Virtue Monism and Medical Practice: Practical Wisdom as Cross-Situational Ethical Expertise

Abstract

I. INTRODUCTION

In this paper, we defend the centrality of practical wisdom (or phronesis) not only within a virtue-ethical theory but also in applied ethics generally, with a particular focus on its significance in clinical settings. In this perspective, let us first consider a fictional clinical case:

A sixty-two-year-old woman, Liza, with metastatic lung cancer is offered a fourth cycle of experimental chemotherapy by a new doctor. Her previous doctor had suggested discontinuing this type of treatment after the third cycle. He felt that the best options had already been provided and that the side effects of the therapy would be too severe. Liza is tired and discouraged from trying to slow down the disease without seeing any significant results, at least for the past year. She has been sick¹ for almost five years, and she is inclined to refuse the chemotherapy treatment. What is the right course of action for the new doctor to take? Should he try to persuade Liza to go through with the new treatment in the hope that it will buy the patient some time, or should he just accept the fact that she has struggled enough with her disease, and it may be time to let her go?

Such a case is quite common in medical experience. Despite its frequency, neither a deontological nor a consequentialist approach seems able to address it successfully. On the one hand, deontologism assumes that it is possible and sufficient to apply rules and principles to any specific case in order to act well. However, there is no particular rule or principle that says whether or not this fourth course of chemotherapy should be administered in this particular clinical situation; nor is it easy to derive action guidance from any general rule, such as “act out of beneficence,” “act non-malevolently,” or the like. The specificities of the case at hand make it very hard to infer what beneficence or non-malevolence would require of the doctor here and now. On the other hand, consequentialism tries to weigh the pros and cons and decide on the basis of expected outcomes, but even such a procedure in this situation may end up in a continuous revision of the two options, because there is no evidence of what would yield the best outcome.

To value the patient’s attitude and will would undoubtedly be crucial in the decision-making process, but this is often difficult to accommodate within the two models, which primarily focus on their axiomatic assumptions and/or rational computation. Moreover, situations like Liza’s do not allow one to rely entirely on the will, because there is no clear decision from the patient. Liza tends to refuse the treatment because she is tired and hopeless, but she has not made up her mind yet, and seems to need some qualified advice. Hence, appealing to the patient’s will is not always conclusive and might even be inappropriate when the patient is not ready to make her own decision and requires successful interaction with healthcare professionals to understand and act responsibly.

Admittedly, both deontologism and consequentialism exhibit significant, and arguably excessive, levels of abstraction, generalism, and formalism, prompting a revaluation of the general ethical approach in medical ethics to capture the particularities of real-life situations more accurately. This is why several studies have proposed the adoption of a particularist virtue-ethical perspective, precisely to avoid the abstractness, the empirical inadequacies, and, ultimately, the impasses of these two normative models (Arthur et al., 2015; Kotzee et al., 2016; Conroy et al., 2021). Even when medical doctors claim to be guided only by a deontological or a consequentialist perspective, in fact they frequently make their decisions on different grounds, that is, by relying on their expertise, both technical and ethical, and by referring to certain notions of the good for the patient, all-things considered.

In Liza’s case, the right decision and action must necessarily be particular. Protocols and consequences might be significant to the extent that they are adjusted and actualized to better fit the uniqueness of each case: how to approach Liza to get her cooperative consideration? Has she been carefully listened to and openly informed about all aspects of treatment and refusal? Was she given the time she needed to understand her situation, or was she impatiently pushed to proceed? Recognizing this “particularistic richness” is typical of virtuous agents, who learn to act generously, honestly, courageously, justly, etc., in carrying out their professional duties.

Moreover, within an Aristotelian framework, the proper display of virtuous behavior, after making the right moral choices, is considered as typical of phronesis (i.e., practical wisdom), and with good reasons. It is not by chance that phronesis in health care has been extensively studied as a highly effective tool for the practice of medical ethics (Plews-Ogan and Sharpe, 2022; Boudreau et al., 2024). Phronesis is generally understood as a meta-virtue providing rational guidance to the other (ethical) virtues. Thus, it is held responsible for adjudicating hard choices or conflicts among competing values promoted by different virtues. Neo-Aristotelian scholars have recently restated the importance of phronesis in moral theory and practice (Hacker-Wright, 2015; De Caro, Marraffa, and Vaccarezza, 2021; Kristjánsson and Fowers, 2022), advancing conceptions and empirically informed models of the psychological underpinnings of this complex trait (Snow, Wright, and Warren, 2021; Darnell, Fowers, and Kristjánsson, 2022). However, it remains controversial what practical wisdom is, what its functions and features are, and whether and how it could be empirically observed and measured. In fact, some authors are skeptical about the possibility of measuring phronesis (Swartwood, 2020), while others even claim its philosophical implausibility (Miller, 2021) and psychological redundancy (Lapsley, 2021). While elsewhere some of us argue in detail that these critiques do not hold (De Caro, Navarini, and Vaccarezza, 2024), in this article, we propose a positive account of practical wisdom as ethical expertise, in which we identify the necessary conditions for being a practically wise agent and suggest preliminary ideas about the possible operationalization of these conditions. In this light, we recently advanced the “Aretai model,”² which rebuts the traditional Aristotelian difference between phronesis and specific ethical virtues (De Caro and Vaccarezza, 2020; De Caro, Navarini, and Vaccarezza 2024). More specifically, according to this model, virtue consists entirely in the possession of practical wisdom, understood as a kind of cross-situational ethical expertise. In this light, it is possible to account for the best medical practices, such as when doctors give good medical advice or make responsible clinical decisions employing highly integrated moral “structure.” Let us consider Liza’s case. For doctors to grasp what is more likely the best option for her in her particular situation, general medical expertise is not sufficient, since they also need to employ practical wisdom.

In general, the core hypothesis of this paper is that practical wisdom should be understood as a high-order competence that can account for the manifestation of virtuous behavior in different practical contexts (De Caro, Marraffa, and Vaccarezza, 2021). In our view, practical wisdom both enables cross-contextual stability and flexibility (apt responses to several practical challenges, including novel and unfamiliar ones), and includes moral motivation. As some of us have maintained elsewhere (De Caro et al., 2024; Niccoli et al., 2024), the defense of monism regarding virtue suggests that practical wisdom should be conceived of as the ratio essendi of the specific virtues that are displayed by agents with a high track record of apt responses to different kinds of practical challenges. Conversely, cross-situational virtuous behavior (what the Aristotelian tradition traces back to different ethical virtues) is phronesis’s only ratio cognoscendi: it is only by observing such a cross-situational manifestation of virtuous behavior that we can infer the existence of phronesis as a unified, higher-level competence. Thus, our account of phronesis critically relies on a relatively underexplored phenomenon: the ability to transfer (cf. Barnett and Ceci, 2002) specific ethical skills across different kinds of morally relevant situations.

In Section II of the article, we present the idea that practical wisdom should be conceived of as virtue altogether, namely, as a kind of expertise generating virtuous behavior. We then highlight our monistic account of phronesis (i.e., the view that it has ontological priority over specific ethical virtues) and explain how our model differs from more orthodox Aristotelian accounts.

In Section III, we present our model of practical wisdom as ethical expertise, according to which phronesis, besides its monistic nature of virtuousness as such, is a form of excellence in making appropriate “all-things-considered” decisions in practical situations. This implies recognizing the central role of emotions as deeply integrated—not merely controlled or tolerated—in the process (Navarini et al., 2021; Navarini, 2023; Valenzuela, 2024). We then address a possible objection to this view, stating that it is impossible to define objective success conditions for all-things-considered decisions, such as complex moral choices. To this objection, we respond by suggesting that it appears possible to evaluate excellent performance in specifically ethical decision-making skills, and that this can be a promising candidate to identify different levels of competence in practical decision-making. In this section, we illustrate four ethical skills that practically wise agents necessarily display to a greater extent than others.

In Section IV, we claim that phronesis coincides with the excellent performance of these skills throughout the moral domain, even in very diverse circumstances: practical wisdom qualifies then as cross-situational ethical expertise. A constitutive feature of practical wisdom is the ability to decide and act well in a stable, consistent, and flexible way across different situations and practical challenges.

II. PRACTICAL WISDOM AS EXPERTISE AND VIRTUE MONISM

Although multi-component, empirically informed models of practical wisdom have been recently proposed (Darnell, Fowers, and Kristjánsson, 2022), only a few have conceptualized it as a form of expertise, as opposed to a virtue traditionally understood (Swartwood, 2013; Tsai, 2022). However, we believe that none of those expertise accounts is sufficiently clear about two theoretically and practically relevant aspects: (a) the main relations between the acquisition and performance of practical wisdom and the specific ethical virtues and (b) the relevance of cross-situational competence as a core aspect of practical wisdom.

This has been highlighted in Liza’s case: even when doctors claim to be guided only by a deontological or a consequentialist perspective, they in fact frequently decide on a different ground, that is, by referring to a certain notion of the good for the patient, all-things considered, and by relying on their expertise, both technical and ethical.

Neo-Aristotelian philosophers have recently proposed novel influential reconceptualizations and operationalizations of practical wisdom. In this paper, however, we employ a model that parts ways from these and combines these insights by drawing on views that model the acquisition and manifestation of wisdom and virtues as analogous to the learning and performing of expert skills in non-moral domains. Our account diverges from orthodox neo-Aristotelian accounts for the main reason that they understand virtues as specific dispositional traits that should be cultivated, shaped, and oriented toward particular ends by specific training (e.g., Carr and Steutel, 1999; Kristjánsson, 2015). According to these views, phronesis is a sort of additional meta-virtue that orchestrates the ethical virtues, which can nonetheless be cultivated independently through habituation during early character development. As Kristjánsson and Fowers (2022) note, however, within this framework it remains unclear when, and due to which training, phronesis would emerge as a result of the previous development of the virtues. On the contrary, we claim that virtue consists entirely in the possession of practical wisdom, understood as a domain-general (though specifically ethical) expertise. In other words, it is crucial to the Aretai model that practical wisdom is the only virtue that explains and allows virtuous behavior in different situations (De Caro, Marraffa, and Vaccarezza, 2021). Thus, our account entirely avoids relying on single ethical virtues, traditionally conceived of as conceptually, psychologically, and developmentally independent character traits. This means that we propose a monistic account of virtue, according to which it is only phronesis (as ethical expertise) that exists, while the single ethical virtues are merely manifestations of such competence.

A second difference follows from this first difference. By assuming the developmental priority of specific virtues over phronesis, neo-Aristotelian views leave little room for the possibility of individual moral change, once one’s character has been shaped. On the contrary, by assuming the priority of phronesis, our model suggests that the development of more general cognitive and practical capacities can shape the improvement of already developed inclinations and character traits even later in life, opening the door to a more optimistic view of individual moral change. Such moral change also allows for the progressive acquisition of professional phronesis, and specifically of medical phronesis, that represents one of the most crucial fields in which this kind of expertise can be fully displayed.

Partly as an alternative to neo-Aristotelian standard models, among practical wisdom scholars “skill models” of virtue (Annas, 2011; Stichter, 2018) and wisdom (Swartwood, 2013; Tsai, 2022) have been proposed, suggesting that these seemingly elusive constructs can be investigated through the language of expert skill acquisition. A theoretical strength of this approach is that it conceives the acquisition and performance of virtue/wisdom through the lens of an increasingly studied phenomenon, i.e., expertise acquisition and performance more broadly conceived (Phillips, Klein, and Sieck, 2004; Kahneman and Klein, 2009; Ericsson, Hoffman, and Kozbelt, 2018). This approach contributed to making philosophical reflection on wisdom and virtue more scientifically robust, and consistent with psychological research. Moreover, it made virtue-theoretical accounts of moral psychology more comprehensive and convincing than alternative models of moral decision-making (e.g., Haidt, 2001; Greene, 2014) because of its emphasis on the multi-dimensional, integrated, diachronically dynamic, and cross-situational nature of moral experience (see Sauer, 2012; Alfano, 2013; De Caro, Niccoli, and Vaccarezza, 2018; De Caro, Marraffa, and Vaccarezza, 2021), as well as on the socio-epistemic and comparative aspects of moral competence (e.g., Cholbi, 2007; Driver, 2013; Watson and Guidy-Grimes, 2018). The psychological and epistemological research on non-moral expertise can provide useful scientific and philosophical insights for understanding practical wisdom as a kind of expertise in handling morally relevant situations.

Broadly conceived, expert skill, ability, and performance in each area allow those who possess these capacities to consistently deliberate and act (1) appropriately to the context and (2) reliably better than non-experts. Of course, different domains present distinct features, raise different challenges, and require specific competencies. The Aretai model of phronesis agrees with a crucial thesis of these accounts: namely, that practical wisdom should be understood as an outstanding competence (or set of skills) that allows one to decide well with respect to the specific aspects that make situations and choices morally relevant. However, even though we agree with the general framework of the virtue-as-skill approach, these accounts treat specific ethical virtues as context-specific skills that enable appropriate moral responses by the agent, conceiving them as distinct from—and developmentally prior to—the possession of practical wisdom. Stichter, for example, claims that phronesis cannot be understood as a skill (or expertise) since skills (and expertise) only concern technical abilities regarding means to achieve ends of practices that are already clearly defined; phronesis, instead, would be a form of wisdom pertaining to ends of value, rather than means (Stichter, 2015, 2018, 2021). In relation to these ends, Stichter argues, it is problematic to speak of the acquisition or possession of competence in a manner analogous to technē. We agree that phronesis and technical competencies are distinct, but we do not believe that this necessarily implies that one cannot be more proficient than others in reflection, deliberation, and actions concerning ends of value. The distinction does not commit us to advocating the controversial thesis that one can be an expert about the content (or substance) of these ends. Conversely, we believe that one can be more skilled or competent than others in some fundamental capacities that enable the perception of conflicts between values, deliberation about how to solve them, or the realization of some ends of value in morally complex circumstances (see Section 2).

Finally, while being in considerable agreement with existing accounts of practical wisdom as expertise (Swartwood, 2013; Tsai, 2022), in those accounts it remains unclear what implications such a reconceptualization of practical wisdom has for a broader understanding of virtuous character and its development. Also, our model differs from these accounts not only because it stresses the ontological priority of practical wisdom over the single virtues, but also because of its implications at the educational level (De Caro, Marraffa, and Vaccarezza, 2021), with special focus on continuing education in medicine and healthcare professions.³

III. PRACTICAL WISDOM AS ETHICAL EXPERTISE: DOMAIN AND CONSTITUTIVE SKILLS

The notion of expertise, as anticipated in the previous section, refers to a kind of excellence: it implies that there is a set of characteristics that some agents possess to a greater extent than others. The discussion about which is the preferable account of expertise is open (Watson, 2020). However, for the purposes of this paper, we work with the following definition of an expert:

EXPERT. Agent E is an expert in domain D with respect to population P only if, compared to others in P, E possesses outstanding skills and understanding in D.⁴

If we apply this general definition to the domain of morality, we obtain the following working definition of a moral expert:

MORAL EXPERT. Agent W (wise) is an expert in the domain of morality with respect to population P only if, compared to others in P, W possesses outstanding skills and understanding in that domain.

While it is notoriously problematic to define the precise boundaries of the moral domain (Gert, 2020; Machery and Stich, 2022), certain features can be identified in situations that make them morally relevant, and that are absent (or present in a much lower degree) in non-morally relevant situations. It is quite uncontroversial that morality has a peculiar, non-instrumental concern with the harm or benefit of subjects affected (actually or only potentially) by other people’s actions (see, e.g., Railton (2017)), and with the distribution of the benefits and burdens of social interactions (Brink, 1989). Moreover, many moral questions, issues, and choices are relatively uncontroversial, and a correct answer can reasonably be believed to exist. However, regarding more controversial questions, principles, norms, and values conflict, and it is unclear what the best solution might be. Our hypothesis is that practically wise individuals are more competent than the average population in making decisions of this kind. Specifically, we contend that practically wise agents perform better than others in situations in which one has to decide what to do “all-things-considered”—i.e., when multiple variables are at stake and no clear or correct goals are in view (contrary, e.g., to chess, in which the goal is winning the game, but like in our initial Liza's case).

According to some critics, the main problem of a model of practical wisdom as ethical expertise (and of ethical expertise in general) is precisely the difficulty of defining clear normative standards for what ought to be done in complex all-things-considered decisions. Some have even suggested that defining success conditions for these kinds of decisions is hopeless (Hursthouse, 1999; Swartwood, 2020, 79–81, 90), since appropriate, all-things-considered, responses to specific situations are usually hyper-contextual and genuinely controversial (McGrath, 2008). We agree that no simple set of principles or rules can easily capture what ought to be done, all-things-considered, in each situation (Hursthouse, 1999, 56). Nonetheless, we believe that higher levels in the development and exercise of a few general ethical skills can allow agents to react, reason, and act better in morally relevant situations by displaying less biased considerations of the interests at stake, more refined deliberative capacities, clearer goals, and better motives. Some agents may make more carefully all-things-considered evaluations and decisions than individuals with lower levels of development in the exercise of these capacities. In our view, excellent performance in the essentially non-instrumental kind of reflection constitutive of practical wisdom can be conceived of as a specifically ethical kind of expertise, since it requires the development, exercise, and manifestation of skills that are necessary to deal with morally relevant situations.

Consequently, we have identified four fundamental ethical skills which characterize phronesis functioning and represent necessary conditions for its uprise, possibly showing psychological correlates. It is important to notice that, given the four skills involved, the kind of expertise in making moral decisions that we propose is not an intellectualistic one: phronetic agents are surely well-equipped for understanding the relevant moral issues and for grasping the right thing to do, but they are also more capable of actually doing that, namely, of acting consistently. Moreover, this kind of expertise is not a rationalistic one: phronetic agents surely act according to reason, but they do not leave emotions aside. On the contrary, they often experience “morally shaped” emotions and/or an emotionally oriented tendency toward good choices, thanks to the self-reinforcing circle of regulated emotions and moral virtuousness.

• (i) Moral perception:⁵ the ability to perceive/detect and conceptualize the morally relevant factors of situations and potential conflicts between them (conflict detection).

By ‘morally relevant factors,’ we mean that several objective morally relevant factors can be identified, on which basically every normative ethical theory agrees (while assigning different weights and priorities to them). A possible list of these factors includes: the production of pleasure and reduction of suffering; the realization or frustration of interests/preferences; the modification of the indicators of well-being; the recognition of which subjects are worthy of moral consideration; the respect or violation of rights, autonomy, and liberties; the respect/violation of justified moral norms; merit; equality and fair distribution of resources; and responsibility (see, e.g., Kagan, 1998).

A core aspect of expertise in any domain is a significant degree of intuitiveness in understanding and decision-making.⁶ Just like experts understand and deliberate more quickly and more easily than non-experts in their areas of expertise, in our view moral perception, conflict detection, and whether to engage or not in careful deliberation are skills that practically wise agents perform with greater automaticity and less effort than others in all-things-considered morally relevant decisions (see Dreyfus and Dreyfus, 1991). Usually, experts have large repertoires of chunks stored in memory—perceptual and semantic patterns derived from illustrative or prototypical examples of past cases—relevant to their domain of expertise that allow them to quickly recognize and retrieve relevant information. This allows experts to minimize their mental workload by efficiently chunking and organizing information and automating cognitive processes that are crucial for decision-making (Ericsson and Kintsch, 1995; Gobet, 1997, 2005; Widmayer, 2004; Bilalić, McLeod, and Gobet, 2009).

Apart from having excellent intuition, phronimoi also possess good metacognitive skills. This ability helps experts to decide appropriately, in front of complex choice problems, whether to rely on their intuition or to engage in further careful deliberation. In the case of all-things-considered decisions, phronimoi understand more quickly whether the situation at hand presents configurations of morally relevant aspects that they encountered previously, or whether the specific (novel or particularly complex) configuration of the situation calls for engagement in further deliberation. This explains why phronimoi are generally quicker in giving the correct response in familiar situations or relatively uncontroversial cases when there is a reasonably correct solution. However, in front of novel, complex, or controversial moral problems, practically wise agents may take more time than average to deliberate. Nonetheless, they would still identify more quickly than others whether there is a need to engage in further deliberation, and about what it is worth deliberating. On the contrary, non-phronimoi are likely to give quick, pre-reflective intuitive answers guided by habit even in novel, unfamiliar, and/or complex situations, while such situations would require more careful, contextual, and goal-oriented deliberation (see Greene, 2017).⁷ Finally, novices generally base their judgments on relatively simple, context-insensitive, and thus often inaccurate, heuristics.⁸

• (ii) Moral deliberation: the ability to represent different goals, outcomes, and courses of action, as well as the reasons supporting them, and to balance their relative worth.

Deliberation may be developed to an expert level and is subject to individual differences. Some training programs cultivate general decision-making competence (Seiler, Fischer, and Voegtli, 2011; Bruine de Bruin, Parker, and Fischhoff, 2020) and informal reasoning (Van Gelder, Bissett, and Cumming, 2004). The psychological literature on expertise (Hoffman, 1998; Feltovich, Prietula, and Ericsson, 2006) details the deliberative capacities developed with experience in certain fields. First, experts represent problems in more articulated and abstract ways, whereby the relevant concepts are deployed thoroughly and become interrelated in functionally meaningful ways. For example, expert firefighters interpret emergency scenarios dynamically, taking into consideration both their precedents and possible evolution, while novices decide based on immediately available and perceptually salient characteristics (Klein, Calderwood, and Clinton-Cirocco, 2010). Furthermore, experts’ reasoning process is more goal-oriented, sequential, and precise than the novices’ (Jeong, and Kim, 2022).

Moral deliberation is qualitatively different from other types of reasoning and requires skills not involved in other types of expertise (Hacker-Wright, 2015; Stichter, 2015): above all, it requires a critical evaluation and reflective comparison of ends—not just the means to achieve already established goals—in light of a broader conception of the good life. Research in moral psychology, supported by advances in cognitive neuroscience and computer science, has shown that moral decisions often involve an interplay (and sometimes a competition) between deliberative, goal-oriented, and prospective decision-making processes on the one hand (“System 2”) and intuitive, habitual, and retrospective processes on the other (“System 1”) (Greene et al., 2004; Cushman, 2013). Some scholars have suggested that the deliberative processes of the former kind are more reliable in the case of novel or complex moral deliberations (Greene, 2014). This type of deliberation relies on a mental representation of the available choice options, a sort of cognitive map of the choice environment, and the expected consequences (and consequences of consequences) of possible actions based on available information. This type of decision-making process (“model-based”) is much more dependable and flexible compared to automatic and intuitive decisions based on habit and affective learning (“model-free”), because it allows for real-time revising of the reference model, for instance, because of significant changes in the choice environment or new information pertaining to it. Ethical experts are better equipped to deliberate; they have a more lucid representation and navigate more effectively within the map of available choice options.

• (iii) Emotion regulation: the ability to reflectively endorse, detach from, or shape one’s affective experiences.

Decision-making in high-stakes situations requires excellent self-regulation skills, such as reward processing, risk management, and delay discounting. An emerging branch of cognitive psychology research calls such skills “hot” executive functions, underlying their equal importance to “cold” executive functions, involved in classical purely cognitive top-down processing (Zelazo and Carlson, 2012). This especially concerns ethical decisions, involving human-kind situations, which often solicit shaking emotions (Rozin et al., 1999; Greene et al., 2004). On the other hand, such human situations require some sensitivity from a decision-maker and attunement with one’s emotions to integrate rational and emotional components of every situation. This skill in moral decision-making often manifests as the weighting of emotional experience adequately to one’s goals, allowing its management, in terms of both down- and up-regulation (Helion and Ochsner, 2018).

We believe that an expert ability in emotional regulation is an essential feature of practical wisdom. Effective emotional regulation does not manifest as a submission or silencing of emotions to “reason” (according to the rationalist model spanning from Plato to Greene). However, it does not entail a complete overpowering of emotions over analytical and decision-making capacities either, since the latter can be compromised and biased when subjected to strong emotional influences (De Caro and Marraffa, 2016). Good emotional regulation involves integrating emotions into the decision-making process, with the awareness that they (both one’s own and those of others) can be important sources of information in morally salient situations. Therefore, effective emotional regulation may require both the ability to critically detach and reflectively endorse (or distance oneself) from one’s affective experiences and/or the reflective shaping and education of one’s emotional responses (Hursthouse, 1999).

Regarding these abilities, some could notice that psychopathic or extremely immoral individuals may be highly skilled in detecting morally relevant aspects of situations, understanding others’ mental states, and engaging in rational and consistent deliberation (Nichols, 2004); but obviously, since they employ such skills to harm others, such individuals should not be judged to be wise. Having a good grasp of what one ought to do, then, is not enough to qualify as practically wise; rather, it is required that one also act according to that grasp. In our view, this requirement can be rendered by the construct of moral motivation.

• (iv) Moral motivation: the ability (a) to care about moral aspects of life and (b) to act according to what one cares about.

This construct encapsulates two other essential aspects that phronimoi must possess. First, a phronimos should exhibit beyond average a heightened motivation to consider moral aspects of life, especially when conflicts between values are at play. Second, this fundamental motivation to morality needs to translate into actions that are consistent with the agents’ best judgments, beliefs, and actions. Practical wisdom does not just demand that one drily reflect on what makes possible ends worth(less) to pursue: wise agents, unlike akratic agents, act consistently with what they consider good or right, without facing significant motivational obstacles preventing them from doing what they believe should be done.⁹

In light of the considered features, we propose revising our working definition of “moral expert” as follows:

MORAL EXPERT* Agent W is an expert in the domain of morality with respect to population P only if W possesses outstanding moral perception, moral deliberation, emotion regulation, and motivation in all-things-considered decisions in that domain compared to others in P.

III. PRACTICAL WISDOM AS CROSS-SITUATIONAL ETHICAL EXPERTISE

The skills that we have identified as integral elements of practical wisdom not only encompass the intellectual features traditionally ascribed to phronesis but also the motivational aspects traditionally attributed to specific ethical virtues. This move aligns with our global reconceptualization of specific ethical virtues as manifestations of general ethical competence, phronesis. In this light, even the motivational facets traditionally associated with specific ethical virtues are to be understood as necessary aspects of the broader ethical competence (wisdom) that manifests through virtuous behavior within particular contexts (De Caro, Marraffa, and Vaccarezza, 2021). In other words, motivation, like all other features of wisdom, is not compartmentalized in different domains but is unitary throughout the entire moral domain. The more we observe virtuous behavior in different situations, the more we can infer the likelihood of an underlying capacity that enables and accounts for such behavior.¹⁰ This explains another necessary element in our account of phronesis: the cross-situationality of virtuous behavior as a privileged indicator of phronesis in real-life situations.

As previously said, we take practical wisdom as a peculiar kind of expert skill: practically wise agents possess an outstanding level of general but specifically ethical skills—moral perception, moral deliberation, emotion regulation, and moral motivation—to address complex, all-things-considered decisions. While the set of skills we identified may not be exhaustive, we believe it is essential for one to be considered an expert in all-things-considered decisions about what to do in specific situations (Swartwood, 2020).

Morally relevant decisions may be required in very diverse contexts (such as familiar interpersonal relationships and public choices). Consequently, a crucial element of our account is that practical wisdom should be conceived of as “cross-situational” ethical expertise—i.e., excellent performance in the aforementioned ethical capacities across situations that require all things considered decisions about what should be done. We suggest that a constitutive aspect of phronesis is the ability to perceive, deliberate, and act well in morally relevant scenarios stably and consistently across diverse situations and contexts, including novel and complex ones. In other words, ethical expertise should be transferable across situations.¹¹ The higher the number of situations and the greater the “distance” between situations or domains in which an agent possesses and applies outstanding levels of the aforementioned capacities, the higher the likelihood that such a cross-situational competence is explained by the presence of a higher-level psychological trait rather than by specific competencies or experiences relative to each domain or situation (De Caro, Marraffa, and Vaccarezza, 2021). Hence:

MORAL EXPERT** Agent W is an expert in the domain of morality with respect to population P only if W possesses outstanding moral perception, deliberation, emotion regulation, and motivation in all-things-considered decisions across different situations in that domain compared to others in P.

As said, our proposal promotes a paradigm shift in virtue ethics, from the primacy of a dualistic model, which partitions character into two heterogeneous kinds of character traits (i.e., the ethical virtues and phronesis as an intellectual virtue or as a meta-virtue), to an integrated account of a virtuous character in terms of the possession of ethical expertise as a comprehensive and cross-situational meta-skill (phronesis). Here, we have argued that cross-situational virtuous behavior can be traced back to the possession of ethical expertise, an expert set of skills typical of the practically wise, that fully explains virtuous perception, deliberation, emotion regulation, and motivation. To put it differently, character dualism should be overcome in favor of seeing practical wisdom as the only—not just the main—virtue governing ethical life, and the traditional ethical virtues should be seen as useful labels that name practical wisdom’s manifestations in different kinds of situations. A phronetic doctor is in the best position to identify the proper virtuous behavior in each situation, no matter how nuanced it may be. Turning back to our initial clinical case, Liza’s doctor—if equipped with phronetic character—is able to understand how much to nudge her toward considering the additional treatment as proportionate and when instead it is better to step back. Since many clinical situations are not straightforward and the efficacy of treatments is uncertain, particular decisions and clinical communication should be handled with phronetic care, in addition to clinical competence. While we cannot delve deeper into the notion of phronetic care here, it suffices to say that being a good doctor involves being careful, which in turn means being phronetic or virtuous. In this specific case, the more phronetic or virtuous the doctor, the more careful, skilled, and successful.

Applying our definition of the moral expert to this new doctor, we can assert that to be recognized as phronetic, in addition to his professional expertise, he must possess outstanding moral perception, deliberation, emotion regulation, and motivation in all-things-considered decisions across various situations in that domain. In other words:

• (a) To be morally sensitive, the doctor must perceive the values and virtuous behaviors at stake: Of what is Liza afraid? What role does her family play? What are her priorities? What actions are crucial for the doctor in this specific situation?

• (b) To deliberate correctly, the doctor must understand the moral goals and reasons for the chosen action: What are the potential consequences if Liza starts the treatment but does not benefit from it immediately? How can the doctor support her self-determination? Is suggesting early palliative care to enhance her well-being and decision-making appropriate?

• (c) To be emotionally balanced, the doctor must empathize with Liza’s suffering while also maintaining enough distance to see the situation as a whole.

• (d) To be adequately motivated, the doctor must aspire to excel both as a professional and as a person. This entails wanting to behave well and to embody the qualities of a virtuous practitioner, which in this context primarily involves delivering comprehensive and compassionate care.

IV. CONCLUSION

We have interpreted phronesis as a form of cross-situational ethical expertise, which includes perceptual, deliberative, emotional, and motivational features. In the future, we aim to corroborate the validity of this conception by means of empirical investigations exploring the constitutive skills of practical wisdom; meanwhile, an arguably very valuable educational implication can be drawn from it. Our model allows one to challenge the “standard view” in character education that sees it as primarily a matter of habituating distinct character traits, i.e., fostering behavior associated with such virtuous traits (Kristjánsson and Fowers, 2022). Our proposal, instead, puts the core ethical skills at the center of character educational projects, with potentially significant impact also on health professional ethics, medical formation, and continuing education in medicine. By teaching the abilities that constitute phronesis, our account would gradually provide developing moral agents with a more flexible critical ability to detect the elements that make a situation morally relevant, to deliberate well, and to act well in the widest variety of contexts, with special reference to doctor-patient relationship and clinical context.¹² Furthermore, this approach makes the endless production of lists of virtues—sometimes relative to specific (even obsolete) historical and cultural contexts—unnecessary. In this sense, philosophers would no longer need to think about which traits would be the most appropriate in given situations or domains, thus avoiding the risk of an “unconstrained proliferation of virtues” (De Caro, Marraffa, and Vaccarezza, 2021).¹³

REFERENCES

Footnotes