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.

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.

Using telemonitoring to support personal care planning for adults with learning disabilities.

INTRODUCTION: We report on an evaluation of the Just Right approach for planning care for adults with learning disabilities and how it can support culture change. Just Right combines installing a telemonitoring system with training for care managers in person-centred care planning and the interpretation of charts that summarise activity data for their setting. By providing insights into the needs of individuals Just Right allows existing care provision to be reviewed to ensure it is 'just right'. The Just Right approach can also potentially identify over-care and resources that can released. METHODS: A mixed-methods approach was used, triangulating qualitative and quantitative baseline and follow-up data. Qualitative data were collected before and after implementation from focus groups on barriers, enablers, success outcomes and impacts. A theory of change was developed. Detailed data on individual adults with learning disabilities were collected before and after installation of equipment using a linked online survey completed by their care managers. RESULTS: Nine commissioning local authorities were recruited with 33 care providers serving 417 adults with learning disabilities. Issues relating to implementation included staff acceptance, culture, consent, safeguarding, local authority engagement, interpretation of data and residential setting. Changes to care were identified for 20.3% of individuals, with 66% of providers not identifying any changes because Just Right confirmed that they were providing the right level of support. DISCUSSION: By combining telemonitoring and person-centred care planning, Just Right provides a holistic approach and necessary information for conversations amongst stakeholders about the care needs of adults with learning disabilities. Depending on how it is introduced, and the nature of conversations held, the Just Right approach can potentially change culture, leading to improved outcomes.

Towards an Empirically Informed Account of Phronesis in Medicine.

In the field of medical virtue ethics, the concept of phronesis, or practical wisdom, plays a crucial role. In recent years a number of important theoretical questions have been identified in this regard: (1) is phronesis more akin to thinking or theorizing, or to feeling and intuiting? (2) can phronesis be communicated and explained, or is it individual and personal? and (3) is phronesis needed in all decision-making in medicine, or only in the making of decisions that are ethically fraught? In this paper we argue that, while these questions have received attention on the theoretical level, empirical investigation has the potential to shed light on these questions from the perspective of medical practice in the real world. Indeed, because virtue ethics insists that virtuous action can only be understood properly in the context of real decisions (and not in the abstract), there are good grounds for thinking that understanding phronesis must involve attention to real-world particulars. Empirical investigation, involving in-depth narrative interviewing and analysis, has the potential to shed light on these theoretical questions relating to phronesis.

A place to unwind.

The final article in our leadership series reveals how a learning disability forensic trust made spirituality a core element of a leadership programme for ward managers.

A place To.

The final article in our leadership series reveals how a learning disability forensic trust made spirituality a core element of a leadership programme for ward managers.