Lauris Christopher Kaldjian

This paper draws from a framework of virtue ethics and narrative medicine to present a content analysis and teaching resource of virtue-illustrating stories found in medical journals. As acquired dispositions, virtues are cultivated not merely by listening to lectures but through reflection, experience, role-modeling, practice, and internalization. One way to encourage such cultivation is to use narratives to illustrate moral virtues in action. With this in mind, we identified a literature-based taxonomy of 12 core virtues in medicine, selected a sample of 180 narratives published in medical journals to perform a content analysis and frequency calculation of core virtues they illustrate, and identified a collection of 24 of these narratives to illustrate the 12 core virtues. In decreasing order of frequency, the 12 core virtues found in these narratives were benevolence, humility, practical wisdom, courage, respectfulness, trustworthiness, altruism, cooperativeness, temperance, honesty, integrity, and justice. The taxonomy and bibliographic resource we offer can help medical educators utilize medical narratives to reflect on and discuss core moral virtues in medicine, and the 24 virtue-illustrating narratives are short, accessible, and practical for time-constrained teachers and learners interested in the way stories manifest virtues in medicine. This taxonomical framework and narrative collection can help shine practical light on ethical challenges in medicine—which so often are complex, multilayered, uncertain, and fluid—and on the virtues that enable physicians and other healthcare professionals to respond well to those challenges.

By defending practical wisdom ( phronesis ) as a multidimensional virtue that complements the moral virtues, we offer a critique of “practical wisdom eliminativism”, with special attention to the context of medicine, arguing that the core dimensions of practical wisdom enjoy broad consensus. As the meta-virtue that demonstrates excellence in ethical decision-making, practical wisdom recognizes and employs the best means to achieve good and worthwhile ends by integrating goals, perception of context, moral virtues, deliberation, reason-guided emotion, and motivation. In medicine, practical wisdom encompasses patient-centered deliberation directed toward ends of health and flourishing that promote the patient’s good. To counter the notion that practical wisdom is a redundant concept (the eliminativist view), we provide philosophical arguments, evidence from medical practitioners, and psychometric data from a detailed empirical study of US and UK adults. Practical wisdom has survived for more than 2300 years as a unified and unifying intellectual meta-virtue that guides the moral virtues. We believe the reasons we put forward explain why phronesis should be expected to endure as a meaningful, multidimensional concept reflecting the nature of moral deliberation in response to practical challenges in life and medicine.

Background: Ethical principles of autonomy and beneficence guide clinical decision making. Little is known about how clinicians prioritize these principles and integrate them with virtue ethics when assessing the ethics of persuasion. Objective: Survey medical students about their attitudes and experiences regarding the use of persuasion by physicians in shared decision making. Design: Cross-sectional, on-line survey. Participants: Pre-clinical and clinical medical students at one US medical school. Main Measures: Survey instrument contained 31 items including a three-part clinical vignette, attitudes toward persuasion and ethical principles, experiences observing or participating in persuasion, and demographic information. Bivariate and multivariable analyses were performed, including LASSO regression using a 30-point persuasion score derived from six items. Key Results: 237 students completed the survey (45% response rate). In general, 55.7% supported persuasion by physicians for the good of the patient’s health. Nearly half supported persuasion for an at-risk cardiovascular patient who declines recommendations for walking or statin treatment; 64.1% supported persuasion for a patient with myocardial infarction who wants to leave the hospital against medical advice. While 70.0% believed persuasion is appropriate because it promotes beneficence and nonmaleficence, 16.9% believed persuasion is inappropriate because it disrespects patient autonomy. Most students (81.0%) had seen a good physician role model for persuasion, and 38.0% had willingly participated in persuasion. LASSO regression identified four items contributing positively to the persuasion score (belief that persuasion promotes beneficence/nonmaleficence, observation of a good role model, experience participating in persuasion, male gender) and two negatively (belief that persuasion disrespects patient autonomy, observation of inappropriate use of persuasion). Conclusions: Medical students vary in attitudes toward persuasion of patients by physicians, and variations are associated with differences in ethical beliefs, clinical experiences, and gender. Education regarding the use of persuasion should address ethical justification, experience, and role-modeling—which can be encompassed by virtue ethics.

Practical wisdom is a virtue in medicine that is goal‐oriented, context‐sensitive, and ethically‐grounded. Physicians need practical wisdom to integrate science, practicality, and humanism in ways that promote the good of their patients.

Context: The Covid‐19 pandemic has added a new chapter to discussions about the professional duty to care. To understand how Covid‐19 may have changed medical students' ethical attitudes towards this duty, we analysed policies written before and during the pandemic by first‐year students completing a yearly educational exercise focused on work requirement expectations for healthcare professionals during a hypothetical epidemic. Methods: Within a repeated cross‐sectional design, consensus coding was performed on policies written over 5 years (2017–2021) using a codebook based on eight questions from the educational exercise for summative content analysis. Frequencies provided summative results and comparisons across years used Fisher's exact test. Results: We analysed 142 written policies from 2017 to 2021 representing 884 first‐year students working in small groups. Students' commitment to the duty to care remained stable during the Covid‐19 pandemic, but during the pandemic, students were more likely to support exceptions to the duty to care (e.g. for healthcare professionals with medical conditions or concern for household members' health) and more likely to expect institutions to provide safe working conditions. Ethical values supporting students' policies were largely consistent before and during the pandemic, the most common being beneficence, justice, duty to care, non‐maleficence and utility. Conclusions: Our results suggest that students' support for the duty to care remained strong during the Covid‐19 pandemic. We also found that students supported exceptions to this duty to reflect the needs of healthcare professionals and their families and that they expected institutions to provide safe working conditions. These findings can help inform ethics education and future pandemic preparedness.

When health professionals experience moral distress during routine clinical practice, they are challenged to maintain integrity through conscientious practice guided by ethical principles and virtues that promote the dignity of all human beings who need care. Their integrity also needs preservation during a crisis like the COVID-19 pandemic, especially when faced with triage protocols that allocate scarce resources. Although a crisis may change our ability to provide life-saving treatment to all who need it, a crisis should not change the ethical values that should always be guiding clinical care. Enduring ethical commitments should encourage clinicians to base treatment decisions on the medical needs of individual patients. This approach contrasts with utilitarian attempts to maximize selected aggregate outcomes by using scoring systems that use short-term and possibly long-term prognostic estimates to discriminate between patients and thereby treat them unequally in terms of their eligibility for life-sustaining treatment. During times of crisis and calm, moral communication allows clinicians to exercise moral agency and advocate for their individual patients, thereby demonstrating conscientious practice and resisting influences that may contribute to compartmentalization, moral injury, and burnout.

Background: Practical wisdom is considered a multidimensional virtue of enduring relevance to medicine. Though it has received increasing attention in recent years, proposed frameworks for practical wisdom can differ, and little is known about how medical students and physicians describe its dimensions and relevance. Methods: We used structured interviews, employing open‐ended and closed‐ended questions, to describe how medical students and physicians understand practical wisdom and identify the kinds of clinical situations they believe require practical wisdom. We interviewed 102 participants at two US medical schools in 2021, comprising a voluntary response sample of 40 pre‐clinical medical students and 40 clinical medical students and a purposive sample of 22 nominated physicians. Interviews were conducted by videoconference using a structured interview guide. Open‐ended responses were coded using qualitative content analysis (directed and conventional) and tabulated; closed‐ended responses were tabulated. Quotations provided qualitative illustrations, and frequencies were used for summative results. Results: Participants considered practical wisdom clinically meaningful, broadly relevant and multidimensional. Most described it as deliberative, goal‐directed, context‐sensitive, integrated with ethics and marked by integrity and motivation to act. Many described it as experience‐based, person‐centred or problem‐solving. Participants also selected an average of 15.6 (SD = 4.9) additional virtues as being essential for practical wisdom in medicine and described a broad range of clinical situations that require practical wisdom in medicine. Conclusions: Participants described practical wisdom as a multidimensional capacity that entails deliberation, depends on a constellation of other virtues and is broadly applicable to medicine. Most agreed it is goal‐directed and context‐sensitive and involves ethics, integrity and motivation. Efforts to teach practical wisdom in medical education should clarify its dimensions and highlight its relationship to virtue ethics, professionalism, clinical judgement and the individualised care of patients as persons.