Virtue, progress and practice

摘要

The reasonable man adapts himself to the world; the unreasonable one persists in trying to adapt the world to himself. Therefore, all progress depends on the unreasonable man. (G.B. Shaw) [1] There are questions so resistant to easy resolution that we tend to ignore them for as long as we can, but so fundamental that they keep returning whenever we try to discuss anything that really matters with any degree of seriousness. Such questions are often deemed ‘philosophical’ in nature,1 and questions of this sort in clinical practice include: what is good practice in medicine and health care? What do we mean by progress in these areas? How do we recognize virtue when we see it? How do we support and promote it? How do I become a more virtuous practitioner? One problem with these questions is that we do not know precisely how to go about resolving them. We lack a clear and agreed method for producing answers that all rational parties will accept, and that are sufficiently full and detailed to be of any practical use – meaning, answers that can guide our decisions in specific cases. We can translate this problem into yet another question, but it is similarly philosophical in form: in terms of which methods, and with recourse to which sources of knowledge and evidence, can we aspire, rationally to reach sound conclusions on the nature of progress, virtue and good practice? This further, methodological question cannot credibly be avoided. It would be bizarre indeed if empirical evidence had no bearing on these vital questions, but how precisely we use evidence to answer them, and which evidence we use, is by no means obvious. It is not as though there were some missing piece of information that we could one day just find, that would reveal the answers in much the same manner as Douglas Adams's imagined ‘Deep Thought’ computer revealed that the answer to the question ‘what is the meaning of life, the universe and everything?’ was in fact ‘42’[2]. Certainly, there are texts, articles and published guidelines telling us how to practice more ‘ethically’[3,4], use evidence more effectively [5,6] and frame policies that will guarantee that quality and excellence become the ‘hallmarks’ of our respective organizations [7,8]. Unfortunately, such guidelines, handbooks and ‘how-to’ texts rarely have anything to say that is at once substantive (that goes beyond the platitudinous) and is also supported by a clear and rigorous account of the reasoning linking their premises to their conclusions [4,6,9,10]. Authors purporting to offer ‘practical’ advice too often recognize no requirement to supply convincing, explicit argumentation in support of the conclusions they invite their readers to accept [8,11] and are likely to regard the request for supporting arguments as unreasonable. Like the Deep Thought computer, they supply an answer, but not the working out. Their background assumptions and underlying conceptual framework – the implicit premises and normative structures that shaped their answers, that determined these answers as opposed to other possible ones – are apparently not worth discussing, of no interest to ‘busy practitioners’[5] and those ‘employed in the more mundane processes of what is called real life’[12]. The current climate is, and has for some time been, one of ‘moderate anti-intellectualism’[11]. It is considered reasonable for human beings – at least, those deemed responsible professionals – to apply their intellectual capacities to the learning of sometimes complex techniques, to know and follow conventions for good practice in their areas of work: ‘how-to’ questions are the legitimate preoccupations of the rational, professional mind. But it is deemed ‘intellectual’ in a derisory sense – somehow strange, bolshy or ‘other worldly’[5,12]– for a professional to want to understand the reasons behind the current conventions and to contribute to the debate about their appropriateness and sustainability. The characteristically philoso