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)

The personhood of the physician is a crucial element in accomplishing the goals of medicine. We review claims made on behalf of the humanities in guiding professional identity formation. We explore the dichotomy that has evolved, since the Renaissance, between the humanities and the natural sciences. The result of this evolution is an historic misconstrual, preoccupying educators and diverting them from the moral development of physicians. We propose a curricular framework based on the recovery of Aristotelian concepts that bridge identity (...) and activity. The humanities and the natural sciences, jointly and severally, can fulfill developmental, characterological and instrumental purposes. (shrink)

The practice of medicine involves continual change, driven by a constant stream of developments in the understanding of biological structure and function relevant to human diseases, and the parallel improvements in pharmacologic and other technological interventions. This change is also driven by evolving social philosophies, ethical trends, and lifestyles. As products of society, doctors absorb contemporary values and norms. Indeed, it would appear that the ethical norms and standards of medical practice are flexible, and that the characteristics of medical practice (...) at any particular point in history may reflect the mores of the times rather than any enduring moral imperatives.However, a common perception .. (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)

This article is intended to revive, through a critical reinterpretation, the bio-psychosocial model of George Engel. Engel’s first description in 1977, was very broad, encompassing too many aspects of medicine. In his later work, he focused his model as an epistemology for clinical medicine. However, what medicine mostly retained were minor aspects of the 1977 article, namely a multi-factorial approach to the etiology of diseases and a call to complement biomedicine with a psychosocial concern in order to re-humanize medicine. We (...) suggest that, properly understood as a clinical epistemology, Engel’s model retains its transformative potential for contemporary medicine.Our discussion begins with a.. (shrink)

Reflection has been proclaimed as a means to help physicians deal with medicine’s inherent complexity and remedy many of the shortcomings of medical education. Yet, there is little agreement on the nature of reflection nor on how it should be taught and practiced. Emerging neuroscientific concepts suggest that human thought processes are largely nonconscious, in part inaccessible to introspection. Our knowledge of the world is fraught with uncertainty, ignorance and indeterminacy, and influenced by emotion, biases and illusions, including the illusion (...) of not having illusions. Neuroscience also documents that lifelong learning processes may hone nonconscious cognition to high levels of sophistication, allowing rapid and precise perceptions, judgments and actions in complex situations. We argue that knowledge of mechanisms underlying human thought may be useful in designing educational programs to foster desired attributes such as curiosity, critical self-awareness and intuitive acumen in medical professionals. The juxtaposition of neuroscientific insights with ideas from Kant on reflective judgement, van Manen on tact, and Aristotle on phronésis, supports a concept of reflection that manifests as wise practice. We suggest that reflection in medical education should be an imperative for educators seeking to guide learners to manage the complexity and “messiness” of medical practice, and a role-modelling mode of medical practice characterized by self-correcting behaviors that culminate in good and right professional actions. An example illustrates reflective practice in the teaching and learning of physicianship. (shrink)

BackgroundPrevious empirical work among physicians has led us to propose that clinical practice is experienced by clinicians as an engagement-in-the-clinical-situation. In this study, we pursue our exploration of clinical practice ‘on its own terms’ by turning to the experience of patients.MethodsPhenomenological analysis of in-depth individual interviews with 8 patients.ResultsWe describe the patient experience as a set of three motifs: the shock on the realization of the illness, the chaos of the health care environment, and the anchor point provided by an (...) engaged physician. We draw on Heidegger’s notion of solicitude to show that patients are actively ascertaining the physician’s engagement in their care.ConclusionsThese findings lead us to question the classical “dual discourse” of medicine that offers a dichotomous account of clinical practice as the addition of care to cure, art to science, humanism to technique, and person to medical case. We found no such distinctions in our empirical investigation of clinical practice. Rather, in our synthesis, practice appears as a unitary experience. The physician’s solicitude for the patient entrains engagement in the clinical situation. Moreover, the solicitous, engaged physician constitutes an anchor point for the patient. (shrink)

Surveillance programs supporting the management of One Health issues such as antibiotic resistance are complex systems in themselves. Designing ethical surveillance systems is thus a complex task (retroactive and iterative), yet one that is also complicated to implement and evaluate (e.g., sharing, collaboration, and governance). The governance of health surveillance requires attention to ethical concerns about data and knowledge (e.g., performance, trust, accountability, and transparency) and empowerment ethics, also referred to as a form of responsible self-governance. Ethics in reflexive governance (...) operates as a systematic critical-thinking procedure that aims to define its value: What are the “right” criteria to justify how to govern “good” actions for a “better” future? The objective is to lay the foundations for a methodological framework in empirical bioethics, the rudiments of which have been applied to a case study to building reflexive governance in One Health. This ongoing critical thinking process involves “mapping, framing, and shaping” the dynamics of interests and perspectives that could jeopardize a “better” future. This paper proposes to hybridize methods to combine insights from collective deliberation and expert evaluation through a reflexive governance functioning as a community-based action-ethics methodology. The intention is to empower individuals and associations in a dialogue with society, which operation is carried out using a case study approach on data sharing systems. We based our reasoning on a feasibility study conducted in Québec, Canada (2018–2021), envisioning an antibiotic use surveillance program in animal health for 2023. Using the adaptive cycle and governance techniques and perspectives, we synthesize an alternative governance model rooted in the value of empowerment. The framework, depicted as a new “research and design (R&D)” practice, is linking operation and innovation by bridging the gap between Reflexive, Evaluative, and Deliberative reasonings and by intellectualizing the management of democratizing critical thinking locally (collective ethics) by recognizing its context (social ethics). Drawing on the literature in One Health and sustainable development studies, this article describes how a communitarian and pragmatic approach can broaden the vision of feasibility studies to ease collaboration through public-private-academic partnerships. The result is a process that “reassembles” the One Health paradigm under the perspective of global bioethics to create bridges between the person and the ecosystem through pragmatic ethics. (shrink)

Van Rensselaer Potter (1911-2001), le biologiste à l’origine du terme « bioéthique » dans les écrits nord-américains, considère que « real bioethics falls in the context of the ideals of […] Aldo Leopold », un forestier, philosophe et poète ayant marqué le XXe siècle. Associer Leopold à Potter a pour effet de placer la bioéthique dans la famille des éthiques de l’environnement, ce qui la différencie du sens conventionnel retenu en médecine et en recherche depuis le Rapport Belmont (1979), une (...) déclaration ayant propulsé l’institutionnalisation de la bioéthique en Amérique du Nord. Cependant, diviser la bioéthique entre le médical et l’environnemental est réducteur. Potter propose au contraire une bioéthique globale s’intéressant aux enjeux situés à leur interface, dont ceux concernant la terre, la vie sauvage, la surpopulation, la consommation, etc. Cet article vise à amorcer un nouveau chantier d’analyse de la pensée de Potter en s’appuyant sur l’héritage de Leopold en biologie. Une synthèse de cette vision potterienne est proposée de manière à considérer son œuvre comme un tout cohérent s’intégrant aux grands débats qui transcendent les XXe et XXIe siècles. Sa vision apparaît comme une sagesse collective et prospective sous la forme d’une science de la survie et d’un code de bioéthique. Dépassant l’éthique de l’environnement, son association avec Leopold offre un modèle de la complexité s’imposant comme cas indissociable du contexte qui l’englobe, en améliorant nos façons d’intervenir en pratique dans un monde en constante transformation, à titre de gouvernance adaptative et de sagesse de la responsabilité. (shrink)

Cet article explore les conséquences pour le libéralisme politique de considérer l’existence d’un pluralisme raisonnable au sujet des différentes conceptions du juste. Comment une conception publique de la justice peut se développer malgré un désaccord raisonnable et profond sur les termes mêmes de cette justice ? En comparant le libertarisme, la justice comme équité et l’égalitarisme strict, il sera montré que les concepts fondamentaux de ces conceptions du juste sont essentiellement contestés. En guise de solution, deux conditions seront suggérées afin (...) de faire en sorte que la conception publique de la justice en soit une de tolérance politique : premièrement, elle devra se baser sur une liste de droits minimaux reconnus par les différentes conceptions raisonnables du juste; et deuxièmement, si la conception publique de la justice a pour ambition de se développer au-delà du dénominateur commun, elle devra offrir des mesures compensatoires à ceux supportant des conceptions du juste plus restrictives. À certains égards, cette problématique et ces accommodements s’apparentent à ce qui est déjà proposé au sujet de multiculturalisme. (shrink)

The concept of metaphor as primarily a vehicle for conveying ideas, even if unusual ones, seems to me as wrong as the parent idea that a metaphor has a special meaning. I agree with the view that metaphors cannot be paraphrased, but I think this is not because metaphors say something too novel for literal expression but because there is nothing there to paraphrase. Paraphrase, whether possible or not, inappropriate to what is said: we try, in paraphrase, to say it (...) another way. But if I am right, a metaphor doesn't say anything beyond its literal meaning . This is not, of course, to deny that a metaphor has a point, nor that that point can be brought out by using further words. . . . My disagreement is with the explanation of how metaphor works its wonders. To anticipate: I depend on the distinction between what words mean and what they are used to do. I think metaphor belongs exclusively to the domain of use. It is something brought off by the imaginative employment of words and sentences and depends entirely on the ordinary meanings of those words and hence on the ordinary meanings of the sentences they comprise. Donald Davidson is University Professor of philosophy at the University of Chicago. He is the author of many important essays, including "Actions, Reasons and Causes," "Causal Relations," and "Truth and Meaning," coauthor of Decision-Making: An Experimental Approach, and coeditor of Words and Objections, Semantics of Natural Language, and The Logic of Grammar. (shrink)

Dans ce texte, je propose d’adapter la théorie de l’agentivité collective de List et Pettit de manière à considérer les nations comme des agents. Cet exercice pourrait ainsi conférer un argument supplémentaire aux théories des droits collectifs s’intéressant aux groupes nationaux puisque ces derniers pourront véritablement être reconnus comme des sujets de droits, capables d’autodétermination et de revendications morales. La théorie des droits collectifs de Seymour sera utilisée comme modèle à cet égard. Bien que le libéralisme politique dans lequel s’inscrit (...) Seymour refuse de se prononcer sur des problèmes métaphysiques, il est intéressant d’ouvrir la possibilité conceptuelle que des groupes nationaux soient des agents à part entière. Pour ce faire, il faudra déterminer comment un agent national peut prendre des décisions et comment il peut subir des actions, en plus d’étudier ce que cela pourrait impliquer pour la responsabilité collective des nations. (shrink)

What is the relation between a reason and an action when the reason explains the action by giving the agent's reason for doing what he did? We may call such explanations rationalizations, and say that the reason rationalizes the action. In this paper I want to defend the ancient - and common-sense - position that rationalization is a species of ordinary causal explanation. The defense no doubt requires some redeployment, but not more or less complete abandonment of the position, as (...) urged by many recent writers. (shrink)

"Davidson begins by harking back to an early interest in the classics, and an even earlier engagement with the workings of grammar. In the pleasures of diagramming sentences in grade school, he locates his first glimpse into the mechanics of how we conduct the most important activities in our life - such as declaring love, asking directions, issuing orders, and telling stories. Davidson connects these essential questions with the most basic and yet hard to understand mysteries of language use - (...) how we connect noun to verb. This is a problem that Plato and Aristotle wrestled with, and Davidson draws on their thinking to show how an understanding of linguistic behavior is critical to the formulating of a workable concept of truth. Against a whole army of contemporary philosophers, Davidson argues that the concept of truth is not ambiguous.". (shrink)

In the Treatise of Human Nature , Hume argues that, because we have adequate ideas of the smallest parts of space, we can infer that space itself must conform to our representations of it. The paper examines two challenges to this argument based on Descartes's and Locke's treatments of adequate ideas, ideas that fully capture the objects they represent. The first challenge, posed by Arnauld in his Objections to the Meditations , asks how we can know that an idea is (...) adequate. The second challenge, implicit in Locke's Essay , asks how an empiricist can characterize an idea as inadequate, as both picking out an object and yet failing to capture it fully. In showing how Hume responds to these challenges, his theory of perceptual representation is explained and his treatment of space is related to his scepticism. His conclusion is shown not to be a characterization of space as it exists wholly apart from our powers of conception. Instead, in an adumbration of Kant, his claim is restricted to space as it appears to us. (shrink)

There is more than one way to say that composition is identity. Yi has distinguished the Weak Composition thesis from the Strong Composition thesis and attributed the former to David Lewis while noting that Lewis associates something like the latter with me. Weak Composition is the thesis that the relation between the parts collectively and their whole is closely analogous to identity. Strong Composition is the thesis that the relation between the parts collectively and their whole is identity. Yi is (...) right that Strong Composition does not fully reflect my view. We must recognize further what, borrowing Lewis's characterization, could be called the "stronger, and stranger" Composition thesis, or what I'll call the Stronger Composition thesis for short. On Strong Composition, it is only collectively that the parts are identical with the whole. On Stronger Composition, they are individually identical with it as well. I will explain and motivate this thesis. (shrink)

La gestion des compétences et son principal instrument, le référentiel de compétences, sont très répandus dans les grandes organisations canadiennes publiques et privées. La compétence éthique y est de plus en plus intégrée, sans toutefois qu’elle soit clairement définie. L’usage de ces référentiels pour « gérer » la compétence éthique des employés et des cadres pose également de nombreux enjeux pratiques et éthiques dont on doit prendre la mesure si l’on veut prétendre œuvrer à son développement. Ce texte vise à (...) mettre en lumière certains de ces enjeux et ainsi offrir quelques pistes de réflexion pour de futures recherches et pour les intervenants qui souhaitent intégrer la compétence éthique dans les référentiels. (shrink)

Background:Intensive care unit nurses are providing care to COVID-19 patients in a stressful environment. Understanding intensive care unit nurses’ sources of distress is important when planning interventions to support them.Purpose:To describe Canadian intensive care unit nurse experiences providing care to COVID-19 patients during the second wave of the pandemic.Design:Qualitative descriptive component within a larger mixed-methods study.Participants and research context:Participants were invited to write down their experiences of a critical incident, which distressed them when providing nursing care. Thematic analysis was used (...) to analyze the data.Ethical considerations:The study was approved by the ethics committee at the researchers’ university in eastern Canada.Results:A total of 111 critical incidents were written by 108 nurses. Four themes were found: (1) managing the pandemic, (2) witness to families’ grief, (3) our safety, and (4) futility of care. Many nurses’ stories also focused on the organizational preparedness of their institutions and concerns over their own safety.Discussion:Nurses experienced moral distress in relation to family and patient issues. Situations related to insufficient institutional support, patient, and family traumas, as well as safety issues have left nurses deeply distressed.Conclusion:Identifying situations that distress intensive care unit nurses can lead to targeted interventions mitigating their negative consequences by providing a safe work environment and improving nurses’ well-being. (shrink)

How is it possible for David Hume to be both withering skeptic and constructive theorist? I recommend an answer like the Pyrrhonian answer to the question how it is possible to suspend all judgment yet engage in active daily life. Sextus Empiricus distinguishes two kinds of assent: one suspended across the board and one involved with daily living. The first is an act of will based on appreciation of reasons; the second is a causal effect of appearances. Hume makes the (...) same distinction, only he extends the sort of assent involved in daily life to theoretical matters as well. He is a skeptic both in finding no reason to grant the first sort of assent and in being subject to the second. (shrink)

Fifteen essays addressing conceptions of individualism and holism as they emerged in Chinese literature and philosophy from the time of Confucius and Chuang-tzu to the present.

Our century has witnessed violence on an unprecedented scale, in wars that have torn deep into the fabric of national and international life. And as we can see in the recent strife in Bosnia, genocide in Rwanda, and the ongoing struggle to control nuclear weaponry, ancient enmities continue to threaten the lives of masses of human beings. As never before, the question is urgent and practical: How can nations--or ethnic groups, or races--after long, bitter struggles, learn to live side by (...) side in peace? In An Ethic for Enemies, Donald W. Shriver, Jr., President Emeritus of Union Theological Seminary, argues that the solution lies in our capacity to forgive. Taking forgiveness out of its traditional exclusive association with personal religion and morality, Shriver urges us to recognize its importance in the secular political arena. The heart of the book examines three powerful and moving cases from recent American history--our postwar dealings with Germany, with Japan, and our continuing domestic problem with race relations--cases in which acts of forgiveness have had important political consequences. Shriver traces how postwar Germany, in its struggle to break with its political past, progressed from denial of a Nazi past, to a formal acknowledgement of the crimes of Nazi Germany, to providing material compensation for survivors of the Holocaust. He also examines the efforts of Japan and the United States, over time and across boundaries of race and culture, to forgive the wrongs committed by both peoples during the Pacific War. And finally he offers a fascinating discussion of the role of forgiveness in the American civil rights movement. He shows, for instance, that even Malcolm X recognized the need to move from contempt for the integrationist ideal to a more conciliatory, repentant stance toward Civil Rights leaders. Malcolm came to see that only through forgiveness could the separate voices of the African-American movement work together to achieve their goals. If mutual forgiveness was a radical thought in 1964, Shriver reminds us that it has yet to be realized in 1994. "We are a long way from ceasing to hold the sins of the ancestors against their living children," he writes. Yet in this poignant volume, we discover how, by forgiving, enemies can progress and have progressed toward peace. A timely antidote to today's political conflicts, An Ethic for Enemies challenges to us to confront the hatreds that cripple society and threaten to destroy the global village. (shrink)