A virtuous framework for professional reflection

Background

When reflecting on professional practice, it is important to have an understanding of what it means to be a professional. In the medical profession this enables an individual to assess themselves against expectations, and to develop themselves in a range of complex and diverse settings.

At present such reflection is often based on compliance with guidelines or regulations drawn up by professional bodies. This has three consequences. The first is that it assesses (and so promotes) competence in professional behaviour rather than excellence. The second is that people find ways of ‘gaming the system’ rather than developing professionalism. Finally, this approach reduces professional behaviour to rules which may be unclear, conflicting and not applicable to a variety of situations.

Professions are often understood as having particular characteristics; for example a systematic body of knowledge, independence of judgement and autonomy and adherence to a code of ethics.^1,2 Often these features are held as totemic, and can be fiercely defended to the detriment of the professional's clients. For example, the autonomy of doctors can be used to obstruct reasonable managerial practices, or wider team inclusion.

An alternative model for understanding professions, and for reflection on professional practice, is found in virtue ethics.^3,4 Virtue ethics was the dominant way ethics was thought about in the West up to the Age of the Enlightenment, when other approaches (such as deontology and consequentialism) came to dominate.⁵ This model forms the basis of this article which suggests that considering the purposes of medicine, and the character needed to achieve them, is as important as competency and rules. It argues that virtue ethics provides an invaluable framework for reflecting on the professional practice of doctors; reflection which can be supported by dialogue with fellow doctors, managers, healthcare professionals and patients.

This approach requires consideration of the moral purposes of a profession, including its ultimate aim (telos). It then considers the character needed to reach that telos, in terms both of the virtues (character traits) and how those virtues are orchestrated. The telos unites both practical and moral elements; you cannot be a ‘good doctor’ without providing the right (technically correct) treatments and exhibiting the right (ethically correct) traits.

Telos

Understanding the ‘telos’ of the medical profession is a first step. Exploring a doctor's telos provides an understanding of why and what they are doing; specifically an understanding of how that profession helps others in society to flourish or thrive.³ Thus the telos of medicine might be summarised as ‘to help people flourish by enabling them to optimise their health’.

This phrase is deceptively simple, yet contains many things that need unpacking. For example, is it possible that flourishing is not always enhanced by improving health? Who or what are the people and health that doctor feels responsible for? Both practical and moral dimensions are relevant; technically brilliant doctors whose patients do not flourish are not achieving their telos.

Consideration of their telos can allow a doctor to integrate their professional practice and wider behaviours such as social/political campaigning or academic research into their professional behaviour. For example, social issues, poor housing, alleviation of poverty, climate change or cost of living may be integral to their telos of ensuring that the people under their care flourish though improved health.⁶ However, if a doctor's concern for social justice or the environment is not connected to improving flourishing through health then, while they may be acting as good members of society, they are arguably not acting qua doctor. These issues may be particularly important for doctors in managerial or political roles, understanding how and if these roles support their medical telos.

How the telos is interpreted will depend in part on the medical discipline, the role and the ambitions of the individual. An understanding of telos can be used to frame discussions about professional practice. Is a particular procedure (such as cosmetic surgery) enhancing flourishing through improved health? Or is there a better way to achieve the same goal, for example by improving the patient's self-esteem?

The practice of medicine, as with any occupation or profession, results in benefit not only to the clients (patients), but to the professional themselves. Such benefits can be divided into two categories: internal or external goods.⁵ Internal goods derive from the telos of the profession, and relate to the fulfilment obtained by the accomplished performance of that practice. External goods relate to benefits that can be achieved equally elsewhere, for example status and money. This is seen in other practices; an international athlete may derive riches and recognition through their sport, but should also obtain internal goods through the skilled and engaged practice of a worthwhile activity. The loss of balance between internal and external goods can result in loss of joy or direction in one's professional life which should be considered in any reflective framework.

Virtues

Virtues can be thought of as character traits of a person. They are not static, and can be developed or lost over time. A virtue is more than an action, it encompasses a state of mind (being generous is more than giving money to people). In a virtue perspective, a professional should cultivate those virtues that enable them to reach to their telos. Philosophical thought since Plato has often stressed 4 cardinal virtues; justice, temperance, courage and practical wisdom. However, there are no universal agreed lists of virtues, as they are dependent on time and context.⁵

It is possible to reflect on medical professional practice using the cardinal virtues. Justice is thought about as being fair, and doctors should bear in mind distributive fairness. Justice also is concerned with ‘rendering what is due to others’, and a doctor with a well-developed sense of justice will seek to ensure that their patient's needs and wants are considered. Justice also requires consideration of others involved in the healthcare system; those in the team and indeed different disciplines and organisations. When doctors fail to make difficult decisions (for example around DNACPR) they burden others with that duty and cause unnecessary work, emotional stress and professional risk to others in the team. They fail to show them justice.

Temperance is the virtue of self-control or self-regulation. This is a central virtue for doctors, allowing them to decide when to intervene and when not to. This is the virtue that controls the impulse to perform supra-heroic surgery, or make ‘instinctive’ decisions without due consideration. It requires respecting and understanding others (colleagues' and patients' views).

Courage is key to any role involving decisions. Doctors need courage to listen to others, have challenging conversations, make difficult decisions and undertake complex procedures.

Practical wisdom or phronesis more than any other virtue differentiates the good doctor from the competent. Phronesis is the balancing and orchestrating of the virtues, allowing a doctor to judge the right level to calibrate each virtue in order to best achieve their telos.⁷ In medicine it encompasses their technical skills, but is more than a learned technique or knowledge. Practical wisdom allows medical professionals to deploy their technical skills appropriately, including when (and when not) to use a technique. A competent doctor knows how to perform CPR, a wise doctor knows when not to perform it. This judgement can be more difficult when the doctor's situation is causing burnout and chronic stress.

In a regulatory rules-based framework, most professional reflection concentrates on whether a doctor is competent in a particular technique, rather than on whether a doctor knows when and how to deploy their learned knowledge. Developing and reflecting on phronesis in clinical situations can help drive a constant learning and improvement of knowledge and technical skills.

A key concept of Aristotle is that each virtue should be held at a golden mean appropriate to the situation.⁸ Deficiency or excess of any one virtue leads to poor professional practice. To take the example of courage: too much courage can be dangerous in a doctor – they will undertake procedures that they are not equipped to do. Equally cowardice can lead to others being forced to make their hard decisions. The mean will change depending on the context. A surgeon's virtue of courage will be in the fore during an operation, but more balanced with other virtues when reviewing imaging or as part of a multidisciplinary discussion. Reflecting on contrasting situations helps a good doctor develop their virtues.

Other virtues

We have used the example of the four cardinal virtues, developed in a particular time and culture (for elite males). However, there is no agreed list of virtues. A different approach is to reflect on what virtues are useful for medical practice. One study, using tools derived from positive psychology,⁹ suggested that the key character strengths of a doctor are fairness, honesty, judgment, kindness, leadership and teamwork.¹⁰ However, many items on this list are more similar to skills or competencies (leadership, teamwork), which depend upon but are not in themselves virtues.

We would suggest that one key trait of a good medical professional is clinical curiosity, which drives a doctor to ask questions about their patient, their strengths, their context and their disease with a view to understanding how best to maximise the health and flourishing of their patient. It has been suggested that doctors with high levels of curiosity are rated highly by fellow professionals (for example when referring family members).¹¹

Declaration of interest

AJTG is a non-executive director of Health Education England. He is writing in a personal capacity.