Virtue, progress and practice

The reasonable man adapts himself to the world; the unreasonable one persists in trying to adapt the world to himself. Therefore, all progress depends on the unreasonable man. (G.B. Shaw) [1] There are questions so resistant to easy resolution that we tend to ignore them for as long as we can, but so fundamental that they keep returning whenever we try to discuss anything that really matters with any degree of seriousness. Such questions are often deemed ‘philosophical’ in nature,1 and questions of this sort in clinical practice include: what is good practice in medicine and health care? What do we mean by progress in these areas? How do we recognize virtue when we see it? How do we support and promote it? How do I become a more virtuous practitioner? One problem with these questions is that we do not know precisely how to go about resolving them. We lack a clear and agreed method for producing answers that all rational parties will accept, and that are sufficiently full and detailed to be of any practical use – meaning, answers that can guide our decisions in specific cases. We can translate this problem into yet another question, but it is similarly philosophical in form: in terms of which methods, and with recourse to which sources of knowledge and evidence, can we aspire, rationally to reach sound conclusions on the nature of progress, virtue and good practice? This further, methodological question cannot credibly be avoided. It would be bizarre indeed if empirical evidence had no bearing on these vital questions, but how precisely we use evidence to answer them, and which evidence we use, is by no means obvious. It is not as though there were some missing piece of information that we could one day just find, that would reveal the answers in much the same manner as Douglas Adams's imagined ‘Deep Thought’ computer revealed that the answer to the question ‘what is the meaning of life, the universe and everything?’ was in fact ‘42’[2]. Certainly, there are texts, articles and published guidelines telling us how to practice more ‘ethically’[3,4], use evidence more effectively [5,6] and frame policies that will guarantee that quality and excellence become the ‘hallmarks’ of our respective organizations [7,8]. Unfortunately, such guidelines, handbooks and ‘how-to’ texts rarely have anything to say that is at once substantive (that goes beyond the platitudinous) and is also supported by a clear and rigorous account of the reasoning linking their premises to their conclusions [4,6,9,10]. Authors purporting to offer ‘practical’ advice too often recognize no requirement to supply convincing, explicit argumentation in support of the conclusions they invite their readers to accept [8,11] and are likely to regard the request for supporting arguments as unreasonable. Like the Deep Thought computer, they supply an answer, but not the working out. Their background assumptions and underlying conceptual framework – the implicit premises and normative structures that shaped their answers, that determined these answers as opposed to other possible ones – are apparently not worth discussing, of no interest to ‘busy practitioners’[5] and those ‘employed in the more mundane processes of what is called real life’[12]. The current climate is, and has for some time been, one of ‘moderate anti-intellectualism’[11]. It is considered reasonable for human beings – at least, those deemed responsible professionals – to apply their intellectual capacities to the learning of sometimes complex techniques, to know and follow conventions for good practice in their areas of work: ‘how-to’ questions are the legitimate preoccupations of the rational, professional mind. But it is deemed ‘intellectual’ in a derisory sense – somehow strange, bolshy or ‘other worldly’[5,12]– for a professional to want to understand the reasons behind the current conventions and to contribute to the debate about their appropriateness and sustainability. The characteristically philosophical attitude, once thought definitive of the professional outlook [11], of asking ‘why?’ questions – why does that follow? why these goals, rules and assumptions as opposed to others? – is met with suspicion in many contemporary organizations [13–16]. Far from being genuinely unreasonable, such an attitude is, as Shaw notes [1], a permanent prerequisite for progress. The point of Adams's Deep Thought story is not simply the absurdity of hoping to answer questions that are in fact philosophical in nature with recourse to a quasi-scientific calculation. There is an inherent absurdity in the idea of simply accepting an answer on a fundamental matter relevant to the conduct of one's own life, while showing no desire to scrutinize or even comprehend the thinking behind it. Such an answer is in an obvious sense ‘meaningless’ to those who purport to ‘just accept’ or ‘work with’ it, in much the same way that ‘42’ is meaningless as an answer to the question ‘what is the meaning of life, the universe and everything?’ To practice ‘on the basis’ of an answer one has no real understanding of is, in just as obvious a way, to act thoughtlessly. Whatever we mean by a rational, responsible practitioner, the person who ‘never thought of thinking for himself at all’[11] would not seem to be it. We need to think carefully and for ourselves about how to formulate the questions, and about the types of argument we might employ to address them. We cannot rule out the possibility (and indeed there are strong arguments in favour of the view) that ‘doing the working out’ with regard to such fundamental matters is part and parcel of being a virtuous practitioner, and that only a community made up of such persons can make real progress [1,8,11]. Fortunately, despite anti-intellectual influences and the (truly unreasonable) pressures upon practitioners' time and energy in the contemporary world [17], there are still many ‘unreasonable’ men and women who want to understand and control their practices, to question the basis for their activities and who are prepared to subject dominant ideas and assumptions to critical scrutiny. The pages of this journal have for many years supplied ample illustration of the fact that penetrating, intellectually serious discussion of pressing questions facing researchers, clinicians and policy makers is not only possible but necessary, if we are to secure improvements and avoid the pitfalls of dogmatism and the spurious triumphalism that has characterized much of the mainstream debate about progress, evidence, policy and practice in medicine and health care [18–24]. In 2010, the journal presented its first ever philosophy thematic edition, including papers by some of the most original and incisive thinkers the discipline has to offer on a vast range of subjects of urgent practical import [11]. This, the second thematic edition of the Journal of Evaluation in Clinical Practice to focus specifically on the application of philosophical methods and argumentation to medicine and health care, provides an even greater range of papers [25–60] on the themes of progress in medicine, virtue in practice, and evidence and methodology in research and evaluation. Articles bring fresh and challenging analyses of the relationship between progress in the science and the practice of medicine, the role and limitations of statistical reasoning in medical research, patient involvement, autonomy and rationality, the relationship between reason and emotional engagement in the life of the good practitioner, the role and value of uncertainty in health care and how to promote virtue in practice. Authors raise urgent methodological and epistemological questions about cultural bias in the generation of evidence and its implications for technological and scientific advances in medicine; medical knowledge and reductionism; epistemic biases in the researching of patient involvement in health care practices; the relationship between experience, narrative and evidence in the formation of arguments with practical conclusions; person-centred and patient-centred approaches to medicine and the increasingly important role of medical humanities in developing new conceptions of practice and new directions in medical research. The edition incorporates a section on empirical research and philosophy, which includes articles and commentaries on the nature and status of tacit knowledge, virtuous actions and practice, evidence-based decision making and the relationship between context and good practice. In addition, there is a section on values-based practice (VBP); a debates section incorporating responses to articles in the previous philosophy thematic (on questions as divergent as the relationship between evidence-based medicine [EBM] and the philosophy of science, the epistemic claims of homeopathic practitioners and the ethics of conscience clauses for practitioners in the issue of referrals for abortion); detailed, critical reviews of two extremely significant new publications on statistical research and EBM, and a conference report. 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