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)

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)

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 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)

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)

SummaryNeither an infant one week old nor a snail is a rational creature. If the infant survives long enough, he will probably become rational, while this is not true of the snail. If we like, we may say of the infant from the start that he is a rational creature because he will probably become rational if he survives, or because he belongs to a species with this capacity. Whichever way we talk, there remains the difference, with respect to rationality, (...) between the infant and the snail on one hand, and the normal adult person on the other; this difference is discussed here.The difference consists, it is argued, in the having of propositional attitudes such as belief, desire, intention and shame. This raises the question how to tell when a creature has propositional attitudes; snails, we may agree, do not, but how about dogs or chimpanzees? The question is not empirical; the question is what sort of empirical evidence is relevant to deciding when a creature has propositional attitudes.It is next contended that language is a necessary concomitant of any of the propositional attitudes. This idea is not new, but there seem to be few arguments in its favor in the literature; one is attempted here.Crucial to the considerations advanced is the idea that belief depends on having the concept of objective truth, and that this comes only with language.RéuméNi un bébé d'une semaine, ni un serpent ne sont des créatures rationnelles. Si le bébé survit assez longtemps, il deviendra probablement rationnel, mais ce n'est pas vrai pour le serpent. Sil'on veut, on peut dire d'emblee du bébé qu'il est une créature rationnelle parce qu'il le deviendra s'il survit ou parce qu'il appartient à une espèce qui possède cette faculté. Quoi qu'on dise, la différence subsiste, en ce qui concerné la rationalité, entre le bébé et le serpent d'une part, la per‐sonne adulte normale de lcar;autre, et c'est cette différence qui sera discutée ici.La différence consiste, selon l'auteur, en une capacityé d'avoir des attitudes propositionnelles telles que la croyance, le désir, l'intention et la honte. Ceci pose la question de savoir quand on peut dire qu'une créature a des attitudes propositionnelles; on peut se mettre d'accord sur le fait que les serpents n'en ont pas, mais qu'en est‐il des chiens et des chimpanzés? La question n'est pas empirique, elle est de savoir quelle donnée empirique va décider si oui ou non une créature a des attitudes propositionnelles.L'auteur prétend que les attitudes propositionnelles s'accompagnent nécessairement du langage. Cette idèe n'est pas nouvelle, mais il semble qu'il y a peu d'arguments qui la soutiennent dans la littérature. On en trouvera un ici, où l'on montre qu'un élément crucial de a croyance dépend de l'acquisition du concept de vérité objective, qui ne se développe qu'avec le langage.ZusammenfassungWeder ein eine Woche altes Kind noch eine Schlange sind rationale Wesen. Wenn das Kind lange genug überlebt, wird es sich wahrscheinlich zu einem vernünftigen Wesen entwickeln, wäh‐rend das für die Schlange nicht zutrifft. Wenn wir wollen, können wir vom Kind sagen, dass es von Anfang an cin rationales Wesen ist, weil es im Fallc des Ubcrlebens vernünftig werden wird oder weil es zu einer Spezies mit dieser Fähigkeit gehört. Wie auch immer wir das ausdrücken, bleibt bezüglich der Rationalität der Unterschied zwischen dem Kind und der Schlange einerseits und der erwachsenen Person andererseits zurück. Dieser Unterschied wird hier diskutiert.Es wird argumentiert, dass der Unterschied in der Fähigkeit besteht, psychologische Haltun‐gen wie Glauben, Begierden, Absichten und Scham zu haben. Damit erhebt sich die Frage, wie man entscheiden kann, wann ein Wesen solchc Einstellungcn hat; Schlangen, wird man zugeben, haben keine; wie steht es aber mit Hunden Oder Schimpansen? Die Frage ist keine empirische, sondern betrifft die Frage, welche Art von empirischen Belegen für den Entscheid relevant ist, ob ein Wesen derartige Einstellungen hat.Es wird die These aufgestellt, dass Sprachen ein notwendiger Begleitumstand einer jeglichen propositionalen Haltung ist. Der Gedanke ist zwar nicht neu, aber es finden sich wenige Argu‐mente zu seiner Stützung in der Literatur; eines wird hier ausgeführt.Entscheidend für die vorgelegten Betrachtungen ist die Auffassung, wonach Glaube vom Begriff der objektiven Wahrheit abhängt, und dieser kommt erst mit der Sprache. (shrink)

SummaryNeither an infant one week old nor a snail is a rational creature. If the infant survives long enough, he will probably become rational, while this is not true of the snail. If we like, we may say of the infant from the start that he is a rational creature because he will probably become rational if he survives, or because he belongs to a species with this capacity. Whichever way we talk, there remains the difference, with respect to rationality, (...) between the infant and the snail on one hand, and the normal adult person on the other; this difference is discussed here.The difference consists, it is argued, in the having of propositional attitudes such as belief, desire, intention and shame. This raises the question how to tell when a creature has propositional attitudes; snails, we may agree, do not, but how about dogs or chimpanzees? The question is not empirical; the question is what sort of empirical evidence is relevant to deciding when a creature has propositional attitudes.It is next contended that language is a necessary concomitant of any of the propositional attitudes. This idea is not new, but there seem to be few arguments in its favor in the literature; one is attempted here.Crucial to the considerations advanced is the idea that belief depends on having the concept of objective truth, and that this comes only with language.RéuméNi un bébé d'une semaine, ni un serpent ne sont des créatures rationnelles. Si le bébé survit assez longtemps, il deviendra probablement rationnel, mais ce n'est pas vrai pour le serpent. Sil'on veut, on peut dire d'emblee du bébé qu'il est une créature rationnelle parce qu'il le deviendra s'il survit ou parce qu'il appartient à une espèce qui possède cette faculté. Quoi qu'on dise, la différence subsiste, en ce qui concerné la rationalité, entre le bébé et le serpent d'une part, la per‐sonne adulte normale de lcar;autre, et c'est cette différence qui sera discutée ici.La différence consiste, selon l'auteur, en une capacityé d'avoir des attitudes propositionnelles telles que la croyance, le désir, l'intention et la honte. Ceci pose la question de savoir quand on peut dire qu'une créature a des attitudes propositionnelles; on peut se mettre d'accord sur le fait que les serpents n'en ont pas, mais qu'en est‐il des chiens et des chimpanzés? La question n'est pas empirique, elle est de savoir quelle donnée empirique va décider si oui ou non une créature a des attitudes propositionnelles.L'auteur prétend que les attitudes propositionnelles s'accompagnent nécessairement du langage. Cette idèe n'est pas nouvelle, mais il semble qu'il y a peu d'arguments qui la soutiennent dans la littérature. On en trouvera un ici, où l'on montre qu'un élément crucial de a croyance dépend de l'acquisition du concept de vérité objective, qui ne se développe qu'avec le langage.ZusammenfassungWeder ein eine Woche altes Kind noch eine Schlange sind rationale Wesen. Wenn das Kind lange genug überlebt, wird es sich wahrscheinlich zu einem vernünftigen Wesen entwickeln, wäh‐rend das für die Schlange nicht zutrifft. Wenn wir wollen, können wir vom Kind sagen, dass es von Anfang an cin rationales Wesen ist, weil es im Fallc des Ubcrlebens vernünftig werden wird oder weil es zu einer Spezies mit dieser Fähigkeit gehört. Wie auch immer wir das ausdrücken, bleibt bezüglich der Rationalität der Unterschied zwischen dem Kind und der Schlange einerseits und der erwachsenen Person andererseits zurück. Dieser Unterschied wird hier diskutiert.Es wird argumentiert, dass der Unterschied in der Fähigkeit besteht, psychologische Haltun‐gen wie Glauben, Begierden, Absichten und Scham zu haben. Damit erhebt sich die Frage, wie man entscheiden kann, wann ein Wesen solchc Einstellungcn hat; Schlangen, wird man zugeben, haben keine; wie steht es aber mit Hunden Oder Schimpansen? Die Frage ist keine empirische, sondern betrifft die Frage, welche Art von empirischen Belegen für den Entscheid relevant ist, ob ein Wesen derartige Einstellungen hat.Es wird die These aufgestellt, dass Sprachen ein notwendiger Begleitumstand einer jeglichen propositionalen Haltung ist. Der Gedanke ist zwar nicht neu, aber es finden sich wenige Argu‐mente zu seiner Stützung in der Literatur; eines wird hier ausgeführt.Entscheidend für die vorgelegten Betrachtungen ist die Auffassung, wonach Glaube vom Begriff der objektiven Wahrheit abhängt, und dieser kommt erst mit der Sprache. (shrink)

* [Irrationality]: ___ Irrationality, like rationality, is a normative concept. Someone who acts or reasons irrationally, or whose beliefs or emotions are irrational, has departed from a standard.

Summary To judge a belief, emotion, or action irrational is to make a normative judgment. Can such judgments be objective? It is argued that in an important class of cases they can be. The cases are those in which a person has a set of attitudes which are inconsistent by his or her own standards, and those standards are constitutive of the attitudes. Constitutive standards are standards with which an agents' attitudes and intentional actions must generally accord if judgments of (...) irrationality are to be intelligible.RésuméJuger irrationnelles une croyance, une émotion ou une action, c'est faire un jugement normatif. De tels jugements peuvent‐ils ětre objectifs? On montre qu'ils peuvent l'ětre dans une classe importante de cas: ceux où une personne a un ensemble d'attitudes qui sont inconsistantes avec ses propres normes, ces normes étant constitutives des attitudes considérées. Les normes constitutives sont des normes avec lesquelles les attitudes et les actions intentionnelles des agents doivent s'accorder pour que les jugements d'irrationalité deviennent intelligibles.ZusammenfassungWenn wir einen Glauben, eine Emotion oder eine Handlung als irrational beurteilen, so fällen wir ein normatives Urteil. Kann ein solches objektiv sein? Es wird argumentiert, dass dies für eine wichtige Klasse von Fällen zutrifft. Die Fälle sind diejenigen, in welchen eine Person eine Menge von Haltungen hat, die nach ihren eigenen Massstäben unvereinbar sind, und wo diese Massstäbe für die Haltungen konstitutiv sind. Konstitutive Massstäbe sind solche, mit denen die Haltungen und absichtlichen Handlungen des Handelnden im allgemeinen übereinstimmen müssen, wenn Urteile über Irrationalität verständlich sein sollen. (shrink)

Immanuel Kant was a German philosopher. He is a central figure of modern philosophy, and set the terms by which all subsequent thinkers have had to grapple. He argued that human perception structures natural laws, and that reason is the source of morality. His thought continues to hold a major influence in contemporary thought, especially in fields such as metaphysics, epistemology, ethics, political philosophy, and aesthetics.

The central propositional attitudes of belief, desire, and meaning are interdependent; it is therefore fruitless to analyse one or two of them in terms of the others. A method is outlined in this paper that yields a theory for interpreting speech, a measure of degree of belief, and a measure of desirability. The method combines in a novel way features of Bayesean decision theory, and a Quinean approach to radical interpretation.

Neo-Humean instrumentalist theories of reasons for acting have been presented with a dilemma: either they are normatively trivial and, hence, inadequate as a normative theory or they covertly commit themselves to a noninstrumentalist normative principle. The claimed result is that no purely instrumentalist theory of reasons for acting can be normatively adequate. This dilemma dissolves when we understand what question neo-Humean instrumentalists are addressing. The dilemma presupposes that neo-Humeans are attempting to address the question of how to act, 'simpliciter'. Instead, (...) they are evaluating actions from the agent's normative perspective. (shrink)

Anomalous Monism is the view that mental entities are identical with physical entities, but that the vocabulary used to describe, predict and explain mental events is neither definitionally nor nomologically reducible to the vocabulary of physics. The argument for Anomalous Monism rests in part on the claim that every true singular causal statement relating two events is backed by a law that covers those events when those events are appropriately described. This paper attempts to clarify and defend this claim by (...) tracing out some conceptual relations among the concepts of event, law, and object. (shrink)

Whitehead's magnum opus is as important as it is difficult. It is the only work in which his metaphysical ideas are stated systematically and completely, and his metaphysics are the heart of his philosophical system as a whole.

The generation of evidence is integral to the work of public health and health service providers. Traditionally, ethics has been addressed differently in research projects, compared with other forms of evidence generation, such as quality improvement, program evaluation, and surveillance, with review of non-research activities falling outside the purview of the research ethics board. However, the boundaries between research and these other evaluative activities are not distinct. Efforts to delineate a boundary – whether on grounds of primary purpose, temporality, underlying (...) legal authority, departure from usual practice, or direct benefits to participants – have been unsatisfactory. (shrink)

The central propositional attitudes of belief, desire, and meaning are interdependent; it is therefore fruitless to analyse one or two of them in terms of the others. A method is outlined in this paper that yields a theory for interpreting speech, a measure of degree of belief, and a measure of desirability. The method combines in a novel way features of Bayesean decision theory, and a Quinean approach to radical interpretation.

In lieu of an abstract, here is a brief excerpt of the content:Scepticism About Persons in Book II of Hume’s TreatiseDonald C. AinslieBook ii of Hume’s Treatise—especially its first two Parts on the “indirect passions” of pride, humility, love, and hatred—has mystified many of its interpreters.1 Hume clearly thinks these passions are important: Not only does he devote more space to them than to his treatment of causation, but in the “Abstract” to the Treatise, he tells us that Book II (...) “contains opinions that are altogether as new and extraordinary” (T 659) as those found in Book I. And, he says, these opinions constitute “the foundation” (T 646) for his treatment of morals and politics in Book III.2 The mystery arises, however, because in the actual text of [End Page 469] Book II Hume never spells out what makes his opinions on the passions “new and extraordinary,” nor why they are foundational for his moral theory.Thus some of his interpreters, notably Norman Kemp Smith, conclude that Hume was simply mistaken in his assessment of his treatment of the passions. While his accounts of the will and of motivation (in the early Sections of Part iii of Book II) are significant, Kemp Smith takes the extended analysis of the indirect passions to spring merely from his misplaced enthusiasm for associationist psychology. As such, the philosophical lessons to be learned from the first two Parts of Book II are slim.3 Páll Árdal, in contrast, tries to construct for Hume what he seems to have omitted—a philosophical rationale for his obvious interest in the indirect passions. Árdal starts by drawing attention to the role these passions play in Hume’s moral philosophy, in particular, his repeatedly connecting the indirect passions to the moral sentiments of approval and disapproval. Árdal concludes that Hume means to equate the moral sentiments with particular kinds of indirect passions. The first two Parts of Book II are of interest, on Ardal’s reading, because it is there that he shows us how moral sentimentalism can be founded on something more fully naturalistic than Hutcheson’s somewhat mysterious “moral sense.”4I argue against Árdal’s interpretation in §2. But this reopens the problem of accounting for Hume’s interest in the indirect passions. I offer my view in §§3–5 where, like Árdal, I provide a reconstruction of Hume’s discussion of these passions in order to show how it has an underlying philosophical motivation. My claim is that Hume relies on the indirect passions to explain how we form beliefs about persons as bearers of features that make them into who [End Page 470] they are. It is by feeling an indirect passion towards someone that we think of her as more than accidentally related to some quality, such as her country, her riches, her family, or even her character traits. In support of my interpretation I point to the many parallels Hume draws between the indirect passions and the associative mechanism he offers to explain our forming causal beliefs (I.iii). And I suggest that, just as Hume’s associative explanation of causal beliefs is necessitated by his scepticism about intrinsic “necessary connexions,” so also his associative mechanism for our beliefs about persons—the indirect passions—is necessitated by a certain kind of scepticism about persons. This is not the scepticism about persons that we find in “Of personal identity” (I.iv.6), where Hume argues against the view that our perceptions inhere in a simple soul; it is rather a scepticism about there being intrinsic features of persons that define them as who they are.But, before I explain in more detail what my claim amounts to, it will help to have available a brief description of the mechanism that Hume’s takes to explain the indirect passions.1. THE MECHANISM FOR THE INDIRECT PASSIONSA passion, for Hume, is a simple impression felt in response to various circumstances. Because of their simplicity, we cannot define passions by putting their characteristic feeling into words; instead, Hume thinks, we can only delineate “such circumstances, as attend them” (T 277). Passions are indirect if those circumstances include as an outcome the focusing of attention onto a person... (shrink)

Anomalous Monism is the view that mental entities are identical with physical entities, but that the vocabulary used to describe, predict and explain mental events is neither definitionally nor nomologically reducible to the vocabulary of physics. The argument for Anomalous Monism rests in part on the claim that every true singular causal statement relating two events is backed by a law that covers those events when those events are appropriately described. This paper attempts to clarify and defend this claim by (...) tracing out some conceptual relations among the concepts of event, law, and object. (shrink)

Faced with the liability of newness, a scarcity of resources, and concerns of survival, new firms frequently encounter difficult ethical decisions and might be pressured to make choices that run counter to the tenets of more developed ethical and moral reasoning. This study explores the impact of newness and entrepreneurial orientation on the ethical climate of firms. Data collected from 304 individuals across 37 firms indicated that firm newness was more strongly related to ethical climate than was an entrepreneurial orientation. (...) Results also revealed that firm newness may be usefully conceptualized in both continuous and categorical terms, with each operationalization holding a somewhat different relationship with climate. Finally, results revealed that firm size was related to several types of ethical climates. (shrink)

David Lewis has recently developed the notion of conversational scorekeeping as a way of explaining the acceptability of utterances in various contexts and the manner in which this acceptability changes in a rule-governed manner. I will expand Lewis's discussion by showing how the acceptibility of conditionals is linked to conversational score. In particular, I will argue that at least one controversial issue concerning the logic of conditionals, the interpretation and use of conditionals with disjunctive antecedents, may be resolved by applying (...) Lewis's notion of an accommodation rule for conversational scorekeeping. (shrink)