I told you before that I would do my best to avoid bringing up phronesis, but a superb essay by Lisa Rosenbaum, national correspondent at the New England Journal of Medicine, is forcing my hand.
In “The Paternalism Preference — Choosing Unshared Decision Making,” Rosenbaum calls into question the gradual shifting of the burden of decision-making onto patients in the name of informed consent and autonomy.
The essay begins by examining the issue from the patient’s perspective, but Rosenbaum’s reflection then turns to the role of the physician. She remarks:
But science cannot answer a question at the core of our professional identities: As information-empowered patients assume greater responsibility for choices, do we assume less?
The answer to that question has to do with our understanding of what constitutes good medical decision-making. Clearly, the prevailing notion assumes that good medical decisions come after a rational approximation of an objective biological reality, a “predictive analysis” that forms the core of “evidence-based medicine.”
That idea follows naturally from the philosophical empiricism which is at the basis of our health care system. Under that framework, the acquisition of medical knowledge and the identification of the best treatments are processes of hypothesis testing. The notion that doctors should disclose these processes and invite the patient to share in a dispassionate scientific activity would make sense.
But such an idea is highly inimical to what we naturally consider good medical care to be. Rosenbaum tells us that
In an essay entitled “Arrogance,” published posthumously in 1980, former Journal editor Franz Ingelfinger describes his experience as a patient with adenocarcinoma of the gastroesophageal junction — the area he’d studied for much of his career. As he considered the trade-offs of chemotherapy and radiation, receiving contradictory expert opinions, he and his physician family members became “increasingly confused and emotionally distraught.” Finally, one physician friend told him, “`What you need is a doctor.’”
Herbert L. Fred who, in my opinion, is the most accomplished medical educator and bedside clinician alive,¹ also conveyed the process of good doctoring in a trenchant essay, “Milton + Sutton = Mutton,” in which he proposes Mutton’s law of optimal care: “Know what to do and when to do it.” These are not empty words conveying a silly aphorism. They are meant precisely to drive the point that M.D. stands for “Make Decisions.”
Economist Timothy Terrell wrote with his late father and family physician Hilton Terrell an arrestingly intelligent essay about “Medical Information and Bureaucracy: F.A. Hayek and the Use of Medical Knowledge.” While the article covers a lot of ground, a passage pertinent to the question of medical decision-making gives this penetrating insight about clinical diagnosis:
Diseases are aggregate constructs that, while they usually have a sine qua non, rarely show a perfectly congruent pattern from one patient to the next. Hypothyroidism manifests a broad range of symptoms, for example. To declare that a set of particulars in any one patient qualifies as a particular disease is to make a judgment about whether a patient falls on this or that side of a fuzzy line.
Thus, the physician’s determination that a patient has a certain disease is a decision as opposed to a discovery about a set of symptoms that will always vary in type and degree from patient to patient.
The ideas expressed by Rosenbaum, Fred, and the Terrells, all defend the notion that medicine is serving the uncertain particular. In that service, the methods of EBM can never play a decisive role, since EBM can only deal produce means derived from the studies of aggregates.
In a formidable paper titled “Particularism in health care: challenging the authority ot the aggregate,” Sandra Tanenbaum, professor of public health at Ohio State University, notes that
The knowledge of particulars in medicine is both epistemologically and politically divergent from EBM’s knowledge of means. First, it is knowledge for practice in a way that, despite claims to the contrary, ‘evidence’ is not. EBM views medicine as an applied science, that is, a conformance to statistical research findings in the care of individual patients. The knowledge of particulars, however, admits to the incongruence of general principles or aggregate findings with individual patient care and requires a ‘reparticularization.’
That “reparticularization” of general principles to the individual at hand, must be “epistemologically plural and fully reasoned,” and take advantage not only of scientific knowledge, but also of tacit knowledge, intuition (reflection-in-action), pattern recognition, and other modes of experiential knowledge.
Tanenbaum explains that this use of a plurality of knowledges to make a decision in (and for) the particular is what Aristotle and the ancient wise ones called phronesis, practical wisdom, or prudentia.² That ethical principle remained forceful for centuries, until it withered in the post-Cartesian era.
Rosenbaum concludes her essay by saying:
The doctors I admire most are characterized not by how much they know but by a sophisticated intuition about how best to share it. Sometimes they tell their patients what to do; sometimes they give them a choice. Sometimes, when discussing treatment options, they cover all seven tenets of informed consent. Sometimes, instead, seeing the terror of uncertainty in a patient’s face, they make their best recommendation and say, “I don’t know how things are going to turn out, but I promise I’ll be there with you the whole way.”
That is a great illustration of doctors deciding and not simply disclosing the results of a discovery. That is a great rendition of Mutton’s law, of doctors knowing what to do and when to do it.
That, my friends, is a perfect example of phronesis.³
1. Full disclosure: Herb Fred was my residency mentor and is one of my dearest friend and a frequent writing collaborator.
2. We should not confuse the ancient virtue of prudence with the modern understanding of the term. Under the original (teleological) meaning, taking a big risk may precisely be the prudent (right) thing to do.
2. Phronesis has a justification in philosophical anthropology based on the hylomorphic principles of potency and act. But about this, I will say nothing more…