Abstract
Exploring informal components of clinical reasoning, we argue that they need to be understood via the analysis of professional wisdom. Wise decisions are needed where action or insight is vital, but neither everyday nor expert knowledge provides solutions. Wisdom combines experiential, intellectual, ethical, emotional and practical capacities; we contend that it is also more strongly social than is usually appreciated. But many accounts of reasoning specifically rule out such features as irrational. Seeking to illuminate how wisdom operates, we therefore build on Aristotle’s work on informal reasoning. His account of rhetorical communication shows how non-formal components can play active parts in reasoning, retaining, or even enhancing its reasonableness. We extend this account, applying it to forms of healthcare-related reasoning which are characterised by the need for wise decision-making. We then go on to explore some of what clinical wise reasoning may mean, concluding with a case taken from psychotherapeutic practice.
This is a preview of subscription content, log in via an institution to check access.
Similar content being viewed by others
Notes
They argue that major ‘problem-based’ approaches to teaching reasoning in medical education tend to rely on one of the following emphases: acquiring factual knowledge in the context in which it will be applied; the mastery of general concepts in a way which allows them to be applied to new, but similar, problems; or the acquisition of examples which will aid in recognising comparable patterns in the future [5, p. 146]. See also, for example, Dochy et al. [6]. It would be interesting to compare such approaches with traditional strategies for the invention and retention of arguments in the history of rhetoric—which show striking parallels.
William Stempsey indicates that medical examples are more telling than psychiatric ones with regard to the question whether, in general, medical and natural-scientific terms are laden with emotions and values [13, p. 6]. In rhetorical terms, this is an argument ex hypothesi: something which happens where it seems less likely can therefore probably be expected where it seems more likely. A similar approach might be applied to the connections between rhetorical reasoning, wisdom, and medicine. We intend nonetheless to explore psychiatric examples, partly because they are more readily available to us, but partly because they make particularly clear how reasoning wisely and taking wise decisions with regard to patients is not paradigmatically a one-off decision. This applies in general medicine also, but discussing it would need to despatch the caricature of doctors’ activities (reinforced by some contemporary health-care policies) as converging rapidly on a judgement about what prescription to write, while patients’ reactions are envisaged chiefly in terms of leaving the surgery.
The distinctions between different types of premisses and rules for arguing (reputable opinions, special topoi, and general topoi) are illuminating for this discussion but are too complex to pursue in detail here.
Since a diagnosis is geared to a particular patient with particular symptoms at a particular time, it is frequently based on an enthymeme arguing ‘from the general to the particular’. A third group of enthymemes, which is mostly treated separately as ‘rhetorical induction’ rather than as a case of rhetorical deduction, comprises inference from paradigms. This is in an induction by incomplete enumeration and cannot be logically conclusive; but such inferences make up much of what is taken to be experience (see Aristotle [18, A 981a5–12]). The skilful accumulation and use of such inferences depends in part on the capacities and ability of the arguer: it needs discernment to see what the relevant similarities in particular circumstances really are.
This approach carries its own form of important political danger, in addition to being incorrect in itself: the danger that some person or class or institution will define itself as the sole carrier of rationality in a society, and everyone else must submit to being ‘rationally’ organised. Note too that arguments against introducing ethics into reasoned arguments are often based on the assumption that they are emotionally-based and therefore irrational. But the consequences of excluding ethics from reasoned arguing would have appalling implications.
We are grateful to the parents’ group in the UK which gave us access to their meeting on March 7, 2008, and for their inspiring demonstration of what wisdom in practice can be like.
Other contemporary approaches to questions demanding wisdom include Sternberg’s ‘balance’ theory [26], assessing wise responses in terms of their fits with their contexts, or Baltes’ and Staudinger’s stress [27] on people with exceptional experience, open-mindedness, maturity, or empathy. Note also Schon’s [28] explorations of ‘artful competence’ or work in health care literature such as Lauder’s [29] or Coles’s [30]. These positions are insightful and usually reflect some elements of older traditions, but may curtail the scope of ethical, political, and interpersonal activities involved in wisdom, stripping ‘wisdom’ of many tensions and complexities.
References
Edmondson, R. 2005. Wisdom in later life: Ethnographic approaches. Ageing in Society 25: 339–356.
Edmondson, Ricca, and Jane Pearce. 2007. The practice of health care: Wisdom as a model. Medicine, Health Care and Philosophy 10 (3): 233–244.
Geva-May, Iris. 2007. “We seem to have always spoken in prose…” Policy analysis is a clinical profession: Implications for policy analysis practice and instruction. Policy Studies Journal 35 (2): 135–164.
Simon, Herbert A. 1956. Rational choice and the structure of the environment. Psychological Review 63 (2): 129–138.
Norman, Geoffrey R., and Henk G. Schmidt. 1999. The psychological basis of problem-based learning: A review of the evidence. In Problemorientierte Medizinerausbildung in München, ed. Hans Zehetmair and Klaus Peter, 139–157. Munich: Hanns-Seidel-Stiftung. Reprint of 1992 article in Academic Medicine 67: 557–565
Dochy, Filip, Mien Segers, Piet van den Bossche, and David Gijbels. 2003. Effects of problem-based learning: A meta-analysis. Learning and Instruction 13 (5): 533–568.
Wortberg, Walter. 2008. Environmental medicine and health in industrialised nations: Cases from Germany. In Environmental argument and cultural difference: Locations, fractures and deliberations, ed. Ricca Edmondson, and Henrike Rau, 233–258. Oxford: Peter Lang.
Double, D.D. 2006. Clinician bias in diagnosis and treatment. In The power of belief: Psychosocial influence on illness, disability and medicine, ed. P. Halligan, and M. Aylward, 189–204. Oxford: Oxford University Press.
Egidi, Massimo. 2003. Discrepancies: Competing theories and ideologies as cultural traps. In Cognitive developments in economics, ed. Salvatore Rizzello, 20–52. London: Routledge.
Elstein, Arthur S. 2000. Clinical problem solving and decision psychology: Comment on the epistemology of clinical reasoning. Academic Medicine 75 (10): 134–139.
Higgs, Joy, Mark Jones, Stephen Loftus, Nicole Christiansen, ed. 2000. Clinical reasoning in the health professions, 2nd ed. London: Butterworth-Heinemann.
Fulford, K.W.M. 2004. Ten principles of values-based medicine. In The philosophy of psychiatry: A companion, ed. J. Radden, 205–234. New York: Oxford University Press.
Stempsey, William E. 2000. Disease and diagnosis: Value-dependent realism. Dordrecht: Kluwer.
Aristotle. 1984. Nichomachean ethics. In The complete works of Aristotle: The revised Oxford translation, Vol. 2, 1729–1867 (trans: Jonathan Barnes). Princeton: Princeton University Press.
Edmondson, Ricca. 1984. Rhetoric in sociology. London: Macmillan.
Woerner, Markus H. 1990. Das rthische in der Rhetorik des Aristoteles. Freiburg/Br: Alber Verlag.
Edmondson, Ricca. 2007. Rhetorics of social science: Sociality in writing and inquiry. In The handbook of social science methodology, ed. William Outhwaite, and Stephen Turner, 479–498. London: Sage.
Aristotle. 1945. Rhetorica (trans: Roberts, W. Rhys). Oxford: Clarendon Press.
Aristotle. 1965. Prior and posterior analytics (rev. text with introduction and commentary by W.D. Ross). Oxford: Clarendon Press.
Woerner, Markus H. 1982. Enthymeme—Ein rückgriff auf Aristoteles in systematischer absicht. In Rhetorische rechsttheorie, ed. Ottmar Ballweg, and Thomas-Michael Seibert, 73–98. Freiburg/Br: Alber Verlag.
Burnyeat, Myles. 1994. Enthymeme: Aristotle on the logic of persuasion. In Aristotle’s rhetoric: Philosophical essays, proceedings of the 11 th symposium Aristotelicum, ed. D.J. Furley, and A. Nehamas, 3–55. Princeton: Princeton University Press.
Lynn, Lawrence E. 1996. Public management as art, science, and profession. Chatham, NJ: Chatham House.
Lynn, Lawrence E. 1999. Teaching and learning with cases. New York: Chatham House.
Sackett, David L., R.B. Haynes, P. Tugwell, and G. Guyatt. 1991. Clinical epidemiology: A basic Science for clinical medicine. London: Little Brown.
Edmondson, Ricca. 2008. Wisdom and older people in Ireland. Senior People Education Studies (Wuhan, China) 2 (36): 73–76.
Sternberg, Robert J. 1998. A balance theory of wisdom. Review of General Psychology 2: 347–365.
Baltes, Paul, and Ursula Staudinger. 2000. Wisdom: A metaheuristic (pragmatic) to orchestrate mind and virtue toward excellence. American Psychologist 55: 122–135.
Schon, Donald. 1983. The reflective practitioner: How professionals think in action. Aldershot: Ashgate.
Lauder, W. 1994. Beyond reflection: Practical wisdom and the practical syllogism. Nurse Education Today 14 (2): 91–96.
Coles, Colin. 2002. Developing professional judgment. Journal of Continuing Education in the Health Professions 22 (1): 3–10.
Author information
Authors and Affiliations
Corresponding author
Additional information
Ricca Edmondson, Jane Pearce, and Markus H. Woerner belong to the Galway Wisdom Project.
Rights and permissions
About this article
Cite this article
Edmondson, R., Pearce, J. & Woerner, M.H. Wisdom in clinical reasoning and medical practice. Theor Med Bioeth 30, 231–247 (2009). https://doi.org/10.1007/s11017-009-9108-2
Published:
Issue Date:
DOI: https://doi.org/10.1007/s11017-009-9108-2