Abstract
Today, modern Western medicine is facing a quality-of-care crisis that is undermining the patient–physician relationship. In this paper, a notion of the epistemically virtuous clinician is proposed in terms of both the reliabilist and responsibilist versions of virtue epistemology, in order to help address this crisis. To that end, a clinical case study from the literature is first reconstructed. The reliabilist intellectual virtues, including the perceptual and conceptual virtues, are then discussed and applied to the case study. Next, a similar method is employed to examine the responsibilist intellectual virtues, including curiosity, courage, honesty, and humility, and to apply them to the case study. To round out the discussion, the love of knowledge and both theoretical and practical wisdom are explored and applied to the case study. The paper concludes with a brief discussion of how the notion of an epistemically virtuous clinician addresses the quality-of-care crisis, in terms of the connection between ethical and intellectual virtues, and of the notion’s implications for medical education.
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Notes
For example, Roberts and Wood define virtue as “an acquired base of excellent functioning in some generically human sphere of activity that is challenging and important” [2, p. 59].
According to Roberts and Wood, the epistemic goods represent more than simply the notion of justified true beliefs, if such goods are attainable, but rather a richer or broader notion that includes “warranted true belief, acquaintance, and understanding” [2, p. 33]. In addition, transmission or communication of the epistemic goods from teacher to pupil is an important epistemological issue.
Although the faculties are innate, in that such faculties as sight and hearing are not learned per se, this does not mean that their use cannot be developed through training or learning. Thus, the faculty of sight can be sharpened though learning to use it under specific conditions. For example, a clinician can learn to use sight effectively in observing certain clinical signs that are indicative of specific illnesses.
For example, Duncan Pritchard examined the role of reliabilist virtues in the acquisition of diagnostic knowledge [12]. Another example is Erica Zarkovich and R.E.G. Upshur, who used the ethical virtue of conscientiousness and the intellectual virtue of judiciousness to evaluate evidence-based medicine (EBM) [13]. Edmund Pellegrino critiqued their evaluation, arguing that a more fundamental virtue, which serves better to evaluate the uncertainty of both medical ethics and epistemology and not just the best evidence associated with EBM, is prudence [14].
Virtue theory has been utilized more to examine the morally or ethically virtuous physician than the epistemically virtuous physician [15].
I must caution the reader that my purpose in this paper is not to address the debate over the priority of either reliabilist or responsibilist virtue epistemology.
I must also caution that this case study is not chosen because the clinician is perfect in terms of representing the virtuous epistemic agent but rather because he illustrates sufficiently the intellectual virtues important in the practice of clinical medicine.
The essay was part of a collection of papers on the health problems associated with violence against women [17].
Of course, perception can be influenced by concepts, which have been shown to determine what a person observes under specific conditions.
Reid also recognizes that perceptions are related to conceptions through prior beliefs [19].
It is important to note that the perceptual virtues can be divided into the physical and the mental. The physical perceptual virtues are part of the process that does not necessarily involve conscious awareness, while the mental perceptual virtues do. In other words, the physical dimension of the perceptual virtues gives epistemic agents contact with the world, while the mental dimension allows such agents to mediate consciously that contact.
“The unique distinction of sight,” claims Hans Jonas, “consists in what we may provisionally call the image-performance, where ‘image’ implies these three characteristics: (1) simultaneity in the presentation of the manifold, (2) neutralization of the causality of sense-affection, (3) distance in the spatial and mental senses” [20, p. 136]. The consequence of sight’s uniqueness is that the mind often goes where sight leads [20, p. 152]. Of course other senses, like hearing or touch, also function to lead the mind but sight is considered predominant or preeminent.
These conditions can also include environmental factors like adequate lighting or appropriate observation distance (not too far or close).
Weinberg also exhibited intellectual (in)sight when he observed that the patient’s physical appearance was transforming before his eyes.
It is interesting to note that Weinberg failed to ask any questions about or to make any clinical inference from the patient’s refraining to take Communion, even though she was a faithful Catholic. As Augustine noted centuries earlier, if the faithful are able to partake in Communion they do unless they have not repented of mortal sin. Here we see a failure of the Weinberg’s inferential powers in the first consultation. Of course, this might not be a failure of his conceptual virtues per se but rather ignorance of Roman Catholicism and its practices.
Virtue epistemologists, like Roberts and Wood, claim that the goal of virtue epistemology is not simply justified true belief, although such belief is important, but the maturation of a robust epistemic agent [2].
Intellectual curiosity involves a strong drive or desire to know. According to Neil Cooper, it “is the capacity and the willingness to be interested and involved, even obsessed, with the object of inquiry” [22, p. 461].
Intellectual courage often involves leaving an epistemic comfort zones to forge new notions of reality. “Serious exploring of ideas,” notes Thomas Rivers of this virtue, “risks shattering our preconceived notions, our images of the world” [23, p. 251].
It is well known among physicians that patients who are victims of abuse can be difficult and frustrating to treat [24].
“Intellectual honesty,” as Louis Guenin articulates it, “assures that forthrightness dominates, delivering candor when it counts” [25, p. 218].
Pellegrino and Thomasma define intellectual honesty, with respect to medical practice, also in negative terms as “the habitual disposition not to deceive, or to move positively to reveal what we know and do not know about the clinical situation—the diagnosis, treatment, prognosis, and so on” [15, pp. 25–26].
The patient had been seen by other gastroenterologists, who may or may not have observed the dark rings, and if they had observed them, chose for one reason or another not to enquire about the patient’s sleeping pattern. Dark rings under the eyes may not be a clinically significant sign for gastroenterologists to enquire about given the clinical boundaries of biomedical model for gastroenterology. Only someone, like Weinberg, operating outside those boundaries and on a more humanized version of the model, might inquire.
Alfred Tauber gives an apt example of inhumane care in which an oncologist summarily discharged a patient suffering from pancreatic cancer from the hospital, with these words: “My dear lady, I am sorry to say that you have cancer of the pancreas. There is nothing we can do for you. You will simply have to get used to the idea that you will die soon. I’m not sure when, but if I were you, I would put my things in order. You will be discharged tomorrow” [27, pp. 119–120]. After that the oncologist, along with an entourage, abruptly left the patient.
As Rivers points out, at a fundamental level, being a good person and being a good knower go hand-in-hand and the virtues, both ethical and epistemic, play an important role in connecting the two [23]. He illustrates the connection between the two with the dangers associated with unlocking the secrets of the atom or DNA. Intellectual curiosity must be tempered with ethical responsibility.
Vrinda Dalmiya proposes a “care-based epistemology” in which care is the fundamental virtue that connects all other virtues, whether epistemic or ethical [28]. Thus, the epistemic agent cares not only in terms of delivering the epistemic goods but also with respect to the person to whom the goods are delivered and the ethical context in which they are delivered. In this way, care functions to connect both the epistemic and the ethical. Weinberg certainly exhibited this care virtue by not only caring about the clinical epistemic goods but also by taking care to see that the goods were therapeutically efficacious.
Caution must also be exercised in taking on the patient in the first place, given the potentially large number of patients who may demand more intense health care attention. In response to a letter to the editor of the journal where Weinberg’s essay was originally published and which questioned whether physicians have enough time to spend on every patient needing such attention [29], Weinberg writes: “The intense relationship described in my article does not imply that a physician must serve as a personal counselor for every patient…. Occasionally, however, the needs of a patient call us to commit ourselves beyond screening questions, beyond referrals, beyond the convenient or the comfortable. The main point of my article,” he goes on to stress, “is that such intervention is not to be feared. What I really learned was that to “…own the problem, fix it, be responsible…” can provide one of the most exquisite joys of our profession” [30, p. 427].
Granted, the unspecified nature of a well rounded education may allow students to tailor their education to their specific needs; however, some larger goals and the enumeration of criteria for achieving those goals cannot hurt in trying to ensure that physicians have some resources in addressing challenging issues that confront modern clinical practice.
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Acknowledgments
I am particularly grateful to Todd Buras, Bob Kruschwitz, Bob Roberts, Fred Tauber, Kay Toombs, and anonymous reviewers of Theoretical Medicine and Bioethics for their insightful comments on and discussion of earlier versions of this paper. Baylor University supported my scholarship with a sabbatical award and a URC grant.
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Marcum, J.A. The epistemically virtuous clinician. Theor Med Bioeth 30, 249–265 (2009). https://doi.org/10.1007/s11017-009-9109-1
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DOI: https://doi.org/10.1007/s11017-009-9109-1