Practical wisdom in complex medical practices: a critical proposal

  • C. M. M. L. Bontemps-HommenEmail author
  • A. Baart
  • F. T. H. Vosman
Scientific Contribution


In recent times, daily, ordinary medical practices have incontrovertibly been developing under the condition of complexity. Complexity jeopardizes the moral core of practicing medicine: helping people, with their illnesses and suffering, in a medically competent way. Practical wisdom (a modification of the Aristotelian phronèsis) has been proposed as part of the solution to navigate complexity, aiming at the provision of morally good care. Practical wisdom should help practitioners to maneuver in complexity, where the presupposed linear ways of operating prove to be insufficient. However, this solution is unsatisfactory, because the proposed versions of practical wisdom are too individualistic of nature, while physicians are continuously operating in varying teams, and dealing with complicated technologies and pressing structures. A second point of critique is, that these versions are theory based, and thus insufficiently attuned to the actual context of everyday medical practices. Now, our proposal is to use an approach of practical wisdom that enables medical practices to counter the complexity issue and to re-invent the moral core of medical practicing as well. This implies a practice oriented approach, as thematized by practice theory, qualitative empirical research from the inside, and abduction from actual performed practical wisdom towards an apt understanding of phronèsis.


Practical wisdom Complexity Practice theory Care ethics Qualitative empirical research 


  1. Anderson, R. A., and R. R. McDaniel Jr. 2000. Managing health care organizations: Where professionalism meets complexity science. Health Care Management Review 25 (1): 83–92.CrossRefGoogle Scholar
  2. Aristotle. 2009. The Nicomachean ethics. Oxford: Oxford University Press.Google Scholar
  3. Baart, A., and F. Vosman. 2015a. Zorgpraktijken onderzocht door professionals en onderzoekers. Care practices researched by professionals and researchers. In De patiënt terug van weggeweest, [The patient comeback], eds. A. Baart and F. Vosman, 7–21. Amsterdam: SWP.Google Scholar
  4. Baart, A., and F. Vosman. 2015b. Een lastige familie die niet lastig is. Verslag van een onderzoek dat te denken geeft. [A difficult family, which is not difficult. Report of an inquiry that makes you think. In De patiënt terug van weggeweest, [The patient comeback], eds. A. Baart and 181–206. Amsterdam: Vosman.Google Scholar
  5. Boyd, C. M., et al. 2005. Clinical practice guidelines and quality of care for older patients with multiple comorbid diseases: Implications for pay for performance. JAMA. 294 (6): 716–724.CrossRefGoogle Scholar
  6. Braithwaite, J., and J. Plumb. 2015. Exposing hidden aspects of resilience and brittleness in everyday clinical practice using network theories. In Resilient health care. The resilience of everyday clinical work, eds. R. L. Wears, E. Hollnagel and J. Braithwaite, Vol 2, 115–129. Farnham: Ashgate.Google Scholar
  7. Brothers, K. B. 2011. Dependant rational providers. Journal of Medicine and Philosophy 36: 133–147.CrossRefGoogle Scholar
  8. Chambliss, D. F. 1996. Beyond caring. Hospitals, nurses, and the social organization of ethics. Chicago: The University of Chicago Press.Google Scholar
  9. Cilliers, P. 2013. A crisis of knowledge: Complexity, understanding and the problem of responsible action. In Genomics and democracy; Towards a ‘Lingua Democratica’ for the public debate on genomics, eds. P. Derkx, and H. Kunneman, 36–59. New York: Rodopi B.V.Google Scholar
  10. Cooke, M. 2013. A more ambitious agenda for medical education research. Journal of Graduate Medical Education 5 (2): 201–202.CrossRefGoogle Scholar
  11. Dekker, S. 2011. Drift into failure. From hunting broken components to understanding complex systems. Farnham/Burlington: Ashgate Publishing Ltd.Google Scholar
  12. Dunne, J. 1993. Back to the rough ground: “Phronèsis” and “Technè” in modern philosophy and in Aristotle. Notre Dame: Univ. of Notre Dame Press.Google Scholar
  13. Eikeland, O., and D. Nicolini. 2011. Turning practically: Broadening the horizon. Journal of Organizational Change Management 24 (2): 164–174.CrossRefGoogle Scholar
  14. Freidson, E. 2001. Professionalism: The third logic. Chicago: Univ. of Chicago Press.Google Scholar
  15. Fricker, M. 2007. Epistemic injustice. Power and the ethics of knowing. Oxford: Oxford Univ. Press.CrossRefGoogle Scholar
  16. Füchtbauer, L. M., B. Norgaard, and C. Backer Mogensen. 2013. Emergency department physicians spend only 25% of their working time on direct patient care. Danish Medical Journal 60 (1): A4558.Google Scholar
  17. Gawande, A. 2010. The checklist manifesto. How to get things right. London: Profile Books Ltd.Google Scholar
  18. Giddens, A. 1990. The consequences of modernity. Stanford: Stanford University Press.Google Scholar
  19. Hafferty, F. W., and D. Levinson. 2008. Moving beyond nostalgia and motives: Towards a complexity science view of medical professionalism. Perspectives Biology Medicine 51 (4): 599–615.CrossRefGoogle Scholar
  20. Hall, D. E. 2011. The guild of surgeons as a tradition of moral enquiry. The Journal of Medicine Philosophy 36: 114–132.CrossRefGoogle Scholar
  21. Heijst Van, A. 2011. Professional loving care. An ethical view of the healthcare sector. Leuven: Peeters.Google Scholar
  22. Held, V. 2006. The ethics of care: Personal, political, and global. Oxford/NewYork: Oxford Univ Press.Google Scholar
  23. Heuts, F., and A. Mol. 2013. What is a good tomato? A case of valuing in practice. Valuation Studies 1 (2): 125–146.CrossRefGoogle Scholar
  24. Hollnagel, E., R. L. Wears, and J. Braithwaite. 2015. From Safety-I to Safety-II: A white paper.
  25. Judkins, S. 2015. Emergency; Real stories from Australia’s emergency department doctors. Australia: Penguin Groop.Google Scholar
  26. Kaldjian, L. 2010. Teaching practical wisdom in medicine through clinical judgement, goals of care and ethical reasoning. Journal of Medical Ethics 36 (5): 299–320.Google Scholar
  27. Kaldjian, L. 2014. Practising medicine and ethics: Integrating wisdom, conscience and goals of care. Cambridge: Cambridge Univ Press.CrossRefGoogle Scholar
  28. Kemmis, S. 2012. Phronèsis, experience, and the primacy of praxis. In Professional knowledge; Practical wisdom in the professions, eds. E. A. Kinsella, and A. Pitman, 147–163. Rotterdam: Sense Publishers.Google Scholar
  29. Kinghorn, W. A. 2010. Medical education as moral formation: an Aristotelian account of medical professionalism. Perspectives in Biology and Medicine 53 (1): 87–105.CrossRefGoogle Scholar
  30. Kinsella, E. A., and A. Pitman. 2012a. Engaging phronèsis in professional practice and education. In Phronèsis as professional knowledge; Practical wisdom in the professions, eds. E. A. Kinsella, and A. Pitman, 1–13. Rotterdam: Sense Publishers.CrossRefGoogle Scholar
  31. Kinsella, E. A., and A. Pitman. 2012b. Phronèsis as professional knowledge: Implications for education and practice.”. In Phronèsis as professional knowledge; Practical wisdom in the professions, eds. E. A. Kinsella, and A. Pitman, 163–173. Rotterdam: Sense Publishers.CrossRefGoogle Scholar
  32. Klaver, K., E. van Elst, and A. Baart. 2014. Demarcation of the ethics of care as a discipline: Discussion article. Nursing Ethics 21 (7): 755–765.CrossRefGoogle Scholar
  33. Kotzee, B., A. Paton, and M. Conroy. 2016. Towards an empirically informed account of phronèsis in medicine. Perspectives in Biology and Medicine 59 (3): 337–350.CrossRefGoogle Scholar
  34. Kristjánsson, K. 2015. Phronèsis as an ideal in professional medical ethics: Some preliminary positionings and problematics. Theoretical Medicine and Bioethics 36 (5): 299–320.CrossRefGoogle Scholar
  35. Kunneman, H. 2010. Ethical Complexity. In Complexity, difference and identity, eds. P. Cilliers, and R. Preiser, 131–164. Dordrecht: Springer.CrossRefGoogle Scholar
  36. Laugier, S. 2015. The ethics of care as a politics of the ordinary. New Literary History. 46 (2): 217–240.CrossRefGoogle Scholar
  37. Lombarts, M. J. M. H. 2015. Competence-based education misses the essence of the medical profession. Perspectives on Medical Education 4: 326–328.CrossRefGoogle Scholar
  38. MacIntyre, A. 1985. After virtue. London: Duckworth.Google Scholar
  39. Mesman, J. 2002. Uncertainty in medical innovation: Experienced pioneers in neonatal care. [Ervaren pioniers; Omgaan met twijfel in de intensive care voor pasgeborenen.] Maastricht: Aksant.Google Scholar
  40. Mol, A. 2009. The logic of care; Health and the problem of patient choice. London: Routledge.Google Scholar
  41. Montgomery, K. 2006. How doctors think: Clinical Judgement and the practice of medicine. Oxford: Oxford University Press.Google Scholar
  42. Moore, G. 2005. Corporate character: Modern virtue ethics and the virtuous corporation. Business Ethics Quarterly 15 (4): 659–685.CrossRefGoogle Scholar
  43. Moore, G., and R. Beadle. 2006. In search of organizational virtue in business: Agents, goods, practices, institutions and environments. Organization Studies 27 (3): 369–389.CrossRefGoogle Scholar
  44. Nicolini, D. 2012. Practice theory. Work and organization. An introduction. Oxford: Oxford University Press.Google Scholar
  45. Nicolini, D., and P. Monteiro. 2017. The practice approach: for a praxeology of organizational and management studies. In The Sage Handbook of Process Organization Studies, eds. A. Langley, and H. Tsoukas., London: Sage Publications Ltd.Google Scholar
  46. Nortvedt, P., and F. Vosman. 2014. An ethics of care: New perspectives, both theoretically and empirically? Nursing Ethics 21 (7): 753–754.CrossRefGoogle Scholar
  47. Olde Rikkert, M. 2017. Complexity-Science verbindt evidence en context based practice. Context en bewijs gaan prima samen. [Complexity-science links evidence and context based practice. Context and evidence can go hand in hand.]. Med Contact 72 (31–32): 34–36.Google Scholar
  48. Pellegrino, E. D., and D. C. Thomasma. 1993. The virtues in medical practice. New York: Oxford University Press.Google Scholar
  49. Pitman, A. 2012. Professionalism and professionalisation: Hostile ground for growing phronèsis? In Phronèsis as professional knowledge; Practical wisdom in the professions, eds. E. A. Kinsella, and A. Pitman, 131–147. Rotterdam: Sense Publishers.CrossRefGoogle Scholar
  50. Plsek, P. E., and T. Greenhalgh. 2001. Complexity science: The challenge of complexity in health care. BMJ 323 (7313): 625–632.CrossRefGoogle Scholar
  51. Polanyi, M. 1969. Knowing and being. Chicago: The University of Chicago Press.Google Scholar
  52. Porter M. E., and E.O. Teisberg. 2006. Redefining health care: creating value-based competition on results. Boston: Harvard Business School Press.Google Scholar
  53. Reeve, J., et al. 2013. Generalist solutions to complex problems: Generating practice-based-evidence—the example of managing multi-morbidity. BMC Family Practice 14: 112.CrossRefGoogle Scholar
  54. Rosa, H. 2013. Social acceleration. A new theory of modernity. New York: Columbia University Press.CrossRefGoogle Scholar
  55. Schatzki, T. 1996. Social practices. A Wittgensteinian approach to human activity and the social. Cambridge: Cambridge University Press.CrossRefGoogle Scholar
  56. Schmidt, R. 2012. Soziologie der Praktiken. Konzeptuelle Studien und Empirische Analysen. Berlin: Suhrkamp.Google Scholar
  57. Sellman, D. 2012. Reclaiming competence for professional phronesis. In Phronesis as practical knowledge; Practical wisdom in the professions, eds. E. A. Kinsella, and A. Pitman, 115–130. Rotterdam: Sense Publishers.Google Scholar
  58. Tilney, N. 2011. Invasion of the body; Revolutions in surgery. Cambridge: Harvard University Press.CrossRefGoogle Scholar
  59. Timmermans, S., and I. Tavory. 2012. Theory construction in qualitative research: From grounded theory to abductive analysis. Sociological Theory 30 (3): 167–186.CrossRefGoogle Scholar
  60. Tonkens, E. 2008. Mondige burgers, getemde professionals. Marktwerking en professionaliteit in de publieke sector. In [Empowered citizens, tamed professionals. The free market and professionalism in the public sector]. Amsterdam: Uitg. Van Gennep.Google Scholar
  61. Tronto, J. C. 1993. Moral boundaries. A political argument for an ethic of care. New York: Routledge.Google Scholar
  62. Tronto, J. C. 2013. Caring democracy, markets, equality and justice. New York: New York University Press.Google Scholar
  63. Upshur, R. 2014. Do clinical guidelines still make sense? No. The Annals of Family Medicine 12 (3): 202–203.CrossRefGoogle Scholar
  64. Verbeek, P. P. 2011. De grens van de mens. Over techniek, ethiek, en de menselijke natuur. [Human boundaries. About technology, ethics and human nature.]. Rotterdam: Lemniscaat.Google Scholar
  65. Viafora, C. 1999. Toward a methodology for the ethical analysis of clinical practice. Medicine, Health Care and Philosophy 2: 283–297.CrossRefGoogle Scholar
  66. Vosman, F., and A. Baart. 2008. Aannemelijke zorg. Over het uitkoken en verdringen van praktische wijsheid in de gezondheidszorg. In [Plausible care. About the vaporisation and suppression of practical wisdom in health care.]. The Hague: Uitgeverij Lemma.Google Scholar
  67. Vosman, F., and A. Baart. 2011. Relationship based care and recognition. Part two: Good care and recognition.”. In Care, compassion and recognition: an ethical discussion, eds. C. Leget, C. Gastmans, and M. Verkerk, 201–229. Leuven: Peeters.Google Scholar
  68. Vosman, F., and A. Baart. 2015. Zorg uit zorg denken. [Thinking care from care.]. In De patiënt terug van weggeweest. [The patient comeback.] eds, eds. A. Baart, and F. Vosman, 43–57. Amsterdam: SWP.Google Scholar
  69. Vosman, F., and A. Niemeijer. 2017. Rethinking critical reflection on care: Late modern uncertainty and the implications for care ethics. Medicine, Health Care and Philosophy 20 (4): 465–476.CrossRefGoogle Scholar
  70. Vosman, F., J. den Bakker, and D. Weenink. 2016. How to make sense of suffering in complex care practices? In Practice theory and research; Exploring the dynamics of social life, eds. G. Spaargaren, D. Weenink, and M. Lamers, 117–130. New York: Routledge.Google Scholar
  71. Vriens, D., J. Achterbergh, and L. Gulpers. 2016. Virtuous structures. Journal of Business Ethics Scholar

Copyright information

© Springer Nature B.V. 2018

Authors and Affiliations

  • C. M. M. L. Bontemps-Hommen
    • 1
    Email author
  • A. Baart
    • 2
  • F. T. H. Vosman
    • 3
  1. 1.St Jansdal HospitalHarderwijkThe Netherlands
  2. 2.Optenta Research Focus AreaNorth-West UniversityVanderbijlparkSouth Africa
  3. 3.University of Humanistic StudiesUtrechtThe Netherlands

Personalised recommendations