An A–Z of medical philosophy

P is for Phronesis

Phronesis means ‘practical wisdom’. For Aristotle it is one of the most important human excellences or virtues. It acts as a central controller for all of our faculties and without it our actions are ineffective. It is the conductor of the orchestra of our thoughts, skills, and behaviours, juggling different issues and goals and guiding us to the best actions. Practical wisdom certainly needs both knowledge and reasoning but also mature judgement.

Aristotle would have been astounded at our persistent attempts to navigate our actions in a complex world by using algorithms, whether NICE guidelines or administrative protocols. Phronesis puts reflective and mature human judgment, not rules, bang in the middle of all complex decisions. Therefore making the best judgment in a complex situation does not rely on having the best algorithm but on being the best person. Best in the sense of one who is skilled, who has trained themselves by reflection on experience, and also by integrity of character.

We tend to think of guidelines, rules, management systems, and frameworks as inevitable marks of progress in the modern world. But what if a lot of this effort were mistaken? Yes, of course there is evidence that some ways of doing things are better than others. But evidence often relates to linear rules (‘if A is X then do Z’). The real world presents us with complex situations (‘A is approximately X but we do not know if B is currently Y or W and it seems likely that D and H will influence this situation in ways that may be difficult to predict’). Different patients have different priorities. William Osler said that: ‘It is much more important to know what sort of a patient has a disease than what sort of a disease a patient has.’

In the real world we end up having to trade off apples with aardvarks and we have to reinvent the answer to match each individual patient. So could the complexity of the world mean that linear guidelines that focus on one problem at a time are not the best fit to problem solving? In his brilliant book The Paradox of Progress James Willis demonstrates how the world is too complicated to be controlled by simple rules. The most complex object in the known universe is the human brain. Could it be that our brains, evolved over many thousands of years as the best problem-solving machine known, might usually be better than sets of rules? Willis’ book was published almost 20 years ago but the making of rules does not seem any less. The problem with using human judgment in complex situations is firstly that people have to think, and we often train people not to think. Secondly, horror of horrors, there may be inequity in the quality of problem solving we get from different people.

The advantage of using guidelines and algorithms is that they give a reliable answer and tend to be fair. But might we just be giving second-rate answers, reliably and fairly? Could the better policy be to teach people to think? I think Aristotle might be just a little disappointed with the industrialised one-size-fits-all medicine that we are pushed to practice. When I am sick I want a doctor with phronesis.