The importance of practical wisdom for shared decision making


The importance of practical wisdom for shared decision making 

He who [has practical wisdom] is skilled in aiming, in accord with calculation, at what is best for a human being in things attainable through action. ~ Aristotle

The concept of practical wisdom (also called phronesis or prudence) was first described by Aristotle in Book 6 of the Nicomacean Ethics. It was recently popularized by Barry Schwartz and Kenneth Sharpe in their 2011 book Practical Wisdom. (1) Schwartz defines practical wisdom as the combination of: 

“... the will to do the right thing with the skill to figure out what the right thing is.” (2)

I first became acquainted with the concept of practical wisdom when I watched Professor Schwartz’s 2009 TED talk titled “Our Loss of Wisdom”. (3) In a related blog post, Schwartz said: 

Most doctors want to practice medicine as it should be practiced. But they feel helpless faced with the challenge of balancing the needs and desires of patients with the practical demands of hassling with insurance companies, earning enough to pay malpractice premiums, and squeezing patients into seven-minute visits--all the while keeping up with the latest developments in their fields. (2)

I was attracted to the idea because I agree with Schwartz and Sharpe that, in many ways, medical practice could benefit from a strong infusion of practical wisdom. 


In 2020, Paul Kioko and Pablo Requena Meana published an article in the Journal of Medicine and Philosophy called Prudence in Shared Decision-Making: The Missing Link between the “Technically Correct” and the “Morally Good” in Medical Decision-Making. (4)  They posit that goal of shared decision making is to reach a “technically correct and morally good” decision and that the best way to achieve the goal is through the practice of practical wisdom, as first described by Aristotle and later expanded on by Thomas Aquinas. Although it is written from the standpoint of the clinician, they point out that the lessons involved apply equally as well to patients. 


In the introduction, the authors remind us that the physician-patient relationship is a moral activity that:

“… involves two people in very unequal positions – one sick and technically naive, the other healthy and technically astute – who must work together to reach a right and good medical decision.”

However in terms of decision making, both practitioner and patient have complementary areas of expertise that need to be combined in order to reach a good decision: The practitioner in knowledge of disease and its management and the patient in their knowledge of their illness experience, life circumstances, attitude toward risk, and personal values.  


Quoting Pelligrino and Thomasma, (5) they propose that a good medical decision must be both technically good and appropriate for the involved patient:

“Medicine being an art concerned with other persons necessarily involves the values of that person.”

They then argue that the best way to achieve a good medical decision, as so defined, is by application of Aristotle’s concept of practical wisdom (Phronēsis) which they define as the

“… perfection of the deliberative process leading up to a shared decision [based on] … a true grasp of the overall good of the patient as well as an assurance of the correctness of the therapeutic means to achieve it.”

To do so: 

“… the three classical phases of prudence must continuously occur in the physician; deliberation, judgment, and the command to therapeutic action in conformity with the overall good of the patient.”

They conclude: 

The unfortunate reality of modern medical practice is that many erroneous medical decisions are constantly being made. Importantly, the vast majority of these errors are committed, not through a lack of good will, but by a lack of prudence.  If Shared Decision-Making is indeed an ethical imperative in the physician–patient relationship, then we would argue that the virtue of prudence is an ethical imperative in Shared Decision-Making.”

Musings

This article provides a thought provoking commentary on shared decision making that adds considerable depth to the more practical discussions of shared decision making commonly found in clinical journals. Everyone interested in shared decision making would benefit by reading and reflecting on it. (Unfortunately this article is behind the journal’s paywall and not freely available as far as I can tell.)

References

1. Schwartz B, Sharpe K. Practical Wisdom. New York: Riverhead Books; 2011. 

2. Practical Wisdom: The Right Way to Do the Right Thing | Psychology Today [Internet]. [cited 2021 May 7]. Available from: https://www.psychologytoday.com/us/blog/practical-wisdom/201012/practical-wisdom-the-right-way-do-the-right-thing

3. Schwartz B. Our loss of wisdom [Internet]. [cited 2021 May 7]. Available from: https://www.ted.com/talks/barry_schwartz_our_loss_of_wisdom

4. Kioko PM, Requena Meana P. Prudence in Shared Decision-Making: The Missing Link between the “Technically Correct” and the “Morally Good” in Medical Decision-Making. J Med Philos Forum Bioeth Philos Med. 2021 Feb;46(1):17–36. 

5. Pelligrino ED, Thomasma DC. The Virtues in Medical Practice. Oxford: Oxford University Press; 1993.

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