtues, joined with the relevant complex scientific processes involved, result in the moral craft or art of medicine.

Medicine as a Moral Practice

Clinical judgment is a process of moral deliberation about clinical realities. As with other professions, medicine relies on relationships grounded on attributes such as trust, integrity, and compassion that form the moral basis of clinical practice. This is what we referred to earlier as the internal morality of medicine, which in the Aristotelian framework we adopt in this paper, presupposes an objective good. Our purpose is to provide an alternative account that challenges some of the fraught tenets of contemporary medicine. Briefly, though, unlike Aristotle’s thinking and as noted by H. Tristram Engelhardt Jr., our modern pluralistic society does not afford an authoritative singular account of the good. Consequently, in the modern context, the moral life is reduced to respect for autonomy, since it has become generally believed that imposing any view of the good life or rules of beneficence would be considered immoral (i.e., against one’s autonomous notion of beneficence). The only remaining justification for actions is the principle of permission (Engelhardt, 1996). Respect for autonomy, then, becomes by default the highest good in the clinical encounter. Patients are entitled to a set of medical procedures according to a contractual agreement that recognizes the rights of patients as consumers and the duties of physicians as providers, with the relational nature of this interaction given little attention. In this context, how should the good of the physician (i.e., moral agency) be understood with regard to these patient rights and the internal morality of medicine? To answer this question, we must first examine what is meant by the internal morality of medicine.

The Internal Morality of Medicine and the Agential View

According to Pellegrino and Thomasma, standards of excellence in medicine constitute an “internal morality of medicine—something built into the nature of medicine as a particular kind of human activity” (Pellegrino and Thomasma, 1993, 42). Key to understanding the terminology of the internal morality of medicine is the notion of practice: “[b]y a practice I am going to mean any coherent and complex form of socially established cooperative human activity through which goods internal to that form of activity are realized in the course of trying to achieve those standards of excellence which are appropriate to, and partially definitive of, that form of activity, with the result that human powers to achieve excellence, and human conceptions of the ends and goods involved, are systematically extended” (MacIntyre, 1984). According to MacIntyre, a practice is a form of human activity contingent on how people relate to each other. Medicine is first and foremost a relational endeavor between two individuals (or among more—as care is usually delivered nowadays in teams). The patient is in a vulnerable state due to a particular physical or mental ailment; and the physician possesses the knowledge and expertise required to assist the patient. The distinctive nature of the relationship between the physician and the patient is built on moral attributes, standards of excellence, or internal goods, without which the practice of medicine would be reduced to a set of technical skills. MacIntyre makes an important distinction between internal goods and external goods. Internal goods are essential to the practice, maintain its moral integrity, and are necessary for the realization of its ends. External goods do not contribute in a direct manner to the fulfillment of that practice. For instance, personal wealth or political power do not directly contribute to the ends of medicine, whereas character traits like compassion or trustworthiness and excellent clinical skills do and therefore are goods internal to clinical practice. The inherent moral dimensions of clinical practice become even more apparent when we consider (1) the inequality of the medical relationship; (2) the fiduciary nature of the relationship; (3) the moral nature of medical decisions; (4) the nature of medical knowledge; and (5) the ineradicable moral complicity of the physician in whatever happens to the physician’s patients (Pellegrino and Thomasma, 1993, 42). These set the context in which virtues can be manifested and the ends inherent to medical practice realized (Pellegrino and Thomasma, 1993; Drane, 1995; Jotterand et al., 2016).

The internal goods of medicine, however, are not sufficient to sustain the moral identity of the physician, because a moral identity is not only shaped by professional standards but also by moral commitments outside one’s professional context. In other words, every dimension of moral agency, including the role of personal moral commitments and aspirations to be or become a particular type of individual (and a particular kind of physician) are displayed in the agency of the physician. The moral attributes physicians display are dependent on the moral identities physicians have developed over their lifetimes in their families, friendships, and communities, including religious communities, political parties, and professional associations. The development of a professional moral identity is a multifaceted process that brings personal and professional sources of moral authority together and sometimes into tension with each other (see Fig. 1 above). There is no moral neutrality in a physician’s professional identity. The integrity of one’s moral agency depends on acting in the professional context according to both personal and professional values. Putative professional values that disregard or contradict practitioners’ personal moral values are morally problematic.

At the same time, it would be unacceptable to ignore professional values and standards in favor of one’s personal preferences (e.g., discrimination against a particular group of people).⁴ The upshot is that there must be a high degree of alignment between the personal morality of practitioners and the fundamental purposes of the medical profession. The agential view preserves an essentialist view of medicine and its shared dimension as a community of practice. It creates space for the agency of the physician to be protected, supported, and enriched by other sources of moral authority outside the medical profession. Ultimately, flourishing in the medical profession necessitates the development of a personal moral philosophy of clinical practice. In the case above, Dr. P’s agential compass, her own moral commitments and aspirations, can be part of her conversation with the patient in the context of the clinical and moral issues that they face together, rather than beginning by invoking general rules or regulations. Once the foundation of the physician-patient relationship is established, then the other considerations can be discussed in turn.

Rethinking Professionalism in Medicine

The perspective put forward about professional identity formation contrasts sharply with the contemporary moral discourse prevalent in society, which has also permeated medicine. Lamenting the absence of teleology in a broader historical and social context, MacIntyre rightly notes that “once the notion of essential human purposes or functions disappears from morality, it begins to appear implausible to treat moral judgments as factual statements” (MacIntyre, 1984, 59). This means that the modern moral self is characterized by its ability to free itself from external restraints and judge a situation “from a purely universal and abstract point of view that is totally detached from all social particularity. Anyone and everyone can thus be a moral agent, since it is in the self and not in social roles or practices that moral agency has to be located” (MacIntyre, 1984, 32). The moral self represents its own self-ruling point of reference and, therefore, need not be liable to anyone as a moral agent nor to any narrative or social practice (e.g., medicine). Contemporary morality relies on assumptions partially estranged from the historical, religious, and socio-cultural context in which they emerged. Thus, such morality attempts to create a social moral order without a robust moral vision (Brague, 2019). As MacIntyre notes, this “loss of traditional structure and content” has liberated the modern self “from all those outmoded forms of social organization” that provide hierarchical structures, context, and purpose (MacIntyre, 1984, 60). Charles Taylor calls this situation an “identity crisis, an acute form of disorientation” that underscores the necessity to link (moral) identity and some kind of orientation in the moral space (Taylor, 1989). One must then develop a robust understanding of what is good beyond what is simply permissible (compliance). To know “who you are” is precisely an exercise of introspection and deliberation (i.e., practical wisdom). It demands a certain level of comprehension of notions of the good essential for the development of a moral identity. Only subsequently can an individual orient the moral self, because knowing who you are attaches notions of the good to meaning, which results in purposeful behavior and actions.

Medicine is not immune to the socio-political, economic, and ideological pressures that have reconfigured morality in society, especially since the 1960s. Bioethics manifests in medicine as this broader intellectual movement in ethics. It attempts to provide moral guidance to the medical profession “supported by a collage of attractive socio-political agendas for legal and public policy change” (Engelhardt, 2013, 55). More importantly, though, bioethics filled an intellectual vacuum resulting from “(1) the deflation of medicine as a quasi-guild, (2) the secularization of American society, and (3) the erosion of the cultural standing of traditional authority figures” (Engelhardt, 2013, 55-6). During the same period, the medical profession underwent a decline that led to its slow deprofessionalization. According to Elliot Krause, medicine in the United States lost its guild authority when it started interacting with the state and capitalism (Wolinsky, 1993; Krause, 1999; Engelhardt, 2002; Jotterand, 2005). This point is corroborated by Donald W. Light, who traces the loss of status that led to the deprofessionalization of medicine to the need to contain cost through more efficient practice patterns (Light, 1993).

Faced with the inability to preserve an independent professional and moral identity, medicine recreated its identity according to the canons of bioethics, largely free from any tradition or narrative sufficient to sustain medical practice. This has resulted in a moral framework characterized by competing pragmatic priorities and utilitarian considerations within which moral issues are discussed and disputed, but no consensus is forged. The morality modern culture has created cannot generate neutral criteria for adjudicating, much less resolving, moral disputes, and this is especially noticeable in medicine. Thus, the moral identities of physicians must be linked to a narrative that entails the process of acquiring a “moral identity”; i.e., the context in which virtues can be manifested depends on the values shared by a community. Such community—medicine, say—must be committed to promoting such values within an ongoing tradition that provides the conditions for individuals to place “the self in relation to a good to which the virtues are intrinsic” (Hauerwas, 1985, 353).

The loss of a unified and clearly articulated teleological basis for the moral foundation of medicine hinders medical practitioners and students by reducing them to mere “providers”⁵ detached from the long history of Western medicine and it’s evolving, fundamentally moral vision. The epidemic of work-related distress, exhaustion, and diminished effectiveness among physicians, often referred to as “burnout,” is likely attributable at least in part to moral distress. This is the distress that occurs when professionals, due to either internal or external constraints, fail to carry out ethically appropriate actions. The related phenomenon of moral injury, first described in military combatants, is the harm suffered when one violates one’s own deeply held moral beliefs. Our understanding of these psychological constructs, thought to explain a great deal of negative mental and physical suffering among individual physicians and the loss of physicians to suicide, career change, and early retirement, are evolving and being debated. While significant efforts are being made to address the well-being of physicians, it is rare that such strategies explicitly aim to strengthen physicians’ personal moral philosophy of clinical practice and therefore their practical wisdom (Day et al., 2021). We contend that the integration of practical wisdom in medical education (UME, GME, and CME) offers opportunities to discuss upstream challenges related to moral distress before they lead to moral injury and burnout. For instance, at our institution, we are working on the integration of practical wisdom in one of the 7 Doctoring Curricular Threads called “Character & Professional Development” which will be part of the new curriculum at Medical College of Wisconsin. Developing the capacity to deliberate well allows individual physicians to cope with the initial emotional response to distress and to process the lingering long-term effects of the loss of moral integrity.

In the case above, the physician should consider whether her initial recommendation for cardiac transplantation is so fundamental to her moral agential view that she cannot in good conscience abide by the patient’s refusal. If so, and if persuasion proves ineffective, the physician may need to seek to transfer the patient’s care to another clinician whose agential view allows the assumption of engagement with and care of the patient. Conversely, the physician after deliberation may conclude that cardiac transplantation is not required by the moral ends of medicine, and the physician might consider how her intellect and emotions are being influenced by the patient’s resistance to her recommendations, refusal to bring family into the conversation, and religious understanding of what is required and what is not. The right choice under these particular circumstances will be better made with the recognition of the moral agency of the physician. This process of deliberation on the best course of action recurs in many such moral encounters and cumulatively will further develop the physician’s practical wisdom—to be able to make such decisions morally and wisely. What is key here is that the physician understands this conversation as one in which she needs to act as a moral agent and not simply a technical consultant. Practical wisdom empowers physicians to delineate professional boundaries, discern the proper interplay between professional and personal values, and exercise moral agency well within the clinical encounter.

IV. CONCLUSION

In light of the increasing challenges of the medical profession to meet the healthcare needs of society and the obligation to rethink how to train future physicians to navigate the tumultuous waters of modern medicine, this paper critically reassesses medical professionalism. As was the case in ancient Greece, the art of medicine should be understood as cohering with, not contradicting, the science of medicine. A critical examination of the art of medicine in contemporary culture reveals a need to recover attention to the good of the physician in medicine. We argue that the good of the physician depends on the ability to develop the emotional, cognitive, and volitional capacity to reflect and evaluate the implications of an action (or a series of actions) when two or more potential goods compete. A careful examination of practical wisdom, as an intellectual virtue and a disposition to make good judgments, provides a way of addressing the moral and emotional challenges physicians face in their practice. The suggested philosophical position, the agential view, allows the cultivation of practical wisdom and other virtues to maintain one’s moral integrity while serving patients in need of good care using good judgment. This is an ambitious project. It requires both a paradigm shift moving beyond current bioethics and a reconsideration, among other things, of the role of philosophical inquiry in medicine.

ACKNOWLEDGMENTS

This project was made possible with support from the Kern National Network for Flourishing in Medicine (KNN) through an investment from the Kern Family Foundation. The authors would like to thank the following individuals for their invaluable insights in the early conceptualization of the manuscript: M. Chris Decker, Tavinder K. Ark, Christopher S. Davis, Julia Schmitt, and Jeffrey Amundson. Special thanks to Julia Bosco for his help with the design of Figure 1.

REFERENCES

Footnotes