Aristotelian Practical Wisdom (Phronesis) as the Key to Professional Ethics in Teaching.

This article is about a virtue ethical approach to the professional ethics of teaching, centred around the ideal of phronesis (practical wisdom) in an Aristotelian sense. It is grounded empirically in extensive research conducted at the Jubilee Centre for Character and Virtues into teachers and other UK professionals, and it is grounded theoretically in recent efforts to revive an Aristotelian concept of phronesis as excellence in ethical decision-making. The article argues for the need for a virtue-based approach to professional practice, based on time-honoured Aristotelian assumptions and culminating in a conceptually viable construct of phronesis as a psycho-moral integrator and adjudicator. After setting some of the historical background in Sect. 1, Sect. 2 charts the most relevant empirical findings. Section 3 introduces a call for phronesis as a guide to virtue-based professional ethics: its role, nature, and methods of instruction. Section 4 adds some caveats and concerns about if and how phronesis can be cultivated as part of teacher training. Finally, Sect. 5 offers some concluding remarks about the novelty and radicality of the approach on offer in this article.

Theranostics: Timing is Everything.

On stage, and in real life, timing is critical for success. Theranostic cancer care epitomizes the central role of timing in the evolution of efficacious molecular targeted radioligand therapy and its incorporation into routine clinical practice of oncology. Nuclear medicine has returned to its therapeutic roots, having been founded as a medical specialty, over three-quarters of a century ago, with radioiodine therapy of thyroid cancer. The very recent oncologist acceptance of 68Ga/177Lu/225Ac-PSMA effectiveness in treating prostate cancer has re-established the role of the physician in nuclear medicine. This article addresses various important issues in respect of timing related to this resurgence. Training of the required new workforce in technical -omics expertise and physicianly virtues is an urgent priority. Precision in radioligand therapy requires definition of individual radiation absorbed dose (Gy) to tumor and to critical normal organs, preferably prospectively. It is time to abandon one-size-fits-all administration of fixed activities (GBq) in arbitrary cycle intervals and duration. The time has also come to design combination sequenced theranostic-immuno-chemotherapeutic approaches to metastatic cancer to address unmet needs, particularly in pancreatic carcinoma; exploiting the potential of new fibroblast activation protein inhibitor radioligands targeting the tumor microenvironment. Public perception of all things "nuclear," including nuclear medicine, has recently recovered from the general opprobrium and radiophobia of the last half-century. Nuclear is the new green. At last, there have arisen propitious circumstances for the future development of theranostics: The timing is right, now.

Discovering clinical phronesis.

Phronesis is often described as a 'practical wisdom' adapted to the matters of everyday human life. Phronesis enables one to judge what is at stake in a situation and what means are required to bring about a good outcome. In medicine, phronesis tends to be called upon to deal with ethical issues and to offer a critique of clinical practice as a straightforward instrumental application of scientific knowledge. There is, however, a paucity of empirical studies of phronesis, including in medicine. Using a hermeneutic and phenomenological approach, this inquiry explores how phronesis is manifest in the stories of clinical practice of eleven exemplary physicians. The findings highlight five overarching themes: ethos (or character) of the physician, clinical habitus revealed in physician know-how, encountering the patient with attentiveness, modes of reasoning amidst complexity, and embodied perceptions (such as intuitions or gut feeling). The findings open a discussion about the contingent nature of clinical situations, a hermeneutic mode of clinical thinking, tacit dimensions of being and doing in clinical practice, the centrality of caring relations with patients, and the elusive quality of some aspects of practice. This study deepens understandings of the nature of phronesis within clinical settings and proposes 'Clinical phronesis' as a descriptor for its appearance and role in the daily practice of (exemplary) physicians.

Theranostic Innovation by Humane N-of-One Cancer Care in Real-World Patients.

Patients with relapsed or refractory metastatic cancer unresponsive to standard therapies have motivated nuclear physicians to develop innovative radioligands, precisely targeted to tumor molecular receptors, for effective treatment of specific advanced malignancies. Individual practitioners in departments of nuclear medicine across the world have performed first-in-human studies on compassionate patient usage N-of-One protocols. These physician-sponsored studies then evolved into early-phase clinical trials and obtained real-world data to demonstrate real-world evidence of effectiveness in prolonging survival and enhancing quality of life of many so-called "End-Stage" cancer patients. Virtually all the therapeutic radiopharmaceuticals in current clinical oncology have been discovered and developed into effective specific treatments of targetable cancers by individual doctors in the course of their hospital practice. Pharma industry was not involved until many years later when performance of mandated Phase 3 randomized controlled trials became necessary to achieve regulatory agency approval. This article traces the history of several novel theranostic agents developed from compassionate N-of-One studies by hospital physicians over the past 36 years. It acknowledges the collegiality and collaboration of individual nuclear medicine specialists, worldwide, in pioneering effective humane therapy of particular advanced cancers unresponsive to conventional treatments.

A virtuous framework for professional reflection.

Reflection on professional practice (either individually or in dialogue with peers or seniors) will often focus on doctors' skills. This approach emphasises compliance and competence. This paper suggests that an alternative and useful lens for professional reflection and development can be drawn from the framework of virtue ethics to encourage consideration of the ultimate purpose of medicine, and the character or virtues needed to be a good doctor. This alternative approach supports doctors to reflect on and develop their virtues, including practical wisdom, which orchestrates the doctor's skills and virtues. This emphasis on purpose and character within professional reflection promotes excellence, rather than just competency, and engages with what motivated most doctors to enter medicine.

Scrubbing With Aristotle: Cultivating Surgical Wisdom through Inflection Points.

Surgical educators and researchers have well-considered a breadth of topics related to surgery. However, there is one concept that is notably absent in this corpus: surgical wisdom. In this perspective, we draw on work from Aristotle and psychology research to introduce the concept of phronesis, which we believe is useful for understanding surgical wisdom. We further illustrate how this concept can be a useful tool for surgical educators through the discussion of four distinct functions of phronesis, and illustrating the ability of these functions to help learners cultivate knowledge at important decision points, or inflection points, in surgical training and a surgical career.

Triangle of Trust in Cancer Care? The Physician, the Patient, and Artificial Intelligence Chatbot.

Trust, as a philosophic paradigm, is predominantly interpersonal, between human beings, and is differentiated from reliance. Can a person trust an inhumane amoral agent, such as a large language model artificial intelligence (AI) chatbot, to manifest the goodwill and willingness normally required in order for it to be deemed trustworthy? This article explores the relationship between the cancer patient, their physician, and AI chatbot in a proposed tripartite, consultative, personalized approach to shared-care in precision molecular oncology. It examines the nature of trust between human agents and machines. It also contemplates AI-enhanced technical precision in state-of-the-art cancer management, complemented by trustworthy, holistic clinical care by a physician, for each individual patient. "To what extent can the user "trust" GPT-4?" Peter Lee,1 Microsoft Research 2023.

Ethical sense, medical ethics education, and maieutics.

CONTEXT: The toolbox of instructional methods available to medical ethics educators is richly stocked and well-catalogued. However, the history of ideas relating to its contents is relatively under-researched in the medical education literature. HISTORY: This paper proposes an approach to professional medical ethics education that adapts the ancient maieutic, question-asking method associated with Socratic dialogue, and particularly its uptake in educational theory developed by nineteenth and twentieth century American pragmatic philosophers, who in turn were profoundly influenced by the eighteenth century Common Sense school of philosophy from the Scottish Enlightenment. THEORY: The 'ethical sense' postulated in this article is a distant echo of moral sense in Scottish Enlightenment thought. However, ethical sense as posited here is not the natural faculty variously theorised by Scottish Enlightenment philosophers such as Francis Hutcheson and Thomas Reid, but derives from the pre-understandings of students with respect to professional medical ethics. CONCLUSIONS: The ethics educator can engage the ethical sense of students through maieutic 'teaching and learning by asking' in relation to actual clinical narratives, beginning not with the teacher's questions but importantly with those of the learners based on what they would need to know in order to determine the professional ethical obligations entailed.

Philosophy of Cancer Theranostics.

Imagine a theranostic nuclear physician oncologist engaged in a Socratic philosophic dialogue. Questions that may be posed include the status of our current knowledge base of radiomolecular tumor biology, the meaning of precision in personalized dosimetry, the nature of responsibility for direct patient care, and the moral and ethical dimensions of individual quality of life (QOL) when survival is prolonged. This review invites reflective enquiry into one's personal practice of theranostics in cancer care, with the objective of optimizing clinical outcomes, not only in terms of prolonged survival but also individual QOL, in respect of its meaning for each patient, both physically and emotionally.

On Moral Nose.

There are many authors who consider the so-called "moral nose" a valid epistemological tool in the field of morality. The expression was used by George Orwell, following in Friedrich Nietzsche's footsteps and was very clearly described by Leo Tolstoy. It has also been employed by authors such as Elisabeth Anscombe, Bernard Williams, Noam Chomsky, Stuart Hampshire, Mary Warnock, and Leon Kass. This article examines John Harris' detailed criticism of what he ironically calls the "olfactory school of moral philosophy." Harris' criticism is contrasted with Jonathan Glover's defense of the moral nose. Glover draws some useful distinctions between the various meanings that the notion of moral nose can assume. Finally, the notion of moral nose is compared with classic notions such as Aristotelian phronesis, Heideggerian aletheia, and the concept of "sentiment" proposed by the philosopher Thomas Reid. The conclusion reached is that morality cannot be based only on reason, or-as David Hume would have it-only on feelings.

Life-Saving Cancer Care.

What, precisely, are we seeking to achieve in offering 'life-saving' treatment to patients with cancer? Research funding agencies and pharmaceutical industry media releases, and government cancer screening programs all promise that their cancer programs save lives. But everybody dies. The nature of life and death from cancer is explored philosophically in this essay, with particular reference to the quality of life, and its meaning, during the period of prolongation of survival by 'life-saving' cancer care.

Responsible Radionuclide Cancer Care.

The landscape of nuclear oncology is rapidly changing. The advent of molecular radionuclide theranostics, multidisciplinary tumor board decision making, artificial intelligence and radiomics interpretation of diagnostic imaging, evolution of pharmacogenomics prediction of tumor response, and regulatory requirements for prospective individual dosimetry are just some of the elements which are broadening the essence of physician responsibility. The burgeoning knowledge base essential for mastering the emergent technologies, and their profound effect on moral philosophic aspects of provision of cancer care, are challenging. The new relationship of the theranostic nuclear physician with respect to shared care of the individual patient, particularly with regard to transparency, accountability, and responsibility for targeted radionuclide diagnosis and therapy of cancer, will be explored in this update.

How rural nurses in Southern New Zealand navigate their ethical landscape-A qualitative study.

OBJECTIVE: To explore rural nurse experiences of ethical issues and their management of these as a first step in a programme of work to address rural nurses' ethical needs. DESIGN: This study was qualitative, using mixed qualitative techniques to gather data, which was analysed using a general inductive approach. SETTING: Primary health care in 2 regions of Aotearoa New Zealand. PARTICIPANTS: Eleven nurses working in the West Coast (District Health Board) region and 9 working within the Southern District Health Board region. INTERVENTION: Participants took part in either a focus groups or an interview with members of the research team. MAIN OUTCOME MEASURES: To document ethical issues that confronted these rural nurses and how they navigated these issues. RESULTS: Three themes were identified: 'Signals and Silences,' 'One and Other' and 'Frustrations and Freedoms.' A continuous thread through these themes was the concept of phronesis, or what is sometimes called practical virtue. This practical virtue largely developed through their own experiences, rather than through educational or health system specific support or resources. CONCLUSIONS: We found that rural nurses' deal with specific issues related to the rural setting, such as resourcing and isolation, while maintaining a relationship with the communities they serve and their professional autonomy. Additionally, we discovered the ways in which rural nurses deal with the ethical issues they encounter to be practically focussed. However, rural nurses need supportive leadership not only to sustain the moral agency they demonstrate but also to further develop their ethical decision-making practices. The provision of a clinical ethics tele-service delivering both training opportunities and an on-call consult support service would provide a potential solution.

Using practical wisdom to facilitate ethical decision-making: a major empirical study of phronesis in the decision narratives of doctors.

BACKGROUND: Medical ethics has recently seen a drive away from multiple prescriptive approaches, where physicians are inundated with guidelines and principles, towards alternative, less deontological perspectives. This represents a clear call for theory building that does not produce more guidelines. Phronesis (practical wisdom) offers an alternative approach for ethical decision-making based on an application of accumulated wisdom gained through previous practice dilemmas and decisions experienced by practitioners. Phronesis, as an 'executive virtue', offers a way to navigate the practice virtues for any given case to reach a final decision on the way forward. However, very limited empirical data exist to support the theory of phronesis-based medical decision-making, and what does exist tends to focus on individual practitioners rather than practice-based communities of physicians. METHODS: The primary research question was: What does it mean to medical practitioners to make ethically wise decisions for patients and their communities? A three-year ethnographic study explored the practical wisdom of doctors (n = 131) and used their narratives to develop theoretical understanding of the concepts of ethical decision-making. Data collection included narrative interviews and observations with hospital doctors and General Practitioners at all stages in career progression. The analysis draws on neo-Aristotelian, MacIntyrean concepts of practice- based virtue ethics and was supported by an arts-based film production process. RESULTS: We found that individually doctors conveyed many different practice virtues and those were consolidated into fifteen virtue continua that convey the participants' 'collective practical wisdom', including the phronesis virtue. This study advances the existing theory and practice on phronesis as a decision-making approach due to the availability of these continua. CONCLUSION: Given the arguments that doctors feel professionally and personally vulnerable in the context of ethical decision-making, the continua in the form of a video series and app based moral debating resource can support before, during and after decision-making reflection. The potential implications are that these theoretical findings can be used by educators and practitioners as a non-prescriptive alternative to improve ethical decision-making, thereby addressing the call in the literature, and benefit patients and their communities, as well.

The fundamental role of storytelling and practical wisdom in facilitating the ethics education of junior doctors.

Practical wisdom is a key concept in the field of virtue ethics, and it has played a significant role in the thinking of those who make use of virtue when theorising medical practice and ethics. In this article, we examine how storytelling and practical wisdom play integral roles in the medical ethics education of junior doctors. Using a qualitative approach, we conducted 46 interviews with a cohort of junior doctors to explore the role doctors feel phronesis has in their medical ethics practice and how they acquire practical wisdom through storytelling as an essential part of their medical ethics education. Through thematic analysis of the interviews, we discuss the key role storytelling about moral exemplars and role models plays in developing medical ethics education, and how telling stories about role models is considered to be one of the most useful ways to learn medical ethics. We finish by developing an argument for why practical wisdom should be an important part of medical ethics training, focusing on the important role that phronesis narratives should have in teaching medical ethics.

Professional judgement in clinical practice (part 3): A better alternative to strong evidence-based medicine.

Parts 1 and 2 in this series of three articles have shown that and how strong evidence-based medicine has neither a coherent theoretical foundation nor creditable application to clinical practice. Because of its core commitment to the discredited positivist tradition it holds both a false concept of scientific knowledge and misunderstandings concerning clinical decision-making. Strong EBM continues attempts to use flawed adjustments to recover from the unsalvageable base view. Paper three argues that a promising solution is at hand if we can manage several modes of inclusion. A modified original, moderate version of EBM continues though usually overshadowed. As definitively laid out by Sackett in the 1990s, clinical decision making is intended to be person-centered, recognizing and integrating multiple modes of evidence and knowledge that have been marginalized: professional experience, illness narratives, and individual patients' values and preferences. Complementary resources are at hand: interpretative understanding and practice, such as philosophical anthropology, hermeneutical phenomenology, complexity theory, and phronetic practices respond to the major problems and open new possibilities. Phronesis is especially important in regard to public decision making. Within part 3 an additional tone necessarily occurs. While most of papers 1, 2, and 3 are written in the classical mode of contrasting the theoretical-logical and empirical evidence offered by contending positions bearing on the decision making and judgement in clinical practice, a shift occurs when considerations move beyond what is possible for clinical practitioners to accomplish. A different, discontinuous level of power operates in the trans-personal realm of instrumental policy, insurance, and hospital management practices. In this social-economic-political-ethical realm what happens in clinical practice today increasingly becomes a matter of what is "done unto" clinical practitioners, of what hampers their professional action and thus care of individual patients and clients.

Psychotherapy as a skilled practice.

While psychotherapy is related to both science and art, it is primarily a craft activity requiring the development of skilful practice, epitomized by the discipline of the analytic attitude. In terms of the forms of knowledge outlined by Aristotle, this places psychotherapy in the realm of 'technê' (arts and craft) rather than epistêmê (science). In particular, the technê of psychotherapy is concerned with the development of phronesis (practical wisdom) in both patient and analyst and its ultimate aim is concerned with the promotion of eudaimonia, a state of well-being considered by Aristotle to be definitive of 'the good life'. It is therefore fundamentally an ethical endeavour. The nature of psychotherapeutic skill is illustrated by analogy with three other forms of technê - music, meditation and pottery. Clinical examples illustrate the crafting of interpretations and the art of patient holding.

Alors que la psychothérapie est rattachée à la fois à la science et à l'art, il s'agit en premier lieu d'une activité artisanale qui requiert l'acquisition d'une aptitude pointue, incarnée par la discipline de l'attitude analytique. Se référant aux formes de savoir énoncées par Aristote, la psychothérapie se situe dans le domaine de « technê ¼ (les arts et l'artisanat) plutôt que celui d' « epistêmê ¼ (la science). Notamment, le technê de la psychothérapie concerne le développement de phronesis (la sagesse pratique) à la fois chez le patient et l'analyste. Son but ultime est de promouvoir l'eudaimonia, un état de bienêtre qu'Aristote considère comme le signe de «la vie bonne¼. De ce fait il s'agit d'une œuvre fondamentalement éthique. La nature du savoir-faire de la psychothérapie est illustrée par une analogie avec trois autres formes de technê - la musique, la méditation, et la poterie. Des exemples cliniques illustrent le façonnement des interprétations et l'art de « bien tenir ¼ le patient.

Si bien la psicoterapia se relaciona tanto a la ciencia como al arte, se trata principalmente de una actividad artesanal que requiere el desarrollo de una práctica calificada, encarnada en la disciplina de la actitud analítica. En los términos de las formas de conocimiento descriptas por Aristóteles, esto ubica a la psicoterapia en la dimensión de la 'technê' (artes y oficios) en lugar de la 'epistêmê' (ciencia). En particular, la technê de la psicoterapia concierne al desarrollo de la phronesis (sabiduría práctica) en ambos paciente y analista, y su meta principal atañe a la promoción de la eudaimonia, estado de bienestar considerado por Aristóteles como característico de 'la buena vida'. Es por lo tanto, fundamentalmente, una labor ética. La naturaleza de la habilidad psicoterapéutica es ilustrada en analogía con otras tres formas de technê - música, meditación y cerámica. Ejemplos clínicos ilustran el oficio artesanal de la interpretación y el arte de contener al paciente.

Child health care nurses' use of teaching practices and forms of knowledge episteme, techne and phronesis when leading parent education groups.

This study explores child health care nurses' pedagogical knowledge when supporting parents in their parenthood using various teaching practices, that is how to organise and process the content during parent education groups in primary health care. The aim is to identify teaching practices used by child health care nurses and to analyse such practices with regard to Aristotle's three forms of knowledge to comprehensively examine child health care nurses' use of knowledge in practice. A qualitative methodological design alongside the analysis of video-recordings was used. The results showed that child health care nurses used four teaching practices: lecturing, demonstration, conversation and supervision. Their use of episteme was prominent, but they also seemed to master techne in combination with episteme during the first three teaching practices. During the conversation teaching practice, the child health nurses rarely succeeded. Consequently, they missed opportunities to identify mothers' expressed concerns and to act in the best interests of both the mothers and their infants by the use of phronesis. In health care, however, theoretical episteme is superordinate to productive knowledge or phronesis, which also became evident in this study. Nevertheless, more interactive pedagogical practices are needed if more use of phronesis is to become a reality in parent education groups.

Phronesis in Medical Ethics: Courage and Motivation to Keep on the Track of Rightness in Decision-Making.

Ethical decision making in medicine has recently seen calls to move towards less prescriptive- based approaches that consider the particularities of each case. The main alternative call from the literature is for better understanding of phronesis (practical wisdom) concepts applied to decision making. A well-cited phronesis-based approach is Kaldjian's five-stage theoretical framework: goals, concrete circumstances, virtues, deliberation and motivation to act. We build on Kaldjian's theory after using his framework to analyse data collected from a three-year empirical study of phronesis and the medical community. The data are a set of narratives collected in response to asking a medical community (131 doctors at various stages of their careers) what making ethically wise decisions means to them. We found that Kaldjian's five concepts are present in the accounts to some extent but that one of the elements, motivation, is constructed as playing a different, though still crucial role. Rather than being an end-stage of the process as Kaldjian's framework suggests, motivation was constructed as initiating the process and maintaining the momentum of taking a phronesis-based approach. The implications for medical ethics decision-making education are significant as motivation itself is a highly complex concept. We therefore theorise that motivation is required for leading in, continuing and completing the actions of the ethical decision taken. Appreciating the central importance of motivation through the whole of Kaldjian's framework has implications for cultivating the virtues of phronesis and courage to take the right course of action.

Doctors that "doctor" sickness certificates: cunning intelligence as an ability and possibly a virtue among Swedish GPs.

The relations of power between healthcare-related institutions and the professionals that interact with them are changing. Generally, the institutions are gaining the upper hand. Consequently, the intellectual abilities necessary for professionals to pursue the internal goods of healthcare are changing as well. A concrete case is the struggle over sickness benefits in Sweden, in which the Swedish Social Insurance Agency (SSIA) and physicians are important stakeholders. The SSIA has recently consolidated its power over the sickness certificates that doctors issue for their patients. The result has been a stricter gatekeeping of sickness benefits. In order to combat the inroads made by state institutions into sickness certification, and into the sphere of medical practice, some doctors have developed cunning "techniques" to maximize the chance to have their sickness certificates accepted by the SSIA. This article attempts to demonstrate that cunning intelligence-the ability of the weak to "outsmart" a stronger adversary-plays an important role in the practice of medicine. Cunning intelligence is not merely a defective form of prudence (phronesis), nor is it simply an instance of instrumental reason (techne), but rather an ability that occupies a distinct place among the intellectual abilities generally ascribed to professionals.