This article examines clinical wisdom, which has emerged from a broader study about nurse managers' influence on proficient registered nurse turnover and retention. The purpose of the study was to increase understanding of proficient nurses' experience and clinical practice by giving voice to the nurses themselves, and to look for differences in their practice. This was a qualitative study based on semistructured interviews followed by analysis founded on Gadamerian hermeneutics. The article describes how proficient nurses experience their (...) practice. Proficient practice constitutes clinical wisdom based on responsibility, thinking and ethical discernment, and a drive for action. The study showed that poor working conditions cause proficient nurses to regress to non-proficient performance. Further studies are recommended to allow deeper searching into the area of working conditions and their relationship to lack of nurse proficiency. (shrink)

The recent interest in wisdom in professional health care practice is explored in this article. Key features of wisdom are identified via consideration of certain classical, ancient and modern sources. Common themes are discussed in terms of their contribution to ‘clinical wisdom’ itself and this is reviewed against the nature of contemporary nursing education. The distinctive features of wisdom (recognition of contextual factors, the place of the person and timeliness) may enable their significance for practice (...) to be promoted in more coherent ways in nursing education. Wisdom as practical knowledge (phronesis) is offered as a complementary perspective within the educational preparation and practice of students of nursing. Certain limitations within contemporary UK nursing education are identified that may inhibit development of clinical wisdom. These are: the modularization of programmes in higher education institutions, the division of pastoral and academic support and the relationship between theory and practice. (shrink)

To precisely define wisdom has been an ongoing task of philosophers for millennia. Investigations into the psychological dimensions of wisdom have revealed several features that make exemplary persons “wise.” Contemporary bioethicists took up this concept as they retrieved and adapted Aristotle’s intellectual virtue of phronesis for applications in medical contexts. In this article, we build on scholarship in both psychology and medical ethics by providing an account of clinical wisdom qua phronesis in the context of the (...) practice of psychoanalysis and psychodynamic psychotherapy. With the support of qualitative data, we argue that the concept of clinical wisdom in mental healthcare shares several of the key ethical dimensions offered by standard models of phronesis in medical ethics and serves as a useful, albeit overlooked, reference point for a broader development of virtue-based medical ethics. We propose that the features of clinical wisdom are pragmatic skills that include, but are not limited to, an awareness of balance, the acceptance of paradox, and a particular clinical manner that maintains a deep regard for the Other. We offer several suggestions for refining training programs and redoubling efforts to provide long-term mentorship opportunities for trainees in clinical mental healthcare in order to cultivate clinical wisdom. (shrink)

To precisely define wisdom has been an ongoing task of philosophers for millennia. Investigations into the psychological dimensions of wisdom have revealed several features that make exemplary persons "wise." Contemporary bioethicists took up this concept as they retrieved and adapted Aristotle's intellectual virtue of phronesis for applications in medical contexts. In this article, we build on scholarship in both psychology and medical ethics by providing an account of clinical wisdom qua phronesis in the context of the (...) practice of psychoanalysis and psychodynamic psychotherapy. With the support of qualitative data, we argue that the concept of clinical wisdom in mental healthcare shares several of the key ethical dimensions offered by standard models of phronesis in medical ethics and serves as a useful, albeit overlooked, reference point for a broader development of virtue-based medical ethics. We propose that the features of clinical wisdom are pragmatic skills that include, but are not limited to, an awareness of balance, the acceptance of paradox, and a particular clinical manner that maintains a deep regard for the other. We offer several suggestions for refining training programs and redoubling efforts to provide long-term mentorship opportunities for trainees in clinical mental healthcare in order to cultivate clinical wisdom. (shrink)

A long-debated question in the philosophy of health, and contingent disciplines, is the extent to which wise clinical practice (“clinical wisdom”) is, or could be, compatible with empirically validated medicine (“evidence-based medicine”—EBM). Here we respond to Baum-Baicker and Sisti, who not only suggest that these two types of knowledge are divided due to their differing sources, but also that EBM can sometimes even hurt wise clinical practice. We argue that the distinction between EBM and clinical (...) wisdom is poorly defined, unsupported by the methodology employed, and ultimately incorrect; crucial differences exist, we argue, not in the source of a particular piece of clinical knowledge, but in its dependability. In light of this subtle but fundamental revision, we explain how clinical wisdom and EBM are—by necessity—complementary, rather than in conflict. We elaborate on how recognizing this relationship can have far-reaching implications for the domains of clinical practice, medical education, and health policy. (shrink)

We briefly respond to Bursztajn and colleagues’ commentary on our article, “Clinical Wisdom in Psychoanalysis and Psychodynamic Psychotherapy: A Philosophical and Qualitative Analysis.”.

The relationship between evidence-based medicine (EBM) and clinical judgement is the subject of conceptual and practical dispute. For example, EBM and clinical guidelines are seen to increasingly dominate medical decision-making at the expense of other, human elements, and to threaten the art of medicine. Clinical wisdom always remains open to question. We want to know why particular beliefs are held, and the epistemological status of claims based in wisdom or experience. The paper critically appraises a (...) number of claims and distinctions, and attempts to clarify the connections between EBM, clinical experience and judgement, and the objective and evaluative categories of medicine. I conclude that to demystify clinical wisdom is not to devalue it. EBM ought not be conceived as needing to be limited or balanced by clinical wisdom, since if its language is translatable into terms comprehensible and applicable to individuals, it helps constitute clinical wisdom. Failure to appreciate this constitutive relation will help perpetuate medical paternalism and delay the adoption of properly evidence-based practice, which would be both unethical and unwise. (shrink)

In response to the article by Baum-Baicker and Sisti, I will consider the kind of wisdom involved in therapeutic listening; the role of life wisdom; and the challenge of imparting clinical wisdom to young health professionals’ education.

Exploring informal components of clinical reasoning, we argue that they need to be understood via the analysis of professional wisdom. Wise decisions are needed where action or insight is vital, but neither everyday nor expert knowledge provides solutions. Wisdom combines experiential, intellectual, ethical, emotional and practical capacities; we contend that it is also more strongly social than is usually appreciated. But many accounts of reasoning specifically rule out such features as irrational. Seeking to illuminate how wisdom (...) operates, we therefore build on Aristotle’s work on informal reasoning. His account of rhetorical communication shows how non-formal components can play active parts in reasoning, retaining, or even enhancing its reasonableness. We extend this account, applying it to forms of healthcare-related reasoning which are characterised by the need for wise decision-making. We then go on to explore some of what clinical wise reasoning may mean, concluding with a case taken from psychotherapeutic practice. (shrink)

Clinical decision making is a challenging task that requires practical wisdom—the practised ability to help patients choose wisely among available diagnostic and treatment options. But practical wisdom is not a concept one typically hears mentioned in medical training and practice. Instead, emphasis is placed on clinical judgement. The author draws from Aristotle and Aquinas to describe the virtue of practical wisdom and compare it with clinical judgement. From this comparison, the author suggests that a (...) more complete understanding of clinical judgement requires its explicit integration with goals of care and ethical values. Although clinicians may be justified in assuming that goals of care and ethical values are implicit in routine decision making, it remains important for training purposes to encourage habits of clinical judgement that are consciously goal-directed and ethically informed. By connecting clinical judgement to patients' goals and values, clinical decisions are more likely to stay focused on the particular interests of individual patients. To cultivate wise clinical judgement among trainees, educational efforts should aim at the integration of clinical judgement, communication with patients about goals of care, and ethical reasoning. But ultimately, training in wise clinical judgement will take years of practice in the company of experienced clinicians who are able to demonstrate practical wisdom by example. By helping trainees develop clinical judgement that incorporates patients' goals of care and ethical reasoning, we may help lessen the risk that ‘clinical judgement’ will merely express ‘the clinician's judgement.’. (shrink)

In order to understand the lived experiences of physicians in clinical practice, we interviewed eleven expert, respected clinicians using a phenomenological interpretative methodology. We identified the essence of clinical practice as engagement. Engagement accounts for the daily routine of clinical work, as well as the necessity for the clinician to sometimes trespass common boundaries or limits. Personally engaged in the clinical situation, the clinician is able to create a space/time bubble within which the clinical encounter (...) can unfold. Engagement provides an account of clinical practice as a unitary lived experience. This stands in stark contrast to the prevailing notion, referred to as a dual discourse, that describes medicine as the addition of humanism to science. Drawing on Aristotle’s notion of phronesis and Sartre’s definition of the situation, we illustrate how this novel perspective entwines clinical practice, the person of the clinician, and the clinician’s situation. (shrink)

The concept of the art of healing is intrinsically connected with the idea of healing powers. There are at least three possible approaches to that idea and all of them have different implications for the problem of medical wisdom. These are: the idea of the healing powers of nature, the idea of the healing powers of science, and the idea of the healing powers of physician's personality. Having critically discussed those ideas I sketch an ideal of a wise physician (...) as someone who has a particular kind of knowledge, good judgement, and self-trust. Medical knowledge is certainly a necessary condition of being a wise doctor but it is not the sufficient one. And this is why patients generally prefer to seek help of “naturally wise physicians”. (shrink)

Reproductive counseling includes counseling of prospective parents by obstetricians, clinical geneticists, and genetic counselors regarding, for example, the use of assisted reproductive technologies, prenatal testing, and preimplantation genetic diagnosis. Two different views on wisdom and the goal of reproductive counseling are analyzed. According to the first view, the goal of reproductive counseling is to help prospective parents reach a wise decision. A specific course of action is recommended by the counselor in contrast to other possible alternatives. According to (...) the second view, the goal of reproductive counseling is not to help prospective parents reach a wise decision but to help them reach their own decision wisely. It is the prospective parents who should make the decision, and it is their value commitments that should be decisive. It is argued that the second approach is to be preferred to the first. It combines respect for autonomy with a recognition of the need for assistance in decision-making. Both the first and second views relate the goal of reproductive counseling to wisdom. A problem is, however, what wisdom more precisely means — there are many different views. A casuistic view of wisdom is investigated. This view roughly defines wisdom as practical prudence in dealing with particular cases. What characterizes a casuistic decision-making method is elaborated in more detail. Applied to the second view, a casuistic view of wisdom implies that the counselor should encourage prospective parents to take into consideration the nature of the particular problem at hand, the context of the problem, their own individual identities, their personal value commitments, and various alternative perspectives, values and arguments. (shrink)

Decision-making depends on bringing evidence together with values: decision theory for example employs probabilities and utilities; health economic decisions employ measures such as quality of life. The hypothesis guiding this chapter is that bringing evidence together with values in clinical decision-making requires an exercise of phronesis. Our aim however is not to justify our guiding hypothesis. It is rather to outline an account of phronesis that is in principle fit for the purposes of clinical decision-making if our guiding (...) hypothesis is correct. The chapter has three sections. Section 1 describes the growing gap between evidence and values in clinical decision-making: the missing link, we suggest, required to bridge this gap, is an appropriate account of phronesis. Section 2 provides an initial characterisation of the required account of phronesis via Michael Polanyi’s twin stipulation on the nature of tacit knowledge. Section 3 then fills out the required account using John McDowell’s characterisation of phronesis as a situation specific but at the same time conceptually structured form of practical discernment. A McDowellian account of phronesis, we argue, in satisfying Polanyi’s twin stipulation, provides an in-principle bridge between evidence and values. We conclude with a note on some of the further requirements if the gap is to be bridged not only in principle but in practice too. (shrink)

Psychoanalysis and Wisdom applies psychoanalytic insights to one of the great examples of wisdom literature, the Ethics of the Fathers, an ethical tractate of the Talmud. Paul Marcus quotes key passages from the Ethics of the Fathers, providing a psychoanalytic commentary to enlarge and deepen our understanding of its contents and focusing primarily on what constitutes a flourishing life. Marcus then considers what psychoanalysis can provide in its engagement with this classic of the wisdom teachings, such as (...) illuminating aspects of the Ethics that are overlooked or underappreciated, and how "pearls of wisdom" from the Ethics can be incorporated into psychoanalytic theory and practice. The book contains clinical material as well as the insights of philosophers like Martin Buber, Gabriel Marcel, and Emmanuel Levinas. Psychoanalysis and Wisdom will appeal to readers interested in psychoanalysis and psychotherapy and to academics and students of psychoanalytic studies, religious studies, Judaic studies, and philosophy. (shrink)

This article is an introduction to a special issue of Theoretical Medicine and Bioethics on clinical reasoning. Clinical reasoning encompasses the gamut of thinking about clinical medical practice—the evaluation and management of patients’ medical problems. Theories of clinical reasoning may be normative or descriptive; that is, they may offer recommendations on how clinicians ought to think or they may simply attempt to describe how clinicians actually do think. This article briefly surveys these approaches in order to (...) show the complexity of clinical reasoning and the inadequacy of any one theory for capturing the full richness of clinical reasoning. The authors of this issue offer both normative and descriptive elements in their accounts. Topics discussed include the importance for clinical reasoning of tacit knowing, risk assessment, narrative and hermeneutics, wisdom, and virtue epistemology. (shrink)

In 2006, the Chief Medical Officer for England published the report Good Doctors, Safer Patients in a call for strengthened regulation of the medical profession. The changing relationship between patients and doctors in the United Kingdom arises from the interplay between societal expectation and clinical governance, personal formation and professional practice, private being and public doing. The wisdom of professional practice is in the habits of professionals, a practical wisdom that is the reflex of professional identity. Socialization (...) into a profession is the formation of such identity through the legitimate peripheral participation of the apprentice, oriented towards the contingent granting of admission to the community of practice. The conditional nature of continued insider status, permitting members to interact with clients across the professional boundary, is essential to the contract through which the profession enjoys the privileges conferred by society. The governance of the profession is therefore also necessarily circumscribed, a political reality that is currently evidenced in the regulation of medical practice in the United Kingdom. (shrink)

Rationality in medicine is frequently construed as hypotheticodeductive. This article argues that such a model gives a distorted view of the rational character of an enterprise that makes judgments about individual human well-being. Medicine as a science is a practical human science. Seen as such, its rational orientation is one that applies general knowledge to particular situations. It is argued that such an orientation is not deductive but interpretative. The Aristotelian concept of practical wisdom (‘phron sis’) is used as (...) a model of the rational orientation of clinical judgment. Keywords: clinical judgment, rationality, human sciences CiteULike Connotea Del.icio.us What's this? (shrink)

In the quest for identity and healing, what belongs to the humanities and what to clinical psychology? Ginette Paris uses cogent and passionate argument as well as stories from patients to teach us to accept that the human psyche seeks to destroy relationships and lives as well as to sustain them. This is very hard to accept which is why, so often, the body has the painful and dispiriting job of showing us what our psyche refuses to see. In (...) jargon-free language, the author describes her own story of taking a turn downwards and inwards in the search for a metaphorical personal 'death'. If this kind of mortality is not attended to, then more literal bodily ailments and actual death itself can result. Paris engages with one of the main dilemmas of contemporary psychology and psychotherapy: how to integrate findings and insights from neuroscience and medicine into an approach to healing founded upon activation of the imagination. At present, she demonstrates, what is happening is damaging to both science and imagination. (shrink)

Phronesis is often described as a ‘practical wisdom’ adapted to the matters of everyday human life. Phronesis enables one to judge what is at stake in a situation and what means are required to bring about a good outcome. In medicine, phronesis tends to be called upon to deal with ethical issues and to offer a critique of clinical practice as a straightforward instrumental application of scientific knowledge. There is, however, a paucity of empirical studies of phronesis, including (...) in medicine. Using a hermeneutic and phenomenological approach, this inquiry explores how phronesis is manifest in the stories of clinical practice of eleven exemplary physicians. The findings highlight five overarching themes: ethos (or character) of the physician, clinical habitus revealed in physician know-how, encountering the patient with attentiveness, modes of reasoning amidst complexity, and embodied perceptions (such as intuitions or gut feeling). The findings open a discussion about the contingent nature of clinical situations, a hermeneutic mode of clinical thinking, tacit dimensions of being and doing in clinical practice, the centrality of caring relations with patients, and the elusive quality of some aspects of practice. This study deepens understandings of the nature of phronesis within clinical settings and proposes ‘Clinical phronesis’ as a descriptor for its appearance and role in the daily practice of (exemplary) physicians. (shrink)

This book moves away from the frameworks that have traditionally guided ethical decision-making in the Western clinical setting, towards an inclusive, non-coercive and, reflective dialogic approach to moral decision-making. Inspired in part by Jürgen Habermas's discourse theory of morality and principles of communicative action, the book offers a proportionist approach as a way of balancing out the wisdom in traditional frameworks, set in the actual reality of the clinical situation at hand. Putting this approach into practice requires (...) having a conversation, a dialogue or a discourse, with collaboration amongst all the stakeholders. The aim of the dialogue is to reach consensus in the decision, via mutual understanding of the values held by the patient and others whom they see as significant. This book aims to underscore the moral philosophical foundations for having a meaningful conversation. Life and Death Decision in the Clinical Setting is especially relevant in our contemporary era, characterised medically by an ever-increasing armamentarium of life-sustaining technology, but also by increasing multiculturalism, a multiplicity of faiths, and increasing value pluralism. (shrink)

Waterman's clinical anecdote highlights several important concepts related to aging, as his own journey with chronic pain leads him to explore an "unconventional" craniosacral therapy. He draws important connections between epistemic humility and wisdom, and he touches on related topics of cognitive neuroscience and ageism. In particular, his comment that, "Perhaps one hallmark of successful aging is when the growth of wisdom outpaces the depletion of mental plasticity" is ripe for further discussion.Waterman asks the question of whether (...) epistemic humility results from wisdom. While I surmise that the answer is yes, these concepts present interesting questions related to the nature of wisdom in the context of... (shrink)

Clinical musings on the nature of reality and "known experience." Therapists must rely on their clients' reporting of experience in order to assess, treat, and offer help. Yet we all experience the world through various filters of one sort or another, and our experiences are transformed through several nonconscious processes before reaching our conscious awareness. Science, philosophy, and wisdom traditions share the belief that our awareness is very restricted. How, then, can anyone accurately report their experience, let alone (...) get help with it? Neuropsychologist Aldrich Chan examines how our experience of reality is assembled and shaped by biological, psychological, sociocultural, and existential processes. Each chapter explores processes within these domains that may act as "veils." Topics in the book include: the default mode network, cognitive distortions, decision-making heuristics, the interconnected mind, memory, and cultural concepts of distress. By understanding the ways in which reality can be distorted, clinicians can more effectively help their clients reach their personal psychotherapeutic goals. (shrink)

Randomized and double-blind clinical trials are widely regarded as the most reliable way of studying the effects of medical interventions. According to received wisdom, if a new drug or treatment is to be accepted in clinical practice, its safety and efficacy must first be demonstrated in such trials. For ethical and scientific reasons, it is generally considered necessary to monitor a trial in various ways as it proceeds and to analyze data as they accumulate. Monitoring and interim (...) analyses are often conducted by a so-called data monitoring committee (DMC), a group of experts independent of both sponsors and investigators. On the basis of DMC recommendations, sponsors sometimes decide to discontinue trials .. (shrink)

This paper's philosophical ideas are developed from a General Nursing Council for England and Wales Trust‐funded study to explore nursing knowledge and wisdom and ways in which these can be translated into clinical practice and fostered in junior nurses. Participants using Carper's (1978) ways of knowing as a framework experienced difficulty conceptualizing a link between the empirics and ethics of nursing. The philosophical problem is how to understand praxis as a moral entity with intrinsic value when so much (...) of value seems to be technical and extrinsic depending on desired ends. Using the Aristotelian terms poesis and praxis can articulate the concerns that the participants as well as Carper (1978) and Dreyfus (in Flyvbjerg, 1991) among others share that certain actions or ways of knowing important for nursing are being devalued and deformed by the importance placed on quantitative data and measurable outcomes. The sense of praxis is a moralized one and most of what nurses do is plausibly on any account of normative ethics a morally good thing; the articulation of the idea of praxis can go some way in showing how it is a part of the discipline of nursing. Nursing's acts as poesis can be a part of how practitioners come to have praxis as phronesis or practical wisdom. So to be a wise nurse, one needs be a wise person. (shrink)

Now in its fourth edition, Rational Diagnosis and Treatment: Evidence-Based Clinical Decision - Making is a unique book to look at evidence-based medicine and the difficulty of applying evidence from group studies to individual patients._ The book analyses the successive stages of the decision process and deals with topics such as the examination of the patient,_the reliability of clinical data, the logic of diagnosis, the fallacies of uncontrolled therapeutic experience and the need for randomised clinical trials and (...) meta-analyses. It is the main theme of the book that, whenever possible, clinical decisions must be based on the evidence from clinical research, but the authors also explain the pitfalls of such research and the problems involved in applying evidence from groups of patients to the individual patient._ For this new edition, the sections on placebo and meta-analysis and on alternative medicine have been thoroughly updated, and there is more focus on insufficient reporting of harms of interventions. The sections on different research designs describe advantages and limitations, and the increased medicalisation and the effects of cancer screening on health people are noted. A section on academic freedom when clinicians collaborate with industry and ghost authors is added._ This essential reference work integrates the science and statistical approach of evidence-based medicine with the art and humanism of medical practice; distinguishing between data, sets of data, knowledge and wisdom, and their application. Such an intellectually challenging book is ideal for both medical students and doctors who require theoretical and practical clinical skills to help ensure that they apply theory in practice. (shrink)

Psychedelic or ecodelic medicines (e.g., psilocybin, ayahuasca, iboga) for the care and treatment of addiction, post‐traumatic stress disorder, cancer, cluster headaches, anxiety, and depression have surged to the forefront of discussions about mental health in the US, leading to the emergence of well‐capitalized biotech companies offering multimillion‐dollar IPOs. Venture capital website Pitchbook reports “continuing investor interest and growing acceptance of what until recently was seen as a fringe area of medicine.” As scholars, activists, and practitioners who have been healed by (...) these medicines and applaud the recent wave of decriminalization after a long, strange trip of mass incarceration and widespread dangerous misinformation, we look forward to a culture that makes these medicines available in a safe and affordable way that respects the lineages of the knowledges that are essentially and not accidentally bundled with these plants—Indigenous and counterculture wisdoms for whom these medicines were never “fringe,” but always foundational. In place of corporadelia's pursuit of standardization, we emphasize the care and wisdom of the Indigenous and countercultural teachings—traditions that have made psychedelics available to the emerging corporate/research partnership in the first place. These knowledge traditions offer foils to the ongoing translation of university peer‐reviewed research into market copy, technical articles, and IPOs, and the concomitant emergence of psychedelic pundits. In particular, we examine instances where prominent researchers have overstated the findings of existing clinical trials in public‐facing representations of the field. We argue that these corporate priorities and tactics are being aided by a new wave of psychedelic “thought leaders” who seek to delegitimize non‐hierarchical approaches to knowledge production and community support within a psychedelic commons. While prominent psychedelic psychiatrists and behaviorists are focused on rooting out and transforming individual habits of mind, we argue that there is another, latent potential for psychedelics to draw attention to—and transform—the invisible, hegemonic infrastructures and ideologies that subtly naturalize and perpetuate deeply unequal societies. (shrink)

_The Social Work Psychoanalyst's Casebook_ begins with an interview with Dr. Sanville, who reflects on her evolution as a social work analyst, theoretician, writer, teacher, and leader. These reminiscences are followed by accounts of nine analytic treatments, each of which offers an unusual window into what actually transpired between analyst and analysand during the treatment hours. These case studies concern particularly troubled, often traumatized patients-the very "hard to reach" or "difficult to treat" clients with whom social workers have long been (...) familiar. They include a reanalysis by the same analyst of a patient whose first therapy ended in a stalemate; an account of transference and countertransference phenomena during termination; a report on the analysis of a young woman who experienced both chronic and stress-related trauma; and an account of the special issues involved in the treatment of an aging woman. Most of the case studies reflect the influence of Dr. Sanville, whose work has long evinced the therapeutic imagination and disciplined creativity to which all the contributors aspire. Tthe contributors to this volume offer the salutary reminder that analytic work is built on a relationship of respect and empathy and that treatment success follows from the therapist's willingness to accommodate the unique needs of individual patients. In honoring Jean Sanville, _The Social Work Psychoanalyst's Casebook_ speaks to the robustness of a multidisciplinary approach to psychopathology that transcends the bounds of any single profession-an approach in which contemporary psychoanalysis is enlarged by the insights and emphases of social work just as social work is enriched by the clinical wisdom of psychoanalysis. (shrink)

Increasingly, medical students are required to face up to ethical issues in their training and practice. At the same time, there is growing interest in philosophy courses in the ethical issues raised by medical practice. This textbook, designed primarily for students of medicine, develops the issues to a philosophical level complex enough to be satisfying to students of philosophy as well as MA students on applied ethics courses. The author advocates an approach to medical ethics which breaks out of the (...) straitjacket of the narrow choice between utilitarian or deontological theory, and contains a valuable discussion of practical wisdom. It maintains a balance between case studies and philosophical arguments - which are developed in a historical context, and will be of interest at all levels of the medical profession. (shrink)

Increasingly, medical students are required to face up to ethical issues in their training and practice. At the same time, there is growing interest in philosophy courses in the ethical issues raised by medical practice. This textbook, designed primarily for students of medicine, develops the issues to a philosophical level complex enough to be satisfying to students of philosophy as well as MA students on applied ethics courses. The author advocates an approach to medical ethics which breaks out of the (...) straitjacket of the narrow choice between utilitarian or deontological theory, and contains a valuable discussion of practical wisdom. It maintains a balance between case studies and philosophical arguments - which are developed in a historical context, and will be of interest at all levels of the medical profession. (shrink)

Armed with expanded federal funding for human embryonic stem cell research and new methods for deriving pluripotent stem cells, stem cell researchers in the U.S. are poised to proceed with unprecedented speed toward the development of new clinical therapies. Staring into the new dawn of regenerative medicine, many observers may assume that the only responsible route to the clinic, both scientifically and ethically, is through FDA-approved clinical trials processes. Conventional wisdom dictates that, like pharmaceutical drugs and the (...) use of biological therapeutics, stem cell-based therapies will have to pass through a series of controlled studies — initially to assess safety and toxicity, then efficacy and comparative efficacy — before they can be justifiably administered to patients outside a clinical trials context. (shrink)

Evaluating the impact of clinical ethics support services remains a challenging task. 1 Against this background, we applaud the authors for developing a theoretical framework that aims to explain how repeated moral case deliberations may promote ‘practical wisdom’ in healthcare professionals and improve the quality of care in health facilities. 2 In our view, it is of particular value to draw attention to the learning processes that may be induced by ethics support services. Understanding such learning processes on (...) the individual and organisational level is a prerequisite for longitudinal research designs that may be suitable to study the impact of specific ethics support services on criteria deemed relevant in patient care. 3 In our comment, we would like to focus on one aspect, which we deem necessary to be able to explain the possible impact of ethics support on the quality of healthcare. This is the... (shrink)

Working retrospectively in an uncertain field of knowledge, physicians are engaged in an interpretive practice that is guided by couterweighted, competing, sometimes paradoxical maxims. When you hear hoofbeats, don't think zebras, is the chief of these, the epitome of medicine's practical wisdom, its hermeneutic rule. The accumulated and contradictory wisdom distilled in clinical maxims arises necessarily from the case-based nature of medical practice and the narrative rationality that good practice requires. That these maxims all have their opposites (...) enforces in students and physicians a practical skepticism that encourages them to question their expectations, interrupt patterns, and adjust to new developments as a case unfolds. Yet medicine resolutely ignores both the maxims and the tension between the practical reasoning they represent and the claim that medicine is a science. Indeed, resolute epistemological naivete is part of medicine's accommodation to uncertainty; counterweighted, competing, apparently paradoxical (but always situational) rules enable physicians simultaneously to express and to ignore the practical reason that characterizes their practice. (shrink)

In this issue of JCE, Baum-Baicker and Sisti present senior psychoanalysts’ views of wisdom.Although views on wisdom differ widely, there is agreement that when ethical conflicts arise, wisdom may be critical in bringing about an optimal result. Here I will present recent empirical findings on wisdom and the ways careproviders may acquire and apply it, especially in ethical conflicts. The findings are not well-known and may seem counterintuitive; I selected them, in large part, for those reasons. (...) A core challenge may be to decide when to give patients standard care and when to make exceptions. In this issue of JCE, Baum-Baicker and Sisti discuss exceptions and Bursztajn and colleagues consider how these exceptions may be further validated as evidence-based treatments. (shrink)

There is an old saw in health policy that everyone wants health care that is good, fast, and cheap — but it’s impossible to have more than two of these at one time.A similar bit of folk wisdom seems intuitively true for the development and testing of new pharmaceutical products. The public is in a bind. We want breakthrough drugs, and fast. But we also want these drugs to be affordable, thoroughly tested, safe, and effective. It seems we can’t (...) have it all.In this paper, we will not claim that one can have it all — but that we can do far better than we are at present. First, we review extensive data on contemporary problems in the design, conduct, and analysis of industry-sponsored clinical trials. Finding major issues that have been solidly documented over more than a decade, we provide many examples of the multifarious ways in which industry-funded trials have been manipulated to raise the likelihood of producing industry-friendly results. (shrink)

The current study sought to assess the mediating role of green market orientation dimensions in the relationship between social risk and new product performance among European Multinational Enterprises (EMNEs). We also assessed the moderating role of entrepreneurial orientation in the relationship between green market orientation and new product performance. The study was based on primary data gathered from 317 EMNEs in Ghana. After various validity and reliability checks, ordinary least squares (OLS) analysis was performed to estimate the various relationships hypothesized (...) in the study. The study finds that social risk has a negative effect on the success of EMNEs' new products. This negative effect is however nullified by the positive mediating effects of strategic green market orientation, tactical green market orientation and internal green market orientation. Entrepreneurial orientation also played a significant moderating effect in the relationship between green market orientation dimensions and EMNEs' new product performance. Based on this, theoretical and managerial contributions were made. (shrink)