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. A key goal of the philosophy thematic edition is to promote interdisciplinary discussion, between philosophy and allied humanities disciplines on the one hand and medical practitioners and researchers on the other. The report on the workshops in the philosophy of medicine and health care at King's College, London, is a fine illustration of the mutually beneficial nature of such interdisciplinary dialogue [60]. Part of our goal is to show not only that philosophy (along with allied humanities disciplines) has an indispensible contribution to make to the discussion of practice, but that the problems of practice provide the proper context for real progress in philosophy. The idea that 'proper' philosophy is somehow detached from the 'mundane' concerns of ordinary life is an aberration, and the philosophers of today need to relearn the skills of Socrates in engaging, attentively, with the claims and the thinking of the broader populace, in particular those engaged in practices vital to our collective well-being. Applied philosophy is not an 'offshoot' of the subject but a return to its roots, in the rigorous questioning and systematic analysis of human thought about the concerns we face in the processes of real life. The attempt to address these concerns helps us to think more carefully about what philosophy is, to challenge and refine our ideas about proper methodology in the subject [8]. The edition opens with a series of original papers on the nature of progress in medicine. We can perhaps agree easily enough that progress in medicine is significantly associated with progress in the biological sciences and in clinical research, but determining the nature of the relationship and its implications for practice is less straightforward. While we may have a good intuitive sense of what we mean by 'progress in science', agreeing a formal account that can settle real controversies has proved a more challenging prospect [16,61–66] and even if we had a shared account of progress in science, this may not translate easily into a shared conception of progress in medical practice [59,67–69]. Jeremy Simon achieves an impressive balance of accessibility and intellectual weight in a fascinating paper, introducing readers to underlying theoretical arguments about the metaphysics of medicine, and of diseases in particular [25]. Simon presents a new account of the nature of diseases, by appealing to the most persuasive features of rival realist and constructivist positions in the philosophy of science, and an insight into what progress in medicine looks like if we understand diseases in this way. Another insightful contribution, that of Leen De Vreese [26], takes as its starting point the important distinction between what scientific progress means for a particular domain, such as medicine, and the question of scientific progress in general. The paper rigorously outlines the methodological differences this distinction implies, based on the goals of the distinct areas being subjected to analysis, and applies these arguments to the proper goals of research in the medical sciences and to EBM in particular – showing how critically thinking about EBM from the point of view of progress can help us to put its favoured methodologies in the right perspective [26]. Approaching the issue of progress in medicine from a radically different angle, Ignaas Devisch looks at the debate about autonomy in medicine, and a traditional way of construing that debate that equates autonomy with progress and its opposite, 'heteronomy'– the determination of behaviour by 'outside' influences – with (an implicitly regressive) medical paternalism [27]. With detailed reference to the debate about why autonomous people make unhealthy choices, Devisch demonstrates that debates about progress that appeal to such oppositions are based on unrealistic conceptions of choice and the human condition, proposing instead the concepts of 'oughtonomy' and 'nudging' as the basis for solutions to the problems inherent in influencing individual health choices without being offensively paternalistic [27]. James Penston's work [28,70] presents a significant and comprehensive challenge to contemporary orthodoxy regarding rationality and progress. It addresses reasoning and progress in medicine specifically, but has implications for the way we discuss policy and practice that extend far beyond this area. His contribution to this edition [28] outlines his attack on statistical methods in medical research, in particular the use of epidemiological studies and large-scale randomized controlled trials (RCTs). Presenting arguments which he recognizes will be regarded by many as heretical, he questions the benefits of these methods and attacks the products of what some regard as 'the very paradigm of modern medical research' as a 'pig in a poke'. (These rigorous and important arguments, and their implications for the future direction of medical research, are taken up again in the reviews section of this edition [58] by an author whose own rather different views on statistical research [71] are similarly subjected to incisive critical attention [59].) The section concludes with a provocative and challenging discussion of EBM and 'epistemological imperialism'[29]. Helen Crowther et al. provide the powerful illustration of haematology to raise serious concerns about the claims of EBM to provide a method for determining the safety and efficacy of medical therapies and public health interventions. Drawing on research which suggests that EBM may be riven through with cultural bias, both in the generation of evidence and in its translation, the authors argue that technological and scientific advances in medicine accentuate and entrench these cultural biases, to the extent that they may invalidate the evidence we have about disease and its treatment. They note that this creates a significant ethical, epistemological and ontological challenge for medicine and our thinking about medical progress. Populist contributions to the debate about rationality and professional practice accept implicitly certain contemporary dichotomies, most obviously between 'reason' and 'emotion', and as a consequence are likely to dismiss traditional conceptions of 'virtue' as outdated and irrelevant to 'our' modern (or indeed post-modern [47]) world. Our intellectual forefathers were by no means ignorant of the distinction between reason and emotion, but had the wisdom to regard reasoning as an activity of the whole person, a human organism with dispositions and attachments, engaged in the project of making sense of the world and capable of functioning more or less well with respect to others [8,67,72]. They may, perhaps, have been better placed than some contemporary commentators to appreciate the significance of the fact that practitioners are persons, and that 'the clinical encounter is an encounter between persons'[73]. Discussion of the virtues – the dispositions and responses relevant to functioning well as a whole person in a given social context – provides not only a realistic approach to discussing good practice. A consideration of virtue also restores the idea of judgement to a central place in this discussion, its having been displaced to the sidelines and relegated to something akin to 'opinion'– a form of 'low-grade evidence' in some contemporary quarters [74]. Stephen Buetow notes that in the current intellectual climate, uncertainty is more likely to be cast as a problem for evidence-based care to minimize than as a virtue. But viewed from the perspective that practice is a human activity, certainty is frequently unrealistic and unwise while uncertainty, he argues, is often natural and wise, promoting hope, creativity and a critical attitude, nurturing safety and protecting against excess [30]. Bolstering his argument with reference to Karl Popper's work on fallibilism in the philosophy of science [75], he argues refreshingly for a discussion of uncertainty that is open and positive, treating it and the fact that practitioners are persons as something to highlight, not as some regrettable if ineliminable flaw. A stimulating and important paper by James Marcum examines the role of 'the compound virtue, of prudent love' in the practice of clinical medicine [31]. Explaining the conceptual links between the ideas of the wise person, the wise action and the virtuous practitioner, Marcum argues convincingly for the need to incorporate the ethical and intellectual virtues into the medical curriculum, defending the 'virtues' approach against other possible positions in moral epistemology and outlining methods of teaching virtue– to create environments that cultivate professional virtue in our schools and practice settings. The ideas of both Marcum and Buetow are nicely complemented by the highly inventive approach of Petra Gelhaus, whose paper on 'Robot Decisions' utilizes the science fiction of Isaac Asimov to highlight the role of human emotions in rational decision making, contrasting even the best-designed 'infallibly rule-oriented' robot doctor to the sort of human agency required for virtuous practice in a complex and often inherently uncertain world. Her work brings out the indispensible nature of the emotional virtues in any credible account of rational human agency and thus in any defensible notion of good practice [32]. 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