Challenges Facing the Appeal to Practical Wisdom in Medicine and Beyond

Abstract

I. INTRODUCTION

The virtue of practical wisdom is seeing a resurgence of interest among scholars, both in discussions of virtue in general and in discussions of particular disciplines like medicine. This is all for the good. For too long, many virtues have been neglected by researchers, practical wisdom among them.

As work on practical wisdom and medicine accelerates, now is a good time to outline some important challenges that any approach to developing an account of this virtue faces. Here, I develop five such challenges. To be clear, I am raising these merely as challenges, not as objections. Furthermore, the main goal is to provide a guide to the challenges themselves and some of the options available for tackling them, rather than trying to resolve them here.¹

Section II of the paper provides background on the functions that have been assigned to practical wisdom and how Aristotelians tend to conceive of virtue. Section III then raises the first three challenges. Sections IV and V develop the remaining two challenges.

II. THE STRUCTURE AND FUNCTIONS OF PRACTICAL WISDOM²

Most contemporary writers about practical wisdom adopt an Aristotelian approach to conceptualizing virtue. On what I call this Standard Approach, there are four main claims. Here is the first one:

• (1) Practical wisdom is a character trait.³

As a character trait, practical wisdom is expected to affect how a person thinks and acts whenever it is triggered or activated. This is a generic point; the same is true for other character traits like honesty and compassion. How exactly practical wisdom uniquely impacts a person’s thoughts and actions depends on what functions are assigned to it, an issue we take up in a moment.

These are two more commitments of the Standard Model:

• (2) Practical wisdom is a virtue, and furthermore, it is an intellectual virtue.⁴

• (3) Practical wisdom is necessary for the possession of moral virtues.⁵

On this way of thinking, there are different kinds of virtues, the relevant ones being intellectual and moral virtues.⁶ The Standard Model claims that practical wisdom is a virtue, naturally enough, but not a moral virtue. Why? One reason is given by (3), since if it is necessary for possessing all the moral virtues, and if were a moral virtue itself, then practical wisdom would be necessary for possessing itself.

Here is the last commitment of the Standard Model as I am going to understand it:

• (4) Practical wisdom is not sufficient for the possession of the moral virtues.⁷

As we see in the next section, this is a crucial commitment that distinguishes the model from its main rival, the Socratic Model, according to which practical wisdom is both necessary and sufficient for moral virtue. The key point for now is that, on the Standard Model, moral virtues are distinct from practical wisdom and carry out their own functions as well.

Summing up, here is what I take to be a faithful representation of the approach:

The Standard Model. Practical wisdom is a character trait that is distinct psychologically from the moral virtues, but that is necessary for them to count as virtues.⁸

In the contemporary philosophical literature on practical wisdom, Daniel Russell, Nancy Snow, and Kristján Kristjánsson hold the Standard View, among many others. It also seems to align well with the work of Neville Chiavaroli, Stephen Trumble, Stephen Tyreman, Lauris Kaldjian, Aisha Malik, and Eric Beresford, among others, in the philosophy of medicine and medical education literatures.⁹

The Standard Model gives us some idea of how practical wisdom is structured and how it relates to other virtues. But, what exactly is practical wisdom supposed to do? What, in other words, are the functions that are to be carried out by this virtue? In the last 50 years, there have been a number of functions that have been mentioned. But, there is no agreement on what belongs on the list. Below I highlight six of the most prominent functions.

To begin, here is a function having to do with ends:

The End-Setting Function: Practical wisdom fixes or at least plays an important role in fixing the ends of the moral virtues.¹⁰

In the medical context, general ends could include preventing suffering and promoting the well-being of others. These are examples of very broad ends, so another function that has sometimes been assigned to practical wisdom is:

The End-Specification Function: Practical wisdom adopts the general end of a virtue and specifies it more precisely for the particular situations that the virtuous person encounters.¹¹

Hence, more specific ends in a medical setting might be alleviating the suffering of this particular patient or being transparent in communicating with a patient about what the risks are with different treatment options.

It is one thing to identify what our general and more specific ends are. It is another thing to justify the choices of ends. Hence there is this possibility:

The Justification Function: Practical wisdom provides good reasons to justify the choice of ends adopted by the virtues.¹²

So, an end like not deceiving patients, for instance, might be justified on the grounds of respecting the dignity of every person.

These functions focus on ends, but what about means? Does practical wisdom have anything to do with determining how best to achieve or pursue means to our ends? A function commonly assigned to practical wisdom is the following:

The Instrumental Function: Practical wisdom decides the best means to pursue in achieving the ends of the moral virtues.¹³

If the goal is to prevent the patient from suffering, then in certain cases the best means of doing so might be to withhold distressing news until a later time and place when the patient can handle it better.

Speaking of handling things, another very popular job given to practical wisdom is this one:

The Handling Conflicts Function: When two or more moral virtues lead in opposing directions, practical wisdom decides how best to resolve the conflict.¹⁴

For example, the virtue of compassion might favor not telling the patient the disturbing news, while the virtue of honesty could favor disclosing the facts when the patient asks about them. Practical wisdom can determine which of the two virtues should have priority in a given case. A similar job would need to be carried out for conflicts between different moral principles or moral values.

Finally, let me mention an epistemic function:

The Perception Function: Practical wisdom ensures that the virtuous person perceives the morally relevant features and considerations pertaining to a given situation.¹⁵

In the same example, if practical wisdom carries out this function, then it might enable the doctor to observe and anticipate what stresses the patient is already experiencing and what the effects might be on the health of the patient, were the truth to be told.

I could go on listing other functions that have been assigned to practical wisdom, and indeed, Sophie Grace Chappell has gone so far as to outline 15 of them.¹⁶ For purposes of this paper, though, we do not have to go through each of them. Instead, let me highlight one example of an account of practical wisdom in the medical context, which combines several functions together. Lauris Kaldjian, perhaps the leading contributor in this area, has distinguished five different functions that he assigns to practical wisdom:

1. Pursuit of worthwhile ends (goals) derived from a concept of human flourishing.

2. Accurate perception of concrete circumstances detailing the specific practical situation at hand.

3. Commitment to moral principles and virtues that provide a general normative framework.

4. Deliberation that integrates ends (goals), concrete circumstances, and moral principles and virtues.

5. Motivation to act in order to achieve the conclusions reached by such deliberation. (Kaldjian, 2010: 559)¹⁷

Three of these look like the End-Setting, Perception, and Instrumental Functions. The other two are less commonly cited functions, which we might call the Commitment Function and the Motivation Function.

Strikingly, when we proceed to examine other accounts of practical wisdom, we find that each writer has a list of functions to offer. But we also find no agreement whatsoever as to which functions apply to practical wisdom and which do not.¹⁸ So, while there is a fair amount of consensus in favor of the Standard Model, there is nothing approaching consensus about what practical wisdom is actually supposed to do. This takes us to the first three challenges.

III. THREE CHALLENGES TO APPEALING TO PRACTICAL WISDOM IN MEDICINE AND BEYOND

The first challenge to invoking practical wisdom in the medical context is clearly assigning some but not all of the potential functions to practical wisdom in a justifiable way. We can put the challenge succinctly this way:

The Arbitrariness Challenge: How can we provide a justifiable list that ascribes certain functions to practical wisdom, and the remaining functions to the individual moral virtues or other character traits? Without proffering some justification, any such list can appear to be arbitrary.¹⁹

To illustrate, let us return to Kaldjian’s account. We just saw the five functions he chose. Now take a competing account to this one, an account that does not assign, say, the Motivation Function to practical wisdom. Which account is to be preferred here? On what basis would we say that Kaldjian’s approach is superior to this rival one?

One way some writers proceed is to privilege some functions over others on the basis of whether Aristotle, for instance, had them on his list. But if Aristotle does not have sufficient justification for the choices that he made of certain functions over others, then this only moves the concern about arbitrariness back one level. Whether in fact Aristotle was justified or not, however, is a question that is beyond the scope of this paper.

Another approach to consider in addressing the arbitrariness challenge is to gather empirical data about how either people in general or certain populations like doctors or medical students conceive of practical wisdom. Using this data, we might be able to defend making choices in favor of certain functions over others. Indeed, several papers have recently appeared that might be put to this use in the medical context.²⁰

This approach needs to be carried out with care, though. For instance, Kaldjian and his colleagues interviewed 102 medical students and physicians at two US medical schools. Among the questions asked were seven yes/no ones about specific functions of practical wisdom, including Kaldjian et al. (2023):

Practical wisdom in medicine requires reasoning that is focused on goals that provide a general direction or purpose for decision-making in a given situation.

Yes—95% No—5%

Practical wisdom in medicine requires motivation to act according to what you think is best in a given situation.

Yes—83% No—14%

So, it looks like we can safely assign at least these two functions to practical wisdom on empirical grounds.

Now we need to be careful here. The question is whether a given function should be assigned to practical wisdom as opposed to individual moral virtues (or maybe some third option). And, I would expect that if you had asked similar questions about individual moral virtues, like the following, you would have seen similarly high percentages:

The virtue of compassion in medicine requires motivation to act according to what the person, who possesses it, thinks is best to do in helping others in a given situation.

So, what we really need is empirical information that might be helpful to get at whether different functions belong specifically to practical wisdom or to the moral virtues.²¹

At this point, it is not clear that any account of practical wisdom on offer in recent years does a good job of addressing the Arbitrariness Challenge. Having said this, let me mention two other important responses. One is simply to embrace arbitrariness initially, and then see what the resulting account looks like.²² Rather than trying to legislate what is inside and what is outside the scope of practical wisdom, this more pragmatic approach would encourage the proliferation of multiple accounts to see which ones bear the most philosophical fruit. Authors would then need to be careful not to claim to provide an account of practical wisdom as such, but rather of one among many ways of construing practical wisdom.

A second way to avoid the Arbitrariness Challenge altogether is to refuse to choose from among the different potential functions. Instead, we could welcome all of them. So, practical wisdom identifies ends, specifies them in contexts, determines means, perceives relevant information, motivates behavior in line with what is judged right, and so on.

By not having to make a choice between functions, arbitrariness is avoided. The problem, though, is that the Standard Model is undermined in the process. For now, we come to the second challenge:

The Independence Challenge: If many functions are ascribed to practical wisdom, then there is nothing to having a moral virtue besides just having practical wisdom. But for the Standard Model, moral virtues are supposed to be distinct from practical wisdom, with their own functions to carry out.²³

In other words, claim (4) of the Standard Model is rejected:

(4) Practical wisdom is not sufficient for the possession of the moral virtues.²⁴

Metaphorically speaking, practical wisdom swallows up all the moral virtues.

So much, one might say, for the Standard Model. There is nothing that says that practical wisdom in the medical context has to be understood using an Aristotelian framework. Indeed, there is a prominent historical approach waiting in the wings, which harkens back to Plato:

The Socratic Model. Practical wisdom is not distinct psychologically from the moral virtues; rather “when one is virtuous, what one really possesses is the single virtue of practical wisdom.” (De Caro, Vaccarezza, and Niccoli, 2018, 294)²⁵

This model agrees with (1) through (3) of the Standard Model but rejects (4). Practical wisdom is necessary and sufficient for possessing the moral virtues.

Putting things less abstractly, consider a deeply virtuous person. On the Standard Model, we would understand her psychology as possessing a number of distinct psychological dispositions—one for honesty, one for courage, one for compassion, and so on for every moral virtue. On top of that, there would also be another virtue of a different kind, an intellectual virtue of practical wisdom.

The Socratic Model is much more parsimonious. For this deeply virtuous person, there is only one virtue, which is practical wisdom. Honesty, courage, compassion, and the like are simply manifestations of that virtue in particular contexts. So, when, say, an opportunity to deceive a patient arises, practical wisdom would be operative in determining ends and means, perceiving relevant considerations, motivating behavior, and the like, ultimately leading to outward behavior. Since it pertains to matters of deception, we would call that behavior honest, but not because of the work of a distinct trait of honesty.

The Socratic Model is not interested in defending the rival Standard Model, and so is not threatened by the Independence Challenge. Rather, it readily accepts that there is nothing to a moral virtue beyond practical wisdom itself. Furthermore, it does not have to deal with the Arbitrariness Challenge either, since it does not pick and choose between functions that are assigned to practical wisdom and functions that are not.

However, we are not in the clear yet. Both the Standard Model and the Socratic Model give rise to a third obstacle, which I call the Unity Challenge. Let me introduce it indirectly.

Consider these capacities: regulating heartbeat, hearing sounds, and speaking in English. Each of these by itself makes perfect sense. But then, suppose I say that there is also a trait that encompasses all of them and that does additional work of its own. You are likely puzzled—why think there is any such trait above and beyond the individual capacities themselves?

Or consider an example that has to do with personality. Take these capacities: being shy, having a good memory, and thinking carefully. Again, each of these by itself makes perfect sense. But it would be rather odd to postulate a fourth thing, a trait of some kind that encompasses all of them and does causal/explanatory work of its own.

Now consider these capacities: handling conflicts between moral principles and values, perceiving what is relevant in a given situation, and being motivated to act. Once again, they make sense in their own right. But now, suppose I said there is a fourth thing here, a trait called practical wisdom, that is somehow above and beyond these three capacities, and yet carries them all out at the appropriate time and place. Here too, this might strike us as an odd way to look at things.

This is one way to illustrate the Unity Challenge. Stated more generally, it goes like this:

The Unity Challenge. If there are multiple functions ascribed to practical wisdom, then the challenge is to explain how they would all be carried out by a single character trait, especially given how diverse the functions tend to be.²⁶

Note that this is an especially difficult challenge for the Socratic Model. After all, it ascribes a huge number of diverse functions to practical wisdom—Handling Conflicts, End-Setting, End-Specification, Justification, Instrumental, Motivation, Perception, and all the rest. Is it plausible to think that there is one single character trait that does all these jobs?

It is also a challenge for the Standard Model. By default, the Standard Model ascribes the Handling Conflicts function to practical wisdom since that is not a task that individual moral virtues would carry out. Advocates of the model have at least a few more tasks in mind for practical wisdom to carry out, such as the Instrumental Function. But even with just these two—Handling Conflicts and Instrumental—there arises a Unity Challenge.

Let us step back for a moment. At this point, if you are interested in incorporating practical wisdom into the medical context, where might you go next? Here are some options:

• (i) Support the Standard Model and address the Arbitrariness, Independence, and Unity Challenges.

• (ii) Support the Socratic Model and address the Unity Challenge.

• (iii) Look to develop another model.

As indicated already, my goal is just to clarify the challenges themselves, rather than try to resolve them. But let me end this section by very briefly gesturing in the third direction.

In recent work, the philosopher Sophie Grace Chappell, psychologist Dan Lapsley, and I have each independently developed what might be called the Eliminativist Model.²⁷ Here is how I like to put it:

Practical Wisdom Eliminativism. We should reject the appeal to one intellectual virtue, practical wisdom, which is supposed to carry out some or all of the functions associated with practical wisdom. Instead, for each function, we can appeal to a distinct trait that corresponds to that function.²⁸

So, there would be capacities for carrying out the Handling Conflicts Function, capacities for the Instrumental Function, and capacities for whatever other functions you might think have to be exercised alongside the moral virtues. But there would not be, on top of all of those particular capacities, an additional trait of practical wisdom.

By rejecting the existence of practical wisdom as its own character trait, the Eliminativist avoids the Unity and Independence Challenges. There is still an Arbitrariness Challenge, though, since we still need to know what is going to be done by the moral virtues and what is going to be done by independent capacities like those associated with Handling Conflicts.

Much more could be said about the three challenges and the Standard, Socratic, and Eliminativist Models.²⁹ This much is sufficient for now, however, so we can shift gears to the two remaining challenges.

IV. THE OBJECTIVITY OF PRACTICAL WISDOM

For those who believe that practical wisdom can make a significant contribution to medical practice, we have seen that it is important but challenging to specify what exactly practical wisdom is and what its functions are.

Let us suppose, though, that we can move past these challenges. A natural issue to consider next is whether there is any objectivity to practical wisdom. We can put this in terms of a challenge as well:

The Objectivity Challenge. Is there anything normatively objective that governs the functioning of practical wisdom? If so, how is that outlook justified? If not, what is the best alternative outlook, and how is it justified?

To spell this out in more detail, it helps to tie the discussion to particular functions associated with practical wisdom.

As the representative example, let us take Handling Conflicts. When in the medical context conflicts arise between competing values, principles, or virtues, is there one correct way to resolve the conflict objectively? To focus the question, here is a case from the philosopher Tom Carson:

Suppose that a man has just had open heart surgery and is temporarily in a precarious state of health. His surgeon says that he must be shielded from any emotional distress for the next few days. Unbeknownst to the patient, his only child, Bob, has been killed in an automobile accident. When the patient awakens after the surgery, he is surprised that Bob is not there and asks, “Where is Bob?” You fear that in his condition, the shock of learning about Bob’s death might cause the man to die. (Carson, 2010, 19–20)

Here honesty to the patient conflicts with non-malevolence. Is there a correct answer as to which one should take priority?³⁰

One option is that there is no correct answer to this question. On this approach, there are no standards of right and wrong that can adjudicate such conflicts. This would be more of a nihilistic approach.

Another option is to say that there is a correct answer to this question, but it is an answer that is constructed in some way by human beings, whether actual human beings or human beings who have been improved somehow. This would be more of a constructivist approach.

Yet another option is to say that there is a correct answer to this question, and it is an answer that is independent of human beings in the sense that we do not fix that answer and our thoughts about it cannot change what that answer is.³¹ This would be more of an objectivist approach.

Debates between such approaches make a difference. For instance, from a nihilist starting point, it does not matter, morally speaking whether the doctor ends up telling the truth to his patient or withholding the information, as there is no right answer as to what should be done. In contrast, from an objectivist starting point, we can assume that withholding the information is either objectively correct or objectively wrong. The doctor with practical wisdom would presumably be able to reliably detect what the correct answer is in situations involving normative conflict.

We can frame similar options for each of the other functions as well. Even something like the Motivation Function would raise these issues. I will not run through the options again, but there can be normative questions about whether the doctor’s motives are objectively appropriate, including the content of the motives (for instance, whether they are self-interested or altruistic) as well as their strength.

Now to be clear, it would be unreasonable to expect researchers on practical wisdom in the medical context to have to wade into the highly technical and complex literature in contemporary meta-ethics. That is asking too much. Rather, the challenge here is just to say something about the nature of normative reality and the ways in which the different functions of practical wisdom would be attuned to that reality if it even exists in the first place.³²

V. THE PARTICULARITY OF PRACTICAL WISDOM

It is hard to see how there would be much interest in incorporating practical wisdom into medical practice if one also held a nihilistic outlook about normative reality and thought that the practically wise doctor never arrives at any correct answers about right and wrong, good and bad. So, I assume that there are correct answers to be had, whether they are constructed or objective. The final challenge to be considered in this paper concerns the nature of those correct answers.

Much of the recent interest in practical wisdom and medicine seems to be driven by dissatisfaction with an earlier emphasis on rules, combined with a hope that practical wisdom can be a promising avenue for focusing on the particularity of medical decision-making. Here are a couple of examples of this sentiment³³:

Chiavaroli and Trumble: “Scientific knowledge may form its basis, but the practice of medicine requires judgement as to the appropriateness of a particular diagnosis, investigation or management approach with each patient in every situation, regardless of how many times such a decision may have been made before.” (2018, 1006)

Jonsen and Toulmin: “. . . clinical knowledge requires what Aristotle calls ‘prudence’ or phronesis: practical wisdom in dealing with particular individuals, specific problems and the details of practical cases or actual situations.” (1988, 33)

It certainly seems right to stress that many situations arise as a doctor that involve complex decision-making and require incorporating a number of different considerations and factors. There are very difficult challenges in this neighborhood, to be sure, but they are not what I am calling the Particularity Challenge:

The Particularity Challenge. For the doctor with practical wisdom, are there correct answers that are arrived at when making difficult medical decisions, answers that are compatible with and derivable from general normative rules, or are there no such rules governing correct decision-making in medicine?

To illustrate, let us return to Carson’s case of the doctor who is considering withholding information about the death of her patient’s son. We are assuming that there is a correct answer about whether what the doctor did was right or not. Indeed, let us just assume that she did the right thing in withholding the information and that as a person with practical wisdom, the doctor was able to figure that out for herself.

Now the question becomes, is this only the correct answer for this very particular situation, or is it derivable from more general rules which can apply to other situations as well? Here I will highlight three general ways of addressing this challenge.

The first is to say that the doctor’s correct answer is derivable from the one true rule or principle that governs all of morality. Examples of this rule could be one of Kant’s formulations of the categorical imperative, the principle of utility, or the golden rule. The idea would be that, in some cases, the correct application of such a rule would require paying attention to numerous features of a situation in order to arrive at the answer.

A second way of addressing this challenge is to say that there is no one general rule from which answers to difficult medical decisions are derivable. But there is a host of moral rules that do exist nevertheless, even if they cannot be derived from one ultimate rule. This is a moral pluralist approach, famously associated in normative ethics with W. D. Ross, and in bioethics with Beauchamp and Childress.

In our example, there could be a rule pertaining to not deceiving other people, which is coming into conflict with a rule pertaining to protecting other people from harm. There is no more foundational rule that decides which of these conflicting rules has priority in this case. But there is, nevertheless, a correct answer about how the conflict should be resolved. What practical wisdom can do is help to determine what that answer is, as it carries out the Handling Conflicts Function. Indeed, Ross himself appealed to practical wisdom as the means of properly sorting out conflicts between his prima facie duties to arrive at the correct answer.³⁴

A third way of addressing the challenge is to say that there is no rule of any kind from which answers to difficult medical decisions are derivable. Rather, there are correct answers which are particular just to that one situation. So, in this very specific case, the correct answer is for the doctor to withhold the information from her patient. But even though they might seem to be similar, other cases where a doctor has an opportunity to withhold important information have their own correct answers and need to be evaluated on their own terms. This is a particularist approach to thinking about the kinds of answers that might be available in difficult medical decision-making cases.³⁵

This is a broad schema of three different ways of addressing the particularity challenge, and obviously each of them needs much further development. Depending on the details of this development, it may not be exhaustive either. For instance, some versions of casuistry focus just on the ethical analysis of particular cases and look like they belong in the third camp. Other versions focus on assessing particular cases using principles and could belong to one of the first two camps. Yet other versions look to actual cases first and formalize our responses to them as moral principles, which in turn can be helpful in determining correct answers in future cases. This might take the form of a fourth approach to the particularity challenge.³⁶

To be clear again, there is no expectation that researchers on practical wisdom have to wade into the also highly complex literature on moral rules and moral particularism.³⁷ That would also be asking too much. Rather, the expectation is just that researchers in this area take a well-reasoned stand on the following: what their enthusiasm for practical wisdom’s sensitivity to the particularities of medical contexts really commits them to about the nature of the answers that are available.

VI. CONCLUSION

In this paper, I have tried to develop, at least in a preliminary way, five important challenges of which researchers interested in incorporating practical wisdom into medical practice should be cognizant, and about which they ideally have something to say. In raising these challenges, my aim is not to be pessimistic about the prospects of marrying practical wisdom and medicine. Indeed, I hope that this marriage goes through. I am just trying to be cautious upfront about the difficulties that could get in the way of a peaceful coexistence.³⁸

REFERENCES

Footnotes