Health practitioners have been under fire about their approach to ethical decision making since the 1960s and recent media scandals have not allowed practitioners, policy makers, patients and their communities to relax in this regard.
This study has focussed on one practice community, doctors, and the meanings they associate with good decision making. The findings have revealed new insights into the subject and the final workshop in March 2018 will present those insights and gather feedback from a range of stakeholders to help us work with them for the common good in this highly challenging and contested area moving forward.
What is 'phronesis'?
Phronesis or practical wisdom is a concept which advocates a way to make ethical decisions that are grounded in an accumulated wisdom gained through previous practice dilemmas and decisions. It can be considered as a leadership ability to make decisions that draw on experience from many previous practice situations and allows a leader to come to a wise decision when there seems to be many competing demands in any given situation. For a doctor it is a way to take all the virtues of relevance to any one patient decision into consideration and take action that brings the best outcome for that patient and their community. Ethical decision making can be complex with the “right” decision in one set of circumstances, for one patient not being the right decision for another. It is in effect an “executive virtue”, which by keeping the stakeholders central to the process, allows ethical decisions to be executed in practice rather than discussing conceptual theoretical principles or just trying to follow a range of guidelines.
The Phronesis and the Medical Community project began in May 2015 with a 3 year Arts and Humanities Research Council (AHRC) grant. The project offers a unique methodology that combines virtue ethics (humanities) with a film based depiction of findings and analysis as part of a virtual community (arts). The latter forms a learning resource for medical schools and other CPD providers to help them with their medical ethics teaching. Although the resources are aimed at doctors at any stage of their career the resource could also be used by any health and social care discipline wishing to improve teaching associated with ethical decision making.
The project is led by HSMC but with strong collaborative input from across the University of Birmingham and from Universities of Warwick and Nottingham. Our primary research questions are:
- What does phronesis (practical wisdom) mean to practitioners?
- To what extent is phronesis cultivated, maintained and moulded over the educational and practice life of doctors in the UK?
- To what extent can phronesis be promoted through educational and practice interventions?
The study is exploring how doctors through their professional careers cultivate phronesis (practical wisdom) in the midst of navigating the complex world of healthcare in an era of markets and user choice. It is exploring how they make context-dependent, localised and ‘good’ decisions for patients and the wider community. It is also examining the role that phronesis plays in strengthening and sustaining trust between the medical community and wider health and social care community in which they practice.
Whilst there is a wealth of theoretical work on medical ethical decision making there has been very limited empirical work. The literature review found only 14 studies of phronesis in healthcare of which nine were focussed on nursing. The project has therefore been designed to address this gap in empirical research.
We have collected rich narrative by interviewing 140 Doctors from Birmingham, Warwick and Nottingham as they navigate their way through pre-clinical education, clinical training and into consultant or GP roles. This has been complemented this with observations, reflective diaries, workshops and patient and public focus groups. The latter designed to understand wise decision making and its impact on trust in the medical profession from a patient and public perspective.
Video based odyssey
The methodology adopted is a hybrid that combines narrative based interview approaches with an arts and humanities analysis to produce an educational debating resource in the form of a video based odyssey. This methodology is applicable to other sectors such as care, education, law and business and therefore the research promises much wider social and economic benefit.
The odyssey is made up of six episodes that follow a consultant and GP as they navigate their way from medical school to experienced practitioners. Data analysis has identified a set of ‘virtue continuums’ which doctors tell us have a bearing on their decision making and which seem to change as they develop experience and practical wisdom. The odyssey collates the findings by using the narratives collected in an anonymised form to construct the storylines and scripts to convey the complexity of ethical decision making and where phronesis can be observed or not. The resource is not meant to be conveying ‘this is how it should be done’ but to convey the collective wisdom from our participants and allow students to debate the morality of each situation. The odyssey debating resource was designed and developed with the University of Cumbria who host ‘Stilwell’ (a fictional town in the UK) virtual community in which the odyssey storylines are based. The learning resource and associated materials will be piloted in partnership with Medical Schools in early 2018 with further impact and engagement funding being sought to enable evaluation and expand the engagement and impact through UK medical schools and CPD providers in 2018/2019.
Dates and project timeline
Dr Mervyn Conroy, (PI, HSMC), Dr Aisha Y Malik (HSMC), Catherine Weir (HSMC), Mr James Liddiard ( HSMC), Catherine Hale (Co-I, Warwick Medical School), Lt Cdr Alan Brockie, Royal Navy (Co-I, HSMC), Dr Chris Turner (Co-I, Coventry and Warwickshire Hospital ), Deborah Biggerstaff (Co-I, Warwick Medical School), Dr Richard Knox (Co-I, Nottingham Medical School), Dr. A. Hewison (Birmingham Medical and Dental School) , Joanne Plumb (Co-I, University Hospitals, Birmingham), Professor Philip Begg (Co-I, University Hospitals, Birmingham), Gabrielle Thompson (patient representative) and Stilwell team based at University of Cumbria.
- The final report will offer significant and improved understanding of how medical students and doctors acquire phronesis; how they generate and transmit professional values; negotiate ethical problems and apply virtues. It will also offer a methodology for researching the complex aspects of phronesis using a combination of arts and humanities and social science approaches.
- A professionally produced series of video clips of doctor-doctor, doctor-patient, doctor-staff, doctor-next of kin interactions; which focus on and illustrate the development of phronesis through the practical resolution of ethical dilemmas. This would link to wider virtual community media (Stilwell) and become a resource for Medical Schools, Health Education England, NHS (both primary and secondary care) and other medical and allied healthcare educational establishments.
- Peer reviewed publications (one theoretical and one methodological).
- Two policy papers on the impact of this work on medical education and public trust in the medical community.
- Conference papers.