I did not study philosophy as an undergraduate, but perhaps I should have. Apparently I would have facilitated my path to medical school.1 And perhaps I would have gained some insight into how best to care for my new patient with atrial fibrillation. She was admitted from the emergency department, short of breath and with a racing heart. Her EKG confirmed atrial fibrillation so she came to the telemetry floor on a diltiazem drip which slowed her heart rate from 150 down to around 100. On further exploration of her history she had been having episodes like this for the past few months, all resolving spontaneously until now. Her echo showed some left atrial enlargement, and she was concerned that her heart “was betraying her.” We discussed rate versus rhythm control, stroke risks and what ongoing care and follow up she would need.
The multiple questions regarding what is best for my patient are informed by scientific evidence, but do not end there. This woman will need to continue to see medical providers and the next step in her care will involve conversations with her regarding her activity goals, her stroke risk, and her home situation. How confident am I in her follow up with a primary care provider? The answer to this last question will likely depend on the relationships between primary care and cardiology, and both of those tied into payor source. As I stare at the chart and sit talking to her, whatever medical “good” I can offer her is complicated by a myriad of factors that have to do with my skill as a clinician, the depth of our physician-patient relationship, and both her and my role in our larger society. Ultimately, I am her physician, and there will be no “good” at all until I make a decision and act.
The physician’s job combines both an intellectual component and a practical component, often referred to as the science and art of medicine. I can apply good scientific evidence to atrial fibrillation care, the intellectual component. Yet, no study entirely comprehends my patient’s particular health issues, community and family support or insurance payor – so decisions about care require wisdom, or the practical component. Aristotle wrote about this particular dualistic nature of thinking in The Nicomachean Ethics, and called it phronesis, or practical wisdom.
Phronesis , then, must be a reasoned and true state of capacity to act with regard to human goods.2
Aristotle pulls in the initial requirement of “reasoned” in creating the capacity to act, and then completes his definition with action in the service of “human goods.” Numerous commentators have remarked how well this formulation seems to fits the physician-patient relationship:
(1) Phronesis deals with human affairs…; (2) it deals with things that can be otherwise; (3) it deals with things that have a telos [a known goal]; (4) for phronesis it is more important to know… the particular situation, and to reach a decision here and now, than to know only the principles in a universal and abstract way.3
When no formula is available we have to act kata ton orthon logon (‘according to right reason’).4 The only way to have “right reason” is to be steeped in intellectual virtue, i.e. to have studied at medical school followed by residency, but also moral virtue, which is defined by the end goal of being a human.
For my patient with new atrial fibrillation, as her medical situation becomes complex, the goal of our care as physicians becomes less clear. We conveniently label these gradations in care, “full care” or “palliative care,” but the reality for a patient is often much more subtle. Some patients want full care but still choose aspirin as anticoagulation simply due to its ease of use. The telos, or goal, essential to Aristotle’s use of practical wisdom, is just as essential to a physician’s interaction with the patient. Without knowing the patient’s desires, aspirations and habits, choosing medical treatments will be nonsensical. “All human activities aim at some good,” opines Aristotle, and he deems this good to be “happiness.”5 In medicine, we aim at maximizing the health of patients, and recently have realized that this more often means asking them, “What is a good day for you? How can I help you reach a goal which is realistic for you? What is your happiness?”
As I struggle with a leadership role in my hospital, I have re-read The Nicomachean Ethics. The practical wisdom of Aristotle resonates with me regarding modern healthcare. Our intellectual knowledge of medicine has never been stronger, with daily journal publications, and yet as knowledge-based computer systems become more sophisticated so that access to that body of information is easier, the physician’s role in applying practical wisdom seems to also grow in importance.
Long after Aristotle, Immanuel Kant and other modern philosophers rationalized moral action away from the classical view of virtue ethics. Kant famously proposed duties, or things that were good in and of themselves, the so-called “categorical imperative.” Gone were the nuances of practicality in Aristotle, replaced with rational ends that must be pursued by everyone in all situations. I wonder if this categorical imperative gave birth to paternalism in medicine, and the rebellion against it certainly laid the foundations for the loss of shared moral meaning.6 Pluralistic societies realized that one person’s categorical imperative is only another person’s foolish custom, leading to the post-modern ethical position that “all moral judgments are nothing but expressions of preference, expressions of attitude or feeling.”
Years ago I practiced full-spectrum medicine in a small rural clinic. In that setting when there was a question as to what care to offer in a complex situation, after explaining the facts as best I could, I always asked the patient, “what do you want to do?” Often the reply would be, “what do you think is best?” I could ask my one partner in the clinic, who would give me his opinion, and of course I could read what science had to say in my bookshelf. Ultimately I made the choice alone, as did every other practitioner I knew in a few hundred mile radius. Occasionally I saw patients who had gone to these other doctors, and often I pondered the medical decisions they had made due to over-utilization – is that because they do these tests in their offices and personally benefit from them? – and sometimes what appeared to be missed diagnoses but might have simply been a “practice style.” In the complex cases, the really important ones for people as they face a health crossroads, I had no other objective means of evaluating others’ decisions. How can we recapture practical wisdom in a pluralistic world?
Often, while I am caring for patients in the hospital and working with my entire team of therapists, nurses and discharge planners, I feel like a citizen of the old Athenian city-state. We interact based on what Aristotle would call friendship: “it is a virtue or implies virtue…, it aids older people by ministering to their needs and supplementing the activities that are failing from weakness.”7 My team works together based on shared skills and excellence, we judge each other’s actions based on their “virtue” towards the patient whereby an incompetent nurse or doctor is not ignored. And yet our relations are cordial, even friendly, throughout our daily interactions in the service of patients. Like nowhere else in our current culture, my hospital work bears out Aristotle’s claim that “every art and every inquiry, and similarly every action and pursuit, is thought to aim at some good…”8
Inside my health system, the telos for patients is quite clear, and in fact summarized in its mission statement: “Care you can have faith in.” Like all health systems, we strive to provide a continuum of care with the goal of maximizing our patients’ health. Every day, staff show up to work and assume their shared place in our common city-state, subsuming our outside roles to our shared telos of the patient “good.” And because we share a common end-goal for patients, the physician’s practical wisdom comes back in to play. We can use our intellectual wisdom, combine it with our practical wisdom, as we make diagnoses and implement treatments that are scientifically based but individually-tailored to each specific person in his or her context. The rest of my culture is fragmented in the post-modern world, but at work the classical model of virtue ethics harmonizes actions, day after day.
My health system, as every health system in America, is undergoing fundamental changes as we move from volume-based payments to value-based payment systems. This transition is painful as it disrupts how we are able to provide the best care. As we face the changes in reimbursement, I find it remarkable how our telos for patients has remained unchanged. The physician’s social contract has always required the best interests of patients and continues to do so regardless of the payor system. Many of my colleagues are understandably nervous regarding the emphasis on cost-control with new bundled payment programs, or the preoccupation with “metrics” under MIPS and MACRA. These programs are supposed to re-orient health systems, and their doctors, to value rather than volume. Aristotle prefigured these attempts by 2500 years, reminding us that we should not move from volume to value, but from volume to virtue.
- Paul, Jung. “Major Anxiety: If You Think Biochemistry Is Your Ticket Into Medical School, Think Again.” The New Physician Sep. 2000: n/a. Major Anxiety. Web. 13 May 2014.
- Aristotle. The Nicomachean Ethics, trans. David Ross. New York: Oxford University Press, 1998. Page 143.
- Braude, Hillel. Intuition in Medicine: A Philosophical Defense of Clinical Reasoning. Chicago: University of Chicago Press, 2012. Page 44.
- Aristotle. Page 152.
- Aristotle. Page 1.
- MacIntyre, Alasdair. After Virtue. Notre Dame: University of Notre Dame Press, 1984. Page 12.
- Aristotle. Page 192.
- Aristotle. Page 1.