In a recent article in the Chronicle of Higher Education (1), Prof. David Hoekema considers how virtue is taught on college campuses. He suggests that the “unacknowledged” ethicists on campuses fall generally into three categories: professors (of all disciplines, by virtue of the examples they set in the way they teach and administer their courses and live their lives), student-life staff (as they help students discern their own intentions and values), and student leaders (who by their community endeavors and accomplishments serve as peer-to-peer moral exemplars).
As an “acknowledged” ethicist at a medical school, I am drawn to Prof. Hoekema’s discussion and its concrete engagement of the means by which academic communities may attempt to encourage moral growth and virtuous practice among adult learners. And as a physician-ethicist involved in the professional development of future physicians, I am particularly interested in the potential for ethics education and training to translate into ethical practice in a profession that is all about making decisions that are, at their root, moral. In medicine, this combination of morality and decision making invites a close consideration not only of virtue in general but of a particular virtue – that of practical wisdom.
Physicians are trained to solve medical problems, and these problems are often highly demanding due to the complex manifestations of disease and the multiplicity of diagnostic and therapeutic alternatives. Moreover, the presentation of disease as an experience of illness means that patients present themselves to physicians through multiple dimensions of human experience (biological, psychological, social, spiritual), and the unfolding of illness in real time means that decisions must often be made amidst uncertainty – either due to incomplete information or the unclear wishes of patients or their surrogates. These demands reflect the need for practical wisdom.
What might practical wisdom in medicine look like? To approach this very large question, we do well to consider how practical wisdom has been understood in the past, especially by thinkers whose influence has been sufficiently potent to endure into our own time. Aristotle’s phronesis (2) and Thomas Aquinas’ prudentia (3) both serve as rich and related repositories from which to gain an understanding of what practical wisdom entails and how practical wisdom is inseparable from a larger framework of virtue and ethics (at least within Aristotelian and Thomistic traditions).
My reading of these historical resources leads me to conclude that the search for practical wisdom in medicine raises a number of basic questions. What are the worthwhile goals of medicine? What vision of human flourishing should inspire these goals? How does the empirical work of medicine (gathering and organization of facts) inform its ethical judgments? Which ethical frameworks have the capacity to support practical wisdom? How can we deliberate in medicine in such a way as to integrate goals, concrete circumstances, and moral virtues and principles – and make that integration transparent? And lastly, how can education and training in medical ethics enhance the motivation that learners need to have in order to make them act on (and not only think about) their ethical judgments?
I read Prof. Hoekema’s assessment of the ethical resources available on college campuses as evidence of his vision of a college campus as a community of moral agents who share a common moral space that has the potential to encourage moral growth among students. Such a vision should resonate with medical educators, especially given the particular practice (of medicine) that is the defining professional feature of their moral enterprise. Academic medical centers are communities of practice in a very special sense, and it is in the midst of these communities that practical wisdom can be learned, if novices are sufficiently guided and supported as they struggle, through success and failure, to gain something that comes only through experience. But experience alone is no guarantee, since the cultivation of practical wisdom requires an integration of multiple domains – clinical reasoning, ethical analysis, moral motivation, and professional identity – as well as dedicated effort by both institutions and educators. Creating training environments marked by such integration is an invitation for substantial and enduring engagement. I wonder what the prospects for such engagement in medical schools may be.
by Lauris Kaldjian, M.D., Ph.D., University of Iowa
References
1. Hoekema, David. The unacknowledged ethicists on campuses. Chronicle of Higher Education, January 24, 2010 (http://chronicle.com/article/The-Unacknowledged-Ethicists/63681/).
2. Aristotle. Nicomachean Ethics. Indianapolis: Bobbs-Merrill Educational Publishing; 1962.
3. Aquinas, Thomas. Summa Theologica: a concise translation. Westminster, MD: Christian Classics; 1989.
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