Phronesis and Ethical Decision Making for Clinical Leaders: a Moral Debating Resource

Dr Mervyn Conroy (Senior Fellow, HSMC)

PhronesisRecent concerns for GPs and medical consultants include taking care of their mental health, risks relating to medical negligence litigation, rationing of resource as part of deciding upon treatment and trying to make decisions between differing courses of treatment. Phronesis as a concept offers a practical and ethical approach to managing these professional quandaries and deciding on a way forward.

Phronesis: the ‘executive virtue’ as a vital concept for leadership

The reason Phronesis, or practical wisdom is of specific interest is that it is considered to be the executive virtue amongst many others such as integrity, collaboration, justice, etc. So theoretically it enables health care leaders to find a way to balance all considerations and make a wise decision on the way forward. Similar to what a chairperson would do at a meeting full of diverse people and opinions. Until now empirical work on phronesis with clinicians or other professions for that matter has been very limited. This three year Arts and Humanities Research Council (AHRC) funded research project asks the medical community what it means to them to make wise ethical decisions when faced with quandaries such as those mentioned above. The outputs include a set of fifteen virtues (including phronesis) with stories and a video series showing a Consultant and GP enacting the participants’ stories to convey the virtues - including what the participants consider to be wise and unwise decisions. So it could be argued we have encapsulated the wisdom of 131 participants from the medical community on what it means to them to make wise decisions.

The inspiration for this three year phronesis research project (May 2015-May 2018) started in 2002 with NIHR funded study. At that time I asked mental health (MH) service managers what it means to them to be leading change to services based in part on the 1999 National Service Framework (NSF). This was a narrative study and what I found is their stories conveyed ‘ethical resistance’ to the imposed changes because they felt they were not bringing well-being to staff and to their patients. Their stories aligned with Alasdair MacIntyre’s shocking conclusion in his 1981 book After Virtue that we live in a time and civilisation ‘after virtue’. In other words the managers felt the changes being imposed on mental health services were not ‘virtuous’ and instead had an emphasis on saving money, increasing status or gaining power. Plus the impositions from above were missing the contextual nuances or particularities and seemed authoritarian.

Virtues vs. Values

What are virtues and how are they different to values? The two terms are often used interchangeably and ‘virtues’ discarded as an old fashioned term for values. However, there is literally a world of difference. Values are about what is of value to an individual, a group of individuals or an organisation and practice virtues are about acting in a way that brings good outcomes for all in a society and across all societies. Phronesis being the ‘executive virtue’ is therefore a vital concept for leadership and in this case clinical leadership as it is not just a concept for bringing wise decisions for patients but also well-being for their communities and wider society. According to MacIntyre decisions (including technical decisions) in a practice have an ethical dimension embedded within.

What did MacIntyre suggest would bring virtue back to our working practices - not just health care – but all our practices including in the private sector? Given scandals seem to have rocked many arguably trustworthy practices such as banking, cricket, and recently maternity and acute services in the health sector what are we missing in the professional education of our leaders? MacIntyre’s call was clear; he said what was lacking across the board are moral debating resources in professional education. So how do we create a moral debating resource for health care leadership and practice?

A tool to allow practitioners to reflect and debate

There have been various attempts to put right the loss of virtue in health and social care, including in medical practice. Attempts such as: ethical practice guidelines and principles from the many health and social care professional bodies, encouraging organisational values and one of the latest – leadership for all or distributed leadership. Sadly all these miss MacIntyre’s main call for moral debating resources; a resource that allows practitioners to reflect and debate on what is appropriate for their practices and each individual patient or client and community.

So this was my challenge – to try to find a modern moral debating resource for health care practice. Which practice in health care do I start with and what would be the form of the ethical debating resource? The literature indicated that medical practice in particular seemed to be tiring of the many ethical guidelines from professional bodies and others and was looking for something more than what are termed de-ontological or general principles. Phronesis (practical wisdom) in a way offers this as it is a theory about practitioners taking wise and ethical leadership actions when many competing demands/virtues are at play e.g. money, time, legalities, personal stress, fairness, family needs, community needs, limits to treatments, cultural awareness, etc. The concept also works when considering individual patients as well as in broader leadership considerations. It is underpinned with making decisions based on the particularities of the situation.

These initial considerations spawned the idea of researching medical practice, using the virtue of phronesis as the theoretical framework and using the findings to create an ethical debating resource. So I discussed the idea with others and we developed a team of researchers and co-investigators from across Birmingham, Warwick and Nottingham universities, and we successfully applied for funding to the AHRC for this project.

Research findings enacted on film

To create a moral debating resource we used a novel virtual community (Stilwell) consisting of a film series and other media that I had previously used for executive leadership education in social services to enact the findings from the phronesis research project. Our starting question for our 131 medical students and doctors at all stages of their careers was ‘What does it mean to make wise ethical decisions for your patients? Participants recounted stories of particularly wise or unwise decisions that they or others had made and that had influenced them in their thinking. Our two characters (professional actors playing a GP and Consultant) in the ‘Stilwell’ film series then enacted some of the stories we were told. We have not produced a resource that is saying ‘this is how it should be done’ – all it does is convey the modern day wisdom from our participants in the career odyssey of our two characters. So not a set of guidelines, but it can be used by medical schools and CPD providers to allow debate of what they feel are the wise ethical actions for their particular contexts and patients – which is precisely what MacIntyre says is missing.

To summarise, the aim of the phronesis project is to help health care leadership professionals in times of resource constraints, patients with ever more complex needs and increasing risk of litigation to find a way to make decisions that will mean they stay resilient and at the same time bring good outcomes for their patients and their communities.