Medical Education as Moral Formation:An Aristotelian Account of Medical Professionalsim
The medical professionalism movement, bolstered by many influential medical organizations and institutions, has in the last decade produced a number of conceptual definitions of professionalism and a number of concrete proposals for its measurement and teaching. These projects, however laudable, are misguided when they treat professionalism as a unitary descriptive concept rather than as a contested and therefore primarily evaluative one; when they conceive professionalism as a domain of medical practice separable in principle from other domains; and when they treat professionalism as, in principle, a specifiable goal or product of sufficiently well designed educational curricula. The logic of professionalism-as-product corresponds to the logic of techne (art or practical skill) in Aristotle's Nicomachean Ethics. Aristotle provides a cogent argument, however, that the moral excellences denoted by "professionalism" cannot be "produced" or even prespecified in the concrete; rather, they must be acquired through long practice under the careful concrete guidance of teachers who themselves embody these moral excellences. Phronesis (practical wisdom) rather than techne must therefore be the guiding logic of educational initiatives in medical professional formation, with particular emphasis on close mentorship and on the moral character both of students and of those who teach them.
If the recent commitments and actions of medical professional organizations, journals, and accrediting bodies are any guide, it is clear that American medicine has in the past decades become increasingly introspective about the moral weight of its practice. Influential voices within academic medicine, responding to external critics, have called attention to the moral complexity of physician involvement with the pharmaceutical industry, to the scope and impact of medical errors, and to the widespread presence of a "hidden curriculum" within medical education that undermines in practice the moral behaviors and beliefs which students bring with them to medical school and which are ostensibly taught in formal ethics curricula (Angell 2000; Coulehan and Williams 2001; IOM 2000; Relman 1980). The unquestioned professional dominance of American physicians in the mid-20th century has become the increasingly questioned and tenuous professional identity of physicians in the 21st century: financially beholden to public and private funding sources, faced with a general public that is increasingly wary and suspicious of skyrocketing health-care costs, struggling to maintain an equitable quality of care for a population with high levels of chronic disease, and in increasing competition with other health-care providers, physicians have increasingly been forced to take a hard look at the moral dimensions of medical practice (Freidson 2001).
This moral pressure has given rise to the modern "medical professionalism" movement. Although internal debates about the nature of medicine-as-profession have always accompanied medical practice, the last decade has witnessed an oft-noted explosion in interest in and writing about "professionalism." Hafferty and Levinson (2008) trace the recent development of the medical professionalism movement in four successive and overlapping "waves." In the first two waves, influential medical journal editors warned sharply and increasingly frequently about the ethical impact of commercialism in medicine and spurred a number of writers and organizations to produce concrete statements about the positive content of medical professionalism (e.g.,ABIM Foundation 2002; Swick 2000). In the third and fourth wave, medical educators have increasingly attended to how professionalism can be assessed and measured, and how professional behavior can be taught within the framework of medical education (Cruess, Cruess, and Steinart 2009; Stern 2006). These research initiatives have been propelled and supported by a substantial organizational infrastructure, including the Association of American Medical Colleges' Medical Professionalism Project (Inui 2003), the American Board of Internal Medicine's Project Professionalism (1995), and the Accreditation Council for Graduate Medical Education (ACGME), which in 1999 designated professionalism as one of the six "core competencies" required for ongoing accreditation (ACGME 2005) . One could add to this account the influence of popular journalistic writing (Gawande 2002), the increased emphasis on "humanism in medicine" and the white-coat ceremony made possible by the Arnold P. Gold Foundation (Goldberg 2008), and the influential report of the Institute of [End Page 88] Medicine (2000) on the frequency and prevalence of medical errors. This collective movement has spawned many hundreds of published articles, several books, several dedicated journal issues, and a wide and creative array of curricular initiatives and institutional reforms at academic medical centers throughout the United States and around the world.
There is a great deal to celebrate in the modern professionalism movement. The collective and institutional moral failures to which the movement is a response are undeniably and pervasively real; the moral candor and psychological realism of many current writers on medical professionalism is admirable; the ideals and behaviors propounded by the various professionalism "charters" are laudable; and the institutional and curricular initiatives widely reported in the professionalism literature are interesting and almost certainly beneficial to their adopting institutions. But I wish to argue that despite these strengths, the modern professionalism movement at times threatens to confuse, rather than to clarify, the role of medical educators in nurturing "professional" physicians. I will argue, specifically, that the concept of "professionalism" appears to be a self-evident and transparent moral concept to which all conscientious physicians can widely assent but is in fact a contested term that is used in different ways by different clinicians and therefore hides important disagreement behind a façade of uniformity. I will argue that it is conceptually unhelpful to conceive of professionalism, as the ACGME does quite explicitly and as much of the movement does implicitly, as a domain of medical practice that can be examined and understood in isolation from other domains.
Finally, relying heavily on modern interpreters of Aristotle, I will argue that some (though certainly not all) modern writers on professionalism threaten to subsume professionalism into the "technical project" of medicine and medical education, in which professionalism is understood as a product of a particular educational system or process rather than as a description of the way that morally excellent clinicians practice. This last point will require an extended excursion into the moral philosophy of Aristotle. But I do not wish this practice-oriented critique to obscure either the value of much of the professionalism movement or the moral seriousness of its most outspoken proponents. Although Aristotle's moral theory sharply challenges some modern approaches to professionalism education, it can nourish, enrich, and support others, including those that explicitly draw on Aristotle as a resource (Pellegrino 2002; Pellegrino and Thomasma 1993). It is therefore my hope that medical educators concerned about physician professionalism will find Aristotle to be both a nimble interlocutor and—perhaps even more—a kindred spirit. [End Page 89]
Three Problems with Professionalism
Professionalism Is a Polyvalent Concept
The first problem with professionalism is that is a polyvalent and diverse concept that is treated as a unitary one. Professionalism, like competence, is a noun that carries implicit evaluative weight (Foot 2002); there is no way to say that a physician exhibits professionalism without, at least ostensively, issuing praise. But if professional is nothing more than a term of approbation, such that "Dr. Z is very professional" means nothing more, roughly, than that "Dr. Z is a very good physician," then to speak of competency in professionalism, as the ACGME does, would be redundant. If in fact professionalism is to function not only as an evaluative term but also as a descriptive one, naming a set of skills, traits, or attributes in which physicians can be more or less competent, it must take on specific positive content. But what is this content, and how is professionalism to be specified? What exactly is it?
The modern medical professionalism literature is resplendent with a dizzying array of proposed definitions of professionalism, nearly all of which name behaviors and traits that no morally earnest person would dare to criticize. Swick (2000), in perhaps the boldest individual effort of this type, defines professionalism as adherence to nine behaviors intended to reflect the nature of a profession and the nature of medical practice: physicians are to "subordinate their own interests to the interests of others"; to "adhere to high ethical and moral standards"; to "respond to societal needs"; to "evince core humanistic values, including honesty and integrity, caring and compassion, altruism and empathy, respect for others, and trustworthiness"; to "exercise accountability for themselves and for their colleagues"; to "demonstrate a continuing commitment to excellence"; to "exhibit a commitment to scholarship and to advancing their field"; to "deal with high levels of complexity and uncertainty"; and to "reflect upon their actions and decisions." The 2002 Physician Charter on Medical Professionalism, naming professionalism as "the basis of medicine's contract with society," frames professionalism according to the three principles of the "primacy of patient welfare," "patient autonomy," and "social justice," with 10 related professional "commitments" (ABIM Foundation 2002). The ACGME describes resident professionalism as the demonstration of
respect, compassion, and integrity; a responsiveness to the needs of patients and society that supercedes self-interest; accountability to patients, society, and the profession; and a commitment to excellence and on-going professional development; . . . a commitment to ethical principles pertaining to provision or withholding of clinical care, confidentiality of patient information, informed consent, and business practices; . . . [and] sensitivity and responsiveness to patients' culture, age, gender, and disabilities.
(ACGME Outcome Project 2004) [End Page 90]
No sensible clinician would argue that these definitions, and many others like them, describe laudatory behaviors, attitudes, and beliefs, and this universal evaluative consensus is often assumed to be at the same time a universal descriptive consensus about what does, and does not, count as professional behavior. But when the use of professionalism in real-life clinical settings has been examined empirically, the answer appears to be considerably more complex. Take, for example, the following clinical anecdotes recently published by two medical students:
• In his clerkship evaluation, a student complained that canceling over half of the clinical lectures was unprofessional. A year later, this confidential evaluation was cited as evidence of "unprofessional expectations."
• An attending, working in the acute oncology ward with immunosuppressed patients, instructed students that it was unprofessional to take sick days "unless you are comatose."
• During a case conference, a student questioned the appropriateness of performing a rectal exam, and stated that the rectal exam may sometimes be used as a form of student and patient abuse. The student later received an evaluation noting that question was "inappropriate" and indicated an "unprofessional resistance to learning." (Brainard and Brislen 2007, pp. 1011–12)
Do these anecdotes describe abuses of the concept of professionalism? Perhaps so; but this then begs the important question: how would one know that this is the case? How does one know to which of the many definitions of professionalism to refer, and how would one know whether any definition is an adequate one? What is the criterion of adequacy for a definition of professionalism in which "this is professionalism" means something other than "I value this?" Who has the authority to decide what professionalism is, and what it is not?
These questions are pressed further by two studies that have presented resident and attending physicians with clinical vignettes and have asked these physicians to rate the degree to which the vignettes did or did not depict unprofessional behavior. In the first study, 30 faculty members (15 internists and 15 surgeons) were shown five videotaped scenarios in which medical students were placed in "professionally challenging situations" and interviewed regarding what would count as professional student behavior in each case; the authors noted "substantial disagreement both between and within faculty about what constitutes professional and unprofessional behavior in medical students" (Ginsburg, Regehr, and Lingard 2004, p. S3). In the second study, 58 internal medicine residents and 27 internal medicine faculty members were presented with 16 written vignettes depicting various "unprofessional" behaviors and were asked to rate whether each was "not a problem" or was an example of "minor," "moderate," or "severe" unprofessional behavior (Borrero 2008). The investigators did not [End Page 91] find a hypothesized generation gap in the responses of attending faculty and trainees, but they did find substantial disagreement among the faculty and trainees about what did, and what did not, count as unprofessional behavior.
Some of the clinicians in these studies might wish to argue that other clinicians are misunderstanding the "true" nature of professionalism, but again we are left to ask: how would one know that this is the case, and how are disputes about what counts as professionalism to be arbitrated? The diverse ways in which professionalism is applied in actual clinical settings points to philosopher Ludwig Wittgenstein's (2001) dictum that in many cases "the meaning of a word is its use in the language"—that in order to understand what a term means, what often counts is not how the word is defined in a logical system but rather how it is used in the common life of a community of speakers. Once seen in this way, ongoing disputes about the abstract definition of professionalism—such as, for example, a recent spate of papers squabbling over the precise nature of the relationship of "professionalism" to "humanism" (Cohen 2007; Goldberg 2008; Swick 2007)—appear increasingly arbitrary and unfounded. What counts is how the concept of professionalism is used and applied.
The examples above demonstrate that the closer one gets to difficult on-the-ground clinical situations, the less useful professionalism seems to be, as a concept, in clarifying specific appropriate behaviors. If this is true, then professionalism is less useful as a descriptive term for specific behaviors than as an evaluative term that clarifies that a particular behavior is praiseworthy or excellent—we might even say, morally excellent. Following this use, I understand professionalism to be a term connoting moral excellence in clinical behavior. The clear question, of course is: how does one recognize moral excellence when one sees it? Where does one gain the specific content? Or is professionalism only a platitude?
Professionalism Cannot Be Considered in Abstraction from the Whole of Medical Practice
The second difficulty with professionalism as it has emerged in the modern medical professionalism movement is in the relationship of professionalism to other aspects of medical practice. Most explicitly in the ACGME formulation of "core competencies" for residents and residency programs, but implicitly in much of the modern literature, professionalism is conceived as a domain of medical practice that can be measured and assessed independently from other domains: professionalism for the ACGME is complemented by the "core competencies" of "patient care," "medical knowledge," "practice-based learning and improvement," "interpersonal and communication skills," and "system-based practices" (ACGME 2007). But do we really want to accept this compartmentalization of professionalism? Is professionalism really separable, even in principle, from the other ACGME core competencies? Can a physician really exhibit [End Page 92] competence in professionalism and at the same time be severely deficient in patient care skills, medical knowledge, interpersonal communication skills, and an ongoing commitment to self-improvement? Are none of these latter domains constitutive of professionalism? Again, we are less interested in finding the correct abstract definition of professionalism—since it is likely that none exists, and at any rate we would not know how to recognize it if we were to find it—than in asking how professionalism is actually put to use in our everyday conceptions of medical practice. One might reasonably argue, for example, that a broader conception of professionalism that encompasses some or all of the other ACGME competencies more faithfully reflects the use of professionalism in everyday discourse than does the compartmentalized conception of the modern professionalism literature. In this conception, professionalism is less a separately analyzable domain of medical practice than an overarching evaluative description of the excellent practice of medicine as a whole.
An adherent of a narrower, more compartmentalized conception of professionalism might, of course, strenuously object to this. But on what grounds? Why should a narrower conception of professionalism have any more of a claim than a broader conception? My point here is not to argue that this broader conception of professionalism, which I favor, must be the case, but rather that deciding between the two is not, for the most part, a matter of logical debate. We can search all we want for the essence of professionalism, but again, how would we know when we have found it?
Professionalism Is Not a Product
The third problem with professionalism—which many may not perceive, at first, as a problem at all—is the degree to which much (though not all) modern writing on medical professionalism conceives professionalism as a product of a good medical education. Take, for example, the following quotation from Shelton (1999), which like this paper attempts to bring Aristotelian virtue theory into the modern debate about professionalism:
It is time to commit ourselves to developing a model of virtue, perhaps publicly promoted as professionalism, using the Aristotelian framework as a lens through which we can better examine and comprehend our teaching mission. . . . We need to think critically about the range of concrete clinical capacities to which the virtues of the "good doctor" correspond and the Aristotelian means that define them. These characteristics should be formulated and agreed upon as goals of education in response to the real challenges of medical practice. Specific curricular objectives must then be developed, with testable outcome measures, to accomplish these goals.
(p. 673)
Several things are important to notice about the author's approach here. First, the nature of professionalism is presumed to be specifiable in advance of the [End Page 93] implementation of any educational initiative. Before doing the work of educating students for professionalism, that is, we can readily speak about what professionalism is. Second, once these goals are specified, the principal educational question becomes not "What is professionalism?" but rather "How can we design an educational system (such as a medical school curriculum) which will allow us to attain the prespecified goal of professionalism?" The focus, in other words, is less on the end being pursued than on the appropriate means for the attainment of that end. The adequacy of these means can then be tested against the prespecified standard, as long as "testable outcome measures" are provided: the "standards of excellence which virtue requires" are presumed to be publicly available and quantifiable standards. Third—and here I go beyond what Shelton says explicitly to what I take to be the logic of this approach—if the end is specified in this way and the means by which to achieve these ends are clearly established, then any sufficiently skilled person, adequately trained in the correct educational method, can successfully implement the end. In fostering the professionalism of medical trainees, it may help if a teacher is a humanistic, compassionate, professional physician, but such traits of character are not, strictly speaking, necessary: one could in theory fake it, deciding to teach by the book rather than according to one's own inner inclinations that spring from one's character.
This three-part conception of means-end rationality, in which (1) the end or goal is specified in advance of the application of "method" or "technology," (2) the focus is on the best method or technology by which to attain the pre-specified end, and (3) the successful application of the method or technology does not directly depend on the moral character of the agent, should be familiar to us if only because it is the air we breathe in the everyday world of modern medicine. This mode of reasoning, which we might refer to as the technical project of modern medicine (Dunne 1993), is attractive because it highlights the "scientific" nature of medical practice. It is the logical backbone of the modern evidence-based medicine (EBM) movement: to count as evidence-based, modern therapeutics must have quantifiable outcome goals, must advance clear methods or technologies for the attainment of these goals, and must leave open the possibility of replication by others applying the same method or technology in a standardized way. "Health," perhaps the most common and yet most elusive concept in medical practice, must always for EBM be quantifiable, operationalized to clear variables such as the mortality rate. It is not difficult, therefore, to see how well-intentioned medical educators might desire to turn professionalism education into an evidence-based technique.
The technical project of modern medicine would have been recognizable to Aristotle because he was among the first, in his Nicomachean Ethics, to describe it. What I have been calling the "technical project" corresponds with Aristotle's conception of techne, often rendered as "art" in contemporary translation but the etymological root of our "technology" and "technique," which for Aristotle was [End Page 94] a mode of practical, or deliberative, reason. But it was not the only mode: Aristotle distinguished the logic of techne from the logic of another mode of practical reason known as phronesis or "practical wisdom." I want to argue that professionalism is more responsibly understood under the logic of phronesis than under the logic of techne and the technical project, and that this has significant consequences for how we understand ourselves as medical teachers and how we understand professionalism education. This requires, however, a brief introduction to the logical progression of the Nicomachean Ethics.
Aristotle and the Practice-Known Good
Aristotle opens his ethical masterpiece, the Nicomachean Ethics, by asserting that the good (agathos) is "that at which all things aim," the goal of all action (1094a). This is at first glance a remarkably optimistic assessment of the human condition: every time humans act toward some goal or end, for Aristotle, they are seeking after the good as they understand it. That is not to say that all actions aim at the same thing: Aristotle holds that different actions seek after different goals, such that the end of medicine is health, the end of shipbuilding is the vessel, and the end of household management is wealth. But these individual activities, for Aristotle, do not serve themselves alone; they all act in service of a larger cause. This larger cause is the correct ordering of the polis, the political community, and so politics, in Aristotle's technical sense of this term, is the master science of the good. We pursue the sciences of medicine, of shipbuilding, and of household management, in other words, not for their own sake but rather be-cause they are essential to the sustenance of a community that meets the basic needs of its citizens and allows them to join the community in pursuing what is good. The right ordering of this community is known as politics (1094b). But the good is not, for Aristotle, simply a matter of convention, as if every community, however corrupt, set its own standard for what is good. The ultimate or highest good for Aristotle, that good at which all else aims and toward which all other goods are means, is eudaimonia, often translated as "happiness" but more properly translated as "human flourishing." Eudaimonia names the state of one who has the material goods necessary for the pursuit of the good life (who is not, for example, being tortured) and whose life is ordered in a way consistent with overall excellence in harmony with his or her fellow citizens (1097a–1097b).
All of this would remain little more than platitude, however, unless Aristotle addresses how we recognize the good when we see it and how we know what eudaimonia is, and it is here that Aristotle's theory becomes both more pessimistic and more interesting. For Aristotle, humans have a natural orientation to the good, in that we seek the good in all of our actions; but we do not by nature comprehend what the good is. In order to know the good, one must have been trained by good teachers who can enable one to understand what the good is, and is not: "to be a competent student of what is right and just, and of politics [End Page 95] generally, one must first have received a proper upbringing in moral conduct" (1095b).
To comprehend the good, then, one must have been instructed by good teachers; but this still does not tell us what the good is, either in the case of limited goods or in the case of eudaimonia, the highest good. Aristotle answers this by stating that in order to better understand what eudaimonia is, we should think of what the human "proper function" is. Aristotle understands the concept of the human "proper function" by invoking an analogy between a good human and a good artist or a good craftsman: "Just as the goodness and performance of a flute player, a sculptor, or any kind of expert, and generally of anyone who fulfills some function or performs some action, are thought to reside in his proper function, so the goodness and performance of man would seem to reside in whatever is his proper function" (1097b). Aristotle then argues (contestably) that if we want to know what the human "proper function" is, we should look at how humans differ from other animals; and that if we do so, we will find that humans differ from other animals specifically in our ability to live in accordance with reason. Because humans alone are rational animals, "The proper function of man, then, consists in an activity of the soul in conformity with a rational principle or, at least, not without it" (1098a). But what does it mean, practically, to live according to reason? Aristotle partly clarifies this by stating that it has to do with living up to one's own standards, and he again uses the analogy of a good musician. He states that we can know what the human "proper function" is in that "it is the same in kind as the function of an individual who sets high standards for himself: the proper function of a harpist, for example, is the same as the function of a harpist who has set high standards for himself" (1098a). An activity is therefore well performed when "it is performed in accordance with the excellence [arête] appropriate to it." Summing this together, Aristotle states that "we reach the conclusion that the good of man is an activity of the soul in conformity with arête [excellence or virtue], and if there are several virtues, in conformity with the best and the most complete," over a complete lifetime (1098a).
So far, then, we see that for Aristotle the good is the aim of all action; that politics is the master science of the good, and that eudaimonia, human flourishing, is the highest good; that the good can only be known through proper education; that good is known through the concept of "proper function" which, when attained, can be understood as excellence or virtue; and that the proper human good is activity in conformity with virtue. All of this still sounds quite platitudinous, however, and begs the pressing question: how do we recognize excellence, or "proper function," when we see it? Aristotle has much to say about this, but he flatly and consistently refuses to give a categorical answer that does not depend on the moral character of both the learner and his or her teachers. He distinguishes two kinds of excellence (or virtue): intellectual excellence, which concerns what is true, and moral excellence, which concerns what is good and therefore is inextricable from action. Intellectual excellence is more simple to [End Page 96] acquire than moral excellence: it "owes its origin and development chiefly to teaching, and for that reason requires experience and time" (1103a). One does not necessarily have to be a good person in order to know what is true, at least much of the time. But it is quite different for the moral excellences, or virtues, the knowledge of which requires not only teaching, experience, and time but also the acquisition of habit, ethos. One acquires moral excellence, for Aristotle, by practicing moral excellence until moral excellence becomes, so to speak, internal to one's nature:
The virtues we acquire by having put them into action, and the same is true of the arts. For the things which we have to learn before we can do them we learn by doing: men become builders by building houses, and harpists by playing the harp. Similarly, we become just through the practice of just actions, self-controlled by exercising self-control, and courageous by performing acts of courage.
(1103b)
Conversely, one who builds badly becomes, over time, a bad builder:
Characteristics (habits) develop from corresponding activities. For that reason, we must see to it that our activities are of a certain kind, since any variations in them will be reflected in our habits. Hence it is no small matter whether one habit or another is inculcated in us from early childhood; on the contrary, it makes a considerable difference, or, rather, all the difference.
(1103b)
We can make this concrete by saying that becoming a good person is much like becoming a good physician. One becomes an excellent physician not by studying medical theory (though of course that is essential and prerequisite), but by practicing medicine in an excellent way such that excellent practice is so ingrained that it becomes second nature. If one does not make a habit of excellence and practices medicine poorly, on the other hand, one will become a lousy physician. In the same way, if one wants to be a good person, one must practice doing the good; if one does not make a habit of doing the good, one becomes, in time, a lousy person.
But we still have not answered our pressing question: how do we recognize moral excellence when we see it? Aristotle still refuses to provide an abstract answer:
Any discussion on matters of action cannot be more than an outline and is bound to lack precision; for as we stated at the outset, one can demand of a discussion only what the subject matter permits, and there are no fixed data in matters concerning action and questions of what is beneficial, any more than there are in matters of health. And if this is true of our general discussion, our treatment of particular problems will be even less precise, since these do not come under the head of any art which can be transmitted by precept, but the agent must consider on each different occasion what the situation demands, just as in medicine and in navigation.
(1103b–1104a) [End Page 97]
We see, then, that for Aristotle neither the good of medicine—"health"—nor the proper human good—eudaimonia—can be understood abstractly. Both can be understood only by those who are sufficiently habituated into excellent practice so as to be able to recognize it in individual situations.
Close, on-the-ground, concrete moral mentorship is therefore absolutely essential, for Aristotle, if one is ever to become a person of moral excellence. As a result of having been taught by teachers of excellence what excellence is in concrete situations, and having practiced excellence over time under the guidance of these teachers, one becomes the kind of person for whom excellence is internalized and who then, importantly, sets the standard for what constitutes moral excellence in a given situation." Acts are called just and self-controlled," Aristotle writes, "when they are the kind of acts which a just or self-controlled man would perform," and furthermore, one can be called just and self-controlled only when one performs these acts "in the way that just and self-controlled men do" (1105b). Such an account seems circular only if one insists on an abstract definition of excellence rather than an exemplification; for Aristotle, however, moral excellence is known in the concrete only in its exemplification. Aristotle famously formulates the various moral excellences as means between two vices: courage is the mean between recklessness and cowardice, generosity the mean between extravagance and stinginess, and so on. It is by navigating the mean between excess and deficiency that we experience pleasure and pain "at the right time, toward the right objects, toward the right people, for the right reason, and in the right manner" (1106b). But what the "golden mean" is in any given situation cannot be known in the abstract; it can only be known with reference to how a person of moral excellence would act in a given situation. Aristotle is quite clear that virtue or excellence is a matter of "observing the mean," which is "defined by a rational principle, such as a man of practical wisdom [phronesis] would use to determine it" (1106b).
We have now arrived at a crucially important concept—that of practical wisdom, or phronesis—which provides an important conceptual alternative to the technical project of modern medicine, and about which more needs to be said. But we may first note three ways that Aristotle's theory challenges certain modern educational approaches to professionalism education. First, unlike modern approaches that attempt to specify abstract accounts of professionalism (through principles, duties, laws, or even conceptual accounts of "the virtues") and then to determine how these accounts should be applied in particular situations, Aristotle begins with attention to the action of the morally excellent person in particular situations and only from that develops his larger, more abstract, moral theory. Moral excellence for Aristotle cannot be defined in the abstract but only through reflection on the concrete situations in which actions of excellence are (or are not) performed. Second, although Aristotle would support preparatory didactic instruction in the intellectual disciplines relevant to clinical practice (not only the sciences but also, for example, history, sociology, and moral theory), he [End Page 98] would likely doubt that any top-down teaching initiative would directly translate to morally excellent practice. For Aristotle, it is not talking about the virtues, but only practicing the virtues, that leads to virtuous practice. Preparatory instruction may (or may not) be useful for subsequent moral deliberation, but it must not be mistaken for the thing itself: for Aristotle, as I will argue in more detail below, "what professionalism requires" in particular cases is discovered not theoretically but rather in practice, through the moral discernment of the clinician of excellence in on-the-ground particular situations. Third, unlike modern case-based curricular methods that present students or trainees with morally challenging case descriptions, invite them to deliberate about what to do, and therefore implicitly foster the idea that the essence of professionalism is the deft application of rational analysis to ethical dilemmas, an Aristotelian approach would emphasize that moral excellence in clinical practice is much less about discursive rationality than about the character that displays itself most readily in clinical situations—the middle of the night, while fatigued, under duress—in which rational analysis is most unlikely.
If this is true, it should be clear that the various modern codes of medical professionalism such as the Physician Charter on Medical Professionalism (ABIM Foundation 2002), while occasionally helpful for clarifying certain ethical boundaries beyond which no clinician should tread, are much too abstract and general to do much work either in the description of how professionalism actually works on the ground or in changing on-the-ground physician behavior. Prescriptive codes of ethics—filled either with positive abstract ideals or of negative "thou shalt not" proscriptions—are not sufficient to produce physicians of moral excellence.
"Phronesis" as an Alternative to the Technical Project
If abstract charters and codes are too general to sustain medical professionalism, how should medical educators think about the moral and professional formation of those whom they supervise? What kind of education fosters the growth of the moral excellences we think of as "professionalism" among students and trainees? In his discussion of the types of rational inquiry that culminate in action or production (practical rationality), Aristotle provides two models for how professionalism education could be conceived: the model of techne, or producing; and the model of phronesis, or practical wisdom.
The logic of techne is already quite familiar to us. Techne is the logic of poiesis, production, and demands that a product be specified toward which the right means can be applied. Although the right application of the means may demand considerable training (Aristotle considers medicine, after all, as a mode of techne, though it is debated whether he should have done so [Phillips 2002; Waring 2000]), one need not necessarily be a person of excellent moral character in [End Page 99] order to do so correctly. Professionalism education as techne, as we have already discussed, would involve specifying what professionalism is and then working hard to design the best educational strategy or system for the production of professionalism among medical trainees.
The problem with this approach from an Aristotelian perspective, however, is that although techne is a perfectly appropriate way to understand shipbuilding and may even be an appropriate way to understand the technical aspects of medical practice, it is emphatically not the way that Aristotle understood moral education and moral formation. Moral excellence, for Aristotle, is not a product, in that it cannot be produced by any system; practical reason related to matters of good and evil is to be understood according to the alternative logic of phronesis, practical wisdom.
Aristotle directly compares techne and phronesis by stating that if techne is practical reason leading to production (poiesis), phronesis is practical reason leading towards action (praxis). Unlike techne, therefore, the function of phronesis is not to make or produce anything, but rather to guide human action in a particular way, a way in conformity with excellence consistent with eudaimonia (1140a). Unlike a particular exercise of techne, which may or may not be virtuous depending on what is being produced and how the production occurs, the exercise of phronesis is always virtuous, because it is always oriented toward human excellence.
To be a person of phronesis, practical wisdom, is to be the kind of person who, in any concrete situation, discerns the good and finds the right way to achieve it. The person of practical wisdom, the phronimos, is also a person of "good sense," gnome, who "has the sense to forgive others" when appropriate, who embodies sympathetic understanding, who possesses "mature intelligence" and good judgment (1143a). The physician of practical wisdom is the kind of colleague whom other clinicians trust; the kind of supervisor one can count on to be honest, conscientious, and fair; the kind of doctor one would trust with a parent, a spouse, or a child at the most painful and vulnerable time of his or her life. The physician of practical wisdom is the physician who best embodies "professionalism" as that concept is described by the modern professionalism movement.
Importantly for Aristotle, though, and in marked contrast to techne, this good doctor cannot develop phronesis, at least not for long, without developing all of the other moral virtues or excellences as well. Vice has an intensely corrosive effect on good practical decision-making because it tends to prevent a person from fixing his or her sights on what is good. The cowardly person, for example, will be too overcome by fear to consistently know and do the good, and so phronesis requires the moral excellence of courage. The excessively pleasure-seeking person will be too overcome by self-seeking desire to consistently know and do the good, and so phronesis requires the moral excellence of self-control. But there is for Aristotle a wonderful "feed-forward" relationship between phronesis and the other excellences as well: the moral excellences are required for the development of phronesis, which is itself a type of excellence, but once acquired, [End Page 100] the exercise of phronesis enables the further development of all of the other moral excellences. So for Aristotle there are powerful theoretical reasons why one cannot consistently embody the excellences of professionalism without being an excellent person at the same time.
Second, and also in marked contrast to techne, the action consistent with moral excellence in any particular situation cannot be specified with any precision prior to the deliberation of the practically wise person. Although generalized theoretical knowledge is important for phronesis, it is never sufficient: moral excellence is discovered only as it is exercised, as the phronimos engages particular situations in a morally excellent way (1142a). It cannot be otherwise specified. Practically, then, there is little point in arming medical trainees with a list of precepts of professionalism and expecting them to apply them straightforwardly in the complex situations of clinical practice. Unless these physicians are the sorts of persons who through a lifetime of practice and habituation have cultivated the excellence of practical wisdom by formation in particular types of moral communities, the precepts will probably be useless; and furthermore, if practical wisdom is present, the precepts will probably be unnecessary. The practically wise person does not need general guidelines about how to act morally; the practically unwise person cannot successfully and consistently apply such guidelines when they are given, and might not even try.
The acquisition of practical wisdom, like the acquisition of the moral excellences, takes a very long time. Aristotle provides no theory of moral development in the modern sense, but he clearly holds that the process starts in early childhood as parents and caregivers encourage the developing moral agent to feel pleasure at some things and revulsion at others, to value some actions and to disvalue others, to conquer certain fears and to heed others, to discipline certain cravings and wants and to pursue others. This process is neither simple nor straightforward, and it becomes more complex as the child grows: the task of moral education is soon shared with grandparents, teachers, coaches, religious leaders, peers, and many others. The emerging moral self is shaped not only at home but also in classrooms, on sports teams, in religious communities, in peer groups, in work settings, and so on. By the time the child reaches medical school, a lot of moral formation—probably the most influential, self-shaping, and important—has already taken place, for good or for ill. For Aristotle, professionalism education is at best a continuation of this long trajectory.
That is not to say that medical training programs cannot be powerfully formative moral communities in their own right, for good or for ill. They clearly can be, at least some of the time (Feudtner, Christakis, and Christakis 1994; Satterwhite, Satterwhite; and Enarson 2000), and Aristotle would want medical education to occur in the same way that any other successful education in moral excellence occurs: not in abstraction but in the close everyday encounter of students with teachers of moral excellence, in an environment that minimizes hindrances to the exercise of the moral excellences, such that over time, and [End Page 101] through ongoing practice and habituation, the moral excellence and practical wisdom of the teacher becomes the moral excellence and practical wisdom of her students. That kind of close-to-the-ground approach, for Aristotle, is the only way that medical education is likely to contribute to the development of the moral excellences of professionalism.
Conclusion: "Phronesis" in Practice
I have already discussed several practical implications of this argument for modern medical debates about "professionalism." I conclude with four more.
First, to state the obvious: if Aristotle is correct that the ability to make practically wise choices is dependent on the possession of good moral character, and if moral character is formed in important ways by the time an individual starts medical training, then the identification and recruitment of prospective students and trainees with good moral character is critically important for the fostering of a culture in which the excellences of professionalism are exercised and valued. This is, fortunately, an actively debated topic in the professionalism literature (Greenburg et al. 2007; Stern, Frohna, and Gruppen 2005).
Second, it is unreasonable to expect that students and residents will develop the excellences of professionalism if those excellences are not valued by and embodied in their teachers. The most important thing that an institution can do, if it values professionalism, is to recruit, support, and retain teachers of moral and clinical excellence. If this is not done, every other professionalism initiative or program is likely to fail. There is now a substantial literature on the "hidden curriculum" in medical education, which is basically the process by which idealistic but morally naïve students are fed moral platitudes in their preclinical medical curriculum and then are sent out to the wards where their real moral medical education begins. The problem is that this education is more often than not an education in vice rather than moral excellence, as students internalize and then replicate the unprofessional attitudes and practices of their residents and attendings (Coulehan 2005). The only way to combat this corrosive hidden curriculum, though, is from the ground up, replacing teachers of vice with teachers of excellence.
Third, as others have previously argued (e.g., Ginsburg and Stern 2004), educational initiatives that attempt to communicate a "cognitive base" for professionalism must link intimately with actual on-the-ground practice. Aristotle makes much of the need for instructors in the moral life and affirms that theoretical knowledge is a helpful resource for phronesis, but it is important to remember that the archetypal teacher of excellence is not, for Aristotle, the lecturer behind the podium but rather the master harpist carefully shaping the technique and style of the aspiring beginner (1103b). There is surely a need, in the harpist's education, for some introduction to music theory, or to the history of [End Page 102] harp-music, or even for some mindful theoretical reflection on what it means to play the harp well, but the harpist's most formative education comes when the teacher, listening intently to a player's carefully rehearsed training-piece, jumps up and proclaims, "Ah, yes, that's right!" Aristotle would predict that professionalism initiatives will be powerful only to the extent that they foster that kind of pedagogical intimacy.
Fourth, despite my expressed pessimism about the utility of top-down curricular approaches to the teaching of professionalism and my repeated emphasis that the most powerful moral education happens close to the ground in the close everyday interaction between students and their clinical teachers, there is still a profoundly important role for the institution. For Aristotle it is politics, not ethics, that is the master science of the good, and politics is specifically the science of organizing a community in such a way that the moral and intellectual excellences are provided the proper conditions to flourish. Academic medical centers are one such type of (particularly complex) political community, and although the leadership of the academic medical center cannot force the excellences of professionalism on students, trainees, and other clinicians—since the moral excellences are not acquired in that way—neither can the moral excellences flourish without the enabling support of the institution. Institutions, when they are working well, provide both the material soil within which the practices of moral excellence are able to grow and the proper conditions for that growth to be nurtured, sustained, and guarded (MacIntyre 1984). Many of the institutional and curricular initiatives described in the recent medical professionalism literature are consistent with, if not in explicit agreement with, this vision, and are therefore worth celebrating (Brater 2007; Humphrey et al. 2007). This is the theoretical way, I would propose, for the institutional literature on professionalism to go on.
