Megan E. L.

Brown
Mario Veen
Gabrielle Maria Finn Editors

Applied
Philosophy
for Health
Professions
Education
A Journey Towards Mutual
Understanding
Applied Philosophy for Health Professions
Education
Megan E. L. Brown · Mario Veen ·
Gabrielle Maria Finn
Editors

Applied Philosophy
for Health Professions
Education
A Journey Towards Mutual Understanding
Editors
Megan E. L. Brown Mario Veen
Imperial College London Erasmus University Medical Center
London, UK Rotterdam, The Netherlands
Hull York Medical School
York, UK
The University of Buckingham
Buckingham, UK

Gabrielle Maria Finn

The University of Manchester
Manchester, UK
Hull York Medical School
York, UK

ISBN 978-981-19-1511-6 ISBN 978-981-19-1512-3 (eBook)

https://doi.org/10.1007/978-981-19-1512-3

© The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature
Singapore Pte Ltd. 2022
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This book is dedicated to the memory of Flint
Victor Brophy.
Foreword

We want your technology, but not your philosophy.

A Dean spoke these words to me with a determent facial expression. He wanted

the problem-based learning technology (e.g., small group discussions, self-directed
learning) for his students, without exposing the students to philosophies underlying
the education (e.g., humanism, constructivism). These philosophies would not match
with the students’ cultural values. This made me reflect on how philosophy relates to
education, and how education relates to philosophy. We investigated these two ques-
tions in different national cultures and found that: problem-based learning philoso-
phies affect student’s ideas, and the student’s ideas affect problem-based learning.
Education and philosophy are inextricably linked. The Dean dreamed a hopeless
dream with his wish for education without philosophy.
I’m a journal editor, an educational researcher, and an educator, and I find philos-
ophy to be important, but distant and inaccessible (or a closed cave to stay within the
philosopher’s world). Writing on philosophical topics seemed more something for
my smart colleagues form the medical ethics department, than for a normal academic
like myself. They have studied philosophers’ complex ideas written down on many
pages in even more complex language for many years. I had not come further than
Freire’s Pedagogy of the oppressed—which I loved—and an attempt to read Arendt’s
The human condition—which I never finished. But now there is the Applied Philos-
ophy for Health Professions Education: A Journey Towards Mutual Understanding
to open the world of philosophy for educators. The book offers both an introduction
and a more in-depth discussion of the philosophy of health professions education.
Applied Philosophy for Health Professions Education introduces educators into
a wide range of philosophical topics. Several chapters provide a philosophical
perspective on contemporary educational issues, e.g., assessment, identity forma-
tion, empathy, social media. Other chapters focus on what philosophical concepts
can mean for health professions education, e.g., Stoicism, ontology, phronesis, femi-
nism. Two chapters are devoted to the philosophy of science. These two chapters are
relevant for both producers (i.e., researchers) and consumers (i.e., educators, policy

vii
viii Foreword

makers) of health profession education research. I was personally excited that the
editors have included a chapter on Freire’s work. The editors—Megan Brown, Mario
Veen, and Gabrielle Finn—have taken the book’s subtitle A journey towards mutual
understanding seriously. Most chapters have been authored by a combination of
clinicians and/or educators, and experts in philosophy. These unique author combi-
nations result in a book that combines in-depth exploration of philosophical concepts,
with practical examples and cases, written in a clear and accessible language. The
editors and authors have made a remarkable performance by offering us an acces-
sible, practical, and scholarly introduction into the meaning of philosophy for the
health professions education. This is the first book to accomplish bridging the gap
between both worlds.
Dear health professions education reader, you no longer have to be afraid of
philosophy. And this book may give you the language (and the will) to engage
that Dean who demands your educational technology but dismisses the philosophy
underpinning them.

Professor Erik Driessen

Professor and Chair, Department of
Educational Development and
Research, Faculty of Health, Medicine
and Life Sciences
Maastricht University
Maastricht, The Netherlands
Preface

This book is a journey towards mutual understanding—it says so in the title—but

between whom? In this book we bring together the voices of emerging and established
healthcare professionals, educators, and researchers with the voices of philosophers.
In doing so, we hope we have captured the beginnings of an applied philosophy
for health professions education that is both grounded in theory, but practical in
orientation. We, the editors, are all interested in or have studied philosophy, yet
have noticed during our time in health professions education that it is relatively
underutilised within the field. We hope in reading this book that you will begin to
see what insights philosophy can offer our interdisciplinary field and, in doing so
(and perhaps putting some of these insights into practice in your own educational or
research practice), that we can move the field towards a more truly interdisciplinary
position.
This book was written for all of those interested or invested in health professions
education—from ‘on the ground’ clinicians and educators, to those with interests
in research and formal academic positions. Some chapters are more introductory in
nature, whilst others offer a more theoretical ‘deep dive’ into various philosophies.
This is intentional, and we hope there is something for everyone in this book. We
envision this book could be particularly useful for those completing postgraduate
studies in health professions education and research.
We are indebted to the contributing authors of this edited volume for their
wisdom, effort, and insight. In alphabetical order by surname, the following trainees,
undergraduate students, postgraduate students, clinicians, educators, researchers,
philosophers, and those that defy easy labelling contributed to this book:
• Rola Ajjawi. Centre for Research in Assessment and Digital Learning, Deakin
University, Melbourne, VIC, Australia. Email: rola.ajjawi@deakin.edu.au
• Joop Berding. Before his retirement affiliated with Rotterdam University of
Applied Sciences, The Netherlands. Email: jwa.berding@ziggo.nl
• Robyn Bluhm. Department of Philosophy and Lyman Briggs College, Michigan
State University, East Lansing, Michigan, USA. Email: rbluhm@msu.edu

ix
x Preface

• Megan E.L. Brown. Medical Education Innovation and Research Centre, Imperial
College London, UK and Health Professions Education Unit, Hull York Medical
School, University of York, UK. Email: megan.brown@imperial.ac.uk
• Jamie Buckland. Department of Philosophy, University of York, UK. Email:
jamie.buckland@york.ac.uk
• Jessica L. Bunin. Department of Medicine, Uniformed Services University of the
Health Sciences. Email: jessica.bunin@usuhs.edu
• Benjamin Chin-Yee. Division of Hematology, Western University, London,
Canada, and Rotman Institute for Philosophy, Western University, London,
Canada. Email: benjamin.chin-yee@lhsc.on.ca
• Camillo Quinto Harro Coccia. University of Cape Town, Cape Town, South
Africa. Email: camillo.coccia@uct.ac.za
• Paul Crampton. Health Professions Education Unit, Hull York Medical School,
University of York, UK. Email: paul.crampton@hyms.ac.uk
• Adam Danquah. Faculty of Biology, Medicine and Health, University of Manch-
ester, Manchester, UK. Email: adam.danquah@manchester.ac.uk
• Anne de la Croix. Amsterdam UMC, Research in Education, Faculty of
Medicine, Vrije Universiteit Amsterdam, The Netherlands. Email: A.delacroix@
amsterdamumc.nl
• Tim Dornan, Queen’s University Belfast, Northern Ireland, UK and Maastricht
University, The Netherlands.
• Angelique N. Dueñas. Department of Medical Education, Northwestern Univer-
sity Feinberg School of Medicine, Chicago, IL, USA and Health Professions
Education Unit, Hull York Medical School, University of York, UK. Email:
angelique.duenas@northwestern.edu
• Sarah Louise Edwards. University Hospitals of Leicester, Leicester Royal
Infirmary, Leicester, UK. Email: se181@leicester.ac.uk
• Kevin Eva. Centre for Health Education Scholarship, University of British
Columbia, Vancouver, Canada. Email: kevin.eva@ubc.ca
• Gabrielle M. Finn. Division of Medical Education, School of Medical Sciences,
Faculty of Biology, Medicine and Health, The University of Manchester, Manch-
ester, UK and Health Professions Education Unit, Hull York Medical School,
University of York, UK. Email: gabrielle.finn@manchester.ac.uk
• Jonathan Guckian. Leeds Teaching Hospitals Trust, Leeds. Email: Jonathan.
guckian@outlook.com
• Neil Guha. School of Medicine, University of Nottingham, Nottingham, UK.
Email: neil.guha@nottingham.ac.uk
• Frederic W. Hafferty. Division of General Internal Medicine and Program in
Professionalism and Values, Mayo Clinic, Rochester, Minnesota, USA. Email:
Hafferty.Frederic@mayo.edu
• Nigel Hart. School of Medicine, Dentistry, and Biomedical Sciences, Queen’s
University Belfast, Northern Ireland, UK. Email: n.hart@qub.ac.uk
• Jenny Johnston. School of Medicine, Dentistry, and Biomedical Sciences, Queen’s
University Belfast, Northern Ireland, UK. Email: j.l.johnston@qub.ac.uk
Preface xi

• Amelia Kehoe. Health Professions Education Unit, Hull York Medical School,
University of York, UK. Email: millie.kehoe@hyms.ac.uk
• Martina Ann Kelly, Undergraduate Family Medicine, Cumming School of
Medicine, University of Calgary, Calgary, Canada. Email: makelly@ucalgary.
ca
• Abigail Konopasky. Center for Health Professions Education, Uniformed Services
University of the Health Sciences and Henry M. Jackson Foundation for the
Advancement of Military Medicine. Email:abigail.konopasky.ctr@usuhs.edu
• William Laughey. Health Professions Education Unit, Hull York Medical School,
University of York, UK. Email: william.laughey@hyms.ac.uk
• Tim LeBon. Psychotherapist, UK. Email: timlebon@gmail.com
• Alexander MacLellan. Department of Psychology, University of Bath, Bath, UK.
Email: akem20@bath.ac.uk
• Annalisa Manca. School of Medicine, Dentistry, and Biomedical Sciences,
Queen’s University Belfast, Northern Ireland, UK. Email: annalisa.manc@gmail.
com
• Nabilah Yunus Mayat. Airedale NHS Foundation Trust, UK. Email: n.mayat@
nhs.net
• Barett Michalec, Edson College of Nursing and Health Innovation, CAIPER,
Arizona State University. Email: barret.michalec@asu.edu
• Jacob Pearce. Specialist and Professional Assessment, Australian Council for
Educational Research, Camberwell, Victoria, Australia.
• Grace Peters. Veterinary Communication for Professional Excellence, Colorado
State University, United States. Grace.peters@colostate.edu
• Nicole Piemonte, Creighton University, School of Medicine, Phoenix Regional
Campus
• Bryan C. Pilkington, School of Health and Medical Sciences, College of Nursing,
and Department of Philosophy, Seton Hall University and Hackensack Meridian
School of Medicine
• Margaret Plews-Ogan, University of Virginia School of Medicine, USA. Email:
mp5k@hscmail.mcc.virginia.edu
• Marina Politis. School of Medicine, Dentistry and Nursing, University of
Glasgow, Glasgow, UK. Email: 2364733p@student.gla.ac.uk
• Wouter Pols. Before his retirement affiliated with Rotterdam University of Applied
Sciences, The Netherlands. Email: wouterpols1@gmail.com
• Holly Quinton. Queens Road Surgery, Consett, County Durham, UK.
• Cristina Richie. Philosophy and Ethics of Technology, Technische Universiteit
Delft, Delft 2628, The Netherlands. Email: c.s.richie@tudelft.nl
• Charlotte Rothwell. NIHR Applied Research Collaboration North East and
Cumbria, Newcastle University, UK. Email: charlotte.rothwell@ncl.ac.uk
• Tinu Ruparell, Department of Classics and Religion, University of Calgary,
Canada.
• Sven Peter Charlotte Schaepkens. Erasmus Medical Centre, Rotterdam, The
Netherlands. Email: s.schaepkens@erasmusmc.nl
xii Preface

• Kenneth E. Sharpe. Swarthmore College, Swarthmore, Pennsylvania, USA.

Email: Kenneth.e.sharpe@gmail.com
• Walter Tavares. The Wilson Centre for Health Professions Education, University
Health Network, University of Toronto, Temerty Faculty of Medicine, Toronto,
Ontario, Canada. Email: walter.tavares@utoronto.ca
• Jon Tilburt, Mayo Clinic, Scottsdale, Arizona.
• Marije van Braak. Erasmus Medical Centre, Rotterdam, The Netherlands. Email:
m.vanbraak@erasmusmc.nl
• Lara Varpio. Center for Health Professions Education Uniformed Services Univer-
sity of the Health Sciences Center for Health Professions Education. Email: lara.
varpio@usuhs.edu
• Mario Veen. Department of General Practice, Erasmus Medical Center Rotterdam,
The Netherlands. Email: m.veen.1@erasmusmc.nl
• Simon Verwer. Amsterdam UMC. Email: s.verwer@amsterdamumc.nl
• Lena Wånggren. School of Literatures, Languages and Cultures, University of
Edinburgh, UK. Email: lena.wanggren@ed.ac.uk
• Tasha R. Wyatt. Center for Health Professions Education, Uniformed Services
University of the Health Sciences, Bethesda, Maryland; USA. Email: Tasha.
wyatt@usuhs.edu

USA Megan E. L. Brown

Mario Veen
Gabrielle Maria Finn
Contents

1 Philosophy as Praxis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Megan E. L. Brown, Mario Veen, and Gabrielle Maria Finn
2 Philosophy of Education: Towards a Practical Philosophy
of Educational Practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Wouter Pols and Joop Berding
3 Subjectification in Health Professions Education: Why
We Should Look Beyond the Idea of Professional Identity
Formation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
Simon Verwer and Marije van Braak
4 The Serious Healer: Developing an Ethic of Ambiguity Within
Health Professions Education . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
Mario Veen and Megan E. L. Brown
5 Acknowledgement: The Antidote to Skillification (of Empathy)
in Health Professions Education . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
Anne de la Croix, Grace Peters, and William F. Laughey
6 Tracing Philosophical Shifts in Health Professions Assessment . . . . . 67
Walter Tavares, Jacob Pearce, and Kevin Eva
7 The Significance of the Body in Health Professions Education . . . . . 85
Gabrielle Maria Finn, Frederic W. Hafferty, and Holly Quinton
8 The Philosophy of Education: Freire’s Critical Pedagogy . . . . . . . . . . 103
Jennifer L Johnston, Nigel Hart, and Annalisa Manca
9 The Philosophy of Social Justice: Lessons for Achieving
Progress in Health Professions Education Through
Meaningful Inclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119
Angelique N. Dueñas, Marina Politis, and Adam Danquah

xiii
xiv Contents

10 The Future of Healthcare is Feminist: Philosophical Feminism

in Health Professions Education . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141
Lena Wånggren and Gabrielle Maria Finn
11 The Philosophy of Agency: Agency as a Protective Mechanism
Against Clinical Trainees’ Moral Injury . . . . . . . . . . . . . . . . . . . . . . . . . 157
Abigail Konopasky, Jessica L. Bunin, and Lara Varpio
12 “What Does It Mean to Be?”: Ontology and Responsibility
in Health Professions Education . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 173
Tasha R. Wyatt, Rola Ajjawi, and Mario Veen
13 The Philosophy of Science: An Overview . . . . . . . . . . . . . . . . . . . . . . . . 187
Amelia Kehoe, Charlotte Rothwell, and Robyn Bluhm
14 Tensions Between Individualism and Holism: A Philosophy
of Social Science Perspective . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 205
Paul Crampton and Jamie Buckland
15 Ethics Education in the Health Professions . . . . . . . . . . . . . . . . . . . . . . 219
Bryan C. Pilkington
16 Climate Change and Health Care Education . . . . . . . . . . . . . . . . . . . . . 233
Cristina Richie
17 The Philosophy of Technology: On
Medicine’s Technological Enframing . . . . . . . . . . . . . . . . . . . . . . . . . . . . 251
Benjamin Chin-Yee
18 Philosophy as Therapy: Rebalancing Technology and Care
in Health Professions Education . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 267
Martina Ann Kelly, Tim Dornan, and Tinu Ruparell
19 Is Social Media Changing How We Become Healthcare
Professionals? Reflections from SoMe Practitioners . . . . . . . . . . . . . . 279
Nabilah Yunus Mayat, Sarah Louise Edwards,
and Jonathan Guckian
20 Phronesis in Medical Practice: The Will and the Skill Needed
to Do the Right Thing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 293
Margaret Plews-Ogan and Kenneth E. Sharpe
21 In Pursuit of Time: An Inquiry into Kairos and Reflection
in Medical Practice and Health Professions Education . . . . . . . . . . . . 311
Sven Peter Charlotte Schaepkens and Camillo Quinto Harro Coccia
22 The Application of Stoicism to Health Professions Education . . . . . . 325
Alexander MacLellan, Megan E. L. Brown, Tim LeBon,
and Neil Guha
Contents xv

23 Teaching Dignity in the Health Professions . . . . . . . . . . . . . . . . . . . . . . 339

Bryan C. Pilkington
24 The Ambiguities of Humility: A Conceptual and Historical
Exploration in the Context of Health Professions Education . . . . . . . 351
Barret Michalec, Frederic W. Hafferty, Nicole Piemonte,
and Jon C. Tilburt
25 Concluding Remarks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 371
Megan E. L. Brown, Mario Veen, and Gabrielle Maria Finn
Abbreviations

AAMC Association of American Medical Colleges

ACP American College of Physicians
AI Artificial Intelligence
ASHA American Speech-Language-Hearing Association
BCE Before Common Era
BJGP British Journal of General Practice
CBME Competency Based Medical Education
CBT Cognitive Behavioural Therapy
CHA Cambridge Health Alliance
CIC Harvard Medical School Cambridge Integrated Clerkship
CoP Community of Practice
COVID-19 Coronavirus disease 2019
CPR Cardiopulmonary resuscitation
CQC Care Quality Commission
CRT Critical Race Theory
EDI Equality, Diversity and Inclusion
ER Emergency Room
GED General Educational Development tests
GMC General Medical Council
GP General Practice
HCP Healthcare professionals
HMS Harvard Medical School
HPE Health Professions Education
IBM International Business Machines Corporation
ICE Ideas, Concerns and Expectations
IFMSA International Federation of Medical Students’ Associations
IPE Interprofessional Education
JAMA Journal of the American Medical Association
JSE Jefferson Scale of Empathy
LGBTQIA+ Lesbian, Gay, Bisexual, Trans, Queer, Intersex, Asexuality, Plus
(Includes many other terms such as non-binary and pansexual)

xvii
xviii Abbreviations

LIC Longitudinal Integrated Clerkship

LSS Liverpool Stoicism Scale
MA Master of Arts
MD Doctor of Medicine
NHS National Health Service, United Kingdom
NYU New York University
OSCE Objective Structured Clinical Examination
PIF Professional Identity Formation
SABS Stoic Attitudes and Behaviours Scale
SEAM Harvard Students for Environmental Awareness in Medicine
SoMe Social Media
SP Simulated Patient
UK United Kingdom
US United States
UVA University of Virginia School of Medicine
WA Widening Access
WHO World Health Organisation
WP Widening Participation
Chapter 1
Philosophy as Praxis

Megan E. L. Brown, Mario Veen, and Gabrielle Maria Finn

The best physician is also a philosopher

Galen, Title of a Treatise (165–175 BCE), cited in Chapter 18 of this volume

Although health professions education has philosophical roots (Veen and Cianciolo
2020), it has drifted far from its original moorings as the field has developed and
is little-represented within contemporary health professions discourse. Philosophy
asks fundamental questions about human experience, knowledge, ethics, and truth.
Taken from the Greek words ‘philein’ which means ‘to love’, and ‘sophia’ which
means ‘wisdom’, philosophy offers a new lens through which contemporary issues
within medical education can be scrutinised (Veen and Cianciolo 2020).
The question of just what philosophy ‘is’ is a contentious one (Wilson 1986).
The Oxford Companion to Philosophy notes this debate but does offer a short defini-
tion—“philosophy is thinking about thinking” (Honderich 1995). Another definition,
offered by Deleuze and Guattari (1991), is that the task of philosophy is to create,
form and invent concepts. Take, for instance, the term ‘health professions educa-
tion’, about which we could ask: ‘what is health?’; ‘what is professionalism?’; ‘what
is education?’. The chapters in this book engage with deep questions about these
fundamental concepts in our professions.

M. E. L. Brown (B)
Imperial College London, London, UK
e-mail: megan.brown@imperial.ac.uk
M. E. L. Brown · G. M. Finn
Hull York Medical School, University of York, York, UK
e-mail: gabrielle.finn@manchester.ac.uk
M. Veen
Department of General Practice, Erasmus University Medical Center, Rotterdam, The Netherlands
e-mail: m.veen.1@erasmusmc.nl
G. M. Finn
The University of Manchester, Manchester, UK

© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2022 1
M. E. L. Brown et al. (eds.), Applied Philosophy for Health Professions Education,
https://doi.org/10.1007/978-981-19-1512-3_1
2 M. E. L. Brown et al.

But how do we go about answering such fundamental questions? In The Purpose of

Philosophy (199978), Isaiah Berlin argues against the idea that philosophy is about
unanswerable questions. He distinguishes philosophical questions from questions
that may be hard to answer, or even, in principle, unanswerable, such as scientific
questions or formal mathematical questions. For instance, ‘how do we cure cancer?’
is a complex question with no answer at present, but we do know the method for
answering it: through medical science. For philosophical questions, the method for
answering that question is not obvious. So while ‘what is health?’, for instance, can
be treated as a scientific question and approached from a medical or psychological
perspective, it can also be treated as a philosophical question. When it is treated as
a philosophical question, as we do with the questions in this volume, we often start
with questioning assumptions or presuppositions related to the issue.
In the health professions, we often admit to enjoying clarity and certainty—being
able to definitively diagnose someone’s undifferentiated illness, discussing likely
treatment outcomes, knowing exactly how to analyse a set of qualitative data, perhaps
even knowing the path for most effective instruction of healthcare learners. A lack of
consensus regarding what philosophy ‘is’ may be unnerving for some. But yet another
way of seeing philosophy is that it is primarily a practice, and that what this practice
is, exactly, is to be discovered in practicing it. In this case, this means reading through
the various chapters in this book and using them in a dialogue with your everyday
practice in the health professions, whether you are a teacher, trainee, researcher or
programme director. In lieu of being able to offer certainty, we would encourage you
to sit with, become familiar with, and eventually embrace this ambiguity, and the
ambiguity that will, without doubt, be brought to the fore of your experience as you
read this book (more about ambiguity later in Chapter 21).
There are different ways of thinking about the question of what philosophy ‘is’. In
this book, we will try to do justice to this diversity, but our perspective is by no means
definitive, or even universally applicable. Certainly, philosophy involves the study of
fundamental questions (such as “What is health?”, “What is illness?”), but it defies
classification as a field or discipline (there is an academic discipline of philosophy, but
this alone is not philosophy in its entirety). It is more of an approach, an openness
to asking questions about our thoughts and practice and is more concerned with
asking questions than necessarily being able to answer them (Midgley 2018). It is
thinking about things we may not usually think about, and critically, at that (Raphael
1994). Whereas educational theory offers explanations—narratives or models of the
world—philosophy is more of an activity, a questioning of one’s assumptions in order
to find coherence in the chaos without becoming too rigid. Even without necessarily
providing answers or explanations, like a theory might, asking questions is powerful,
as questioning established ideas, practices, attitudes, and institutions opens a space
for discussion and reflection that can lead to progress (Buckingham 2011). Simply
put, as you read this book, philosophy happens in how you take the book and use it
to examine and question your own practice.
Before we introduce you to our thoughts regarding why we need philosophy,
and particularly this project of moving towards a sort of philosophical praxis—an
applied philosophy—for health professions education, we should also consider why
1 Philosophy as Praxis 3

philosophy matters. Why, as Galen suggests in the quote that heads this chapter, is
the best physician (or healthcare professional), also a philosopher?
Firstly, living well is important for our own flourishing, and in promoting and
enabling the flourishing of others (Wilson 1986). In order to understand how to live
well—how to think and act in accordance with reason—readers must be able to make
sense of philosophy. This is not just a case of understanding the language philosophers
use (though there are many philosophical texts that are densely written), but also a
case of appreciating how the message contained in that text should influence one’s
thoughts or actions in the world. In health professions education, you will perhaps
be most familiar with philosophy as a lens through which to consider ethical practice
and decision-making as a clinician (see Chapter 24 for more on contemporary ethics
education). Whilst valuable (we have included a chapter on this topic and think most
would agree that healthcare professionals should practice ‘ethically’), instructing
healthcare students in philosophy is not the only way in which we can philosophise
our field. We must think more broadly as to how philosophy might meaningfully
influence our educational practice and research.
In Chapter 2, Pols and Berding suggest that the health professions “need philos-
ophy as a clarifying and ‘meaning-producing’ discipline”. We agree and would
add that this need has been overlooked. Although health professions education is
frequently touted as being ‘interdisciplinary’, the field is increasingly limited through
its failure to meaningfully engage with wider discourse, such as that within philos-
ophy. Indeed, research and pedagogical strategy within health professions education
is increasingly monodisciplinary, drawing most frequently on theories developed for
use specifically within health professions education (Laskowski-Jones 2016; Allen
et al. 2006; Rotgans 2012; Hautz et al. 2016; Paton et al. 2020). This is concerning,
as transdisciplinary research has been shown to more readily address complex social
issues, and transdisciplinary education produces healthcare graduates who are better
prepared for the collaborative, interprofessional reality of medical practice (Morley
and Cashel 2017; O’Sullivan et al. 2010).
The transdisciplinary and practical application of philosophical concepts directly
to contemporary issues within health professions education may yield new insight.
Although some contemporary issues within the field are relatively recent in inception,
such as the desire to produce trainees with high levels of ‘tolerance of ambiguity’,
some issues have persisted for decades, such as inequality, and medicine’s burnout
epidemic. The field has wrestled, or continues to wrestle, with these issues whilst
often affecting little practical progress or change. Indeed, Kahlke et al. (2020) note
that there is often a disconnect between ‘knowing and doing’ in health professions
education. In this book, we explore, explain, and apply philosophical concepts to
contemporary issues or areas of interest within health professions education to help
educators think about the structure and dynamics of said issues. As Midgley (2018)
suggests, philosophy is:
all about how to think in difficult cases – how to imagine, how to visualise and conceive and
describe this confusing world… in a way that will make it more intelligible as a whole. (50)
4 M. E. L. Brown et al.

In other words, not only is philosophy “thinking about thinking” (Honderich 1995),
but it is particularly so in regard to difficult cases that promote an understanding that
acts as a basis for action. As a practically pitched overview, we hope you will agree
that this book offers an accessible entry-point to philosophy for health professions
practitioners, educators and researchers—translating “knowing” to “doing”. This is
what we mean by applied philosophy—it is a bridge between the practical concerns of
health professions education as an educational field, and the broader, more conceptual
and foundational questions that flow beneath the surface of all we do. As with building
a physical bridge, our metaphorical bridge building will take time, resources, and
collaboration. Though this book begins a conversation, it lays only the foundations
for the bridge’s construction. An applied philosophy for health professions education
is very much in its infancy, though we hope this book is a starting point in progressing
this type of thinking about thinking. To begin to build a bridge between practice and
philosophical concepts in our field, in this book we offer insight regarding how to
think about difficult cases or topics the field has struggled with. In doing so, we
focus on the practicality or praxis of philosophy to research and educational strategy
within the field, offering guidance regarding how to manage the transition from
philosophical reflections to practical pedagogy.
This book is not exhaustive. Whilst, as discussed, herein we lay the foundations
for a bridge between philosophical concepts and practice within health professions
education, there is much beyond these initial building blocks that we could have
included. Our selection inevitably reflects our own backgrounds, experiences, and
perspectives. Though we aim to speak to the field of health professions education
(and, indeed, have endeavoured throughout to make clear applications that we believe
transcend professional boundaries), all three editors are most closely associated with
medical education. In addition, all three editors are based in the Western hemisphere.
This book, perhaps, would be best framed as an applied philosophy for Western
medical education. We hope further articles, books, and volumes, may explore appli-
cation and different philosophical approaches relevant to non-Western settings. In
selecting our chapter topics, we considered the field of health professions educa-
tion, discussing where we saw there to be gaps or ‘absences’ (Paton et al. 2020)
which might benefit from exploration through philosophical lenses. For example,
Chapter 16 considers ‘Green Bioethics’, applying bioethics to the issue of climate
change and planetary health within health professions education. Bioethics is much
broader than this, as the chapter author Richie demonstrates through her historical
overview of bioethics at the beginning of the chapter. Yet, we perceived climate
change and climate change education as outstanding and urgent issues in our field
that might benefit from thorough dissection from a bioethics standpoint. Others may
see different gaps or absences than we have—we welcome such discussions, as it is
this type of critical engagement that will advance our plight for an applied philos-
ophy for health professions education. As you read, we encourage you to reflect on
whether you agree with the gaps or absences we have identified and solicited chapters
to consider. If not, what would you do differently, or add? Tell us—engage the health
professions community with your thoughts of applied philosophy for the gaps you
see. This is how we can generate new philosophical ideas in our field.
1 Philosophy as Praxis 5

This book is a journey towards mutual understanding. By this we mean the

drawing together of students, practitioners, educators, researchers, and philosophers
to develop a new way of thinking about contemporary issues within health profes-
sions education. We have tried to balance these voices within each chapter, creating
author teams with varied backgrounds, experiences, and practice. In doing so, each
chapter constitutes a conversation between the theoretical and the practical from
those engaged in this dialogue. As you will see, some chapters are more conceptual
in nature, as they are concerned with offering overviews of whole disciplines of
practice and knowledge (e.g., Chapter 17 considers the Philosophy of Technology),
whereas some chapters lean more towards application (e.g., Chapter 19, which applies
insights from Chapter 17 to the sticky technological issue of social media).
Though the structure of each chapter varies—some include case studies, others
offer a historical timeline of philosophy as it pertains to a particular focus or area of
study—each chapter is structured so that it concludes with five practice points for
practitioners, educators, and researchers. These practice points represent the culmi-
nation of our attempt at creating an applied philosophy for health professions educa-
tion based on the more conceptual, theoretical, or historical explorations embedded
in each chapter. We would encourage readers to pause and reflect on the potential
significance of these practice points to their own day-to-day work as practitioners,
educators, or researchers. We hope, through such reflection, you find use for our
authors’ recommendations. In doing so, we, as a community, enact the ‘applied’ part
of our applied philosophy for health professions education. Without your action,
the applied philosophy that has begun to take shape through this volume remains
illusory.
You may read this book as you see fit, but, as editors, we have some suggestions
as to how might approach this volume. For those seeking in-depth immersion in
applied philosophy for health professions education, we suggest you read this book
in chronological order. Instead of grouping the chapters by topic or philosophical
approach, we have intentionally grouped them in a kind of narrative, or journey, that
we hope to be supportive of a question or area of interest that you may have in relation
to health professions education. We will show an example of how one could take
an issue such as ‘autonomy’ through the chapters in Chapter 25 where we offer our
concluding thoughts. We hope that this suggestion of choosing one or more areas of
your own interest and reading the chapters in order with that in mind will offer new
philosophical and practical angles on what matters most to you in your profession
or education.
We speculate this approach may be most appropriate for postgraduate students
in health professions education research e.g., Master’s level and PhD students. You
may not have the time to dedicate to reading the book in this way. Indeed, there may
only be a select few chapters you believe to be relevant to your practice (though we
would suggest that you may find chapters you thought were not strictly relevant to
your practice may help you look at your practice in unique and surprising ways). For
those with less time or a specific focus, each chapter may also be read in isolation,
though, as you read, it will become apparent that many of the chapters in this book are
connected. Even if you are only interested in learning more about applied philosophy
6 M. E. L. Brown et al.

as it pertains to, say, social justice within health professions education (Chapter 9),
you would be best placed at least also reading the chapters which connect to your
primary chapter of interest. We have signposted these connections in the text of each
chapter.
We would like to conclude our introduction with another quote from Midgley that
we hope you will take as a guiding light in reading this volume. Below, Midgley
compares philosophy to plumbing to stress its necessity and inherent practicability.
As you read this book, we encourage you to picture philosophy and its need in our
field thusly:
Is philosophy like plumbing? I have made this comparison a number of times when I have
wanted to stress that philosophising is not just grand and elegant and difficult, but is also
needed. It is not optional… Plumbing and philosophy are both activities that arise because
elaborate cultures like ours have, beneath their surface, a fairly complex system which is
usually unnoticed, but which sometimes goes wrong. In both cases, this can have serious
consequences. Each system supplies vital needs for those who live above it… conceptual
confusion is deadly, and a great deal of it afflicts our everyday life. (139–142)

References

Allen, David, Mark Penn, and Lois Nora. 2006. “Interdisciplinary Healthcare Education: Fact or
Fiction?” American Journal of Pharmaceutical Education 15 (2): 70.
Berlin, Isaiah. 1999. “The Purpose of Philosophy.” In Concepts and Categories: Philosophical
Essays. Princeton: Princeton University Press.
Buckingham, Will. 2011. The Philosophy Book. London: Dorling Kindersley.
Deleuze, Gilles, Guattari, F. 1991. What is philosophy? Columbia University Press.
Hautz, Wolf E., Gert Krummrey, Aristomenis Exadaktylos, and Stefanie Hautz. 2016. “Six Degrees
of Separation: The Small World of Medical Education.” Medical Education 50 (12):1274–1279.
Honderich, Ted. 1995. The Oxford Companion to Philosophy. Oxford: Oxford University Press.
Kahlke, Renate M., Meghan M. McConnell, Katherine M. Wisener, and Kevin W. Eva. 2020.
“The Disconnect Between Knowing and Doing in Health Professions Education and Practice.”
Advances in Health Sciences Education 25 (1): 227–240.
Laskowski-Jones, Linda. 2016. “Interdisciplinary Education: Learning Together from the Same
Playbook.” Nursing 46 (4): 1–6.
Midgley, Mary. 1992 “Philosophical Plumbing.” Royal Institute of Philosophy Supplements 33:
139–151.
Midgley, Mary. 2018. What Is Philosophy For? London: Bloomsbury Publishing.
Morley, Lyndon, and Angela Cashell. 2017. “Collaboration in Health Care.” Journal of Medical
Imaging and Radiation Sciences 48 (2): 207–216.
O’Sullivan, Patricia, Hugh Stoddard, and Summers Kalishman. 2010. “Collaborative Research in
Medical Education: A Discussion of Theory and Practice.” Medical Education 44 (12): 1175–
1184.
Paton, Morag, Ayelet Kuper, Elise Paradis, Zac Feilchenfeld, and Cynthia Whitehead. 2020. “Tack-
ling the Void: The Importance of Addressing Absences in the Field of Health Professions
Education Research.” Advances in Health Sciences Education 26 (1): 5–18.
Raphael, D. D. 1994. Moral Philosophy. Oxford: Oxford University Press.
Rotgans, Jerome I. 2012. “The Themes, Institutions, and People of Medical Education Research
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Education 17: 515–527.
1 Philosophy as Praxis 7

Veen, Mario, and Anna T. Cianciolo. 2020. “Problems No One Looked For: Philosophical
Expeditions into Medical Education.” Teaching and Learning in Medicine 32 (3): 337–344.
Wilson, John. 1986. What Philosophy Can Do. London: Macmillan Press.
Chapter 2
Philosophy of Education: Towards
a Practical Philosophy of Educational
Practice

Wouter Pols and Joop Berding

2.1 Introduction

Like health care, education is not a thing, but an activity. Educational activities take
place within institutional frameworks of practices, such as schools, day care centres,
children’s homes, youth clubs, and families. But what does ‘educational practice’
mean? It is a practice of child rearing, upbringing, and teaching in which educators
interact with children and young people with the intention of helping them grow
up. Growing up is not so much attaining an adult status, but concerns becoming
acquainted with the world in which one lives and taking responsibility for what one
does in that world. Taking responsibility is not an activity that can be produced in a
child or adolescent by an educator, and neither can that child’s activity of becoming
acquainted with the world. An educator can help children and young people to attain
these activities—they can show them how to do it, invite them to act, but they cannot
do it for them; children and young people must become acquitted with the world and
take responsibility by themselves. Education always implies self-formation. Without
the self-activity of children and young people, education can never succeed.
Nowadays, educational practices are informed by very different theories: psycho-
logical, sociological, economic, managerial theories, and so on (cf. Bartlett and
Burton [2006] 2016). Education is no longer studied from a single angle; current
educational practices are studied through a multidisciplinary lens. The theories that
inform educational practice describe and explain the educational process from the
perspective of the discipline they stand for. So, today, there are many descriptions
and explanations of the processes that take place in the field of education. Within

W. Pols (B) · J. Berding

Rotterdam University of Applied Sciences, Rotterdam, The Netherlands
e-mail: wouterpols1@gmail.com
J. Berding
e-mail: jwa.berding@ziggo.nl

© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2022 9
M. E. L. Brown et al. (eds.), Applied Philosophy for Health Professions Education,
https://doi.org/10.1007/978-981-19-1512-3_2
10 W. Pols and J. Berding

this multidisciplinary approach, there is one discipline that distinguishes itself from
the other disciplines: philosophy of education.
Philosophy does not describe and explain processes as other disciplines that inform
education do; it is not focused on the functioning of processes, on cause-and-effect
relations. Instead of that it clarifies and tries to understand the meaning of education.
The philosophical focus is a focus on concepts. The intention of philosophy is to
open a field of thought through the concepts it develops. Philosophy of education
presents concepts that allow child rearing, upbringing, and teaching to appear as an
educational practice. This chapter deals with philosophy of education as a philosophy
of educational practice.
In Sect. 2.2, we consider some examples of thinking regarding education in the
history of philosophy, latterly describing the rise of philosophy of education in the
last century. In Sect. 2.3, we give some examples of different philosophy of educa-
tion positions, not only those with roots in the English-speaking world, but also
from the non-English speaking world. Later, in Sect. 2.4, we focus on the practical
philosophical concept of pedagogy as it was developed by the French educationalist
Philippe Meirieu. Finally, in Sect. 2.5, we describe similarities between the educa-
tional and health professions, and the importance of a practical philosophy for these
professions.
Before we progress further, there is something important we must clarify. Even
though philosophy of education is about the education of children and not yet
grown-up young people, certain views may be important for professionals working
with grown-up students in health professions education. Where that is the case
(particularly within Sect. 2.4), we will clearly highlight this applicability.

2.2 Philosophy and Education

Growing up is a social and cultural phenomenon. One needs fellow human beings
to become a grown-up person, humans who point to, who show, who indicate the
direction one should go, and help and support one in doing so.
When societies develop, people start to think about how this process of growing
up should take place.

2.2.1 Plato and Aristotle on Education

In the Athenian society of the fifth and fourth century BCE, education was one of
the topics of what the Athenians called philosophy, literally: desire (philein) for
knowledge and wisdom (sophia). We find in the work of Plato (427–347 BCE) and
Aristotle (384–322 BCE) several places where education is discussed. For both,
politics and education are closely related. Plato was a more elitist philosopher than
Aristotle. In his The Republic, he describes the education he wants to give to the best
2 Philosophy of Education … 11

among the young male Athenian citizens, the ones that are the best suited to it. The
intention was that they would later lead the state. Aristotle, on the other hand, did not
differentiate between the male citizens of Athens. All free male citizens should be
able to achieve a happy and virtuous life. That life isn’t a life in isolation, it is a life
of togetherness, a life of acting together. This implies a crucial educational task with
important political implications. A state where humans can reach their destination of
a happy and virtuous life will be a strong state as it is a state supported by happy and
virtuous people. Virtue requires a guideline. In his Politics Aristotle ([335/323 BCE]
1990) writes: “There are three things which make men good and virtuous; these
are nature, habit and rational principle” (40). He states that these things must be in
harmony with one another. To put them into harmony requires not only knowledge,
but also wisdom; so, philosophy as the source of knowledge and wisdom provides
the guideline, both in politics and education.
Nature, habit, and ‘the rational principle’ are the basis of education in ancient
Greece. Educators have to consider the nature of the child they are educating, help
them to develop good habits and, by helping them to master the essentials of Greek
culture, to develop not only physically and musically, but also intellectually, and
morally. In Greek education, the emphasis was on what the educator does. But
the activities of the child or young person are rarely mentioned. There is only one
exception: Plato’s description of the dialogues Socrates had with Athenian citizens,
including young men. Especially in the early dialogues, Socrates tests the ideas and
beliefs of his interlocutor; by doing this, he challenges the young man he talks with to
think for himself, or in other words: to put the—according to Plato, innate—rational
principle into practice. Here comes into existence what we call ‘self-activity’ today.
In the history of philosophy, it is a very long time before educators emphasize self-
activity as a crucial educational act. The French writer Michel de Montaigne (1533–
1592) does so in one of his Essays (‘Of the Education of Children’, [1580] 2007) ,
almost two thousand years later: “I would not have [the teacher] start everything and
do all the talking but give his pupil a turn and listen to him” (55).

2.2.2 Rousseau and Kant on Education

The philosopher who really put self-activity in the spotlight was the Geneva-born
Jean-Jacques Rousseau (1712–1778). In his philosophical novel, Emile, or Educa-
tion, he describes the development of a young boy (Emile) into a grown-up man. The
development seems automatic; Rousseau describes it as a natural process. Emile is
all self-activity. He feels free; through the activities he undertakes freely, and the
experiences gained, he develops. Rousseau ([1762] 1921) writes:
Let [your pupil] always think he is master while you are really master… No doubt he ought
only to do what he wants, but he ought to want to do nothing but what you want him to do
(84–85).
12 W. Pols and J. Berding

Rousseau takes nature as a guideline for Emile’s education, for him nature is the basis
of what Aristotle called the rational principle. He organizes Emile’s environment in
such a way that he can develop naturally. The environment shapes his habits, and
through what he undertakes and experiences, he masters the essentials of culture, he
learns to read, to write, and to calculate, and to orient himself in time, place, and
space. Subsequently, he becomes capable of distinguishing good and evil. He learns
it all by himself, as a self-active young man, but it is Rousseau who encourages him
to do so, by engaging him in situations that provoke all these learnings.
As is the case with Plato and Aristotle, for Rousseau, too, education and politics
are closely related. A democratic society in which people can live as free citizens—
Rousseau describes this society in his The Social Contract—, needs people who are
educated as free humans. The Emile is the pedagogical counterpart of the political
The Social Contract.
The great German philosopher Immanuel Kant (1724–1804) was impressed by the
Emile. It is said that he forgot his daily walk when he was reading the book. Rousseau
taught that humans are corrupted by society; on the other hand, Kant ([1784] 1963)
said that they are made of ‘crooked wood’ out of which ‘nothing perfectly straight
can be built’. Humans are imperfect. They should be aware of that: they need to
know what exactly they can know, must do, and may hope. That is why humans
need education. Kant recognizes the importance of discipline; it can result in what
the Greek called good habits, but discipline is not yet education. Education requires
self-activity; its intention is to make free. Freedom does not mean doing what you
want. Freedom requires the recognition of a super-individual, rational law to which
humans measure their actions. That must be taught and can’t be without restraint,
Kant argues. In his lecture on education he states:
One of the greatest problems of education is how to unite submission to the necessary,
restraint with the child’s capability of constraint moral exercising his freewill – for restraint
is necessary. How am I to develop the sense of freedom in spite of the restraint? (Kant [1803]
1900, 27)

Rousseau hid this question behind the educational environment where Emile grew
up. Kant made this question the crux of education.
Even when confronted with this major problem, Kant still expects a lot from
education. He does not believe that by following the law of nature humans could
improve themselves. Improving themselves, however, is a human’s most important
task. Kant hopes that generation after generation humanity will get better. In addition
to this, education is not only the link between the generations, but also the lever for
improvement. Cultivation, civilization, and moralization are the necessary steps to
take in education. It is through the step of moralization that humans make themselves
free. So, unlike Rousseau, it is not by following the law of nature within Kant’s
philosophy that frees humans, but the rational principle mentioned by Aristotle, long
ago.
2 Philosophy of Education … 13

2.2.3 Dewey on Education

For Kant, the older generation’s task is to educate the younger in such a way that
they could become cultivated and civilized, but, above all, become moral and free
humans. One could say that education is a certain kind of intergenerational communi-
cation. The North American philosopher John Dewey (1859–1952) would agree (for
detail on Dewey’s other work see Chapter 17, which considers Dewey’s pragmatist
philosophy of technology). One hundred and thirty years after Kant’s lectures, he
writes in his Democracy and Education ([1916] 1966) “all communication is educa-
tive” (5). Dewey considers the cultural processes that take place between people as a
process of interaction. In such a process, mutual adjustments take place. Such adjust-
ments lead to shared experiences. For Dewey, these experiences are crucial; they not
only bring people together, but also create a common world. He writes: “Commu-
nication is a process of sharing experience till it becomes a common possession. It
modifies the disposition of both the parties who partake in it” (9). What Kant calls
cultivation, civilization, and moralization are nothing but different forms of commu-
nication. These super-individual forms, which could be compared with Kant’s super-
individual, rational law cannot exist without the self-activity of the participants—of
the educator, but foremost of the one who is educated: the child or adolescent: “Edu-
cation is not an affair of ‘telling’ and being told, but an active and constructive
process” (38). Such a process allows children and young people to break their habits,
acquire new knowledge and skills, and relate to their fellow human beings in a new
way, perhaps a morally more considered way. We speculate the same may be true of
educators invested in this process.
Aristotle considered nature, habit, and reason (the rational principle) as the crucial
elements of education. We conclude that he was right. In the history of educational
thinking those core elements appear in new configurations time and time again.

2.3 The Rise of Philosophy of Education

In the Western world, whilst the importance of education increased in the nineteenth
century it truly amplified in the 20th. Education Acts were introduced, new schools
were set up, teacher training was improved, and the first chairs of pedagogy were
established at universities.

2.3.1 Pestalozzi, Herbart, and a Practice-Based School

Pedagogy

The educational ideas that had developed over centuries and were given new forms in
the second part of the eighteenth century, spread across Europe and North America.
14 W. Pols and J. Berding

The German-speaking countries played a major role in this. In Switzerland, Johann

Heinrich Pestalozzi (1746–1827) developed a pedagogy focused on head, heart,
and hand aiming “to forge oneself through his own work” (Pestalozzi [1797] 1968,
98). He was inspired by Rousseau; he wrote about education, but besides his writing
he set up different educational institutions where he put his pedagogy into practice.
In Germany, Johann Friedrich Herbart (1776–1841) developed—partly in discussion
with Kant—a ‘pedagogical science’, twenty years later. Herbart met Pestalozzi in
Switzerland. There, he started as a tutor, but soon he went back to his homeland
and became a professor in philosophy and pedagogy. The purpose of education was,
according to him, to form a moral and many-sided character. To this end, education
must provide the right mental representations, both in culture and nature. Pestalozzi’s
and Herbart’s ideas became the leading pedagogical ideas in the nineteenth century,
over Europe and North America, the former in the first part of the century, the latter
in the second.
At the end of the nineteenth century, a movement of educational renewal emerged,
emphasizing child’s activity, aimed at gaining and sharing culturally determined
experiences. Many people, practicians, and theoreticians joined this movement.
Dewey, who put his ideas into practice in his Laboratory School, was one of them.
All those ideas entered the school, through training, through individual teachers who
tried to change school practice, and through newly established schools that put a new
pedagogy into practice. It led to several new practice-based school pedagogies.

2.3.2 The 20th Century and the Rise of Philosophy

of Education

The twentieth century brought new changes. Compulsory education was introduced
throughout the Western world. Education became a human right. Over the century
education was gradually extended, becoming longer and longer. New social sciences
such as psychology, sociology, economics emerged that started to investigate human
activities, including educational activities. Contrary to philosophy, they did not focus
on the meaning and purpose of the activities, but on the functioning of the processes
that would determine them. During the twentieth century, education increased in
importance. Now, school was important not only for the intellectual and moral devel-
opment of new generations, but for the development of a country’s economy. Policy
makers began to emphasize learning outcomes. As a result, teachers were subjected
to ever higher demands. No longer were they trained at normal schools or stand-alone
teacher colleges, but at universities. There, they were introduced to the results of the
now emerged social sciences. These sciences began to prescribe certain approaches,
stating that certain skills were necessary to obtain desired outcomes. The image of
practice was no longer determined by a practice-based school pedagogy, but by a
multidisciplinary field of research results that provided prospective teachers with the
necessary knowledge and skills to act as able educational professionals.
2 Philosophy of Education … 15

The contribution of the social sciences to teacher education provided a new view,
not only of educational practice, but also of the teacher within this practice. The
social sciences describe how development and learning processes proceed, how such
processes can best be managed and what resources can be used to achieve certain
goals. But they do not describe the educational meanings of what one is doing, the
educational aims one pursues, what is at stake when one is teaching. The social
sciences cannot do that; philosophy can do it. With the rise of the social sciences
within the field of education a new branch of philosophy arose named philosophy
of education. In the English-speaking countries this new branch focused initially
on clarifying the concepts used in the educational field: ‘education’, ‘development’,
‘curriculum’, ‘teaching’, and so on (cf. Hirst and Peters 1970). The method used was
that of language analysis. But soon, concepts of philosophy were used to shed new
light on educational processes. In the 1960s, one of the most prominent philosophers
of education in the English-speaking world, Richard Peters (1919–2011), introduced
Ludwig Wittgenstein’s (1889–1951) concept of initiation into the philosophy of
education. Following him, he stated that “education… has to be described as initiation
into activities or modes of thought and conduct that are worthwhile…” (Peters [1966]
1970, 55). Concepts of other philosophers were also introduced: concepts of Hannah
Arendt (1906–1975), Emmanuel Levinas (1906–1995), Jacques Rancière (1940),
and many others. Arendt enriched the philosophy of education with the concept of
‘to introduce into the world’, Levinas with ‘the face of the Other’, and Rancière with
‘the equality of intelligence’. Each of these concepts sheds new light on education,
but by doing so, it also calls into question existing educational practices. Nowadays,
philosophy is no longer just a clarifying and ‘meaning-producing’ discipline; it also
is a critical discipline. Its intention is more and more to encourage us to start ‘thinking
again’ (Blake et al. 1998), aimed not only at prospective teachers, but at everyone
involved in education, teachers in practice, managers, and policy makers.

2.3.3 The Intellectual ‘Home’: Discipline or Educational

Practice?

Today, philosophy of education is an important discipline within the field of sciences

that deal with education. It is a discipline with its own voice: a critical voice aiming at
meaning and purposes. From different philosophical perspectives, it focuses not only
on various educational target areas, but also on the different parts of the broad field of
contemporary education (Blake et al 2003; Siegel 2009; Smeyers 2018). Despite the
large differences between sciences dealing with education and philosophy of educa-
tion, there is also a similarity: the intellectual ‘home’. This home is the discipline,
for instance psychology, sociology, or economics, and—concerning philosophy of
education—philosophy (Biesta 2012). The home is not the practice of education.
The practice is the object of study, the object investigated by different sciences and
to which philosophy applies its concepts. It is approached from the outside, and not
16 W. Pols and J. Berding

approached as a practice with its own ‘dignity’, a practice with inherent meanings,
purposes, and principles.
However, there are exceptions to the above-described dominant view. Even in
English-speaking countries where this is particularly the case, there are exceptions,
for example the work of the North American David Hansen (1952). Contrary to the
dominant view, the ‘home’ from which Hansen departs is not that of philosophy, that
of the discipline, but that of educational practice. So does the Dutch-born Gert Biesta
(1957). Hansen’s starting point for his reflections on education is what teaching means
for teachers and the goals they pursue in educational practice (cf. Hansen 1995); and
Biesta’s starting point for thinking through the concepts he uses—concepts he derives
from various philosophical resources—is also, like Hansen, the inherent meaning
and purpose of educational practice (cf. Biesta 2014). There are more exceptions
to this dominant view, notably in the German-speaking countries and in several
neighbouring countries, like Scandinavia, the Netherlands, Belgium, and France
(Biesta 2011).

2.3.4 Pedagogy as Part of the Humanities

As we have seen, Germany played an important role in spreading pedagogical ideas in

the nineteenth century. This was not only done by newly established educational insti-
tutions where innovative practices took place, but also by universities. In Germany,
the first chair of pedagogy was established in 1778, in Halle. Herbart was a professor
in philosophy but also in pedagogy, from 1802, first in Göttingen, later in Königsberg.
He gave lectures on pedagogy, but also acted as teacher educator in the experimental
school that was affiliated with the university. In Germany, educational theory and
educational practice were closely related from the beginning. Pedagogy (in German:
Pädagogik) means not only the theory of education, but also the practice of it. Peda-
gogy as it developed in Germany from the end of the nineteenth century, uses, as
part of the humanities, philosophical methods (phenomenology and hermeneutics)
to investigate educational practice. Even though the influence of social sciences in
educational research dominates nowadays, the philosophical inspired, humanities
research approach to the study of education remained in Germany, and in some other
countries as well.
After the Second World War, a phenomenology-based pedagogy was developed
in Germany and the Netherlands. The Dutch educationalist Martinus Langeveld
(1905–1989) states in his Beknopte theoretische pedagogiek [Concise Theoretical
Pedagogy] ([1945] 1971):
We wish to analyze [the educational] phenomenon only as such for now. We do want to
interpret it from another source than from itself… we start in a phenomenological way (29).

Langeveld starts his investigation from educational practice itself, from the experi-
ences of the educators in the educational field and the ones they educate. By inves-
tigating these experiences in a phenomenological way, unprejudiced, he achieves
2 Philosophy of Education … 17

insight in what education is all about: bringing children and young people to grown-
up-ness, but at the same time considering their desire to be someone themselves.
Although phenomenological pedagogy disappeared in the Netherlands after the
1990s, it persisted in Germany, where it has flourished in recent years (cf. Brinkmann
et al. 2017). By way of the Dutch-born Max van Manen (1942), it was spread in
Canada and the United States (Van Manen 2015; Friesen et al. 2012).
The hermeneutic-based pedagogy also persisted in Germany. In his Forgotten
Connections (2014), translated into English, Klaus Mollenhauer (1928–1998) inves-
tigates the ‘becoming’ of current educational practices. Using pictures, all kinds of
texts, including experiences put in writing, he reconstructs the basic structure of
educational practice. According to him, this structure consists of two pairings: the
first of presentation and representation, the second of Bildsamkeit and self-activity.
The first has to do with the fact that educating implies becoming acquainted with the
world. To achieve grown-up-ness, children and young people need educators who
show them the world. This can be done directly by presentation and indirectly by
representation, through artifacts and symbols. The second concerns the educator’s
view of the child. Only if the educator considers children and young people as
bildsam, as humans that have the capacity to form themselves, and challenges them
as self-active humans to do so, can they achieve grown-up-ness. Langeveld would
entirely agree.
German pedagogy considers theory and practice as closely linked. In education,
practice cannot exist without theory, neither theory without practice. Educational
practices are cultural-historical practices where theories and practices continuously
influence each other. We still find ways of doing and thinking from the past in current
practices. The question is what educators today find worthwhile. In what way do they
intend to continue the historically grown practice? Mollenhauer (2014) writes:
Children should be brought up not as if they were [simply] material to be changed and formed.
Instead, they should be raised in support of a kind of power and potentiality that develops
itself, in a dialogical relationship, in a kind of mutual interchange or call and response (93).

2.4 Philosophy of Education as a Theory of Practice:

Meirieu’s View

In Herbart’s first lecture in 1802, he makes a remarkable statement: “First, let’s

distinguish pedagogy as science from the art of upbringing’ (Herbart [1802–1832]
1986, 55). Science as theory is general, practice is individual. That is why theory is
always “too much and at the same time too little” (ibidem). There is a gap between the
more general theory and the more individual practice. According to Herbart, practice
needs ‘tact’; this can only be achieved by doing and reflecting on what one does in
practice. That’s not saying theory is not important. It is important, in preparation for
practice and reflection on practice. In the introduction of his Allgemeine Pädagogik
[General Pedagogy] from 1806, Herbart speaks about theory as a map. The map
18 W. Pols and J. Berding

allows the educator to determine their direction, but also helps them find the way
they want to go and to reflect on the results of it.

2.4.1 Meirieu’s Pedagogy as a Map

The French educationalist Philippe Meirieu (1949) affirms Herbart’s stance of peda-
gogy as a map. For him, pedagogy is an ‘educational doctrine’ that consists of loose,
heterogeneous elements, “a number of reflections and ideas” that enable the educator
“to take on a pedagogical challenge” (Meirieu 2004, 136). Pedagogy is a practical
theory, an ‘in-between theory’, between sciences and philosophy on the one hand,
and on the other hand practice, and the experiences gained there. It is, indeed, a map
to orient on educational practice, and to reflect on the gained experiences.
At the most basic level, educators should make the map by themselves. The starting
point of the map is not science, nor philosophy; it is practice, more precisely: the resis-
tance of the child or adolescent that the educator experiences. Meirieu speaks about
‘a pedagogical moment’. According to him, the heart of such a moment is resistance;
it’s the moment that the educator experiences that a child or adolescent escapes their
power (Meirieu 1995). The child or young person has their own will. During such
a moment, the educator experiences that children and young people aren’t objects;
they are subjects; they have, as Langeveld said, the desire to be someone themselves.
That is an experience-based, pedagogical fact. But that fact does not absolve the
educator of the responsibility to introduce children and young people into the world
and help and support them as self-active young humans to grow up, and achieve
grown-up-ness.
In his Le choix d’éduquer [The Choice to Educate] (1991), Meirieu states that
the act of education is based on a choice. It is a choice for the child as subject. In
education, the crucial question is always: “Do I allow the other, the one in front of
me, to be a subject, even if it goes against me?” (12). For Meirieu, the educator is able
to say ‘yes’ to this question because they believe in a child’s educability. They does
so, because they are convinced of the child’s inherent capability to form themselves,
convinced of what the Germans call Bildsamkeit. Based on this conviction, Meirieu
argues that the fundamental task the educator stands for is twofold: to call the child
as subject into presence, and to provide them with the cultural tools, and help to use
them, to be able to inhabit the world in which they live.
A teacher, who is always an educator as well, can only accomplish this task
within an educational safe space. A school should be a safe place where children and
young people can communicate and gain experiences with the cultural tools they are
offered. Safety requires a law to which all participants measure their actions. This
law functions as a ‘third party’ and positions one against the other. Within such a
safe space children and young people can appear as subjects and learn to work with
the cultural tools offered them. At the same time, it is a place where they learn to live
together. School is a form of community life, as Dewey said, a mini society where
2 Philosophy of Education … 19

citizenship is learned (Meirieu 2004). The other fundamental task of an educator or

teacher, respectively, is to install such a safe place, a safe mini society.
Here we can learn lessons for the education of health professionals. Here too, self-
activity and confidence in the student’s Bildsamkeit is crucial. Only if the health care
student is addressed as a subject, is challenged as a subject to pick up medical tools
and challenged to work with them, can they become a responsible health professional.
That is only possible if the place in which health professions education takes place is
a safe place in which students can make mistakes and can learn from their mistakes.
The place where health care education takes place should be a place of professional
togetherness, a place where the professional attitude of healthcare workers is put into
practice daily, by professional health professions educators firstly, and, following
their educators, by students.

2.4.2 A Situated Philosophy

Back to Meirieu’s pedagogy. The pedagogy he puts into practice can be called a “situ-
ated philosophy” (Burbules 2018, 1424). It is a practical philosophy. Like philosophy
of education, it generates meanings and indicates purposes. Above all, however, it is a
practical philosophy through the concepts it proposes; these concepts make practice
appear as an educational practice that challenges the educator to act. Meirieu’s prac-
tical philosophy does not give clues and hints, it points, from the concepts presented,
in a direction, ways to go, to special points to notice, to obstacles to overcome. It
is indeed a map, a map to orient oneself, to determine one’s direction, to find one’s
way, to help to make decisions.
You may have noticed that Meirieu’s practical philosophy is part of a long-standing
philosophical and pedagogical tradition. Concepts of many philosophers and peda-
gogues can be found in it. They form a loose network together; they are the conceptual
crossroads on a pedagogical map. For example, self-activity, Bildsamkeit, and the
law as ‘third party’. All kinds of other forms of knowledge, practical and theoretical,
can be connected to it. Meirieu does so, but he also challenges the user to do it them-
selves. And that is indeed also an educational task: to elaborate the maps educators
are working with based on the experience they are gaining in the educational field.

2.5 Some Final Remarks on the Similarities Between

the Healthcare and Educational Professions

Despite differences in training and work, there are striking similarities between the
health and educational professions. Both professions exist by the grace of rela-
tionship. Health professionals such as doctors, nurses, and therapists work with
20 W. Pols and J. Berding

Table 2.1 Practice points

Health professions educators should be aware of the importance of:
1 Philosophy within health sciences
2 ‘Situated philosophy’ as orientation aid (map) to professionals in health care practice
3 Trust in students’ capability to form themselves
4 Self-activity
5 A safe place to be educated in

people, that is also the case with educational professionals such as teachers, child-
care workers, and coaches. Both professions are informed by a wide field of scien-
tific disciplines. Today, both the practice of health care and education are viewed
through a multidisciplinary lens. However, sciences describe and explain, but do not
describe the meaning of what takes place in healthcare practices, nor what the ulti-
mate purpose of it is. Education pursues grown-up-ness, health care pursues health.
But what do these terms mean? Science can’t answer this, but philosophy can. That is
why within the field of health professionals—as with the educational professionals—
science needs to be supplemented with philosophy. But don’t they need a practical
philosophy as well? A situated philosophy of healthcare situations? Don’t doctors,
nurses, and therapists need maps, too? Maps to orient themselves, to determine their
direction, to find their way, to help to make decisions.
Further, what of the healthcare professional who educates prospective healthcare
professionals? What else can they learn from philosophy of education? To reiterate
our earlier discussion, we believe that they may learn the importance of trust in a
student’s capability to form themselves, the importance of self-activity, and of a safe
place to be educated in (Table 2.1).

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Chapter 3
Subjectification in Health Professions
Education: Why We Should Look
Beyond the Idea of Professional Identity
Formation

Simon Verwer and Marije van Braak

3.1 Introduction

The relation between teaching and learning in health professions education is a

complex one. Thinking about health professions education from an educational-
philosophical outlook in a recent article, Biesta and van Braak (2020) critiqued what
they called a common way of thinking about health professions education: teaching as
an intervention that causes learning. The article’s central argument that health profes-
sions education, and, more specifically, medical education (still) (too much) relies
on this assumed causal relation between teaching and learning, has induced many
reactions in the field. Medical teachers and researchers across different disciplines
have stated that this is not (anymore) an accurate description of how the field views
teaching and learning.1 Yet, in health professions education literature, the discourse
that we use to describe teaching points in the contrary direction. For one, the way we
construct and research curricula (in terms of learning goals, related key activities, and
how teachers can contribute to those), shows how interrelated teaching and learning
are assumed to be. Further, although health professions education research may have
moved away from linear notions of causality, in practice, ‘evidence-based’ still func-
tions as a marker of quality which drives curricula towards somewhat generalized
assumptions about how education ‘works’.

1Interested readers can tune in to the discussion, at https://keylimepodcast.libsyn.com/episode-298

and https://twitter.com/MarioVeen/status/1353974383128289280?s=20.

S. Verwer (B)
Amsterdam UMC, Amsterdam, The Netherlands
e-mail: s.verwer@amsterdamumc.nl
M. van Braak
Erasmus Medical Centre, Rotterdam, The Netherlands
e-mail: m.vanbraak@erasmusmc.nl

© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2022 23
M. E. L. Brown et al. (eds.), Applied Philosophy for Health Professions Education,
https://doi.org/10.1007/978-981-19-1512-3_3
24 S. Verwer and M. van Braak

These descriptions of health professions education correspond to what the

educationalist Gert Biesta has described as learnification (Biesta 2010):
…the redefinition of all things educational in terms of learning – such as calling students
learners, calling schools learning environments or places for learning, referring to adult
education as lifelong learning, and seeing teachers as facilitators of learning. (Biesta 2019,
549)2

In short, learnification is the refocusing of education from teachers and the curriculum
to learners and their learning (Biesta 2020b).
A conceptual area within health professions education where learnification
becomes visible is that of Professional Identity Formation (PIF). PIF is a well-
researched and commonly applied concept that describes the process of becoming a
healthcare professional, such as a doctor, i.e., developing a professional identity. The
use of PIF in health professions education is tied to the dominance of the language of
learning: it entails a focus on what the learner needs to do, experience, and develop
to become an established member in the field of practice (e.g., Cruess et al. 2019).
This focus may have diverted attention from other concepts that describe aspects of
a person’s formation as a professional.
In this chapter, we focus on one such concept: subjectification. Subjectification
is one of the domains of purpose proposed by Biesta and van Braak in their alter-
native view of health professions education. It describes the process of appearing
as a subject (Biesta 2010)—an utterly relevant process in the context of forma-
tion of a professional self, since it draws attention to the subjectivity of the person
whose professional identity is formed. In the following sections, we will explore
the relation between PIF and subjectification, and describe how subjectification can
be of additional value in health professions education. To do so, we first formulate
a consensus about PIF in the current health professions education literature. Next,
we argue why medical educators might want to look beyond PIF towards subjecti-
fication by contrasting the concepts in three respects: (1) as different approaches to
the matter of existence (psychological versus philosophical); (2) in their relation to
socialisation as a domain of educational purpose (part of versus addition to); and (3)
the relation to the self involved in the concepts (who I am versus how I exist). We
conclude the discussion with several suggestions for health professions educators
and health professions education researchers.

2 On potential reasons for this development, Biesta writes: “Although the learnification of contem-
porary education comes out of a number of different, only partially related developments (for a
discussion see Biesta 2010), it partly stems from the suggestion that teaching limits the freedom
of students whereas learning provides opportunities for students to be free and enact their freedom
outside of the control of the teacher. That is why teaching—and quite often we nowadays hear
‘traditional teaching’—is seen as problematic, outdated and ‘of the past,’ whereas learning is seen
as contemporary and ‘of the future” (Biesta 2019, 550).
3 Subjectification in Health Professions … 25

3.2 Consensus About PIF in Health Professions Education

PIF research within health professions education investigates “the process through
which physicians acquire their professional identities” (Cruess et al. 2014, 1446).
The concept, sometimes also referred to as professional identity development, was
discussed in the context of health professions education as early as 1957 (Merton
1957) and is firmly rooted in broader developmental theories that have received much
attention in educational and pedagogical research traditions (see Cruess et al. 2014
for an overview). Involvement with the concept in the field of health professions
education has spiked in the past decade (Cruess et al. 2019). A much-used definition
of PIF is the process of achieving a “representation of self” which is an internalization
of “the characteristics, values, and norms of the medical profession, resulting in an
individual thinking, acting, and feeling like a physician: think, act, and feel like
a physician” (Cruess et al. 2014, 1447). In general, PIF in the health professions
education field is understood to be a process of socialisation, a process of ‘growing
into the profession’ (see e.g., Jarvis-Selinger et al. 2012; Wald et al. 2015). The
profession recognizably represents norms, values, and ways of being and doing, by
which established members of the profession can be recognized as representatives
of that profession. Rather than having control over this process, however, health
professions education is seen as providing the context in which the process is situated.
Medical educators’ jobs are facilitative to this end, they must help students “form, and
successfully integrate their professional selves into their multiple identities” (Goldie
2012, e641; Rees and Monrouxe 2018).
In the educator’s task to facilitate PIF, we see a dual focus: development of the
self at the level of the individual (psychologically), and development of the self
at the collective level (becoming part of social structures) (Jarvis-Selinger et al.
2012; Sawatsky et al. 2020; Wald et al. 2015). This duality could be described
as a core challenge of PIF—PIF is about finding a balance between personal and
professional identities in a normative context that includes dynamic interactions
between both (Cruess et al. 2014; Holden et al. 2012; see also Beijaard et al. 2004,
on professional identity formation in general education context). Finding that balance
is a negotiation process that can result in “identity dissonance”, that is, a situation
in which professional identities are discordant with personal identities (Monrouxe
2010, 42; Costello 2005). Once this balance is achieved, however, professionals move
from ‘doing’ to ‘being’, inching closer towards full participation3 in their healthcare
community of practice (Cruess et al. 2014).
Currently, we notice that research on PIF within health professions education
most often assumes one of two related orientations. Firstly, some research focuses
on the unique individuality of those who are becoming part of a healthcare profession.

3 In situated learning theory, legitimate peripheral participation refers to “the particular mode of

engagement of a learner who participates in the actual practice of an expert, but only to a limited
degree and with limited responsibility of the ultimate product as a whole” (Lave and Wenger
1991 14). Members of a profession, according to this theory, develop from legitimate peripheral
participation to full participation as they gain experience in the profession.
26 S. Verwer and M. van Braak

Cruess et al. (2015) describe the individuality of that process in terms of a multitude
of influences that impact the process differently for different people:
Multiple factors within and outside of the educational system affect the formation of an
individual’s professional identity. Each learner reacts to different factors in her or his own
fashion, with the anticipated outcome being the emergence of a professional identity. (718)

The diversity in factors and responses to factors described in this quote makes
fostering PIF in health professions education difficult—what should we focus on
facilitating, what for, and with what effect? Sawatsky et al. (2020) provide some
suggestions to that end. Their fundamental recommendation is to create space for
openness and vulnerability, authenticity and diversity, weaknesses and feedback
through positive role modelling. Wilson et al. (2013) also provide evidence for
the importance of role modelling. Additionally, they describe how participation in
communities of practice (which originates in social theory; Lave and Wenger 1991)
and narrative reflection with peers also foster PIF. If identity is seen as a repre-
sentation of the self, constructing and sharing stories relating to one’s identity as a
professional helps to form that identity in relation to other members’ participation
in that profession (Wilson et al. 2013).
The second orientation relates to the influence of the environment on the develop-
ment of identities. Recent research from a constructionist viewpoint has focused on
the social aspects of identity formation. This type of research draws attention to the
way identities are co-constructed through interaction in social settings, enacted inter-
actionally through language, and not limited to the realm of an individual’s cognition
(Monrouxe 2010; Monrouxe and Poole 2013; Monrouxe and Rees 2015). Although
this second orientation indeed widens our perspective on the construct of identity
from the individual to the collective, it still describes how an individual’s identity is
developed within a social setting.
In health professions education in general, the focus on personal growth of each
individual (even beyond PIF) gets reduced to personal learning goals, lists of compe-
tencies, personal development plans, and core activities (see e.g., Sawatsky et al.
2020; Jarvis-Selinger et al. 2012). These are all examples of the language of learning:
attention is foremostly given to who this specific learner is, what this specific learner
needs, how this specific learner develops and how the teacher can contribute to that
learning. Consequently, PIF-centred educational activities focus predominantly and
excessively around the autonomous individual.
Now there’s the rub.
Historically, education is a place that contributes to the way a person exists as a
free person in the world (Biesta 2010). That is, education is more than the formation
of an individual to fit in a prespecified professional mould. That is also to say that
education is more than a handmaid to learning. It goes beyond learning, so to speak
(Biesta 2006), in the sense that it creates room for more than learning alone. It creates
room for a person to exist in the world.
To describe what it means to create room for a person to exist in the world, or,
put differently, to describe education in an educational manner, we need a discourse
3 Subjectification in Health Professions … 27

or language which is suited to ‘deal with’ teachers, learners, and the curriculum,
and ‘takes into account’ the fact that we exist in the world (Biesta 2012a).4 This
discourse, Biesta argues (2010), centres around the question what education is for—
its purpose.

3.3 Three Domains of Educational Purpose

What education is and what it is for are complex questions. Biesta has developed
a series of ideas around notions of content, purpose, and relationships to deal with
those questions in a constructive way. The starting point here is that the “language of
learning is not sufficiently precise” because “the whole point of education (..) is not
to ensure that students learn, but that they learn something, learn it for a reason, and
learn it from someone” (Biesta and van Braak 2020, 450, italics in original). Having
made the distinction between learning and education from an intentional, relational
perspective, Biesta suggests three domains of educational purpose: qualification,
socialisation, and subjectification. These domains of purpose can also be seen as
functions of education (for an extensive discussion see Biesta 2010).
Qualification is the domain which includes the transfer of knowledge and skills:
any education will be concerned with the question of what knowledge and skills
should be made available and mastered by people taking part in that education.
Socialisation concerns getting acquainted with a profession’s ways of knowing and
being, its norms and values. It is no question that becoming educated also involves
interaction with a certain representation of what is considered valuable or not, in
terms of behaviours and identities. The extent to which socialisation should be
aimed for, however, can be questioned from the next domain. Subjectification is
Biesta’s third function or domain and is the focus of our discussion. In short, this
domain draws attention to the observation that education is always concerned with
the (im)possibilities of the individual and his or her capacities, for example in relation
to questions around notions of freedom, emancipation, and responsibility.
An important point to stress here is the fact that these functions or domains can
be separated from a theoretical, conceptual perspective, while in practice any educa-
tional activity affects these three domains at the same time. Whatever didactic model
or activity is chosen (e.g., the more teacher-centred lecture or a student-centred lesson
based on an problem-based inquiry approach), at any time, qualification, socialisa-
tion, and subjectification are happening, in a positive or negative sense. The rele-
vance of these domains for health professions education specifically is in the way
they provide a “precise discourse” that allows us to ask not whether participants in

4 An interesting question for further research, which we will leave open for now, is how health profes-
sions education as a discipline is historically more closely related to the psychological research tradi-
tions than to pedagogy, and how this could account for the dominance of psychological perspectives
on education in health professions education.
28 S. Verwer and M. van Braak

health professions education are learning, but “whether their education addresses
all three domains of purpose” (Biesta and van Braak 2020, 451). In the context
of health professions education, addressing the three domains of purpose entails
that education “needs to aim for professional qualification, professional socialisa-
tion, and professional subjectification (Biesta and van Braak 2020, 452, italics in
original).
Intuitively (as we have learned from interactions with medical educators in
response to these domains), professional subjectification very much sounds like the
formation of individuals within a professional community. Yet, professional subjecti-
fication and PIF are fundamentally different processes. In that sense, our introduction
of professional subjectification in the next section is not meant to replace the concept
of PIF. Rather, we present it as an addendum: why should medical educators look
beyond PIF towards subjectification?

3.4 Professional Identity Formation and Subjectification

In what follows we will argue for the value of subjectification in addition to PIF by
juxtaposing PIF and subjectification on three key points: (1) as different approaches to
the matter of existence, (2) in their relation to socialisation as a domain of educational
purpose, and (3) the concepts’ relation to the self. A summary of these points is
presented in Table 3.1.
We work from the assumption that “theory is crucial for the conceptualization
of the phenomenon one wishes to investigate” (Biesta 2020a, 13) and approach
theory as “theory-as-a-specific-answer-to-a-specific-question” rather than “theory-
as-truth” (Biesta 2020a, 11). With that said, the specific question for our chapter
could be articulated as: How can medical students not only form their identity as
professionals but what can they do with it, and what does this ask from medical
educators?

Table 3.1 Comparison of

Professional Subjectification
PIF and subjectification
identity formation
Approach to the Psychological Philosophical
matter of existence
Relation to Foremostly linked Different from
socialisation to socialisation socialisation
Relation to the self 3rd person 1st person
perspective: Who perspective: How
am I? do I exist?
3 Subjectification in Health Professions … 29

3.4.1 PIF as a Psychological Concept Versus Subjectification

as a Philosophical Concept

A first difference between PIF and subjectification seems to be their approach to

the matter of existence. Traditionally, questions about the matter of existence belong
to the domain of philosophy called ontology: the philosophical study of being in
general (see Chapter 12 for a discussion on ontology in health professions education).
Ontologists try to clarify what it may mean to speak about existence, becoming, and
reality. As such, ontology is part of metaphysics.5 Ontology and metaphysics have
not been very present within the research tradition of health professions education
which has been more related to psychology and sociology.6
The concept of subjectification, like its related terms subjectness and subjectivity,
has not been used much in health professions educational literature.7 As a concept,
subjectification is notoriously hard to grasp. It is not our aim here to make a philo-
sophical argument per se. What we do want to show is how approaching medical
students from the specific philosophical background related to subjectification sparks
a different kind of educational thinking, discourse, and practice. We will do so by
presenting two short arguments.
The first argument is that subjectification implies that the subject is subject to
their own existence. The fact that we exist in the world is an important given that we
should not ignore, since it enables and limits our possibilities, both as educators and
as human beings in general. Like the authors of Chapter 12 will later point out, it may
be utterly helpful to move beyond the traditional focus on individual autonomy to an
alternative ontology that focuses on the relationships between individuals. An explicit
stance on how we exist means that relationships become the central focal point of an
educational approach to education: to ask, ‘how do I exist?’ means also to ask, ‘how
do I relate to others, the world and also to myself?’. These types of questions are
often asked by philosophers of education working from traditions like existentialism,
pragmatism, hermeneutics, and phenomenology. What these approaches generally
share is an explicit stand towards the matter of existence: human beings exist in the
world—and that very existence in the world confronts us with a range of (educational)
challenges.

5 Merrian-Webster dictionary defines metaphysics as a “division of philosophy that is concerned

with the fundamental nature of reality and being and that includes ontology, cosmology, and often
epistemology”.
6 It would be interesting to study in more depth how configuration of health professions education

as an academic discipline has influenced the surfacing of certain concepts (for a reconstruction of
the history of the discipline, see ten Cate 2021).
7 An informal Google Scholar search in June 2021 using [“medical education” and “subjectifica-

tion”] only yielded 429 hits, [“medical education” and “subjectness”] resulted in 28 hits, [“health
professions education” and “subjectification”] in 25 hits, and [“health professions education” and
“subjectness”] led to none. The combination of “medical education” or “health professions educa-
tion” with “subjectivity” resulted in considerably more hits, but these mainly concerned bias-related
meanings of subjectivity.
30 S. Verwer and M. van Braak

The notion of PIF does not so clearly provoke statements of how we exist or, put
differently, where we exist, nor how existing in the world is an activity or engagement
as such. Philosophically, PIF seems to focus more on epistemological questions such
as how human beings construct meaning within social contexts. Questions on how
knowledge—or identity—is or should be constructed are omnipresent, evident also
in the many references to theories of learning as constructivism, cognitivism, and,
more recently, constructionism (see Sect. 3.2), but ontological statements seem rather
absent.
To better understand and to stress the importance of ontology in educational
theory, we point to the notion of resistance. The notion of resistance could function
as a clarifier between PIF and subjectification, as we will explain with an example.
As subjects existing in a world, we experience resistance. We are not only actors,
but also sufferers in the sense that we are subject to others and the world (Arendt
1958; Biesta 2014). This experience can be frustrating, since the world does not
always listen to us, so to say.8 Within the context of education, teachers experience
resistance because students are free to make their own choices, which often do not
align with what teachers have in mind for them. Students experience resistance when
discovering that mastering certain subject matters challenges them to stay put and
invest more time and energy than initially allocated. Approaching education from the
standpoint of subjectification does not lessen the experience of resistance, as such,
but reconfigures the relationship to it.
Giving meaning to resistance from the perspective of identity formation may not
fully or less adequately capture the educational value of such experiences: identity, as
such, does not tell us much about how to exist in the world. For education, this means
that an educational purpose for health professions education should be to address the
questions of existence, resistance, and frustration in a fruitful manner.9
The second argument for the introduction of subjectification instigating a different
kind of educational thinking, discourse, and practice is the idea that existing as a
subject is related to freedom, emancipation, and responsibility (Biesta 2014) in a
way that identity is not. By approaching students-as-subjects, educators open up an
educational view wherein students can not solely be objects who are to be formed.
That is something most educators would agree with, but it is not always easy to
describe what that means in the process of becoming a healthcare professional. It
is at this point we think the notion of subjectification could enrich the conversation
within health professions education when discussing questions like what it means
to become a (good) doctor. Not only does subjectification provoke other questions
than PIF, but it also introduces to the discussion elements, e.g., how to deal with

8 “The first thing that the experience of resistance teaches us is that the world we live and act in – and
this includes both the material world and the social world – is not a projection of our mind but has
an existence of its own. This means that it is fundamentally other” (Biesta 2012b, 94–95).
9 For a different take on this topic, we refer readers to Vlieghe and Zamojski who would say that

such an aim would qualify more likely as an ethical aim and not so much as an educational one
(Vlieghe and Zamojski 2019, 73).
3 Subjectification in Health Professions … 31

responsibility, that could benefit positively from more explicit attention in medical
school.10
Making implicit ontological assumptions of educational theory and practice
explicit, and approaching students as subjects with their own freedom, agency,
and responsibility are two arguments that show the difference between PIF as a
psychological and subjectification as a philosophical concept.

3.4.2 PIF as Socialisation Versus Subjectification

as Different from Socialisation

Professional Identity Formation is, rightly so, often considered as part of socialisa-
tion. Brown and Finn (2021) in their discussion of the concept state that:
To advance knowledge in regard to mechanisms of social reproduction within health
professions education, scholars must carefully consider what they mean when they say
‘socialisation’. (781)

In discussing the three domains of purpose, Biesta (2020b) specifically conceptual-

izes socialisation as:
The (re)presentation of cultures, traditions, and practices, either explicitly but often also
implicitly, as the research on the hidden curriculum11 has shown. (92)

The work of identity takes place within this domain because it is aimed at reproducing
specific identities:
…the “work” of identity actually takes place in the domain of socialisation. It is, after
all, in that domain that education seeks to provide students with access to traditions and
practices, with the invitation to “locate” oneself in some way in such traditions and practices
(bearing in mind that this is not a process over which we have total control, also because our
self-identifications may be quite different from how others identify us). (Ibid., 99)

What Biesta proposes here is that socialisation is a question of becoming part of an

already existing order. This is a legitimate and useful task of education. Education
always implies the question of what ‘we’ want to conserve and transmit to new
generations. Society legitimately demands education socialises students. For health
professions education, this question often comes in the form of professionalism
discourse (see, for example, Cruess et al. 2014).

10 For more on the connection between identity and responsibility in medical education, see Yardley
et al. (2020).
11 The hidden curriculum in medicine was first described by Hafferty and Franks in 1994 as “the

values, attitudes, beliefs, and related behaviors deemed important within medicine” and that are
internalized “not within the formal curriculum but via a more latent, one, a “hidden curriculum,”
with the latter being more concerned with replicating the culture of medicine than with the teaching
of knowledge and techniques” (864–5). Here, Hafferty and Franks closely link the hidden curriculum
to socialisation processes.
32 S. Verwer and M. van Braak

Whereas socialisation is aimed at the (re)production of a certain social order

through the creation of identities, subjectification cannot be reduced to a certain order
and, in a sense, disturbs it, or adds something new to it. Subjectification functions in
a different realm than socialisation.
Building on Jacques Rancière’s ground-breaking theory of emancipation, Biesta
(2014) states that:
Subjectification is about the appearance – the ‘coming into presence’, as I have called it
elsewhere (Biesta 2006) – of a way of being that had no place and no part in the existing
order of things. Subjectification is therefore a supplement to the existing order because it
adds something to this order…. (47)

An overfocus on socialisation—or paying too little attention to the question how

doctors-to-be may alter their professional order—may lead to a reduction of the
possibilities of students to emancipate and develop their own ways of being within
the profession. A critique may, thus, be that PIF works (implicitly) from a perspective
which does not make (enough) space for the recognition of the potentiality of medical
students.

3.4.3 PIF’s Third Person Perspective Versus

Subjectification’s First-Person Perspective

The last core difference between PIF and subjectification, or the related difference
between identity and subjectness, is that identity is linked to a third person perspec-
tive, whereas subjectification approaches education from a first-person perspec-
tive. Whereas identity concerns the abstract question of who I am, subjectification
emphasizes the question specific how I am.
Research on PIF builds on literature in developmental psychology (Cruess et al.
2015). This psychological point of departure means that the focus of personal growth
in the context of becoming a doctor is mostly understood as an individual pursuit to
become part of a pre-existing profession (i.e., identity within that profession)—albeit
the social nature of a person’s identity construction is increasingly acknowledged in
identity research within the health professions (e.g. Monrouxe 2010; Monrouxe and
Poole 2013; Monrouxe and Rees 2015). The question here is who you are as a person
and professional—a question of identity. From an educational point of view (Biesta
2014), identity formation, be it professional or otherwise, ultimately is about the
question of how you are as a person and what you can do with your identity:
[I]t seems safe to say that identity concerns the question of who I am, both in terms of what
I identify with and how I can be identified by others and by myself. The question of subject-
ness, however, is not the question of who I am but the question of how I am, that is to say,
the question of how I exist, how I try to lead my life, how I try respond to and engage with
what I encounter in my life. It therefore includes the question regarding what I will “do”
with my identity – and with everything I have learned, my capacities and competences, but
also my blind spots, my inabilities, and incompetence – in any given situation, particularly
3 Subjectification in Health Professions … 33

those situations in which I am called upon or, to put it differently, in which my “I” is called
upon. (Biesta 2020b, 99)

From the third person perspective that identity entails, we can describe ourselves as
being so and so, doing this and this, and working in that and that function. In doing
so, we identify with others or groups of others. Education, in this line of thinking:
Is seen in terms of the creation of particular identities – the lifelong learner, the good
citizen, the high-achieving student – and in terms of the creation of a competitive, stable,
and successful social order. (Biesta 2006, 99)

This perspective acknowledges the social nature of identity formation but leaves out
what we consider a key issue in describing what it means to ‘be in the world’. An
issue that the idea of subjectness, indeed, does address.
Subjectness, in contrast to PIF, entails a first-person perspective and has to do
with the idea of irreplaceability. In linguistics, the subject is literally the one doing
the action, not the one or the thing to which things are done. In the context of the
formation of medical students, subjectness is about being an agentive subject, who
can take initiative and exists in the world (see Chapter 11 for an interesting view
on agency in health professions education). Subjectness is about how I exist, that is,
what I can do with my identity in the world around me.
For medical students the question of what they can do with their identity as a
doctor is a very relevant one. For medical educators it may show how subjectifica-
tion somehow changes the way in which they look at the development of students:
having a vision, embedded in a curriculum, on how medical student form their profes-
sional identity may fall short from what we consider as an educational task: teaching
students how to exist in the world by dealing with their freedom and its limitations.
The difference between a third- and first-person perspective thus is highly rele-
vant when thinking about ‘formation’: it constitutes the difference between treating
students as objects which are to be formed, versus subjects with agency and freedom
to choose.

3.5 Conclusion

We started out by claiming that Professional Identity Formation is a conceptual

area within health professions education where ‘learnification’ as a development
becomes visible. Starting from the three domains of educational purpose suggested
by Biesta, we suggest that PIF is foremostly a domain of socialisation, exemplified in
an overfocus on individual learning goals, competences, and pre-moulded trajectories
of development. Thinking about education in an educational manner, identity may
not be the only concept we should concern ourselves with regarding the formation
of students.12 What it means to become a good doctor can not only be a question

12 Our approach developed here differs from Vlieghe and Zamojsk’s (2019), who state “that educa-
tional equality is about sameness, but not in relation to any identity”(p. 48). Interested readers are
referred to their work for further discussion.
34 S. Verwer and M. van Braak

of identity. As subjects, we are subject to specific situations and we find ourselves

‘thrown’ into the world, existing and taking up our own existence in a way in which
only we ourselves can do.
Thus, subjectification seems a promising concept for educators and education-
alists to use as a springboard to embark on conversations concerning questions of
freedom (lacking a certain pre-established malleability), responsibility, and activity.
Subjectification helps us to understand what we really mean when we want to create
room for individuals to express themselves as unique and increasingly established
members of the medical profession (see Lave and Wenger 1991). A radical idea would
be to suggest that we avoid the use of the idea of PIF altogether, since it constrains
the formation of students too much to the domain of socialisation and may even facil-
itate an instrumental approach of treating students as objects rather than subjects.
For now, we would suggest that health professions education look beyond the idea
of identity towards the notion of subjectification, without disregarding identity as an
apparently fruitful domain of research and practice.
Two critical notes need to be made about this chapters’ discussion on PIF and
subjectification, though. First, subjectification, though valuable as an addition to
PIF, seems to instigate confusion sometimes: what exactly does it mean, how is it
related to identity? Despite it being hard to grasp and even harder to put to practice
(more on that below), the concept of subjectification may help health profession
education to conserve its educational character.
A second critical note is that identity discourse may be more flexible than what
is presented here. For example, we speculate that the notion of ‘identity dissonance’
could be fruitfully related to the idea of subjectification. Such links between identity
and subjectness could move discussion in the field beyond a contrastive approach to
PIF and subjectification towards a productive dialogue.

3.6 Implications for Practice

The conceptual differences between PIF and subjectification have consequences for
health professions education research and for how we ‘treat’ students in health profes-
sions educational practice. We summarize these in Table 3.2 and discuss some in more
detail in Sect. 3.6.1 and 3.6.2.

3.6.1 Implications for Health Professions Education

Research

We would like to draw attention to two broad suggestions for health professions
education researchers. First, health professions educators should be conscious of
3 Subjectification in Health Professions … 35

Table 3.2 Practice points

1 Recognize the complexity of educational practice by paying attention to the connection
between often implicit philosophical assumptions about existence and educational theory
2 Add subjectification as a specific concept to health professions education discourse to
enrich discussion and practice
3 Approach students as subjects, emphasizing their freedom and uniqueness, not solely as
objects
4 Do not treat subjectification as a learning outcome but create room for students to ‘come
into presence’
5 Teachers and students can develop a grownup manner through which they can engage with
the idea of existing as a subject in the world, which entails dealing with the experience of
resistance

often implicit educational theory in health professions education discourse—such as

the implicit notion of the link between learning and teaching.
Second, we suggest that the three domains of educational purpose, and subjec-
tification specifically, could bring about a new and more educational conversation
in health professions education literature. Future research could attend to subjecti-
fication as a research object to further facilitate its place in the health professions
educational curriculum.

3.6.2 Implications for Health Professions Education Practice

In terms of teaching, the chapter’s discussion of PIF and subjectification leads to

three suggestions. Firstly, educators must strive to challenge views that conceptu-
alise students as objects. Students in higher education may sometimes be reduced to
‘numbers’ or ‘objects’, whereas our educational task and responsibility should be to
make space for students to exist as subjects. This would mean that we view teaching
not as something which is done to students, but as something which is experienced
by students, individually and collectively. The relational aspect and the existential
nature of the concept of subjectification are very valuable in this plight.
Secondly, educators must understand that students cannot be ‘subjectified’.
Starting out from the three domains of educational purpose, we could conceptually
envision students becoming more qualified and socialised. Subjectification, however,
presupposes initiative from the subject itself, and can therefore never be done to them.
Hence, we would suggest educators refrain from oversimplified operationalisations
of subjectification as a learning outcome.
Third, related to our discussion of the notion of resistance, it is important to
realize that teachers and students not only experience and react to resistance, but that
teachers and students can also use or to coexist with resistance to achieve what has
been called a “grown-up” way of existing in the world (Biesta 2019).
36 S. Verwer and M. van Braak

In terms of curriculum design, we suggest that educators and institutions create

room for ‘coming into presence’. Subjectification cannot be done to students, but
education can create room for it. To create room means to leave room within the
limits of socialisation, refraining at times from recreating a specific social order (e.g.,
explicitly assigning teacher-related tasks to students to involve them in the process
and avoid traditional hierarchical order, or creating open slots in the infrastructure
of a training programme for issues that are topical to students at that point in time,
or emphasizing the possibility of doctors-to-be to enrich the world of medicine with
their unique contribution). It also means space to discuss questions of freedom,
emancipation and existence—which may not be forefronted, or approached in the
same manner, if education and student formation is viewed through the lens of PIF.

Acknowledgements We would like to thank Gert Biesta, Tim Fawns, and Wouter Pols, whose
ideas have inspired and, in some cases, directly influenced the ideas developed in this chapter. Also,
we thank the editors for their helpful feedback on an earlier version of this chapter.

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Chapter 4
The Serious Healer: Developing an Ethic
of Ambiguity Within Health Professions
Education

Mario Veen and Megan E. L. Brown

4.1 Introduction

Though of relatively recent popularity within our field, philosophers have wrestled
with ambiguity for millennia. With roots in the Latin word ambiguus, which can be
taken to mean “doubtful” or “double meaning” (Pinkus 2013), the focus of philosophy
has often been to escape doubt, to deduce the singular meaning of the cosmos, of
life, and of people, to eliminate uncertainty from our interactions with the world.
Of late, ambiguity, or inexactness, has been acknowledged as inherent to prac-
tice as a healthcare professional (Luther and Crandall 2011). There may be ambi-
guity, for example, in diagnosis, or creating optimal management plans. Yet, interest
in this topic and area of study succumbs to the notion that ambiguity should be
reduced, tolerated only when avoidance is impossible. Developing an ethic of ambi-
guity within health professions education (HPE) that encourages trainees and educa-
tors to embrace the fundamental role of ambiguity in human existence is necessary
to help learners succeed within the increasingly uncertain landscape of healthcare.
In this chapter, we consider the tensions between ambiguity and certainty that
manifest within HPE and propose de Beauvoir’s foundational text “The Ethics of
Ambiguity” ([1947] 2018) as a guide in developing pedagogy which facilitates
adaptable professional identity formation amongst trainees (see Chapter 3 for an
overview of identity literature in the field and proposed alternative to the concept of
professional identity).

M. Veen (B)
Department of General Practice, Erasmus University Medical Center, Rotterdam, The Netherlands
e-mail: m.veen.1@erasmusmc.nl
M. E. L. Brown
Imperial College London, London, UK
e-mail: megan.brown@imperial.ac.uk

© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2022 39
M. E. L. Brown et al. (eds.), Applied Philosophy for Health Professions Education,
https://doi.org/10.1007/978-981-19-1512-3_4
40 M. Veen and M. E. L. Brown

4.2 Tensions Between Ambiguity and Certainty

Ambiguity is, rather ironically, itself an ambiguous term. It is, therefore, important
to consider: what is ambiguity, and how do we relate to it? These two questions
are interconnected. If ambiguity is an undesirable state where we do not yet have
desirable clarity, then our relationship might be one of accepting when we cannot
change ambiguous situations and seeking out clarity where it is possible to do so.
However, if ambiguity is not ‘not yet certainty’ but, instead, a default condition of
our existence, then we must come to terms with this fact of life. In this way, the very
definition and conceptualisation of ambiguity we adopt within HPE influences the
way we handle the concept within pedagogy and research.
We anticipate that, within HPE, there may be differences in the value and impor-
tance individuals place on the concepts of ambiguity and certainty. As the health
professions and science are intimately related, those that prefer certainty may connect
their relationship with ambiguity to a standing in, or preference for, the natural
sciences. These leanings are often referred to as a basis for the claim that certainty is,
and should be, the default. However, this is no longer the case (Prigogine and Stengers
1997). Quantum physics, for instance, operates on the basis that it is fundamentally
impossible to have certainty, and works with probabilities: a quantum particle has an
ambiguous position that is described as a field.

4.3 Ambiguity Within Health Professions Education

Though there is no consensus definition (Hancock and Mattick 2020), research within
HPE has attempted to cast light on the experiences of practitioners in reference to
ambiguity, sometimes with aim of minimising or eradicating ambiguity, and some-
times with aim of informing educational strategies that teach others how to handle
the experience of ambiguity. A particularly popular concept within HPE literature is
‘tolerance of ambiguity’. Tolerance of ambiguity has been associated with improved
wellbeing amongst healthcare trainees and reduced risk of burnout (Hancock and
Mattick 2020). The online Cambridge English Dictionary (2020) defines the noun
‘tolerance’ as ‘the ability to deal with something unpleasant or annoying, or to
continue existing despite bad or difficult conditions’. Words matter, and the use
of the term ‘tolerance’ implies that, definitionally, ambiguity is an unpleasant expe-
rience that we should seek to avoid. Though some authors have attempted to rede-
fine ‘tolerance’ to reflect a range of positive and negative psychological responses
towards ambiguity (Hillen et al. 2017), the tacit message inherent to the use of this
term remains suggestive of a desire to avoid ambiguity. Indeed, the body of research
concerning ambiguity within HPE seems to continue to interpret ambiguity as a nega-
tive experience. Despite attempts to remove the negative connotations of the term
‘tolerance’, ambiguity is not conceptualised as a default condition of our existence,
but as an absence of certainty, a distressing black hole within HPE.
4 The Serious Healer … 41

Viewing ambiguity only through this lens—as an absence of certainty—stifles

opportunities to progress thinking within HPE. If, instead, we conceptualise ambi-
guity as a default condition of existence, approaches to teaching and practice may
be revolutionized in ways that could promote wellbeing beyond existing pedagogy.

4.4 Simone de Beauvoir and Ambiguity

Simone de Beauvoir is the veritable mother of ambiguity as a topic of contemporary

discourse within academic circles, and her writing offers one such fresh view of
ambiguity as a condition of existence, rather than an addition to it. An intellectual
associated with the philosophical tradition of existentialism (the core tenant of which
is that existence precedes essence), de Beauvoir philosophises at length about the
nature of ambiguity and how to rationalise the concept in her foundational work ‘The
Ethics of Ambiguity’ ([1947] 2018).
For de Beauvoir, ambiguity arises from a tension inherent to the human condition.
Human beings are both subjects and objects simultaneously. A subject has agency
and is free to decide and act in the world, whereas an object is at the mercy of other
forces and has no will of its own. Just think of an operation: the surgeon is in control;
they decide where to cut and how. But the patient in this scenario is just a body, an
inanimate object that has no say in their operation.
As human beings, we have a material body that is made of the same stuff as rocks
and plants and tables. A table will never be a rock, just like a 1.80-m-tall person will
never be a 1.50-m-tall person. If we are genetically disposed to have blue eyes, or to
have a high risk of a certain disease, we are at the mercy of these ‘facticities’. At the
same time, we can be aware of our height, of our medical condition, and continuously
recreate ourselves through choices and actions. Whether I am courageous or not
depends on what choices I make in high-risk situations, each time. If I have been
lazy or cowardly in the past, I can transcend this now by acting in an ambitious or
courageous manner.
In addition to the ambiguity of our human condition—of the tension between
our bodies and minds—there is also an ambiguity between an individual’s past
(which has happened and is therefore a known, given thing) and the future they
are about to freely create. Given that the future effects of our present choices cannot
be known, we feel the ethical weight of every decision we make. This is a “felt ambi-
guity between antecedent limits (facticity) and future possibilities (transcendence)”
(Schroeder 2005, 299).
Ambiguity also pertains to what human beings create. Advances in technology,
often perceived as progressive and positive, have led to negative outcomes. De Beau-
voir names the atomic bomb as one such example. As we see in Chapter 16, our
current way of life which has given us so much prosperity and fostered significant
advancements in healthcare, also now endangers the livability of our home planet. In
medical decision-taking, health care professionals are acutely aware that a surgery
can be a solution and a risk at the same time. All medication has some kind of
42 M. Veen and M. E. L. Brown

side effect, and, sometimes, the cure is worse than the disease. Ambiguity arises
from the unknown effects of our decisions. Chapter 17 also describes our ambiguous
relationship with technology. Bernard Stiegler (2013) calls this the pharmacological
dimension of technology: the same technique can be a poison, or a potion depending
on how you use it.
The ambiguity of decisions de Beauvoir calls our attention to also extends to
decisions and actions concerning others: what I choose and create freely may impede
the freedom of others. They can become tools in my plan, means to an end. Upholding
and advancing the freedom of others is, as we will discuss later in this chapter, the
basis of de Beauvoir’s recommendation for an ethics of ambiguity—a way of living
in an ambiguous world where each one of us create our own meaning through our
choices and actions.
De Beauvoir calls on us to embrace the fundamental ambiguity of our existence
that comes about through tensions in the human condition, tensions between the past
and future, tensions regarding human creation, and tensions concerning the freedom
of others. Without ambiguity, de Beauvoir argues, we would not have either freedom,
or ethics. We only have ethics because we can make mistakes. Ethics—including
medical ethics—are no instruction manual for what to do in each situation. On the
contrary, ethics are necessary because there is an inherent ambiguity for which no
instruction manual can provide a solution. Even the choice for which set of guidelines
to use, and when to adhere to or deviate from them is a free choice.
Translating this call to education: there is only the possibility to learn if there
is the possibility to fail. Failure—at a task, or failing to answer a teacher’s ques-
tion, for instance—is not an impediment to education, it is its very condition. In all
these ways and more, ambiguity is foundational to education. Even the construc-
tion of certainty—as imbues the stereotype of the paternalistic all-knowing white
coat-wearing doctor—is not a negation of ambiguity, but a response to it, namely, by
treating the world as a collection of facts and certainties.
In the remainder of her book, de Beauvoir takes one’s relationship to ambiguity as
a starting point to describe different levels of maturity. The degree to which, and way
in which, I relate to my human condition defines where I am in this typification. Once
we have accepted that ambiguity is the human condition, and the default condition
within HPE, then we can draw upon de Beauvoir’s typification as a description of
professional identity development.

4.4.1 The Game of Being Serious: The Serious Healer

Children generally grow up in a protected environment in which all ambiguity is

shielded off to them by adults. Unaware of the financial, health, and ethical choices
their parent had to make in the convenience store to choose the food they have on their
plate, children are simply tasked with eating. Their parents are their idols, literally, in
the sense of all-knowing, all-powerful gods. They are unaware of how they lie awake
at night thinking about which choices to make. When children play with each other
4 The Serious Healer … 43

and imitate a ‘mother’ or a ‘doctor’, de Beauvoir writes, they are actually serious.
The role they play is that of the idol. The “game of being serious” (de Beauvoir
[1947] 2018, 39) is to treat choices and values as things. Bedtime is just as real a
thing as a table you can bump into. This is not just the case for children.
At one point in our lives, however, the illusion of living in an unambiguous world
is shattered, and the world is revealed to be profoundly ambiguous. The transition to
adulthood—not in the sense of age, but in the sense of having a mature relationship to
ambiguity—depends on how people respond in those moments in which existential
ambiguity is revealed. This can be the moment when a loved one dies, when an adult
breaks out in tears, or even a moment where an adult hesitates. Most people, at least in
the early stages of their identity development, respond to the condition of ambiguity
by remaining serious. It means that they now choose one identity, but consequently
treat this identity as a real thing instead of a choice. They start to believe that they are
the identity they have created. In de Beauvoir’s existentialist philosophy, at least, we
never are an identity (an essence). We are nothing in essence and always becoming.
Within HPE literature, professional identity development is most commonly
conceptualised as a fluid process—one’s identity is not fixed but, rather, always
forming, shifting, and changing (Monrouxe 2010). We see de Beauvoir’s philosophy
echoed here in that we are always becoming. At the beginning of healthcare training,
students are highly motivated, but their sense of what it means to be a healthcare
professional is often unrealistic and idealistic. The attending (or consultant) appears
as an all-knowing physician, and the best one can do is to imitate them as closely
as possible. However, there is always a moment in training where students realize
that even the most senior members of the healthcare team are operating on the basis
of an ambiguous world. There are no perfect choices. At these moments, students
and trainees can either choose to embrace ambiguity, or to choose one identity or
model for being a healthcare professional that they stick to as the way a doctor should
act. For instance, is their ‘move’ to always refer to ‘the evidence’ as if the scien-
tific literature will tell them what to do, ignoring science’s inherent uncertainty and
epistemological pluralism (Tonelli and Bluhm 2021)?
The “game of being serious” is not just played by children. As De Beauvoir
([1947] 2018) remarks, “all men have been children” (37). She writes that this game
…can take on such an importance in the child’s life that he himself actually becomes serious.
We know such children who are caricatures of adults. (idem, 39)

Writing in the 1940s, De Beauvoir commented on women of her time who could
be playful not despite their not being regarded fully adult (e.g., having the right
to vote), but because of it: “they can exercise their freedom, but only within this
universe which has been set up for them, without them (39).” It is easy to connect
this to the context of medical education, and the debates about students being ‘in
the lead’ and having to take ownership of their training. If we do not regard them
as mature learners from the start, we might present certain guidelines and ways of
dealing with ambiguous situations as set in stone. It also makes clear that “serious”
does not primarily refer to our everyday use of the term, as a stern attitude, but to
regarding values as things.
44 M. Veen and M. E. L. Brown

The crucial point here is that, if a person’s response to ambiguity is to stick to one
identity, they regard their identity as fixed. They may be highly talented and have
chosen a way that very closely fits with how we want healthcare professionals to be
and act in our society. Their fixed identity may work under given circumstances, but
if circumstances change and require them to be or become something else, they run
into difficulty. The serious healer has made their choice of what kind of doctor or
nurse or physiotherapist to be at one discrete moment in time. In one instance they
recognise ambiguity, in the sense that there are multiple possibilities for how to ‘be’
a member of their profession, and run from it, sticking to one way of being for the
rest of their professional career.
But, de Beauvoir continues, there are other options. We need not all be serious
healers in regard to our professional identities. There are chances for development
beyond this stage, towards more mature identities, or ways of being.

4.4.2 The Nihilistic Healer

When approaching life as a serious healer fails, individuals may adopt a nihilistic way
of being. Faced with circumstances requiring identity flexibility and adaptability but
being unable to change in the way they need due to their choice of a fixed identity,
a serious healer may become conscious of being unable to meet the demands of
their profession, their patients, their colleagues, their students. Feeling unable to be
anything, they may become a nihilistic healer, who actively chooses to be nothing.
Deciding to give up any values in the face of a meaningless existence is an attempt to
rid nihilistic healers of the anxiety of their free human condition. If they decide to be
nothing, they deny the world, and they deny themselves. In contrast to children who,
arguably, also deny the world, for nihilists, denial is a choice—they are aware of the
world, of their freedom to choose, but run from this by retreating into nothingness.
There is a parallel between de Beauvoir’s nihilist and the family of philosophical
views known as relativism. Relativists argue that facts are relative to an individual
person, or the context in which they are assessed. You may be familiar with a relativist
yourself, when disagreeing with them they may return—‘you have your opinion, I
have mine, and they are all equally valid’. In relativism, you can choose to be who
you want, to have the opinions you want regardless of the ‘facts’ of the matter. This
is true only because relativists subscribe to a nihilistic view of the world, existence
is all equally meaningless and pointless. Unlike the serious healer, who believes that
there is only one model for being a healthcare professional, nihilistic healers focus
on nothingness, the rejection of all values and fixed ways of being as a futile form
of control. For students and trainees, it is of paramount importance to understand
that, just because there is not one fixed identity of a healthcare professional, does not
mean that practice is boundary-less and chaotic, that people can be whatever type of
healthcare practitioner they want to be. Healthcare practice, importantly, must adhere
to safety standards, if we don’t treat people in certain ways or to certain guidelines,
they will get sick and may even die. The nihilist is dangerous in a medical setting
4 The Serious Healer … 45

because they refuse to engage meaningfully with ambiguity, to make necessary deci-
sions. Though nihilists and relativists may think they are no longer taking a stand for
anything, because everything is pointless, not taking a stand on anything, precisely is
the stand nihilists and relativists take. Retreating into nihilism and refusing to make
resolute decisions or take a stand for colleagues or patients is not only dangerous,
but a decision in and of itself.
Within healthcare, nihilistic healers may also appear disillusioned, to reject the
values of their profession or values they once held dear. They may possess little-to-no
motivation to practice, or to work towards achieving a set of goals, even goals which
are self-serving. Becoming a nihilistic healer is a negative response to the failed
approach of ‘serious healer’. It is not a stage we all travel through, or an approach
to life we all experience in the same way. Support is paramount and recognising
nihilistic views of the world as a possible response to difficulties in dealing with the
ambiguity of existence should inform healthcare professional education and support.

4.4.3 The Adventurous Healer

Emerging from a nihilistic orientation, or directly in response to the failure of a

“serious” approach to life, an individual may become an adventurous healer. Adven-
turers aim their efforts and lives at the pursuit of pleasure, and of glory. They do not
deny their existence as nihilists do but acknowledge their desires and take delight
in the pursuit of them. Adventurers are unattached to the end goal of their pursuits,
enjoying action for its own sake, rather than for the pursuit of freedom for others.
In the pursuit of their goals, they may treat other people as objects, as things, rather
than as free and subjective beings.
Adventurous healers may view making a diagnosis within medicine as an expres-
sion of freedom and subjectivity. They may not see themselves as bound by “serious”
values such as those responsibilities associated with long-term patient follow up,
complex treatment, side effects of diagnosis and treatment, negative mental health
sequelae because of their input. Making an accurate and complex diagnosis is a
conquest to adventurous healers, they do not experience any particular attachment
to, or connection with, the patients they meet, beyond their pursuit of this conquest.
In this way, adventurers are indifferent to the content of their choice—they do not
care who they treat, or for what reason, so long as the conquest exists.
They also wish to have their freedom, their conquest, recognised by others—
they may seek self-promotion which acknowledges their skills, or to amass material
wealth in recognition of their plight. In this way, patients are treated as objects by
the adventurous healer, as ‘things’ through which adventurous healers express and
realise their own freedom. Rather than being genuinely motivated by the needs of
others, adventurers are primarily concerned with their own gratification and action
for action’s sake. Though adventurous healers embrace freedom to a greater degree
than serious healers or nihilistic ones, this approach to life and healthcare practice
is still a character of “bad faith” (Reynolds 2006, 150)—it is inauthentic—in that,
46 M. Veen and M. E. L. Brown

through embracing their own freedom, adventurous healers fail to recognise and
uphold the freedom of others—in this case, of patients.

4.4.4 The Passionate Healer

In time, the adventurous healer’s motivations may change, and they may attempt to
make themselves complete through the pursuit of projects, rather than through more
self-serving pursuits. With this change, they become the ‘passionate healer’.
The passionate healer is the closest of the aforementioned ways of living towards
accepting and upholding freedom, but similarly to the adventurous healer, the
passionate healer treats other people as objects in the pursuit of their own, personal
freedom. Passionate healers seek fulfillment by throwing themselves into their
hobbies, relationships, and their jobs. Unlike the adventurer, the passionate healer is
not indifferent to their patients, to the reasons why they are engaging with them, they
are, instead, passionately attracted to them. In many ways, the passionate healer is
similar to the serious healer. Like serious healers, passionate healers choose a value
to live by and organise their life around their value. Within healthcare, this may be
work with a particular patient population or demographic, with people with a certain
disease or illness, or with patients receiving a particular sort of treatment. However,
unlike the serious healer, who denies their freedom by adhering to a fixed identity,
the passionate healer chooses this identity as an expression of personal freedom.
However, passionate healers still fail to treat others as subjective, free beings as
they conceptualise patients as objects of their passion e.g., their passion for a certain
treatment modality, disease management or social justice value. As de Beauvoir puts
it:
…the whole universe is perceived only as an ensemble of means or obstacles through which
it is a matter of attaining the thing in which one has engaged his being. Not intending his
freedom for men, the passionate man does not recognise them as freedoms either. He will
not hesitate to treat them as things. (28)

One could suggest whether, if the value a passionate healer is devoted to is noble,
such as the pursuit of social justice, or treatment of a rare and complex disease,
whether it matters that they may treat individual people as objects. Yet, being driven
by their passion makes passionate healers potentially dangerous in a medical setting.
Like the adventurous healer, they may demand their passion is recognised and vali-
dated by others, seeking this validation at the expense of upholding patient freedom.
Everything is ultimately subordinate to their passion, they are blinded by it, and in
professions that demand the holistic care of patients, and a patient-centered approach
to practice, this way of being is at odds with best practice.
4 The Serious Healer … 47

4.4.5 The Genuinely Free Healer

The character we should all aspire towards, according to de Beauvoir, is that of the
genuinely free human. Freedom is crucial to all ethical action. Without realising our
personal freedom and upholding the freedom of others, it is impossible to live a
moral existence. The genuinely free person, for de Beauvoir, is the only character
who can promote the freedom of others. In healthcare roles, where significant power
dynamics exist between practitioners and patients, actively promoting the freedom
of patients is essential in the pursuit of patient-centered care that values the thoughts,
opinions, experience, and lives of patients.
Realising freedom involves embracing the ambiguity of existence, rather than
shying away from it, and acknowledging it as a foundational premise of our being. In
doing so, we can make free choices in our day-to-day lives, and take responsibility
for these choices, our attitudes, opinions, and values. This is the only way in which
humans can justify their actions, if recognition and embracement of ambiguity and
personal responsibility is at the heart of the moral choices we make. Freedom is not an
absolute value—viewing it as such would risk turning one into a serious person who
prizes a transcendent value and fixed identity above all else—rather, it is developed
through our relationships with other people. Freedom is not even really a value as
such, rather an end we should all aim to achieve in our interactions with others.
It is impossible to know the future, and so impossible to know whether the deci-
sions we make will uphold the freedom of others. The important thing here is intent,
recognising one’s own freedom and the freedom of others requires the active pursuit
of liberation, the desire of freedom for other people. For de Beauvoir, upholding
the freedom of others involves social and political action to liberate the oppressed.
Regarding health care, this may involve advocacy in regard to social determinants
of health, national policy, or legislation. It involves recognition that the freedom of
others is central to identity as an ethical health care practitioner, and that this requires
social and political action.

4.5 Towards a Pedagogy of Ambiguity Within Health

Professions Education

We can draw upon de Beauvoir’s recommendations to offer insight as to how we can

move towards facilitating a pedagogy of ambiguity within HPE. De Beauvoir ([1947]
2018) remarks that the “serious man” is the most widespread of all disingenuous
attitudes towards ambiguity, because “every man was first a child” (37). We speculate
that the same may be true of healthcare students and trainees—they are most likely to
adopt the attitude of a ‘serious healer’ regarding the development of their professional
48 M. Veen and M. E. L. Brown

identity. As such, the following practice points are posed with the intention of shifting
the dial amongst students and trainees, encouraging them to become genuinely free.

4.5.1 Start with Yourself

We recommend that those interested in moving towards a pedagogy of ambiguity

within HPE first reflect on their own relationship with ambiguity, and attitude towards
it. The more we recognise our own discomfort with ambiguity, or ways of coping
with ambiguity that align with one of the disingenuous attitudes de Beauvoir outlines,
the more readily we will be able to identify similar struggles amongst students and
trainees. Possessing the ability to identify when a student may be struggling to cope
with the ambiguity of medical practice is an essential first step in providing students
with the support they need to move towards an attitude of genuine freedom regarding
ambiguity. Further, de Beauvoir highlights that the genuinely free individual is the
only person that can truly promote the freedom of others. Given this, in order to
support the professional identity development of those one teaches and supports,
educators and faculty must also embrace ambiguity themselves to become genuinely
free. This is, perhaps, easier said than done—we do not expect educators or faculty
who may currently possess a ‘serious’ attitude to become genuinely free overnight.
Rather, we encourage all those invested in HPE to reflect on their attitudes, challenge
them, and consider how they can aspire towards genuine freedom in the way that de
Beauvoir illuminates.

4.5.2 Acknowledge Ambiguity

We have already mentioned the necessity of embracing ambiguity. Referring to earlier

points in this chapter, we feel ambiguity is best conceptualised as the ‘ground’ of
certainty. That is, ambiguity is fundamental to our experiences, and certainty depends
on ambiguity as a preceding condition. In Chapter 5, the concept of ‘acknowledge-
ment’ is proposed in reference to the practice of empathy. Applying this concept to
ambiguity, it can be said that we all must acknowledge ambiguity to work towards a
pedagogy of ambiguity within HPE. Acknowledgement is defined by Chapter 5 as
‘any communicative behaviour that grants attention to others and thereby makes room
for them in our lives’. We must grant attention to ambiguity as a fact of medicine.
Acknowledging the condition of ambiguity within medical practice and HPE opens a
relationship with the concept and helps us become familiar with ambiguity as a way
of being, as opposed to something that is merely experienced, within our professional
lives.
4 The Serious Healer … 49

4.5.3 Start Early

Often within HPE, we try to protect or shield our students and learners from certain
complexities, only opening complex doors at later stages of their training. De Beau-
voir might say of this that, in protecting students from considering and acknowledging
ambiguity, we treat them as children and shape them to be ‘serious’—we have not
offered them the chance within our pedagogy or curricula to develop in any other
way. Exposing students to the practice of ambiguity and engaging in open, honest
discussion about the ways in which we may acknowledge the ambiguity of medicine
at an early stage of students’ healthcare training and careers may go some way to
encouraging students to move past a ‘serious’ attitude to ambiguity.

4.5.4 Connect Embracing Ambiguity and Ethical Action

For de Beauvoir, embracing ambiguity or, as we have proposed, acknowledging

ambiguity, is the precedent to ethical action. That is, without developing one’s rela-
tionship with ambiguity, it is impossible to act in a truly ethical way that supports
and promotes the freedom of patients. We speculate that positioning ambiguity as
central to the ethical practice of medicine may increase interest in discussion of
the concept amongst institutional leaders, faculty, and students themselves. Many
healthcare professionals are drawn to healthcare as a way to do some good in the
world. Ambiguity is an important key in unlocking this potential, by way of ethical
action.

4.5.5 Focus Action on the Needs and Freedom of Patients

The final practice point we would like to highlight concerns focusing on the needs and
freedom of patients within education and educational spaces, rather than on upholding
abstract values. As we have previously discussed, freedom is not an absolute value,
it is developed through our relationships with other people, and is an end to aspire
towards within interactions. As educators, we must all reflect on the ways in which we
actively pursue the liberation of patients, and any abstract values or ideals that may
be preventing us from upholding freedom for others. The concept of professionalism,
for an example, may be treated by a ‘serious healer’ as an abstract value that is prized
and pursued above all else—their professional identity is fixed to this concept. Yet,
it is increasingly recognised that organisational definitions of professionalism are
often restrictive, iniquitous, and may prevent engagement with advocacy for patients
(Brown et al. 2020).
50 M. Veen and M. E. L. Brown

Table 4.1 Practice points

1 Start with yourself and lead by example by reflecting on your own relationship with
ambiguity and certainty
2 Acknowledge ambiguity as a fact of medicine
3 Start early with students and trainees in regard to the acknowledgement of ambiguity
4 Promote embracing or acknowledging ambiguity as a precedent to ethical action within
medicine
5 Focus action on the needs and freedom of patients, rather than on upholding abstract
values

Action in this context, for de Beauvoir, involves social and political action to
liberate the oppressed. Within HPE, this may involve engaging with, and encour-
aging student engagement with, healthcare advocacy and the challenging of the social
inequities at the root of healthcare inequality. Upholding a concept like profession-
alism as an abstract value above the needs and freedom of patients in this context
contributes to the oppression of patients and is a character of bad faith regarding
ambiguity. As such, this practice point recommends that, at the core of students’,
trainees’ and practitioners’ professional identities must be a focus on the needs and
freedom of patients. Chapter 9 considers concrete ways in which a desire for social
justice may be practically enacted within HPE and so is also of relevance here.
The practice points outlined in the above sections are summarised for clarity in
Table 4.1.

4.6 Conclusion

In this chapter, we set out to consider the tensions between ambiguity and certainty
that manifest within HPE, and the ways in which de Beauvoir’s comprehensive
text ‘The Ethics of Ambiguity’ can act as an authority in developing a pedagogy
of ambiguity within HPE. We propose that such a pedagogy would act as a robust
facilitator of professional identity within higher education, encouraging students to
acknowledge ambiguity at a formative stage of their education, supporting them as
they come to terms with the fact of ambiguity within medicine, and promoting ethical
action through a focus on the liberation, or freedom, of patients.
Ambiguity is not something we must merely learn to tolerate within HPE—rather,
it is foundational to our very professional development. Reframing pedagogy in a
way which recognises that ambiguity is the ground to certainty will move HPE and
research closer to a central aim of HPE. That is, closer to graduating professionals
who respect and uphold the freedom of others, above all else.
4 The Serious Healer … 51

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Chapter 5
Acknowledgement: The Antidote
to Skillification (of Empathy) in Health
Professions Education

Anne de la Croix, Grace Peters, and William F. Laughey

5.1 Introduction: Empathy and Education

You want to study medicine. Ever since you were very young, you have wanted to help
people. When you were 10, your next-door neighbour ended up in a wheelchair after a
serious car accident. You loved your neighbour and often went over for a chat, and to see if
you could help her. She always used to say that her doctors could learn a lot from you. You
don’t think you actually did anything. But the conversations with your neighbour started
your fascination with illness and health. Since then, you haven’t been able to imagine a more
meaningful career than to work with people who are ill. You want to help them, to be there
for them and their loved ones. You hope to get into medical school.

The challenge with a concept as complex as empathy is agreeing on a common

definition. Without this, educators and researchers find themselves teaching and
researching a variety of concepts, any of which may bear the label of ‘empathy.’ This,
indeed, is the position in which we find ourselves: there is no one accepted definition
of clinical empathy (Mercer and Reynolds 2002). There is a level of agreement that
empathy is composed of cognitive, affective, action, and moral components, though
researchers disagree as to the relative importance of these (Morse et al. 1992) and
most attention is given to cognitive and affective components. For example, the
Jefferson Scale of Empathy (JSE), emphasises the cognitive aspects of empathy,

A. de la Croix (B)
Research in Education, Faculty of Medicine, Amsterdam UMC, location Vrije Universiteit
Amsterdam, Amsterdam, The Netherlands
e-mail: a.delacroix@amsterdamumc.nl
G. Peters
Veterinary Communication for Professional Excellence, Colorado State University, Fort Collins,
CO, USA
e-mail: Grace.peters@colostate.edu
W. F. Laughey
Hull York Medical School, University of York, York, UK
e-mail: william.laughey@hyms.ac.uk

© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2022 53
M. E. L. Brown et al. (eds.), Applied Philosophy for Health Professions Education,
https://doi.org/10.1007/978-981-19-1512-3_5
54 A. de la Croix et al.

arguing that affective involvement is in the realms of sympathy, rather than empathy
(Hojat et al. 2002). Halpern (2003), on the other hand, describes how feelings are
central to our understanding of empathy, and that true empathy depends on a degree
of emotional resonance with the other.
Of course, in HPE, ‘the other’ generally refers to the patient, though empathy
for colleagues and students is also important. It is reasonable to consider whether
empathy in the patient context is different from any other kind of empathy. In prin-
ciple, we don’t believe it is, but there are specific considerations. The concept of
empathy includes the concept of opacity—the idea that whilst you may share the
thoughts and feelings of another, you still retain your sense of self and don’t become
the other (Bizzari et al. 2019). This sense of self in a clinical situation is also a sense
of professional self. This may modulate empathic reactions: for example, empathy
for a relative may provoke tears, whilst empathy for a patient may, more often, be
expressed in words of comfort for professional reasons. In addition, clinical empathy
is driven by an ethos of care, and outcomes are more likely to carry health benefits,
including the provision of emotional support, the desire to help problem-solve and
the intention to prescribe or intervene in other therapeutic ways.
Whatever analogies or personal definitions we use for empathy, there is general
agreement that empathy is connected to attentive listening. The psychologist Carl
Rogers (1986) argued that for therapists to have empathy for clients they needed
to actively listen and feedback thoughts and feelings. This link between listening
and empathy has also been implicit within research with Simulated Patients (SPs)
(Laughey et al. 2018). Indeed, whenever SPs talked about listening, they also talked
about empathy, and vice-versa. SPs also detailed the types of attributes that allow
patients to know that listening is taking place—attributes like eye contact; nodding;
the mirroring of body language; asking the types of questions that indicate the clin-
ician is hearing cues and picking up on them; summarising back to the patient to
check understanding; and asking the kinds of open questions which help patients tell
their story. Active listening combined with an interest in the whole illness picture,
where clinicians explore not just the patient’s symptoms, but how they affect the
patient’s life, and consider the patient’s perspective—including the classic triad of
ideas, concerns and expectations (ICE)—are at the heart of empathic, patient-centred
approaches to communication (Kurtz et al. 2017).
In a philosophical inquiry into the nature of empathy, Davis (1990) argues that
empathy is akin to a process of ‘crossing over’ in which a person suddenly finds they
are closely aligned to another, a crossing that simply happens when the conditions are
right and that cannot be forced. In those moments of eye contact, attentive listening,
and striving to understand the perspective of the other, there will be empathic oppor-
tunities when thoughts and feelings resonate. Davis likens it to falling in love, again
something that cannot be forced.
An analogy that is often used to capture the essence of empathy is “the ability to put
yourself in somebody else’s shoes”, or “the ability to put yourself in somebody else’s
story” (Laughey et al. 2018, 665). Whilst this a helpful metaphor, it does not capture
the full scope of the concept. Empathy has efferent as well as afferent components
(Morse et al. 1992). It is all very well for a clinician to experience empathy for a
5 Acknowledgement: The Antidote to Skillification (of Empathy) in Health … 55

patient, but unless they communicate this back, the patient may never know. A fuller
analogy may therefore be, ‘the ability to let somebody else know that you have put
yourself in their story’. This is, perhaps, why SPs generally welcome the so-called
‘empathetic statement’ (Laughey et al. 2018). Empathic statements usually take the
form of brief statements of empathy, such as, ‘I’m sorry to hear that’, or ‘I imagine
that must be difficult for you’. These are one of the ways doctors demonstrate to
patients that empathy is being felt. However, SPs also urge caution—it is easy to
detect when an empathic statement is being forced out, essentially delivered in such
a way that it is clear it is not sincerely meant. This problem of fake empathy is a
significant one, and contemporary approaches to medical education are unwittingly
exacerbating it (Laughey et al. 2020b).
There is good evidence that students freely admit to faking empathic statements
(Laughey et al. 2020a). In teaching, they are encouraged to make statements of
empathy even at times when they are not feeling empathic; they also witness their
supervisors and peers making similarly hollow statements. In assessment, they feel
the surest way to ‘tick the empathy box’ is through the liberal application of empathic
statements, which in the pressured setting of an Objective Structured Clinical Exam-
ination (OSCE) assessment are almost always forced, rather than natural. This is a
situation that students feel uncomfortable with—the disconnect between the giving
of empathy and the feeling of it. This problem has been termed ‘empathic dissonance’
and defined as “the mental discomfort experienced by the act of making expressions
of empathy that are not sincerely felt” (Laughey et al. 2020a; 2020b, 428).
The difficulty with insincere statements of empathy is that they cut across other
efforts to create the empathic moment. This casts doubt on any attempts by educators
to encourage students to force empathic statements, including the advice of the four
habits model (advocated by one of the USA’s leading health care providers, Kaiser
Permanente)—this model recommends clinicians make at least one empathetic state-
ment per encounter (Frankel and Stein 1999). Whilst the spirit of this advice may be
well meant, if it results in clinicians trying to force an empathetic moment, the deli-
cate conditions that encourage empathic ‘crossing over’ may be undermined. Using
models and ‘grids’ to force specific behaviour, however well intended, can lead to a
process we call skillification.

5.2 Skillification

You got into medical school. It is wonderful and you love it. It is also hard, hard work. The
study load is incredible, and you need to work a job on the side to make enough money.
The exposure to suffering, illness and disease can be confronting, and learning about the
limits of health care is tough and can dampen your spirits. Your OSCEs are coming up, in
which you need to demonstrate your competencies. You desperately need to pass the test,
and start looking at the score list for the different stations in the OSCE. You start preparing,
by practicing empathic expressions.
56 A. de la Croix et al.

It is beautiful that the call to humanize medicine has been heard in medical education.
A ‘good doctor’ has ample clinical knowledge and is skilled in doing a physical exam-
ination or a surgical procedure, but, in recent decades, there is agreement that there
should be more: a doctor should be a pleasant person to interact with, for colleagues
and patients alike. The ‘human touch’ of physicians has found its way into medical
education in many shapes and forms, and the growing attention to empathy is one
of them. Empathy is a beautiful concept and is one of many concepts that has been
introduced to medical education to humanize medicine and stress the importance of
connection. Other such concepts include patient-centredness, compassion, reflection,
collaboration, and communication. Yet when complex concepts—characterized by
their elusive nature—are applied in medical education, they are forced to take on a
different form to survive in the field. Indeed, the science of medicine requires a posi-
tivist paradigm, where things can be known (see Chapter 10 for expansion on this).
But when elusive concepts appear within positivism, the Tyranny of Metrics forces
complexity into neat grids (Muller 2019). Empathy turns from a ‘fuzzy’ concept into
a set of phrases to utter in an exam, something you can ‘do’, rather than experience
or create.
We call the problem behind empathic dissonance and fake empathy ‘skillifica-
tion.’ We define skillification as the process of defining, delineating, and inevitably
reducing features of human communication in order to measure their use and assess
how students use them. A similar process has been described by Nimmon (2020) as
‘technification’. It starts with creating clear definitions and continues with descrip-
tions of what a particular concept ‘looks like’ in practice. These traits are then
translated into an observation grid, an assessment matrix, or a checklist. Common
communication skills,1 for example, include tasks like open-ended questions, reflec-
tive listening, summaries, and empathic statements. The emphasis on observable
behaviours as skills is concerning, as it may be teaching the natural empathy out of
students and moving them to a forced and unconvincing representation of empathy.
It is also concerning as communication becomes a very specific endeavour, damp-
ening diverse ways of expression and disadvantaging non-native speakers (Atkins
and Roberts 2018). Skillification translates aspects of connection into tickable boxes
of visible behaviour, which, in the process, disregards diversity and humanity—it
is a reductionist approach. This way of working is of key importance in other parts
of health professions (protocols for patient safety, ways of working in operating
theatres), yet does not work when applied to ‘unmeasurables’ such as communication,
empathy, and reflection.

1 Communication, however, is so much more—Prof. John Skelton at the University of Birmingham

in the UK consistently rejected the word ‘skills’. Rather, in his department, teaching was all about
‘clinical communication’—part of the reason his team thrived was because that concept was left
undefined. We argue that leaving the precise meaning of complex concepts such as ‘empathy’
undefined might prevent skillification. It will however present the field with a different set of
issues,namely: how to deal with ambiguity and how to measure progress of the undefined? This
might be tricky, but we feel it is preferred over the danger of the current skillification: cynicism
towards empathy, and a bad reputation of such a meaningful concept.
5 Acknowledgement: The Antidote to Skillification (of Empathy) in Health … 57

Reflection is another rich and complex concept that has been reduced to a checklist
of visible behaviours devoid of personality. In requiring students to reflect on an
activity, often in written assessed reflections, “reflective zombies” arise because of
the dominating urge to make concepts measurable (de la Croix and Veen 2018, 394).
Students learn to move through the visible behavioural steps that they have learnt
to mean ‘being reflective,’ possibly without actually reflecting in their own unique
way. A consequence is that reflection is falling into disrepute for being a meaningless
check-box exercise. This is ironic, since reflection was first introduced into medical
education to add richness, depth, and value. The skillification of reflection is similar
to what we described is happening with empathy: empathy is operationalised as a
list of visible (often verbal) behaviours, allowing (or forcing?) students to ‘perform’
empathy without experiencing it or living it. Literature about ‘gaming-the-system’
(Rees and Knight 2007; Mak-van der Vossen et al. 2019; De Leng et al. 2019) is
fascinating, as it shows that students know what they need to show to progress and
succeed in a specific context. Gaming-the-system behaviour can be linked to the
(sometimes seemingly invisible, yet dominant) epistemological stance in the field: if
measurement criteria are clear, students will steer towards those criteria when being
observed or assessed. We fear this hinders learning about oneself and about human
connection, so called ‘transformative learning’ (Mezirow and Taylor 2009), in which
personal differences need to be explored and affective learning plays a big role.
A driver for these unwanted side-effects (empathic dissonance, zombies, gaming-
the-system, etc.) in medical education is the urge to assess and measure everything.
This is a strong urge in any educational setting, but, perhaps, it is even stronger in
medical education. This makes sense, as monitoring and measuring have clear merits:
it gives us insight in health care needs and can help in controlling quality—both very
important when it comes to preserving life and avoiding death. The epistemolog-
ical hierarchy is strong in medicine, and it privileges positivist, seemingly ‘objec-
tive’ research. However, the influence of this positivist paradigm extends to domains
where it, perhaps, should not meddle. The epistemological hierarchy maintains that
only knowledge that can be objectively measured is worthwhile knowledge. And our
complex concepts pertaining to humane medicine have had to conform to this orien-
tation to gain legitimacy. But applying checklists and measuring tools to empathy
and reflection, for example, can have negative effects on the way medical students’
humanity is allowed to develop, as everything has to be demonstrated, everything has
to be ‘countable’. The urge to measure complex concepts (i.e., empathy, reflection,
professionalism, communication, collaboration, etc.) according to well-defined gold
standards that often take the shape of rubrics, checklists, or questionnaires, might
lead to superficial learning and the eventual dismissal of complex concepts.
It is an ongoing dilemma in education –how to teach and assess ‘the human
touch’ without creating zombies, without stimulating gaming-the-system behaviour,
and most of all, without limiting the diversity of viewpoints and personalities in
the classroom, and the authenticity of future doctors. Students strongly associate
empathy with virtue, something that makes you a better person and a reason why
you came to medical school (Laughey et al. 2021). Without a certain ethos, students
are not prepared or willing to undertake the time, mental, and emotional labour into
58 A. de la Croix et al.

developing connections with patients. Students need to be prepared to make a habit of

adopting that listening agenda and deploying those attributes of hearing the patient—
it’s not just having the skills to do them, it’s having the ethos, the drive, the “ought.”
Skills alone are not enough, yet, somehow, they have become the focus. Scholars
have attempted to overcome skillification by conceptualising empathy as a position
or a stance, but, ultimately, empathy in medical education is deeply entrenched in a
discourse of skillification that essentializes communication rather than envisions it
as a life-constituting activity.
If we can reset, and move away from skills and towards attributes, we may firm
up the belief in the value of empathy, or, at least, stop driving this cynicism towards
it. The reductionist, technicist approach causes more harm than good when it comes
to teaching empathy (and reflection, communication, etc.). We argue that digging
around in philosophy and embracing philosophical complexity is necessary. One
philosophical notion in particular, namely acknowledgement, feels like the right
antidote to skillification.

5.3 Acknowledgement

You made it. You are a doctor. And sometimes you actually get to do what you wanted: help
people and be there for them. Every day, you get to use a snippet of knowledge, a little trick,
or a spark of insight from your training. And every day you learn more. One day, you meet
a lady who ended up in a wheelchair after a serious car accident. She reminds you of your
neighbour. You are not able to cure her or help her in her new life with a disability. These
are the limits of medicine. Instead, you sit and talk to her while she waits to be picked up.
You listen to her story without saying anything. She feels your concern and care. She thanks
you. You don’t think you actually did anything. But you are making things better. Through
connection. By acknowledging.

We propose the notion of acknowledgement as an antidote to the skillification of

empathy in medical education. Importantly, we are not suggesting acknowledge-
ment replaces empathy to become the new “pièce de resistance,” as we fear this
leads to an inevitable breakdown whereby medical educators then distil and assess
“acknowledgement.” Historically, acknowledgement goes by many names and finds
itself among many traditions—Bateson’s (1972) notion of validation, and Buber’s
(1988) description of confirmation, to name a few. Yet, we present a philosophical
portrait of acknowledgement, inspired by Michael Hyde’s ontological theorization
and clarification, to generate a conversation about how we conceptualize and teach
human connection in health professions education.
Michael J. Hyde in his book The Life-Giving Gift of Acknowledgment (2006)
defines acknowledgement as “any communicative behaviour that grants attention to
others and thereby makes room for them in our lives” (1). Indeed, acknowledgement
is an observable behaviour, but it is the ontological nature of that behaviour that
5 Acknowledgement: The Antidote to Skillification (of Empathy) in Health … 59

distinguishes it from becoming a check-box exercise. Acknowledgement is a moral

and ethical act rooted in the metaphysics2 of relationality.
The need for every human being to be acknowledged is fundamental to relation-
ality, as Levinas (1969) states, “the social relation… is the ultimate event” (221;
emphasis added). Hyde takes up Levinas’ claim in stating that it is the
…ontological structure of existence that makes possible acknowledgement…the originating
force for the human propensity to wonder about ‘who we really are’ and ‘where we really
come from’. (10)

Acknowledgement is an act that was first done for us—whether explained through the
Big Bang, the Creation narrative, or any other generative myth (as Hyde unpacks)—
some opening brought about existence and the ability to question it.
The fact that we question our existence makes it possible for us to acknowl-
edge and cultivate the existence of others. Hyde develops acknowledgement through
Heidegger’s notion of being (da-sein):
…that place, “there” (“da”), where being (“sein”) can show itself to a consciousness that
can not only feel, see, and hear its presence in the materials of everyday life, but can also
reflect on and articulate understanding of the perceived event. (39)

In other words, it is our self-reflexive capacities to question existence that are

embedded with the foundations of acknowledgement. In discussing being, Heidegger
(1962 [1927]) claims that the human is, “distinguished by the fact that, in its very
being, that being is an issue for it” (32; as quoted by Hyde 2001, 38). But our own
existential concerns are not enough as when we reflect on our being, we find that it is
interwoven with the existence of Others. We are only able to question our existence
through the acknowledgement of others—without which, where might we find the
language to even think (Jaynes 2000)?
Therefore, we ought to carry on the dialogic process of acknowledgement that
was first afforded to us, as, without it, social death is inevitable. Hyde illustrates
the importance of acknowledgement by asking, “what would life be like if no one
acknowledged your existence?” The isolation, loneliness, anxiety, suffering, and
loss of such an existence demonstrates what Hyde calls “social death.” Social death
occurs through repeated communicative refrains (i.e., avoiding a smile, moving past
someone, dismissing a plea, etc.) and institutionalized forms of discrimination (i.e.,
racism, sexism, ageism, etc.). We are all in need of acknowledgement; it is a recur-
sive process that frees humanity from the despair of social death through attentive
communicative action. We offer acknowledgement to others as a life-giving act. This
goes beyond mere recognition, or noticing, to a sustained openness towards others,
“even if, at times, things become boring or troublesome” (Hyde 2006, 4). Most
importantly, acknowledgement steers through the questions of empathic resonance
and invites us to cultivate a space for being together through sustained openness,
attention, and communicative action.

2 The Oxford Dictionary of Philosophy, 2nd edition, defines metaphysics as ‘the branch of philos-
ophy that deals with the first principles of things, including abstract concepts such as being, knowing,
identity, time, and space’ (Blackburn 2005).
60 A. de la Croix et al.

As we move through the world, we come face to face with others who issue
calls for response (that no one else can respond to in that particular moment). Hyde
poses a question-and-answer sequence—“Where art thou?”/“Here I am”—to show
the impact of our responsiveness in the continuous unfolding of acknowledgement
in our existential existence. In coming face to face with others, there is the possi-
bility of response, which is “the essential human deed” (Stambaugh 1992). Barad
(2003) turns to the phrase “response-ability”, as in the ability to respond and a moral
obligation to do so. Acknowledgement is that essential communicative act whereby
we grant attention to others and make room for them in our lives. Hyde emphasizes
the verbal and non-verbal dimensions of acknowledgement, but, like Barad (2003)
(see Chapter 12 for more detail on Barad’s ontological approach), adds that commu-
nicative acknowledgement, “needs what it brings into being for the sake of ourselves
and others: a space, a place, the planet’s crust at the very least” (18) extending
beyond human activity to the post-human affective entanglements of intra-activity
(using Barad’s vocabulary; see also Iedema 2011). Acknowledgement is a cultivating
activity that creates space for others—physically and metaphysically.
Existential disturbances demand we question the nature of being, which are
inherent to clinical practice. When coming face to face with life-changing illnesses
or accidents, how we understand and make sense of world shifts. As Hyde (2006)
eloquently states,
…the face of a dying person speaks to us a fact of life that most people would rather forget.
In avoiding their presence, we deny them the respect of acknowledgement and thereby run
the risk of contributing to their pain and suffering of their social death. (185)

In moments of existential instability, the “call of conscience” rings out—“where art

thou?” To answer this call of conscience (“here I am”) we acknowledge, we show
up, and stay open. Interestingly, this is not unlike the moral approach to empathy
described by Halpern (2001), who uses the term ‘compassionate curiosity’: a drive
to remain engaged with patients and stay curious about their situation. It is not a
cognitive, affective, or epistemological process (like “stepping in another’s shoes”),
but an ontological one.
Indeed, we can envision resistance to this sustained openness to others and the
practitioners’ need for acknowledgement. We colloquially hear practitioners say,
“if I connect with everyone, I’ll burnout,” or, “I can’t be dependent on my super-
vising clinician or my patient to acknowledge me, because I’ll be dissatisfied.”
Acknowledgement is not a one-to-one activity, but a:
…caress of a ‘suffocating embrace’ that is always challenging us to overcome its inherent
pain and suffering by way of action– the very thing whose constant performance [acknowl-
edgement] sooner or later incites fatigue and weariness and thereby leads us back to the
suffocating embrace…human beings can take control of themselves, and even in the face of
horrifying circumstances display courage and responsibility. (Hyde 2006, 121–122)

The metaphysical conditions of acknowledgement push us to acknowledge others

and pull us from others so we may sustain aside from their acknowledgement. Being
in the waves of existence does not negate the necessity of acknowledgement to our
existence—in the throws we act, even if we float for a moment.
5 Acknowledgement: The Antidote to Skillification (of Empathy) in Health … 61

The philosophical orientation of acknowledgement redirects us from questions

of knowing (epistemology) to questions of being (ontology) (see Chapter 10 for
full considerations of these terms). It is not about whether acknowledgement (i.e.,
empathy, patient-centred communication or whatever we want to call it) authentically
occurs, or how we can know a medical student or physician accomplishes it. When we
occupy ourselves with such questions—as the discourse of skillification requires—
we become stuck in a black box of beetles (mental unknowables) that ultimately
impinge how medical students might connect with patients. We can never know
whether acknowledgement or empathy are authentically experienced (Wittgenstein
1963; Veen et al. 2020). In fact, Heidegger’s ontological shift presupposes inauthen-
ticity and invites self-reflection in the process of becoming (as being would have
us to do) as a way through it. As Veen (2021) states, “the path to authenticity is to
reflect on the ways in which I am always already in some way inauthentic” (144).
For human connection in medical practice, it is questioning, ‘How am I connecting
or not really or even faking it? Why? What is that doing? What else is there?’
As human beings, we are often calling into question our own existence, or
witnessing disruption in the lives of others (Hyde 2018). Attuning our consciousness
to the calls from others (“where art thou”) and acknowledging the humanity before us
(“here I am”) to genuine depths of care is profound. The ethos of acknowledgement
fosters the abilities for us to know together through shared space and attention, as
well as provides the opportunity for us to self-reflect on that relationality. Acknowl-
edgement creates a dialogic space for us to dwell together and deliberate, which
foregrounds collaborative agency and humanizes the Other before us. As clinical
educators, we envision this deeper existential meaning as one that philosophy offers
medical education, if only to start the conversation about what we are doing is doing.

5.4 Conclusion

You have been practicing medicine for 10 years now. After roughly 10 years of training
and 10 years of practice, you start thinking about what has helped you the most in the way
you communicate with patients. You remember one or two communication techniques from
medical school. A few impressive consultations between a consultant and a patient, that you
observed during your clinical rotations, have stuck with you. But the most important contri-
bution to being a ‘good communicator’ is harder to pinpoint. It is the movies you watched, the
friends you made, the books you read, the way you relate to your family, the many different
patients you met, the travels you made, the emotions you felt, the conversations you had.
Communication is contact. And contact is acknowledgement. Of others – and of oneself.

In this chapter, we illustrated the challenge of empathy in medical education, how

skillification works, and how it can turn a rich and meaningful concept into a super-
ficial ‘skill’. This worrying trend robs medical students of truly learning about
humane health care and can make us all cynical about complex concepts in medical
education as the meaning is ‘skillified’ out of them. We propose the concept of
acknowledgement as an antidote to skillification.
62 A. de la Croix et al.

Table 5.1 Practice points

1 Rethink and reconsider assessment practices
2 Talk about complex concepts and their meaning (and do not define them strictly)
3 Make use of patient participation in the curriculum
4 Invest in medical humanities
5 Create acknowledgement between teachers and learners

We are not trying to replace the concept of empathy with the concept of acknowl-
edgement. Rather, by allowing acknowledgement to inform the underlying philos-
ophy of connection, we can combat skillification and revitalise concepts like empathy,
connection, and communication. We envisage medical education to rest on a healthy
underground of acknowledgement.
This is all well and good to philosophize about, but health professions educators
are people of action. So, what can we do to move toward a learning culture that is
antithetical to skillification? We believe that there are five areas of key importance
when designing curricula in which students are allowed to let their humanity grow
and develop. They are summarised in Table 5.1 and elaborated on below.
First, as assessment and measurement lie at the heart of skillification problems,
it is worth having a closer look at what needs to be assessed and why. The natural
tendency in education is to start with learning outcomes and ways to check if these
are obtained. An assessment and quality control plan might be high on the list of
actions to undertake when designing curricula. However, for more intangible aspects
of development and growth, such as empathy, some free space in the curriculum might
be more suitable. We would like to challenge educators to think about assessment-
free areas in the curriculum, as well as develop arguments that justify them within a
tyranny of metrics and positivism.
Second, we need to take a close look at the way in which “traveling concepts” (Bal
2009, 13) such as reflection, professionalism, empathy, communication, collabora-
tion, leadership, are operationalised in the field of medical education. This requires
philosophical and critical analysis of the field. We need to ask each other, and our
students: what does patient-centredness mean to you? When did you experience
empathy? When and how do you reflect? In the humanities, philosophy, and social
sciences, talking about complex concepts is standard practice. It is a very different
model to that of stating empathy can be defined as this and it sounds like that. Inviting a
dialogue based on lived experience is a fertile ground for cultivating unique humanity.
Third, to stimulate connection and contact, students might benefit from taking the
patient’s perspective. Involving patients in both the pre-clinical and clinical part of
medical school is advisory. Wonderful examples of patient participation in educa-
tion are luckily not hard to find, for example: GP trainees joining patients as partners
in medical consultations (Mol et al. 2019), medical students visiting the homes of
families with a special needs child to learn about the life with disability (Anderson
5 Acknowledgement: The Antidote to Skillification (of Empathy) in Health … 63

et al. 2019). These meetings can help forge bonds between future health care profes-
sionals and patients, will stimulate acknowledgement and make it easier for students
to understand the patient perspective.
Although conversations with patients can be fruitful, witnessing them in aesthetic
form can be transformative. The poems, stories, plays, and art that has been created
around medical practice offers a starting place for conversations about complexity.
Art has the power of ‘making strange’ (Kumagai and Wear 2014) and allows for deep
learning that stretches beyond the cognitive level. In the words of painter Georgia
O’Keeffe: “I found I could say things with color and shapes that I couldn’t say
any other way - things I had no words for.” Interpretation is inherent to art, as
is how we interpret and make sense of ourselves in relation to it. Reflection on
ourselves, on others, on relationships, requires changes in perspective, which the arts
and humanities specialise in. Good art changes us, and perhaps in further integrating
the medical humanities, we can begin to cultivate physicians who consider their own
relations to the profession (Finn et al. 2021).
Finally, and perhaps most importantly, as health professions educators we should
be the givers and receivers of the life-giving gift of acknowledgement. Acknowl-
edgement as a space-creating activity can be used to create a clear space where
students feel welcome as their whole selves, including their everyday concerns and
contingencies. Perhaps in doing so, we reconsider how we are pushing such intense
pressures (perhaps only because we’ve experienced this sort of brutal indoctrination
ourselves). Hyde has much to say about education and acknowledgement function,
so it is with his words we leave you this final consideration:
…by giving others the right and appropriate attention, listening and remaining open to
them, and thereby creating a dwelling place… to feel at home while they discuss matters
of importance and learn to care for one another’s ideas. Genuine acknowledgement requires
nothing less than entertaining this process of engagement. (Hyde 2006, 182)

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Chapter 6
Tracing Philosophical Shifts in Health
Professions Assessment

Walter Tavares, Jacob Pearce, and Kevin Eva

6.1 Introduction

Assessment of clinical competence continues to challenge the health professions,

leading educators and researchers to seek new solutions to existing and newly iden-
tified problems. Broadening definitions of competence, increasing complexities of
practice, cultural variations including socially constructed performance norms or
expectations, the valuing and devaluing of some features of assessment (e.g., objec-
tivity and subjectivity), newly identified limitations in the way assessment is enacted,
and much more, provide ongoing stimuli for advancement and change. Other related
shifts, including new programs of research (e.g., entrustment), the introduction of
educational approaches or policy changes (e.g., competency-based education), or
simply broadening ways of thinking about assessment problems and solutions (e.g.,
careful delineation of what is (or is not) accessible to observers) also keep the field
searching for ways to improve practice and manage unintended consequences.
But what is driving these shifts in assessment theory and practice? Health profes-
sions education (and, indeed, education in general) has shifted in the underlying
philosophical positions shaping practice over the past 50 years and the subdo-
main of educational assessment is no exception. The implications of this general

W. Tavares (B)
The Wilson Centre for Health Professions Education, University Health Network, Toronto, ON,
Canada
e-mail: walter.tavares@utoronto.ca
Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
J. Pearce
Australian Council for Educational Research, Camberwell, VIC, Australia
e-mail: jacob.pearce@acer.org
K. Eva
Centre for Health Education Scholarship, University of British Columbia, Vancouver, BC, Canada
e-mail: kevin.eva@ubc.ca

© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2022 67
M. E. L. Brown et al. (eds.), Applied Philosophy for Health Professions Education,
https://doi.org/10.1007/978-981-19-1512-3_6
68 W. Tavares et al.

philosophical evolution are far-reaching but are not always clear in terms of how
thinking about assessment has evolved nor with respect to their implications. In this
chapter, we offer examples that illustrate how shifts in perspective have influenced
practices in this domain in an effort to make the various worldviews currently influ-
encing the world of health professional assessment more transparent and, ultimately,
to promote future advances.
Some advances in this realm have resulted from tweaks to strategy within a consis-
tent worldview, but others have been revolutionary, clearly linked to (or representa-
tive of) different ways of thinking. In the latter camp, Schuwirth and van der Vleuten
(2020) described three distinct phases, spread over the last five decades, during
which emphasis has shifted from measurement, to judgement, to systems of assess-
ment (Schuwirth and van der Vleuten 2020). In the first phase, the prominent focus
was on deconstructing competence to its component parts, striving to avoid human
judgment and promoting strategies aimed at achieving objectivity and reliability. A
core assumption driving this perspective was that, to be fair, competence had to be
quantified and objectively measured. This phase is characterized by psychometric
approaches and positivist views as the search was for means of uncovering truth and
eliminating the noise that occluded it. As limitations inherent in the measurement
paradigm became understood, including increasing awareness of context specificity,
limitations of objectivity, and broader notions of expertise, a second phase emerged
in which the focus turned to “assessment as judgment.” This phase witnessed a
greater reliance on work-based assessments, more versatile uses of assessment (e.g.,
the use of narrative feedback) and the valuing of observer differences in human judg-
ment (ten Cate and Regehr 2019; Hodges 2013). Psychometrics was still dominant,
but positivist views became de-emphasized as post-positivist, and in some cases
constructivist or interpretivist, views began to take hold. Notions of ‘error’ began to
change, as variation was argued to offer richness and meaning to assessment data
rather than simply being ‘noise’ that had to be eliminated. Most recently, medical
educators have begun to conceive of “assessment as a system” with greater recog-
nition of the complexity of education and context; this phase values judgement and
highlights the “fuzzy boundaries” between acceptable and unacceptable assessment
solutions because unintended consequences and wicked problems abound; further,
it promotes the construction of meaningful holistic narratives over sets of individual
assessment instruments. Programmatic assessment is dominant here, with notions of
constructivism, interpretivism and pragmatism offering better representations of the
ways of thinking that led to this state.
Transitions such as those described above reveal at least three implications that
anyone seeking to understand assessment in health professional education should
consider. First, as the philosophical positions influencing education in general have
changed, it is only natural that they would influence perspectives on assessment,
leading to new ways of understanding problems and deriving solutions in this domain.
By philosophical positions we mean:
…sets of recognized assumptions and commitments or intellectual frameworks that provide
assessment scholars with lenses for examining assessment problems and solutions. (Tavares
et al. 2020, 2)
6 Tracing Philosophical Shifts in Health Professions Assessment 69

These philosophical positions influence how we think about, define, and represent
the construct of interest (e.g., what is competence), what strategies and methods
provide the best means to assess that construct, and what counts as justification
in support of any claims made through the assessment activities and data generated.
More fundamentally, they influence how we think of assessment itself: is it sensible to
draw meaning from one person judging another’s empathy? Is the act of evaluation
a social or cognitive endeavour? In formulating an assessment, are we accessing
constructs that reflect the individual or formulating representations based on our
own understanding?
Second, there are practical benefits to examining assessment through the lens
of philosophical positions. For instance, as constructivist/interpretivist views take
greater prominence, a greater emphasis has been placed on the use of language to
address limitations associated with the formative use of numerical ratings (Hanson
et al. 2013) requiring that different standards are brought to bear when determining
the utility of assessment strategies. That is, challenges related to the usefulness,
structure, or defensibility of any one assessment tool or process become highlighted
and new solutions brought forward through insights shaped and guided by adopting
different philosophical positions.
Third, while transitions in thought can illustrate tensions in assessment, it is
possible for different philosophical positions to co-exist and, as a result, it is partic-
ularly important to clearly state the position from which one is arguing. Disagree-
ments about how to proceed, legitimacy debates, the use of familiar and similar
language while holding different meanings, and the mixing and matching of ideas
while focusing purely on methodological activities in the absence of their philo-
sophical underpinning all sum to create confusion and non-productive conflict when
individuals’ assumptions and commitments are not made transparent or not given
sufficient attention (Tavares et al. 2020). These moments, however, also create valu-
able opportunities for generative conflict leading to marked advances in assessment
practice (Pearce and Tavares 2021).
It is, thus, in moments of transition in assessment that the applied value of consid-
ering philosophical positions can most readily be observed, and insights generated. In
this chapter, therefore, we draw on instances in which philosophy has been applied,
sometimes implicitly, to spark transitions in assessment in health professions educa-
tion. Doing so will demonstrate the importance of interrogating philosophical posi-
tions to more deeply understand how shifts in assessment configurations occur. While
this literature continues to evolve, our intention is to reveal where and how shifts have
occurred over time to illuminate what they mean for our community going forward.
As such, we do not seek to prove any one philosophical position right or wrong; nor
do we believe it to be fundamentally flawed that proponents of each or various posi-
tions continue to contribute to the field; instead, we describe philosophical shifts as a
means to be generative and, hopefully, stimulate new arguments and ideas by offering
focus regarding what matters to assessment experts and how bridges might be built
between theory and practice. Meaning and understanding shapes design, interpreta-
tion, and determinations of quality. As such, we hope to use the analysis of several
70 W. Tavares et al.

specific transitions as a means for enabling readers to use philosophical positions as

meaningful and helpful tools for assessment development and argumentation.

6.2 Overview

To explore the impact of philosophical positions in assessment we have selected five

examples. First, we discuss the labelling of assessment as formative or summative
along with reasons researchers have come to challenge that dichotomy. Second, we
explore how increasing emphasis on formative activity (assessment for learning) has
led to programmatic assessment; here we describe how its evolution has shifted over
time and how its development as an approach has leveraged different philosophical
positions. That evolution has placed greater emphasis on rater-based assessments
and, hence, our third example focuses on the role of raters (assessors) in assess-
ment processes, examining how different philosophical positions have influenced
how assessors are prepared for their task, what their contributions mean, and how we
might use raters to make decisions about competence. Common critiques of rater-
based assessment have focused on reliability challenges, so example four explores
assessment transitions from the position of metrics used to determine a tool’s utility.
Specifically, we explore how the movement from Classical Test Theory to Gener-
alizability Theory should be conceived of as an evolution in thinking, not simply
an expansion of the underlying mathematics. This example, in particular, outlines
how one’s philosophical position cannot necessarily be inferred from the tools they
apply. Finally, we end with a look at the most fundamental of all concepts in the
assessment world, validity, scoping its transition over time along with how different
philosophical positions have been applied to that concept.
Each of these examples has been written as a vignette in its own right, indepen-
dently illustrating a shift in the applied philosophy underlying assessment practices
in the health professions. Taken as a whole, though, we argue that they illustrate
that assessment’s utility is not defined simply by the tools or methods one chooses
to use, but by the interaction between those choices and the stakeholders by whom,
on whom, and with whom they are engaged, thereby illustrating how fundamental
philosophical perspectives are in this domain.

6.3 Example 1: The Formative Versus Summative

Admonition

One need not look far to see how the move away from positivist views of education,
with their assumption of an underlying reality, have begun to influence thinking about
assessment practices. The first thing typically taught in any course on assessment is
that it is critical to know the purpose to which assessments are being put (Yudkowsky
6 Tracing Philosophical Shifts in Health Professions Assessment 71

et al. 2019): if creating a summative record of achievement (assessment of learning)

is our priority, then the reassurance offered by principles of objectivity, reliability
and validity are easily perceived as paramount to ensure that trainees are being
advanced or held back based on trustworthy and meaningful metrics; if, in contrast,
assessments are offered primarily for formative purposes (assessment for learning),
then lower standards in that regard are acceptable and greater attention should be paid
to enabling professional development by questioning if the assessments are directing
students to the right activities, stimulating motivation for further improvement, and
enabling effective feedback to be provided.
Cynically, one can see this distinction as a means for maintaining assessment prac-
tices that don’t hold up to psychometric scrutiny (by justifying them as ‘for learning’
rather than ‘of learning’) or as a means of rationalizing why assessment designers in
‘summative’ situations should not concern themselves with whether or not construc-
tive feedback is provided. The problem with this dichotomy, however, derives from
the notion that the tools themselves have no knowledge of the purpose to which they
are put. That is, one can label an Objective Structured Clinical Examination (OSCE)
as being purely for formative purposes, but what matters in terms of its impact is the
implications the event holds from assessment candidates’ perspectives (Pugh et al.
2018). If students perceive a threat to their academic progress, professional identity,
or anything else, they are fully justified in treating any instance of assessment as a
high-stakes moment, focusing on performing as well as they can and hiding their
deficits rather than openly engaging in the discussions or behaviours that might best
serve their learning (Mann et al. 2011). That is, they would be right in pursuing the
behaviours that are most likely to offer reward in terms of ‘maximizing their grade’
rather than taking advantage of the developmental opportunity a “formative” assess-
ment is meant to offer. At the same time, students do learn from summative exams, by
virtue of preparatory activity, the retrieval-enhanced learning induced by taking the
test, and any impetus the experience creates that leads candidates to look up answers
to questions with which they may have struggled (Gielen et al. 2003). To ignore how
we might optimize their capacity to do so by claiming ‘that’s not our purpose,’ there-
fore, is to harm the quality of our education and healthcare systems by not taking
advantage of some of the best data candidates could ever have to empirically guide
their development (Eva et al. 2016).
The philosophical shift here is the recognition that assessment does not occur in
a vacuum distinct from the beliefs of the people involved. Constructivism helps us
to understand this given its emphasis on the social construction of reality. So, too,
does hermeneutics and its teaching that the intent conveyed by a text (assessment
in this instance) is filtered through the interpretation of others rather than acting on
the world directly. Regardless of the explicit intent of the assessment designer, the
impressions of the assessment takers (i.e., the recipients) and those at the institutional
level using the assessment data matter and should not be ignored because they play
a crucial role in determining the outcomes observed.
In fact, we would go so far as to say they play a critical role in determining the
culture of medicine. Like most dichotomies, the black and white distinction between
formative and summative assessment is a fallacy. If we continue to represent the
72 W. Tavares et al.

world in black and white terms, we should not be surprised when trainees then apply
this type of thinking elsewhere, perhaps to perceive that medicine is simplistically
about being right or wrong; that they treat uncertainty or mistakes, even in moments
intended to be formative, as an indication that one is insufficiently skilled (Ilgen
et al. 2019); nor should we be surprised that they appear reticent to disclose aspects
of competence with which they are struggling (Mann et al. 2011).
One of the practical outcomes of this transition in thinking has been a reframing of
the focus of assessments from formative vs summative to consideration of the stakes
that are explicitly involved in any moment that might be deemed an assessment (Eva
et al. 2016). That is, thinking about the extent to which a decision with repercussions
will be made based on a particular event offers a better way of directing learner
priorities, specifying the way data will be used rather than trying to convince learners
that they should treat the activity as purely summative or purely formative in nature.
Defining stakes on a continuum from high to low offers a way of moving away from
black and white thinking to gradations, plausibly signalling a shift from discrete or
reductionist tendencies in assessment to more nuanced and holistic appreciations.
This is important because saying “don’t worry, this is only formative” can lack
credibility or feel akin to an educational bait and switch both by virtue of learners
mistrusting claims that the judgments formed will not influence their standing in the
program and by virtue of having less confidence in the veracity of the data/feedback
enabled; at the same time, to say “this assessment is purely summative” is to abdicate
the responsibility of anyone seeking to improve healthcare through assessment (Eva
et al. 2016). This movement from thinking of assessment as dependent upon stated
purpose only, to treating it as equivalent to a diagnostic opportunity with emphasis on
the way in which learners engage with it has forced extensive re-consideration of what
we choose to do with information about trainee performance when it is generated,
leading to promotion of programmatic assessment models that focus heavily on how
assessments are approached by students.

6.4 Example 2: The Shifts to and in Programmatic

Assessment

The programmatic approach to assessment in health professions education repre-

sented a major shift in thinking. Moving away from treating assessment purely as a
measurement problem, the initial emergence of programmatic assessment as an idea
treated assessment as an optimisation problem aimed at exploring how we might
strike an ideal balance between the differing strengths and weaknesses of individual
instruments to achieve the best overall outcomes (van der Vleuten 1996). The notion
was built on an earlier utility model for assessment, which looked at striking the right
compromise between potentially competing factors—validity, reliability, educational
impact, acceptability, and cost. The fundamental value proposition advanced through
the layering on of programmatic assessment, however, was the notion that optimizing
6 Tracing Philosophical Shifts in Health Professions Assessment 73

the assessment of competence requires treating the whole programme of various

assessment tools and opportunities as greater than the sum of its parts.
At its core, advocates of programmatic assessment propose that there are poten-
tially rich and meaningful data from assessment processes that can be useful for both
progression decision-making purposes and educational purposes, but that the former
should be put into play only after sufficient information has accumulated. As such,
programmatic assessment models place great importance on how assessments are
approached by students. One of its explicit aims, in fact, was to re-position assess-
ment in the space of instructional design to emphasize the importance of high-quality
feedback (van der Vleuten and Schuwirth 2005). To do this, programmatic assess-
ment encourages the removal of pass/fail decisions from individual assessments.
This facilitated the transition away from traditional formative/summative distinc-
tions by thinking of stakes along a continuum, as outlined in the preceding section;
no individual moment is high stakes, but the accumulation of evidence about learner
progression can enable high stakes decisions. This necessitated a more longitudinal
approach with decisions meant to occur at checkpoints rather than after each and every
measurement. Expert committees were tasked with making the high-stakes decisions
by drawing on assessment evidence accumulated from a range of lower-stakes assess-
ment moments. In programmatic assessment, it is the diversity of methods and the
triangulation of disparate forms of assessment data that build an evidence-base to
inform decision-making (van der Vleuten et al. 2019; Dent et al. 2021).
Applying a philosophical lens to analyse this shift more thoroughly allows us
to uncover concurrent implicit shifts within programmatic assessment (Pearce and
Tavares 2021). For instance, in the initial conceptualization of programmatic assess-
ment, reliability was cast as a sampling problem. Proponents of the approach noted
that higher reliability metrics were achieved with increased testing time, which
consequently led to suggestions to gather more data. This is illustrated in the
often-cited pixel metaphor in which a poor resolution image of learner competence
becomes clearer with more data points. Such a metaphor is grounded in psychome-
tric or measurement-based thinking, assuming that a unitary conception of learner
competence can somehow be captured as long as different methods are used over
time.
As programmatic assessment evolved, however, a stronger emphasis on the role
of assessment for learning emerged as a central tenet and learning became more
embedded into assessment activities. This implies that assessment is not simply
aimed at gaining a clear impression of a static image, but rather, that the measure-
ments themselves alter and influence the image in ways that may prevent it from ever
appearing as a uniform whole. In less metaphorical terms, this transition brought with
it a deliberate blurring of the measurement vs learning boundaries explored in the
preceding section, leading to greater acceptance now that learners should be mentored
and coached while taking on more shared responsibility for their learning and assess-
ment if the pedagogical opportunities assessments create are to be effectively dual
purposed.
More recently, a range of qualitative research approaches have permeated the
programmatic assessment discourse, moving hand in hand with the emergence of an
74 W. Tavares et al.

explicit constructivist/interpretivist framework (Ginsburg et al. 2015). Notions such

as information richness, narrative feedback and meaningfulness of data now appear
more often in the assessment discourse with the idea that learners need to be supported
to build insight from assessment data to overcome blind spots created by their current
conceptions (Eva et al. 2014). This move towards a constructivist ontology when it
comes to competence, coupled with the emphasis on rich and meaningful evidence
to ensure robust and credible committee decisions, is quite a radical departure from
earlier conceptions of assessment in which it was simply assumed that truth would
be recognizable and improvements actionable if good data were provided.
Today, programmatic assessment has become a consolidated sub-discipline in
health professions assessment, and we have noticed a more explicit pragmatist
approach to programmatic thinking as implementation attempts proliferate (Pearce
and Tavares 2021). That is, some have aimed to incorporate aspects of programmatic
assessment without necessarily subscribing to its entire framework. As programmatic
assessment continues to evolve, many new questions and tensions arise. No longer is
sampling considered a means to eliminate error of measurement and get at an under-
lying truth; rather, it has become better recognized that learners change with time, that
competence development is neither unitary nor consistent, and that context matters,
all of which sum together to suggest that there might be meaning in variability
observed rather than that variability necessarily reflects weakness in assessment.
Research in rater cognition has come to celebrate such diversity and idiosyncrasy of
judgment rather than assuming that the fundamental purpose of sampling is to do
away with the varied perspectives they bring to bear on the assessment of learner
competence.

6.5 Example 3: The Shifted Role of Assessors in Assessment

Increasing awareness of the complexity and context-dependence of clinical practice

has made assessment of competence reliant on assessor judgment. Any performance-
based assessment of clinical competence, in fact, involves at least three components:
the selection or generation of clinical stimuli (be they workplace-based or simulation-
based); a learner interacting with that stimulus and displaying performance features
(given that not all qualities are available for observation in any one performance; de
la Croix and Veen 2018; Veen et al. 2020); and, an assessor who attends to, processes
and translates performance features against a standard of some kind (Gauthier et al.
2016).
It is perhaps in this domain that the three broad transitions described in the intro-
duction to this chapter best illustrate changing philosophical assumptions. In the
era of “assessment as measurement”, assessors were viewed as useful to the extent
they could provide accurate and objective representations of the performance they
observed, including whether or not they were effective at translating their observa-
tions onto the provided data collection instruments. Measurements of performance,
6 Tracing Philosophical Shifts in Health Professions Assessment 75

that is, were expected to be reported numerically with ways of confirming their accu-
racy occurring through consideration of reliability (i.e., the extent to which raters
agreed with one another about how candidates should be differentiated) as defining
the degree of error inherent in the process. Ways of improving rater performance
included efforts to train them to be more accurate and more objective, to provide
them with more comprehensive tools aimed at reducing bias, or to eliminate poorly
functioning raters (Eva 2018). In other words, opinion was viewed as “error” needing
to be eliminated if the data were to live up to the standards set by those holding posi-
tivist views. As challenges persisted and research continued, new ways of thinking
emerged.
Over time, in fact, assessors became increasingly valued for their judgement;
while recognized as fallible and subjective, the unique perspectives individual raters
brought to bear became thought of as valuable indications of the variety of ways
in which an assessment candidate would be viewed in the real world of practice
(Gingerich et al. 2014a, b). Assessors, in other words, came to be recognized as
bringing something to the assessment process precisely because of their diversity
of perspective and their capacity to reflect the complexity of environments, interac-
tions, and practices trainees could expect to encounter. Rather than bottlenecks in
assessment activities, it is their unique backgrounds influencing their judgments as
raters that enables them to produce more holistic representations of the multifaceted
activities in which healthcare practitioners are expected to engage, not anything
sufficiently reductionistic that could be perceived to be “objective”.
This change in viewpoint led to many shifts in practice. For instance, researchers
called for greater emphasis on rater judgement rather than striving to generate tools
that would overcome or limit their capacity to use insight (Crossley et al. 2011).
In valuing rater judgment, it also became clear that numerical ratings were limited
and that other forms of data collection were necessary, particularly the use of narra-
tive if raters’ perspectives were to be made sufficiently clear to enable learners to
understand and benefit from those perspectives. The philosophical assumptions in
this “assessment as judgment” era of assessment, therefore, moved away from posi-
tivist ideals towards post-positivist assumptions (i.e., that measurement will always
contain some degree of “error”) and constructivist/interpretivist ways of thinking
in which what was previously conceived of as “error” could now be considered to
contain some degree of previously unrecognized “signal.”
As a third, and slightly different, aspect of a philosophical shift related to the
role of assessors in assessment, it is also worth noting that this view that assessor
differences are informative, not regrettable, also included a transition from cognitive
orientations to assessment as a social practice. Even simple efforts to judge learners’
cognition, after all, are coloured by social factors that impact on what they are
willing to reveal (i.e., the best we can observe is their expressions of their cognition),
demanding recognition that assessment always takes place in a social context. In this
regard, Gauthier’s review illustrates that rater-based assessment was almost exclu-
sively treated as a cognitive, information processing, activity with assessors’ roles
being to make observations followed by processing and integrating the information
76 W. Tavares et al.

collected (Gauthier et al. 2016). As new ways of thinking have emerged, the cogni-
tivist approach became seen by many as necessary, but insufficient (Govaerts 2016).
That is, the complex processes and interactions assessors have with trainees/learners
came to be seen as a social process that enabled judgment rather than simply being
a bias impacting upon it (Gingerich et al. 2011). Social influences, thereby, became
thought to improve assessor contributions by reflecting the activities in which trainees
were expected to engage during their clinical work and the competencies required to
engage effectively in those activities. This corresponds with a shift in thinking about
where competence exists—in the mind of the individuals, or in the dynamic interac-
tion individuals have with team members, with considerable implications regarding
what assessors are asked to attend to (Tavares et al. 2018). Combined with increasing
use of narratives, the value of “subjective and collective” became a rallying cry for
many in health professions education (Sebok-Syer et al. 2021; Hodges 2013). Inter-
estingly, accepting the transitions described in this section demands expansion of the
criteria we use to evaluate assessment strategies, but does not necessarily require a
full-fledged abandonment of the tools that have been so strongly associated with the
preceding positivist era.

6.6 Example 4: From Classical Test to Generalizability

Theory

The foundation on which many of the criticisms of rater-based assessment outlined in

the preceding example are based clearly highlight a particular worldview. When we
get into the use of statistics to test the adequacy of our assessment protocols it is easy
to conflate numerical with objective and, in turn, real. If competence is a trait that can
be assigned to a particular trainee about a particular task, then the numbers that derive
from our assessments should consistently reflect that competence regardless of who
is offering the rating. Anything less than reliable measurement, the argument goes,
suggests that the data collection strategy is flawed and untrustworthy as a statement
about the candidate’s ability.
What if performance is more a reflection, however, of a wide array of issues
including patient characteristics, recent experience, psychological state, and other
contextual factors that determine trainee competence rather than being independent
of it? Further, what if performance is sufficiently multifaceted that assessors’ variable
backgrounds and the resulting variability in their perspective makes it such that even
two rational and neutral assessors could reasonably come to starkly different conclu-
sions about its quality (Gingerich et al. 2014a, b)? Content and context specificity
have been recognized for decades and, quite intuitively, one would never dream of
basing a judgment about someone’s knowledge in a very broad domain like medicine
on a few multiple-choice questions. Yet, we still express surprise when a single
observation of communication skills is (or even a few are) imperfectly reliable. The
problem with this disconnect between the complexity inherent in human behaviour
6 Tracing Philosophical Shifts in Health Professions Assessment 77

(including what may not be directly accessible to observers) and the expectation
of replicable judgments, however, does not derive from our use of rating scales,
numbers, or statistics; it derives from the way we think about them. Nowhere is this
more evident than in the formulation of the statistics themselves.
Classical test theory, the traditional formulation of our reliability coefficients, was
developed to enable mathematical determination of what portion of variance in the
data emanating from an assessment can be attributed to “true” differences between
candidates (in relation to the “error” contributed by other facets) (Yudkowsky et al.
2019). If the variance observed is largely driven by random noise or determined
by anything other than candidates themselves, then the reliability coefficient will
be low and one must worry about using the data to make claims about candidates.
Cronbach’s work on Generalizability Theory extended these models in an effort to
enable the “error” variance to be parcelled out into more specific facets (e.g., does
it derive from rater differences, from differences between cases, from differences
in time, or from something else?) (Cronbach et al. 1972). Doing so allows better
decisions to be made regarding how to improve upon an assessment’s measurement
properties. The true genius in his reformulation, however, has nothing to do with the
mathematics (which are not all that different) and everything to do with the way in
which he encouraged us to consider what the numbers tell us (which is unfortunately
often overlooked).
In offering Generalizability theory to the world, Cronbach argued we should
do away with the notion of measuring “true” variance. That is, despite continuing
to use objective statistics in an effort to reflect the robustness of collected data,
he recognized that what observations arose could only be generalized within the
universe of observations collected. For example, if we measure what proportion of
variance is attributable to candidates when they are evaluated by multiple raters at a
particular point in time, those data tell us nothing about how well those scores will
generalize to a different point in time or to a different set of cases. Internal consistency,
inter-rater reliability, and test–retest reliability, therefore, are not simply different
ways of measuring a tool’s reliability; rather, they reflect fundamentally different
tests of the extent to which data collected can be generalized across variables of
item, rater, and time, respectively. As such, although we still try to determine the
number of observations required to achieve a stable indication of one’s strengths
and weaknesses, transitioning from “true” variance to “subject variance” and from
“error” variance to “residual variance” offers an explicit acknowledgement that our
observations are constrained and determined by a variety of factors that are not always
recognized (nor always observable).
This subtle but important difference in philosophy has marked implications as
fundamental as whether or not it even makes sense to claim “the reliability of assess-
ment instrument X is 0.yy”. Too often we treat reliability as an entity in its own
right when it is nothing more than a statistical calculation for which interpretation
should be heavily dependent on implementation, context and philosophical position.
Further, while under-recognized still, decades later, this shift from striving to measure
objective “truth” without error towards striving to offer empirical evidence aimed at
78 W. Tavares et al.

building evidentiary and context-limited frameworks led to an even broader transi-

tion in our thinking about validity, championed by Kane (2013a), that suggests it to
be a construction founded in argument rather than something that can be achieved
full stop.

6.7 Example 5: Shifting Configurations in Validity

Validity remains the fundamental consideration in the development and evaluation of

assessment; as such, it is perhaps not surprising that it has undergone several philo-
sophical shifts over time that include evolving ways of defining and demonstrating
validity evidence. Today, validity can be defined as the degree of theoretical and
empirical evidence or confidence one has in the claims made based on data gener-
ated by an assessment process. In its simplest form, validity involves a clear statement
about what is being claimed in assessment and consideration of whether those claims
are warranted, given the available evidence. There is broad consensus that validity
is best conceptualised as an argument-based model involving intended inferences or
interpretations; however, this was not always the case, further illustrating that what
claims to validity one can make are a matter of the philosophical position applied.
Here we provide a brief history of validity, demonstrating shifts in the way we think
about the concept in a manner that returns us to the notion of truth (the root of so
many philosophical debates).
Earlier models of validity included an emphasis on three types: criterion, content,
and construct validity (Kane 2013a). The first two, respectively, refer to comparing
new assessment models against a plausible or ‘true’ criterion measure and empha-
sizing how a sample of questions or performances represents the construct of interest.
While criterion validity usually implies an empirical test, content validity gener-
ally occurs using rational grounds or expert opinion to stake claims that a suffi-
ciently representative sample of all possible questions has been included to reflect
the breadth of the construct desired to be measured. However, both criterion and
content validity models were deemed insufficient or at least to harbour significant
limitations (Kane 2001). For example, determining a suitable criterion could be
impossible in some cases, and content validity models are subject to confirmatory
biases. As such, construct validity was presented as an alternative that emphasized
the role of theoretical expectations in interpreting assessment outcomes. That is, if
a theoretical model suggests that experts should perform better than novices, and if
empirical data support that model, then claims of validity could be made. Construct
validity, however, is dependent on having a well-established theory, a factor that
serves as both its strength and limitation. In the absence of strong theories, in the
context of competing theories, or in instances where it is not clear how to trans-
late theory into something that can be assessed, validation efforts become unclear.
This is one of the observations that led validity theorists to propose and elaborate an
argument-based approach, one that could still take place even without a fully formed
or formal theory.
6 Tracing Philosophical Shifts in Health Professions Assessment 79

In this brief summary of how validity has changed over time, one can observe a
transition in ways of thinking that have become more complex and abstract, moving
from efforts to prove concrete and specific theories towards empirical evidence
generation and reporting of one’s intended meaning and uses in an effort to warrant
assertions in support of claims or counterclaims.
In health professions education specifically, these different philosophical positions
all remain active, illustrating, in part, that application differences are reflective of
distinct worldviews, rather than simply an evolution of thought with newer models
necessarily replacing those that came before them. For instance, St-Onge et al. (2017),
identified three distinct perspectives on validity that remain present in our literature.
The first positions validity as a test characteristic that draws mostly on psychometric
concepts; the second presents validity as an argument-based evidentiary chain that
is described as “mostly psychometric”, suggesting other philosophical assumptions
have made their way into validation strategies; the third categorization describes
validity as a social imperative, with the underlying philosophical position drawing
more on expert judgment and social consequences of assessment than psychometrics.
The authors of this work discussed how different users of validity may hold different
views in what serves as legitimate conceptualizations of the concept.
All of this sums together to speak to the fundamental philosophical notion of
‘Truth’ and how one’s perspective, be it explicit or not, drives application in assess-
ment domains just as much as it does in the domains covered in other chapters of
this book (see, for example, Chapter 12 on questions of Ontology; or Chapter 9
regarding social justice). Validity scholars have debated what validity claims mean
in relation to truth with arguments generally falling within two views: those who wish
to make claims about ‘true beliefs’ and those who wish to make claims about ‘justi-
fied beliefs’ (Kane 2013b; Borsboom and Markus 2013). In the ‘true belief’ position,
validity obligates a degree of certainty that equates to truth. In other words, the effort
of measurement is aimed at something stronger than simple justification because the
latter is subject to making false or incorrect claims that can seem compelling but are
based on faulty logic. In contrast, those who adopt a ‘justified beliefs’ position, make
no claims to truth, and argue that doing so is faulty in part because truth can never be
known with certainty. While accurate conclusions are expected, truth is beyond what
science or validity can promise. Values, more than truth, therefore, take precedence
with the goal being to ensure simply that claims can be justified based on the best
available evidence. These are two very opposing views with practical consequences
in what can be claimed and what educators might need to be comfortable with and
accept.

6.8 Discussion

Our aim in offering this chapter has been to describe how shifts in philosophical posi-
tions have informed health professions assessment and to outline implications of such
shifts in perspective. We believe it important to be aware of the worldviews that have
80 W. Tavares et al.

led to particular efforts to identify and solve assessment problems both for the sake
of guiding one’s own thinking and to minimize communication problems between
individuals. In most assessment contexts, philosophical positions play a fundamental
role, yet they are too-often left implicit; that is, they inform the way assessment work
is conceived, designed, deployed and appraised, but they are often not sufficiently
attended to or spoken outright, leaving their implications not fully appreciated. The
examples we have offered illuminate how worldviews have influenced, guided, and
shaped the contours of assessment practices in the health professions over time along
with the shift towards constructivist ways of thinking that has taken place in health
professions education more generally.
The way we conceive of philosophical positions need not necessarily align with
traditional philosophy of science paradigms (Chalmers 2013). While, at times, it may,
we use the term more simply to represent variable yet inherent underlying assump-
tions, intellectual frameworks or fundamental vantage points that then inform how
one determines the quality or suitability of assessment practices. New assessment
ideas can come from anywhere and their utility, adoption and acceptance is depen-
dent on, and determines what, we come to “know” about assessment problems and
the solutions offered. Therefore, philosophical presuppositions have a role in assess-
ment, but associated commitments need to be clearly attended to and marked beyond
simply claiming their existence in assessment work.
When attention is paid to philosophical positions, this shines a new light on the
thinking that guides our assessment practices. For instance, the utility of an assess-
ment is more routinely seen now as an interaction between people, providing oppor-
tunities for a more fundamental focus on (and acceptance of) judgment, and a means
of influencing learning through assessment. These philosophical shifts do not inval-
idate the use of techniques that have stood the test of time (given that it is how the
assessment tools are used that matters), but they do necessitate a broadening of tech-
niques and the criteria used to evaluate them, as illustrated through the development
of programmatic assessment, and thinking of validity as argumentation rather than
an entity that can be proven. Reflecting on the use of philosophy in assessment has
meant assessment problems can be examined productively in new ways. Not as a
means of giving up entirely on gains achieved through earlier ways of thinking, but
by (a) critically examining the limitations of approaching assessment in a particular
way (e.g., competence as a purely psychological trait to be measured without error),
and (b) by providing insights for what solutions might be necessary if we are to
optimize assessment designs and practice. There remain, however, many cautions to
consider.
Despite the general shift towards constructivism/interpretivism, the assessment
community is increasingly diverse in the way assessment scholars think about assess-
ment problems and their solutions (Tavares et al. 2020). The transition is, therefore,
likely better described as a broadening of the philosophical positions (including
positivism, post-positivism, constructivism, and pragmatism) being used to interro-
gate assessment (and education), which sometimes creates conflict. On one hand,
6 Tracing Philosophical Shifts in Health Professions Assessment 81

such broadening of perspectives serves to advance assessment science, but on the

other it can raise confusion and doubt regarding what might be best or even why
one might approach assessment in a particular way at a particular time and place.
Indeed, core features in assessment (e.g., conceptualizations of competence, the use
of narratives, validity strategies) can be associated with a range of different philo-
sophical assumptions and commitments, as illustrated in the examples outlined in this
chapter. Increasing crosstalk is leading to uncertainties about how to proceed, fuelling
legitimacy debates about methods without attention to underlying assumptions (i.e.,
logical incoherencies), the potential for problematic mixing of assumptions, different
perspectives about what serves as high quality assessment (i.e., different understand-
ings of the same concepts) and, therefore, threats to defensibility and validity. If
validity is an argument, then cohesiveness is a core criterion through which it should
be judged.
In the absence of the clarity of thought that can arise through cohesive under-
standing, unproductive debates about how best to proceed continue in part because
there is diversity in the philosophical positions educators and researchers bring to
assessment conversations without either revealing them or being clear about their
meaning. As such, assessment scholars can find themselves talking about the same
thing, sometimes using the same language, with very different intentions and under-
lying meanings. Making the underlying positions explicit permits a more dispas-
sionate conceptual analysis and highlights ways in which one’s decisions follow
from assumptions and commitments. When done well, this yields scope and space
for discussion and fruitful dialogue, opportunities for clarity, fair critical analysis,
and careful evaluation of arguments.
As assessment continues to evolve, new solutions may experience difficulty if
they are in tension with prevailing philosophical positions and may require some time
until more aligned philosophical assumptions can be made explicit and resolved in
the community. For example, consider the role of competence committees in assess-
ment. This relatively new assessment model in health professions education, which
has mainly summative functions—ultimately deciding on progression to the next
phase of training or autonomy and social accountability goals—is challenged with
several competing strategies and philosophical assumptions (Pack et al. 2019). Is their
decision-making more defensible using statistical models (e.g., Bayesian techniques)
to reach outcomes, or committee member judgment (Hauer et al. 2016; Zoanetti and
Pearce 2020)? Are examinations of the degree of sampling in trainee assessment data
intended to support triangulation or error reduction? Should competence committees
seek and leverage subjective or objective data? Is the “collective” (i.e., assembling
of information) better when it includes an assemblage of diverse or highly consistent
views? Given the implications of the answers to these and many other questions,
and the importance of competence committee work, it is vital that we understand
how individual and collective philosophical positions shape their role, processes, and
effects. If these positions are left implicit, assumed, or unattended to, it is unlikely
82 W. Tavares et al.

that clarity of understanding and consistency of practice within committee, let alone
across institutions, could ever be achieved.

6.9 Conclusion

In summary, reflecting on the relationship between philosophical positions and

assessment science provides opportunities and mechanisms through which miscom-
munication and insufficient practice might be resolved, permitting an open space for
the identification and critical examination of guiding assumptions, commitments, and
intellectual frameworks. Doing so can help the assessment community re-examine
and reformulate existing and future assessment ideas in a manner that can allow
complex assessment challenges to be approached in logical and abstract ways that
enable practical issues to be more deeply understood and advanced. We have seen
this in action in the ways thinking about the formative vs. summative distinction
have changed, in how notions of programmatic assessment have evolved, in how the
role of raters (assessors) has shifted dramatically, in the ways that statistical anal-
ysis is conceived, and in the ways in which argument about an assessment’s validity
are structured and advanced. Numerous existing and future areas of assessment can
benefit from more routine consideration of applied philosophy. By examining philo-
sophical positions in action through transitions in the way health professional educa-
tion has treated our assessment practices, our intention is to advance the conversation
on applied philosophy in assessment, stimulating theoretical and practical insights
about assessment generally as well as better thinking (and, most importantly, more
informed and deliberate conversation) about specific assessment problems and their
potential solutions (Table 6.1).

Table 6.1 Practice points

1 Philosophical positions in assessment are sets of recognized assumptions and commitments
or intellectual frameworks that offer lenses for examining health professions education’s
problems and solutions
2 Examining common assessment problems, applied solutions and features (e.g., the purpose of
assessment, the role of assessors, and validation priorities) provide examples of philosophical
influences and shifts in health professions education
3 Philosophical positions inform the way assessment work is conceived, designed, deployed,
and appraised, but they are often not made explicit or sufficiently attended to, thus leaving
their implications not fully appreciated
4 Regardless of the explicit intent of the assessment designer, the impressions of assessment
recipients and the broader social context in which the assessment takes place matter and
should not be ignored because they play a crucial role in determinations of assessment quality
5 Examining assessment through an applied philosophy lens promotes reflecting on the
relationship between assumptions and assessment practice, can stimulate theoretical and
practical insights about assessment, and generates more informed and deliberate conversation
about specific assessment problems and their potential solutions
6 Tracing Philosophical Shifts in Health Professions Assessment 83

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Chapter 7
The Significance of the Body in Health
Professions Education

Gabrielle Maria Finn, Frederic W. Hafferty, and Holly Quinton

7.1 Introduction

The word body is very equivocal. When we speak of a body in general, we mean a specific
part of the material, and set the amount which the universe is composed. But when we speak
of the body of a man or woman, we hear any matter which is united with the soul of man.
(Descartes 1649, 11)

The human body is the one thing we all have in common, and its death is our only
guarantee. Long held as an object of significance and curiosity, the body occupies
an ambiguous status—it is both what we are and what belongs to us (De Vignemont
2007). This ambiguity is a result of the nature of the body, one that is formulated in
a number of binary oppositions:
The body is both the Same and the Other; both a subject and an object of practices and
knowledge; it is both a tool and a raw material to be worked upon. (Encyclopedia.com 2021)

Within health, it is both a lived body and an object of scrutiny.

In this chapter, we consider the nature of the human body and the different mean-
ings and discourses ascribed to it. We describe our views on the various discourses
of the body, namely the symbolic, aesthetic, sexual, and scientific. In doing so we
explore links to philosophy, as well as pertinent considerations for contemporaneous

G. M. Finn (B)
Faculty of Biology, Medicine and Health, School of Medical Sciences, The University of
Manchester, Manchester, UK
e-mail: gabrielle.finn@manchester.ac.uk
F. W. Hafferty
Division of General Internal Medicine and Program in Professionalism and Values, Mayo Clinic,
Rochester, MN, USA
e-mail: Hafferty.Frederic@mayo.edu
H. Quinton
Queens Road Surgery, Durham, UK

© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2022 85
M. E. L. Brown et al. (eds.), Applied Philosophy for Health Professions Education,
https://doi.org/10.1007/978-981-19-1512-3_7
86 G. M. Finn et al.

curriculum development, and implications for healthcare professionals. We advo-

cate for increased awareness of the imperative to evolve our body lexicon, the need
for recognition of the feminist body, as well as inclusivity in bodies, and finally,
we explore the potential presence of a hidden curriculum of bodies within health
professions education.

7.2 What Is the Body?

What is the body? This seems like an obvious question. The human body is our
physical substance. It is a mass composed of living cells and extracellular mate-
rials—classified into tissues, organs, regions and systems. The body has long been a
subject of social and scientific fascination, critique, and condemnation, from the first
documented dissections as early as the third century BCE1 in Alexandria. Indeed,
Anatomy is the oldest scientific discipline of medicine (Finn 2013, 2017). Yet, the
body holds more than a biological significance.
One can consider the body within several discourses: symbolic; aesthetic; sexual;
and scientific (Finn 2013, 2017). First, the body can be considered as a symbol of
self—that is, the body as a being, as oneself. Second, there is the notion of the body
within a scientific discourse, the object of scientific study, mapping, and investigation.
In this discourse, the body is an eco-system, home to all the organisms that live within
it, and on it. Next, we have the aesthetic, or artistic discourse, of the body, where
the body is objectified, beautified, and revered for its physical significance. Finally,
there is the sexual, or erotic, discourse of the body which concerns the significance
of the body held by the beholder, self or other.
Of course, aside from these discourses, the body itself is often viewed as a work of
art, with paintings of the body becoming mere representations of the innate aesthetic
discourse of the naturally artistic human form (Finn et al. 2020). Considering the
aesthetic discourse, the words of theatre critic Kenneth Tynan are poignant:
The buttocks are the most aesthetically pleasing part of the body because they are non-
functional … these pointless globes are as near as the human form can ever come to abstract
art. (Tynan 1966, 432)

This quote, itself, provides an example of the simultaneously opposing yet comple-
mentary discourses that the body holds, the symbolic, aesthetic, sexual, and
scientific.
As an object of philosophical thought, the most cited perspective in reference to
the body is that of mind–body dualism, namely Cartesian thinking (Mehta 2011;
Buckingham 2011). Dualism is the view that the mind and body exist as separate
entities. Representing this philosophical position, René Descartes believed that there
is a bi-directional interaction between mental and physical substances (Buckingham
2011). In this duality, the mind controls the body, but the body is also able to influence

1 Before the Common Era.

7 The Significance of the Body in Health Professions Education 87

an otherwise rational mind (Tim 2012), for example in an act of passion (Mehta 2011;
Buckingham 2011). Descartes states that the mental can exist outside of the body, but
the body cannot think. In this chapter we wish to consider the multiple, varied, messy
meanings and significances of the body and how these meanings and significances
manifest within a contemporary health curricula and clinical practice environment.

7.3 How Do We Perceive Our Body as Self? The Symbolic

Discourse of the Body

When considering the body as self, we are describing two philosophical stances,
bodily awareness and myness. Firstly, let us consider what philosophers call bodily
awareness.
Bodily awareness is how conscious and connected you are to your own body. The
underlying assumption is that we are aware of our body differently from other objects,
such as a chair or stone. For example, we know we have a number of senses: sight;
hearing; smell; taste; and touch (Smith 2006). Our senses provide us with a means by
which to gather information concerning objects surrounding us, including our own
bodies. As well as these five senses, we are aware of our own body in a unique way,
set apart from the way we are aware of any other object. For example, we have an
awareness of our position, orientation, movement, and size of our limbs, our sense of
balance, and our awareness of bodily sensations including pains, pressure or temper-
ature (Smith 2006). These features can be grouped together under the umbrella term
of ‘bodily awareness’ (Bermúdez 2011). As Bermúdez notes, we are embodied, and
we are aware of our bodies/selves from the inside through different forms of bodily
awareness (Bermúdez 2005, 2011, 2015). Bodily awareness bears a special relation
to self, and to self-awareness (De Vignemont 2020). Thus, it needs consideration
within healthcare training due to being experienced differently by individuals. For
example, communication skills are important when trying to elicit information from
patients on how they experience themselves in any given environment.
Further to this bodily awareness is how we then perceive our body to be our self.
This is the notion of ‘myness’, which can be defined as the property of belonging
to the subject, and something that has attracted increasing attention in the literature
(De Vignemont 2013, 2020). Thus, the central tenant is that one experiences one’s
body as one’s own by virtue of having a feeling of ‘myness’ (De Vignemont 2020).
For example, if we were to fold our arms, we identify the limbs as our own, while
concurrently unable to misidentify the arms as belonging to someone else (Bermúdez
2005, 2011, 2015). Shoemaker (1968) noted that this bodily experience is resistant to
error through misidentification relative to the person. “We experience our bodies as
our own in a virtue of felt ‘myness’ that goes over and above the mere experience of
one’s bodily properties” (Bermúdez 2015, 643). Note, myness has also been contested
in favour of bodily ownership (De Vignemont 2013).
88 G. M. Finn et al.

7.4 Ownership and Disownership of the Body

Traditionally, in seeking health care, the lines or boundaries of ‘myness’ are

breached—at least to some extent. While classes on patient communication or history
taking may forefront the importance of ‘the patient’s story’ or of ‘the patient’s experi-
ence’, in point of fact, a good part of the diagnostic process requires both patient and
provider to privilege or prioritize external measures of bodily properties including
those that may be that may be beyond or external to bodily sensations. Yes, you can
read in a textbook or class readings that much of what you need to learn about diag-
nosing a patient’s problem can be attained via ‘the history’, but in practice this often
is not what happens. Instead, we routinely turn to diagnostic and treatment modali-
ties that allow ‘us’ (whomever) to ‘read’ the body in ways that might be considered
by the individual undergoing such procedures as being quite strange, mysterious, or
essentially not-of-me (e.g., alien).
We routinely—and have for eons—differentiate between ‘symptoms’ (what the
patient reports) and ‘signs’ (what all our exogenous tools and tricks tell us)—and
we prioritize the latter over the former. We even diminish the veracity or validity of
symptoms by using phrases such as ‘the patient claims’, ‘the patient reports’ or ‘the
patient denies’ in recording those elements of the ‘story’ that comes from the patient
(after all, we don’t write in the patient’s chart that ‘the test says’ or that someone has
a blood pressure of x/y ‘according to the test’).
In sum, and post that initial history gathering, one’s sense of self as a biological
system, including the uniqueness in which we are aware of our own bodies often
is discounted (and routinely so). This includes any claim that we (as the patient
and thus ‘object” of such diagnostic and treatment modalities) might make (directly
or indirectly) as to our uniqueness, given the dominating presence within clinical
medicine of treatment protocols and practice guidelines.

Case Study 1: Bodily Disownership

Not all that long ago, one of the authors of this chapter had a foot injury (talus
bone) and then subsequently broke a metatarsal bone in the same foot. Not
long afterwards, they were taken aback when a family member pointed out
that they were saying ‘the foot’ (as opposed to ‘my foot’)—all to no small
embarrassment that they had been unconsciously externalising and disowning
what might otherwise be considered an essential part of their anatomy.

There is a weird tension within Case Study 1 and the aforementioned examples.
On the one hand, and on the personal responsibility side, there is the ‘my’ of ‘my
cancer’ and, on the other, there is the disownership side of ‘the cancer’. There is
a significant body of literature on ownership and disownership. Briefly, here are
four examples. Firstly, is the documented phenomena ‘the alien hand sign’ whereby
patients experience a feeling of estrangement between themselves and one of their
7 The Significance of the Body in Health Professions Education 89

hands (Goldberg and Bloom 1990). There are also instances whereby individuals
experience their limb as alien yet still believe that it belongs to them (Sacks 1991;
Cole 1996; De Vignemont 2007). Or conversely, individuals experience their limb as
alien but then attribute the limb as belonging to someone else (Feinberg et al. 1998).
Finally, Phantom limb syndrome, whereby an individual experiences sensations in
a limb that has been removed, is a further example of the complexities of how
differently the body resonates for people (Flor 2002). The aforementioned examples
also link to bodily integrity, the subjective bodily experience of wholeness (Slatman
and Widdershoven 2010). The learning for healthcare is that people own and disown
their bodies in different ways. Healthcare practitioners should consider how patients
own or disown their bodies and be mindful of their language with respect to bodily
ownership. This is akin to the Körper-Leib distinction, translations of which include:
“physical/material body’ versus ‘lived/animated body’; or ‘objective body’ versus
‘subjective body’ (Slatman 2019). Health requires awareness of the body as object
and the lived body as a point of perception and agency (Slatman 2014, 2019).

7.5 The Scientific Discourse of the Body

The body has long been an object of study and a foundational element in the evolution
of medicine as a discipline. Take, for example, anatomy, the study of the body as
an academic discipline. Human dissection has long been the first encounter a health
professions student has with the body. Often deemed a rite of passage, this interaction
between the living and the dead is the subject of much anticipation, anxiety, and
excitement. Cadavers are regarded by some as ‘the first patient’ or by others as
‘the silent teacher’. For students training to save, improve, or bring new life into
society, this early focus on cadaveric form seems a juxtaposition. Further, it is rare
that the patient in clinical practice is, in fact, deceased. The scientific discourse of
the body risks objectification and depersonalisation—concerningly, the potential is
to disempower patients—the owners of the body. Further, the scientific discourse
of the body and its associated subjectification can result in alienating learners and
patients alike. This can range from tacit messaging to the intentional exclusion of
different types of people, and thus different bodies, within both the anatomical and
clinical arenas. We will discuss this in our subsequent considerations of the hidden
curriculum of the body.
Through the scientific study of the body, and, indeed, through the diagnostic lens of
clinical assessment, the body is at risk of objectification. Much of health professions
education calls for this objectification as both a desired end point of diagnostic and
treatment work, and as a desired cognitive and emotional state of the worker. Within
social philosophy, objectification is linked to disavowing the humanity of others.
This clearly opposes the patient-centric approaches advocated within health care
settings, or, by extension, learner-centric approaches advocated for within modern
health professions education. Such objectification could be considered directly at
90 G. M. Finn et al.

odds with the biopsychosocial model2 utilised within clinical medicine and within
curricula.

7.6 Blurred Boundaries—Buying Bodies

Perhaps the most omnipresent discourse, the aesthetic of the body, unites the
discourses we describe. Whether representing the body scientifically (for example,
in biological diagrams), visualising the body erotically, or considering how we look
to both ourselves and others, the aesthetic discourse is present. Now more than
ever, people pay top dollar to look good—this can range from purchasing apps
or watches to track biometric data for fitness purposes, to more invasive cosmetic
surgery procedures.
Concerning the relationship between the aesthetic discourse of the body, norma-
tivity, and health, two pertinent examples offer different views on the relevance
within healthcare. Firstly, biometrics and cosmetic procedures, and secondly, artistic
representations of the body within the scientific literature.
Biometric data is available in abundance—you can buy a piece of yourself
(Alterman 2003; Tanwar et al. 2019) and quantify reality (Ghilardi and Keller 2012).
There are commercial and medical purposes (which are not mutually exclusive).
Consumers can buy a view inside their own body from blood tests for thyroid func-
tion to smartwatches that track heart rate, steps, or food macronutrients. As well as
the commercial access to the body, potentially capitalising on aesthetics, there are
also helpful innovations such as continuous blood glucose monitoring with smart-
phone alerts. This instant access to the body changes the relationship between us and
our bodies—there are legal, ethical, personal, and social implications too (Alterman
2003; Tanwar et al. 2019). There are positives, with increased health and fitness, but
dangers with bountiful data that people may not understand or know the ‘normal’
parameters for. Further to this is the increased risk of social exclusion based upon
biometric identity data, or a more pertinent example of digital immunisation pass-
ports. As such, the duality of the body as object and as self becomes blurred—for
example, with the need for ethical guidelines for the timing and use of data that
promote equity, public health education, anti-discrimination, privacy, and flexibility
(Jecker 2021; Osama et al. 2021). Similarly, there is now shopping mall access to
aesthetic procedures such as Botox, fillers, and other more invasive surgical cosmetic
procedures. Again, the scientific and aesthetic discourses of the body have become
blurred—there is no longer a dichotomy. The desire to be attractive is recognised for
attracting interest, as well as economic and social necessity (Aufricht 1957).
Bodily (anatomical) variation is normal, entire atlases are devoted to documenting
such variation (Acland 2003; Bergman 2021), yet ‘normal’ prevails. What does

2The biopsychosocial model was first incepted by George Engel in 1977. It is an approach or
model which considers and examines the interconnections between biology, psychology, and socio-
environmental factors.
7 The Significance of the Body in Health Professions Education 91

normal mean in this context? It means the archetypal representation of something that
does not exist within the variability of ‘real life’—often and traditionally represented
within the archetype of the white male. For example, Cardiopulmonary Resuscita-
tion (CPR) mannequins are predominantly white. So, too, are human biology posters.
When inclusivity of bodies is sought, it still is limited and typically manifests a black-
or-white dichotomy. However, the field of dermatology has shown some progress
away from the narrow demographic of cadaveric and medical models in the strive
for decolonisation of health services and portrayal of the variety of skin tones in
the healthcare curriculum (Finn et al. 2022). This deficit is being slowly closed with
the publication of texts like that by Dr Malone Mukwende, a medical student at
St George’s University of London who co-authored, ‘Mind the Gap’, a textbook
including imagery and descriptions of clinical signs and symptoms in black and
brown skin (Mukwende et al. 2020). Alternatively, Professor Susan Taylor, who
published ‘Dermatology for Skin Color’ warned against the existence of a sepa-
rate textbook, reporting this as encouraging ‘otherism’ (McFarling 2020). Moving
forward, when we represent the body in textbooks and cadaveric material, teaching
staff should reflect, research, and act to provide and incorporate curriculum and core
texts which educate students in disease manifestation, diagnostic skills, and health
promotion to serve the ethnic mix of the current population. This may take the form
of auditing and editing teaching materials with bioinformatics and population data.
It is important to note that, throughout this process, representatives of diverse ethnic
groups should be consulted before curricula innovations are implemented.

7.7 The Feminist Body

To men a man is but a mind. Who cares what face he carries or what form he wears? But
woman’s body is the woman.
(Ambrose Bierce 2008 [1906], 15)

Within all the discourses of the body there is a gendered body. Historically, there has
always been a significant focus on women’s bodies as ‘other’ (for more on this, see
Chapter 9, which focuses on women as the ‘Other’). Traditionally women’s bodies
were the subject of art, the subject of scrutiny, and the subject of objectification
(Lennon 2018). There was recent outrage when the Royal College of Midwives
omitted women and postnatal mother from an infant sleeping leaflet, instead, using
a collective “postnatal people” in an attempt to be gender inclusive (Carr 2021).
Public fury on social media was rooted in the omission of the words ‘women’
and ‘mother’, perceived as a reductionist oversimplification and act of cancellation.
Although gender-neutrality is not an act of reduction, removal of the word mother
was interpreted as misogyny.
From a philosophical point of view, what it means to be human and what the body
is has long been viewed as male (Buckingham 2011). De Beauvoir documented a
narrative of the body as experienced throughout the different stages of a woman’s
92 G. M. Finn et al.

life (De Beauvoir 1973; Dietz 1992; Buckingham 2011; For more on De Beauvoir’s
other works, see Chapter 4). She noted that during childhood the experiences of girls
and boys are very different—young girls are trained into a different way of inhabiting
their bodies. Distinguishing the changes in the body during puberty, for example,
she notes the body becomes a source of horror and shame for girls. They become
aware of their lack of physical power and thus begin to exhibit an associated timidity.
De Beauvoir proffers an account in which young girls undergo a training in bodily
habits which structure the possibilities for interaction with their world. Critics of de
Beauvoir lambast her naive use of existentialism, a philosophical approach which
emphasises the existence of an individual person as both a free and responsible agent
able to determine their own development through acts of the will (Lennon 2018).
However, Le Doeuff (1980) argued that de Beauvoir made three notable transforma-
tive thoughts with respect to existentialism. Firstly, that she overcomes the limitations
of the concepts of woman as object and the Other (La Caze 1994). Secondly, her
thinking makes it possible to theorise oppression by taking into account women’s
concrete situation. Finally, she eliminates images of the female body as ‘holes and
slime’ that are proffered in Sartrian thinking (La Caze 1994). These transformative
thoughts that de Beauvoir presents still frame our philosophical thinking in regard
to the female body today.
Acknowledging the feminist body is important within healthcare education. The
notions of shame, power, inhibiting bodies, and scrutiny noted by de Beauvoir all
present challenges that impact on the way the female body is presented in education
and healthcare. An example of this can be demonstrated in reference to the field of
obstetrics and gynaecology.

Case Study 2: The Feminist Body and Our Body Lexicon

‘Geriatric-primigravida’ is a term still used to describe a pregnancy when the
pregnant woman or trans-man is over the age of 35 years (Royal College of
Obstetricians and Gynaecologists 2013).
Emily is 36, she is pregnant for the first time and is currently 14 weeks
gestation. She has visited her General Practitioner multiple times with pelvic
cramps and some spotting (light bleeding). Ultrasound scans and antenatal
tests have revealed a healthy pregnancy with no current complications. She is
fit and well. Given her repeated attendance, her General Practitioner asks if she
is anxious and she sobs that she is too old to be pregnant that she was referred
to at her antenatal appointment as a ‘geriatric-mother’.

Let’s consider Emily further. In the UK, the Office for National Statistics (ONS
2021) quote 65 years of age as being ‘old age’ and ‘oldest-old’ over 85. Old, elderly,
and geriatric are interchangeable words. Age is associated with functional decline,
7 The Significance of the Body in Health Professions Education 93

but the terms ‘geriatric’ and ‘elderly’ don’t seem to be appropriate for a 36-year-
old as the old do not (apart from extremely rare exception) bear children. While
there is, undeniably, a continuum of risk associated with pregnancy as maternal age
increases (Royal College of Obstetricians and Gynaecologists 2013), the wording
and terms used to describe the functions of the female body should be used with
the same sensitivity as discussing a cancer diagnosis or approaching mental health
problems. The statistics support this call for terminology change—geriatric/elderly
mother labels should be made redundant in modern healthcare (Spalding 2021).
A further example of how women’s health has long been problematised, includes
the taboo and stigma of menstruation (McLaren and Padhee 2021; Thapa and Aro
2021; Babbar et al. 2022). The menstruating female body is no longer deemed
sexual, and has even been deemed ‘ill’ (Leviticus 20:18) (Olyan 1994; Wenham
1979). Menstruation has been linked to impurity and a lack of cleanliness—here
we see our framing of the symbolic body. Such notions of uncleanliness are well
documented within religious texts (e.g., the Bible), such as Leviticus (12:2) who
problematises post-partum bleeding, and menstruation (15:20). Historically, women
have been labelled as ‘unclean’.
In their book “The Revolting Self”, Powell et al. (2015) suggest that revulsion is
usually developed from admonishment by caregivers to protect a child from disease
or harm. Revulsion to one’s own body is thought to be an ‘undervalued cause of
depression’ and helps to explain avoidance of health screening behaviours rooted in
a negative a-posteriori view of oneself. Other phrases and visual descriptors related to
women’s bodies in medicine carry subversive disdain of female bodily function. This
disgust has historically been applied to menstrual blood. Menstrual blood is rarely
shown accurately—as a shade of red in advertising, but the same colour as urine
in infant nappy/diaper advertising. Menstrual blood is not akin in any way to urine
and advertisement messaging is minimising uterine function. Bleeding is messy,
but menstrual blood is portrayal is tightly and neatly controlled. Sadly, a quarter of
women report not understanding the mechanism of their monthly cycle and around a
fifth are too embarrassed to talk about it to close family friends or a partner (ActionAid
2017). Anecdotally, one author of this chapter notes that in their clinic patients often
apologise before they talk about menses. Diminishing or hushing dialogue of the
labia, vagina, and uterine function prevents empowerment. Slang terms pertaining
to female genitalia are still considered some of the crassest in the English language;
similarly, a cervix is sometimes referred to as ‘incompetent’ and pregnancy can ‘fail
to progress’. Terminology surrounding penile is a lot less fatalistic when it comes to
erectile difficulties, suggesting that the penis is ‘dysfunctional’.
Equality and empowerment are not achieved if female body and function lexicons
are fatalistic or filled with outdated negative connotation. Healthcare teaching needs
to highlight these repressive or minimising descriptions of the value, age, and bodily
fluids of the human body, with menstruation education and an empowered lexicon
which is both patient-centred and accurate in reality of the body’s function.
94 G. M. Finn et al.

7.8 Sexual Bodies

Consideration of the sexual discourse of the body presents a multiplicity of chal-

lenges, including but not limited to the multiple meanings of sex, the conflation of
sex and gender, and the taboo nature of the subject. Before considering the sexual
discourse of the body, we must consider the terms pertinent to this discussion. This
section considers how we define sex, gender, sexual orientation, and sexuality for
the purposes of this chapter and as parts of the sexual discourse of the body.

7.8.1 Sex

One definition of sex refers to the physical differences between people who are
male or female (Newman 2021). There are also people who are intersex. A person’s
sex is assigned at birth—typically based upon their physiological characteristics,
including their genitalia and chromosomes (for an alternative view, see Chapter 10).
This assigned sex is called a person’s ‘natal sex’. Sex is typically considered binary,
neglecting to consider intersex. However, recent debate has surrounded sex with the
idea of two sexes being viewed as simplistic. In a well-cited paper, Ainsworth (2015)
describes how “biologists now think there is a wider spectrum than that” (288).

7.8.2 Gender

Gender is how a person identifies. Unlike natal sex, gender is not binary, rather
it is a broad and fluid spectrum along which a person may identify. When a person
identifies as the same gender as their natal sex, they are cis-gender. Gender may differ
from natal sex and could include transgender, nonbinary, or gender-neutral. Further,
gender also exists as within a social construct, for example with gender roles or norms
(Newman 2021). Newman (2021) describes these as the socially constructed roles,
behaviours, and attributes that a society considers appropriate for men and women.
As our understanding of sex and gender evolves (see Chapter 10 for a thorough
discussion of this), our lexicon is failing to keep pace with this evolution (Finn et al.
2019, 2021). As Lazarus (2021) describes, within healthcare settings and healthcare
education, there is an increasing need to find terminology that accurately reflects the
bodies it represents. Yet, healthcare continues to struggle to describe bodies outside
gendered terms. Training healthcare professionals to recognise that expression of
gender, sex and sexuality may not align to our traditional medical lexicon is of
paramount importance.
7 The Significance of the Body in Health Professions Education 95

7.8.3 Sexuality

Sex embodies a multiplicity of purposes, including pleasure, procreation, the forma-

tion and definition of relationships, the communication of norms, values, attitudes,
and expectations. Sex is also the provision of a major mechanism of subjection,
abuse, and violence. Sex is interwoven with sexual orientation. Sexual orientation
is a person’s identity in relation to their inherent or immutable enduring emotional,
romantic, or sexual attraction to other people. It is defined in relation to the gender
or genders to which they are sexually attracted.

7.8.4 Implications for Health

Historically, within western philosophy, sex and sexuality have received limited atten-
tion. Where it has been discussed, it has been problematised and denigrated. Liter-
ature notes that both its pleasures and power can ruin lives. The arguments that sex
should be for the purposes of procreation only, and the links to morality, have resulted
in a topic that even present-day remains taboo. Within healthcare, this is problem-
atic. For example, avoidance of cervical screening, or a delay or failure to report
medical problems pertaining to the bowel and genitourinary area, are well known.
Furthermore, it is well established that health inequalities exist for many marginalised
groups, including the LGBTQIA+ community (Finn et al. 2021), particularly with,
for example, the stigma associated with sexually transmitted diseases or discussing
reproductive organs.
We teach communication skills extensively about the hidden agenda and the ‘by
the way’ last minute raising of sexual, genital, or bowel and bladder concerns after a
person has ascertained how accessible a clinician is—having built up a rapport over a
consultation. Our self-concept including myness develops over time but is influenced
by our interactions with others and the beliefs held about our characteristics; our
self-esteem, ideal self, and self-image (Baumeister 1999; Argyle 2017).

7.9 The Hidden Curriculum of the Body

As previously discussed within this chapter, students will encounter the body in
many forms within their training as health professionals. These forms include bodies
(or body parts) as pathological or anatomical specimens, (e.g., cadavers), graph-
ical representations of bodies or body parts via media as such as videos or still
images, computer simulations, and via living forms such as simulated patients,
healthy volunteers, peers, faculty (as role models), and actual patients.
96 G. M. Finn et al.

There are numerous factors and interactions (e.g., communication, logistics, phys-
ical examinations, curriculum planning), each with the potential to unfold across
an array of formal (intended and structured) and other-than-formal (unintended and
unstructured) teaching–learning opportunities. Thus, there is the potential for discor-
dance between learning that is intended (often as set by faculty or the training insti-
tution) and that which is experienced (by learners). In short, there can be tension
between ‘the talk’ and ‘the walk’, or between ‘policy’ and ‘practice’. Within the field
of education, and in referencing these interstitial spaces, the term most frequently
used is the hidden curriculum—which refers to the tacit, implied, unwritten, unoffi-
cial, and often unintended behaviours, lessons, values, and perspectives that students
learn during their education (Hafferty and Finn 2015; Finn and Hafferty 2020;
Matthan and Finn 2020).
An example of a hidden curriculum of bodies is the selection of ‘healthy volun-
teers’ or ‘simulated patients’ within a class on communication skills or diagnostics.
We begin by asking whether the bodies learners are being presented reflect the full
range of what they will encounter in practice or whether there is a backstage selection
process that isn’t being made explicit to these learners? Are there screenings or other
manipulations so as to present learners with an ‘optimal’ body type? Are volunteers
or actors with slender bodies chosen more frequently? Does the historic white male
archetype remain omnipresent? Are there cultural issues at play in the recruitment of
‘practice volunteers’ that are never spoken about? Perhaps there are implicit screen-
ings that ensure the simulated patients students examine present no ‘unreasonable’
diagnostic challenges (whether that be for students or the course director or faculty)
…
Let’s take, for example, arranging simulated patients for a teaching session on
the respiratory system. Firstly, using a cis-female patient with breast tissue might
be viewed as problematic as the breasts may block access to the lungs. Secondly,
teachers may (wrongly) worry the female breast presents the risk of sexualising
the context. Thirdly, there is added, and potential, inconvenience associated with a
perceived necessity to arrange for chaperones if a female is chosen as the volunteer for
a respiratory examination. All these issues may be taking place ‘backstage’, perhaps
even unconsciously, for those arranging the simulated exercise. The subsequent—
and hidden—arrangement is that faculty may then opt to utilise male patients or
female patients with smaller breasts.
This background manipulation or screening by faculty also extends to the selection
of imagery within the curriculum, as discussed by Matthan and Finn (2020; Finn and
Matthan 2019). They report a historic absence of variation in presentation of different
body morphologies, races, and the spectrum of gender. In digital teaching materials,
for example, there are few representations of anorexic bodies, of morbidly obese
bodies, of non-white bodies, of female bodies, and of trans-gender bodies (Finn et al.
2022). Instead, what is on offer is, at best, an idealised modal body that represents the
middle of the spectrum, and at worst a white male archetypal representation. Learning
from idealised versions of bodies runs the risks of perpetuating health inequalities.
7 The Significance of the Body in Health Professions Education 97

We risk students seeing bodies in a clinical environment that they have not seen in
training. We risk a hidden curriculum of body normalcy, one in which maleness and
athleticism gets privileged. We risk a limiting students’ thinking on the body to the
binary and to the heteronormative.
Finally, it is important to note that the hidden curriculum of medicine has been
misrepresented as space that: (a) includes ‘hidden agendas’ and thus is driven by
intentional deception or backstage motives (the hidden curriculum is more a socio-
logical than psychological construct—although see one exception below); (b) exists
only to highlight discordance or to shine a light on negative behaviours and profes-
sional misconduct (there can be concurrence between the other-than-formal and
formal dimensions of organisational life; (c) is singular (hidden curriculum) and thus
unidimensional rather than plural (hidden curricula); (d) is something that is expe-
rienced by all individuals in the same way (while there may be common messaging
driven by structural or cultural factors, this messaging may not be unilateral and
homogeneous; (e) that all disjunctions between the formal and other-than-formal
can be resolved by transferring tacit learning into formal instruction; and (f) can be
deliberately manipulated to transform what has been tacit and informal into lessons
that are and surreptitiously manipulated towards desired ends—something that has
been termed ‘teaching by stealth’ (Aka et al. 2018).

7.10 Conclusion

To summarise, and on a surface level, the body appears conceptually simple—a living
organism composed of the Cartesian mind–body dualism. When it is broken, we seek
healthcare, often within this dualism (e.g., for mental health versus physical health
reasons). What we have emphasised in this chapter is that such representations and
reproductions within healthcare and healthcare education reflect this rather narrow
view of the body. In such ways, the scientific discourse of the body often neglects to
consider the symbolic, sexual, and aesthetic discourses. Awareness of such discourses
and their potential significance for individuals could go some way towards improving
healthcare and reducing the inequality experienced by certain groups based upon
having certain bodies, for example female or black bodies. As societal views of
the body evolve, our lexicon and teaching of the body within health need to keep
pace. We advocate for a more inclusive approach to how the body manifests within
healthcare curricula—noting the spectra of gender and race, in particular. For too
long, the body has been considered male, with females dismissed as ‘other’. We
started with the idea of mind–body dualism, and as we know, dualism is reflected in
all sorts of things, however, the discussions within this chapter have shown that the
body is more complicated and that dualistic framings should be a thing of the past.
Healthcare should not default to a scientific view of the body as object (Table 7.1).
98 G. M. Finn et al.

Table 7.1 Practice points

1 When developing curricula, create space for consideration of the discourses of the body.
Acknowledging that dualistic thinking about the body is no longer a useful lens—the body is
too complex for such a reductionist view
2 Advocate for the critical engagement of health professionals and students with their own
orientation towards their body—noting that individuals differ
3 Normalise the sexual discourse of the body with health professions education and healthcare
delivery. Only through open discourse will the sexual discourse no longer be so taboo
4 Campaign for the use of inclusive language and the need for an evolving body lexicon,
particularly with respect to biological, genetic, and anatomical terminology. Educate health
professionals and students on the need for a patient-centric lexicon—explaining the nuances
and being mindful of the challenges of labelling, diagnostic or otherwise e.g., geriatric
mother, obese etc.
5 There is potential for a hidden curriculum of body normalcy or body optimisation for certain
educational activities, for example in the use of subconscious or deliberate backstage
selection processes of cadavers, simulated patients, or healthy volunteers. Awareness of the
potential for tacit messaging is paramount

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Chapter 8
The Philosophy of Education: Freire’s
Critical Pedagogy

Jennifer L Johnston, Nigel Hart, and Annalisa Manca

8.1 Introduction

We have to go from what is essentially an industrial model of education, a manufacturing

model, which is based on linearity and conformity and batching people…We have to recog-
nize that human flourishing is not a mechanical process; it’s an organic process. (Robinson
2006)

Adopting a critical pedagogy offers a radical reorientation for health professions

education. Focusing on power and structural inequalities, it poses a strong rebuttal
to conservative voices who maintain that medicine is and should be apolitical. First
theorised in the 1960s by Paulo Freire, a Brazilian educationalist drawing on Marxist
tradition (Freire 1972), critical pedagogy has been highly influential in other social
sciences, especially in Latin America, but has been little known in Anglophone
medical education to date (Tarlau 2014; Halman et al. 2017). It was first used to
advocate literacy education among those in poverty but has been translated to multiple
contexts and extended by other theorists (hooks 1994; Giroux 1985).
Denouncing mindless banking models of education, Freire locates our very
humanity in the development of conscientização (critical consciousness). This is
a phenomenological way of being in the world and with the world that flattens power
structures and empowers learners to address inequality (Freire 1972). The world of

J. L. Johnston (B) · N. Hart · A. Manca

Centre for Medical Education, Queen’s University Belfast, Belfast, Northern Ireland, UK
e-mail: j.l.johnston@qub.ac.uk
N. Hart
e-mail: n.hart@qub.ac.uk
A. Manca
e-mail: amanca01@qub.ac.uk

© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2022 103
M. E. L. Brown et al. (eds.), Applied Philosophy for Health Professions Education,
https://doi.org/10.1007/978-981-19-1512-3_8
104 J. L. Johnston et al.

medical education is strongly influenced by a strongly positivist biomedical tradi-

tion, the clinical gaze (Foucault 2003), and societal privilege, so that the develop-
ment of critical consciousness offers an important means of addressing social justice
in healthcare (Ross 2015). Beyond that, it offers individuals a profound intellec-
tual awakening through the transformative development of conscientização (Smith
1976).
We introduce critical pedagogy’s key concepts, discuss its genesis, evolution, and
future, and provide a case study into its practical application within undergraduate
education in a General Practice (GP) context.

8.2 Banking Models and Industrialised Education

School systems in the global north are broadly a product of industrialisation, driven
by the twin masters of efficiency and profitability (Welch 1998). Practical examples
include the classic rows of identical desks, uniforms, rigid curricula with little space
for creativity or individuality, and teachers whose dual role is to control and instruct.
All of this results in learners moulded towards a place in society predetermined by
characteristics such as race, class, gender, and other structural constructs of power.
Freire called this type of education a banking model: students’ minds are
empty, passive ‘bank accounts’ into which teachers make ‘deposits’ of pre-approved
knowledge. A good student in this conception accepts a subordinate position and
unquestioningly takes care of their deposits:
The teacher teaches and the students are taught;
the teacher knows everything and the students know nothing;
the teacher thinks and the students are thought about;
the teacher talks and the students listen -- meekly;
the teacher disciplines and the students are disciplined;
the teacher chooses and enforces his choice, and the students comply;
the teacher acts and the students have the illusion of acting through the action of the teacher;
the teacher chooses the program content, and the students (who were not consulted) adapt
to it;
the teacher confuses the authority of knowledge with his or her own professional authority,
which she and he sets in opposition to the freedom of the students;
the teacher is the Subject of the learning process, while the pupils are mere objects. (Freire
1972, 68–69)

Banking education is a means of oppression, preventing the development of

creative or critical thought so that learners become ‘automatons’. Freire echoes
Gramsci’s concept of hegemony- that is, power exercised by coercion rather than
force, in which education plays a key role in keeping the proletariat compliant and
subdued (Gramsci et al. 1971). Gramsci called the subsequent lack of conscious-
ness of oppression manufactured consent. A common and persistent example is that
8 The Philosophy of Education: Freire’s Critical Pedagogy 105

of uncritical colonising curricula, where education is used even in current times

to explicitly suppress First Nations peoples (for example, in North America and
Australasia) eliding the experience of those oppressed by hegemonic colonial atti-
tudes reflected in schools, colleges and universities (King 2021; Canuto and Finlay
2021; Woldeyes and Offord 2018).
Underpinning banking models is a positivist epistemology assuming education
to be value neutral and removed from moral or political influence (Giroux 2011).
A focus on objectivity means that learners are authoritatively presented with clean
and uncontested ‘facts’. Education in this sense exists to reproduce discourses and
practices of power, and to minimise dissenting voices. Teachers who unthinkingly
reproduce generational power structures in this way were referred to by Freire as
‘bank clerks’ (Freire 1972).

8.3 Relevance to Medical Education

Our focus here is on the training of doctors, but we hope that many of these concepts
are resonant and transferrable to the education of other healthcare professions.
Multiple social, educational and clinical discourses influence medical education.
Neoliberalism is one of the most important: the current dominant economic ideology
of the global north, it is the natural capitalist successor of early industrialism. Its
central tenet is the permeation of free market forces and individualist discourse into all
aspects of society (Fine and Saad-Filho 2016). Since the 1990s, neoliberal discourse
has infiltrated the university sector, leading to repeal of grants, their substitution
with loans, and substantial increases in university fees, while academic freedom
of thought has become constrained by the need to remain appealing in the market
(Vernon 2018). In the neoliberal university, students are consumers, research is a
commodity, and staff are trading pieces in a global capitalist game.
Throughout tertiary education, elements of banking models combine with neolib-
eral rhetoric to define students’ learning experiences. Tightly defined admissions
procedures (never more so than in medical schools) make entry requirements less
attainable for those without privileged backgrounds. In large lecture halls, the banking
model looms large as lecturers make deposits into students’ accounts. At graduation,
traditional academic dress marks hierarchical status, yet this apparent meritocracy is
subject to significant structural bias (Zivony 2019).
Medical education is not exempt from these discourses (Mayes et al. 2016).
Doctors occupy a high-status position, and their training is a competitive industry in
itself. Neoliberal trends fuel the cultural dominance of a privileged few, with access to
medical training from socioeconomically deprived populations inevitably restricted
as costs become prohibitive (Moberly 2016). Emphasis is on individual account-
ability rather than creative team working. Curricula are tightly regulated through
industrial-level assessments (General Medical Council 2021).
As early as 1908, Flexner problematised industrialised medical education:
106 J. L. Johnston et al.

Each day students were subjected to interminable lectures and recitations. After a long
morning of dissection or a series of quiz sections, they might sit wearily in the afternoon
through three or four or even five lectures delivered in methodical fashion by part-time
teachers. Evenings were given over to reading and preparation for recitations. If fortunate
enough to gain entrance to a hospital, they observed more than participated. (Cooke et al.
2006, 63)

It is not difficult to interpret Flexner’s comments as a form of banking. Despite

Flexner’s negative commentary, this pedagogical approach continues to have traction
(Halman et al. 2017). When combined with the strong positivist influence on medicine
from bioscience, medical students are afforded a position as passive recipients of
information without agency, humanity, curiosity, or creativity. A key example is the
current dominance of competency-based medical education (CBME).
With a well-intentioned aim of improving and standardising approaches on patient
safety and care, focusing on the needs of communities, CBME is an outcome-oriented
approach to learning which dominates much of medical education in the global north.
With an initial focus on patient safety, the CBME movement has become problematic
through its rigid implementation in teaching, assessment, and professional develop-
ment (ten Cate and Billett 2014). Examples of competency-based curricula include
Canadian CanMEDs (Royal College of Physicians and Surgeons of Canada 2021)
and the UK Outcomes for Graduates (General Medical Council 2020).
CBME curricula are complemented by assessment, often through the hegemonic
Objective Structured Clinical Examination (OSCE). We have extensively criticised
both OSCEs and their close cousin simulation education for having expanded beyond
their original remit (Johnston et al. 2020; Reid et al. 2021) and for drawing on
industrial models, for example with simulated patients and mass testing of students
regimented by regular bells (Gormley et al. 2021). In the UK, the national Medical
Licensing Exam will be introduced in 2024 and will consist of a large-scale OSCE
(General Medical Council 2021). Yet, this one-size-fits-all approach pays no heed
to local community needs or contexts. OSCEs and simulation education have unin-
tended consequences for learning, too, in becoming the only forms of medicine
which students will know: clean cut, with the clinician in control and the patient
following an obedient script (or indeed, replaced by a mannequin). Students, too,
in the role of doctors, follow unconvincing set scripts leading to ‘shotgun’ answers.
Simulation suites ensure that a deadly clinical encounter can simply be reset, and the
game started from scratch with no casualties (Johnston et al. 2020). It is our position
that this in no way prepares students for dealing with humans or the messiness of
real-life clinical practice, unless countered by a strong critical and humanistic focus
on learning in the workplace.

8.4 Rejecting Banking Models

Freire’s critical pedagogy explicitly links individuals with their contexts. Following
the existentialist thinking of de Beauvoir and Sartre (de Beauvoir 1997; Sartre 1992),
8 The Philosophy of Education: Freire’s Critical Pedagogy 107

Freire held that meaning does not exist outside phenomenological experience of the
world. Without the ability to critique and be fully open to the world, banking models
of education end with learners unable to fully achieve their human potential. Yet the
need to become fully human is an ontological vocation, making banking education
nothing short of a dehumanising endeavour (Freire 1972). See also the relevant
chapters on Ontology (Chapter 12) and Technology (Chapter 17).
Translated to medicine, banking approaches stymie our full potential as human-
istic, rather than purely technical, doctors. The everyday dialogues of teaching and
learning offer a means of reproducing or resisting these power relations. Critical
pedagogy is Freire’s call to arms for educators to engage in counter-hegemony
against the reproduction of oppression (Gramsci et al. 1971). He offers the alter-
native of problem-posing education: students and teachers engage in reflection and
action through constant formative dialogue. This intersubjectivity allows both to
develop agency and criticality, while recognising each other as conscious human
beings (Smith 1976).
Problem-posing education simultaneously shifts the emphasis from positivism
to co-construction and levels the power gradient between student and teacher.
Learning becomes bidirectional through dialogue (Bakhtin 1981). Education is
openly acknowledged as inherently political. Both participants (learner as teacher,
and teacher as learner) become cognisant of oppression, including their own posi-
tionality regarding oppressive practices. Problem-posing education allows the devel-
opment of a theory of mind- a meta-consciousness of the conscious existence of
oneself and others.

8.5 Raising Critical Consciousness in Medicine

Developing critical consciousness does not imply a single threshold event but rather
ongoing real-world practice (praxis). Education is therefore a practice of freedom,
whereby transformation of self and society ensue.
Critical pedagogy is not yet particularly well known in medical education; our
2019 scoping review found only 20 relevant papers. We identified 4 key themes: social
awareness, cultural awareness, political awareness, and awareness of educational
dynamics. These represent important areas where problem-posing activities can be
developed. Critical pedagogy embodies action, not just thought, and so has real-life
pedagogic applications in clinical workplaces as well as in universities (Manca et al.
2020).
The project of introducing conscientização to medical curricula is not without
challenge, however, since it constitutes a form of counter-hegemonic practice defined
by action against mainstream hegemonic assumptions. Many healthcare educators,
particularly clinicians, are in their second career. Unless they have been exposed to
social science, they may bring to education a constrained position of naïve realism and
biomedical positivism. Taking on a critical stance is a paradigm shift (a foundational
shift in concept and practice) for these educators, and one that they are therefore
108 J. L. Johnston et al.

unlikely to take spontaneously. Students, meanwhile, may not have experienced

problem-posing education. They, too, face a paradigm shift in becoming critically
conscious. Yet the benefits of doing so include a shift away from neoliberal influence
and back towards medicine’s social contract. Healthcare inequalities may be better
addressed by humanistic doctors who are more than merely excellent technicians;
within empathic dialogue, clinicians may come to an understanding of the embodied
experience of sociocultural determinants of health and develop strategies to treat
people rather than illnesses. Such doctors learn to construct themselves as much more
than Foucault’s seminal clinical gaze (Foucault 2003), embracing the ontological
vocation of becoming fully human.
In our case study, we draw on empirical work undertaken for Dr Manca’s doctoral
thesis to illustrate how critical consciousness can be enacted in medical education.
She conducted ethnographic observation of an exemplar of UK university-based
undergraduate medical education in a general practice (GP) in 2018–2019. It becomes
evident that GP educators cultivate students’ understanding by focusing on values,
rather than just competencies. The pursuit of critical consciousness can be seen not as
linear, but as a dialectic process. Educational practices can be seen to be potentially
transformative for both learners and environments, with GP teachers reaffirming their
own clinical vocation.

8.6 Case Study: Enacting a Critical Pedagogy Within

Undergraduate GP Teaching

Context: The GP course explored here was a four-week module in year four of
an integrated, systems-based, five-year curriculum. This was the first substantial
introduction to GP work in students’ experience to date. An introductory central
teaching week was followed by three weeks in practice. Subjects taught formally
included the philosophy and practice of primary care, and how it differs from the
secondary care settings which students were more used to. A substantial review of
the course in 2017–2018 recognised and enhanced the inherent orientation towards
critical consciousness, mainly allowing more space for discussion and reflective
dialogue.
Research questions: We focused on exploring the following elements:
• How teaching is structured, and what educational strategies GP teachers used.
• How knowledge is enacted throughout educational practices and pedagogical
relations.
• How GP teachers managed the dynamics of power and authority.
• How GP teachers attended to conflict within teaching.
8 The Philosophy of Education: Freire’s Critical Pedagogy 109

8.6.1 Integrating GP Work into Existing Knowledge

of Clinical Practice

GP teaching gave students an understanding of primary care as it was enacted in

teachers’ educational and clinical practices. Sessions were structured to facilitate
students’ gradual entry to primary care, referred to as ‘GP Land’. This mild idiosyn-
crasy established general practice as an autonomous and boundaried entity outside
of the hospital system in which students had spent most time to date. Teachers
portrayed GP as an enclosed domain which integrated interprofessional practices
while maintaining a core philosophy in which the axiology was relational care.

8.6.2 External Integration: Moving Past Positivist Bank

Deposits

Some sessions built on previously acquired knowledge, challenging assumptions

while transferring knowledge to the new context. Students were introduced to wider
sociocultural, political, and historical influences on general practice, including legis-
lation, deprivation, class, race, gender and immigration. These were not necessarily
known to students. Exploring these influences constituted an early challenge to the
positivist biomedical model of medicine.

8.6.3 Education in Dialogue

The first formal educational activity of the course, undertaken in the university, was
one of disruption. Students (around 40 altogether) were assigned to groups of 7/8
people and asked to physically move position within the room, lifting their chairs and
replacing them in small circles. At the end of this operation, the room format had
completely changed from typical lecture style to 6 circular formations distributed
across the room. GP teachers explained that students would work in these groups
throughout the period of formal teaching. The first task was to find a name for their
“GP Practice”- that is, their group. By engaging students in disrupting the expected
activity of a didactic teaching session, students were brought to a temporary shared
identity as a ‘Practice’. This physical and mental shift, combined with contextual
discussion of GP work, encouraged them to begin to empathise with. This simple
exercise explicitly challenged banking education and afforded learners an active
role. A pedagogic intention to mitigate hierarchical relations between teachers and
students was expressed:
(GP teacher): “We hope you talk to us… we won’t talk to you very much [said with
irony]”
110 J. L. Johnston et al.

Teachers established a dialogic (i.e., taking place in mutual dialogue), not didactic
learning relationship at the outset, accepting a consonant degree of risk in teacher-
student interaction. The clear intention was to keep everyone engaged, even at
the back of the room, or those who may regard GP teaching as irrelevant. This
strategy created a safe environment where students spontaneously asked questions
and contributed to discussions without fear of humiliation or retribution.

8.6.4 Staying Authentic to Clinical Practice

Teaching moments intertwined with practical tasks based on real-life situations and
were accompanied by group-based reflective dialogue in which students were invited
to think critically about the social context they were discovering or talking about.
Although university based, GP teachers continuously brought discussion back to
clinical practice, often sharing authentic anecdotes. The tacit pedagogy embedded
in these practices involved an orientation to problem deconstruction and analysis,
questioning attitudes and facilitating interactions within a highly responsive and
friendly environment.

8.6.5 Risk-Taking Educational Practice

The course was constituted by formal documents such as a study guide. In class,
these were used not to reify positivist ‘bank deposits’ but as a template from which
to work creatively. Students were encouraged to see the study guide as a platform
from which to launch their clinical experience, rather than a reductive list.
Most GP teachers included storytelling in their sessions, offering narratives that
were tangential to the main discussion and using these to respond to students. Educa-
tional practices were persistently dynamic, not static. Students were often given
opportunities to ask questions, explore aspects interesting to them, and to share
cases from their clinical practice. In this way, students informally directed content, a
pedagogical choice predicated on teachers with the ability and disposition to manage
educational risk.

8.6.6 Pedagogy as Activism

The course was constructed around transformative practices directed towards socio-
political change:
1. Fostering learners’ attitude to be future active and activist members of the
medical profession.
8 The Philosophy of Education: Freire’s Critical Pedagogy 111

2. Reforming how medical education is taught and assessed within—and

outwith—the medical school.
The ethos of the GP course was to familiarise students with the discipline of
General Practice. Students were introduced to the distinguishing character of GP
and its underpinning philosophy. Stated in the study guide was the central aim not of
influencing students to become GPs, but to foster understanding of the differences in
primary and secondary care. Teachers implicitly understood that the information they
shared was not the only knowledge with value. The pedagogy embedded in this course
constituted a form of counter-hegemonic practice, resisting tick-box competencies.
This was reflected in both formative and summative assessments. Formative case-
based discussions happened throughout teaching. Summative assessment (mandated
by the medical school) consisted of positive engagement with a logbook containing
workplace-based assessments, and formal case-based discussion facilitated by a GP
tutor. We see this choice of assessment as an embodiment of the teachers’ intrinsically
activist ethos, which again manifests a different philosophical underpinning than the
more popular CBME approach.

8.6.7 Knowledge and Power

Hegemony is constituted in the realm of knowledge: a set of formed ideas can either
legitimise or question social structures. How knowledge was enacted within the
GP course showed how students developed the range of ‘possibilities for action’
(Foucault 2003) from which they drew agency to take constructive action in the
world. We identified 5 ways in which knowledge has been enacted in educational
practice: as generative, shared, interactive, co-constructed, and goal oriented.

8.6.8 Knowledge as Generative

New ideas were dynamically integrated with existing ones, thus generating new
knowledge. An early group task was a perfect example of this: students were asked to
think of words or phrases to describe general practice, deciding on the top 3 positive
and the top 3 negative words or phrases. During the general discussion, teachers
expanded on all these words and phrases with the students, providing examples from
their clinical practice, and inviting students to critically examine stereotypes and
assumptions:
(GP teacher): “Who suggested time-wasters?”
(Medical student): “In the most diplomatic way possible… Many patients come
and some don’t really have an appropriate reason for an
appointment”
112 J. L. Johnston et al.

(GP teacher): “Ok that’s brilliant… The words appropriateness and time
wasters stuck with me… I think there’s no such thing as appro-
priateness in a consultation… you may perceive it differently
but from a patient’s perspective it is not the case, it is never a
waste of time” […] “There is always an opportunity there for
patient advocacy… which is about wellness… connecting the
patient to that wellness”
So, in this instance (similar practices happened throughout), the teacher used
students’ pre-existing, uncritical knowledge to generate a new more critical under-
standing. Students were given the opportunity and the means to generate meaning
through creative integration of new ideas with their existing knowledge and
experience.

8.6.9 Knowledge as Shared

Personal experience was exchanged among students and teachers in a process of

creating (co-constructing) shared new knowledge. Both students and teachers shared
their ideas about GP. Often, lectures were designed to be discursive1 : in one example,
two lecturers performed as a dialectic whole, conducting conversational exchanges
of experiences and ideas. Here, elements of GP were identified, conceptualised, prob-
lematised, deconstructed and given meaning, creating a new, more sophisticated, idea
of GP which was then shared by the group. Students and teachers both experienced
a dialectic between spontaneity (unexamined knowledge) and conscious direction.
Through holding spaces for critical tension between “old” and “new” ideas, new
knowledge was generated and became mutual.
These pedagogical choices required a moral commitment to caring about the
‘other’. Trust is essential to grant others custody of one’s own knowledge because
the other is then empowered as trustee of knowledge. This aspect of critical pedagogy
requires a strong sense of safety in the classroom and an ethos of mutual reciprocity.

8.6.10 Knowledge as Interactive

We have seen that this GP curriculum was dialogic and closely aligned with clinical
practice. Teachers actively engaged students by involving them in practical group
tasks in which not only students discussed real-life case scenarios, but also used tools,
such as guidelines or prescriptions, that were real-life artefacts of clinical practice.
Teaching did not stand alone, but interacted with reality, objects, and contexts of
authentic clinical practice.

1 We use the term “discursive” here to signify a reflective practice through language use.
8 The Philosophy of Education: Freire’s Critical Pedagogy 113

In one instance, a prescribing group task brought the discussion towards practical
and socio-economic issues. Here, they discuss the rationale for prescribing parac-
etamol. In the area of the UK concerned, there are no prescription charges, making
this free to patients.
(GP teacher): “How much does a prescription cost to the NHS...£0 for children,
£8 for adults, but about £20 in total, GP time etc.…”
(Student): “We thought that maybe the family can’t afford paracetamol”
(GP teacher): “This is important, paracetamol is generic and very cheap. So, it
all depends...think of the person in front of you… we don’t treat
conditions but the person with a condition”
Here, the GP teacher directed students in a reflective, critical dialogue connecting
clinical practice with practical social context. In this sense knowledge was enacted
as interactive, and as existing in its dynamic interactions with reality.

8.6.11 Knowledge as Co-constructed

Unlike traditional banking models, students’ answers or solutions never marked the
end of a task. These were always followed by extensive discussion in which teachers
made explicit links with the clinical world and social contexts, often illustrated by
anecdotes. Knowledge was expanded and treated critically through interpersonal
discursive dynamics. The following comment was made in relation to a complex
discussion of how core ethical principles should be enacted:
(GP teacher): “There’s no answer there, we are just trying to highlight the
complexities…”
Throughout the course, students’ responses were deconstructed, problematised
and reconstructed to collaboratively find alternative possibilities, envisaging alterna-
tive courses of action and possible consequences. In this sense, knowledge was not
considered objective, as something positivist merely transmitted to students, but as
something that is co-constructed through the discursive dynamics among students
and teachers. Didactic, lecture-style moments were minimised, and always used as
occasions to provide extra context to the discussions.

8.6.12 Knowledge as Goal-Oriented

In this demonstration of critical pedagogy, knowledge acquisition was not an objec-

tive in its own right, but a means to addressing a wider, political goal. Hence, it has
a particular direction: in the ethics discussion mentioned above, placing quite lofty
and disembodied ethical principles within on-the-ground contexts helped students
towards deeper understanding through feeling and passion. It is in this way that they
114 J. L. Johnston et al.

can contribute to social change and justice. The epistemological ramifications of this
idea (understanding through feeling and passion) for educators is that knowledge is
an engaged scholarship in the service of humanity (Brookfield and Holst 2010).

8.6.13 A Coherent Critical Pedagogy

We have shown how knowledge was enacted as a dialogic social entity. GP teachers
fostered students’ development through educational interventions based on their
potential and current knowledge. Paraphrasing Gramsci, learning happened through
students’ spontaneous and independent effort, with teachers functioning primarily as
overseers and friendly guides. They provided scaffolding by giving students the right
amount of assistance at the right time. Knowledge was enacted as a co-constructed
entity; teachers often stressed, directly or indirectly, that they did not necessarily
know more than students. Rather, they valued students’ knowledge as an asset for
inter-personal growth, both in the educational and in the clinical environment.

8.7 Developing a Critical Pedagogy

Perhaps the most important aspect of the case study above is one which we delib-
erately withheld: that is, most of the GP teachers mentioned had had no formal
knowledge of Freire and Gramsci a priori. In other words, it is possible to be innately
critically conscious without an academic awareness of the theoretical concepts. This
offers an essential opening for agency. For example, as a GP, Dr Johnston has found
that her instinctive orientation towards educational dialogue comes from her patient
interactions, and her commitment to criticality grew from a need to enact social
justice within the practice of medicine. For those at the beginning of developing a
critical pedagogy, we suggest that reflexivity is the most important place to start.2
We have suggested several curricular choices and pedagogic activities below
which may be used as a jumping-off point in creating a problem-posing approach.
Educators are cautioned, however, to steer clear of the hegemonic ‘tick boxing’ char-
acteristic of CBME, which might prevent the development of a critical pedagogy. In
terms of evaluation, we suggest that when both teachers and learners start to question
the orthodoxy that a benchmark of criticality has been reached.

2 We offer the following as possible starting points: first, consider long cherished ideas and assump-
tions, and try to trace their roots; what influences are acting on teachers, and what innate values are
they oriented to? What is their purpose in taking part in educational activity? Dialogue with oneself
and others is a way of life for critical pedagogy and can be easily introduced through supportive
teacher development.
8 The Philosophy of Education: Freire’s Critical Pedagogy 115

8.7.1 Potential Problem-Posing Interventions

Curricular choices:
• Problem-based learning can become a basis for problem-posing education, either
at a curricular or simple group task level.
• Longitudinal integrated clerkships and workplace-based assessments, as conduits
which exceed the expectations of CBME, and contest industrialised medical
education.
• Workshops supporting staff reflexivity and introducing concepts of critical
pedagogy.
Class-based activities:
• Move the furniture if the classroom is set up in a banking orientation.
• Design case-based discussions with dialogic plenary.
• Peer to peer teaching.
• Explore students’ and teachers’ personal axiologies.
• Contest the clinical gaze/ doctor as technician.
• Include authentic stakeholder narratives and phenomenological work.
• Use ‘Theatre of the Oppressed’: creative interactions which involve students
as both players and interacting audience, and which are structured to highlight
oppression and encourage criticality (de Carvalho Filho et al. 2020).3

8.8 Limitations and Future Directions

As with any theoretical perspective, there are potential boundaries and limitations in
working with critical pedagogy. We outline here three of the most significant for us:
• Critical pedagogy represents a highly philosophical position, with Freire’s key
texts written in a challenging dialectic form (based on new insights gained from
juxtaposing argument and counter-argumentation in) translated from the original
Portuguese. These aspects make it much less accessible to those without a social
science background unless facilitation and training are provided. This is one of
many instances where the agency of students and staff may be limited by structural
contexts.
• There is a theoretical contradiction between the grand theory of Freire’s Marxist
roots and critical, situated and highly constructionist practice. This is important
because any counter-hegemonic movement may eventually become inflexible and
hegemonic in itself. To satisfy the needs of the grand project of Marxism, critical
pedagogy would necessarily lose much of its power. This contradiction can, in our

3 Drawing strongly on Freire, the concept is that the audience take part in the artistic work as ‘spect-
actors’, creating an unusual dialogue which both analyses and challenges inequalities. See Boal
(1985) for more.
116 J. L. Johnston et al.

opinion, be resolved at an individual and community, rather than grand structural

level.
• Lastly, Freire’s mission was to liberate the oppressed, but the proletariat he
refers to are presented somewhat homogeneously, with little regard to separate
marginalised groups. To explore the experiences and needs of particular groups,
we direct readers to bell hooks’ more recent extension of Freire’s work, Teaching
to Transgress (hooks 1994).

8.9 Positionality

We are passionate advocates of critical pedagogy throughout all aspects of medical

education. We are all critical, constructionist medical educators with different back-
grounds. Dr Johnston and Professor Hart are clinical academics and practising GPs
in a deprived part of Belfast, NI, still a divided post-conflict city where critical peda-
gogy is highly relevant. AM is an educationalist and psychotherapist from a social
science background, who is originally from the same place as Gramsci (Sardinia) and
has lived and worked in Scotland, England, and Northern Ireland. Our perspective is
an emic one. Both Dr Johnston and Professor Hart teach on the course used for the
case study.

8.10 Conclusion

In this chapter, we have critically deconstructed neoliberal medical education, which

continues to promote the efficiency of banking models at the cost of students’ ‘onto-
logical vocation’ to become fully human. We have presented key aspects of Freire’s
theory and given an example of how critically conscious principles may be translated
practically into action. We advocate strongly for education as a practice of freedom
and for the development of critical consciousness as an essential tool with which to
address social inequalities in healthcare. Below we offer some useful practice points
for educators getting started with their own critical pedagogy (Table 8.1).

Table 8.1 Practice points

1 Encourage reflexivity amongst students and staff
2 Always pay attention to social and political contexts
3 Engage students in friendly dialogue to flatten hierarchies
4 Use narratives (stories) in teaching
5 Move the furniture to facilitate dialogic learning
8 The Philosophy of Education: Freire’s Critical Pedagogy 117

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Chapter 9
The Philosophy of Social Justice: Lessons
for Achieving Progress in Health
Professions Education Through
Meaningful Inclusion

Angelique N. Dueñas, Marina Politis, and Adam Danquah

9.1 Introduction: What is Social Justice, and Why Does It

Matter?

… Medicine as a social science, as the science of human beings, has the obligation to point
out problems and to attempt their theoretical solution…
Rudolf Virchow (1821–1902)

While often regarded as the purview of politics, ethics, and law, social justice and its
principles are an equally important venture in health professions education (HPE).
Ensuring that individuals are empowered to have fair access to healthcare, education,
and knowledge should be a fundamental value held by the healthcare community.
Indeed, in recent years, there has been an increase in medical organisations directly
addressing social justice (Alberti et al. 2018; Kuper et al. 2017; Woollard and Boelen
2012).
Social justice, both as an action and as a guiding moral philosophy or belief, can be
a complex topic for those from traditionally scientific disciplines to engage in (Rawls
1971). The word ‘justice’ alone is a complex notion; while often aligned with a sense
of what is morally “right”, justice can mean different things, depending on context and

A. N. Dueñas (B)
Department of Medical Education, Northwestern University Feinberg School of Medicine,
Chicago, IL, USA
e-mail: angelique.duenas@northwestern.edu
Health Professions Education Unit, Hull York Medical School, University of York, York, UK
M. Politis
School of Medicine, Dentistry and Nursing, University of Glasgow, Glasgow, UK
e-mail: 2364733p@student.gla.ac.uk
A. Danquah
Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
e-mail: adam.danquah@manchester.ac.uk

© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2022 119
M. E. L. Brown et al. (eds.), Applied Philosophy for Health Professions Education,
https://doi.org/10.1007/978-981-19-1512-3_9
120 A. N. Dueñas et al.

philosophical viewpoints (Lambert 2018). As such, it is important here, at the onset

of this chapter, to provide our definition of social justice. Social justice is the view
that all individuals deserve equal economic, political, and social opportunities and
rights. Social justice demands that society and social institutions ascribe to this moral
imperative. No matter who you are or your work, we take the position in this chapter
that social justice should be an important goal for all practitioners and educators,
and one that all feel comfortable engaging with. Medicine and health professions do
not operate in a void, as some ‘island’ of educational pursuits (Woollard and Boelen
2012) but are a key facet of society.
First, consider the patients that HPE ultimately serves. Concerning health dispari-
ties continue to exist in patient populations, rooted in social justice issues such as lack
of access to quality care, and misalignment of cultural competencies. Students, too,
are affected, with social inequalities affecting access to, and attainment in, higher
education (Cleland and Palma 2018). Similarly, educators will likely face social
justice challenges in their personal and professional lives. This includes ‘glass ceil-
ings’ and ‘sticky floors’ that may be encountered in professional advancement (Finn
et al. 2021) and the navigation of ‘professionalism’ that challenges intersection of
identities (Crampton and Afzali 2021). It is also important to note the inherent injus-
tice within educational and healthcare systems (Bate 2000), including hierarchies
and the challenges some staff may face compared to others (e.g.—the maintenance
staff of a medical building, compared to the dean). Finally, social justice encompasses
topics such as planetary health and climate justice (See Chapter 16 for a discussion
on climate change ethics and education). These challenges highlight the importance
of understanding social justice in medical and health professions education. As such,
we make the argument that every individual associated with HPE should be equipped
to tackle the ‘basics’ of social justice.

9.2 Structure and Reflexive Notes

While an entire book could be used to examine the intersection of social justice and
health professions education—and, indeed, many do exist (Singer and Allen 2017;
Bleakley 2020)—this chapter offers a practical approach to recognizing social justice
issues in HPE work. With three ‘case studies’ we will show how social justice can
play out in ‘real life’. These are subsequently examined with philosophical ‘lenses’,
to show the illuminated power of theories of social justice in HPE. These theories
of social justice are selected and applied to show how thinking philosophically in
this arena can strengthen our understanding and action in everyday encounters with
injustice.
In the realm of social justice, where recognition of privilege is a key element,
reflexivity is particularly important (Teo et al. 2014). Our worldviews, identities, and
affiliations shape the way we engage and discuss topics. Indeed, this is seen already;
social justice is regarded as important in HPE because we (the authors) all believe
it to be. But beyond this basic agreement, our lived experiences differ, thus shaping
9 The Philosophy of Social Justice: Lessons … 121

our contributions and social justice focus. In particular, as a reader, you may have
already noted references geared toward medical education, being extrapolated to a
more general HPE focus. This reflects our area of expertise and affiliations, but it
would be remiss to not recognise the complexities of interprofessional practice and
education (Flood et al. 2019), and biases in perspectives we hold. We encourage
readers, too, to engage in honest reflections of privilege and power, and reflect on
how such philosophies may be applied in your own work.

9.3 Social Justice in Anti-racist Practice: Raimond Gaita’s

Common Humanity as a Basis for Real World Equity
and Compassionate Justice

It is a truism that health professionals’ core motivation is to save, prolong, and

enhance life. But, all lives are not equal in the healthcare system (Gill and Kalra
2020). As well as disparities laid bare by the Coronavirus (COVID-19) pandemic, we
must confront disproportionate maternal mortality rates for Black women compared
to white women (Knight et al. 2018), disproportionate infant mortality for Black
babies compared to white babies in the care of white doctors (Greenwood et al.
2020), the attainment gap for Black medical students and Royal College trainees
(overseas and UK born) (Shah and Ahluwalia 2019) and Black underrepresentation
in senior leadership in the UK National Health Service (NHS) (Kalra et al. 2009).
These disparities have been attributed to epidemiology, lifestyle, culture, etc., but
what place does our culpability have in sustaining and reproducing a system that
does not protect Black lives as it does white? What role does structural racism play?
Case Study 1 presents one way in which racial disparities might be encountered by
healthcare professionals.

Case Study 1: Encountering Racial Disparities

As a busy clinician, editorials are a quick way for you to stay up to date with
the literature. You come across a recent piece from Gill and Kalra (2020) in the
British Journal of General Practice (BJGP) and are struck by their observation
that “all lives are not equal”. They go on to summarise findings related to
COVID-19; that is, that Black and other minoritised ethnic communities have
been disproportionately affected by the pandemic, and that the more than 60%
of health workers who have died have been from these backgrounds.
You are shocked and heartbroken about the loss of life in the health profes-
sions community, and that the bulk of this burden is borne by people from
certain ethnic groups. You are, at the same time, at a loss as to what you can
“do” about this information. Yes, you agree, “health inequalities still abound
and need addressing”, but you are short on time, have full clinics, and your
122 A. N. Dueñas et al.

other educational/professional development work takes up much of any spare

time you do get. By the time you get to Gill and Valra’s assertion that “in the
caring professions, it is often too easy to overlook our culpability in sustaining
and reproducing racism,” it all feels like too much.

9.3.1 The ‘Issue’/Injustice

Close to twenty years ago, de Wildt et al. (2003), in another BJGP editorial, said
it was time for the profession to ‘grasp the nettle’ of racism in response to the
Coker (2001) report on racism in the NHS, and the seminal Macpherson report in
1999, which highlighted that institutional racism played a significant role in the
police force’s mishandling of the investigation into the racially-motivated murder
of Stephen Lawrence (Macpherson 1999). These detail the impact of pervasive, and
yet subtle, forms of racism that healthcare and health education still struggle to
address sufficiently (Wyatt et al. 2021a, 2021b; Crampton and Afzali 2021; Wyatt
and Rockich-Winston 2021; Zaidi et al. 2021). Or, should we say, that those within
medicine struggle to sufficiently address. The shift from the individual to the struc-
tural, systemic, or institutional is often characterised by a sleight of hand, whereby
we are merged into an impersonal system of processes and procedures that institute
prejudice. One consequence is our—as individuals—disavowal of what is essentially
enacted between ourselves, and so responsibility for the consequent state of affairs.
Further, issues of population-level disparities in health outcomes and structural
and systemic racism are broad and sometimes alienating. There is a disturbing truth in
the quotation attributed to Stalin, “one death is a tragedy, a million deaths a statistic”.
Racism is a process founded on stereotypes, “which often make others only partially
visible to our moral faculties” (Gaita 2000, 282). It is difficult enough to empathise
with numbers, but is this capacity, in medicine as in life, already compromised by a
lack of full human regard for the racial other?
Our understanding of racial dynamics has developed considerably in recent years,
with various disciplines elucidating how we treat people of a different colour as
somehow lesser, and the purposes this serves. Critical Race Theory (CRT) is the most
prominent such approach at present (Paradis et al. 2020). CRT’s proponents seek to
show how the ascendant position of white people is maintained through policy and
practice that are legitimised as neutral, but which, on interrogation, are revealed as
racist and harmful to Black people. Although separate, contributions to psychology
and psychotherapy literature can be said to elucidate how seemingly innocuous,
everyday interracial interactions disadvantage Black people (Fakhry Davids 2011),
and how this power dynamic is embedded in the psyche and society, even if such a
clean break between these domains can only ever be illusory (Dalal 2013).
9 The Philosophy of Social Justice: Lessons … 123

Taken together, CRT and the psychological approaches outlined suggest

addressing racism in any real way requires interrogation of both our systems, and
ourselves. But who are we here? And who are you? Before considering a philosoph-
ical approach that attempts to frame social injustices like that in Case Study 1, it is
important to take stock of our own experiences. We (the authors) have found that
the medical education literature often seems to assume a white, male, cisgender,
heteronormative readership (Volpe e al. 2019). One of the authors must own up to
assuming this themselves—and perhaps their own socialisation—with the first iter-
ation of Case Study 1 in a draft of this chapter depicting a white GP within a white
community at a loss at the loss of so many Black lives. ‘Well meaning’, perhaps,
but what then about the perspectives, voices, and agency of those lives? (cf. Spivak
1988). Some of us are living this, while some of us read it on the page. We must work
hard not to do two things, that is: (1) reinforce the very marginalisation we decry with
the all too easy assumption of change and agency being for the white actor (even as
we acknowledge the disproportionate burden on Black shoulders), and (2) fall prey
to the dichotomising processes of racial dynamics, whereby we do cleave a world
full of colour into Black and white.

9.3.2 The Philosophy: A Common Humanity (Gaita)

In his book A Common Humanity, the moral philosopher Raimond Gaita sets out his
rich perspectives on the spectrum of human experiences (Gaita 2013). His thinking
(and feeling) about social justice offers a powerful perspective on making those
people on the page ‘fully our equals’ and, with that, real movement towards them.
Gaita argues that our characteristic embodiment and ways of living, as humans,
condition the concepts with which we think. We cannot stand apart from life and
philosophise, but are rather always inside our lives and bodies, having to “think in the
midst of things” (14; See Chapter 12 on Ontology for further details on being-in-the-
world and embodiment). Going further, Gaita (ibid) argues that the self is morally
constituted:
We cannot radically rescind from the ethical constitution of our inner lives without becoming
unintelligible to ourselves. (53)

This morality, delimited by our bodies and the immediacy of life and relationship
would appear to have much utility for healthcare and health education. It chimes with
Enid Balint’s observation that “at the centre of medicine there is always a human
relationship between a patient and a doctor” (Balint 1993, 11).
Gaita claims that our ethics depend on a responsiveness towards a fully constituted
other, who is able to feel as much as we do and whose life is able to mean as much
to them as ours does to us. Gaita quotes the English philosopher Winch thus:
Treating a person justly involves treating with seriousness his own conception of himself,
his own commitments and cares, his own understanding of his situation and of what the
situation demands of him. (59)
124 A. N. Dueñas et al.

Racism, according to Gaita, involves the denial of this attribution of a common

humanity to the racialised other.
Gaita observes that the anti-racism movement, like feminism (See Chapter 10 for
an in-depth discussion of feminism), expresses a concern for equality which goes
beyond equality of opportunity and access to goods. According to Gaita, this is social
justice due to the insistence that state and civic institutions reveal rather than obscure
the full humanity of our fellow citizens. In doing so, we are, according to Gaita,
enabled to respond to this full humanity, wherein compassion for those mistreated
or afflicted can really be found. Relatedly, consider some of the bases, past and
present, for health inequalities associated with racialised communities, which include
colonialism, historical abuses (Tuskegee, Sims, and Lacks), and ongoing racism
(FitzPatrick et al. 2021). Similar to the question facing former colonial powers, are
we in healthcare obliged to examine our consciences, even for past injustices?
Gaita argues that, in order to have true as opposed to empty pride in a country,
one must be able to feel shame for what has come before. There is much to be
proud of in medicine, but Gaita might counsel that realistic pride comes only after
honesty or acknowledgment (See Chapter 5 for further exploration of the concept
of acknowledgment) that not everyone is part of the constituency to benefit, and
that advances have come at the unacknowledged expense of these same groups. We
should feel ashamed about this fact.
Finally, Gaita’s is an ethics you can bring your feelings to. He recognises, along
with psychotherapists, that feeling is a species of thinking: “A dispassionate judge-
ment is not one which is uninformed by feeling, but one which is undistorted by
feeling” (89). Gaita’s moral philosophy navigates the dilemma of a rationalism that
stands apart from lived reality and an emotionalism that is slave to the dictates of the
heart.

9.3.3 Case Study 1, Revisited

Gaita’s common humanity may require a re-examination of the GP’s responses to

the loss of lives. Being ‘heartbroken’ might signal a sadness borne of an empathy
that grants their colleagues full human status. It might, however, stem from a more
sentimental feeling that keeps these ‘unfortunates’ at arm’s length.
We are not meaning to be judgemental (healthcare practitioners and trainees expe-
rience enough self-attack, e.g., Sampath et al. 2019). Motivations and feelings are
nearly always mixed, but if the application of moral philosophy is to mean more than
wordier rationalisations for our actions (or inaction), then we have to be prepared to
think these things through for ourselves and work out whether we are really moved.
It may be in doing so that we are moved towards addressing ‘the causes of the causes’
of diseases to others (Fitzpatrick et al. 2021).
Psychological theories suggest that racism thrives on unfamiliarity, which creates
the vacuum of relating necessary for the unimpeded development of stereotypes. A
lesson from a common humanity is that we recognise our being in media res (in
9 The Philosophy of Social Justice: Lessons … 125

midst of things), and attempt to connect with people from different communities,
rather than try to fix them from afar.
But what about the implications of Gaita’s common humanity for those living,
rather than reading, about such losses? One unspoken assumption might be that
white people need to extend this full recognition of personhood to people from Black
and other minoritised ethnicities. In this case, would it be safe to assume that such
compassion already flows the other way? If a common humanity means anything,
then it means we must be subject to the same human strengths and weaknesses, so,
no. Gaita suggests that a concern for justice in a community should be a concern
that institutions enable and encourage us always to see. In medicine, we must look
unflinchingly at the damage wrought by differences in power, and what powerful
groups do to retain it. The idealised doctor-patient (or doctor-doctor; doctors are not
equal) relationship is inflected with power differentials that must be seen in order for
us to address them.
How else can this theory be applied to action? The responsiveness necessary to
Gaita’s moral philosophy may require practitioners and students to witness and expe-
rience the lives of those with which they are unfamiliar. Fitzpatrick et al. (2021)
discuss the importance of such ‘experiential learning’ to tackle health inequali-
ties. This should be the case for our colleagues as much as for our patients; Case
Study 1 foregrounds disproportionate loss of healthcare practitioners from Black and
minoritised ethnic backgrounds demonstrating that all healthcare practitioners are
not equal. Psychological approaches suggest we are motivated to keep those we see
as different as strangers even in their midst. In this vein, it has always interested us
that the UK healthcare system has been so prepared to depend on the Global South’s
medical and healthcare workforce (depleting already tenuous healthcare systems in
the process), but, other than what can be validated through Royal College examina-
tion, so unwilling to accept the Indigenous approaches to healing these individuals
bring with them. Perhaps this chapter itself, with its focus on philosophy rooted in
the Western intellectual tradition, cannot escape this charge of ‘epistemological terra
nullius’1 (Dorries and Ruddick 2018). Aside from one’s approach to reading philos-
ophy, we have to work harder to embrace all that colleagues bring, for the benefit of
their wellbeing, and even patient care.
Engaging with others on matters of social justice is the basis for collective action—
a practical application of holism (see Chapter 14 for a philosophy of social science
perspective on holism)—which can be seen in such efforts as the London Aces Hub
Racial Justice Workgroup, which has been founded to shed light on the impact of
racial trauma and facilitate collective action to tackle these harms for individuals and
the community (London Aces Hub Racial Justice Workgroup 2020).

1 Where Indigenous epistemologies and worldviews are not viewed as valid in their own right, but
rather read only for similarities to Western modes of thought (e.g., metaphorical interpretation)—if
not dismissed or derogated—so that space once occupied by Indigenous thought is occupied by
Western scholars.
126 A. N. Dueñas et al.

Engaging with others, especially groups, is also another way to scaffold the
psychologically hard work in trying to see and bear what is happening in the world—
think back to our GP in Case Study 1 who feels it all too much—and see our own part
in this. Desensitisation is what we often must do in healthcare, an important survival
strategy. Or tactic perhaps (none of this has to be conscious), as a strategy to negate
or avoid burnout. It is hard to stay in touch, so the wisdom, support, and energy of
others is essential: reading groups, reflective practice, narrative supervision, Balint
groups, group analysis. In the Western philosophical tradition, we idealise the soli-
tary thinker. Gaita (2013) cautions against this in observing that, though the personal
nature of ethical thinking means we must think things through for ourselves, we
often learn by being moved by what others say and do. Further, “We learn from what
moves us because its epistemic authority is inseparable from the fact it moves us”
(279). Of course, being moved does not entail morality. It is the dialogic engagement
between ourselves and a fully individualised other that allows us to be critically true
to what moves us.
If, according to Gaita’s formulation, social justice is about true responsiveness
to fully realised others, then we have to embrace a medical curriculum that encour-
ages thinking that goes beyond choosing between evidence-based treatment proto-
cols. According to Fitzpatrick et al. (2021), incorporating medical humanities into
curricula would enable further insight into patient experience.

9.4 Beyond the Straight Male Norm: Social Justice

for Women/Non-binary People and the LGBTQIA+
Community with Considerations About Androcentrism
from Simone de Beauvoir’s Theories

We, being men, have our patients, who are women, at our mercy

While, on initial reading, we may condemn this view of medicine from 1867 (King
2002, 396) as one far removed from our 2021 healthcare system, this sentiment
continues to permeate healthcare, with women and other gender and sexuality
minorities still less listened to within medicine (Zhang et al. 2021).
Healthcare professionals are not exempt from harbouring implicit and explicit
biases—the racism which permeates medicine was highlighted in Case Study 1, the
damage exerted by medicine’s white, cis-heteronormative male model is explored
in Case Study 2, whilst biases pertaining to those from widening participation back-
grounds will be discussed in Case Study 3. Importantly, identities held by individ-
uals or collectives are often intersectional and, in practice, cannot be considered in
isolation; this will be revisited in the conclusion of this chapter.
As noted previously, individuals and institutions should confront the biases they
harbour and strive to dismantle these, as well as recognising privileges that they expe-
rience. An individual endeavour can involve ensuring correct and appropriate naming
9 The Philosophy of Social Justice: Lessons … 127

and referring to of peers, colleagues and patients, including the use of pronouns,
as exemplified by the addition of pronouns to the popular UK #HelloMyNameIs
badge which aims to ensure person-centred communication. Case Study 2 outlines an
everyday scenario where appropriate naming and addressing of individuals becomes
pertinent.

Case Study 2: Pronouns, Titles, and Names

You are a medical educator attending a virtual panel on communication skills
teaching in medical schools. As the chair introduces the panellists, you note
that they introduce a female panellist by their first name, but the male panellists
by their title. You are not sure whether the chair might simply be more familiar
with the female panellist. As you examine the event description, you realise that
you had presumed that the panellist, listed as a professor on the programme,
to be a man.
You also note that the Chair has included their pronouns in their Zoom name.
This confuses you, as you deem their pronouns to be ‘obvious’. Later on in the
meeting, someone suggests whether pronouns might warrant inclusion in the
proforma for taking a history that is taught to students, in order to normalise
this question.
As you further discuss history-taking, an audience member mentions that
many students have raised that questions at times can be heteronormative—
defaulting to asking about an opposite-gendered wife/husband as opposed to
the neutral partner or simply asking about social supports.

9.4.1 The ‘Issue’/Injustice

Ensuring the accurate use of pronouns, titles, and names, and not defaulting to cis-
heteronormative assumptions is both a matter of respect and accuracy, but also has
tangible health implications. Over half of LGBTQIA+ individuals having experi-
enced depression in the last year and one in seven avoiding seeking healthcare for
fear of discrimination from staff (Stonewall 2018). 16% of the LGBTQIA+ commu-
nity have had negative experiences due to their sexual orientation when accessing
health services, this statistic is amplified for transgender/non-binary individuals, 38%
of whom have had negative experiences accessing healthcare because of their gender
identity (ibid). Where trans and nonbinary youth’s pronouns are respected by all or
most individuals in their lives, suicide rate is reduced by 50% (The Trevor Project
2020). This also impacts staff and students—LGBT+ doctors report increased levels
of workplace bullying and harassment (BMA and GLADD 2016). Increasing calls for
128 A. N. Dueñas et al.

action in challenging the heteronormative assumptions within healthcare, however,

are being made (Finn et al. 2021).
The inaccurate addressing of individuals is also observed when women (partic-
ularly women of colour) are not titled compared to usually straight, white, male
colleagues (Files et al. 2017). Not only does this devalue women’s (and other groups’)
expertise but given the intrinsic link between respect and patient safety/outcomes, it
would not be unreasonable to suggest that this too may be extrapolated as to how it
affects clinical care. The Civility Saves Lives campaign reports that when someone
is rude to a colleague, there is a 61% reduction in the recipient’s cognitive ability,
staff are 50% more likely to miss a calculation error and there is a 50% decrease
in willingness to help others (O&G Magazine 2018). Evidently, name and naming
‘identities’ are a concern not only for many members of the LGBTQIA+ commu-
nity, but also for other traditionally marginalised groups who are more likely to be
mistitled.

9.4.2 The Philosophy, Androcentrism (de Beauvoir)

Androcentrism describes a ‘male-centred’ perspective, where knowledge of health

and illness predominantly focuses on men, and results from and perpetuates patriar-
chal, misogynistic male worldviews (Verdonk et al. 2009). Throughout all strands of
society, men are viewed as representative of the human species, whilst women are
seen as deviations from this norm (Hibbs 2014). In this vein, Simone de Beauvoir
conceptualises “otherness’”, positing “he is the Absolute—she is the Other” (De
Beauvoir 1949, 37).
De Beauvoir’s concept of othering is relevant to the way in which we treat our
patients and the ‘standard’ patient we centre our teaching on. De Beauvoir’s philos-
ophy is just one example of ‘Norm theory’, which deems women as ‘deviants’ from
the ‘normal’ men (Hibbs 2014). This relates to Foucault’s medical gaze, intrinsi-
cally linked to the male gaze, which describes how healthcare professionals modify
patient experiences to fit a biomedical paradigm, taking a doctor-orientated approach
as opposed to one that is patient-orientated and contributing to medicine’s abusive
power structure and othering (Misselbrook 2013).
Beauvoir’s concept of ‘Otherness’ takes its basis from Hegel’s master–slave
dialectic, her “subject” and “other” preceded by Hegel’s “master” and “slave”. This is
relevant to the historical and present-day paternalism permeating medicine’s culture.
Examples include how, despite Sims’ inhumane treatment of enslaved women in
the nineteenth century, he is still lauded as the father of gynaecology. Indeed, we
continue to refer to the Sims’ speculum. Similarly, many medical eponyms refer to
Nazis, who committed atrocious crimes against humanity.
In The Second Sex, de Beauvoir challenges Plato’s postulating that sex is an
accidental quality, that women and men are equally qualified to become members
9 The Philosophy of Social Justice: Lessons … 129

of the guardian class, provided that women train and live ‘like men’ (De Beauvoir
1949; see Chapter 4 for discussion of de Beauvoir’s other major work). De Beauvoir
brings to the fore how masculine ideology exploits sex differences to create systems
of inequality—this is seen in healthcare, where women’s symptoms are often written
off as psychological, delaying treatment and worsening outcomes (Maserejian et al.
2009). This can be extrapolated to the health inequalities faced by the LGBTQIA+
community.
De Beauvoir also states that where arguments for equality erase sexual differ-
ences, this is counterintuitive, once again establishing the male subject as the abso-
lute, the norm. De Beauvoir’s argument for equality insists that equality is not a
synonym for sameness and argues against a version of ‘equality’ where only men,
or those who emulate them, succeed. Women, too, must acknowledge sexism they
may harbour.
De Beauvoir’s proclamation that, “One is not born, but rather becomes, a women”
(De Beauvoir 1973, 301) alerts us to the sex-gender distinction. It would be reason-
able to expect healthcare professionals to understand the differences between these
terms—gender a social construct used to refer to the socio-cultural differences
between individuals, and ‘sex’ a distinct concept, used to refer to biological differ-
ences between individuals. These nouns, however, continue to be used inappropri-
ately and interchanged, highlighting medicine’s blindness to the social aspect of
gender (Bergoffen and Burke 2020).

9.4.3 Case Study 2, Revisited

Reflecting on de Beauvoir’s philosophy, we revisit the scenario outlined in Case

Study 2 whilst acknowledging the assumptions and stereotypes we inevitably hold.
We must consider how we may manifest a medical or male gaze. Case Study 2
foregrounds the implicit gendered attitudes or stereotypes all of us may perpet-
uate. Despite increasing diversity in patient populations, healthcare professionals do
not always represent this diversity, their unintentional cognitive biases perpetuating
health inequities (Marcelin et al. 2019). Indeed, a recent systematic review revealed
a significant positive relationship between level of implicit bias and lower quality of
care (FitzGerald and Hurst 2017).
De Beauvoir’s ‘norm theory’ may also require a re-examination of the attendee’s
response to the use of pronouns and titles. Norm theory may explain our defaulting to
the use of cis-hetero men—whether in the use of antiquated terms such as ‘chairman’,
which should have no place in institutions or committees, or in assuming professors
to be men. This also extends to defaulting to men within teaching, e.g., encouraging
peer examination on male students, or the over-representation of men in anatomical
textbooks (Parker et al. 2017).
130 A. N. Dueñas et al.

9.5 Social Justice in Widening Participation and Access:

The Capability Approach to Rethink Outreach

Finally, we turn to social injustice less attributed to specific identities, as explored

within Case Study 1 and 2, and more focused on opportunity, particularly educational
opportunity. Around the world, there is serious unequal representation in the back-
grounds and identities of individuals who are healthcare students and practitioners,
particularly in historically elite fields, such as medical education (Garrud and Owen
2018). Such inequity and underrepresentation is seen across many identity demo-
graphics, such as race and ethnicity (Morrison and Grbic 2015), indigenous groups
(Razack et al. 2012), and rurally-located individuals (Dowell et al. 2015). In the UK,
underrepresentation persists in the form of socioeconomic inequity, and as such, this
is often the target of widening participation activities.
Widening participation (WP) and widening access (WA) are terms used in the
UK, and some other countries, to describe the policies and practices designed to
address these inequities in access to higher education (Dueñas et al. 2021; Nicholson
and Cleland 2015). It aligns with diversity-oriented work. While frequently used
interchangeably, there are subtle differences between WP and WA, although these
definitions are debated.2
Case Study 3 presents a scenario for reflection, with perspectives from the planning
side of WP activities, specifically an outreach programme, highlighting differences
in perspectives in this field.

Case Study 3: Planning Widening Participation Activities

You are a state-school teacher that sits on a board of organisers for a national
outreach programme, aimed at diversifying and widening participation in
medical education. In a recent Zoom meeting, one of the leaders for this
programme started a lengthy discussion about how students from state schools
will be so “behind” in academic content. The leader is suggesting re-structuring
the entirety of the outreach programme to focus on more intensive biology,
chemistry, and maths to try and support students in being academically compet-
itive medical school applicants. Something about this conversation makes you
uncomfortable, but you are not at the medical school, so feel you may not have
enough insights to speak up. However, you have had many discussions with
students at your school about how the COVID-19 pandemic has solidified their
commitment to studying medicine, after seeing their families and communities

2 The author here ascribes to specific definitions of WP and WA. WP are policies and programmes
largely aimed at supporting underrepresented individuals in ‘aspiring’ to pursue higher education,
including expanding recruitment and application (i.e.,– educational outreach). WA is more focused
on the system of higher education, enacting policy and programmes that aim to create a ‘fairer’
higher education selection process, that will help ensure underrepresented individuals have better
chances of being admitted (i.e.,—contextual admissions).
9 The Philosophy of Social Justice: Lessons … 131

suffer both economically and in loss of life. As a teacher, you have been really
impressed by these insights. Further, you are concerned that so much focus on
sciences, and only sciences, may deter some students who have been told they
are “behind” in these subjects, from applying to medicine.

9.5.1 The ‘Issue’/Injustice

There are numerous discourses or arguments in favour of WP (as well as some

against), and, as a reader, you may be reflecting on yours after reading Case Study
3, noticing differences in perspectives. As in other sections, it would be remiss to
not acknowledge our views as the authors of this chapter. Here, the position is that
WP (and general diversification) in the field is paramount to its success. WP offers
opportunity for educational enrichment, potential for utilitarian healthcare issues,3
and is the “right” thing to do in terms of social justice and considering the distribution
of educational “wealth”. This multi-perspective, but favourable view, shades the
interpretation and discussion of this work.
Returning to Case Study 3, it would appear that the programme leader might
be ascribing to an educational enrichment argument for WP, rather than a multi-
perspective approach. They appear focused on providing educational activities to
ensure that WP-background students are not academically “behind,” and, therefore,
can be more competitive applicants in the medical school. While perhaps well-
intentioned, this perspective imagines outreach and WP as part of a deficit model.
It assumes, based on standards of excellence, particularly in medical education, that
students who may have lower academic performance, related to circumstance, are at
a deficit to higher performing peers.
This deficit model approach to outreach and WP is problematic for numerous
reasons (Greenhalgh et al. 2004). First, it can be harmful to the students that outreach
attempts to support. In Case Study 3, the state-school teacher the case follows
expresses concerns about this. They worry that this type of discourse and focus
will ultimately discourage their students from pursuing medicine. This is a well-
founded worry: it has been suggested that deficit models can do more harm than help
when it comes to considering WP. Second, it perpetuates the notion that academic
performance is the most important factor in HPE. While high academic achievement
is an important standard in the field, this perspective is not necessarily true. This
point raises philosophical questions in and of itself—what does it mean to demon-
strate ‘excellence’ in healthcare education? Even the most academically ‘excellent’
student would make a terrible doctor or health care practitioner if they lack empathy,

3 The ‘utilitarian’ argument for WP is sometimes conflated with ‘social accountability’ of medical
schools. This posits that institutions should consider patient populations in their recruitment and
training of future healthcare providers.
132 A. N. Dueñas et al.

have poor communication skills, or cannot work in an interdisciplinary team. Further,

individuals who are from similar backgrounds to patients may be better placed to
act with empathy and communicate clearly, having shared life experiences to draw
on, already possessing ‘excellence’ of a different form. This supports arguments for
recruiting health care cohorts that are more representative of the population of all
patients, rather only those from minority, elite groups.
If WP is to reach its full potential and genuinely support minoritised groups,
combatting the deficit model in outreach, and healthcare education, should be a
priority in future policy and practice. It has been posited that drawing on philosophy
may help us to do this, to better inform practice with theory. As such, this chapter
section demonstrates how the theoretical framework and underlying philosophies of
the capability approach may be a useful theoretical lens to grapple with this issue of
deficit models in widening participation (Sandars and Sarojini Hart 2015).

9.5.2 The Philosophy, the Capability Approach (Sen)

At its crux, the capability approach argues that a just and fair society is one that
allows for all individuals to have freedom of choice in who they are and what they do
(Robeyns and Fibieger Byskov 2020). This framework is built on two philosophical
tenets: freedom to attain “well-being” is a moral imperative, and that “well-being”
is linked to what an individual can do/be (if they choose). With origins in the fields
of human and economic development, the capability approach has also been widely
drawn on in considering education, particularly the role of education in social justice
work. These links to broader educational action (Hart 2012), the potential for the
capability approach has been explored to some extent in HPE (Sandars and Sarojini
Hart 2015), particularly for WP-oriented issues.
Specifically drawing largely from Sen’s work (Sen 1992, 1993), as well as Hart’s
that closely aligns with Sen (Hart 2009), engagement with the capability approach
requires understanding of its terminology or core concepts. As such, this work
presents specific definitions of these key terminologies, with examples that link to
healthcare, in Table 9.1. These terms are key in subsequent application of the capa-
bility approach to a WP setting, and, as such, the medical education examples are
geared toward selection.
These concepts, and how they allow individuals to achieve the functionings that
they value most, can be applied to WP, particularly considering the progression of
WP-background individuals into and through HPE. Even in the general selection
examples in Table 9.1, it is easy to see how these concepts and frameworks apply.
WP-background individuals may not have the resources that will make pursuing
higher education or HPE seem to be an attainable option, limiting capability sets,
even if that individual has the aspiration to pursue a health professions career. Further-
more, conversion factors put in place by medical schools can be a huge barrier to
WP-background individuals, including, but not limited to: extremely competitive
grade requirements, associated with school type; application fees; or even the cost of
9 The Philosophy of Social Justice: Lessons … 133

Table 9.1 Capability approach terminology, definitions, and examples

Capability approach terms Definition Medical education example
Capability Opportunity or freedom an A student may have capability
individual has to make choices to pursue medical education, if
of value in their life they can use their resources to
gain admission, and see this as a
worthwhile career path
Functionings Simply put, the valued ‘doings There are many functioning an
and beings’, or what the individual may hold or aspire to
individual can achieve in their in addition to being a doctor,
lives such as being a partner, a parent,
a part-time musician, an avid
gardener, an amateur chef…
Resources What an individual has that can A highly empathetic individual
be converted into capabilities might find this to be a resource
and functionings; resources can in pursuit and consideration of
include: personal (i.e.- medical education as a career;
psychological, skills), social this individual may have an
(i.e.- professional recognition, older sibling who is a doctor,
cultural resources), and providing a social resource; if
environmental (i.e.- location, this individual lives rurally, this
natural resources) may be a physical resource
barrier to medical education
Conversion factors Factors that are enablers or Selection, and the given
barriers to a person’s freedom admissions criteria of a medical
and capabilities; conversion school, are a key organisational
factors can include personal conversion factor that allow or
attributes, but are most prevent an individual from
importantly the social structures considering medical school to
in place around an individual be a capability
Aspiration set Constructed by individual Reflecting on their empathetic
reflection, personal goals for nature, and hearing from their
well-being and life goals; doctor sibling, the individual in
idealised the resources example may
aspire to be a doctor, but may
also consider nursing as a
fulfilling job; their aspiration set
may include a multitude of
clinical careers
Adaptive preferences When an individual internalises An individual who attends a
and accepts conversion factors Medical School open
and resources, influencing day/taster/outreach event may
capability preferences and internalise this experience,
choices resulting in medical education
being higher in their aspiration
set
Capability set (of Potential Collection of capabilities or An individual may have aspired
Functionings) choices, considering the to medicine, among other
aspiration set but also realistic / clinical careers, but if they do
pragmatic, as these consider not meet minimum grade
conversion factors and requirements, their capability
individual choices set cannot include it
(continued)
134 A. N. Dueñas et al.

Table 9.1 (continued)

Capability approach terms Definition Medical education example
Achieved functionings What the individual actually A student, who has the
does or who they are; not all resources, aspirations, and is
potential capabilities are enabled by conversion factors,
possible, nor all potential can be successfully admitted to
functionings achieved medical education, becoming a
medical student

education, itself. Additionally, with deficit-model discourse, and similar discourses

that posit education as a meritocracy, or that medical education or healthcare educa-
tion is not attainable, WP-background individuals may be susceptible to negative
adaptive preferences. This is alluded to in Case Study 3, with the teacher’s concerns
that over-emphasising barriers and deficits will deter their students from applying to
medicine.
But, with knowledge of these elements, the capability approach can be used as a
framework to better understand and support the function of WP and WA. Programmes
and policy can be examined, to help identify what conversion factors are key, what
resources are most important, and how to yield adaptive preferences for inclusive
choices. The capability approach can yield insights for how to use social justice
theory in practical ways, to reconsider distributions of resources and be critical of
social structures.

9.5.3 Case Study 3, Revisited

Returning to Case Study 3, now with knowledge of the capability approach, we can
rethink actions that could have followed this scenario. In the example, it’s clear that,
from the schoolteacher’s experiences, that many of their WP-background students
see medical school in their aspirational functioning. But the deficit model of outreach
proposed does not necessarily help students achieve this functioning; it highlights
shortcomings, instead of emphasising and supporting capability of the individual
to achieve this career if they choose. This leads to concerns about adaptive prefer-
ences that may limit student’s aspiration sets, capability sets, and eventual achieved
functioning.
Informed with theory, this schoolteacher might feel more comfortable speaking
up, citing work like this, or others, to demonstrate to the organisers the social
complexity of the situation. Advocating for students by writing an email or similar
letter, citing these philosophical underpinnings, might be another route for the
schoolteacher to consider. In either case, using the capability approach can be a
helpful philosophical tool to rethink how we go about educational social justice.
9 The Philosophy of Social Justice: Lessons … 135

9.6 Conclusion

In this chapter, we have cast light on just three types of social injustices that mar
HPE. But we have also shown how employing philosophical thinking, and drawing
on theory, can aid, not just in understanding these injustices, but in improving on
work to mediate them. Table 9.2 reiterates the philosophical lenses we have applied
in this chapter, with brief descriptions, for summary.
It is important to note that these are just a mere subset of social justice theories, and
that the proposed ‘solutions’ to tackling social injustices are just one set of possible
actions. As such, Table 9.2 also notes some potential criticisms of these theories, for
readers to reflect on. Further, our ability to address injustice, and indeed function in

Table 9.2 Social justice philosophies, revisited

Philosophical lens Brief description Potential criticisms
Common humanity Our ethics depend on a Is the approach too much based on
responsiveness towards a fully Western individualism, with a
constituted other, who is able to feel veneration of the subjective,
as much as we do and whose life is personal, individual life?
able to mean as much to them as In trying to counter over rationalist
ours does to us. Treating a person philosophies, does the approach
justly involves treating with fall prey to emotionalism?
seriousness their cares and
conceptions. Racism involves the
denial of this attribution of a
common humanity to the racialised
other. Social justice means that state
and civic institutions reveal rather
than obscure the full humanity of
our fellow citizens, which enables
true compassion
Androcentrism Androcentrism describes a Can this essentialism reinforce
‘male-centred’ perspective where gender norms and binaries by
men are viewed as representative of inadvertently creating a dichotomy
the human species, whilst women between ‘andro’ and ‘gyno’?
are seen as an ‘other’. Beauvoir’s Furthermore, does it neglect the
argument for equality insists that nuance behind different levels of
equality is not a synonym for privilege?
sameness, and argues against a How do we ensure we account for
version of ‘equality’ where only men ethnocentrism and heterocentrism
or those who emulate them succeed and do not create a universal false
male versus female experience
Capability approach Social justice means that all Is the capability approach
individuals can achieve personal unnecessarily individualistic?
well-being, by having choice in How do we grapple with
what they do and who they become freedoms/wants that might be
viewed as ‘bad’, that could harm
others?
136 A. N. Dueñas et al.

Table 9.3 Practice points

1 When considering the potential use of social justice philosophy in HPE, reflexive thought on
power and privilege should be continuous
2 A large part of social justice work requires first fully recognizing injustices, then moving to
continuous work in addressing them
3 Social justice work needs to consider all levels of HPE, from the individual to the
institutional to the systemic. Different philosophical frameworks may prove more applicable
in different settings
4 Philosophy and philosophical thinking can add depth to understanding the many types of
injustices that are encountered in HPE every day, but this needs to be translated to action
5 While this chapter focuses on more singular forms of social injustice, intersectionality, and
how it may impact and conflate injustices, needs to be considered

educational settings, is highly variable based on context, location, situation, and, as

mentioned in the introduction, the privilege and power we hold.
We conclude with the importance of recognising intersectionality (Monrouxe
2015; Eckstrand et al. 2016; See Chapter 9 for further discussion on intersectional
approaches), as briefly acknowledged in above sections. The aforementioned case
studies focus on singular forms of justice across race, gender, sexuality, and educa-
tional access to allow readers to engage with particular aspects of the philosophies
presented. ‘Real-life’, however, is rarely that simple. Each of us hold many, inter-
sectional identities, that inform privilege, and thus power, to enact social justice.
For example, an individual who is white, cis-gender, female-identifying, from a
low socioeconomic background, may hold certain power in some spheres, and be
minoritised in others. Further, this individual might have unique views on whether
they consider themselves to be “minoritised” in any given sphere. We are all multi-
dimensional beings, and social justice work should consider this, as those with various
minoritised identities can sometimes, inadvertently, be overlooked.
As previously noted, this chapter represents only a limited exploration into the
world of social justice and, like much of health professions education, continuous
education is critical. True action and allyship relies on all individuals putting in the
work to self-educate. We encourage readers to use this chapter as an invitation to
engage in further social justice reading and as a possible guide for real action. It is
only by way of such continued engagement that justice may be achieved (Table 9.3).

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Chapter 10
The Future of Healthcare is Feminist:
Philosophical Feminism in Health
Professions Education

Lena Wånggren and Gabrielle Maria Finn

10.1 Introduction

Gender bias in healthcare is rife. In 2020, the United Nations reported that nearly 90%
of both men and women across the world’s population harbour some form of gender
bias against women (UNDP 2020). Within medicine, gender bias is associated with
poorer outcomes for women in many domains, including regarding pain management,
and diagnostic delays for gynaecological conditions (Perez 2019; Verdonk et al. 2009;
Winchester 2021). Gender inequality is an ongoing issue within society and, more
specifically, within medicine and health including in medical and health professions
education. Global and national policies often fail to consider gender-related health
risks for people of all genders (WHO 2019). It is clear we need health systems
that consider the intersections of gender with other inequalities, addressing how
“gender norms, unequal power relations and discrimination based on sexual and
gender orientation impede access to health services” (WHO 2019), including in the
delivery of health education.
Philosophical feminism employs philosophical methods to feminist topics and
questions, and so holds the potential to illuminate ongoing issues within health
professions education, such as gender bias, in new and critical ways. Philosophical
feminist inquiry is motivated by desire for social justice and so, through scrutinising

L. Wånggren (B)
School of Literatures, Languages and Cultures, University of Edinburgh, Edinburgh, UK
e-mail: lena.wanggren@ed.ac.uk
G. M. Finn
Division of Medical Education, School of Medical Sciences, Faculty of Biology, Medicine and
Health, The University of Manchester, Manchester, UK
e-mail: gabrielle.finn@manchester.ac.uk
Health Professions Education Unit, Hull York Medical School, University of York, York, UK

© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2022 141
M. E. L. Brown et al. (eds.), Applied Philosophy for Health Professions Education,
https://doi.org/10.1007/978-981-19-1512-3_10
142 L. Wånggren and G. M. Finn

social, cultural, political, and economic phenomena within medical and health profes-
sions education using feminist thought, recommendations may be made regarding
confronting structural inequalities within healthcare.
This chapter considers philosophical feminism broadly, considering the ways in
which gender combines with issues of race, class, disability, sexuality, and gender
identity and examining contributions which have been overlooked in reference to
the field of health professions education. Intersectionality as a concept and practice
is introduced to understand ways in which gendered and related oppressions and
privileges combine to create a need for more complex understanding of philosophical
feminist inquiry in health professions education, and feminist theories of agency in
relation to healthcare are explored. Addressing the structure and dynamics of gender
bias within health professions education, the chapter opens new fields of enquiry and
ways of working. Finally, we offer practical considerations for those in the sector to
consider how philosophical feminism informs their practice.

10.2 Philosophical Feminism: Feminist Thought

and Practice

What has been called philosophical feminism, or feminist philosophy, specifically

examines the role of gender in traditional philosophical concepts, sexist bias in tradi-
tional philosophy, and proposes philosophical feminist theories (Vogler 1995; Alcoff
and Kittay 2007; Garry et al. 2017). However, feminist thought is an interdisciplinary
subject found across academic disciplines, creative practices, and social movements,
from the sciences to the arts.
Feminist theories and practices describe several different interlinked approaches,
all emphasising the role of gender and gendered structures in society. Feminist theory
is often referred to as an umbrella term (Disch and Hawkesworth 2018; Finn and
Brown, In Press). While scholars have emphasised the need to address gender bias
from a localised context, taking into account specificities of local structures and
cultures (Mohanty 2003), feminist approaches share a focus on interrogating concepts
of gender, fighting gender injustice, and analysing the ways in which gender shapes
our lives. Feminism is not just interdisciplinary, but practical, aiming to change the
way we think and order society: feminism is about doing just as it is about thinking;
‘deeds not words’, as the old Suffragette motto noted. Feminist theorist bell hooks
(1984) similarly notes that one cannot simply ‘be’ a feminist, one has to do or advocate
feminism. This chapter uses a broad interchanging and interdisciplinary definition of
philosophical feminism, feminist thought and practice, as terms signifying the ques-
tioning and fight against gendered and intersected oppressive ideologies, practices,
and structures.
10 The Future of Healthcare is Feminist … 143

Feminist thought reaches back millennia, and feminist historiography1 usually

uses the metaphor of ‘waves’ to describe different trends and shifts in feminist move-
ments throughout the years. Despite being a contested metaphor (van der Tuin 2009;
Hemmings 2011; Reger 2017; Grady 2018), it continues to be used both temporally,
as pertaining to a specific historical period, and also as demarcating certain broader
issues occupying feminists during the associated period. The starting point of the
‘First Wave’ of feminism is often located either with the publication of UK writer
and philosopher Mary Wollstonecraft’s (1759–1797) Vindication of the Rights of
Woman in 1792, or with organised women’s movements in the nineteenth century
(demonstrated in milestone events such as the 1848 US Seneca Falls Convention and
the Conference of Badasht in Persia), following intellectual women’s societies that
sprung up in the mid-eighteenth century such as the Blue Stockings Society in Britain.
Located in the late eighteenth, the nineteenth, and the early twentieth centuries, first-
wave feminism took different forms for different women and in different locations
but is usually defined as involving the fight for civil rights such as suffrage, marriage
and property legal reforms, and women’s access to education (including the right to
practice as doctors).
Definitions and interpretations of feminist ‘waves’ differ, however: while Woll-
stonecraft’s Vindication of the Rights of Woman is often seen as the mark of the birth of
modern feminism, with its call for gender justice and criticising of gender bias, history
recalls earlier feminist works such as Christine de Pizan’s medieval The Book of the
City of Ladies (1492) which questions gender bias in literature and history. Further,
figures such as Sojourner Truth in 1850 already questioned not only gender, but
racist thoughts and practices. Due to a white European and US dominance in feminist
historiography, scholars have, until recently, defined the movement as one primarily
concerning middle-class or liberal white feminists’ concerns (such as the right to
own property) in the global North, a perspective which has been proven incom-
plete by postcolonial and transnational feminists noting concerns not only regarding
women’s right to education and suffrage, but also labour conditions, the abolition
of slavery, anti-colonial struggles, and peace building (see e.g. Jayawardena 1986;
Wånggren 2018). Within health professions education, the fight for women’s access
to higher education is crucial, as early female doctors such as Elizabeth Blackwell,
Elizabeth Garrett Anderson, and Sophie Jex-Blake in the nineteenth century fought
for women’s right to study for and obtain medical degrees. Although women now
constitute a huge proportion of health professionals, they remain under-represented
in some specialties and leadership roles (Skinner and Bhatti 2019, Gilmartin et al.
2020).
The Second Wave, usually timed as 1949–1990, highlighted issues of equal pay,
sexual freedom, representation, reproductive justice; this is when feminism entered
knowledge-producing institutions such as universities. Simone de Beauvoir’s The
Second Sex (1949) questioned the notion of gender itself, showing its socially and
historically constructed nature: “one is not born but becomes a woman” (283). Martha

1Historiography is defined by the Oxford English Dictionary as “the study of the writing of history,
and of written histories”.
144 L. Wånggren and G. M. Finn

Weinman Lear first officially documented the term ‘wave’ in a 1968 article, as a
historical benchmark to position current ‘second wave’ feminist struggles against
those of earlier generations, although the term had been in use prior to this publication
(Chamberlain 2017). These are the years in which feminist activists started engaging
most fully with gendered inequalities in health and access to healthcare, highlighting
gender bias and the lack of women’s perspectives within care, and in which feminists
question the perceived objectivity of scientific knowledge—see a fuller examination
of this period below.
The Third Wave, from around 1990 onwards—with Judith Butler’s ground-
breaking book Gender Trouble seen as a milestone—involved a questioning of the
singularity of woman, and a further questioning of the relation between gender and
sex: the multiplicity of women’s experiences is highlighted, noting intersectional
and transnational perspectives, and interlinking gendered with other related issues.
In healthcare professions education this is seen through an increased focus on not
only gendered but other intersecting inequalities, across the globe.
There is currently a self-identified Fourth Wave, from the early 2000s, which
highlights the use of social media and humour to address everyday sexism,
street/workplace harassment, and rape culture (Cochrane 2013; Chamberlain 2017),
seen in the growth of grassroots online campaigns for gender-sensitive health-
care—for example for trans persons, and for under-researched conditions such as
endometriosis and questions of reproductive health (see e.g. Davey 2020; Cysters
2021; and UK campaigns around Period Poverty).
As a result of feminist and antiracist activism across centuries, especially through
the work of Black and anti-imperialist feminists, intersectional theories and practices
have gained ground, bringing a valuing and accepting, rather than denying of, what
Audre Lorde (1984; see also Hill Collins 2000) terms ‘difference’:
Certainly there are very real differences between us of race, age, and sex. But it is not those
differences between us that are separating us. It is rather our refusal to recognize those
differences, and to examine the distortions which result from our misnaming them and their
effects upon human behavior and expectation. (Lorde 1984, 1–2)

Within healthcare professions education, this embracing of intersectional difference

means an increased awareness of shifting perspectives of gender, race, class, reli-
gion, age, disability, sexuality, and gender identity within pedagogy and practice.
Recently, intersectional identities have grown in prominence within the undergrad-
uate curriculum, particularly within basic sciences such as anatomy (Lazarus 2021).
Student cohorts are demanding the redefining of anatomical language in order to
create safer spaces to acknowledge all genders (Lazarus 2021), racial identities and
ethnicities (Finn et al., In Press).
Feminist philosophy broadly means linking theory and practice. In the sciences,
we must specifically trouble the assumptions we have about what is considered
‘knowledge’ by questioning the perceived impartiality of knowledge, and who is in
a position to be seen as a knowledge producer. What is crucial is highlighting the
validity of subjective experiences, especially of marginalised groups, as central to
knowledge production, something which demands reflexivity from those positioned
10 The Future of Healthcare is Feminist … 145

as ‘experts’ (Harding 1986; Haraway 1988; Rooney 2017). Feminist perspectives in

healthcare professions education thus require a questioning of the kinds of knowledge
produced in a healthcare setting, who produces knowledge, how this knowledge is
captured, and what kind of power relations govern the roles attributed to patient and
health professional. It means centring the feminist notions of reflexivity and posi-
tionality as key tools (Erikainen et al. 2021) in designing and delivering programmes.
Embedding reflexivity allows for a critical interrogation into power relations and our
situated places within them, while feminist notions of positionality means recog-
nising that all knowledge, including scientific knowledge, is “situated, plural and
partial”, shaped by the knowledge producers’ social location—this fact enables us
to ask critical questions about who is seen as a knowledge producer (Erikainen
et al. 2021, 9). For example, a young male nurse or doctor and a female patient
in her 60s may have different knowledges about the experience of menopause; one
being clinical ‘expert’ knowledge, the other being personal and experiential. These
differences need to be reckoned with in order to provide a contextualised healthcare
understanding the complexity of the situation.

10.3 Key Terms: Gender and Intersectionality

Gender is one of the key terms within feminist thought and practice, used to examine
and address gender inequality and bias within patriarchal structures. Joan W. Scott’s
(1999) definition of gender links the concept with power, and as working on different
overlapping levels of society:
[G]ender is a constitutive element of social relationships based on perceived differences
between the sexes, and gender is a primary way of signifying relationships of power. (1067)

Scott (1999) maps out the different levels at which gender operates: symbolic and
representational (assumptions about gender difference); normative concepts and
statements (e.g. religious, scientific, and legal doctrines); social institutions and
organisations (organisational); and as subjective identity (how one sees/presents
oneself).
Gender is not, however, the only social category intertwined with health. As such,
health is more fruitfully understood through the lens of intersectionality, that is to say,
alongside other axes of power such as those linked to class, sexuality, race, disability,
sexuality, or gender identity. Intersectionality (Crenshaw 1989) is the notion that
various social and cultural categories such as gender, race, and class, interact and
overlap on multiple levels in the formation of identities and social relations (Cooper
2016). The term started as a main tenet of Black feminism to describe the intersecting
oppressions facing Black women and has now gained influence in contemporary
feminist activism as well as mainstream policymaking. Feminism, in an intersectional
definition, signifies then not only a struggle for gender equality, but “a struggle to
end sexist oppression” which harbours in it “a struggle to eradicate the ideology
146 L. Wånggren and G. M. Finn

of domination”, realising the “inter-relatedness of sex, race, and class oppression”

(hooks 1984, 24–31) alongside other structures of inequality.

10.4 Gender Inequality and Bias in Healthcare

and Professions

In every society, what is considered health or illness, and how the health professions
deal with these terms, are shaped by social, historical, and economic contexts—
contexts that are all gendered. As Angela Davis (1990) declares:
Politics do not stand in polar opposition to our lives. Whether we desire it or not, they
permeate our existence, insinuating themselves into the most private spaces of our lives.
(53)

A key tenet of feminism is, thus, the interlinking of individual with structure—the
personal is political. Gender, that social categorisation of behaviours and beings,
permeates the ways in which health and medicine are structured and how we under-
stand ourselves within it. As part of the 1960s and 1970s women’s movements,
feminist scholars and women’s health activists started addressing issues of gender
within medicine and healthcare—often starting with the issue of ‘women’s health’
as a focus and connected to social movements for women’s health. Since then, the
field has broadened and now encompasses multiple areas including Science and
Technology Studies and the Humanities. We have moved from a focus on ‘women’s
health’ to gender inequalities in health (Hunt and Annandale 2011; Kuhlmann and
Annandale 2012). Feminist critical attention to healthcare has revealed bias and
oppression, as well as opened up new perspectives on health, caring, and knowledge.
Not only does health science itself contain bias, but also practical understandings of
medicine are biased along structures of race, gender, and certain forms of power and
knowledge (Wyatt et al. 2020; Zaidi et al. 2021). For example, health professions
education remains focussed on the white male as the archetypal representation within
textbooks on clinical examination and anatomy (Plataforma SINC 2008; Finn et al.
2022; In Press).
With increased research into both men’s and women’s health, there is a new
appreciation for the complexity of the ‘paradoxical gender differences’ (Bird and
Rieker, 2008, 7) in health that challenges notions of the disadvantage or advantage
of one single gender (MacIntyre et al. 1996). Antiracist and intersectional critiques of
western clinical medicine have recently been brought into focus (Hankivsky 2012),
with new approaches and interdisciplinary pathways to understand intersecting rela-
tions within health. While white women’s experiences were (and probably still are)
for long at the centre of the field of gender and health, there has been a growing body
of work by women of colour and their experiences of health; Black feminists in partic-
ular have contributed much here, through works such as The Black Women’s Health
Book: Speaking for Ourselves (1990) and Wings of Gauze: Women of Color and the
Experience of Health and Illness (1993). In recent years, activists such as Neelam
10 The Future of Healthcare is Feminist … 147

Hera have set up campaigns and networks to raise the voices of marginalised women
and trans people within reproductive healthcare (Cysters 2021), or to address racism
within healthcare (see Walcott and Linton 2018, for stories of racist mistreatment in
mental health care, and a call for changes needed in health professions education).
Alongside a continued struggle for gender-sensitive and antiracist training in health-
care, the end of the twentieth century saw more focus being given to the issues facing
specifically trans and intersex individuals (for example: the Intersex Society of North
America was formed in 1993). However, the health professions curricula have not
kept pace—transgender health and largely also intersex healthcare remains undis-
cussed (Fausto-Sterling 2000b; Finn et al., 2021), while many students in healthcare
professions have little understanding of the healthcare lexicon including ‘cisgender’
(Dubin et al. 2018; Brown et al. 2020). This leads to a healthcare system where
patients rarely encounter trans- and intersex-inclusive healthcare (Bornstein 1994;
Fausto-Sterling 2000a; Halberstam 2017).
Gender inequalities in health have been a major area of both activism and academic
scholarship since the early 1970s. Since then, the search for an explanation for
differences in male and female morbidity and mortality, alongside interest in the
relationship between variations in women’s social circumstances and their health,
has been a crucial part of feminist enquiries into health care and professions (Hunt
and Annandale 2011):
Gender is known to be strongly associated with health status and to exert a significant
influence upon help-seeking and the delivery of healthcare, but it has been a relatively
low policy priority for many governments and also within the health professions until very
recently. … [T]he current evidence base is scattered and fragmentary. Attempts to mainstream
gender into healthcare often turn out to be simplified reports of sex differences without taking
account of the complex life conditions of men and women and the gendered dimensions of
the organization and delivery of healthcare. (Kuhlmann and Annandale 2012, 1)

The lack of a gender-sensitive approach in healthcare leads to women being “rou-

tinely silenced or erased as actors in the production of health, in both the provision
and receipt of healthcare per se as well as in health politics and policy” (Clarke
and Olesen 1999, 3). Even in 2018, so significant still are the gender inequities in
medicine and healthcare that a lexicon of gender bias terms was published (Choo and
DeMayo 2018). One frequently observed gender bias is the maternal wall bias, which
pertains to the stereotyping and discrimination encountered by women (Williams
2004). Women are treated differently because they have children, may want children,
or even just because they may potentially become mothers. Socialisation into gender
roles, and expectations of stereotypical gender expression, has resulted in inflex-
ible, archaic inflexible expectations of men and women. Recently, the maternal wall
was documented within health professions education, with undergraduate students
describing missed opportunities based upon perceptions of the present or future
maternal status (Brown et al. 2020).
Feminist perspectives in health care involve not only a focus on substantive topics
within women’s health such as breast cancer, violence, or reproductive justice, but
also highlighting gendered narratives within medicine, such as the positioning of
the white male patient as norm of what is healthy, or the use of sexist language in
148 L. Wånggren and G. M. Finn

medical research and practice. As Longino (1990) shows, assumptions laden with
social values affect the description, presentation, and interpretation of data; research
on ‘sex-differentiated behaviour’ involves assumptions not only about gender rela-
tions but also about human action and agency. As Emily Martin (1991) has demon-
strated, the ways in which we speak about health-related issues are not ‘scientifically
objective’ but rather carry imprints of gendered, racialised, and other contexts; there
is specific gender bias in scientific and medical discourse, particularly concerning
human reproduction. Martin’s The Woman in the Body (1987) questions the disparity
between biomedical formulations of women’s health and women’s own experi-
ences of, for example, menstruation, birth, and menopause. Querying the negative
perception many have around menstruation, she examines the gendered language
and metaphors in which menstruation has been described, in order to understand
this negativity. As Martin describes in “The Egg and the Sperm: How Science Has
Constructed a Romance Based on Stereotypical Male-Female Roles” (1991), seem-
ingly ‘neutral’ scientific explanations such as “the sperm forcefully penetrates the
egg” are presented with a sexist bias that places women’s part in reproduction as
passive. Black feminist and antiimperialist interrogations have furthermore noted
racist, colonial and class bias within struggles for reproductive justice (Gould 1984;
Kuumba 1999; Silliman et al. 2004).
Adding to Martin’s work on gender bias in science and medicine, and on the role
of women’s own constructions of health outside of biomedical narratives, feminists
have criticised the ways in which medical norms are often based on white, middle-
class men’s bodies, revealing a lack of diversity in health professions research and
education (Lorber and Moore 2002). Until recently most health research focused on
white male subjects, and less is therefore known about how to prevent and treat many
illnesses in women (Bird and Rieker 2008). Because of this, there are still significant
gaps in knowledge regarding health differences between the sexes in health (Marcelin
et al. 2019). For example, men’s and women’s cardiovascular disease symptoms
differ from each other, but since most research was carried out and information
distributed with male patients in mind, women did not benefit equally from this
research (Bassuk and Manson 2004). While gender and race usually are considered
socially constructed, gender and intersecting biases have also worked to exclude
physiological differences or ignored the biopsychosocial effects of sexism and racism
(Sullivan 2015).
As feminist theory and methodology demonstrate, the ways in which we speak
about health-related issues are not ‘scientifically objective’ but rather carry imprints
of gendered, racialised, and other contexts—there is a significant gender bias in scien-
tific and medical discourse. Understanding and addressing biases is a crucial way
to improve health professions education. Introducing structural/unconscious bias or
other Equality, Diversity, and Inclusion (EDI) training is a necessity within health
professions curricula; without such work, health inequalities and differential treat-
ment will continue. Furthermore, those working within the institutions, for example
admissions teams, also need training to ensure diverse and inclusive workforces for
the future. Similarly, an awareness of the hidden curriculum is of paramount impor-
tance (Hafferty and Franks 1994)—tacit messaging, role modelling and other aspects
10 The Future of Healthcare is Feminist … 149

impact learners, educators, and patients alike. For example, students may witness
tutors (Finn and Hafferty 2020) or near-peers role modelling negative behaviours
such as assumptions of cisgender identity or heteronormative patterns when taking
a history (Laughey et al. 2018), or microaggressions based on gender or maternal
status (Brown et al. 2020).

10.5 Reclaiming Health: Gender and Agency

The issue of patient agency and female agency has been crucial to women’s health
movements in the 1960s and onward in challenging male patriarchal control over
women’s health. Feminist theories of agency are thus crucial to considering ways of
improving health professions education.
While modern biomedicine often comes to treat the patient as an object, infringing
on the patient’s agency over their health, this tendency has been critiqued, especially
by feminist health activists who highlight the silencing of women’s experiences
in healthcare. Indeed, biomedical approaches can influence women’s perceptions
of themselves and their bodies, in ways which ‘can ultimately undermine women’
(Clarke and Olesen 1999, 33). In particular, reproductive justice has long been a
central focus of feminist activism and scholarship (Correa and Petchesky 2003).
Certain groups (women, LGBTQIA+ people, people of color, working-class
people) are more likely to be medicalised—treated as medical objects rather than
subjects—and in different ways than others (Riska 2003), since aberrations from the
white male norm is seen as individual biological problems rather than as affected by
social structures. Feminist movements have thus sought to reclaim women’s health
and to focus on women’s own experiences, to regain agency over such debates. In
the late 1960s feminists challenged medical and male control over women’s health,
in movements ranging from local grassroots organisations and self-help groups to
feminist health clinics, advocacy organisations, and scholarly research. In 1976 the
now classic Our Bodies, Ourselves was produced by the Boston Women’s Health
Collective, one of the first in a wide range of writing through which women devel-
oped ways of understanding their own bodies and of challenging sexist bias in the
medical profession.
Storytelling, and sharing stories of pain, have been crucial tools for reclaiming
agency (Wånggren 2016). Two examples of feminist thinkers doing this are Audre
Lorde (1996) and Johanna Hedva (2016, 2017). Lorde in Cancer Journals (1980) and
A Burst of Light: Living with Cancer (1987) and Hedva in their “Sick Woman Theory”
and “Letter to a Young Doctor” both address sexist biases in health professions,
argue for a reclaiming of patient agency in the name of equality and social justice,
and highlight the need for sharing stories of pain in order to heal. Hedva (2017)
addresses a young woman studying to become a doctor, who has written to the
author for advice:
150 L. Wånggren and G. M. Finn

One of the problems with healing in this fucked-up world is that it’s presumed that you,
the doctor, have a set of knowledges that the patient doesn’t, so for the patient to get better,
to be cured, or to heal, they must submit themselves to Doctor’s Orders. … I’m supposed
to trust you simply because you are a doctor. To us patients, this dynamic feels like one in
which we are helpless because it is. It feels one-sided, dangerously unequal. I have to give
my trust to you, but not because you’ve earned it. It’s because you work in the hospital, or
the clinic, a place that is a metonym for medical expertise; it’s because you speak in the
coded language of medicine and wear the white lab coat, a rehearsed performance with its
attendant costume. I don’t feel like you trust me, because you are treating me, or parts of me,
as enemies to be vanquished. … What if, instead, the presumption went both ways—that
the patient was also a specialist, like you, in possession of a set of knowledges, a vision of
a world we’d like to build, that is different from this one, and so by collaborating as equals,
utilizing each person’s skills, we might together build a world that contains multiple parts,
a world that is not only one part—your part?

Writing about her struggle with cancer, Lorde declares that:

Attending my own health, gaining enough information to help me understand and participate
in the decisions made about my body by people who know more medicine than I do, are all
crucial strategies in my battle for living. (1996, 321)

In a quest to reclaim agency over one’s own body, writers, researchers and activists
describe their experiences of pain and struggle: “I had known the pain, and survived
it. It only remained for me to give it a voice, to share it for use, that the pain not be
wasted” (Lorde, 1996, 9).
In health professions education, learning to centre the patient experience,
providing them the right to formulate their own experiences about their bodies
and to assert agency over their narrative, is crucial. Health professions education
scholars have presented much research looking at contemporaneous examples of
gender inequity and the troublesome perpetuation of negative behaviours towards
women (Monrouxe, 2015). Examples from the ethical and professionalism dilemmas
literature, as well as the popular press, include medical students being coerced into
performing intimate examinations on anaesthetised women without consent and
obstetric abuse against women (Carson-Stevens et al. 2013; Santhirakumaran et al.
2019; Shaw et al. 2020). Without open discussion with aspiring clinicians, such
issues continue to manifest and present professional dilemmas for students who feel
conflicted due to perceptions of relative power and hierarchy. Shaw and colleagues
(2020) recently discussed concerns with regard to medical students’ professionalism
development, highlighting the extent to which gender bias is ingrained within medical
systems. Their study reports the normalisation of disrespectful and abusive treatment
of female patients poses immediate and future consequences to the wellbeing and
safety of women.

10.6 Ethics of Care, Vulnerability, and Interdependence

Feminist thought has added much-needed new perspectives within health professions
educations, encircling a feminist ethics of care which emphasises interdependency
10 The Future of Healthcare is Feminist … 151

and vulnerability (Gilligan 1982; Mackenzie et al. 2013; Hauskeller 2020). As Lorde
writes in A Burst of Light, “Caring for myself is not self-indulgence, it is self-
preservation, and that is an act of political warfare” (1996, 332). Feminists have
taken up this call for (collective) self-care to encompass experiences of living with
chronic illness and disability. In a 2016 essay, the aforementioned Hedva proposes
their “Sick Woman Theory”, in which they propose sick bodies—those who, as Lorde
puts it in A Burst of Light, were never meant to survive—as the twenty-first century’s
sites of resistance. In a society where one’s health is defined in relation to whether
one is able to go to work, Hedva (2016) writes, one of the most anti-capitalist protests
is “to care for another and to care for yourself. To take on the historically feminized
and therefore invisible practice of nursing, nurturing, caring”.
Drawing resources from feminist academic research as well as activist groups,
feminist thought and practice allow us to highlight gendered, racialised, classed, and
other intersecting dimensions to health, and to centre not only epistemic justice and
storytelling, but also empathy and an ethics of care.
Of course, promoting discourse on issues such as vulnerability and interdepen-
dency within the educational setting can be difficult and nuanced. Recent literature
in the field of medical humanities advocates for the use of the arts and humanities as
tools for broaching topics that may be sensitive or nuanced; indeed, much feminist
literature and arts explore women’s and gendered experiences of health and illness
(Wånggren 2016; Foster and Funke 2018; Dudley 2021). Example activities could
include: the creation of artworks on what it feels like to experience disease or illness
as a woman; authoring love and breakup letters (Laughey et al. 2021) to the patri-
archy or marginalisation based upon gender; or writing poetry on intersectionality.
Key is the creation of a safer space for discussion.

10.7 Conclusion

Feminist thought and practice help us understand and address existing biases within
health professions education, and to articulate new perspectives and practices that
will serve us better. Alongside and intertwined with feminist activism, antiracist,
LGBTQIA+, and disability activism allow us to counter bias in health professions
practice and education. Feminist health and medicine scholars and activists have
highlighted the sexist biases in science and medicine, questioned the medicalisation
of women’s bodies and minds, and highlighted health inequalities among women and
other groups. Addressing the ways in which social, cultural, and political factors influ-
ence discourses and experiences of health, and understanding the historical roots of
gendered inequalities in health, is crucial in improving health professions education
(Table 10.1).
152 L. Wånggren and G. M. Finn

Table 10.1 Practice points

1 Embed reflexivity practices within programmes, allowing students and professionals to
critically enquire and address their own and the patient’s positionality and how this affects
knowledge production
2 Include intersectional perspectives in handbooks, case studies, and examples, being sensitive
to the different experiences and positionalities of diverse groups (for example: names in
handbook examples should represent the diversity of educators, students, and patients).
Awareness of intersectionality is of particular importance as we navigate efforts to decolonise
the curriculum
3 Include compulsory structural/unconscious bias or Equality, Diversity, and Inclusion (EDI)
training sessions for educators and students
4 Acknowledge and discuss competing discourses on sex, gender, and sexuality, including the
perpetuation of bias and inequity. Embrace the arts and humanities as a tool for creating safer
spaces and an informal approach to discussing gender and associated inequities
5 Remember that addressing equality, diversity and inclusion is a longitudinal process. We are
training the future policy makers; taking the time to sow the seeds and allow understanding to
develop is crucial

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Chapter 11
The Philosophy of Agency: Agency
as a Protective Mechanism Against
Clinical Trainees’ Moral Injury

Abigail Konopasky, Jessica L. Bunin, and Lara Varpio

11.1 Introduction

While the nature of agency is a lively debate (see Chapters 10 and 12), we define it
for our purposes here as the process of using one’s resources to intentionally deter-
mine and pursue goal-directed actions amidst constraints (Ermarth 2001; Martin
et al. 2003; Konopasky and Sheridan 2016). In health professions education (HPE),
the agency harnessed by learners has been closely linked to feedback, assessment,
and learner growth and development (Sweet and Davis 2020; Tripodi et al. 2020).
As these studies illustrate, drawing on conceptualizations of agency can offer valu-
able perspectives through which educators can face HPE’s most intractable problems.
Such “wicked problems”—e.g., teaching interprofessional education and profession-
alism, addressing racial and ethnic disparities, and designing effective remediation
programs (Varpio et al. 2017)—often hamper clinicians’ educational efforts. A partic-
ularly “wicked” problem that is receiving increasing scholarly attention is the moral
injury of medical trainees (Murray et al. 2018; Murray 2019; Borges et al. 2020;
Haller et al. 2020). Moral injury is defined as:

A. Konopasky (B) · L. Varpio

Center for Health Professions Education, Uniformed Services University of the Health Sciences,
Bethesda, MD, USA
e-mail: abigail.konopasky.ctr@usuhs.edu
L. Varpio
e-mail: lara.varpio@usuhs.edu
A. Konopasky
Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD, USA
J. L. Bunin · L. Varpio
Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD,
USA
e-mail: jessica.bunin@usuhs.edu

This is a U.S. government work and not under copyright protection in the U.S.; foreign 157
copyright protection may apply 2022
M. E. L. Brown et al. (eds.), Applied Philosophy for Health Professions Education,
https://doi.org/10.1007/978-981-19-1512-3_11
158 A. Konopasky et al.

the experience of guilt and shame (or profound psychological distress) resulting from
violating one’s morals and values during a severely stressful event. (Haller et al. 2020,
S174)

Moral injury may also result from accumulated experiences as opposed to one
severely stressful event. While associated with burnout—“a syndrome of exhaustion,
cynicism and reduced efficacy resulting from chronic workplace stress” (Freuden-
berger 1975)—moral injury reframes the problem from one of a stressed out indi-
vidual (e.g., who simply needs to do more meditation or relaxation) to the system
that places healthcare providers in a position where they cannot abide by their values
and moral standards (Dean et al. 2019). Episodes of moral injury result from under-
standing one’s moral code and understanding the actions which are consistent with
that code but being unable to accomplish those actions due to external constraints
(Haller et al. 2020).
Below, we illustrate how theories of agency can powerfully support examination
of HPE learners’ moral injury, arguing that this injury can arise out of constraints
on learners’ agency. Trainees in various health professions may experience these
constraints differently, but the existence of constraints on exercising agency is ubiq-
uitous. Oncology fellows may be unable to prescribe an optimal treatment due to
insurance limitations. Internal medicine residents may be unable to spend enough
time caring for their patients due to excessive electronic medical record documenta-
tion and administrative tasks. Psychiatric residents may be unable to share informa-
tion with family members despite a belief that the family may be integral to wellness.
Similarly, nursing and medical trainees in the intensive care unit may be unable to
permit family to visit with a critically ill patient due to a hospital’s COVID-19 visi-
tation policy despite a belief in the value and healing that might result for both the
patient and the family. Repeated experiences like this can erode trainees’ sense of
agency, a complex, unfolding concept that is shaped by the discourses and contexts
across their history (Van Alphen 1999). As described by Talbot and Dean (2018):
Routinely experiencing the suffering, anguish, and loss of being unable to deliver the care
that patients need is deeply painful. These routine, incessant betrayals of patient care and
trust are examples of ‘death by a thousand cuts.’ Any one of them, delivered alone, might
heal. But repeated on a daily basis, they coalesce into the moral injury of health care. (18)

Moreover, if traumatized trainees do not have a language for these “thousand cuts,”
they may give up their subjectivity altogether, abandoning a sense of either agency
or victimization (van Alphen 1999).
In this chapter, we use the case of moral injury to illustrate how philosophical
conceptions of agency can help educators support learners in HPE. We begin by
setting out the problem of moral injury with a case drawn from critical care. We then
address the problem of moral injury by drawing on two philosophical approaches to
agency: (a) what moral and postmodern philosophers have said about what it means
to exercise agency amidst the potential constraints of other agents of social and
institutional structures and (b) what phenomenological philosophers have said about
what it means to have a sense of agency amidst these constraints. We conclude by
offering suggestions for how instructors can better support learners’ sense of agency
11 The Philosophy of Agency: Agency as a Protective Mechanism … 159

to prevent moral injury, and how a nuanced view of agency, like the ones here, can
shape HPE research and practice.

11.2 Case Presentation

An elderly male is admitted to the intensive care unit for respiratory failure and
altered mental status in the context of a hospital admission for COVID one month
prior. He has a complicated medical history, including active forms of cancer with
an estimated prognosis of less than one year to live. Upon admission, he rapidly
decompensates and requires intubation and invasive mechanical ventilation. Several
days into this admission, despite being intubated, he has a particularly lucid day when
he is alert and interactive with the medical staff. The bedside nurse in training spends
several hours discussing his illness with him. She is convinced that he does not want
to remain dependent upon machines for the long term, does not want a tracheostomy,
and does not want cardiopulmonary resuscitation (CPR) in the event of cardiac arrest.
She tracks down the medical team to include an intern, resident, fellow, and attending.
The team reiterates the conversation with the same conclusions. The next day, the
bedside nurse again broaches this conversation with the family present via video
call due to the hospital’s restrictive visitation policy during COVID-19. The patient,
again, consistently communicates his wishes, but he appears less interactive. Over
the next 12 h, the patient decompensates and is no longer consistently interactive
with his care team. During follow up conversations with the family via video, the
family believes that the patient’s decisions were based on delirium and were only a
snapshot in time. They believe that if he were to become more alert, he would most
certainly want aggressive medical care and to be kept alive by all means possible to
include tracheostomy and CPR. Through these conversations, it becomes clear that
the patient had never told his family members of his cancer diagnoses, and that they
had never previously had end-of-life, goals of care discussions.
The care team, determined to honour the patient’s autonomy, obtains an ethics
consultation. While ethics consultation services vary across national healthcare
systems, the service represented in this situation includes a team of volunteers who
may not have formal ethics training, but who provide an ethically based assessment
from an uninvolved perspective. The ethics consultants in this case state that since
there is no documented medical power of attorney, the wife’s decisions stand. The
ethics team further recommends a legal consultation, as is often the course in various
healthcare systems. The legal consultants agree that, due to state policy, the family’s
interpretation of what the patient would want in totality outweighs what the patient
requested when he was lucid. The team moves forward with a tracheostomy. Within
a week, the patient is transferred to a long term ventilator weaning facility. Over the
next few months, he repeatedly gets re-admitted to the hospital for infections. His
care is optimized as much as possible, but he remains minimally conscious and does
not interact with his environment in a meaningful way.
160 A. Konopasky et al.

11.3 Agency Amidst Constraints: Normative Ethics

and Postmodernism

As this case illustrates, the potential guilt and shame of moral injury may be inter-
preted as directly related to the constraints on trainee agency (e.g., being required to
perform futile CPR) and their experience of them (e.g., profound distress for violating
patient autonomy). While constraints are part and parcel of the experience of agency
(see definition above) and health professionals are always able to use their agency
to act against policy (e.g., refusing to perform CPR), this dissonance between self
and system may be new and unexpected for trainees. Both moral and postmodern
philosophers have wrestled with the problem of constrained agents: can one truly
exercise agency amidst external constraints? If not, do the constructs of “right” and
“wrong” truly have meaning? In this section, we review the ways moral philosophers
have tackled the problem of bounded agency and how postmodern philosophers have
dealt with what some posit as the absence of agency. We move to the experience of
agency in the following section.

11.3.1 Consequentialist Normative Ethics: The Problem

of Resource-Bounded Agents

For consequentialist moral philosophers (those focused on the effects of actions

rather than a moral norm [Alexander and Moore 2021; See Chapters 15 and 16 for
more discussion of consequentialist versus deontological philosophy]), the problem
of agency originates in the agent: as humans, we are located in particular times and
places with limits on what we can know (e.g., while I can know what I would want
at the end of my life, I cannot know what all patients in all contexts across the globe
would desire—i.e., it is impossible to understand all of the factors that contribute to
patients’ decision making) and on what we can process (e.g., even if I could interview
1000 patients, I do not have the cognitive processing ability to hold all of that in my
mind at once to cross reference those sets of knowledge and understand “the” truth
about end-of-life decision making). From this perspective, these moral philosophers
ask: With humans’ limited resources, are we truly able to exercise agency in deciding
how we “should” act (Caton 2021)?
Philosophers have posed several solutions to this, with some schools (e.g., util-
itarianism) arguing that a standard of optimal decision making is actually immoral
because it costs so much time and effort in mere computation that could be spent
engaging in other moral actions (e.g., in the case above, when the patient originally
presented to the hospital and decompensated, it would have been immoral to debate
the patient’s end of life goals and code status with the family and other members
of the care team. In reality, at that time, the preponderance of evidence available
indicated that the patient was full code and therefore, immediate intubation was the
moral action). In response to this senseless computation, Christopher Cherniak set
11 The Philosophy of Agency: Agency as a Protective Mechanism … 161

a standard of “minimal rationality,” arguing that “there are often epistemically more
desirable activities for [human agents] than maintaining perfect consistency [in deci-
sion making]” (as cited in Caton 2021). In other words, when I spend all my time
deciding how I should act, I am taking no steps in the world to actually act. Instead,
then, we must lower our standard and aim for “minimal rationality” that is “good
enough,” even relying on heuristics to make decision making “fast and frugal” (Caton
2021). Moral agents, then, determine an acceptable threshold of systematicity and
only engage in computation to that level. As applied to the case above, finding no
obvious documentation of code status and hearing from the family that the patient
wanted to be intubated, plus understanding that the patient would rapidly die without
action are “good enough” to make a decision on moral action. (See Table 11.1 for
summary of philosophical approaches, principles, and examples.)

Table 11.1 Summary of philosophical approaches, principles, and clinical examples

Philosophical approach Principles Clinical examples
Normative ethics Minimal rationality (i.e., Making clinical decisions without
“good enough” ethics) full information, e.g., intubating a
decompensating patient with
unknown code status or moving
forward with an end-of-life plan of
care without fully understanding all
information
Postmodernism Innovation and alternate Weaving the discourse of palliative
discourses (to escape care (making the patient
prison-house-of-language) comfortable) into the discourse of
critical care (encouraging them to
“do everything”) to move forward
Phenomenology Intentional binding Connecting the intention of
empathic communication to honour
autonomy with the outcome of
ensuring the clinical team is aware
of the patient’s goals of care
Purposiveness Helping a student to retrospectively
connect a somewhat haphazard
conversation with the patient with
the intention of helping the team
understand the patient’s goals of care
Sense of control Determining what information is
necessary to place any consult
(global planning); collecting the
information and planning the script
to deliver to ethics consultant for this
specific patient (local planning);
manner of communication during
the act of consulting (sensorimotor
planning)
162 A. Konopasky et al.

In our case study, when the trainees on the care team are determining whether
to move forward with tracheostomy and long-term care, apparently in opposition
of the patient’s wishes, they are operating with a limited knowledge set—as the
family rightly points out, they cannot know what the patient would have said at
some other point in his life. Moreover, particularly as individuals new to medicine,
they cannot possibly be aware of or mentally compute all the aspects of this case,
including consequences of the decision to the individuals involved (e.g., the patient,
family members, and other stakeholders); the hospital policies; relevant laws; and
their own career paths and possible good they might do for other patients in the
future (which could be taken away if they act against the law). This is where the
attendings, working together with a community of multidisciplinary clinicians and
educators, can help the trainee develop a ‘good enough’ decision making process.
The trainees demonstrated agency in their attempt to display the patient’s wishes
to the family via a video family meeting. They constructed a plan based on the
information they had: the patient wanted to limit aggressive care and the family
needed to know this information. While the conclusion of this meeting was not as
expected, it is important for attendings to show appreciation for the proactive attempt
and help trainees to understand that to exercise agency is not necessarily to reach
one’s desired goal. Allowing and encouraging trainees to arrange for and engage in
family meetings and advocate for their patients is a form of agency that may mitigate
the moral injury that might otherwise arise from this experience. Through this work
with their clinical community, trainees can learn what ‘good enough’ decision making
looks like. Finally, educators should keep in mind that what causes moral injury to
one trainee may not to another—experiences of agency are tied up in an individual’s
past experiences and contexts (van Alphen 1999).

11.3.2 Postmodern Philosophy: The

Prison-House-of-Language

While the problem of agency for utilitarian moral philosophers is primarily a compu-
tational one, for postmodern philosophers it is an issue of language and power. The
term “postmodernism” literally signals the end of modernity’s ways of thinking. In
modernism, many “grand narratives” were constructed: e.g., science, reason, and
truth. Postmodernists (e.g., François Lyotard, Michel Foucault, Jean Baudrillard)
position these narratives as illusions that obfuscate or even hide the complexity of
human reality. As Lyotard famously asserted in his text The Postmodern Condi-
tion, postmodernism seeks emancipation from the conformity imposed by these
grand metanarratives: “I define postmodern as incredulity towards metanarratives”
(Lyotard 1984). In other words, these grand narratives lost credibility once they
were recognized as being merely that–narratives, stories, fictions. While we may
11 The Philosophy of Agency: Agency as a Protective Mechanism … 163

perceive ourselves to be making decisions that cause certain effects in our environ-
ment, postmodernists like those mentioned above posited that we are actually in a
prison-house-of-language. Fitzhugh and Leckie (2001) describe it this way:
Premise 1: Human thought is fully shaped by language.
Premise 2: Any given language is a closed system.
Conclusion: Therefore, thought is a closed system. Without access to anything outside
of language, humans cannot act outside the system. (64–65)

Another way to think about it is that individuals live in a reality that they know
and understand through the language and the narratives that surround them (i.e.,
the discourses—systems of meaning and value [Ermarth 2001]—they live in and
through). Thus, individuals can’t live or take actions outside that language and those
narratives. For some postmodern theorists (e.g., Jacques Derrida), it is not possible
to conceive of life or action without doing so through language.
What does this mean for postmodern conceptualizations of human agency? In
this philosophical orientation, agency is a construct of the potentially shifting and
changing discourses within which the individual lives. The context gives the indi-
vidual a finite (and limited) set of linguistic tools (i.e., words and narratives), which
are constantly subject to change. Since the individual can only work with those
tools, agency is limited. Moreover, this limited agency is not distributed equally—
those with more access to dominant discourses have more opportunities for agency
(see Chapters 9 and 10 for more discussion of limits on agency). In our case, the
trainees, in discussing end of life issues with the patient and the family, were oper-
ating within a discourse of modern Western medicine and more specifically, critical
care medicine in the United States, with its structures of white supremacy (Ferrel
2017). The discourse of Western medicine functions to maintain power for some
(e.g., administrators and physicians) and take power from others (e.g., patients, their
family members, minority physicians [Wyatt et al. 2021]). If the trainees had been
functioning within a palliative discourse, this conversation may have happened long
before the situation became dire. The discussion of death and dying may have been
normalized and built on over years instead of being constructed within one meeting.
Whatever discourse(s) our trainees experience, they are operating within that closed
linguistic system. Their agency is locked in the prison of the words and narratives of
the contexts in which they live and work.
Thankfully, a number of postmodernist philosophers have pushed against this
prison-house-of-language conundrum and made a case for human agency. For
instance, Ermarth brings in Ferdinand de Saussure’s notions of langue (i.e., the
potential available in a system of language; e.g., all the possible goals of care discus-
sions that might occur) and parole (the language as used in practice; e.g., all the
actual discussions in existence). The distance between potential and practice means
that language is “forever incomplete-able” (Ermarth 2001, 43). In other words, there
is no complete version of “English” we can identify; rather, we infer the notion
of “English” from our experience of it. Similarly, there is no complete version of
“medicine” or “healing”; rather we infer the notion by our experience and practice
of it. Our language is forever growing and evolving. It is not stable, nor is it ever
164 A. Konopasky et al.

complete. It is in this incompleteness that the potential for agency lies: our linguistic
potential lies beyond what has been said. Human agency lies in the potential that is
distributed across all the speakers of the language as they bring that potential into
practice, as they experiment with language (Ermarth 2001). Within this orientation
of postmodernist philosophy, agency “is not a singularity, but a process, a happening,
a particular expression of systemic value” (Ermarth 2001, 46) The postmodern agent
is a “point of empowerment” who is both created by and creating the discourses
around them (Ermarth 2001, 47). This is not to suggest that the agent is not limited;
the agent is limited by the language that is available, by their ability to innovate, by
their creativity. Rather than the modern agent who is stable and can take clear actions,
the postmodern agent is “smaller, humbler, less passive, more creative, possibly even
more effective” because they creatively bring together all the potential of discourses
to craft their own narrative (Ermarth 2001, 48).
In the practice of critical care medicine within the discourse of Western medicine
and more specifically, the United States medical care system, our trainees may be
stuck in a prison-house-of-language if we, as their educators, do not teach them to
creatively think beyond it. Trainees may feel limited in the degree of medical care
they are allowed to provide within the scope of their training medical license. They
may feel constrained by their role on the medical team and fear repudiation should
they overstep. They may fear the litigation of medical malpractice if their plans result
in untoward consequences or if they refuse to deliver futile care despite the family
begging them to “Do everything.”
The educators on the care team in our case have an opportunity to empower trainees
to practice agency and innovation. While these trainees may indeed be limited by
the scope of their license, the attendings can help them grow and develop mastery
by ensuring they support their efforts and supervise them at appropriate levels. In
our case example, this would be illustrated by appreciating the initiative that the
nursing student took in having end-of-life conversations with the patient but offering
supervision and feedback to help with future discussions. We should encourage and
reward our trainees’ initiative in developing rapport with patients, understanding their
cultural context, and involving their families in their care—even when they approach
it differently than we might or if the result is not as desired. We can demonstrate
appreciation of the risks they are taking as they establish and practice their own style
of communication and patient care. Another important intervention we can make for
trainees is to have open conversations regarding difficult legal and ethical cases (e.g.,
the choice not to perform CPR on a full-code patient) that physicians have personally
encountered and encourage trainees to share honest perspectives on how they might
act. Most importantly, we must ensure that our trainees know that we, as attendings,
carry the ultimate responsibility for our trainees and for our patients. The trainees in
this case, for example, must understand that they will not be placed in legal jeopardy
as a result of well intentioned, appropriately supervised decision making and patient
care.
11 The Philosophy of Agency: Agency as a Protective Mechanism … 165

11.4 A Sense of Agency: Phenomenology

While normative ethics and postmodernism can help instructors to support trainees’
exercise of agency amidst constraints, this process will be of little help in future
situations if these trainees do not experience a sense of agency. To have a sense of
agency for a given action is to feel that “I am the one who is causing or generating the
action” (Gallagher 2012, 18), that I am the author of that action or, in the case of not
doing CPR for instance, inaction (Pacherie 2007). Without this sense of authorship
over action, trainees will not feel capable of initiating action. Unfortunately, a sense of
agency tends to be “short-lived and phenomenologically recessive” (Gallagher 2012,
17). In other words, the feeling of agency that might come from completing actions
across a day recedes into our experiential background and, when we do experience it,
does not last very long. Phenomenological philosophers like Pacherie and Gallagher
have argued that a sense of agency is not a single phenomenon, but can be separated
into more basic component parts. Below we discuss three component parts these two
phenomenologists offer that may be useful for supporting trainees as they develop
a sense of agency in their work: intentional binding, purposiveness, and a sense of
control (Gallagher; Pacherie).

11.4.1 Intentional Binding: Linking Intent and Outcome

Perhaps the most critical element that enables a sense of agency within Pacherie and
Gallagher’s phenomenological approach is noticing a link between one’s intention
to complete some action and the outcome or consequences of that action (Gallagher
2012; Pacherie 2007). For instance, the nursing student in our case study engaged in
detailed, empathic communication with the patient to honor the patient’s autonomy.
The outcome in this case was that the medical team developed a deeper understanding
of the patient, the situation, and the patient’s goals of care. The binding between that
intention (empathic communication to honor autonomy) and that outcome (ensuring
the team knew the patient’s goals of care) is the core of a sense of agency (Pacherie
2007). Instructors can help learners, in the midst of a busy day in class and/or clinic,
to notice this link.

11.4.2 Purposiveness: Characterizing Action

While intentional binding is necessary to a sense of agency, Pacherie (2007) argues

that it is not sufficient. In fact, in studies by Wohlschläger and colleagues (cited
in Pacherie 2007), participants had the same response time when generating actions
themselves as they did when watching others generate actions. These scholars suggest
that this evidence implies that action/outcome binding is not necessarily linked to
166 A. Konopasky et al.

the self. Another important element in a sense of agency revolves around the action
itself and whether it is taken up with a goal in mind. Pacherie calls this purposiveness.
To experience that feeling of authorship, the actions one undertakes should be goal
directed. Had our nursing student not had the goal of addressing the patient’s goals
of care, she might have asked the patient haphazard questions. Instead, while the
patient was lucid, alert, and interactive, she conducted a goal-directed conversation to
understand the factors that contributed to the patient’s end-of-life wishes. Instructors
support trainees’ sense of agency by supporting them in taking on goal-directed
actions. Purposiveness can also be retrospective (Pacherie 2007): if a trainee takes
action without consciously setting an intention, instructors can help them to infer an
intention after the fact, which supports a sense of agency. Pointing out to the student
nurse that in haphazardly asking questions they learned about the patient’s cultural
beliefs and perspective of life and helped the team better understand the patient, for
instance, allows them to retrospectively infer purposiveness.

11.4.3 A Sense of Control: Global Planning, Local Planning,

and Sensorimotor Representation

In addition to intentional binding and purposiveness of action, a sense of agency rests

upon a sense of control: either feeling in control over a relatively expected course
of events or exerting control amidst constraints (Pacherie 2007). Pacherie identifies
three subtypes of control feelings people can experience: rational, situational, and
motor.
Rational control aligns with what we may think agency feels like: it is develop-
ment of a clear intention and a purposive action to carry out that intention; it can
be concerned more globally with types of actions (e.g., “placing consults”) versus
tokens (e.g., “placing an ethics consult for this patient”); and it is subject to external
pressures to be consistent and coherent (i.e., to be rational action). In our case, the
intern experiencing rational control might be determining what information might
be necessary to successfully place a coherent consult to the ethics team.
The next level down, situational control, is more local, more anchored in context,
and usually much closer in time to carrying out the action. The same intern experi-
encing situational control would perhaps be collecting the information and planning
the script they might deliver to the ethics consultant for this specific patient.
Finally, motor control involves our sensorimotor representations. One is not
usually aware of this feeling of control (Gallagher [2012] calls it pre-reflective: either
unconscious or peripheral awareness) unless something goes wrong. For instance,
the student might almost unconsciously be speaking in an excessively loud, pres-
sured manner when they call the ethics consultant until the consultant asks them to
slow down and take a breath, bringing this action to awareness. All three of these
levels of control are important for trainees to experience to have a sense of agency. It
is not enough for a trainee to solely experience motor control, or even more reactive
11 The Philosophy of Agency: Agency as a Protective Mechanism … 167

situational control, but must also be supported in developing the skills to plan more
globally so that they can also experience rational control (note that other philoso-
phers have pushed back against this notion of control, noting that it is often illusory,
e.g., elevator buttons that do not do anything [Žižek 1999]; see Chapter 17 for further
discussion).

11.5 Conclusion

The exercise and experience of agency are fundamental parts of being human and,
as such, are areas philosophers have been wrestling with for centuries. We have
demonstrated here how two aspects of agency—the exercise of agency (discussed
through consequentialist and computational normative ethics and Lyotard’s post-
modern theory) and a sense of agency (discussed through Pacherie and Gallagher’s
phenomenological approach)—can offer instructors valuable tools for helping
trainees both to exercise and experience agency amidst constraints. We suggest
through our case application that the exercise and experience of agency can be protec-
tive factors from the psychological distress of moral injury and that philosophical
constructs can offer instructors tools to support this agency.
This case surfaced many areas that tend to create moral distress for health profes-
sions trainees: insecurity regarding their role on the medical team, inability to know
and understand our patients’ desires over time (we can only know how a patient
answers a given question during their critical care hospitalization—their state of mind
may not be at their baseline), inability to honour patient autonomy, being required
to provide futile care, being unable to effectively communicate consequences of
critical illness to family members, discomfort in discussing death and dying, being
caught between the medical system and the legal system, and being unable to provide
patients with dignity at the end of life. This case was further complicated by COVID-
19 and the resulting inability of the family to spend time with the patient as well as
the inability for the family meetings to occur face to face.
There are actions educators can take to reduce the likelihood that potentially
morally injurious situations result in moral injury. Consistent with normative ethics
and “minimal rationality” (Caton 2021), we are obligated to teach our learners to
make decisions with incomplete information. The intensive care unit may require life
and death decisions to be made in an instant. Further, we may have weeks to make
decisions, but we still cannot learn all necessary information. Inevitably, we will
all make bad decisions. We must teach humility, self-compassion, and help seeking
skills to assist our learners in meeting this challenge and prevent them from becoming
paralyzed from decision making by craving more information.
Following insights from postmodern philosophy, we must also empower our
learners to practice innovation and creativity as they develop their craft and ensure we
do not guide them into a prison-house-of-language. Instead, we must remind them that
there are always alternate discourses to study, cultures to learn from, inventions to use,
facts to discover, language to develop, and connections to make. There are numerous
168 A. Konopasky et al.

opportunities to increase learner creativity and innovation to include poetic inquiry,

innovation curricula, multimedia presentations of research, and medical improvisa-
tion and acting (Brown et al. 2021; Neel et al. 2021; Rieger et al. 2021; Wong et al.
2021). Consistent with phenomenology, we must teach them all stages of a sense
of control in agency: global planning, local planning, and sensorimotor representa-
tion. Successful providers must learn cognitive reasoning, contextual and situational
thinking, as well as procedural skills to practice agency—all are required.
While the three philosophical approaches to agency explored here (consequen-
tialist computational normative ethics, Lyotard’s postmodernism, and Pacherie and
Gallagher’s phenomenology) can offer powerful ways to support learners, agency
is an incredibly rich construct that has been explored across other approaches to
philosophy along with psychology, education, linguistics, and anthropology (Capps
and Ochs 1995; Holland et al. 1998; Quigley 2000; Ahearn 2001; Rogers 2004;
Bandura 2006; Chirkov et al. 2011; Heckhausen 2011). HPE scholars could mine
these fields for insights to support them in teaching and research. For example,
Holland and colleagues, coming from anthropology, argue that one way to exer-
cise agency is by drawing on Bakhtin’s notion of heteroglossia: “the simultaneity
of different languages and of their associated values and presuppositions” (Holland
et al. 1998, 170). They argue that the Naudadan women of Nepal use the songs they
create for the annual Tij festival to engage these different languages, voicing the
idea of the “good Hindu woman” from the public discourse while also critiquing it
from their own embodied experiences (see Chapter 10 for more discussion of agency
from a feminist perspective). In the health professions, we could use this approach to
examine the ways learners may exercise agency by expressing their own embodied
experiences in potentially contested spaces like clerkships (where trainees tradition-
ally have little power). This could help us to better understand these learners and to
provide support for their agency (see Bennett et al.’s [2017] analysis of two medical
student reflections for an example of the use of Holland et al.’s [1998] notion of
agency in health professions education).
An important contribution of philosophical approaches is that they illustrate the
complexity of agency. Our application of philosophical constructs to the case demon-
strates that agency is not a monolithic characteristic that is either there or not, but is
instead a nuanced construct made up of different components that may shift across
people and contexts. As health professions educators, we must consider what kinds
of agency we can support for our learners across the environments in which they
work. For instance, in a study of a GED program (adults seeking high school certi-
fication), Konopasky and Sheridan found that learners explicated different kinds of
agency—and agency support—across times of their lives; they narrated themselves
as facing insoluble barriers in their past schooling and experiencing almost endless
support and possibility in their present GED program (Konopasky and Sheridan
2016). While much of their agency was individual back in high school (when they
had little to no support), they used more joint or collective agency in their GED
program (when they had tremendous support from family and friends). Thus, they
approached each context as an agent differently in order to achieve their intentions.
More nuanced constructions of agency could help us to identify the types of agency
11 The Philosophy of Agency: Agency as a Protective Mechanism … 169

Table 11.2 Practice points

1 The exercise and experience of agency are fundamental parts of being human and becoming
a healthcare professional
2 Attendings or seniors who are cognisant of the external constraints that trainees experience
can decrease the risk of moral injury to those trainees
3 Educators should show appreciation for proactive decision making by learners in the
absence of perfect information
4 Educators must provide supervision and feedback to empower trainees to develop their own
communication and patient care style
5 Educators and institutions should consider how trainees can be helped to experience a sense
of control at the global, local, and sensorimotor decision-making levels

our health professions learners use across contexts and support them in strategic use
of internal and external resources in reaching their goals.
A complex and nuanced approach to agency, like those offered by philosophy,
could be particularly helpful with “wicked problems” like that of moral injury, that are
social and even systemic in nature, resisting definitive formulations or explanations
(Varpio et al. 2017). In order to address further problem spaces such as interprofes-
sional education, racial and ethnic disparities, and remediation, HPE scholars need
to approach the agents in these spaces as complex decision makers. These agents
wrestle with changing constraints and shifting experiences of agency as they engage
in the process of planning and carrying out purposive actions that are “good enough”
to meet internal and external standards. We must offer our learners tools like agency
to function in their complex and shifting environments, while helping them to under-
stand that there is no ideal agent who can compute the “right” decision in every
situation. Instead, agents are innovators, creators, who draw on an imperfect set of
resources to craft a way forward amidst constraints and barriers, but with the support
of other flawed agents like their peers and instructors (Table 11.2).

Disclaimer The opinions and assertions expressed herein are those of the authors and do not neces-
sarily reflect the official policy or position of the Uniformed Services University, the Department
of Defense, or the Henry M. Jackson Foundation for Military Medicine.

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Chapter 12
“What Does It Mean to Be?”: Ontology
and Responsibility in Health Professions
Education

Tasha R. Wyatt, Rola Ajjawi, and Mario Veen

12.1 Introduction

Health professions education (HPE) has traditionally drawn from the practices and
perspectives of biomedical science and cognitive psychology. These disciplines tend
to privilege ontologies where there is an independent reality that exists ‘out there;’
scientists just need to use scientific methodologies to uncover nature’s universal
laws. However, this ontological realism has come with a cost in that it has positioned
humans and non-humans in fixed and static ways, and has contributed to HPE’s near
disregard for the basic ontological question of, “What is it to be? What does it mean
to exist?”.
These questions are fundamental to any profession, however, as the field of HPE
continues to become more racially and ethnically diverse, the field will need to
expand its ways of doing ontology, and more deeply consider what it means ‘to
be’ in HPE. As three HPE researchers who deeply consider issues of ontology in
our work, we propose that educators ask ontological questions to allow for other
conceptualizations of being, specifically by considering ideas around responsibility.
In this chapter, we adopt a philosophical orientation of ontology, where ontology
is something you do rather than a lens or perspective you adopt or switch between.

T. R. Wyatt (B)
Center for Health Professions Education, Uniformed Services University of the Health Sciences,
Bethesda, MD, USA
e-mail: Tasha.wyatt@usuhs.edu
R. Ajjawi
Centre for Research in Assessment and Digital Learning, Deakin University, Melbourne, VIC,
Australia
e-mail: rola.ajjawi@deakin.edu.au
M. Veen
Department of General Practice, Erasmus Medical Center, Rotterdam, The Netherlands
e-mail: m.veen.1@erasmusmc.nl

© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2022 173
M. E. L. Brown et al. (eds.), Applied Philosophy for Health Professions Education,
https://doi.org/10.1007/978-981-19-1512-3_12
174 T. R. Wyatt et al.

We begin by describing what ontology is and why it is needed in HPE, and then
elaborate on the idea of an expanded ontology that considers responsibility. We
consider how ‘being’ might be described as a context within which everything else
takes place, and a ‘nothing’ or a ‘not-yet’ within subjects, and how those in HPE
might keep this space open for their trainees, peers, and patients, who are in the
process of becoming someone/something. In introducing this expanded view, we
hope that health professions educators will create space for trainees to be so that they
might bring their whole selves to the profession.

12.2 What Is Ontology?

Ontology is a highly abstract branch of philosophy that might best be understood

as the science of what is and the claims we can make about the nature of being
and existence. It falls under the branch of metaphysics, which deals with the topic
of being; the other branches include epistemology, axiology, and logic. Being, in a
philosophical sense, represents a clearing or space within which anything can be true
or false, present or absent, real or illusionary. For example, a lie—though false—is
still as a lie; a character in a novel or a dream are not real, but they do exist as
imaginary or dream figures. Further, an event in the past or the future does not exist
now, but it ‘has being’ as a memory or a future possibility.
As such, ontology concerns itself with questions of being in relation to other
beings such as, “In what way do future possibilities exist in contrast to actual events,
or the past compared to the future, or human beings compared to animals, inanimate
objects or technology?” Even more fundamental, “What is this ‘being’ that tells lies,
dreams, engages with past and future events, material objects and other beings? What
do these beings have in common?’ and “What is the relationship between ‘being’
and ‘becoming’?”.
Given its abstract characteristics, one way to visualize ontology is to recall an
experience in getting to know someone and the process that one goes through as
an acquaintance moves into being a friend. Initially, most people think about these
acquaintances in terms of the categories to which they belong; male, in their thirties,
a physician, born in this place but emigrated to another place, soft-natured, etc.
However, as this person becomes a friend, these categories disappear, and the person
is thought about in terms of who they are. Categories and labels are no longer needed
because in the process of getting to know someone better, space has been created for
them to construct the nature of their being.
In similar terms, asking ontological questions, such as “What is a person? What
constitutes a person?” can be a way to intentionally create this space for ourselves,
and others, in which being can emerge. This can be incredibly challenging because
humans have the tendency to use rigid categories and labels for organisation. For
example, in HPE, trainees are often thought about in terms of categories (e.g., 2nd
year student, Hispanic), qualities (e.g. smart, self-directed), or markings that are
added on to the trainee in addition to other qualities (e.g. leader). Labelling trainees
12 “What Does It Mean to Be?”: Ontology and Responsibility … 175

has implications for conceptualizing when students become healthcare professionals,

which is typically thought of as when they complete their professional training. This
conceptualization sits in contrast to other potential ontologies, such as the idea that
students already have a professional identity, one that has provided guidance and
support to them in their journey to and through their professional school. They are
not 2nd year Hispanic students who are smart and self-directed on their way to become
a leader, rather they are already physicians, nurses, dentists, etc. in the process of
becoming.
Doing ontology asks educators to listen to what people say about themselves and
who they are becoming, rather than putting them into categories. Doing so requires
engagement with another dimension; a movement behind or beyond labels to ask
questions, such as, “What do I mean by this label or category? What is this that I am
inquiring about?” Asking these kinds of questions is important because categories
bring ‘baggage’ and assumptions—when we rely on mere categories, we overlook the
fact that our interpretations rely on our understanding and engagement with ontology.
For example, given that HPE thrives on data-driven approaches (e. g. scientific data,
educational data, experiential data), doing ontology would ask why this data is useful;
not “usefulness” in the traditional sense of doing something with the data, but rather
in the sense that it might do something with us, how we see the world, and lead to
new possibilities (Heidegger [1927] 2008).
However, to engage in this kind of questioning, educators must first acknowledge
their own ontology, where it originates, and how it might constrain their views of
others. This is inherently challenging because humans have a “philosophical bias [:]
basic implicit assumptions...about how the world is (ontology), what we can know
about it (epistemology), or how science ought to be practiced (norms)” (Anderson
et al. 2019, 2). This philosophical bias determines some of the fundamental ways in
which we make sense of reality.
HPE’s ontology emphasizes separateness between beings with little considera-
tion to issues of relationships, positionality, and interaction (Dornan et al. 2008;
Kuper et al. 2007). Although these are increasingly recognized in HPE, ontologically
speaking they are recognized as important ‘on top of’ the supposedly more funda-
mental separateness and materiality. In other words, HPE views that first there were
objects, and then people could form relationships with them. However, this perspec-
tive effectively ignores the relationship between beings and the ways in which they
mutually influence each other.
Separateness is emphasized within HPE because its dominant ontology is akin to
that of a rational subject in a cockpit looking out of a window (Crawford 2016); an
idea that draws from Locke and Hume’s views of empiricism1 that the world consists
of matter and facts. Subjective views are positioned as obstructions to knowing the
world that exists outside the window, which can be understood only if individuals
are able to see reality for what it is—concrete, tangible, and independent from one’s
narrow perspective. Expanding further on Crawford’s metaphor, objectivity is the

1 Empiricism is a philosophical stance asserting that all knowledge is rooted in experience and that
there is no knowledge beyond what can be empirically observed about the world.
176 T. R. Wyatt et al.

degree to which the window is clear, whereas subjectivity clouds or in some way
filters it. From this dominant ontology in HPE, we are thought to be wearing coloured
glasses—if we can just manage to take off these glasses, we will be able to see the
world objectively.
This dominant ontology is clearly seen in HPE’s focus on individual autonomy
and its tendency to view students as cognitive entities apart from their environment—
a view indebted to Kant. This view is problematic because it positions students as
empty vessels to be filled with information, who are ecologically isolated from their
larger communities. However, there are alternative ontologies that might be helpful in
rethinking the ways HPE views students and education; alternatives that emphasize
individuals’ relationships to the collective, including the ways we frame relationships
between systems and individuals within those systems. To understand this framing,
we will briefly describe who we are as researchers and the work we do in HPE,
which, in turn, informs our thinking.

12.2.1 Responsibility as Ontology

As researchers, we espouse the idea that responsibility should be included in the

ontological thinking embraced by HPE. Each of us has arrived at this perspective in
our own research and work. Mario Veen came to HPE research from a background in
interdisciplinary philosophy and the humanities, with a special focus on metaphysics
and ontology. His view on philosophy and the role it can play in HPE can be traced
back to three experiences. The first is being introduced to philosophy through an
intense month-long undergraduate summer course in which students would read the
work of one philosopher each day. Thinking about contrasting ontologies engendered
the question of how to acknowledge relativity without succumbing to relativism (i.e.,
asking fundamental questions while still having a foothold). The second was the
experience that the most valuable insights do not come through only ‘intellectual’
work, but involve one’s entire being, including our emotions and our physicality. The
third is being exposed to different cultures through travel and realizing the privileged
position of being born in a Western country with access to commodities that most of
the world does not have.
Rola Ajjawi is a physiotherapist, clinical educator, teacher, and researcher. Her
PhD opened a new world of philosophies of science that were all but ignored in her
original ‘science’ degree. The absence of thinking about ontology in HPE has been
a constant nagging force for her research. Being an Australian immigrant whose
parent was a refugee has given rise to many research questions around becoming,
identities, belonging, and relating. Rola’s current research asks about embodiment
in hybrid learning, where time, space and place constitute identity, belonging, and
being. She also analyses the ontological question of what it means to be human in
12 “What Does It Mean to Be?”: Ontology and Responsibility … 177

a post-digital world, and the implications and responsibility medical educators have
for designing effective learning environments.
Tasha Wyatt is a teacher and researcher who studies the professional identity
formation (PIF) of Black/African American physicians and their experience in
training and practicing in a primarily white profession. Tasha infuses her work
with ontological questions and the importance of responsibility in the process of
becoming a physician and serving one’s community. Her views are grounded in
her experiences of growing up in Hawai‘i during the 1980s, which at the time was
going through a cultural renaissance. Native Hawaiians were emerging with a sense
of self-determination after more than a century of colonization that had removed
Native Hawaiians from positions of political leadership (Young 2006).
This re-emergence of Native Hawaiian values and practices heavily influenced the
public educational system, most notably in the schools’ curricula. Leaders espoused
the idea that to create different kinds of beings, the school system needed to think
about the purpose of school on their own terms (Wilson 1998). As such, they began
to emphasize the indigenous value and practice of relationships and taking respon-
sibility (Wilson 2008). The concept of kuleana, which emphasizes the existence of
a reciprocal relationship between those who are responsible and the thing which
they are responsible for became part of the school’s values and mission. Children
were explicitly taught what their kuleana was and how they should demonstrate it
in a way that emphasises honouring oneself, others, and the land upon which they
lived.
This deliberate political and cultural movement was deeply intertwined with issues
of ontology, what it means to be or exist, and what role responsibility plays in this
process. Educational leaders clearly understood that to change Hawaii’s cultural and
political future, the educational system needed to educate the next generation to think
about and practice new ways of being. Unlike HPE, which tends to think of students
as autonomous beings separate from their larger contexts, the idea that individuals
have responsibility to themselves, and others places humans in a larger ecosystem
that changes the way people relate to each other. Tasha has taken this idea of being
and responsibility into medical education, specifically into her research on how the
PIF experiences of Black/African American physicians is different because they view
who they are and the work they do as physicians as ontologically different than the
views espoused in the medical profession.
Outside our personal research on issues of PIF, relationships between people
and objects, and hybridity in learning, there are several ways in which ontological
responsibility might be interwoven into HPE. In what follows, we present three
thinkers whose ideas contrast with HPE’s dominant ontology. Our aim is not to give
a historical overview of ontological thought, but rather to take three ideas that can
stimulate ontological questions regarding responsibility in HPE.
178 T. R. Wyatt et al.

12.2.2 The Ontological Approaches of Heidegger, Latour,

and Barad

Heidegger, Latour, and Barad are three philosophers whose ideas have direct impli-
cations for thinking about ontological responsibility in HPE. Their work actually
differs on several key issues, however common to them is the rejection of ontological
dualism,2 most associated with Descartes, who emphasized the distinction between
the somatic (body) and the psychological (mind). Descartes’ philosophy was more
subtle than how it is portrayed; however his work has been interpreted as a view
in which the world exists of mind and matter, the inner world and the outer world,
the objective and the subjective. In departing from dualism, we can formulate key
insights about doing ontology in HPE in a different way to what has been handed
down by dominant biomedical models. Rather than orienting to individual minds
and bodies, we assume actor-networks, entanglements, or assemblages of relations
between bodies, things, ideas, and social formations that affect each other. To do this
kind of ontology, individuals must start with themselves and where they are. They
must approach their inquiry with an attitude of openness and be aware that the social
and the material, values and science, are entangled and that there is no default choice
in how to resolve these issues. Doing ontology is an ongoing practice of remaining
aware of, and taking responsibility for, enacting decisions on what it means to be.
The first set of ideas that links ontology to responsibility is found in the work
of Martin Heidegger, whose notion of being-in-the-world has led to current notions
of embodiment, embeddedness, and positionality, which have also found their way
into HPE. Heidegger’s nineteenth century seminal work Being and Time (Heidegger
[1927] 2008) marked a return to ontology after a period in which philosophers like
Descartes and Kant had approached ontology as metaphysics, that is, as a way of
building systems of categorization from a seemingly neutral ‘outside perspective.’
Heidegger’s claim that our being is fundamentally being-in-the-world emphasizes
the idea that we already stand in a fundamental relationship to other beings; we
are not isolated subjects (outside of), but co-determined by others, tools (technics),
and objects. Therefore, the highest form of knowledge is to gather lived experience,
especially as it relates to self. In experiencing the world, an individual creates new
possibilities for thought and action that help to reconsider their position and the way
in which the individual wants to interact within it.
Heidegger describes human beings as ‘having their being before them’ in the
sense that we are responsible for our being. This does not just mean our ‘individual’
being as a person, but our whole being-in-the-world, including its facticity; the state
of affairs that was already there in the world when we entered it, and includes the past
that informs the historical situation in which we live. This perspective has relevance
for HPE, particularly in relation to PIF, whereby a trainee will enter professional

2 Ontological dualism is any kind of ontological perspective that starts with ‘there are two kinds
of beings, namely…’. Typical examples are: spirit and matter, mind and body, God and world.
Ontological monism, in contrast, is the view that everything in existence is the manifestation of one
(type of) being.
12 “What Does It Mean to Be?”: Ontology and Responsibility … 179

school and treat the existing structures as something that has always been there and
that they merely need to train themselves in, copy, and emulate.
Typically, students unreflectively inherit the entire past of HPE as crystallized
in the professional school they enter. However, rather than thinking about PIF as a
passive process of absorption or internalization, identity construction can be refor-
mulated as a process of taking responsibility for that ‘facticity’—the tradition they
have entered and the past they have not lived. They could take ownership of being
a trainee who has ultimate responsibility for the kind of physician they will be for
their patients. This involves critical thinking and dismantling ‘the way things are’
(Paton et al. 2020), but also the realization that they are the ones that will ‘be’ the
profession when they graduate.
The second set of ideas that links ontology to responsibility is found in the work
of the French philosopher, anthropologist, and sociologist Bruno Latour. Central to
Latour’s perspective is that facts are not something that are uncovered in a laboratory,
so much as produced or constructed by communities of scientists (Latour 1987). He
argues that facts do not exist in and of themselves and challenged the distinction
between science and culture (Latour 1993). He views nature and culture as inextri-
cably intertwined into a matrix of social and cultural elements and underscores the
need to include things (materiality) in our thinking and decision-making, as well
as taking stock of the consequences of our actions. The concept of symmetry (that
humans and non-humans are equally agentic) and flat ontology (that all beings exist
on the same plane—none are more real or valuable than another) underpins ideas in
actor-network-theory, where materials and humans are both actants who can effect
change prompting questions of what is done rather than what is intended (Latour
2005).
Latour’s contributions were that materiality is not neutral, and any material way in
which we organize HPE has consequences. Curriculum, assessments, clinical experi-
ences, and their interactions shape students in different ways that have both desirable
and undesirable outcomes. Educators, therefore, have responsibility to think about
the agency of materials that constitute the educational endeavour. For example, in
their sociomaterial ethnography, Macleod et al. (2019) show how video conferencing
technology—a network of buttons, screens, microphones, cameras, and speakers—
far from merely extending the bricks-and-mortar classroom, operate as unintended
“technologies of exposure.” Pressing the ‘button’ to ask a question operates a video
which beams a student’s face into a lecture theatre, leading to lack of question asking.
In another example, the checklist in an Objective Structured Clinical Examination
(OSCE) station agentically shapes the assessor’s actions and together constitutes
competence of the student through a chain of interconnected activities (Bearman and
Ajjawi 2018).
Recently, because of Latour’s emphasis on the relationship between nature and
science, he has brought attention to what he calls “a profound mutation in our rela-
tionship to the world” (Latour 2017, 8). In reference to issues such as climate change,
he argued that the world in (and planet on) which we live can no longer be seen as
a stage on which our human lives play out. Instead, humans need to consider their
decisions on the planet in ways they have not had to before or, in his words, “the
180 T. R. Wyatt et al.

décor [has] gotten up on stage to share the drama with the actors” (Latour 2017, 3).
As climate change continues to affect human health, HPE will need to think deeply
about the relationship humans have to the environment and the ways that the two
interrelate. Responsibility in this context means that HPE will need to more deeply
consider how our collective actions influence the environment because essentially
there is no ‘neutral’ way of being. Even resignation or avoidance of issues, such
as climate change, is still a way of relating that has consequences (Wellbery et al.
2018), which was recently discussed in terms of whether to keep medical resident
interviews remote or resume in-person interviews once the COVID-19 pandemic
subsides (Donahue et al. 2021).
Finally, the third set of ideas that links ontology to responsibility is found in the
work of Karen Barad, who developed her ideas against the background of Heidegger
and Latour amongst other feminist works such as Haraway and Butler (Barad 2007).
She is a physicist and American feminist theorist who posited that the world is made
of entanglements of “social” and “natural” agencies and the importance of studying
these interrelationships. To Barad, responsibility (or response-ability) literally means
the extent to which we respond to the world and the world responds to us. She
underscores that, even in physics, there is no stable material world on the one hand,
and a social world on the other. Rather, the world consists of relationships, or what
she calls intra-actions. She uses this term to replace ‘interaction’ to emphasize that
agency is not an inherent property of beings, rather it is a dynamism of forces. For
example, even when educators think they are not participating in a clinical encounter
while observing their trainees interact with patients, they are in fact a part of the
dynamic forces in the room (Rietmeijer et al. 2021). From Barad’s perspective, all
beings are in relation to each other whether this is recognized or not.
In theorizing the importance of relationships, Barad (2007) also emphasizes what
she calls agential realism, which examines “the material nature of practices and how
they come to matter” (45). In Barad’s relational ontology, matter and meaning are
not separate elements and ‘agency’ is not an attribute of something or someone.
Rather, agency is the process of cause and effect or what might be called an enact-
ment. For example, in doing archival research, Tamboukou (2014) described how
the process of reading and interpreting others’ stories, researchers engage in intra-
actions between space, time, and matter that draws attention to what kinds of data
are gathered and knowledges that are derived. Individuals thus have agency, which is
thought of as “‘doing’ or ‘being’ in its intra-activity” (Barad 2007, 178). It is through
these entanglements of matter, “possibilities for worldly re-configurings” as agency
emerge (Dolphijn and Iris van der Tuin 2012, 55).
In the context of HPE, this means that the object of knowledge cannot be separated
from the practice, or phenomenon that makes it known. HPE should not be viewed
as a collection of people, buildings, technologies, values, etc. because ontologically
there is no clear distinction between these things. Rather, because medical students
train in buildings, which were designed in ways that constrain and afford different
ways of being, we cannot think about the medical student in isolation. They must
be considered in relation to all of the other elements the student interacts with both
human and non-human in the consideration of the optimal training environment.
12 “What Does It Mean to Be?”: Ontology and Responsibility … 181

In medical education, Barad’s work has been used by Johnson (2008) to theorize
the ‘validity’ of a gynaecological simulator, which might be thought of as politi-
cally neutral, but, in fact, has political dimensions. Specifically, in Johnson’s study,
the pelvic simulator simulated the pelvic anatomy as known in a US pelvic exam,
not a Swedish pelvic exam. Johnson (2008) notes “acknowledging the fundamental
aspects of practice in simulator development creates the discursive space to ask whose
practice is being simulated?” (124). Given that practices are context specific, there is
a political implication to constructing simulators that recreate and represent certain
practices as medical norms, raising the question about the role of technology that
might have been previously thought of as neutral:
Understanding that simulators are representing practice means that we must start to think
about which practices are being recreated and taught to new medical practitioners, and start
to ask how and why these practices are being standardized, rather than assuming that the
simulator apolitically and objectively mimics an ontologically ‘true’ patient body. (Johnson
2008, 123)

While Barad’s insights are that matter matters and that relationality and agency
are fundamentally political, Latour’s notion of symmetry hides issues of power in
our relationships with the world because all actants are equally agentic (Johnson
2008). Power cannot easily be located, making it difficult to challenge. Barad coined
the term “ethico-onto-epistem-ology” to highlight entanglement around issues of
power, undergirding the idea that the way we relate to being (ontology) has conse-
quences for how we weigh different ways of knowing (epistemology) and which
actions we can or cannot take (ethics). In other words, any new technology we adopt
in medical education, the methodologies we prefer within research, and the way
we assess students (and thereby make claims to what kind of knowledge are rele-
vant) are all entangled. These decisions help to shape the kinds of individuals our
professional schools produce, and the ways they, in turn, relate to other beings in the
profession.

12.3 Future Directions for Expanding Ontology in Medical

Education

The implications of doing ontology are significant for HPE, yet the influence of
individualism within the field remains clear. HPE’s focus on knowledge or skill as
discrete and measurable components or superficial features of what it is to be a
doctor have preoccupied much scholarship and curricular design. As Weston (1988)
put it: “The missing dimension in medical education is the person, both the person
of the patient and the person of the student. The experiences of both are the very
foundations of learning, growth and healing” (1701).
We have seen a shift towards emphasis on the being as well as ‘doing the work’ of
the physician (Wald 2015), especially in the shift from focusing on professionalism
and professional behaviour to the development of a professional identity. Medical
182 T. R. Wyatt et al.

education now sees that being a physician is not just a matter of being a professional,
but rather a constant state of becoming one. This metaphor of becoming, alongside
acquisition and participation might guide a change in pedagogy that favours a more
developmental approach to thinking about how physicians are created. Learning
as becoming (Hager and Hodkinson 2009) respects the entangled, reciprocal and
dynamic interrelations between individuals and their learning cultures during the
learning process; hence preserving complexity. From this perspective, development
arises both from within and in relation to others (Kilbertus et al. 2018).
However, to shift to a focus of ontological responsibility, HPE will require a
concerted effort to think about how curriculum might engage the whole person, inte-
grating what the students know, how they act, and who they are; Dall’Alba refers to
this as a pedagogy of responsive attunement to what matters (Dall’Alba 2020). Rather
than assessing for authentic reflection, HPE students and educators can instead reflect
on authenticity (whether they feel alignment with who they are) and inauthenticity,
to contribute to the development of a professional identity (Veen 2021).
Thinking about identity in this way has consequences because identity is not a
destination; it is a process in flux—one that involves integration of knowing, acting,
and being in the form of professional ways that unfold over time. Expanding our
view of ontology in HPE is particularly important as the field considers the PIF of
minoritized physicians who come to the profession with different values, commit-
ments, and aspirations than what has traditionally been seen (Wyatt et al. 2020a,
b). Black/African American physicians do not fit the professional identity scripts
that have been handed down through the profession, and their resistance to these
scripts reveals how stifling they can be for those who do not fit the historical norm.
As HPE begins to recognize its own entanglement with its history, it will need
to rethink its curricular choices, and ask new ontological questions that take into
consideration the perspectives of those who have been historically excluded from
the profession.
Of course, these kinds of considerations for change are political. How much time
and space are allocated for certain sub-disciplines is a political question, as is who
is accepted into, and who graduates from, our professional schools. Additionally,
assessment practices, which have hierarchical disciplinary functions (Foucault 1991)
have the power to transform behaviours and shape identities to suit the sanctioned
norms of the institution. Even feedback, the opportunity to tailor the curriculum to the
individual student and encourage learning, can be a tool of control and disciplining
in one’s own image. However, educators can make subtle shifts in their thinking and
interactions to create a clearing or space for students to begin questioning who they
are in relation to themselves and others. It requires that educators practice ontology
by being interested in beings they encounter, including themselves, a fundamental
openness or an attitude of ‘I do not know who this trainee, or what this new technology
is,’ and then remaining open to what is shared in this interaction. Fundamentally,
practicing ontology is asking questions with the purpose of keeping the clearing
open.
12 “What Does It Mean to Be?”: Ontology and Responsibility … 183

Table 12.1 Practice points

1 Ask ontological questions by starting with yourself and where you are
2 Ask yourself what the ethical and material consequences are of categorizing trainees and
other aspects of your work in a certain way
3 Notice the entanglement of matter and social relations, and the borders between different
ontological categories (e.g. technology and human)
4 Decentralize the human as individual in scholarship and focus on the relationship (and
politic) between beings
5 Find ways to create space for trainees and physicians to bring their whole selves to the
profession

12.4 Conclusion

Although HPE is built on an ontology of dualism and prefigured objectivity that has
the potential to limit who others might become, thinking about being as a clearing
or space in which students become who they are challenges this traditional framing.
In hopes of thinking about ontology in a new way, we have forwarded the idea of
responsibility as a focal point in these discussions. Doing so shifts the ontological
‘unit’ away from an entity to a relationship, so that how an individual relates to
others or to their environment is not ‘additional’ to who this individual is, but rather
it determines who they are and co-determines others and their environment. Further,
we are never innocent bystanders of the world in research and practice, but always
in a relationship with it, with responsibilities for others.
If there is one thing that this brief discussion of ontology shows, there are different
ways of answering ontological questions, but what matters more than answering these
questions is to ask them in relation to our everyday practice. We always relate to being
in a certain way and this means that we are responsible for how we do ontology. In
essence, we are always doing ontology, yet we are doing it either by inheriting the
perspectives of others embedded within the profession, or we take it upon ourselves
to consciously do it in a way that supports the goals we have for our students. Given
the changing landscape of HPE, we hope that the community considers expanding
their current ontological perspectives to include the idea of responsibility (Table
12.1).

Disclaimer The opinions and assertions expressed herein are those of the author(s) and do not
necessarily reflect the official policy or position of the Uniformed Services University or the
Department of Defense.

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Chapter 13
The Philosophy of Science: An Overview

Amelia Kehoe, Charlotte Rothwell, and Robyn Bluhm

13.1 Introduction to the Context of Health Professions

Education

Medical [health professions] education is a complex interweaving of the sciences and arts
of education and medicine. At its heart is the welfare of human beings. (Tan et al. 2011, 15)

Regardless of which health profession we are working in, or what our educational or
research approach is, we all have the same goal: to ensure the safety and wellbeing
of our patients, clients, staff, and students. Research is a crucial and fundamental
activity in this goal, being the practice of critical or scientific inquiry.
Whilst there has been a shift in opinion in recent years, for a long time, the
‘scientific method’ that applied to the study of the natural sciences was considered
the ‘best’ method (Bunnis and Kelly 2010; Park et al. 2020). This natural science
approach largely utilises quantitative methods, involving the collection and analysis
of numerical data for statistical analysis. Qualitative methods, on the other hand,
involve the collection and analysis of non-numerical data (for example text or audio)
in order to understand experiences, concepts, opinions, etc. Qualitative methods such
as participant observation have historically been deemed less scientific and weak in
comparison with quantitative methods (Bunnis and Kelly 2010).

A. Kehoe (B)
Health Professions Education Unit, Hull York Medical School, University of York, York, UK
e-mail: millie.kehoe@hyms.ac.uk
C. Rothwell
NIHR Applied Research Collaboration North East and Cumbria, Newcastle University, Newcastle
upon Tyne, UK
e-mail: charlotte.rothwell@ncl.ac.uk
R. Bluhm
Department of Philosophy, Lyman Briggs College, Michigan State University, East Lansing, MI,
USA
e-mail: rbluhm@msu.edu

© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2022 187
M. E. L. Brown et al. (eds.), Applied Philosophy for Health Professions Education,
https://doi.org/10.1007/978-981-19-1512-3_13
188 A. Kehoe et al.

From the 1970s, however, researchers in the social sciences, including education
research, began to think about just how appropriate traditional scientific methods
were for certain lines of inquiry. A debate over the appropriateness of the natural
science model for social sciences enquiry gained momentum (Illing and Carter 2018),
and there was a change in the way we viewed best practice in research. Arguments
largely centered on the differences in focus; people in education and the social
sciences, versus objects in the natural sciences. The terms ‘qualitative’ and ‘quantita-
tive’ signified more than different methods of collecting data; they indicated different
assumptions about how to conduct research in the social world.
What is quite sad, however, is that, for many years and still often now, health
professions education research has been deemed as the ‘poor relation of medical
research’ compared to quantitative exploration and quantifiable outcomes, due to its
focus on ‘people’ and exploration beyond statistics (Bunniss and Kelly 2010, 358).
This is, in part, due to health professionals often coming from traditional science
backgrounds through which they may not have had chance to amass knowledge of
the social science theories often explored within health professions education (Rees
and Monrouxe 2010; Kajamaa et al. 2020). There is certainly a lack of knowledge
of the philosophy of science among those who dismiss this type of research. Thank-
fully, the negativity towards health professions education is no longer overwhelming,
with educational and, in particular, qualitative educational research, continuing to
increase in popularity as its importance becomes evident. Often, issues or dissent
raised regarding qualitative educational research stem from a lack of understanding
about the importance of qualitative approaches and their role within the research
world, along with individual attitudes towards the chosen research methodologies.
We will discuss later in this chapter how we can help to improve this perception
by ensuring we follow the necessary processes when conducting and writing up our
research.

13.2 What Is the ‘Philosophy of Science’ and Why Is It

Important?

The philosophy of science aims to understand how science works, asking questions
about (e.g.) the nature of theories and explanations, how data support theories and
explanations, and how methodological choices by scientists shape the data collected
and the evidence they provide for theories and explanations (Machamer and Silber-
stein 2008). Philosophical perspectives are crucial as they can identify or provide
assumptions and frameworks that guide our research. Philosophical perspectives are
the starting point on which assumptions about research are based, influencing the
researcher’s role, how the study is carried out and the type of knowledge produced.
Bourdieu (1991) describes philosophy of science perfectly as
13 The Philosophy of Science: An Overview 189

the principles of the construction of the object of study as a scientific object and the rules of
delimiting the relevant problems and methods that must be employed to resolve them and to
measure accurately the solutions. (14)

Within social and educational research, a vast literature on philosophy of science has
developed, in large due to qualitative researchers trying to articulate (and to defend)
the value of their research.
Mouton’s (1996) ‘Three Worlds’ Model is a useful way for us to begin to explore
the idea of philosophy of science, distinguishing between different practices, rules,
skills, and role expectations associated with the different positions regarding the
nature of reality and nature of knowledge construction.
• World one (everyday life e.g., during our health profession education; pragmatic
interest). World one consists of the objects of everyday life: individual human
beings; groups; social practices; institutions; and the elements of our physical
surroundings—essentially the things we typically consider make up our social and
physical reality. In World one, peoples’ experiences, engagements with learning,
and self-reflection, contribute to the creation of problem-solving knowledge which
is directed at coping with daily tasks and challenges.
• World two (science and truth e.g., health professions education research; epis-
temic interest). The phenomena of World one (everyday life) are transformed
into objects for systematic and rigorous study; scientific objects of investigation.
The motivating epistemic interest here is the desire to produce a truthful under-
standing of the operations of the natural and social worlds. World two consists
of the academic disciplines of the social, human, and natural sciences; different
methods for investigation; scientific hypotheses, models, and theories; and all the
objects of World one. This world is ultimately built up of scientific knowledge,
scientific disciplines, and scientific research.
• World three (philosophy of science and critical/reflective inquiry e.g., discussion
of the philosophy of health professions education). The phenomena of World two
(science) are explicitly transformed into objects of reflective inquiry driven by a
critical interest, aiming to criticise, dissect, deconstruct, or analyse what scien-
tists do towards the ultimate improvement of science. World three consists of
academic disciplines like the philosophy of science, the sociology of knowledge,
and the history of science; diverse research methodologies broadly guiding scien-
tific inquiry (e.g., positivism versus interpretivism); research ethics, and all of the
objects that are present in World two.
Of interest to us here is the fact that the aforementioned theories, models, and
typologies exist within a body of knowledge within World two’s realm of science.
Attitudes of (e.g.) positivism and realism are placed as part of the meta-science in
World three. These worlds that have been presented are merely a useful way for us to
make sense of how we acquire our knowledge, and act as a guide within our health
professions education. Ultimately, the philosophy of science is the very definition
of ‘science’—what it is and how science operates, both in theory and in practice.
However, scientists often ignore the concepts, assumptions, ideas, and theories that
190 A. Kehoe et al.

they use to make sense of the world and their research, ignoring the very essence of
the philosophy of science.

13.3 Understanding Research Paradigms

The concept of a paradigm has been extremely influential in the philosophy of science.
It can be traced to the physicist and historian, Thomas Kuhn, in his book, The Struc-
ture of Scientific Revolutions ([1962] 2012). Kuhn’s use of the term ‘paradigm’ in this
book is notoriously unclear (Masterson 1970). In a postscript to the second edition of
the book, however, Kuhn clarified that there are two main senses or meanings of the
term. First, a paradigm can be an exemplar: an illustration of how to solve a particular
scientific problem. Second, and more important for the topic of this book, a paradigm
can be a worldview shared by a group of scientists; a shared paradigm gives scientists
a way of understanding their area of research, and also of evaluating research done
in their field, because it provides a set of common beliefs and agreements about how
problems should be understood and investigated, which ultimately shapes what we
are able to do about those problems. According to Guba (1990), research paradigms
can be characterised through their ontology (what is reality?), epistemology (how do
you know something?) and methodology (how do you go about finding it out?). We
will discuss these terms in more detail in the next section of this chapter.

13.3.1 A Closer Look at Ontology, Epistemology and

Methodology

Scientists rely on a number of beliefs and assumptions to carry out their work, which
they may explicitly endorse, or which may remain implicit. Many of these beliefs
can be categorized as belonging to (or expressing) their ontology or their episte-
mology. There are also several overarching perspectives or philosophical stances
that have been articulated in the philosophy of science developed by qualitative
researchers; these encapsulate particular ontological and epistemological positions
that inform the resulting research methods (Illing and Carter 2018). Here, we explain
the concepts of ontology and epistemology, and provide an overview of several
influential philosophical stances.

13.3.1.1 Ontology

Ontology, in general, is concerned with the nature of what exists. It raises questions
about the nature and form of reality and about what can be known about it. Different
sciences focus on different aspects of the world which make up the ‘reality’ for that
13 The Philosophy of Science: An Overview 191

science. Physicists, for example, aim to uncover the nature of the physical world,
including matter, energy, and fundamental forces. Neuroscientists aspire to explain
how the brain works, in terms of such entities as neurons, transmitters, and neural
circuits. Sociologists try to discover the structures and untangle the influence of
social relations, social interaction, and elements of culture; this is also often the
job of medical and health professional educationalists. In each science, the aim is
basically to make sense of the nature of reality and of the objects and processes that
take place within it. Ontological problems therefore rest at the heart of science; as
we try to identify the various entities in the world and explain the way those entities
work.

13.3.1.2 Epistemology

Epistemology is the study of knowledge; it aims to identify what counts as knowledge,

how we acquire knowledge, and what it is possible for us to know. How researchers
address these epistemological questions, however, is related to their answer to the
ontological question (Moon and Blake 2014). Stemming from ontology (what exists
for people to know about) and epistemology (how knowledge is created and what
is possible to know) are our philosophical perspectives, as mentioned previously; a
system of generalised views of the world, which form beliefs that guide our action
(Moon and Blake 2014). As we noted above, quantitative approaches are central in the
natural sciences (e.g., Physics), whilst qualitative methods are needed to investigate
many aspects of social, including educational, phenomena. This distinction also
shows that the methodological approach taken by a researcher follows the answers
to the ontological and epistemological questions discussed above (our philosophical
perspective), focusing on why we have chosen the methods, or tools, that we have to
acquire our knowledge.
It is important to note that methods are merely the techniques that are used to
gather information. Methods are not the same as methodology, which refers to the
study or discussion of methods, such as which ones are appropriate for a study and
why.

13.3.2 Overview of Philosophical Stances Within Research

At a more abstract level, different ontological and epistemological approaches also

differ with regard to their views on the nature and knowability of the world in general
(as well as with regard to the specific phenomena of interest to a researcher in a partic-
ular area of science). This is the level of philosophical stances or paradigms. These
stances can be identified on the basis of their answers to ontological questions such as
“Is there a ‘real’ and a single reality?” and “Are there multiple realities dependent on
whose view is being taken?”, and to epistemological questions such as “Is what can
be known about the world independent of any relationship between the researcher
192 A. Kehoe et al.

and the subject of inquiry, so that the knowledge can be said to be objective?” or (if
the answer to the ontological question is that reality is socially constructed and there
is no single ‘real’ version) “do each researcher and their research participants have
their own version of that reality, so there is no single truth, only one that is known
as a socially constructed reality?” (Illing and Carter 2018).
As indicated in the abstract of this chapter, there has been a shift toward greater
methodological rigor in health professions education. This has come about, in part,
due to a greater understanding of the variety of philosophical stances or paradigms
that underpin and guide our research methodology in order to increase the quality
and integrity of medical education research (Rees and Monrouxe 2010; Bunniss
and Kelly 2010). Further, there is improved understanding of the importance of the
way philosophical stances influence the knowledge that is constructed through the
research and the methods and methodology used to derive that knowledge (Rees
and Monrouxe 2010) Philosophical stances guide the way our research is conducted
from the way one approaches the research, the methods used, and the way data is
analysed and interpreted. For example, if you analyse your data using a thematic
analysis approach from a post-positivist stance, the way you interpret your data will
be different to if you adopt a constructivist approach to your research. In this way,
considering and explaining your philosophical stance at the beginning of your project
is of paramount importance (Braun and Clark 1996).
Broadly speaking, there are four main types of philosophical stances that we will
discuss: positivism, post-positivism, constructivism, and critical theory. Each of these
four stances have their own ontological and epistemological position. There has been
much written about these perspectives, and it is beyond the scope of this chapter to
go into them in depth—for those interested in learning more, there is a plethora of
resources available to this end (for example; Crotty 2003). It is our aim to provide
an overview of each type of philosophical stance and the ontology, epistemology
and methods used within each, as an entry to these sorts of considerations. From a
practical perspective, we will also consider the implications of adopting each stance
for interested health professions education researchers. We will provide an example
later in this chapter to illustrate the impact that taking different stances can make
to the way in which research is conducted, what can be learned from it, and what
recommendations we can draw from it for our own practice.

13.3.3 Positivism

Positivism is rooted in the work of the philosopher Auguste Comte (so-called ‘clas-
sical positivism’) and of an interdisciplinary group called the Vienna Circle (‘logical
positivism’). All of the other philosophical stances we will discuss agree that posi-
tivism should be rejected, though the generally accepted description of this position
does not do justice to the views of actual positivists (Phillips 2000). Despite the exis-
tence of misinterpretations, we can identify the core ontological and epistemological
claims of positivism that are rejected by other philosophical stances.
13 The Philosophy of Science: An Overview 193

• The core ontological claim of positivism is that any claim to knowledge should
be verifiable through sense experience.
• The corresponding empirical claim is that such experiential data provides
an objective (intersubjective) foundation for scientific theories, which express
connections between data using formal logical methods. This epistemological
approach leaves no role for researchers to interpret their data.
• Practical implications for researchers: we can see that it is assumed that
researchers will carry out their research in a vacuum, where there will not be
any outside influences, and the researcher’s prior knowledge and experience will
not have an influence on the collecting and interpreting of data. Researchers look
to prove or disprove a theory or hypothesis, data is deductive in nature and is very
much in the realm of quantitative research (such as clinical trials, surveys, ques-
tionnaires). Findings often add to existing knowledge in the field being studied.
Findings can be generalisable and research quality i.e., rigour, validity, and reli-
ability are easily presented and shown. If we take the recent global pandemic
of COVID-19 as an example, positivist research would be useful in helping to
understand what was done both clinically and within health professions education
(Chow et al. 2021).

13.3.4 Post-positivism

Post-positivism can be traced to the work of Karl Popper ([1959] 1992), who
disagreed with the positivists’ view that increasing amounts of empirical support
made it more likely that a theory is true (i.e., that data ‘confirms’ a theory). Instead,
Popper emphasized that, logically, it is impossible to prove a theory, but it is possible
to disprove one by providing evidence that contradicts it. Kuhn, mentioned earlier,
is also a foundational figure for post-positivist views. Building on Kuhn’s idea of a
paradigm, or worldview, post-positivists emphasize the distinction between reality
and what we can know of it.
• The core ontological claim of post-positivism is critical realism. Critical realism
distinguishes between the real world and the observable world, maintaining that
the real world cannot be observed. What researchers investigate is a product of
our experiences and perceptions of our observations. Researchers do not exist in
a vacuum and are influenced by what is happening around them (Crossan 2003).
• In regard to epistemology, post-positivism adopts an objectivist approach, but,
unlike positivism, where there is only right or wrong, post-positivists believe that
data can be subject to a critical review. Indeed, it is assumed that research can
never be totally objective, no matter how rigorously the research is carried out.
• Practical implications for researchers: whilst this method is still very much orien-
tated toward the more traditionally scientific way of thinking using hypotheses
and theories, it recognises that data are collected in the social world and, therefore,
cannot be controlled as easily as in a laboratory setting, for example, as scientific
experiments can be. Data are therefore subject to some ‘controlled’ influences.
194 A. Kehoe et al.

Data can be collected through both quantitative (e.g., surveys, questionnaires) and
qualitative (e.g., interviews, focus groups) collection methods and triangulation
of data is usually used i.e., more than one type of data are used to help support
a hypothesis. Quality assurance is still achieved through internal and external
validity, reliability, and objectivity.

13.3.5 Constructivism

There are various types of Constructivism depending on your view. Whilst the distinc-
tion between constructivism and constructionism will be explained in Chapter 14, it
is worth briefly paying heed to it here to avoid confusion between these two popular
terms in the context of this chapter. The main distinction between constructivism and
constructionism is explained by Schwandt (1994). Constructivism is understood by
the individual mind, whereas in constructionism meaning is understood through a
societal or cultural context. The main types of constructivism and constructionism
are described by Gergen (2015) as:
• Radical constructivism, which comes from rationalist philosophy and concen-
trates on what an individual takes to be reality. In other words, this type of construc-
tivism highlights the way in which one constructs reality through a systematic
relationship to the external world around them.
• Social constructivism, which highlights that, while each individuals’ mind
constructs reality in its relationship to the world, this process is heavily influenced
by social relationships.
• Social constructionism, which looks at the way self and the world are understood
and influenced by power and social structures such as; the government, schools
etc. (Gergen 2015).
Broadly speaking, and for the purpose of this chapter, constructivism is taken as
the position that knowledge is not discovered but is socially constructed. Everything
has a socially constructed meaning and is dependent on culture and societal values
and experiences i.e., the way we see something even if it has a reality, it may have
a different meaning or be perceived differently depending on how it is viewed by
an individual. For example, death is a socially constructed concept. Whilst it is
reality, it is perceived, understood, and explained differently by different individuals
and societies. Constructivism recognises that there is no right or wrong answer to
something, it is interpretation that gives us our answer.
• The ontological claim of constructivism is either relativism i.e., there are different
realities, which often are at odds with each other, or pluralism, in which different
realities co-exist but are not seen as conflicting. Again, there are several types
of relativism, but, for the purpose of this chapter, we adopt the above definition
of relativism. It is believed that realities are socially constructed depending on
individuals’ experiences, values, and beliefs. Therefore, reality is subjective and
13 The Philosophy of Science: An Overview 195

can change and be fluid, rather than be absolute or fixed. This is a very different
theoretical perspective than positivism and post-positivism.
• In regard to the epistemology of constructivism, proponents of this stance maintain
that there is no objective approach—researchers and the phenomena being studied
cannot be separated. The researcher’s job is to analyse the different interpretations
of what is being said to achieve an understanding of what is happening.
• Practical implications for researchers: it is important for researchers to reflect on
and understand their own experiences, culture, and values and consider how this
impacts their research. Data are inductive and generally collected through qualita-
tive data methods (e.g., semi-structured interviews, focus groups) and is concerned
with explaining ‘why’ something happens rather than ‘what’ is happening. Data
are usually not generalisable as there are often small sample sizes or data are
collected in one specific setting. Though data may not be generalisable, they may
be transferable, however, to other contexts. Quality assurances are through trust-
worthiness, transferability, dependability, and conformability (Lincoln and Guba
1985).

13.3.6 Critical Theory

It is worth noting here that there is no one critical theory, but a collection of theo-
ries. Critical theory originated from the Frankfurt school (which concentrated on
social oppression) but has been expanded and developed since (Chow et al. 2021)
to encompass feminist (reflection that science and research is male dominated) and
Marxist (conflict class struggles and a conflict between capital and labour markets
and how these influence economics and society) perspectives. It is concerned with
questioning the world of objective appearances to expose the ways in which social
oppression took place, for example research looking at racial inequalities in the way
black and white patients are treated (Chow et al. 2021). Central to critical theory is
the belief that the aim of theorizing is to effect social change by addressing social
oppression.
• In regard to the ontology of critical theory, though reality is often seen as objective,
that reality is also conceptualised as subject to continual change. Such change
may encompass changes through history which are influenced by culture, society,
politics, economics, and gender. More recently, global pandemics such as the
COVID-19 pandemic are additional forces of ontological change within critical
theory approaches.
• The epistemology of critical theory is subjectivist and transactional. This approach
assumes the researcher is unable to distance themselves from their prior experi-
ence, values, and knowledge i.e. that the researcher and the object that is under
investigation are intrinsically linked in some way, which facilitates a continuously
changing dynamic.
• Practical implications for researchers: similar to the constructivist stance, it is
important that researchers reflect on their own experiences, values, and culture
196 A. Kehoe et al.

to enable them to better understand and challenge findings with participants.

Research within this paradigm tends to be iterative, using more participatory
methodologies such as case studies, focus groups and observations (Bunniss and
Kelly 2010). Both qualitative and quantitative methods are used to collect data.
Similarly to the constructivist approach, quality assurances are through trust-
worthiness, transferability, dependability and conformability (Lincoln and Guba
1985). If we again take the global pandemic of COVID-19 as an example, critical
theorists could study this pandemic through the lens of social inequality, racial
inequality or political power (Chow et al. 2021).

13.4 Where Are We Now and Where Do We Need to Be?

We must ensure our research has strong theoretical frameworks and that a clear
purpose is highlighted (Bunniss and Kelly 2010; Zaidi and Larsen 2018). Without
such clarity and rigour, the negative perception towards health professions educa-
tion may continue. Some have argued that health professions education research is
(and should be) constructed as a social science (Monrouxe and Rees 2009) and we,
therefore, must engage critically with the questions of research philosophy that are
central to that tradition (Lingard 2007). Due to the complexity of health professions
education, often defined by contextual factors, many writers have challenged the
dominant positivist paradigm within the field, and the field’s focus on experimental
methods (Kuper et al. 2007; Dornan et al. 2008). In this way, there is tension between
defining legitimacy within the previously considered research perspectives and health
professions research in operation (Bunniss and Kelly 2010).
Qualitative research still raises concerns for some, despite its ability to resolve
“real-world” problems (Sandelowski 2004). One key reason that qualitative research
can be perceived as not useful is that the results of multiple qualitative studies are
not generally integrated, synthesized, or otherwise put together, analogous to the
use of meta-analysis in quantitative research. Qualitative research findings contain
information about the subtleties and complexities of human responses to issues we
are concerned with. However, for qualitative research findings to matter, they must
be presented in a form that is assimilable into the “personal modes of knowing...
valuing” (Noblit 1984, 95) and/or doing of potential users, including researchers
and practitioners. After all, bridging the gap between research and practice (both
clinical and educational) is key, with the aim to ultimately benefit patients (Kajamma
et al. 2019). Kajamma et al. (2019) illustrate this well through their presentation of
action research and The Change Laboratory methods; two approaches that involve
qualitative research that led to a change in practice; mixing social action and scientific
inquiry. These approaches help to answer tricky ‘why’ and ‘how’ questions, which
may further help to unlock deep insights to enhance learning and patient care.
Empirical research in the field continues to focus on methodology that describes
the techniques used for data collection and analysis. Describing the tools we use in
a piece of research in this way is not the essence of the qualitative approach—we
13 The Philosophy of Science: An Overview 197

join with Lingard (2007) in suggesting that more of a focus on the ‘orientation’ of
qualitative research is necessary:
Asking questions such as ‘What kind of knowledge are the researchers setting out to make?
What are their views on knowledge, their epistemology? Are they conducting the study from
an ethnographic, a critical theory, or a case study approach? These dimensions matter much
more than the methodological tools because they shape the way the research question is
asked. (S129)

The philosophical stance within which a study is situated will guide how you conduct
the research and, even more importantly, how you interpret your outcomes and results
(Bordage 2009).
Ultimately, the message here is that, whilst the research we are doing within health
professions education is important and a tight-knit community has been built, it is
now time to focus even more on extending this research to a wider scope. In doing so,
findings within our field will have more influence across other fields of research. To
do this, it is essential that we are able to articulate our research assumptions in order
to allow others to critically consider the nature of our knowledge claims within our
discipline (Bunniss and Kelly 2010; Johnston et al. 2018). Academic research stems
from a philosophical tradition of systematic knowledge development; any knowledge
claim is only defensible within a wider set of assumptions about the nature of reality
(Denzin and Lincoln 2000).

13.5 Complexity of Choosing and Explaining Our

Philosophical Perspective: An Example

Whilst we have illustrated differing paradigms or philosophical stances within this

chapter, it is important to note that not all research approaches fit ‘neatly’ within
one paradigm or another. And that can be hard for us to fully grasp. We often like
to be guided by approaches that fit neatly within a box. There are some perspec-
tives that may fall between the ones detailed previously. In order to highlight the
complexity of the issue, we will work through a realist example within this section.
We have purposely chosen realism due to the fact it falls perfectly between differing
paradigms.
Firstly then, let’s start with a bit of background to the realist approach. Realism is
a post-positivist school of philosophy, sitting between positivism and constructivism.
In this case, it is not a simple matter of choosing one paradigm or philosophical stance
over the other. Realism assumes that social systems and structures are ‘real’ and that
individuals respond differently to different interventions in different circumstances
(Kehoe 2017). This is the place in which the example below sits, crossing over the
two paradigms and, therefore, utilising the power and strengths of both.
The key feature of realism is its stress on the ‘mechanics of explanation’ that can
lead to a ‘progressive body of scientific knowledge’ (Pawson and Tilly 1997, 55).
This offers explanatory power when dealing with complex interventions. Wong et al.
198 A. Kehoe et al.

(2012) note that complex interventions do not act in a linear fashion, are reliant on the
people carrying out the intervention, and are highly dependent on the context in which
they take place. Realists would direct us to think in productive ways about complex
problems and create positive developments in the world around us (Kehoe 2017).
Yet, how do we get to our conclusions about this? Figure 13.1 illustrates an example
of how researchers decide, illustrate, and conduct research through considerations of
their philosophical stance. To concord with our realist example, Fig. 13.1 concerns
a realist body of research.

Fig. 13.1 Example realist research study conducted by Kehoe (2017), including theory by Kirwin
and Birchall (2006)
13 The Philosophy of Science: An Overview 199

Within the example from Fig. 13.1, theory-driven synthesis and evaluation ensured
that the overall research aims, and objectives, were met; explaining the contingencies
as to how interventions support overseas qualified doctors in making a successful
transition to the UK workplace and highlighting barriers to a successful transition.
The evaluation sought to explain change brought about by particular interventions
by referring to those individuals who act and change (or not) in a situation under
specific conditions and under the influence of external events (including the inter-
vention itself) (Kehoe 2017). Exploration of the social reality that influences how
the intervention is implemented and how actors respond to it (or not) was sought.
The theory (or grand theory) chosen in the example above (Kirwin and Birchall’s
work [2006]) was selected to guide the research because it encompassed many
elements of overseas medical graduates’ learning and transitioning in a single model.
Interventions developed for this group of health professionals are often complex,
therefore utilizing this model enabled a better understanding of how interventions
could help adjustment for overseas graduates to working within the National Health
Service (NHS). The levels in the model helped to both understand and analyse the
influence of environmental, training and individual characteristics. Ultimately, the
applied nature of the model aided in understanding the contextual factors that are
at work when transferring learning into practice, as well as highlighting potential
mechanisms which were essential for the realist approach.
A synthesis of the mixed methods findings, including literature review, obser-
vations, performance data and 123 interviews, illustrated that three key contextual
levels; organisational, training and individual, will likely impact on the adjustment
of overseas doctors (including performance, retention, career progression and well-
being) (Kehoe 2017). One of the main outcomes was a transferable, theoretical
explanation of how interventions can successfully support the transition of overseas
medical graduates to the NHS.
Ultimately, the way in which this piece of research was developed allowed the
generation of valid explanations as to why and how the observed results of the inter-
ventions being evaluated were achieved (feeding into theory refinement), explaining
the ‘black box’ that is often not addressed in outcome-focused approaches (Wong
et al. 2012). The philosophical stance of the author was important in ensuring
they achieved this understanding about how interventions could be developed and
improved for future implementation.
Whilst the realist approach chosen for this study was entirely the perfect fit in the
author’s eyes as it enabled rich and detailed exploration of the ‘hows’ and ‘whys’
and allowed creativity in the development of the programme theory, it was, at times,
difficult to navigate. There was no ‘clear path’ to follow as it was dependent on
researcher perspective and ability to build a story from the data. What the author
constructed may have been different to what another researcher may have developed
(with possibly a different philosophical perspective), and that knowledge can sit
uneasily, at times. Though the developed programme theory was driven by study
data, this may have differed with an alternative researchers’ differing interpretation.
Based on the experience and reflections of those involved in the above project,
we have developed five take-home messages specifically regarding the use of an
200 A. Kehoe et al.

Table 13.1 Realist research take home messages

Combining the strengths of both qualitative and quantitative methodologies, and of philosophical
stances, can help researchers to identify and triangulate rich evidence that will produce a
coherent and plausible explanation of the contents of the ‘black box’ (Wong et al. 2012)
Exploring more than outcomes and contexts, but causation, is crucial for optimising
development, implementation, and effectiveness, particularly if exploring educational training or
interventions
Much of the success of this perspective (as well as others) is that it relies on achieving
immersion (Wong et al. 2012) i.e., spending enough time in the study to really know what is
going on. In this way, researchers should permit enough time in their project timelines to
immerse themselves fully amongst their data
As interpretation matters in this approach, researchers should think reflexively. To do so, they
should develop theories iteratively as collected data is analysed, look for alternative explanations
during their analysis, and be able to defend their interpretations (Wong et al. 2012)
Dependability as a marker of quality can be assured here through transparency and reliability. To
do so, researchers must ensure full documentation of their approach, and that the research
pathway they have followed is sufficiently illustrated in any written summaries of their research.
The realist approach also holds much credibility and conformability through respondent
validation and ongoing discussions to check the theory (stakeholders, interviews, etc.) (Walsh
2013)—this may be something researchers wish to consider

approach that ‘falls between the lines’ of the four common philosophical stances
we have described in this chapter. We have developed these reflections as there
exists less guidance on philosophical considerations within this approach than within
more widely used and long-standing traditions (e.g., positivism, constructivism). Our
realist research take home messages can be viewed in Table 13.1.

13.6 Conclusion

All researchers must be able to think about and engage in the areas that we have
discussed throughout this chapter, focusing on ontological and particularly epis-
temological discussions about the nature of the knowledge that health professions
education research seeks to create (Bunniss and Kelly 2010). Developing an increased
awareness of the paradigms in use within the field is important because we need to
demonstrate that significant decisions regarding the provision of medical education
and health care are based on a critical understanding of the nature of knowledge
itself. Articulating these underlying assumptions is central to the research task if we
are to be able to critically engage with the findings. Research methodology is not
simply about data collection strategies (methods), but, more importantly, it is about
the philosophical beliefs that determine the nature of the research design.
The quality of research is defined by the integrity and transparency of the research
philosophy and methods, rather than the superiority of any one paradigm. Despite the
chosen philosophical stance, there will still be useful and practical implications for the
13 The Philosophy of Science: An Overview 201

Table 13.2 Practice points

1 All researchers should consider the ontological and epistemological assumptions or
positions they adopt when undertaking health professions education research
2 When writing up research for publication or dissemination in some way, researchers should
detail their philosophical assumptions regarding their research. This will allow other
researchers, and those within other academic fields, to consider the applicability and
relevance of their findings to their own contexts
3 Researchers and educators must be careful not to confuse methods and methodology and
appreciate that central to the question of methodological selection are questions concerning
philosophical orientation
4 Researchers and educators should be careful not to engage in paradigmatic snobbery or
rivalry. The quality of research is defined by the integrity and transparency of the research
philosophy and methods, rather than the superiority of any one paradigm
5 As a community, we must challenge negativity towards the field from other disciplines by
banding together and following necessary the guidelines underpinned by the philosophy of
science outlined in this chapter to increase the perceived rigour of the field

findings of a study. Where there is negativity towards the chosen stance, this is often
a conflict of research assumptions. As a community, we can actively seek to improve
any negativity towards the field by ensuring we follow the necessary guidelines
underpinned by the philosophy of science in any research that we undertake (Table
13.2).

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Chapter 14
Tensions Between Individualism
and Holism: A Philosophy of Social
Science Perspective

Paul Crampton and Jamie Buckland

14.1 Introduction: Health Professions Education

as a Social Science

Health professions education (HPE) as a disciplinary field has emerged from a

plurality of influences. If we were feeling controversial, we could describe it as being
a bastard of a subject. It is neither one thing or the other, with shifting influences and
boundaries through time and space. In effect, it is an interdisciplinary field, where
the discipline’s roots come from a myriad of medical sciences, chemistry, biology,
psychology, social sciences, education, business, linguistics, health economics, and
many more. Nonetheless, from these tentative states has emerged a wealth of excep-
tional research insight that draws on the far corners of knowledge boundaries with
the purpose of bringing clarity to unanswered questions and focusing on the ‘why’
as well as ‘what’ (Cook et al. 2008).
Yet, for many scholars and educators, the roots of HPE remain deeply intertwined
with clinical medicine. The makeup of practitioners are chiefly those who have expe-
rienced ‘hard science’ education in a structured format, where knowledge testing has
been the bedrock of demonstrating competence. This format has largely followed
suit into the educational research undertaken, with the gold standard ‘randomized
controlled trial’ still being seen as the optimal way in which to conduct medical educa-
tion research (Cook and Beckman 2010). The favouring of controlling factors and
minimizing unpredictability largely remains in key metrics when judging research in
the field. Similarly, performance indicators have favoured quantitative reporting of

P. Crampton (B)
Health Professions Education Unit, Hull York Medical School, University of York, York, UK
e-mail: paul.crampton@hyms.ac.uk
J. Buckland
Department of Philosophy, University of York, York, UK
e-mail: jamie.buckland@york.ac.uk

© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2022 205
M. E. L. Brown et al. (eds.), Applied Philosophy for Health Professions Education,
https://doi.org/10.1007/978-981-19-1512-3_14
206 P. Crampton and J. Buckland

impact factors, number of citations, and amount of grant funding captured. Yet collec-
tive scholarship environments which protect research time have been recognised for
how they can foster more meaningful, rigorous research (Ajjwai et al. 2018).
As described in Chapter 13, only in recent years has HPE begun to see a greater
grasp of multiple ways to view and assume ontology, with far-reaching consequences
into methodological approaches (Monrouxe and Rees 2009). This chapter explores
HPE through a social science lens to consider the differences between individual and
team education and research in the field. The concept here of ‘social science’ broadly
refers to all systematic empirical investigation into the activities of human beings,
with a special interest in those things we do together, as part of larger social groups
(Risjord 2014). The acknowledgement of how humans interact, make meaning, and
forge new understandings is catered for within social science positionings. To take
such a stance opens up the possibility of potential multiple subjective ontologies
where truth is less the key attribute, but more a factor in which ways understand-
ings come to be. Professionalism, empathy, and identity development enquiry are
just some of the ways in which social science positionings can foster greater under-
standing of educational processes (Swick et al. 1999; Pedersen 2010). Picking up the
gauntlet, we now expand on conceptualising HPE as a social science by focusing on
the differences between individual and team approaches (Monrouxe and Rees 2009).

14.2 Workplace-Based Learning: Case Studies

A vivid form of HPE which aptly demonstrates the need for social science under-
standings is that of clinical placement experiences in healthcare settings, a form
of workplace-based learning. A large component of HPE courses occur in clinical
workplace settings, outside of more controlled university education environments.
This creates complexity in how learning occurs and is researched, how educator
guidance is structured, and how learning is ultimately assessed. The unpredictable
nature of how a workplace operates and its association to education is impacted by
numerous interrelated factors such as the individuals, teams, regulators, and systems
which may facilitate and/or hinder learning.
Workplace based learning as a social, theoretical, and methodological construct is
complex, as are the environments widely catalogued through a mixture of lenses span-
ning cognitivism, interpretivism, and anti-positivism (Dornan et al. 2007; Teunissen
2015). Although these approaches harbour inherent assumptions, there is the often-
neglected disciplinary stance in which philosophical understandings can glean further
insight regarding ontology, axiology, and methodology. These are explored in further
detail within Chapters 10 and 12 of this book.
For educators and researchers, cultural shifts in which philosophical positions
are brought to the forefront of awareness are needed to help develop other ways
to teach, assess, and conceptualise learning. In reference to scholarship, drawing
explicitly on philosophical debates in HPE is relatively under-developed, with recent
papers beginning to show exceptional promise for the ways in which they may shape
14 Tensions Between Individualism and Holism: A Philosophy … 207

refreshing understandings of longstanding approaches to inform practice for the

benefits of learners, educators, and, ultimately, patients (Veen et al. 2020; Laughey
et al. 2020).
To begin to distil the issues of how differing conceptualisations of individ-
uals and teams may have alternative implications for HPE, let us first look at the
constituent parts critical to learning through an example (Case Study 1). Throughout
the remainder of this chapter, we provide examples which refer back to this case.
Within clinical placements there are many transient groups, often changing on a day-
by-day basis with multiple roles, actions, and states. Considerations of team effec-
tiveness in this environment are largely neglected within HPE, with the fallout being
monumental for individuals in terms of lost resources, enabling negative behaviour
through lack of challenge, and triggering processes which further reinforce inequities
such as lack of fairness. For example, the incidence of bullying, burnout, and lower
psychological wellbeing are sadly well documented with many junior doctors leaving
the profession as their professional education has not prepared them suitably (Carter
et al. 2013).

Case Study 1: The Labour Ward: Student Learning Versus Healthcare

Delivery Team
The labour ward in a busy district hospital is a hotbed of activity on a daily
basis, with any number of healthcare professionals working together to provide
patient care. A dual purpose is to provide education for healthcare students at
any given time, including students from medicine, midwifery, and nursing. The
students may belong to different undergraduate schools, yet when they arrive on
the ward, there is a shared purpose. Various levels of learning spanning under-
graduate to postgraduate interns may also be part of the environment. At times,
there are new and inexperienced learners who then flourish or struggle before
leaving and being replaced by further cohorts. The staffing team, similarly, can
experience turnover in certain roles but, generally, is more stable in its makeup.
The environment may experience acute care, at times, in which teams must
work cooperatively. Herein presents great pressures as there is limited scope
for error and an increased risk of high workload, poor communication, and
hierarchical power between healthcare professions. The environment is moni-
tored by quality standards judging aspects of how care is delivered to maintain
patient safety, excellent education, and continuing professional development.
If situations arise where levels of care are compromised, the environment may
be unpicked for the ways in which it may facilitate such instances to occur.

Informed by the work of Palermo et al. (2014), Case Study 2 focuses on the assess-
ment of competence for health professionals, offering an example which considers
nutrition and dietetics trainees in the workplace. Regulators often mandate that
healthcare professionals must satisfy workplace-based assessments at a postgrad-
uate level to fulfil training aims. Typically, workplace-based assessments will look at
208 P. Crampton and J. Buckland

how a trainee is performing, any strengths and weaknesses in their work, and areas
for improvement. Similarly to Case Study 1, the implications of the ongoing activity
of the workplace and the ways in which individuals are conceptualised within educa-
tion may impact on the feasible development of learners and constructions of how to
educate and research relevant experiences. As with Case Study 1, we will draw on
Case Study 2 to demonstrate how our discussion and analysis of the individualism
versus holism debate is relevant to the field of health professions education.

Case Study 2: Workplace-Based Learning: Student Progress Versus

Patient Delivery
As a nutrition and dietetics trainee develops their experience, they are required
to complete workplace-based assessments. However, within training there are
challenges in how the workplace environment can effectively allow trainees
to learn, and how effectively educators can assess their work according to
required standards. There may be a lack of senior experienced educators which
leads to novice educators being responsible for workplace-based assessments,
presenting yet more noise in guiding learning. Factors relating to the workplace,
such as services provided and the typical workload of staff, as well as working
relationships with other healthcare professions may all impact in some way
on what is achievable. Further, workload demand can limit the time available
for effective assessments of trainees. The lack of case-mix presents limited
opportunities for an individual to be able to observe and interact with the
learning experiences needed in order to pass WPBA. There are also barriers
around the different expectations about what is expected of students, held
by colleagues from different healthcare professions, supervisors, peers, and
individuals themselves.

Throughout the remainder of this chapter, we provide examples which refer back to
the above cases. The cases provide a context for the individualism and holism debate
which draw on different features which interact within workplace-based learning
situations to highlight the overlaps and boundaries between how individuals are
considered separate, interlinked, or as one within a collective. Where relevant, prac-
tice points are also indicated throughout, though they are also captured in full at the
end of the chapter.

14.3 Individualism and Holism in the Philosophy of Social

Sciences

The dispute between individualism and holism in the philosophy of social sciences
can be divided into two distinct (but related) categories:
14 Tensions Between Individualism and Holism: A Philosophy … 209

• The Ontological Issue: What is the ontological status of social phenomena and,
as part of this, their relationship to individuals?
• The Methodological Issue: To what extent may, and should, social scientific
explanations focus on individuals and social phenomena respectively?
(Zahle and Collin 2014)
The ontological issue is perhaps best explicated from within the context of reduc-
tionism (Risjord 2014). Broadly speaking, the social sciences investigate two kinds
of social phenomena: individual agents (such as students within HPE) on the one
hand; and the social ‘objects’ (such as universities and hospitals) on the other. These
positions can be referred to as ontological individualism and ontological holism,
respectively.
For an ontological individualist, there is nothing over and above social phenomena
than distinct individuals with their beliefs, desires, values, professional competencies,
etc. For the ontological individualist, the ontological status of social phenomena can
be reduced to the individuals that make it up (Mill [1872] 1987). The learning of indi-
viduals throughout HPE could perhaps be replicated irrespective of the social institu-
tions in which their learning occurs. The individual has the ability to be able to limit
influences and mediate social interactions without influencing potential behavioural
and cognitive domains. Individuals traverse various social and organisational contexts
coming into social groups but notwithstanding that such phenomena be characterised
by its various entities.
Whereas, for an ontological holist, certain social phenomena (social objects) exist
over and above (or transcend) the collection of individuals that make it up. Durkheim,
for example, maintained that social phenomena and the acts of individual agents
within a social setting can only be explained by invoking the existence of certain
social facts (Durkheim [1895] 1938). More recently, however, it has been argued that
an ‘agency criterion’ is what best answers the question of what it takes for a social
phenomenon to exist (sui generis) over and above the individuals that compose
it. Such an agency criterion holds that social phenomena such as universities and
hospitals exist:
insofar as they qualify as group agents that have attitudes supervenient upon the attitudes of
individuals. (Zahle and Collin 2014, 3; List and Pettit 2011)

To this extent, then, the ontological issue is connected to a further explanatory issue
or, rather, the methodological issue. For ontological holists such as Durkheim, there
are social-level explanations of an agent’s actions within a social setting (method-
ological (or explanatory) holism). For ontological individualists such as Mill, expla-
nations in the social sciences make reference only to individual actions, and social
phenomena are explained as the outcome of individual choices and actions (method-
ological (or explanatory) individualism). We can illuminate the differences between
methodological individualists, and methodological holists, using an example. In Case
Study 1, we considered how workplace-based learning environments are monitored
by quality standards to maintain patient safety and high-quality education. It is this
we shall build on to illuminate the differences between methodological individualism
210 P. Crampton and J. Buckland

and holism. You work in a hospital that has recently been found by the body that
evaluates its quality (in the United Kingdom, for example, this is the Care Quality
Commission or CQC) to be failing to meet minimum standards. Methodological
holists might focus on how a recent economic depression which reduced the funding
your hospital received led to the hospital failing its inspection. Methodological indi-
vidualists, on the other hand, would be dissatisfied with such an explanation—at least,
such an explanation in and of itself. Their focus would be on the behaviours, beliefs,
attitudes, and actions of individuals that led to the hospital failing to pass inspection.
Though we have described these positions as existing in tension with one another
(and they often do), they need not be incompatible. In this example, methodolog-
ical individualists could add depth—micro-level foundations—to the holist’s macro-
level explanation of the cause of the failed hospital inspection by exploring how
individuals’ behaviours, beliefs, attitudes, and actions in response to the economic
depression and subsequent lack of funding culminated in a failing grade.
Whereas we have principally focused on the classification system that divides the
individualism versus holism debate into ontological and methodological positions,
there are other systems of classification. Though it is beyond the scope of this chapter
to detail these in full, we wish to draw your attention to Risjord’s (2014) tripartite clas-
sificatory system, that divides the debate not only into ontological and methodolog-
ical concerns, but also considers the differences between individualists and holists in
reference to theory. We believe this addition to the ontological and methodological
positions we have already outlined has particular relevance to our field. Individualists
in Risjord’s system hold that social science theories can be derived from psycholog-
ical theories, while holists hold that social scientific theories are logically indepen-
dent of lower-level theories. For an interdisciplinary field such as health professions
education, this system offers an interesting lens through which researchers could view
psychological and sociological theory, that the field has historically heavily drawn
upon. Risjord’s additional theoretical domain of the individualism versus holism
debate is no more apparent than within scholarship concerning professional identity
development in the field (for a more thorough discussion of professional identity, see
Chapters 3 and 17). Professional identity can be conceptualised from a multitude of
theoretical positions within health professions education research (Sawatsky et al.
2020; Brown et al. 2021)—some scholars utilise psychological theories (which focus
primarily on the role of the individual in identity development), and others utilise
sociological theories (which focus primarily on the role of interactions and the social
world). In addition, there are those that suggest both explanations are necessary—
psychological and sociological ones—to adequately conceptualise identity formation
in the health professions (Jarvis-Selinger et al. 2012), implying an individualist theo-
retical position where social science theories must be underpinned by psychological
understandings—in this case, of identity. Perhaps unsurprisingly, there are those
that disagree and utilise solely social science theories to offer full understanding of
identity development in different contexts (theoretical holists) (Monrouxe and Rees
2015).
Now that we have considered the various domains in which individualists and
holists may have views that differ (ontological domain, methodological domain,
14 Tensions Between Individualism and Holism: A Philosophy … 211

and Risjord’s [2014] theoretical domain), it is important to examine what impact this
diversity of views and positions might have on health professions education. Building
on these understandings, we suggest that there is an invitation for health professions
education programme directors to openly address the ways in which education is
currently situated within current approaches to reveal the ways in which education
environments are being constructed (Practice Point 1).
To return to Case Study 1 and the quality standards we have previously discussed,
standards and reports issued by those that monitor healthcare organisations (again,
the Care Quality Commission or CQC in the UK) could be viewed to explain insti-
tutions and placement providers in which HPE may be more effective and optimal.
Here, programme directors could examine these documents for both methodolog-
ical individualist and methodological holist explanations for why an environment
either leads to a positive or negative experience for their trainees. Further, specific
education standards within healthcare providers monitored by regulators (e.g., the
General Medical Council, also in the UK) might provide further explanatory power
as to learning experiences afforded within social settings. The cultural approaches
in maintaining and meeting various standards comes with the wider application of
instilling excellent education frameworks through supervision, training, and assess-
ment. The interplay of how various parts of social norms interact within the health-
care system provide both the opportunity for individuals to develop learning, but
also for how learning can be transformed through its occurrence in social level
situations.
Strict methodological (or explanatory) holists could argue that strong methodolog-
ical individualism demands the impossible. We have considered the two approaches
as complementary, as adding depth to one another, in our example of a failing hospital
in a previous section of this chapter. However, strong methodological individualist
positions do exist, which we suggest may be less suitable for exploring workplace-
based learning environments. Methodological individualists believe that the causal
powers of social-level entities are carried by the agents of those entities, just as the
causal power of a clock to chime “cuckoo” is carried by its particular mechanism. A
social-level predicate like “orderliness” will be instantiated in each neighbourhood
by a different set of activities. For example, regarding implications of Case Study 1,
within one nursing school, student punctuality may be the problem, but, in another,
it might be the poor teaching experience. Some nursing schools may have strategic
requirements for educator quality, others may rely on the passion of those who teach.
Multiple realisability means that each individual-level explanation would have to be
different. Individualists contend that interventions (to increase, say “orderliness”)
must target individuals, since only they have causal powers. Explanatory or method-
ological holism, meanwhile, would respond to this argument—for holists, without
the generalising power of terms like “orderliness”, we would not know which set
of individual actions to intervene upon. Therefore, our capacity to implement social
policy depends on a holistic approach. As such, for educators we suggest a need to
consciously moderate the impact of quality standards and service delivery, whilst
having expectations of learners appropriate to the context (Practice Point 2).
212 P. Crampton and J. Buckland

Table 14.1 An overview of the ontological, methodological, and theoretical positions adopted by
individualists and holists
Position in the individualism versus holism Description
debate
Ontological individualism Facts about individuals determine social
facts—in other words, reality is, and therefore
social objects are, made up of individuals. Focus
of study would usually be individual agents: e.g.,
students in health professions education
Ontological holism This position claims that social objects or
entities are independent and autonomous—i.e.,
they are not simply derived from the individuals
that partake in them. Focus of study is usually
social objects in their entirety e.g., a higher
education institution
Methodological or explanatory individualism Social phenomena must be explained by
showing how they result from individual actions
Methodological or explanatory holism This position maintains explanations that invoke
social phenomena (e.g., social structures,
cultures, institutions) should be the focus of
study within the social sciences. It is these social
phenomena that offer explanations for the things
that happen in the world
Theoretical individualism Social science theories can be derived from
psychological theories
Theoretical holism Social science theories are logically independent
of psychological or individualistic theories

In Table 14.1, we offer an overview of the various ontological, methodological,

and theoretical positions outlined in this section to represent the individualism versus
holism debate as applied to contemporary issues in health professions education.

14.4 Differences Between Conceptualising Students Within

HPE as Individuals and Students as Part
of Interprofessional Teams

The philosophy of social sciences has various schools of thought in which theoretical
foundations may privilege particular approaches to understanding and conceptual-
ising individuals’ and social dynamic experiences of learning. Within this section,
we discuss constructivism and constructionism as two distinct approaches to provide
illustrative examples. The awareness of philosophical issues (such as metaphys-
ical/ontological; axiological; epistemological) and the ability to critically evaluate
the philosophical commitments of a theory or methodology can significantly sharpen
14 Tensions Between Individualism and Holism: A Philosophy … 213

social scientific inquiry. The debates around how to recognise and develop compe-
tence may be factored within such foundations as they may privilege the individual
over the group in how education is curated, designed, and delivered.
The relevance of interprofessional teamwork within HPE is increasingly tested,
as teams and individuals transition into new roles and spend too little time to bond
or form meaningful connections. Transitions occur in roles within teams, depart-
ments, and even within organisations. The risk to patient care has, unfortunately,
been demonstrated where ineffective teams have been implicated in lapses in patient
safety standards (Francis 2013). Yet, the actions and responsibility of such teams
may not be seen as distinct, as hierarchy and order play a pivotal role in how the
team functions. Can a student be effective and still learn in an underperforming team?
Hierarchy and order are key features in which teams may be held to account, but
individuals will have little impact, especially students and those at the fringes of
collective activity.
As illustrated in Case Study 2, currently, educational institutions are focusing on
how individuals may learn and progress irrespective of the teams in which they are
placed throughout their learning journeys. Within healthcare systems, there is little
accountability for how education may differ, which is, perhaps, restricted by regula-
tory processes such as meeting set curriculum standards or core competencies. The
individual, therefore, must navigate their own unique barriers and enablers to ensure
they meet required parameters. Educational settings and environments are there to
facilitate such processes, yet they can often inhibit or, even, ruin such pursuits. Here
the case for recognising wider group contexts is apparent, as the social environment
may play a pivotal role in education. Similarly, the unique nature of individuals is to
be embraced through inclusive curricula accounting for differences in learners.
As introduced in Chapter 10, social constructionist approaches are characterised
by attention to the ways in which contexts and social interactions interact with individ-
uals through language, actions, and behaviours to elicit different constructions of the
world (Rees et al. 2020). This approach is distinct from social constructivism which
is more akin to cognitive and individualistic approaches, where knowledge is how a
learner may interpret a situation (for a different interpretation of constructionism that
frames the approach as, still, ultimately an individualistic approach, see Chapter 3).
The way in which knowledge is created in social meaning-making instances is
influenced by co-constructions with others with whom one interacts within a social
context. There are contrasts with pre-set and guided learning outcomes which leads
to difficulties in how assessments may then occur. The individuals become less influ-
ential in how learning occurs, as, through engagement in co-construction, debate, and
the formation of collective understandings, new forms of knowledge are elevated.
Through the example in Case Study 1, multiple implications can be inferred—for
instance, that interprofessional teams are not currently seen, or assessed, as one whole
(Practice point 3). Multi-disciplinary teams are made up of multi-professions which
combine to make decisions and carry out patient care at the interface of education
and service provision. Yet, the HPE field often continues a lack of genuine inter-
professional education across the world, as governing procedures have squeezed
the availability of learning spaces in which cross-fertilisation can flourish. Each
214 P. Crampton and J. Buckland

profession often has their own specific set of learning outcomes, which makes
collective approaches fruitless in how they effectively assess students at a given
time, thereby omitting social level meaning-making. Mainstream institutional and
regulatory changes would be needed to enable a radical approach in which team
apprenticeship type models are the norm, that break down disciplinary hierarchies.
To consider how scholars, educators, and researchers can address such imbal-
ances, in the following section we look more closely at the philosophical debates
surrounding individualism and holism as applied to the case studies outlined earlier
in our chapter. Constructionism is more akin to holism approaches, whereby the
social level environment is privileged in how learning occurs, whereas constructivism
relates more closely to individualism principles in how knowledge is developed,
assessed, and conceptualised.

14.5 Social Phenomena, Intentions, and Collective Action

The ontology of the social world focuses on the ontological status of social
phenomena such as universities and healthcare settings. However in Case Study
1 and Case Study 2, from within the context of HPE, the relevant categories of social
phenomena are much broader and complex, including the type of care provided by
specific departments (e.g., physiotherapy, community practice, labour), multidisci-
plinary and interprofessional teams (e.g., nursing, dietetics, midwifery), governance
and adherence to standards (e.g., healthcare regulators), and the interaction of where
service provision meets education (e.g., clinical and educational supervisors, trainees,
junior doctors, undergraduate students).
The agency criterion holds that the social phenomena at the heart of HPE exist
insofar as they qualify as group agents that have attitudes supervenient upon the
attitudes of individuals. Certainly, everyday talk tends to represent collections of
individual agents as a kind of unity capable of performing in the same manner as
individuals do, but is this talk merely metaphorical (as the ontological individualist
maintains)? Or should it be understood literally (as the ontological holist main-
tains)? When a clinical interprofessional healthcare team saves the life of a patient,
or performs a complex surgical procedure, it seems clear that the team has done
something that no individual can do alone, but is it sensible to maintain (say) the
surgical ward exists insofar as it qualifies as a group agent with an attitude superve-
nient upon the attitudes of the individual agents that compose it? In Case Study 2, the
difficulties in assessing individuals’ competence within workplace-based assessment
challenges whether and how educators should hold individuals accountable for their
progress, or whether the team as a whole should be the unit of measurement (Practice
Point 4).
It is not our purpose to address these complex questions, but, rather, to draw atten-
tion to the fact that once focus shifts from the ontological status of social entities—
such as clinical teams—to social actions—such as team performance—this allows
space for exploring how collective, joint, or group action can be understood, and the
14 Tensions Between Individualism and Holism: A Philosophy … 215

ramifications this might have concerning the ways in which individuals and/or teams
are trained, assessed, developed, and researched within HPE. The effectiveness of
the team within the health service is very rarely accounted for within an individual
students’ learning journey, i.e., there is no difference made in where and how students
train; it is just luck of the draw in whether the department is functioning at a high
level and can support learning in addition to service delivery.
In Case Study 1, the level of activity challenges the effectiveness of the team
providing education, in part, due to the amount of patient care provided. How, then,
how have philosophers thought about collective, joint, or group action? And what
impact might this have on how HPE is conceptualised and researched?
The ontological holist treats groups or teams as a special kind of agent. Given this
idea, when we speak of a surgical team performing a successful operation, we are
literally referring to a unique entity (or collective agent) constituted by the successful
performance of the operation.
A thoroughgoing ontological individualist, on the other hand, rejects the idea
that groups or teams are a special kind of agent along with the very idea of group
agency. Agency is something only individuals possess (for a more thorough handling
of agency, see Chapter 7; for discussions of non-human agency, see Chapters 12 and
16). When a particular member of a clinical team maintains that ‘We intend to save the
patient’s life’, it simply means that that particular member intends to save the patient’s
life (Bratman 1997). This impacts group assessment to the extent that individuals can
maintain competency—after all, it is odd to maintain that one could have an intention
to do something that is beyond their control. Moreover, when a clinical team fails to
meet the governance standards of care required it, perhaps, does not make sense to
maintain that the team has failed in some sense. The level of accountability within
a healthcare team could be seen as the makeup of the performing individuals, be it
their profession, competence, or skill.
Nevertheless, there are difficulties for the throughgoing individualist to the extent
that the joint or collective action of the healthcare team performing an interpro-
fessional teamwork action is something that literally cannot be done by any single
member of the team. For this reason, philosophers such as John Searle (1995) and
Raimo Tuomela (2002) maintain that the individual team members engaged in collec-
tive action form a special kind of ‘we-intention’. So, when the healthcare team intends
to save the life of the patient, each member of the team has we-mode intention to
the extent that each member intends that each member will carry out their role to the
best of their ability, i.e., joint action is the coordinated action of individuals. Granted,
each member of the team has their own individual intentions related to their specific
roles, e.g., the anaesthetist might maintain that the surgical team intends to save the
life of a patient by means her anesthetising the patient, but this doesn’t undermine
we-intention (Practice point 5).
A further related point is to note the connection between we-mode intentions and
the subject of team reasoning. HPE students approach patient care as members of
a team, i.e., issues surrounding patient care are taken to be issues for the team, as
opposed to issues for the individual members of the team, per se. Consequently, we-
mode intentions have a different content to that of I-mode intentions associated with
216 P. Crampton and J. Buckland

individual intentions. In the case of an I-mode intention, an individual will justify

their action based on responsiveness to reasons that reflect their idiosyncratic aims.
By contrast, when an individual forms a we-mode intention, they intend to act as
a member of the team, and are responsive to reasons grounded in the aims of the
group. The group have collectively accepted the goal of saving the life of the patient,
and that is a shared reason for each of the group members to act. Each member of
the clinical team shares the same reason for action, and when individual members
act for that reason, they are acting as a member of the group.

14.6 Conclusion

Taking a philosophy of social science perspective enables educators and researchers

to develop insight into the ways in which HPE may privilege specific aspects of
learning to the detriment of others. The individual versus holism debate contests
departing features within such approaches and may help educators to see the rele-
vance of conceptualising learners and interprofessional teams in different ways.
Within the chapter we focus on workplace based clinical placement experiences
to illustrate such tensions regarding learning and assessment in HPE. The ways in
which students and teams are educated, assessed, and conceptualised brings about
challenges for educators and researchers in how best to facilitate learning within
HPE. The individual and holism debate faces a tension in the clinical workplace with
regard to the agency criterion and collective agents in clinical placement experiences.
Applying this debate to HPE we should ask how and whether individuals should be
considered as a collective within education, or whether the focus of education should
remain as it currently resides, with a principal focus on the education, development,
and assessment of each individual. The implications for how these constituent parts
are considered has several practical implications such as how and whether individ-
uals should be taught and assessed as distinct from the framework in which they
will engage in care, the level of competence reasonably expected by individuals and
teams, and the separation of joint collective actions between clinical case workload
mixes.
As previously noted, it is not our intention in this chapter to decree either way the
approach you must take to research and education within your own context. Rather,
we hope that the debate we have presented causes you to pause and think about the
relevance of these positions to practice in the field. We often assume individualist or
holist positions in research or education without an awareness of the assumptions we
are making and what this may mean for both our practice, and those who are affected
by it—namely, educators, students, and patients. We hope you will use this chapter
to reflect on your own assumptions regarding the relationships between individuals
and collectives, how this influences your practice or the frameworks of education in
which you are invested, and how you can make clear these assumptions and their
possible impacts in your research and teaching from hereon in.
14 Tensions Between Individualism and Holism: A Philosophy … 217

Table 14.2 Practice points

1 For programme directors, to consider individualism and holism approaches and their related
inferences to current HPE designs, education, and assessment
2 For workplace educators, to consider what impacts their environment may have on the
learning that can be achieved, to modify standards according to expectations
3 For educators and researchers, to reveal the relationships between interprofessional and
interpersonal teams as both an individual and social phenomenon that can account for the
multitude of pressures faced
4 For students, to work dynamically with social level factors to raise awareness of how they can
mitigate their sense of self and self-regulated learning processes
5 For all, to critically analyse agency criterion and its ramifications for student learning through
jointly teaching and assessing teams and individuals (and their actions) at appropriate points
in education and service provision

The main insights of this chapter for research and practice within HPE are
summarised in Table 14.2. For the ease of the reader of this chapter, we have divided
these practice points into recommendations for various stakeholders in HPE research
and education.

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Chapter 15
Ethics Education in the Health
Professions

Bryan C. Pilkington

15.1 Introduction

Health Professions education can benefit from the embodiment of a diversity of

perspectives. This is because critical engagement with one’s own orientation toward
health practices better situates one to understanding the perspectives of others—espe-
cially patients and clients—that one serves, as well as placing a practitioner in a better
situation to reflect on, revise, and improve their own practice. Ethics education in the
health professions is no different; however, it can raise additional complexities on
two fronts. First, because the philosophical theories that often underlie ethical princi-
ples germane to the health professions are complicated, there may be a temptation to
avoid their engagement in educating health professionals and restrict ethics content
to professional norms and codes or to engage theories at a superficial level. Second,
because health professions students often find themselves less versed in philosophy
than other areas, their interests are seen to align with (and they are understood to
benefit from) the aforementioned superficial theoretical engagement.
This chapter attempts to respond to these two complexities by highlighting key
but intuitive ideas within three philosophical ethical approaches that undergird or
influence health professions practices—deontological, consequentialist, and virtue-
focused theories. This chapter does not offer a deep dive into any of these theories;
rather it frames each within a basic discussion of the structure of human action.
First, a deontological, rule-focused approach is discussed and connections to a

B. C. Pilkington (B)
School of Health and Medical Sciences, Seton Hall University, Nutley, NJ, USA
e-mail: bryan.pilkington@shu.edu
College of Nursing, Seton Hall University, Nutley, NJ, USA
Department of Philosophy, Seton Hall University, Nutley, NJ, USA
Department of Medical Sciences, Hackensack Meridian School of Medicine, Nutley, NJ, USA

© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2022 219
M. E. L. Brown et al. (eds.), Applied Philosophy for Health Professions Education,
https://doi.org/10.1007/978-981-19-1512-3_15
220 B. C. Pilkington

common principle within healthcare—autonomy—is illustrated. Second, a conse-

quentialist (or outcome-based) approach is discussed and connections to a common
(and increasingly weighty) health field, public health ethics, is illustrated. Finally, a
virtue-focused approach is discussed and connections to a health professions educa-
tion is illustrated. The discussion of theoretical connections—first to a principle,
second to a broad field, and finally to a self-reflective educational feature—allow
for a scaffolding of educational complexity; this complexity is mirrored in the way
in which each theory is discussed. The hope of the chapter is that educators will
embrace this complexity, instead of shying away from it, and that health professions
students will be all the better for it.

15.2 The Structure of Human Action

The complexity of philosophical theories and the interconnectedness of features of

large philosophical systems can offer a daunting task for health professions students
and a heavy lift for health professions educators in teaching ethics courses. Each can,
unfortunately, reinforce the other, resulting in a perception that a superficial engage-
ment with ethics ideas, or the jettisoning of ethics sources in favor of unmoored
professional norms, are viable options for ethics education in the health professions.
However, even those of us who recognize the complicated nature of much philosoph-
ical argumentation and believe that careful philosophical arguments repay rereading
and the time devoted to them should admit that complexity builds as ethics deepens,
and that an introductory course in ethics for the health professions need not (and
should not) be a graduate seminar for dissertation-level philosophy students.
A case in point is the philosophical subfield of action theory. Though deep, wide,
and with a great deal of nuanced implications for ethical theory and practice, one can
take a simple insight from a focus on human action and frame a reasonably deep and
understandable ethics education session or course. Consider the insight that every
human action is made up of a person who performs it, the thing that is done, and what
results from what is done.1 Though there are a host of potential ways to complicate
this picture, remaining at this level of complexity can help us organize three influential
ethical theories and apply them to health professions ethics. This structure also offers
a reasonably straightforward framework for students to understand and to classify or
categorise other theories and approaches that they might take up, vis-à-vis “the big
three.” Consider the following threefold organizing suggestion:
1. Health professions students (and practitioners) most interested in the person,
or the agent, performing the action might be drawn toward the virtues of
practitioners of their chosen health profession;
2. Health professions students (and practitioners) most interested in the action that
is performed by such practitioners might be drawn toward the rules or duties
governing their chosen health profession;

1 I am indebted to David Solomon for making this point clear to me.

15 Ethics Education in the Health Professions 221

3. Health professions students (and practitioners) most interested in the outcomes

or achieving the best results regardless of who specifically they affect and how
they are brought about, might be drawn toward ways to optimize the effects of
their chosen health profession’s practices.
In this way, an insight can be drawn from what is a complex philosophical field of
study and employed to aid health professions students in orienting themselves toward
an ethics approach and offer deeper resources than they may otherwise have engaged.
The following sections take up a theory connected to each point about the structure
of human action, as mentioned above, beginning with rules, moving to outcomes,
and concluding with virtues.

15.3 Rules in Ethics

Encounters between healthcare professionals and patients or clients can be some of

the weightiest interactions in a person’s life. Persons hold their health very dear,
albeit among other things, and they often seek the care of health professionals when
their health is compromised or put in jeopardy. Approaching another person from
a state of vulnerability—both in terms of a weakened state, but also the commonly
vast difference in knowledge2 regarding illness—is not easy and thus places a burden
on health professionals to take particular care in responding. One common guide for
proper response is to follow the rules that govern one’s profession or the ethical
rules that might govern this particular kind of interaction. One feature of ethical care
that health professionals, who are interested in ethical rules, must reflect on, is the
autonomy-paternalism spectrum.3 Educators might find that this spectrum is also
helpful in conceptualizing ethics sessions for students. What this approach suggests
is that ethical rules for health interactions (as well as educational ones) are created
in response to the specialness of particular persons, those who are sick (or who
seek learning) and who can give rules to themselves and follow those rules (hence
the connection to autonomy). Three points frame the remainder of this section; first,
context: history matters; second, knowledge: understanding the perspectives of others
is necessary but not always easy; third, patients (or students) as persons: to avoid
ethical pitfalls, seek to see the patient (or student) as a person.

2Put to the side first-hand knowledge of an experiential sort.

3This image is a rough approximation; a better, but less clear image is that of actions, behaviours,
or approaches to the health profession-patient encounter as gravitating toward different poles, an
autonomy-affirming pole, and a paternalism-embodying pole.
222 B. C. Pilkington

15.3.1 History Matters

Healthcare professionals are in the challenging position of aiding others without

possessing complete information or full control; educators can find themselves in
similar positions. Though the former (information) can be remedied to varying
extents depending on the situation, the latter should not be. Health professionals are
not merely technicians, though technical abilities are important,4 they are also people
who practice with patients, as members of a broader profession, within multiple tradi-
tions of practice, and often focusing on one of a variety of specialties. Were health
professionals technicians, then taking care to respect the autonomy of their patients
and guarding against overly paternalistic approaches to their practice with a patient
would be of less concern. Patients, as persons, possess values, goals, and interests
that might be very different from the physician with whom they share in the thera-
peutic endeavour; this can also be said of teachers and students, though there may be
a unifying cause in their shared engagement in a particular profession. Each patient
has their own life history, relationships, understandings of the world and their place
in it, and reasons that they have sought out the care of a health professional. Because
the patient is a person and not merely a problem to solve, even if perfect technique
is displayed, the health professional has not satisfied their ethical obligations (and
it is worth noting here that rule-based ethics are often deontological in nature, that
is, they focus on duties). It is important to highlight that though healthcare prac-
tices bring great goods to many, ethical violations within their history strengthen the
need to treat patients as persons and to follow rules that arise from engagement with
something so special5 ; as does the overall change in context, helpfully summarized
by Kilbride and Joffe (2018) in a recent piece in the Journal of the American Medical
Association (JAMA) about members of one health profession, physicians:
The rejection of medical paternalism in favor of respect for patient autonomy transformed the
patient-physician relationship. Historically, medicine and society subscribed to the ethical
norm that the physician’s main duty was to promote the patient’s welfare, even at the expense
of the latter’s autonomy. A central assumption of the paternalistic framework was that physi-
cians, because of their medical expertise, knew best what was in the best interest of patients
(1973).

4 See ethicist William May’s classic medical ethics text, The Physician’s Covenant: Images of the
Healer in Medical Ethics (Westminster John Knox Press, 2000) for a discussion of technicians and
other images of physicians—which can be applied more broadly to all health professions—that
guide ethical approaches to healthcare.
5 Some historical examples include violations of freedom in favor of “best interests” (for a discussion

of the famous Dax Cowart case, see Engelhardt, H. T. 1989. Freedom vs. best interest: A conflict
at the roots of health care. In Dax’s Case: Essays in Medical Ethics and Human Meaning, ed. L.
Kliever, 79–96. Dallas, TX: Southern Methodist University Press.), racism in medical research and
practice (including, failures to attend to internalized racism (see Smith, P. 2019. Moral Status and the
Care of Impaired Newborns: An African American Protestant Perspective), racism in research and
race-based medicine (Brandt, A. 1978. Racism and Research: The Case of the Tuskegee Syphilis
Study, The Hastings Center Report, Vol. 8, No. 6 and Johnson, K. 2019. Medical Stigmata: Race,
Medicine, and the Pursuit of Theological Liberation).
15 Ethics Education in the Health Professions 223

Before turning to the challenge of perspective taking and the need for autonomy-
affirming strategies, it is worth highlighting lessons that can be drawn for educa-
tion. Attending to students as people opens up an educational space wherein teacher
and student are partners—“joint adventurers”, to borrow a phrase from the ethicist
Ramsey (1970) who coined the term “patient as person”—suggesting flexibility in
small things, like examples to be used, and large things, like delivery methods. This
kind of approach would not be aligned well with a banking model of education—
dropping facts to be memorized into a student’s head (for a detailed exploration of
resistance against the banking model of education, see Chapter 4)—but rather, as
with health-focused work, it is important to place students (or patients) in the best
possible position for them to succeed (learning material and applying it, or living a
healthy life). Bringing these two areas together, even suggests—in a concrete way—
specific questions around which to theme sessions. For example, attending to context
and history, might suggest an assignment like this:
Familiarize yourself with a few situations throughout the history of your future health profes-
sion in which you believe ethical rules were violated or where a patient or client was not
treated as a person; describe two such situations.

15.3.2 Knowledge and Perspective Taking

The historical change in orientation from healthcare professionals, as those with

knowledge of what is in a patient’s or client’s best interest and informing them what
the course of treatment would be to a relationship of shared decision-making that
has been described by terms like therapeutic alliance or “joint-adventurers”, is due,
in part, to an emphasis on the concept of autonomy. Autonomy is one of the “four
principles” of bioethics (Beauchamp and Childress 2019)6 and, some argue, the most
important of the four (Post and Blustein 2015). The concept’s role in ethics has its
roots in philosophy, is connected with a rules-focused approach, and is especially at
home within the Kantian Tradition.7 A focus on the concept highlights that persons
are self-governing or, according to the Greek roots of the term, that they give the
law unto themselves. Such persons are described in the Belmont Report, an early
document codifying healthcare practice and research norms, as those “…capable of
deliberation about personal goals and of acting under the direction of such delibera-
tion” (National Commission for the Protection of Human Subjects of Biomedical and
Behavioral Research 1979, 4).8 It should be clear that a health professional-patient
relationship defined solely by the health professional would not respect the patient
as a person because they would not have an opportunity for self-rule. Rather, a hall-
mark of autonomy-affirming practices would be the offering of reasons to a person to

6 Though principlism is only one approach to ethical medical practice, it is a dominant approach.
7 See, for example, Kant’s 1785 work, Groundwork for the Metaphysics of Morals.
8 It is worth noting that “early” here refers to modern medical ethics and “bioethics” but not to the

thinking about these issues broadly.

224 B. C. Pilkington

evaluate for themselves and then the opportunity to act on those reasons; this respect
is exemplified through the informed consent process.9 In fact, the Belmont Report
translates the principle of autonomy (which it refers to as “respect for persons”) to the
application of informed consent. The converse of this approach is often described as
paternalism, which is frowned up in healthcare because paternalistic practices fail to
treat patients as persons. This is not to say that good health professionals do not exem-
plify some virtues also possessed by good parents, the image at its linguistic roots
of paternalism, such as care, compassion, and even great effort to safeguard. Rather,
as William May (2000) suggests, “the healer overreaches when he or she justifies
overriding the patient’s wants, wishes, decisions, and judgment on the grounds that
the adult patient is a child, incapable of knowing his or her own good” (39). Simi-
larly, this can occur in education when views or approaches are forced on students
or taught as the only option, instead of allowing students to adopt an approach based
on the best available data and arguments, given their own situation.
Paternalistic relationships suggest that the “parent” figure knows best, and models
for health professional-patient relationships often fail, ethically,10 as noted above,
because even if they are technical experts in their craft, health professionals are not
rulers over their patients’ goals and aims. As highlighted in Cavanaugh’s (2018)
recent medical ethics text on the Hippocratic Oath, “A technique, in itself, does
not include determination toward an end and away from what opposes that end
while an ethic necessarily does” (141). Shared decision-making models are most
fruitful because they bring together the expertise of both the health professional and
the patient and can be guided by ethically sound rules. Health professions students
attracted to a rules-based approach should keep in mind that the patient is the ultimate
decision-maker, thus rooting their approach in the recognition that patients are (or
are capable of) self-governing. This approach is also epistemologically stronger
(for discussion of the term ‘epistemology’, see Chap. 10) because even if a patient
were to share a good deal of information about her life history, health professionals
would still not possess sufficient information to act paternalistically. Even if such
decision-making were ethically acceptable, health professionals cannot fully embody
the perspective of their patients. A good (ethically rule-following) health professional
will learn enough about a patient to be empathetic, but not enough to decide for them.

15.3.3 Patient as Person

Simply put, an ethical approach to medical encounters requires that practitioners

see their patients as persons. Failure to do so, not only by practitioners but by the
healthcare and societal institutions of which they are (and have historically been)

9 This is especially the case when informed consent is not thought of as a document to be signed
but as part of a process of shared decision-making.
10 Put to the side practical considerations about the failure rates or compliance problems if shared

goals are not found.

15 Ethics Education in the Health Professions 225

a part, has led to unethical treatment of patients. One feature of treating patients
as persons is to respect them as autonomous agents. In so doing, physicians should
work toward relationships with patients that are defined by shared decision making
and not by paternalism. Ethical physicians are neither purely technicians, nor do they
fall into the trap of playing God; a healthy respect for autonomy aids in maintaining
that balance.

15.4 Outcomes in Ethics

Though all health professionals are interested in good outcomes, students most inter-
ested in good outcomes—and less interested in who does what to achieve those
outcomes—might be drawn toward a consequentialist approach to ethical practice.
In this section, an outcome-based ethic is described and the prominent role it can
play in public health ethics is discussed.
Consequentialism is the idea that only (or primarily) the results, effects, or conse-
quences of an action (broadly understood) determine its rightness. According to this
kind of philosophical perspective, if a health professional wants to know whether
an action is right or not, they should examine the results from performing or not
performing some action. Consequentialism is not a full theory, in the sense that it
cannot guide a health professional’s actions without first adopting a rubric to evaluate
those outcomes; that is, we need a way to determine and measure what good results
are. Arguably, the most influential consequentialist theory has been put forth by John
Stuart Mill, who advocated for utilitarianism. Utilitarians evaluate the consequences
of an action in terms of its utility (a combination of pleasure and the absence of pain)
and, though Mill’s utilitarianism and other versions of it get complicated quickly in
terms of how to evaluate and measure outcomes, the key to this ethical theory is the
maximization of those good results.11
Teaching utilitarianism to health professions students can be aided with the use
of a decision matrix. Figure 15.1 is a very basic one:
Consider one health professional, say a surgeon, who must decide between
performing a standard surgical intervention (A), attempting a new but not experi-
mental surgery (B), or not determining that the patient is not a candidate for surgery
and referring them to internal medicine (C). Suppose this action affects three people—
the patient (1), her mother (2), and her daughter (3). The numbers in this chart signify
pleasure (positive integer) or pain (negative integer). Utilitarians are looking to maxi-
mize overall utility and so the correct answer is C. Though overly simplistic, this chart
is instructive. It illustrates the main aim of this approach: to maximize the overall
utility; not the utility of a particular person or a set of people, but of everyone. This is

11 Mill’s guiding principle is known as the Greatest Happiness Principle, which states that “…actions
are right in proportion as they tend to promote happiness; wrong as they tend to produce the reverse
of happiness; by happiness is intended pleasure and the absence of pain; by unhappiness, pain, and
the privation of pleasure.” (Mill, J. S. 1863. Utilitarianism. London, Parker, son, and Bourn, 1863).
226 B. C. Pilkington

Fig. 15.1 Decision Matrix

similar to current trends in public health ethics. For example, consider the recent and
ongoing COVID-19 pandemic. Much thinking has focused on all (or at least large
groups of people) and not on individuals. An occupational therapist may determine
that she will see her clients virtually, even though her diagnostic training and practice
were based on in person encounters. If she does this because she is concerned about
the spread of the virus, she may be appealing to a consequentialist approach. This
raises important questions about telehealth, facile execution of standards of care,
and even the weighty philosophical question of “Who counts as one’s patient?” No
person, on a utilitarian view, receives any heavier weighting in the calculating of
results than another—so health professions students may find this approach’s egali-
tarian or democratic nature attractive, especially during their early training. However,
as they advance in their training and begin their practice, they may be inclined toward
other approaches if they develop relationships with clients or believe they owe some-
thing to a particular patient “of theirs” as opposed to another. This language suggests
a duty-orientation that might return them to a deontological, rule-based approach.
Some negative features of Utilitarianism, which can be gleaned from the matrix,
exist, as well. It is an instructive exercise for health professions students to discern
these themes on their own and report back to a larger group for discussion and for
the sharing of self-reflection. For example, students interested in social justice and
health might opt for answer A and find the lack of equity or equality12 in choice

12Without further context and information added to the decision matrix, this distinction cannot
be made. However, building on this basic matrix to fit the needs of a particular group of health
15 Ethics Education in the Health Professions 227

C to be objectionable. Choosing C also means that the decider is comfortable with

some persons (Person 3 in this case) being harmed. This is not to say that Utilitarians
support harm, but that—as occurs in many public health determinations—they accept
that some persons will be negatively affected (be it by direct harm, resources going
elsewhere, or other things, such as their liberties, being curtailed) in order that the
total utility is maximized.
In addition to this kind of exercise being useful in ethics education sessions, it
may also be instructive in framing classroom pedagogy. Given different learning
styles, speeds, abilities, and the way that differently abled persons interact with the
structures of the world, reflecting on the distinction between individual students and
a class of students is useful. Instructors may ask, in reflecting on the success of a
session, whether the class did well or whether all their individual students did well?
Do they allow for assignment flexibility, or do they require the same assignment as a
way to consistently measure performance? Have they succeeded if the class average
is greater than in previous years or if the most students pass the relevant professional
exam or do base the course’s success on the success of each individual student?
Finally, it is worth noting that there are some conceptual challenges that health
professions students—and those relying on the ideas of this section to build a session
or theme of a course—should be aware of. First, determining how to measure utility,
or whatever the good to be maximized is, can be challenging. Is Person 3 in Action
C really at a negative 3? Or could it be a negative 1 or a negative 5? This precision
matters in an approach that takes into account an aggregate number to determine the
rightness of an action. And it is the rightness of the action that Utilitarians claim;
a good Utilitarian does not suggest C, she claims that C is the ethically required
action. In the complicated world of healthcare, the importance of nuanced evaluation
is clear and very much needed for this ethical approach to be adopted. Second, where
do you draw the line? Utilitarians must constantly add in new information to their
calculations given that all implications from a decision are relevant to their calculus—
recall, it is the consequences that they focus on, including the consequences of
those consequences, and so on. Determining what is a relevant consequence is, thus,
an important question. Might health professionals evaluate their work in terms of
the success of a treatment plan, the overall health of their patient, or the health of
members of their community? Even the second option is complicated: Should health
professionals work to address climate change or to bring clean water to dry areas or
healthy nutrition to food deserts? What if these factors affect their patients’ health?
A deeper and richer discussion is needed to address these questions, but in the very
least health professionals and those teaching them must arrive at answers about what
counts as health, healthcare, and what they aim to maximize if they adopt this view.
Analogous questions arise in the teaching of health professions. What properly
falls into the purview of an instructor if she adopts a consequentialist approach as her
classroom ethic? Is she on the hook for the maximally happy lives of her students,
class, program? Should she draw the line at the passing of the professional licensure

professions students is an excellent way to broaden the ethics conversation and to elicit particular
self-reflections about students’ values.
228 B. C. Pilkington

test or, more modestly, should she aim to teach a particular set of skills and attitudes
which she finds to be the most successful for a practitioner of her craft? In the
final section of this chapter, we turn to this last suggestion, which is connected to a
discussion of virtue.

15.5 A Virtue-Focused Ethic

The third, and final, approach to be discussed in this chapter is virtue ethics. For
those health professions students interested most in the person performing the action
in our original tripartite structure or for teachers who focus on students—not a whole
class, school, or particular exam metrics—and find the inculcation and support of
character traits or dispositions that lead to good health practice to be attractive,
a virtue-focused ethic might the right fit. That said, teaching virtues can be more
complicated than teaching the other two ethical approaches and it can be trickier to
regulate and measure in practice. As with the other two theories, health professions
students and teachers are encouraged to adopt the approach that best fits their own
aims, profession, and personality.
Philosophical discussion of virtue often focuses on the work of Aristotle. A para-
doxical combination of intuitive appeal and complication can be gleaned simply from
the question that frames Aristotle’s approach. As opposed to asking how to maximize
utility or how to arrive at the right rules to govern ethical action, he is motivated by a
more practical question: How do we live a good human life? More recently, Alasdair
MacIntyre (2007) has argued for the importance of virtues and health professionals,
such as Edmund Pellegrino (1985) have held a similar focus in building an ethic
specific to a health profession.
One challenge in discussing a virtue approach to health professional teaching and
practice is that particular virtues might be tied, very broadly, to human beings or very
particularly to individual professions. Thus, there is a risk of being both too broad and
not specific enough in executing the aims of this section. To fix ideas, the remainder
of this section draws the reader’s attention to five key features of virtue-focused
approaches; the hope of this section is that the reader will indulge any murkiness in
conceptual articulation and apply the ideas—as they fit—in their own teaching and
practice.

15.5.1 The Five Keys to Virtue Education in the Health

Professions

First, experiences matter. Aristotle ([350 BCE] 1999) is quoted as saying in Nico-
machean Ethics Book 1, “…a young person is not a proper hearer of lectures on
political science; for he is inexperienced in the actions that occur in life, but its
15 Ethics Education in the Health Professions 229

discussions start from these and are about these…” (1095). The key to understanding
this claim is that it is not about youth, but about the knowledge that comes from lived
experience. The seasoned clinician is often able to “see” things that trainees do not.
Second, Aristotle thought that in order to respond well to situations, persons need
to be brought up with good habits. Consider any kind of complex activity—diag-
nosing speech pathology, hitting a baseball, dancing a ballet, overseeing a hospital
system—and who might be best situated to make important determinations and
perform the needed actions relative to that activity. Someone with experience who
has been brought up in the right sorts of ways so that she responds well to unfore-
seen issues, understands what technical competence in the relevant crafts entails, and
whose feedback mechanisms are properly aligned with the endeavor’s goals is the
right choice. Such a person will choose well, given her knowledge, expertise, and
the lack of conflicts of interest (or, as Aristotle would put it, she feels pleasure at
the right sorts of things). More simply put: if you practice good habits, you’re more
likely to get things right.
The next key idea is somewhat controversial. Aristotle argued that different beings
have different functions and that in order to be happy, one needs to perform one’s
function well. This applies to everything: good doorstops hold doors in place, good
sailors sail well, good Physician Assistants (or Associates) care for patients well.
This notion is controversial when applied to human beings as a whole, but offers
a useful lesson, even if intuitive, for practitioners of all sorts. Health professionals
who perform their functions well, will gain more joy from their craft. Teachers who
construct a course of study and engage students well, will enjoy teaching more.13
A related (fourth) key idea involves a description of how one becomes good and
about feeling good, which connects to the aforementioned role that habits play in
forming our characters and to the subsequent topic of practical wisdom. For Aristotle,
persons become good by performing actions in accord with correct reason; that is,
a virtuous person must: (1) know that what is she is doing is a virtuous action; (2)
decide to do that action; (3) do that action from a firm and unchanging state. In other
words, the person of practical wisdom or—for our purposes—an excellent healthcare
practitioner—is one who chooses the right option, knowing it is correct, and does so
in light of their well-formed character. This is a lesson well known by many teachers:
the right answer does not define a successful student; how a student gets to the right
answer matters.
The fifth, and final, key point focuses on a moral exemplar: the person of practical
wisdom (for a detailed discussion of practical wisdom in health professions educa-
tion, see Chap. 20). In fact, Aristotle ([350 BCE] 1999) is said to have defined virtue

13 This idea, that those who perform their function well will be happy, has more depth than this in
text description suggests. What Aristotle means by happiness is different from a Utilitarian, like
Mill; for Aristotle, happiness is eudaimonia, a Greek word meaning something like “good- or well-
spirited,” that is, to have a good demon. In his investigation and exploration of eudaimonia, he
argues that whatever it is, it will be complete, self-sufficient, and not capable of improvement; and
after surveying four different kinds of lives: those devoted to pleasure (hedonism), those devoted
to being honored (politics), those devoted to money, and—the winner—those devoted to living a
deeply reflective life.
230 B. C. Pilkington

in Nicomachean Ethics Book 2 as “…a state of character concerned with choice,

lying in a mean, that is, the mean relative to us, this being determined by a rational
principle, and by that principle by which the man of practical wisdom would deter-
mine it…” (1106). There is much to be unpacked in this description, but for our
purposes the image of the person of practical wisdom for a virtue-focused ethics
of the health professions and for those who teach in the health professions will do
a good deal of philosophical heavy-lifting. If a health professional aims to do the
right thing, according to this approach, they ought to do what the person of practical
wisdom would do. A good nurse will care as the best nurse does, not overstepping
their bounds while remaining fully attentive to their patient and their patient’s family.
They will empathise with their patient, ensure that their patient is fully supported,
informed, and advocated for, and that their therapy (and all this entails) proceeds as it
should. Thus, a good nurse possesses a host of virtues, including patience, empathy,
and care.
Though an analogous description could be offered of a teacher of the health
professions, there is a closer connection between the two areas—health practice
and the training of health practitioners—through the notion of mentorship. The key
insight for health professions instructors and students vis-à-vis the education that they
support and take part in, is the importance of mentorship. Mentors—at their best—
are Aristotle’s practically wise persons, or the aforementioned “excellent healthcare
professionals”. In mentors, ethical practice and teaching come together. If one desires
to be a great nurse, one ought to do what great nurses do and to find out what that
is—in all of its nuanced detail—one must follow that excellent practitioner closely.
It is not enough, on this ethical approach, to follow rules to guide ethical practice or
to work for the best results, one can only have acted ethically when one practically
reasons well. Thus, the future nurse should see how her mentor practically reasons
through medically (and morally) complicated healthcare situations. Aristotle thought
that virtues—dispositions toward the good—of these persons reside in a mean and
that vices live on either side of this mean. The practically wise nurse bravely enters
into the challenging conversation in which they are to disclose a medical error. They
do not cowardly hide behind their hospital’s legal team or try to cover up the mistake;
nor do they brazenly storm into the family’s home to declare with rashness what has
happened. The physician who believes a risky surgical intervention is the best option
for a patient, medically speaking, does not bully their patient into the procedure, nor
do they fail to share their surgical expertise; but to understand how to do this well
involves not only following the rules of informed consent, but the best methods and
practices of an empathic, skilled expert involved in a shared decision-making process
with a patient.
This approach, like the other two theories, has its own drawbacks. It has been
described as perfectionist in always aiming toward excellence and not realistic
enough in the necessary accompanying assessments of health professionals and
health professions students—many are excellent, but many more are good, and
15 Ethics Education in the Health Professions 231

many are serviceable. Might aiming for excellence miss that good practice is suffi-
cient? Secondly, obtaining the right habits and inculcating virtues is not easy nor
is it easy to measure, raising questions for training and evaluation in the health
professions. A final concern about this approach is that relying on the person of
practical wisdom—or the excellent healthcare practitioner—is not as easy or as
straightforward as following a set of rules. It lacks, to borrow from the philosoph-
ical literature, the action-guidingness that we seek in ethical theories. Those health
professions students and teachers attracted to this approach may, nonetheless, seek
out mentors and to serve as mentors because they understand the messy, murky, and
nuanced arenas that healthcare takes place in and the complicated beings that humans
are.

15.6 Conclusion

This chapter has offered descriptions of three ethical theories that could inform health
professionals’ practice and the education of health professions students. In doing so,
it attempted to satisfy its aim of responding to the complexity of some philosophical
material and the lack of familiarity of some health professions students with philo-
sophical approaches by offering clear and intuitive descriptions and avoiding some
of the (albeit important) more complex and less practically relevant features of these
theories. It highlighted connections between theories and common principles, such
as the connection between a rule-based ethic and autonomy, between theories and
large fields like public health ethics, and between theories and teaching through the
discussion of virtue ethics and mentorship. Health professionals and teachers of the
health professions students need not shy away from the theories that should and do
inform their professional codes of ethics nor complex philosophical ideas. With the
structure of human action as a guide and by reflecting on the three ethical theories
connected to different components of it, ethics education in the health professions
can be robust, meet the needs of teachers and students, and be an interesting and
impactful part of a student’s training (Table 15.1).

Table 15.1 Practice points

1 Employ ethical theories, not simply professional norms, in health professions instruction
2 Build mentorship opportunities into health professions, teaching, learning, and practice
3 Offer diverse ethical approaches to health professions students, allowing them to choose the
best fit
4 Embrace philosophical complexity in the ethics education of health professions students
5 Connect ethical theories to daily practices, teaching, and related fields of import to highlight
their benefit
232 B. C. Pilkington

References

Aristotle. [350 BCE] 1999. Nicomachean Ethics. Translated by Martin Ostwald. Upper Saddle
River, NJ: Prentice Hall Library of Liberal Arts.
Beauchamp, Tom, and James F. Childress. 2019. Principles of Biomedical Ethics. New York: Oxford
University Press.
Cavanaugh, T. A. 2018. Hippocrates’ Oath and Asclepius’ Snake: The Birth of the Medical
Profession. New York: Oxford University Press.
Kilbride, Madison, and Steven Joffe. 2018. “The New Age of Patient Autonomy: Implications for
the Patient-Physician Relationship”. The Journal of the American Medical Association: JAMA
320: 1973–1974.
MacIntyre, Alasdair. 2007. After Virtue. Notre Dame, IN: University of Notre Dame Press.
May, William. 2000. The Physician’s Covenant: Images of the Healer in Medical Ethics.
Westminster: John Knox Press.
National Commission for the Protection of Human Subjects of Biomedical and Behavioral
Research. 1979. The Belmont Report: Ethical Principles and Guidelines for the Protection of
Human Subjects of Research. https://www.hhs.gov/ohrp/regulations-and-policy/belmont-report/
read-the-belmont-report/index.html.
Pellegrino, Edmund D. 1985. “The Virtuous Physician, and the Ethics of Medicine.” In Virtue and
Medicine, edited by Earl E Shelp, 237–55. Dordrecht: Springer.
Post, Linda Farber, and Jeffrey Blustein. 2015. Handbook for Health Care Ethics Committees.
Baltimore: Johns Hopkins University Press.
Ramsey, Paul. 1970. Patient as Person: Explorations in Medical Ethics. New Haven: Yale University
Press.
Chapter 16
Climate Change and Health Care
Education

Cristina Richie

16.1 Introduction: An Overview of Medical Ethics

Education

Education is the cornerstone of becoming a competent health care professional.

Ethics education in medical schools and the allied health sciences support the devel-
opment of clinical integrity and reinforces the foundational commitment of medicine
to “do no harm.” Ethical theory underpinning medical ethics in modern Western
societies relies heavily on the four principles of biomedical ethics, developed by
Tom Beauchamp and James Childress in 1979. Also known as the “Georgetown
Mantra,” the principles of respect for patient autonomy, beneficence (do good), non-
maleficence (do not harm), and justice dominated medical education. While the four
principles of biomedical ethics are at the core of medical ethics education, the impor-
tance of the natural world and interconnectedness of humans with larger ecosystems
is also taught in health professions education.
In this chapter, I first provide a brief history of the development of health care ethics
with a focus on the modern theory and content in medical schools. I then examine
the current placement of climate change ethics in medical school education, using
the UK and US as examples for broader health care education. Finally, I identify
five practice points for broader integration of climate change ethics in health care
education, highlighting opportunities—which include broad learning objectives and
flexible delivery methods—and challenges, such as room in the curriculum, instructor
confidence and perceived irrelevance.
In the conclusion, I make a call to include climate change ethics in all medical
and allied health science education.

C. Richie (B)
Philosophy and Ethics of Technology, Technische Universiteit Delft, Delft, The Netherlands
e-mail: c.s.richie@tudelft.nl

© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2022 233
M. E. L. Brown et al. (eds.), Applied Philosophy for Health Professions Education,
https://doi.org/10.1007/978-981-19-1512-3_16
234 C. Richie

16.1.1 History of Medical Ethics

Codes of professionalism and ethics were initially within the domains of physicians
guilds and integrated with medical training. From the beginning of medicine, “ethics”
education has been part and parcel of socialization into the profession. Take, for
example, the statements of Asclepius on the ethics of futile care. Plato (1985) records
that Asclepius “did not think it worthwhile to treat a man incapable of living a normal
life since such a one is of no use to himself or to the state” (407). That is, extending life
merely for the sake of existence is not the purpose of medicine; rather, a physician’s
moral compass ought to be directed at benefit to the State. In the modern era, rule-
based ethical systems like deontology—which makes requirements on moral agents
irrespective of the consequences (Korsgaard 2014)—became the standard form of
ethics education in medical schools (Zhuravleva et al. 1999). Medical deontology
focused on the duties and ethical actions of doctors in providing medical care. Medical
ethics also developed outside of medical schools.
Religious scholars were among the first “medical ethicists” (Curran 2003, 114).
In Catholicism, for instance, a rich system for adjudicating the morality of medical
dilemmas was produced, tracing back to moral manuals like Heribert Jone’s (1946)
Moral Theology. Of course, many of the principles employed in health care ethics
were developed long before Jone, starting with Thomas Aquinas (2008). These histor-
ical moral principles were then developed using casuistry, a case study method for
contemporary medical dilemmas.1 Significant theologically-based intellectual devel-
opments in medical ethics in the United States came from Gerald Kelly (1956) who
developed the principle of totality and the distinction between ordinary and extraor-
dinary means (Jackson 2015). The principle of totality states that a body or physical
system ought to remain intact and not be separated (Kelly 1956). This became foun-
dational for discussions on organ donation, amputation, and artificial fertilization.
The distinction between ordinary and extraordinary means became relevant to end of
life care, whereby ordinary means might be natural feeding and extraordinary means
might be artificial life support) (Kelly 1950).
James Gustafson (1975) also applied ethical theory to health care ethics, such as
the principle of the double effect, which states that if an action has two effects and
one is morally right and one is morally wrong, then the action can be acceptable if
the intention is for the morally right effect (Cahill 2012). This was relevant in pallia-
tive care which can lead to terminal sedation. The principle of cooperation, which
examined an agent’s proximity to participation in morally wrong actions helped
nurses care for women who had abortions, but not perform the abortion directly. The
principle of proportionalism stated that morally wrong actions must have propor-
tional, compelling reasons to justify them and this nuanced the principles of totality

1For an excellent overview of some of these specific uses see: Keenan, James and Shannon, Thomas
eds. 1995. The Context of Casuistry. Washington: Georgetown University.; Keenan, James. 2001.
Notes on Moral Theology: Moral Theology and History. Theological Studies 62: 86–104. For a
modern application, see Keenan, James. 1999. Applying the Seventeenth-Century Casuistry of
Accommodation to HIV Prevention. Theological Studies 60: 492–512.
16 Climate Change and Health … 235

and cooperation. Gustafson’s theological reflection influenced both his Catholic and
Protestant students who later became prominent and diverse medical ethicists, like
Lisa Sowle Cahill, Albert Jonsen, and Stanley Hauerwas. Cahill (2004, 2005) made
major contributions to globally-focused health care, Albert Jonsen’s work on end of
life and beginning of life issues is seminal (Jonsen and Garland 1976; Jonsen et al.
1982), and Stanley Hauerwas’ (1982, 1994) contribution to disability studies remains
a classic work. The influence of Catholic theology—in particular—on medical ethics
was prominent in other mid-twentieth century scholars like William May (1977),
Richard McCormick (1980) and Charles Curran (1979).
The development of health care ethics from outside the medical school also
evolved from non-theological perspectives (Beauchamp and Childress 1979),
although many of the ethicists did have personal spiritual commitments. Daniel
Callahan (1990) cites Joseph Fletcher’s 1954 book Morals and Medicine as “the
first truly fresh manifestation of a growing interest in medical ethics in the post-
World War II era” (3). He notes that, later, non-religious health care ethics emerged
“during the 1960s and 1970s in an era of affluence and social utopianism…(and)
for medicine, it was a time that combined magnificent theoretical and clinical
achievements with uncommonly difficult moral problems” (ibid., 2). In support of
these academic developments, Centers dedicated to bioethical inquiry, which were
comprised of theologians, philosophers, lawyers, policymakers, and doctors—like
the Hastings Center2 —emerged. Other significant developments in Western medical
ethics include Paul Ramsey’s 1970 book, The Patient as Person, a 1974 confer-
ence on bioethics at Haverford College (Callahan 1990), and the 1978 Belmont
Report (National Commission for the Protection of Human Subjects of Biomedical
and Behavioural Research 1979). Today, particularly in Western liberal societies
where the pursuit of health and longevity is often in tension with other social values
like sustainability, expense, and access, balancing moral boundaries with boundless
scientific developments requires discernment filtered through ethical theory.

16.1.2 Modern Day Medical Ethics—Theory

In 1927, Fritz Jahr described bio-ethics as “the assumption of moral obligations

not only towards humans, but towards all forms of life” (Jahr and Sass 2010, 227).
Almost half a century later, the term “bioethics” appeared in English, with a remark-
ably similar meaning. In 1971, oncologist Van Rensselaer Potter used the term
“bioethics” to describe “a global perspective with an ecological focus on how we as
humans will guide our adaptations to our environment” (Potter 1988, 10). Both Jahr
and Potter recognized the interconnectedness of humans and the natural environ-
ment, thus connecting bioethics to the natural world, the world outside of healthcare.
Indeed, the 1978 Encyclopedia of Bioethics defines bioethics as the ethical system
that addresses “problems of interference with other living beings… and generally

2 For further information on the Hastings Center, see: https://www.thehastingscenter.org/.

236 C. Richie

everything related to the balance of the ecosystem” (Reich 1978, 19), thus, indicating
that the environment was an integral part of the original concept of bioethics (Richie
2014).
Yet, a second way of defining bioethics has appeared within academia and
medicine. The so-called Georgetown mantra—respect for patient autonomy, benef-
icence, non-maleficence, and justice—which was developed by Tom Beauchamp
from the Philosophy Department and James Childress of the Religious Studies
department at Georgetown University (1979)—became the standard ethical system
for medical schools. Following this formalization of biomedical ethics, numerous
research centers connected to universities and hospitals arose, focused on the four
principles of bioethics to the exclusion of Jahr and Potter’s original conceptualisation
of bioethics (Sgreccia and Tambone 2003). Thus, the environmental component of
biomedical ethics was forgotten by students, teachers, and practitioners.
The evolution of the concept of bioethics—which was formerly attentive to nature
and interconnected systems—into a more technological-individual field, gave the
appearance that environmental bioethics was a separate discipline from academic
bioethics (Reich 1995). This widespread misperception—resulting in the exclusion
of bio-networks from bioethics—has influenced the theory and praxis of nearly
every ecologist, bioethicist, and health care educator thereafter. Indeed, when Potter
published his second and final book Global Bioethics: Building on the Leopold
Legacy in 1998, he lamented that modern bioethics went in a drastically different
direction than he envisioned, writing:
With the focus on medical options, the fact that bioethics had been proposed to combine
human values with ecological facts was forgotten by many: the ethics of how far to exercise
technological options in the exploitation of the environment was not associated with the term
bioethics (1–2).

16.1.3 Modern Day Medical Ethics—Instruction

Ostensibly, the philosophical contributions of Beauchamp and Childress legitimized

the modern practice of non-clinicians teaching medical ethics. However, bioethicists
have been muckraked, called “thieves of virtue” (Koch 2014), who intervene in
medicine when they should not, since they are not medical professionals, but rather
trained in theology or philosophy (Moreno 2006). Whilst many medical and health
professional schools utilize an ethics or bioethics department for the education of
students, some smaller schools have only one bioethicist who teaches courses in
health care ethics.3

3In Ireland see: Ryan-Fogarty, Yvonne, O’Regan, Bernadette and Moles, Richard. 2016. Greening
healthcare: systematic implementation of environmental programmes in a university teaching
hospital. Journal of Cleaner Production 126: 248–259. In Australia: see Maxwell, Janie and Blashki,
Grant. 2016. Teaching about climate change in medical education: an opportunity. Journal of Public
Health Research 5: 14–20.
16 Climate Change and Health … 237

Despite such variation, ethics is a feature of modern health care education (Reynolds
and Tansey 2007). In the United States, medical schools follow the Association of
American Medical Colleges (AAMC) standards for ethics education, with courses
running across all four years of MD programmes. By 2000, a study of 91 reporting
medical schools in the US and Canada showed that all of the medical schools offered
some form of ethics education (Lehmann et al. 2004). Significantly, “Deans who
reported having a faculty member whose primary responsibility was to teach medical
ethics were twice as likely to have mandatory introductory ethics course (64% versus
32%)” (ibid. 684). The UK also has standards of medical ethics education. In 1993, the
General Medical Council (GMC)’s Tomorrow’s Doctors “place(d) a new obligation
on medical schools to include ethics as part of the core curriculum for the training of
medical students” (Fulford et al. 1997). All reporting schools indicated that they had
ethics resources available to students, primarily in the form of content.

16.1.4 Modern Day Medical Ethics—Content

Content is frequently a point of contention in health professions education. Tension

between curriculum time (Lehmann et al. 2004) and differing faculty views on the
necessity—or frequency—of ethics lead to differences in how much curriculum time
is deveoted to the ethical formation of healthcare professionals and which topics are
covered. A cursory glance at the content areas for medical ethics education in the
United States (Miles et al. 1989) and the UK (Consensus Statement by Teachers of
Medical Ethics and Law in UK Medical Schools 1998) reveal a handful of topics—
such as religious theory, duty to treat those with HIV, and threat of Nuclear war—have
fallen into present day disfavour as they are viewed as irrelevant, while other current
topics—such as genetics or reproduction—are presented in curricula. Developments
in health care and ethics make content a moving target. The Coronavirus Pandemic of
2020 led to an influx of webinars on ethics,4 pandemic responses,5 triage and alloca-
tion,6 and other topics7 aimed at health care students and educators. Despite changes

4 See, for example: Darwich, Bahaa. 2020. Webinar Series: Bioethics and Covid-19 Response in
the Arab region. UNESCO. At https://en.unesco.org/news/webinar-series-bioethics-and-covid-19-
response-arab-region.
5 See, for example: UNESCO Chair in Bioethics Webinar Series Panel Discussions on Medical

Ethics in the Wake of the COVID. 2020. Medical Ethics in the wake of the COVID 19 Pandemics:
The Ethics of Mandatory and Voluntary Interventions: Nonpharmaceutical Interventions -Isolation,
Quarantine, Social distancing and Closures. At https://register.gotowebinar.com/register/468077
0938996247822.
6 See, for example: NASEM Health and Medicine. 2020. Public Workshop: Equitable Allocation of

Vaccine for the Novel Coronavirus. At https://www.eventbrite.com/e/public-workshop-equitable-

allocation-of-vaccine-for-the-novel-coronavirus-tickets-115438574885.
7 See, for example: Empire State Bioethics Consortium. 2020. COVID-19 and Ethics webinars,

What are the obligations of the State during a Pandemic?. At https://www.youtube.com/watch?v=

GJakMSYPKsE; Empire State Bioethics Consortium. 2020. Ethics Consultations During COVID-
19. At https://www.youtube.com/watch?v=kQGqYGYgSyE; Empire State Bioethics Consortium.
238 C. Richie

in content and subject matter, modern health care ethics education retains a core
commitment to broader social issues like justice (Jotkowitz et al. 2004), antiracism
(Braun and Saunders 2017), and environmental sustainability.
To be sure, environmental sustainability does not have to be placed within ethics
curriculum in medical schools, although it certainly has a strong rationale for being
there. Whether addressed as an ethical issue, or as a matter of general educational
competency, the two prongs of climate change related health hazards (as a matter of
patient health) and the carbon emissions of healthcare (as a matter of professional
ethics) define environmental topics that health professions education might cover.

16.2 Models of Climate Change Ethics in Medical

Education

Although medical schools in at least 92 countries (El Omrani et al. 2020)8 have topics
related to climate change ethics and environmental sustainability in their curricula,
the most in-depth data comes from the UK and US, thus each country’s curriculum
use will be discussed. This information has application for broader health professions
education.

16.2.1 Climate Change Ethics in UK Medical Education

There is a small but significant amount of attention to climate ethics in medical school
curriculum in the United Kingdom (Walpole et al. 2015; Walpole and Mortimer
2016; Maxwell and Blashki 2016). In 2015, a team of four professors from Hull
York Medical School, the Centre for Sustainable Healthcare at Oxford, the Medical
School at the University College London, and the Medical School at the University of
Bristol spearheaded a consultation of “healthcare students, healthcare educators and
other key stakeholders” to discuss environmental sustainability in medical education
and define learning objectives for implementation of such curriculum (Walpole et al.
2015, 191). The outcomes of this project were reported by Walpole and Mortimer
in 2016 and are indicative of successful integration of environmental topics into
medical school curriculum in the UK, with relevance for broader health professional
education.
The scholars leading the consultation offered four basic rationale for their project:

2020. The Importance of Palliative Care During The Covid-19 Pandemic. At https://www.youtube.
com/watch?v=PXuNVYLHhHE&feature=youtu.be; Empire State Bioethics Consortium. 2020.
Inequality, Vulnerability, and Health Justice: Learning from the Pandemic. At https://www.you
tube.com/watch?reload=9&v=pMN8KZ1dPO8.
8 El Omrani et al. report that 329 medical schools in 92 countries have formal education on the

topic of health impacts of air pollution in the curriculum.

16 Climate Change and Health … 239

1) environmental change significantly impacts the diseases that health professionals see and
treat, 2). environmentally sustainable practices offer great opportunities to improve public
health and health care services, 3) health services have a large ecological footprint, and 4)
reducing this footprint, saving money and improving patient care can go hand in hand” (ibid.
191).

These four interdisciplinary rationales cover a spectrum of climate concerns in health

care.
Learning objectives were then developed using a modified policy Delphi approach.
The group initially proposed 10 learning objectives developed from key articles
published between 2002 and 2012 discussing climate, the carbon footprint of climate
change, and health impacts of climate change (ibid.). They discussed the:
(a) content of learning objectives, (b) structure and presentation of learning objectives, and
(c) methods for implementation (ibid. 193).

Content areas included simple definitions and background information on sustain-

ability, climate change, and climate change health hazards. Topical areas of social
significance were addressed—such as nutrition and food, pollution, population
growth—as well as those with clinical significance, such as hospital management,
including waste and procurement.
After three rounds of discussion, three learning objectives which aligned with
the General Medical Council’s (GMC) categories of doctor as scholar, doctor as
practitioner and doctor as professional were proposed. They were:
• As a scholar, doctors require an understanding of how the environment and human
health interact at different levels.
• As a practitioner, doctors must be able to apply knowledge and skills around
sustainable healthcare in order to improve the environmental sustainability of
health systems.
• As a professional, doctors must consider the ethical issues posed by the
relationship between the environment and health.
Participants agreed that the delivery of the content should be flexible and tailored
to the needs of the individual medical school, that is, either a single course on envi-
ronmental topics or a “perspective” through which education is disseminated (ibid.
195).
Following this 2015 initiative, a 9-month collaborative project was launched
to educate medical school professors and assess opportunities for integration of
sustainability into the curriculum. Eleven medical school teams applied for the
project, 8 were accepted, and 7 implemented the area of new content (Walpole and
Mortimer 2016). The seven medical schools that integrated topics on environmental
sustainability represent over 20% of the medical schools (n = 33) in the UK at the
time (Medical Schools Council 2018). These participating schools implemented or
augmented sustainability courses or included sustainability as part of an integrated
curriculum. Overall, students welcomed the new and expanded content and imple-
mentation was smooth, however, the professors reported needing more training to
feel confident in delivery (Walpole and Mortimer 2016). This pattern is reflective
240 C. Richie

of other environmental initiatives in medical schools; medical students are active in

petitioning for sustainability ethics in their education,9 while professors and admin-
istrators require more persuasion. In 2020, a study by the InciSioN UK Collaborative
on the integration of “global health education” in medical school curriculum reported
that of 30 reporting medical schools, 20 included “future impact of climate change
on health and healthcare systems” as a learning objective, while 25 listed “environ-
mental and occupational hazards and ways to mitigate their effects” as a learning
objective (4–5). The growth in environmental topics in medical school education
indicates a positive and long-lasting trend.

16.2.2 Climate Change Ethics in US Health Professional

Education

In the United States, students are educated about climate ethics across interdis-
ciplinary health professional degree programs. For instance, Dr. Rebecca Philips-
born at the Emory School of Medicine developed a virtual 4-week Climate Change
and Health curriculum, which includes topics and syllabi to be implemented in her
own, and other, medical schools.10 New York University (NYU) offers a Masters
of Arts in Environmental Bioethics and a 5-year MD/MA program, which has two
tracks leading to the terminal degree (New York University School of Medicine n.d.).
Although NYU expects most of their dual-degree students to enrol in the health ethics
track, the fact that a major university has a degree dedicated to environmental ethics
attests to the growing interest and continued relevance of the discipline. Likewise,
Harvard Medical School (HMS) has a club dedicated to topics connected to environ-
mental ethics. Harvard Students for Environmental Awareness in Medicine (SEAM)
publish a quarterly newsletter and “collaborate with the Longwood (Boston) Green
Campus Initiative on a number of projects to improve energy efficiency and recycling
and to reduce waste among students and staff” (Harvard University Centre for the
Environment, Student Groups n.d.).
In addition to the aforementioned programs at NYU and HMS, the American
Society for Bioethics and Humanities (ASBH) Environmental Bioethics Affinity
Group has informally reported that several members utilize an environmental frame-
work in their ethics courses.11 Jeffrey P. Spike, the former Rabbi Samuel E. Karff
Professor at the McGovern Center for Humanities and Ethics in Houston, Texas added
two hours on climate change and health for the public health and policy program.

9 E.g., see: Harvard University Center for the Environment, Student Groups: Students for Environ-
mental Awareness in Medicine SEAM. N.D. At http://environment.harvard.edu/student-resources/
student-groups.
10 See: Medical Students for a Sustainable Future MS4SF, Guide to Climate and Health Curriculum

Reform in Medical Schools. At:https://docs.google.com/document/d/1lwLv-PZXZTymWbPLT

B3604dvnOvg2gKntIoBo7QH-6c/edit.
11 Communication with the author, 2016.
16 Climate Change and Health … 241

Laurie Zoloth, Professor of Religious Studies and Medical Humanities and Bioethics
at Northwestern University taught a class in the medical school geared toward
discussing the impacts of climate change on public health and ethical responses to
the problem. Cheryl Macpherson, a Professor and Chair in the Bioethics Department
at St. George’s University School of Medicine in Grenada has taught approaches
to climate change in her introductory bioethics course that is required in the 1st
year medical curriculum. Cristina Richie integrated a component on environmental
bioethics into her Health Care Ethics course at Massachusetts College of Pharmacy
and Health Sciences in Boston from 2014 to 2017.
As more socially-engaged students petition for environmental topics in medical
school curricula, there will be increased movements towards climate education in
medical and other health care professional schools. Still, there are many ways in
which climate ethics may be adopted in health care curricula.

16.3 Practice Points: Implementing Climate Ethics

in Health Professions Education

The American College of Physicians (ACP), the second-largest US professional

association of doctors with 148,000 members, has officially recognized the threat
of climate change and made policy recommendations in a formal Position State-
ment (Crowley 2019). They outline the wide range of health consequences of
climate change, beyond the well-known issues of air and water pollution. The
ACP acknowledge the role of the health sector in carbon emissions, and indicate
that:
physicians and the wider health care community have a major stake in addressing climate
change, not only by treating patients experiencing its health effects but also by advocating
for effective climate change adaptation and mitigation policies, educating the public about
potential health dangers posed by climate change, pushing for a low-carbon health care sector,
researching and implementing public health strategies, and adopting lifestyle changes that
limit carbon emissions and may achieve better health. (Gurevich 2020, 128)

In both the UK and the US, as well as other international health professions schools,
climate change must be part of ethics education.

16.3.1 Opportunities

Medical educators argue that:

Health care providers require training on the connections between the climate, ecosystems,
sustainability, and health and their responsibility and capacity in changing the status quo.
(Teherani et al. 2017, 1386042)
242 C. Richie

Hence, there are two opportunities for further implementation of climate ethics
into health professions curriculum: broad learning objectives, and flexible delivery
methods.

16.3.1.1 Broad Learning Objectives

The learning objectives put forth in the UK medical school curricula are broad enough
to house several relevant sustainability topics across health professions education.
Health professions schools that wish to implement sustainability may emphasize the
carbon emissions of health care, in addition to maintaining education on the health
effects of climate change. The ethical rationale for climate ethics in medicine may be
based on duty from a deontological ethical perspective—“do no harm”—or be based
on the impacts of climate change—climate change health hazards—from a conse-
quentialist perspective (Gomberg 1989). A deontological presentation of sustain-
ability relies on the obligation of health professionals to reduce resource use and can
draw on supportive philosophical concepts like medicalization (Szasz 2007), pathol-
ogization (Brinkmann 2016), and overuse of health care (Korenstein et al. 2012)—all
of which have negative impacts on patients through disease burden (Shrime et al.
2015), stigma (Richie 2019a), and medical error (Makary and Michael 2016). A
consequentialist presentation of sustainability, which highlights the negative impacts
of resource use, might be more data-driven and suggest carbon reduction measures
across medical lifecycles (Campion et al. 2015), individual medical procedures (Lim
et al. 2013; Richie 2015), prescribing practices (Richie 2020a), and within hospitals
(Ghersin et al. 2020; Richie 2018). Whereas deontological sustainability can make
strong appeals to green bioethics (Richie 2019b), environmental bioethics (Potter
1971; ten Have 2019), and environmental ethics (England 1993), a consequentialist
sustainability fits within public health (Haines et al. 2006), public health ethics (Kass
2001), and theories of climate justice (Shue 2014).

16.3.1.2 Flexible Delivery Methods

Since sustainability, environment, and health care are intimately linked, they can
be connected with new and foundational topics. Content related to sustainability
in health professions education may be delivered in an integrated format, or in an
individual course. Probably, both need to occur for maximum efficacy. Integrated
formats can connect with topics already present in the curriculum. One UK school, for
instance, is linking climate, health, and migration health; another school is focusing
on sustainability, clinical ethics, and the traditional discipline of law (Walpole and
Mortimer 2016). Other direct connections may include a module on the Hippocratic
oath and the principle of non-maleficence in the context of the professional obli-
gation to reduce carbon emissions in health care (Health Care Without Harm n.d.).
Minimizing carbon emissions in health care can be linked to ethical allocation of
16 Climate Change and Health … 243

medical and institutional resources (National Health Services Sustainable Develop-

ment Unit 2009). Public health, preventative health, and social determinants of health
are relevant for background discussions on climate change health hazards (Galvão
et al. 2009). In this way, education on climate ethics may occur in each year of the
degree program. The primary benefit of integrated sustainability education is topical
reinforcement and comprehensive exposure.
It should not need to be the responsibility of a bioethics department or ethics
instructor to disseminate such information, lest students fall into the trap of thinking
sustainability is only about ethics when it is significant for professionalism and
professional development as well. Integrated formats can also serve as a testing
ground: concepts which are easily grasped or most relevant may be continued, while
more obscure topics or ones that students do not find compelling can be withdrawn.
The primary downfall of integrated sustainability medical education is the potential
for superficiality. Moreover, faculty may need to educate themselves on climate and
health and develop strategies for presenting environmental concepts within their core
courses.
Sustainability in health profession education may also take shape in a founda-
tional or elective course. A foundational course might address general topics such as
Climate and Health, whereas an elective may address specific topics, such as Envi-
ronmental Bioethics, Green Bioethics, Environmental Racism and Social Determi-
nants of Health, or Economics of Health Care Carbon.12 The benefit of a dedicated
course is mastery of material. Moreover, a foundational course could cross multiple
departments including epidemiology, bioethics, and public health, thus distributing
the obligations for sustainable education. The major disadvantage of a core course
in sustainable health is the lack of space—real or imagined—in current medical
school curricula, whereas the primary drawback of an elective is lack of total student
education which reinforces the existing problems of compartmentalizing ecology
and medicine. As with other educational programs, the presentation of foundational
concepts like sustainability in first year core courses, with refreshers throughout the
years, as well as in-depth electives, affirms both the importance and relevance of
sustainability in medical curriculum.

16.3.2 Challenges

Challenges will remain around adoption of climate change ethics within health
professions education curricula. Whereas sustainability in UK medical schools is
supported by the General Medical Council (2009) and National Health Service
(National Health Service Sustainable Development Unit 2009), not all countries have
organisational support for climate ethics. There are three challenges to climate ethics

12For additional course suggestions, see The Centre for Sustainable Healthcare, CSH Sustainable
Healthcare Courses. n.d. At https://sustainablehealthcare.org.uk/courses.
244 C. Richie

in health professional education that need to be overcome: room in the curriculum,

instructor confidence, and perceived irrelevance.

16.3.2.1 Room in the Curriculum

Negotiating room in the curriculum is clearly a barrier to implementation of climate

ethics. Alterations or additions to curricula are almost impossible without adminis-
trative support, student enthusiasm, faculty willingness, and simple, but compelling,
academic resources such as articles, books, powerpoint slides, charts, and sample
syllabi to facilitate teaching (El Omrani et al. 2020; McKimm et al. 2020; Walpole
et al. 2019). This can be overcome by partnerships between institutions and sharing of
resources to reinforce the importance of sustainability in curriculum and set precedent
for wider adoption of such topics.

16.3.2.2 Instructor Confidence

Educators in the allied health sciences who feel underprepared to address envi-
ronmental sustainability may be reminded that they are not expected to be experts
on all topics offered in education and that even in existing courses, they had to at
one point familiarize themselves with new theories, applications, or techniques in
order to maintain relevance for students. Resources on environmental topics, from
peer-reviewed literature, to advanced research fellowships such as those offered at
the Centre for Sustainable Healthcare in specialties including nephrology, psychi-
atry, dental, public health, general practice, ophthalmology, education, anaesthesia,
quality improvement, and surgery13 are available for educators. Once educated,
physicians can provide education to peers through Grand Rounds (Magdo et al.
2007), on-the-job training, and continuing education courses. Physicians can also
lead by example, both outside and within the classroom as advocates of environmental
ethics.

16.3.2.3 Perceived Irrelevance

A change in health care culture, which priorities sustainability in everyday life, would
be a prerequisite to expanding topics in sustainability to educators and students
(Richie 2020b). While students have spearheaded efforts to place sustainability

13 See: The Centre for Sustainable Healthcare. n.d. Home- Who We Are-Fellows and Scholars. At
https://sustainablehealthcare.org.uk/who-we-are/fellows-and-scholars.
16 Climate Change and Health … 245

into medical school curricula, some students may resist changes in curriculum or
find environmental issues irrelevant (Walpole and Mortimer 2016). The extent to
which student opinion should dictate alterations—either additions or subtractions—
in curricula is contested, particularly when they might have epistemological reasons
for rejecting sensitive topics like diversity and inclusion, bias, or, indeed, climate
change. One approach to dealing with student resistance to the latter is simply to
affirm broader institutional statements on sustainability—such as the ones by the
World Medical Association and the American College of Physicians—and rein-
force the aspects of professionalism, ethics, and health that underpin courses or
lectures. The conventional wisdom of medicine, which tends to “focus on treatment
over prevention” must be re-evaluated (Walpole et al. 2019, 6). Prevention is more
sustainable than treatment (Richie 2019b) and is in the best interest of the patient, as
well.

16.4 Conclusion: A Call to Include Climate Change Ethics

in All Health Professions Education

Efforts to integrate sustainability into health professions education have interna-

tional support. The World Medical Association (2009) recognizes that students need
to understand climate change in the context of health. Moreover, in 2020, the Inter-
national Federation of Medical Students’ Associations (IFMSA), which represents
1.3 million medical students in 133 countries (IFMSA, n.d.) drafted a “Vision of
Climate Change in Medical Curricula” (IFSMA 2020). Currently, 129 of the 133
countries represented by the IFMSA have adopted the document (El Omrani et al.
2020). Climate ethics in health care curricula is—and will be—a requirement of
preparing students for their role as health professionals. Indeed, there have been an
increasing number of calls for sustainability in medical schools (Tun 2019; Vujcich
et al., 2020), dental education (Duane et al. 2017, 2019), and nursing (Lori and
Madigan 2020; Lausten 2006; McNeill et al. 2020).
Ultimately, sustainability should be taught in all health care education, not only in
the countries that are most responsible for pollution—such as the US and UK (Pichler
et al. 2019)—but also those countries emerging in the global health care industry.
Carbon emissions do not stay within national borders (Costello et al. 2009); all
countries have a vested interest in educating medical students about sustainability, and
the environmental impact of medical care, thus leading to changed practices—and
changed practitioners (Table 16.1).
246 C. Richie

Table 16.1 Practice points

1 Broad learning objectives allow for maximum alignment with other core and elective courses
2 Flexible delivery methods give instructors latitude to integrate climate change ethics in their
courses and practicums
3 Finding room in the curriculum for climate change ethics can benefit from “piggybacking”
onto topics that are already covered, like ethics and public health
4 Instructor confidence can be built through self-education as a matter of professional
development
5 Perceived irrelevance of climate ethics can be addressed by appealing to broad institutional
support

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Chapter 17
The Philosophy of Technology: On
Medicine’s Technological Enframing

Benjamin Chin-Yee

17.1 Introduction: Questioning Medical Technology

In 2012 IBM,1 in partnership with Memorial Sloan Kettering Cancer Centre,

announced the development of Watson for Oncology, a supercomputing initiative
which applied Artificial Intelligence (AI) to solve one of modern medicine’s biggest
challenges: how to effectively treat patients with cancer. Watson for Oncology,
marketed as a clinical decision-support system, analyses Big Data—from medical
records, pathology and imaging reports to the vast research literature and clinical
practice guidelines—to recommend the ‘best’, personalized treatment for a given
patient. Following this announcement, IBM formed partnerships with major cancer
centres and health systems around the world in pursuit of its goal to revolutionize
cancer care. Ultimately, however, Watson for Oncology did not achieve its aim,
facing mounting criticisms over inaccurate recommendations, lack of sensitivity to
local context, and overreliance on opinion of American experts (Tupasela and Di
Nucci 2020). Yet despite these criticisms, as well as an ongoing paucity of evidence
that the tool improves patient care, the project was an integral part of IBM’s Watson
Health division (2022).2
Over the past decade, enthusiasm for AI in medicine has only grown, and AI’s
ability to offer technological solutions for a wide array of clinical problems now
seems boundless. Watson for Oncology is just one high profile example amongst a
myriad of AI applications in healthcare, which range from interpretation of diagnostic

1 International Business Machines Corporation, an American multinational technology corporation.

B. Chin-Yee (B)
Division of Hematology, Schulich School of Medicine and Dentistry, Western University, London,
ON, Canada
e-mail: benjamin.chin-yee@lhsc.on.ca
Rotman Institute of Philosophy, Western University, London, ON, Canada
2 Since the time of writing, IBM has sold its Watson Health data and analytics business.

© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2022 251
M. E. L. Brown et al. (eds.), Applied Philosophy for Health Professions Education,
https://doi.org/10.1007/978-981-19-1512-3_17
252 B. Chin-Yee

testing to prediction of clinical outcomes and treatment recommendation (Topol

2019). Exuberance for medical AI has been met with concerns over epistemic and
ethical problems posed by these technologies (Chin-Yee and Upshur 2019), including
issues of bias, transparency, accountability, and trust, which link to more general
debates in the ethics of AI (for examples, see Dubber et al. 2020) Engagement with
these philosophical issues is of increasing relevance in health professions education,
which must continually adapt to medicine’s rapidly evolving technological landscape
and reckon with the resulting impact on clinical training and professional identities.
This chapter raises a more fundamental philosophical question prompted by these
recent trends: to what extent are the problems of medicine—that is, the problems
that we train clinicians to address in practice—amenable to technological solu-
tions? Put differently, how did medicine arrive at a point where clinical judg-
ment, once a paragon of human reasoning, became something that might be best
performed by a machine? While such questions are not new—indeed, critiques of
biomedicine’s ‘technological imperative’ are longstanding (for example, see Burger-
Lux and Heaney 1986)—recent developments in Big Data and AI give new impetus
to address these questions and revisit the role of technology in medicine today. To
this end, this chapter undertakes a foray into the philosophy of technology to extract
relevant insights for health professions education.
I begin by discussing the relationship between science and technology and intro-
duce the commonplace positivist view of technology prevalent within the medical
profession. This is followed by a selective survey of approaches in the philosophy of
technology, focusing on critical accounts by three philosophers from distinct periods
and intellectual traditions, Martin Heidegger (1889–1976), Andrew Feenberg (1943),
and John Dewey (1859–1952). I highlight how these philosophers challenge received
views on the place of technology in modern society and offer particularly relevant
insights for questioning medical technologies. This discussion emphasizes three key
themes for health professions education while dispelling three myths of the positivist
position: first, technology does not simply refer to material artifacts but describes
a particular way of thinking and interacting with the world; second, technology is
not value-neutral but rather reflects a range of social choices and human values; and
third, technology does not serve as pure means to fixed ends but instead exists as a
continuum of evolving means and ends. By introducing readers to key issues in the
philosophy of technology, my aim is to support reflection and critical engagement
amongst clinicians, educators, researchers, and trainees with the technologies that
increasingly play a pivotal role in clinical practice.

17.2 Art, Science, or Technology?

Is medicine an art or a science? This oft-repeated false dichotomy, while debunked

by a number of scholars (for examples, see Montgomery 2005; Whitehead and
Kuper 2015; Fuller 2015; Solomon 2015), seems to hold continued traction amongst
17 The Philosophy of Technology … 253

students and healthcare professionals today. Perhaps this is because it gives expres-
sion to a particular uneasiness with medicine’s irreducible uncertainties felt espe-
cially amongst healthcare professionals whose training disproportionately focuses
on medical ‘science’, where ‘science’ continues to be understood in narrow, posi-
tivist terms, as the privileged mode of access to value-free facts about the world.
Preserving the category of ‘art’, encompassing and nebulous, ensures that all of
medicine’s uncertain elements—from intuition and emotion to ethics and values—
can be neatly cordoned off from its more ‘scientific’ base. This perspective still leaves
the path open for medical science to gradually work away at these uncertainties, with
the hope that the vagaries of ‘art’ will soon become relics of a bygone era, the stuff
of Hippocrates and Osler but not befitting the contemporary clinician equipped with
modern science and its technological affordances.
There is a grain of truth in this slightly hyperbolic narrative about scientific
medicine. Positivism and foundationalism are alive and well in medicine today
(See Chap. 13 for an overview of this state of affairs). One example is provided by
the Evidence-Based Medicine movement (for discussion, see Bluhm and Borgerson
2011), which sought to establish clinical epidemiology and its tools as medicine’s
new ‘base’—the new “basic science for clinical medicine” (Sackett 2005). Such
views continue to inform more recent data-driven, quantitative approaches, including
medical AI, which promise to bring us closer to ‘truth’ in diagnosis, prediction, and
treatment decisions (Chin-Yee and Upshur 2018, 2019). While there is a tendency
to classify these developments as advancements in the science of medicine, which
remains the emphasis of health professions education, these latest trends also high-
light medicine’s growing technological dimension. Making sense of these trends and
their meaning for the medical profession, therefore, requires that we ask: what is the
relationship between medicine’s science and its technologies?
According to the received view, the answer is straightforward: technology, simply
put, is applied science. Medical technologies, therefore, are the application of medical
science. Science teaches us how the immune system functions; vaccines are tech-
nologies which leverage that understanding to prevent disease. Science tells us how
cells divide and proliferate; cancer therapies are technologies that exploit this knowl-
edge to abrogate the process. What I have just introduced can be termed the positivist
view of technology, a commonly held perspective that serves as a foil to the critical
approaches discussed below. The positivist view of technology follows from its view
of science. By this account, ‘pure’ science involves the pursuit of theoretical knowl-
edge, which is value-free, ahistorical and universal; technology is the application of
this theoretical knowledge towards the efficient attainment of practical ends.
Three features of the positivist view are worth noting here. Firstly, it is hierar-
chical: science precedes technology, with scientific knowledge forming the basis of
technological innovation. Technology develops as a result of advancement in science
and its disinterested pursuit of theoretical knowledge. Secondly, while technology is
directed at practical ends, these ends are extrinsic to technology itself which exists
as ‘pure means’ to attain predefined ends in the most efficient and rational manner.
This view of technology as ‘pure means’ to an ends is sometimes referred to as naïve
254 B. Chin-Yee

or “straight-line” instrumentalism by its critics (Hickman 1990; Winner 1978). By

this view, technology is value-neutral: although it aims at practical ends, which may
be socially defined according to various interest and values, considerations of design
and function are purely technical and scientifically determined. Thirdly, given that
technology is a direct extension of science and embodiment of its rationality, the
positivist view confers upon technology a certain scientific legitimacy. For the posi-
tivist, science is our best, indeed our only, mode of access to true knowledge about
the world, and this privileged status transfers to technology, whereby technology
offers our best means of attaining practical ends in the world. Sometimes, this latter
perspective is referred to as technological solutionism, or simply solutionism for
short. That solutionism often follows from positivist views of science and technology
is evidenced by how such arguments often emerge from society’s most scientistic
sectors, healthcare included. The rise of solutionism in health professions education
in particular has recently come under scrutiny (Ajjawi and Eva 2021).
Needless to say, positivism has encountered a multitude of challenges, both in
terms of its views of science and technology. On the one hand, its view of science
faced significant criticism by post-positivist philosophy of science. Review of these
criticisms is beyond the scope of this chapter (for background, see Chap. 13), but
a major source came from historians and practice-oriented philosophers of science,
who helped dispel the myth of ‘pure’ science by examining the historical and social
conditions that influence the production of scientific knowledge. Of relevance to our
discussion, such analyses revealed the bidirectional relationship between science
and technology, challenging the hierarchy moving from ‘pure’ science to applied
technology. To cite just one example from the history of medicine, Louis Pasteur’s
research in microbiology, while often rationally reconstructed as ‘basic’ experiments
providing proof of a germ theory of disease, were in fact part of a broader research
programme that relied upon a state-of-the-art laboratory technology, as well as knowl-
edge gained from applied processes of fermentation in the brewing industry and
agriculture (Latour 1993). A plethora of historical and contemporary case studies
bring into question the priority of science over technology, to the extent that some
scholars now prefer ‘technoscience’ as a more descriptive term for the amalgam that
constitutes modern day research (Pickstone 1993). On the other hand, the positivist
view of technology, together with its instrumentalist and solutionist perspectives,
have been the focus of significant criticism in the philosophy of technology, which
I explore in the next section.

17.3 Lessons from the Philosophy of Technology

Philosophy of technology is a growing discipline which has attracted scholars from

a number of different intellectual traditions and orientations. While philosophical
engagement with technology has its roots in antiquity (for discussion, see Franssen
et al. 2009), contemporary philosophy of technology emerged from attempts to
17 The Philosophy of Technology … 255

reckon with the growing presence and influence of technology in modern society.
As the field expanded it became roughly divided between scholars more interested
in questions of design and function of technical artifacts in themselves, often from
backgrounds in engineering and analytic philosophy of science, and those occu-
pied with the broader social and existential impacts of technology, often from back-
grounds in the humanities and social sciences. The latter is sometimes dubbed the
“humanities philosophy of technology” to contrast the “analytic philosophy of tech-
nology” (Mitcham 1994). Although this division is imperfect, and many philosophers
(including Dewey) do not clearly fit within one side, this introduction will focus
mainly on scholars from the so-called humanities tradition, who, by addressing the
human and social dimensions of technology, offer insights of particular relevance
to health professions education. One entry point into this literature can be found in
the work of Martin Heidegger, whose The Question Concerning Technology ([1954]
1977) serves as a seminal text for the field.

17.3.1 Heidegger’s Question Concerning Technology

To understand Heidegger’s philosophy of technology we must first situate it within

his broader philosophical project. The central question for Heidegger’s philosophy
is the question of being. His most celebrated work Being and Time ([1927] 1996)
is a study of the fundamental nature of human existence or “being-in-the-world”.
Heidegger challenged Western philosophy’s dominant interpretation of human exis-
tence as ‘spectators’ perceiving neutral objects in an external world. Rather, according
to Heidegger, we find ourselves “thrown” into a world, already interpreted and imbued
with meaning and significance. In a sense, being-in-the-world can be understood as
practical in its orientation; objects do not appear to us as simply objects, but rather
stand “ready-at-hand”, situated within our larger projects and goals, with imma-
nent meaning through their embedding within specific interpretive contexts. To give
an example, Heidegger writes of how when we perceive a table in a room, what we
perceive is not simply a neutral object, extended in space with specific dimensions and
properties, but rather this particular table, which may be a table-for-writing, a table-
for-dining, and so on. Moreover, our interpretation of this table is not just personal
and idiosyncratic but also incorporates broader historical and cultural valence, felt,
for example, when we perceive our old student’s desk in our grade school English
classroom, or the antique harvest table in our family home. In this way, for Heidegger,
being encompasses a mode of disclosing the world—a mode of “revealing” it to us
in existence.
Heidegger’s philosophy of technology follows from this interpretation of being.
Technology for Heidegger cannot be understood in narrow, instrumentalist terms, as
value-neutral means to an end, but rather constitutes a mode of being—a mode of
revealing the world. As mentioned, Heidegger was a critic of Western metaphysics
and the resulting outlook of modern science, which objectifies the natural world.
256 B. Chin-Yee

But rather than technology being the product of this scientific worldview, Heidegger
reverses the relationship: the misunderstanding of being found in Western philosophy,
and by implication in modern science, is a symptom of technology and its mode
of revealing. Here Heidegger inverts the positivist view, asserting the ontological
priority of technology over science.
What does Heidegger mean when he calls technology “a way of revealing”?
Heidegger points out how technology engenders a particular outlook which shapes
our being-in-the world. For example, he argues that through the technological outlook
of modern mining and forestry we come to view the earth as a source of mineral
deposit or the forest as a source of lumber—ordered “cellulose”, as he calls it
(Heidegger [1954] 1977). Through this way of revealing “everywhere everything
is ordered to stand by”. Technology brings about an “ordering” of the world where
everything is seen as “standing-reserve”. Heidegger refers to this as “enframing”,
through which “the work of modern technology reveals the real as standing-reserve”.
For Heidegger, enframing is the essence of technology: “The essence of modern tech-
nology shows itself in what we call Enframing”. Enframing results in a flattening
of the immanent meanings revealed by pre-technological being, and in this way
threatens the very act of revealing itself. As Heidegger (ibid) writes:
The coming to presence of technology threatens revealing, threatens it with the possibility
that all revealing will be consumed in ordering and that everything will present itself only
in the unconcealedness of standing-reserve (33).

Technology’s way of revealing, however, is not limited to the natural world, but also
threatens to encompass human beings themselves. Herein, for Heidegger (ibid.), lies
the real danger:
As soon as what is unconcealed no longer concerns man even as object, but does so, rather
exclusively as standing-reserve, and man in the midst of objectlessness is nothing but the
orderer of the standing-reserve, then he comes to the very brink of a precipitous fall; that is,
he comes to the point where he himself will have to be taken as standing-reserve (emphasis
added, 26–27).

Such a claim might seem unsurprising today, in a time when the datafication of
day-to-day existence has become fact of life, serving as a reminder of the power of
technological enframing from which human beings are not immune. This enframing
is also seen in healthcare, where data-driven technologies effect an ordering of human
bodies and their data, which ‘stand-in-reserve’ as inputs into algorithms. A full
discussion of Heidegger’s philosophy of technology and its applications to healthcare
could fill a volume of this size. The key takeaway for our discussion is Heidegger’s
view of technology as a “way of revealing” that he calls “enframing”, which for him
captures the “essence of modern technology”.
While Heidegger’s writings on technology have been influential they are not
without criticism. Although some critics characterize him as a Luddite or Romantic,
nostalgically clinging to a pre-technological age, his arguments cannot be so easily
dismissed. Heidegger ([1954] 1977) recognized that we cannot simply return to
a former, pre-technological mode of being but rather argued that we must strive
17 The Philosophy of Technology … 257

to gain a “free relationship” with technology. Heidegger himself was notoriously

obscure about how this might be achieved, and pessimistic about the prospects,
(in)famously stating in his last interview with Der Spiegel “only a god could save
us now” (Heidegger [1966] 2017). For this reason Heidegger is sometimes seen
as a technological determinist, attributing to technology an autonomous power to
inevitably shape humanity and the social world. Some interpretations of Heidegger
attempt to move away from his determinism and its pessimistic conclusions, for
example, offering the possibility of keeping touch with revealing through “focal
things and practices” (Borgmann 1984, 16), or cultivating a plurality of modes of
being which includes the technological (Dreyus and Spinosa 1997). Such approaches
find parallels in health professions education, where some have advocated pluralism
with respect to medicine’s diverse ‘ways of knowing’ (Chin-Yee et al. 2018; Thomas
et al. 2020). I will return to these ideas below but first introduce another philosopher
of technology who attempts to overcome certain limitations of Heidegger’s account.

17.3.2 Feenberg’s Critical Theory of Technology

Andrew Feenberg is a contemporary philosopher of technology who integrates

insights from both Heidegger and the Frankfurt School, especially Herbert Marcuse,
to develop what he calls his “critical theory of technology” (Feenberg 1991, 2002).
While Heidegger remains his starting point for critical reflection on technology, Feen-
berg challenges the essentialist and determinist interpretations found in Heidegger
and other critical theorists, which tend to overstate technology’s autonomy and power
over the social world. Rather, Feenberg’s account not only looks at how technology
shapes society but also how society shapes technology. Here he draws on social
constructivism, which examines how social norms and interests influence techno-
logical design and operation within ‘sociotechnical’ systems (for discussion, see
Bijker et al. 2012).
Feenberg emphasizes the constructivist notion of technological underdetermi-
nation, which holds that considerations of function and efficiency alone under-
determine the design of technical artifacts, which necessarily require additional
social choices. Feenberg cites a famous example from Langdon Winner’s classic
essay “Do artifacts have politics?” (Winner 1980), a question which is answered in
the affirmative. Winner discusses how the low hanging overpasses of New York’s
Southern State Parkway reflect deliberate design choices by their architect, Robert
Moses, who sought to exclude low-income and racialized groups that relied on
buses to access Long Island’s beaches. Winner’s case study illustrates how a tech-
nical artifact, such as a bridge, is not politically neutral but rather can incorporate
racist and classist ideologies in its very design. These ideologies, however, become
concealed, inscribed as “technical code” during the artifact’s production (Feenberg
2010b). “Technical codes” introduce bias, which can be “substantive”, a reflection of
societal prejudices, or “formal”, arising from the very idea of what constitutes a
rational, well-functioning system.
258 B. Chin-Yee

Several scholars offer examples of how design choices encode bias in technical
systems, from search engines to insurance algorithms (for examples, see Benjamin
2019b; Noble 2018; Eubanks 2018). Medicine is also ripe with examples, with histo-
rians and sociologists exposing how what are commonly taken as neutral instruments
can incorporate ideologies of race and gender, from the speculum (Sandelowski 2000)
and spirometer (Braun 2014), to state-of-the-art predictive algorithms (Benjamin
2019a). While some might see these as extreme examples, it is important to note
that all technologies have an inherently normative dimension written in their tech-
nical code, which dictates factors such as which users are included/excluded and
how a technology operates within a given social order. To again use the example
of vaccine design, factors such as appropriate storage conditions, means of trans-
portation, number of doses required and dosing interval, all might have technical and
scientific rationale, but they are also normative, shaping how vaccines are ‘properly’
used, who has access, and who does not.
Bias, therefore, is a basic feature of all technical systems, which one uncovers
by interrogating the co-construction of the technological and the social. According
to Feenberg, technology does not simply entail, as it does for Heidegger, a “way of
revealing” the world as decontextualized objects, the “standing-reserve”, reduced to
functional utility (Heidegger [1954] 1977). Rather, technology must also undergo
a “secondary instrumentalization”, which reappropriates context, giving an artifact
its social meaning and adding additional normative content (Feenberg 2002). For
Feenberg, this process even has the potential to bring about a reconfiguration and
transformation of technology according to human interests.
By bringing together critical theory and social constructivism, Feenberg generates
a dialectic between instrumentalist and determinist perspectives: technology indeed
shapes the social order but at the same time humans maintain their agency to change
technology (for an in-depth discussion of agency, see Chap. 11). This allows him
to propose a more optimistic account, wherein technology is not always oppressive
but can instead serve as a medium for expression of social values, opening up the
possibility of democratizing technical systems. To paraphrase Feenberg (2010a), it
is through technology that today’s values become the facts of tomorrow. This idea
in particular brings Feenberg’s philosophy of technology into close proximity with
John Dewey’s, which I turn to now.

17.3.3 Dewey’s Pragmatist Philosophy of Technology

John Dewey is widely known as a philosopher of American pragmatism, whose near-

century’s worth of writing spanned topics from logic and epistemology to politics
and education. Dewey is less commonly known, however, as a philosopher of tech-
nology, although there is growing recognition of his ideas on technology thanks to
sustained efforts by scholars such as Larry Hickman (1990; 2001), as well as the
17 The Philosophy of Technology … 259

recent publication of a previously lost Dewey manuscript (2012). It is fitting to end

our survey with Dewey, who ties together several of the themes discussed above.
Despite coming from distinct intellectual traditions, Dewey shares Heidegger’s
view of the ontological priority of technology over science. Also, similar to
Heidegger, Dewey’s ([1929] 1984a) view of technology is best understood within a
broader critique of Western epistemology and its “spectator” theory of knowledge.
For Dewey, even more so than for Heidegger, human existence is a practical affair:
we are not spectators of nature, perceiving an external world from which we ascertain
knowledge, but rather are active participants in it. Knowledge, therefore, is not a set
of universal propositions but rather is context-dependent and directed towards a use
or end—not simply knowledge but knowledge-for.
Dewey’s conception of technology follows from this pragmatist perspective. For
Dewey, knowing itself can be understood as a form of technology, where technology
is roughly defined as a method of inquiry and set of tools for resolving problematic
situations. This differs in an important way from Heidegger view of technology as
a mode of revealing. Dewey offers a naturalized account of technology, which—
contra Heidegger—is not a uniquely modern (mis)understanding of being, but rather
a fundamental aspect of how humans cope with the natural and social world. Like
Feenberg, Dewey also rejects Heidegger’s essentialism: there is no ‘essence’ of tech-
nology or of the technological; technology instead describes both the process and
product of inquiry, which is not fixed but rather evolves to fit context and human needs.
As Dewey ([1930] 1984b) put it: “‘Technology’ signifies all the intelligent techniques
by which the energies of nature and man are directed and used in satisfaction of human
needs” (270).
While this definition might seem somewhat broad, Dewey’s writings on tech-
nology are in fact subtle and multifaceted with deep links to his pragmatism, as
explored in detail by Hickman (1990; 2001). For want of space, I will focus on one
central aspect of Dewey’s philosophy of technology, which is his treatment of means
and ends. A first point to make is that Dewey rejected the notion of fixed ends or “ide-
als”, which he argued had been emphasized in Western philosophy since antiquity.
Rather, he sought to elevate means, which he believed had been wrongly denigrated
as “menial” and subordinated to ends. A vestige of this view is perhaps contained in
the positivist position, whereby technology serves as pure means, lacking any content
beyond its function in attaining predefined ends. At the core of Dewey’s philosophy
of technology is the interdependence of means and ends. For Dewey, ends always
arise during the process of inquiry, emerging out of a problematic situation that
demands resolution. He uses the term “ends-in-view” to emphasize the provisional,
revisable nature of ends, which should not be taken as fixed ideals (Dewey [1922]
2008). While ends-in-view form one component of inquiry, means play an equally
important role in determining its course.
This interplay between means and ends is best illustrated by way of example. I
am faced with a patient who is anaemic: my ends-in-view is to identify the source of
blood loss, which suggests a means of investigation, for instance, endoscopy. This
260 B. Chin-Yee

produces a new end, namely, to stop the identified source of bleeding. This end,
however, is not fixed or final; once achieved it must be re-evaluated within the new
situation. For example, if the source of blood loss turns out to be a tumour, additional
ends arise which in turn indicate new means for action. This case highlights what for
Dewey is a general feature of human activity: ends are not extrinsic givens but rather
emerge from within the context of inquiry. Across several of his writings, Dewey
warned against pursuing “fixed” ends, which might be said—to paraphrase another
American pragmatist—to block the path of inquiry (Peirce [1898] 1960).
What are the implications for healthcare? Dewey would be critical of approaches
in medical research and health professions education that reify quality of care based
on narrow metrics, such as adherence to specific guidelines or achieving partic-
ular biomarker targets, which impose fixed ends but often overlook their means and
potential harms. Likewise, he would disparage medical technologies focused on pre-
set performance targets to define success, such as a high area under the receiver
operating characteristic curve for a machine learning model, which may indicate
high sensitivity and specificity but does not attend to use within a wider clinical
context and impact on patient-centered outcomes (for discussion, see Oren et al.
2020). For Dewey, ends must not be extrinsic, built into “off the shelf” technolo-
gies according to prevailing interests, but rather should arise from inquiry aimed at
ameliorating the human condition, and therefore should be democratically instan-
tiated (Waks 1999). Dewey (2012) rejects the positivist idea of technology as pure
means to external ends, which renders technology “indifferent” to its uses, and “sig-
nifies that something else is sure to decide the uses to which it is put” (244). For
Dewey, that “something else” included not only “traditions and customs” but also
“rules of business”, words written—not incidentally—during the Golden Age of
American capitalism. This lesson remains especially salient today, amidst growing
recognition of powerful commercial interests driving the technologization of health-
care, with advances in digital health technologies often coeval with shifts towards
greater privatization (Wamsley and Chin-Yee 2021). Healthcare professionals must
remain vigilant of where the ends of technologies derive, and ensure that providers,
patients, and their communities are engaged in the co-construction of tools. Here
Dewey, not unlike Feenberg and the social constructivists, shows us how ethical
considerations and questions of values play a crucial role in the determination of
technology’s ends and means.

17.4 Conclusion: Technology and the Practical Art

of Medicine

We are now in a better position to revisit the false dichotomy posed at the outset,
that incalcitrant dualism between the art and science of medicine which has the
propensity to devolve into arguments over medicine’s “two cultures” (Wulff 1999;
Snow [1959] 1993), maintaining an erroneous divide between facts and values. As
17 The Philosophy of Technology … 261

Kathryn Montgomery (2005) points out, medicine is best understood as a practice,

or as Dewey might put it, a practical art.
This chapter has highlighted how medical technologies cannot simply be under-
stood as extensions of medical science but rather form a fundamental part of medicine
as a practical art. And as practical art, technology is one locus where facts and
values come together, an idea supported by all three philosophers discussed above.
I conclude by reiterating three main themes from this discussion, which help dispel
myths of the positivist position and offer important lessons for health profession
education. Each theme not only serves as a starting point for critical dialogue between
medical educators and learners but might also be integrated into medical curricula
as a basis for teaching on the ethical and social dimensions of technology, supple-
menting a tendency for technological education to focus on acquisition of discrete
skills and competencies while often overlooking broader questions of context and
application (Table 17.1).

17.4.1 Technology as a Way of Thinking

The first lesson, common to both Heidegger and Dewey, is that technology does
not simply refer to material artifacts or “mechanical forms” but rather encompasses
a way of thinking or being-in-the-world (Dewey [1930] 1984; Heidegger [1927]
1996). Applied to healthcare, this lesson occasions reflection on how technology and
technological thinking shapes our ‘ordering’ of the clinical world and interactions
with patients. It warns against a tendency to see patients as mere ‘standing-reserve’,
reducing their experiences to data, which serve as inputs for use in algorithms (Chin-
Yee and Upshur 2019). Healthcare professionals must be cognizant that these tools
form only one mode of revealing, powerful yet limited. To truly support a ‘free rela-
tionship’ with technology, educators must create space for other forms of ‘revealing’,
for example, by helping to cultivate those “moments of being” which give meaning
to practice (Kumagai et al. 2018). Knowledge from the social sciences and humani-
ties, including philosophy, can help foster this epistemic humility and pluralism with
respect to medicine’s “ways of knowing” (Chin-Yee et al. 2018; Thomas et al. 2020).
This lesson avoids training healthcare professionals who are technically proficient at
gathering data and applying algorithms but who are unable to step outside this mode
of revealing to see a clinical problem from a different angle or appreciating another
perspective not captured by the algorithm.

17.4.2 Technology as Value-Laden

The second lesson, found in all three thinkers, recognizes technology not as the value-
neutral application of science but rather as “teeming with values and potentialities”
262 B. Chin-Yee

(Hickman 1990), which reflect a range of social choices. This lesson in particular
requires us to examine those choices and the biases they encode. It raises critical
questions, such as ‘Who is included?’, ‘Who is excluded?’, and ‘Whose interests does
a given technology serve?’ Such questions should be continually raised in medical
research and health professions education, serving as opportunities to reconfigure
and transform technology’s means and ends, orienting them towards greater equity
and inclusion.

17.4.3 Technology as a Continuum of Means and Ends

The last lesson is that technology does not exist as pure means dictated by external
ends but rather involves a continuum of means and ends, which develop iteratively
through the process of inquiry. This lesson teaches that technology’s ends are fallible,
and alongside means, require revision and adjustment to context.
Returning finally to the opening example of Watson for Oncology, performance
of such a tool cannot be evaluated solely on the basis of pre-defined ends, such as
agreement with expert consensus as is often the case in appraisal of algorithmic
decision-making (Tupasela and Di Nucci 2020). Rather, it requires that we situate
the technology’s use within the uncertain situation in its totality, in this case, the
clinical problem of selecting treatment for a patient with a diagnosis of cancer. From
here we ask: ‘What are the ends-in-view?’ Such a question focuses the problem: Is
it to provide the ‘best’ treatment as defined by the latest clinical trial evidence? Is it
to tailor ‘precision’ therapy for a specific set of genomic biomarkers? Or, rather, is
it to treat this particular person in a way that considers their individual context and
values? Such ends differ in important ways and suggest different means, calling for
different tools or even different modes of thinking altogether.
Healthcare professionals must remain sceptical of approaches that reify ends,
defining success in narrow terms, and instead indefatigably scrutinize means and ends
for their ability to serve the needs of clinicians, patients, and their communities. In
this endeavour clinicians, educators and philosophers all play a critical role, offering
the knowledge and values to shape the medical technologies of tomorrow. The rapid
pace of technological change can be overwhelming for many, giving rise to a tendency
to relinquish control and adopt a determinist perspective—recalling Heidegger, that
“only a god can save us now”. However, to end on a more optimistic note, we might
also reflect on a quote from Dewey ([1934] 2013), who argues for a different type of
faith:
Faith in the power of intelligence to imagine a future which is the projection of the desirable
in the present, and to invent the instrumentalities of its realization, is our salvation. And it is
a faith which must be nurtured and made articulate: surely a sufficiently large task for our
philosophy (48).
17 The Philosophy of Technology … 263

Table 17.1 Practice points

1 Philosophy of technology teaches us to think critically about medical technologies and
offers important lessons for health professions education
2 Technology does not simply refer to material artifacts but instead describes a particular
way of thinking and interacting with the world
3 Technology is not value-neutral but rather reflects a range of social choices and human
values
4 Technology does not serve as pure means to fixed ends but instead involves a continuum
of means and ends which evolve through the process of inquiry
5 These lessons support more reflexive engagement with technology amongst healthcare
professionals to better address the needs of clinicians, patients, and their communities

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Chapter 18
Philosophy as Therapy: Rebalancing
Technology and Care in Health
Professions Education

Martina Ann Kelly, Tim Dornan, and Tinu Ruparell

18.1 Introduction: Contradictions in 21st Century Health

‘Care’

The best physician is also a philosopher

Galen, Title of a Treatise (165–175 BCE).

Fildes’ painting of ‘The Doctor’ (1891; See Fig. 18.1) at the bedside of a sick child
epitomises a type of caring that centres on a patient and their family. Fildes’ moment,
frozen in time, is used to stimulate medical students to discuss doctor-patient relation-
ships (Macnaughton 2000; Olthuis and Dekkers 2003; Tauber 2000; Verghese 2008).
How often, we might ask, does contemporary practice conform to that epitome? Much
of it is delivered in sterile spaces, bustling with members of different professions and
bristling with technologies intoning an anthem of beeps. Steel trolley-beds in wards
have taken the place of wooden beds in patients’ homes and, during the COVID-
19 pandemic, personal protective equipment covers conventional attire. The term
‘healthcare’ has become more organisational than charismatic, with overtones of
electronic medical records integrated with laboratory networks, diagnostic imaging,
and targeted, precision medicines. Artificial intelligence heralds an era when even
wisdom is to be instrumentalised. Healthcare is morphing into a landscape of trade
and policy where bureaucratization and mechanisation subsume, dilute, objectify,

M. A. Kelly (B)
Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
e-mail: makelly@ucalgary.ca
T. Dornan
Queen’s University Belfast, Northern Ireland, UK
Maastricht University, Maastricht, The Netherlands
T. Ruparell
Department of Classics and Religion, University of Calgary, Calgary, AB, Canada

© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2022 267
M. E. L. Brown et al. (eds.), Applied Philosophy for Health Professions Education,
https://doi.org/10.1007/978-981-19-1512-3_18
268 M. A. Kelly et al.

Fig. 18.1 Fildes’ painting of ‘The Doctor’

and quantify people’s individual experiences of care. Health professions education,

meanwhile, espouses caring as its foundational value (Fig. 18.1).
Putting our current practice of highly complex and abstract technological health-
care ‘back in the box’ is not a realistic option, so the aspiration to stay true to caring
values demands urgent reconsideration of what we mean by technology. According
to Heidegger (1962), the old High-German word Sorge equates caring with ‘being
there’ or Dasein. Addressing Heidegger’s ‘question of care’ requires us to interrogate
what we understand as technology. Sorge gives us a philosophical means to reveal or
situate physicians and patients in ways that shed light onto how health professions
education and practice can be caring. The purpose of this chapter is to examine how
philosophy, as a technology of care, can disentangle the complex interrelationships
between caring, technology, and healthcare in ways that help us see patients, students,
clinicians, and practice anew. We use the term ‘caring’ to mean relationships imbued
with the core values of clinical practice, as described above, and ‘care’ to refer to the
system within which these caring relationships may take place.

18.2 Historical Precedents

Galen’s dictum that the best physician is also a philosopher, which heads this chapter,
provides a prompt from the second century BCE to explore the philosophy of caring
and technology. It justifies, also, our quest for a philosophical care: a therapeia
18 Philosophy as Therapy: Rebalancing … 269

or philosophical therapy that can combat suffering. Our next figure, who lived in
the sixth century BCE was the Roman statesman and philosopher Anicius Manlius
Severinus Boethius. A dialogue composed by Boethius (as he is commonly known)
entitled The Consolation of Philosophy (Boethius [523] 2000) was one of the most
influential books of the European long middle ages. At the beginning of the text, the
imprisoned Boethius laments his fate and, indeed, his continued existence when he
is visited by Lady Philosophy:
a woman of a countenance exceeding venerable. Her eyes were bright as fire, and of a
more than human keenness; her complexion was lively, her vigour showed no trace of
enfeeblement; and yet her years were right full, and she plainly seemed not of our age and
time … Her right hand held a note-book; in her left she bore a staff. (16–17)

Boethius, blinded through his tears, is struck dumb by this vision. Lady Philosophy
responds as a physician, saying to him that the time “calls for healing rather than
lamentation […],
Then, when she saw me not only answering nothing, but mute and utterly incapable of
speech, she gently touched my breast with her hand, and said: There is no danger; these are
the symptoms of lethargy, the usual sickness of deluded minds. For a while he has forgotten
himself; he will easily recover his memory, if only he first recognizes me. And that he may
do so, let me now wipe his eyes that are clouded with a mist of mortal things. Thereat, with
a fold of her robe, she dried my eyes all swimming with tears. (22–23)

Boethius remembers her, from his time as a youth:

… even so the clouds of my melancholy were broken up. I saw the clear sky and regained
the power to recognize the face of my physician. Accordingly, when I had lifted my eyes
and fixed my gaze upon her, I beheld my nurse, Philosophy, whose halls I had frequented
from my youth up. (24)

So began the tradition of philosophy as a healer (or rather healing), and carer (caring).
As the second text shows, the mere presence of Lady Philosophy was a powerful
therapeutic effect on Boethius. The next section moves from those early precedents
to a modern articulation of a philosophical discipline: hermeneutics.

18.3 What Is Hermeneutics?

Hermeneutics, put simply, is the theory of interpretation. Historically, religious texts

were the object of hermeneutic inquiry, but hermeneutics has later applied to general
questions of interpretation per se and, more specifically, the interpretation of experi-
ence. This rendered an alternative account of human understanding, reflection, and
subjectivity to the explanatory model of natural sciences. Hermeneutics seeks to
reveal, clarify, and critique conditions which give rise to discourses, beliefs, and
practices through which we engage with the world and each other.
The entry point for hermeneutic inquiry is often a fissure: an experience that
catches us and makes us pause; (Moules et al. 2014) for example, I (Martina) started
270 M. A. Kelly et al.

to write this chapter feeling confident about my understanding of care. As I reflected

on my experiences during the COVID-19 pandemic, I recognised new insights and
interpretations that troubled me. These led me to question what is care, rather than
‘what should care be’, or ‘what does healthcare understand care to be’. Pursuing
questions like mine presents us with ‘texts’, which means any linguistic, symbolic, or
experiential expression of meaning which presents us with the primordial question:
“what am I?” Our response is to construe the text; to interpret it as something.
This very construal-as transforms the text into something new, which prompts new
questions. The hermeneutic dialectic invites us into a circular process of describing
and interpreting through which things reveal themselves.
Through the hermeneutic circle, a thing reveals itself as what we are coming to
understand: it homes in, spirally, towards a tentative and temporary ‘reading’, whilst
simultaneously revealing a plethora of other possible construals-as. The product of
a hermeneutic circle is not an absolute endpoint but a temporary stopping place; a
moment of respite on a potentially unending journey of discovery.
While hermeneutics is just one possibility among several philosophical practices,
it provides useful ways of opening a deeper inquiry into caring. It supports a practice
of questioning, which springs from the natural propensity within us all to reflect
rationally on our experiences of engaging with the world (Gadamer 1981).

18.4 Applying Hermeneutics

A key premise of our proposal that healthcare can be understood as a philosophical

practice is that caring is a specific way of relating to and questioning another human
being. It is an intersubjective exchange between a patient and their physician, which
reveals the particular, situated ways of being human of both patient and physician.
The work of two German philosophers, Hans-Georg Gadamer (1990–2002) and
Martin Heidegger (1889–1976), helped us explore this premise by spirally inter-
weaving hermeneutic ideas with our experiences as clinicians, researchers, teachers,
and patients.
Heidegger’s work helped us mitigate the dominance of technology by reposi-
tioning human experience at the centre of healthcare and health professions educa-
tion. His concept of mitsein, being-with patients in the context of therapeia, supported
our development of a hermeneutic understanding of patient-physician relationships,
which took into account the context, role, and practice of interpretation. Gadamer’s
philosophical hermeneutics, founded on the core concepts of language and tradi-
tion, supported our examination of how dialogue between physicians and patients
can foster understanding, explaining, and fusing horizons. Hermeneutics helped us
destabilise the meaning of care in the very act of delivering an interpretation of care.
This could only be a provisional interpretation, however, since, in Gadamer’s words,
‘interpretation is always on the way’ (Gadamer 1981).
18 Philosophy as Therapy: Rebalancing … 271

18.5 Language

If meaning is shared and emergent, the medium through which this happens is
particularly significant for interpretation: language manifests our understanding of a
disclosed, shared world (Gadamer 2008). Gadamer viewed language as not merely
a vehicle for understanding but as its very manifestation, part and whole. Words are,
of course, part of a tradition which changes over time. As human beings, we inherit a
linguistic tradition, a treasure trove of meaning bearing the marks of history, culture,
and the meaning-making of people who preceded us. Language provides a semantic
network which subtends a particular set of meaningful distinctions providing a struc-
ture through which the world is made intelligible (Simpson 2021, 4). Language, while
not a mirror, is coextensive with the world and forms its manifest semantic articula-
tion. Both language and our particular forms of life are meaningful in and through
their relationship: “in language, experience and knowledge become sedimented and
speak directly to us through the words themselves” (Gadamer 1996).
Understanding, as mediated by language, is not something we acquire and possess
but something in which we participate: a way of being in the world. We live in a
tradition of understanding; but, like fish who are unaware of water, we are hardly
aware of the air we breathe. Attentiveness to language helps us unearth meaning,
open possibilities for interpretation, and reveal forms of life as such. Anticipating,
exploring, and playing with meaning, creates many possibilities. Importantly, too,
this can show us how some interpretations abide and evolve, while others are lost;
what is said/known is always in relation to what is unsaid and unknown. For Gadamer,
each encounter with language is not a simple matter of unselfconscious appropriation
and assimilation, but a thoughtful exercise of historical consciousness. Words provide
transformative awareness of the shape of our being. This consideration of language in
hermeneutics leads us, in the next section, to problematize care by deeply questioning
some common language that underpins it.

18.6 Hermeneutic Reflections on the Language of Care

on Health, Illness, Healing and Implications for Care

Susan Sontag famously wrote “everyone who is born holds dual citizenship, in the
kingdom of the well and the kingdom of the sick” (Sontag 2001, 3). Illness cannot
not exist without health. But what is health? Defined biomedically, as contempo-
rary healthcare is wont to do, health is an ideal blood pressure, cholesterol level,
and Haemoglobin A1c. Technologies that achieve targets defined by evidence-based
guidelines determine citizenship of the kingdom of the well. This citizenship is at a
premium as we extend disease definitions, screen for risks, and label what were previ-
ously considered ordinary human experiences as diseases. Those clinical activities
order the experiences of both patients and clinicians. As Heath (2019) writes: “we
have allowed tests to displace listening, numbers to displace description, technology
272 M. A. Kelly et al.

to displace touch, the objective to displace the subjective” (78). The World Health
Organisation (WHO) definition of health is not merely the absence of disease but a
state of complete physical, mental and social well-being (World Health Organization
1946). This sense of health as harmony-in-well-being sometimes escapes our atten-
tion and always the attention of our technologies of measurement. Health illustrates
the “miraculous capacity we have to forget ourselves” (Gadamer 1996, 96). At least
as far as this chapter is concerned, health is a condition of inner accord, a coherence
with oneself, which cannot be determined by external forms of control (Ibid).
Illness disrupts the harmony of feeling well and being able to engage actively
in the world. It does not represent merely a medical-biological disruption, but an
experience of life-historical and social disconnection. The sick person is no longer
the person she or he was before. They have become “unstuck” from themselves,
having fallen out of their normal place in life and requiring support to re-establish
equilibrium (Gadamer 1996, 42). Illness changes our identity, intimates mortality,
and calls into question our being: the elusive essence of what it means to be human.
Caring, as Sorge, originally meant to grieve, feel concern, or experience anxiety.
When we fall ill, caring recalls our form of life and reconstitutes a way of being from
which we (hopefully only temporarily) stumbled. Caring is a concern about who we
are and who we want to be. Caring for our own health is an original manifestation
of human existence (Gadamer 1996).
Gadamer regards the human task of healing, restoring the totality of our being-in-
the-world, as dwarfing the science of illness (Gadamer 1996). To consider the role
of treatment, Gadamer revisits the German language, where ‘treatment’ (Behand-
lung) and ‘handling’ (handhaben) are etymologically related. Caring is handhaben.
It stems from the skilled and gentle hand of the physician-philosopher, who recog-
nises problems by feeling affected parts of the body, while training a sensitive ear to
what the patient says and observing them with an unobtrusive eye. Recalling Lady
Philosophy, she begins her care of Boethius by saying, “speak out, hide it not in thy
heart. If thou lookest for the physician’s help, thou must needs disclose thy wound”
(Ibid, 28, emphasis authors’ own). Observing Boethius’ fragile, weakened state, she
chooses an initial course of action:
Since thou art distraught with anger, pain, and grief, strong remedies are not proper for thee
in this thy present mood. And so for a time I will use milder methods, that the tumours
which have grown hard through the influx of disturbing passion may be softened by gentle
treatment, till they can bear the force of sharper remedies. (Ibid, 42–43)

Many patients and physicians are aware that over-reliance on technology can be at
the cost of caring. Physical examination, for example, can be more than a diagnostic
procedure. It is an embodied interaction, which can express concern and presence. It
is a bearing witness to illness, and a co-revealing of both the patient’s and physician’s
form of being in the world at that moment. (Kelly et al. 2019).
Treating illness commands our attention to the totality of another person. Healing
means ‘making whole’: not only a successful struggle against illness but caring, in its
broadest sense, for a person (Gadamer 1996). Whole refers to the harmony: the inter-
connectedness of being a human in the world who is linked to others, caught in the
18 Philosophy as Therapy: Rebalancing … 273

flux of experience, partners in a shared life-world. Healing, in this sense, recognises

the simultaneous individual and communal nature of being. Healing relationships
recognise the other in their otherness and defy care being ‘standard’. Recognizing
the other may guide us towards helping them find their own, independent way. It
may help us discharge our responsibility both to be caring and to uphold the freedom
of a patient. Healing thus gives space to the expression of self, as a being in the
world, which allows physician and patient to acknowledge their similarities and
differences. Caring, broadly speaking, is recognising a fundamental human concern
about who we are and who we want to be. Caring, to summarise our philosophical-
hermeneutic exploration, is much more than the instrumental application of ‘compas-
sionate competence’ to a passive, vulnerable recipient of care—a patient. It is, rather,
to understand the person, their illness and our relationship with them in the broader
light of their broader flourishing.

18.7 Philosophy as a Technology of Care

We now consider how, like Lady Philosophy, we might deploy philosophy as caring.
To be specific we examine technology from a philosophical viewpoint, considering
how this could redescribe it as consistent with therapeia. To do this, we distinguish
technology as a collection of tools, processes, instruments, and other contrivances,
from a broader understanding of it to make space for philosophising as care.
No recent thinker has influenced our understanding of technology more than
Martin Heidegger. In his short essay of 1954, The Question Concerning Technology
(Heidegger [1954] 1977),1 he argues three fundamental points. First, that technology
does not refer merely to instruments. It is much more: a way of being in the world.
Second, he proposes that technology is not something we humans make: it pre-exists
us and we become caught up in it. Finally, he warns us of the beguiling, ensnaring
power of technology and points to a deeper understanding, which both explains
technology and, by doing so, shrugs free of its fetters. It is this third proposition that
offers a practical role for philosophy in healthcare.
The key characteristic of technology for Heidegger, its essence, is that it renders
or enframes the world in certain ways for us. For instance, picking up a hammer
renders the world as potential nails. And the hammer also renders us: we become
‘hammer-users’ and are thus enframed by a technology that we deploy. In this sense,
enframing is a natural and unavoidable aspect of technology. However, overreliance
on the instruments of contemporary healthcare renders both patients and physicians
as mere cogs in the bureaucratized machine of technologized practice, squeezing
out possibilities for authentic action and concern. This is a gloomy message because
it seems to make the possibility of a hermeneutic of caring seem Utopian. Strict

1This was originally part of a lecture entitled The Framework and part of a series of 4 lectures
delivered in Bremen in 1949, the other lectures being entitled: The Thing, The Danger, and The
Turning.
274 M. A. Kelly et al.

empiricism abounds, from measuring blood pressure to treating cancer with complex
and expensive machines and algorithms. It is hard to imagine healthcare that is not
dominated by the complex, technological, fiscal, bureaucratic, and political structures
that have become all too familiar.
Ironically, however, technology’s potential undoing is within the essence of tech-
nology. Whilst it cannot be erased, neither can it escape its essence: technology can
itself be rendered as merely a form of enframing—one among many. An alterna-
tive enframing might consist of being open to questions, entering dialogue, being-
with, being prepared to self-reveal, co-creating, and understanding. This hermeneutic
model of clinical practice makes philosophy, itself, a technology: an alternative to
instrumental mechanisation. Doing philosophy, being open to patients in a practice
of questioning and being questioned, cognizant of the mutually imbricated traditions
and subjectivities at play, makes caring intersubjectivity itself, a therapeutic interven-
tion. This hermeneutic of caring describes the preconditions, practices, and outcomes
of authentic engagement with patients. Its technology is philosophy as therapeia. It
is a technology of achieving the ideals of a hermeneutic of care. Philosophy as a prac-
tice of alternative enframing redescribes patient and physician in mutually accepted
ways that articulate caring. Re-thinking technology as not merely a set of tools to
manipulate symptoms towards a ‘cure’, but rather a contingent rendering of being
human, which promises liberation from over-reliance on and naïve use of technology.

18.8 Implications for Health Professions Education

Caring dialogue contrasts informatively with traditional models of the clinical consul-
tation. It is widely assumed that good communication is useful in so far as it hones
the information needed to implement biomedical formulae that will manage ‘the
problem’. This way of thinking about communication presupposes an objective
reality, which exists independently of the participants. While biopsychosocial models
of care accommodate context, they don’t go so far as to frame dialogue as mutu-
ally transformative, nor do they adequately recognise the intersubjective elements
of interpretation. To the contrary, such models subject patients to interrogations,
which objectify both patient and physician as supplicants to scientific dominance.
This biomedical, algorithmic management of ‘care’ reduces the subjectivities of
patients and clinicians to the level of fungible parts of a system – standing reserve
for the biomedical, ‘technologized’ mill. Adopting philosophy as a technology of
care would subvert the instrumentalization of patient and physician and offer new
ways to enframe consultations: communication as.
Hermeneutic engagement requires physicians to bring themselves to consulta-
tions as human beings with a ‘will to share’ (Heath 2019), not as people with
‘detached concern’. This requires physicians to allow conversations to impinge
inwardly, reflecting on their understandings while being open to new understand-
ings that may result from reflection. Physicians can then view patients in the full-
ness of their humanity, minimizing fear, locating hope, explaining, witnessing, and
18 Philosophy as Therapy: Rebalancing … 275

accompanying patients (Heath 2019). In this way, physicians can respond to “the
unconditional imperative to acknowledge every person as a person…. this seems
little, but it is much” (Tillich 1969, 28). Little acts constitute caring. In one of our
studies, (Gillespie et al. 2018) we asked patients to describe their experiences of
caring. Many times, they characterised caring as paying attention to ‘little things’,
such as phoning to check they were OK, and remembering personal details. These
‘little things’ were possible because physicians were humble enough to be prepared
to share themselves (for more on being humble and humility, see Chapter 24).
Unpredictability is an inevitable feature of hermeneutic consultations, which prac-
tice philosophy as a technology of caring. The task is not to provide care as (instru-
mental) ‘solving’. Caring that results from understanding carries risk because it is
uncertain, can take many possible directions, and is the antithesis of finding the
single best answer. It is, as Gadamer suggests, an adventure (Gadamer 1981). The
‘art’ of clinical care, as proposed by Peabody, is an excellence construed between
the patient and the physician—the “secret of the care of the patient is in caring for
the patient” (Peabody 1984, 813, emphasis our own). But adventures don’t just carry
risk, they offer opportunities as well. Caring as hermeneutic understanding provides
opportunities for physicians to broaden their own experience and self-knowledge.
We suggest, based on our own experience, that being willing to “hold oneself open
in the conversation” (Gadamer 1981, 189) offers an emancipatory opportunity for
physicians, which could provide an antidote to the burn-out that results from passive
neutrality. Being oneself and revealing oneself to one’s patient allows one to engage
more genuinely as a carer. It enriches one’s sense of being a physician and nurtures
one’s subjective and existential sense of concern for others. Philosophy as therapeia
reminds us of, transformative possibilities for caring.
Caring focuses on the meaning of meeting here and now. This may sound counter-
intuitive. Surely a consultation should provide a care plan, next steps, prognosis.
Attending to this person, in this moment, according to their concerns, their flour-
ishing, however, shows care about who they are, why they are here, and how they
are feeling in the present tense. We recognise how this is informed by the past and
how this will inform their (and our) future. Illness, care and healing are subjective
experiences, too often minimized by placing undue emphasis on tomorrow making
longevity the unquestioned goal of care. Perhaps, as Gadamer suggests, the relentless
nature of scientific progress, which does not pause sufficiently to allow humanity to
keep up, causes many of contemporary society’s maladies. A caring relationship can
afford a hiatus, when patient and physician take stock of the situation.

18.9 Caveats on a Hermeneutics of Care

Our interpretation of care resulted from conversations between us as authors: two

physicians and a philosopher interested in caring. Our presentation is partial; a tempo-
rary exploration of a topic, to which many other voices could be added. Interested
readers could draw on the writings of Levinas, Gilligan, and Zahavi, to mention a
276 M. A. Kelly et al.

few (Levinas 1969; Gilligan 1982; Zahavi 2014). We also acknowledge that Gadame-
rian ideas have been criticised for being overly romantic and failing to acknowledge
the power imbalance inherent in clinical relationships. For Gadamer, dialogue and
discussion between physician and patient could humanize this imbalance. For a
number of subsequent philosophers, however, Gadamer’s belief in the universality of
hermeneutics and his focus on contextual interpretation and understanding of others
on their own terms border on relativism and are insufficient. Habermas, in a series of
famous debates, argued that philosophical hermeneutics was a systematically inade-
quate basis for critical social theory as it fails to pay attention to socio-political and
economic injustice related, for example, to race, class, culture, and gender. Since
hermeneutics is a ‘view from somewhere’, perhaps blinkered to asymmetrical distri-
bution of agency and resources, we ask researchers to be alert to limitations that
come along with its strengths as a window into society.
Readers wishing to explore these ideas in greater detail may find publica-
tions from the growing field of ‘critical hermeneutics’ informative (Simpson 2021;
Kinsella 2006). This umbrella term combines the orientation of hermeneutics towards
disclosing general grounds for understanding and interpretation with a sensitivity
towards important social, economic, and political factors. We ask readers to be aware
that our privileged access to knowledge and other forms of capital may have made us
insensitive to important social issues. The ‘Black Lives Matter’ movement, increasing
recognition of systemic racism, and the many excess deaths due to unequal distri-
bution of resources during COVID-19 make it important at the time of writing to
scrutinise how societal power manifests itself in the promulgation and policing of
health resources. It also demands a re-attention to medical curricula, their colonial
legacies, and how education plays a role in privileging some voices, whilst stifling
others. For more on social justice within health professions education, see Chapter 8.
These concerns encourage us to be more philosophical, more attentive to the way
technology renders, and more attuned to hermeneutics in how we understand patients
and ourselves. In sum, to be more caring.

18.10 Conclusion

Philosophy becomes therapy when it renders language as care, broadening the

concept of technology beyond the purely instrumental treatment of disease.
Heidegger conceptualised technology as a way of being that pre-exists us and
enframes the world in contingent ways. Within the Gadamerian and Heideggerian
hermeneutics informing our discussion, physicians act as philosophers when they
enframe encounters with patients through dialogue, openness to questions, “being
with” as well as “doing to” patients, revealing themselves, co-creating and under-
standing. This degree of openness creates possibilities for mutual transformation of
physician and patient. Philosophy as therapeia also problematises medical practice
that is solely instrumental and invites physicians’ doing and being within a more
rounded practice of caring (Table 18.1).
18 Philosophy as Therapy: Rebalancing … 277

Table 18.1 Practice Points

1 Care is a form of human understanding, which promotes healing and well-being
2 Technology is a prime suspect for the loss of care in contemporary clinical practice
3 The central place given to human experience by Gadamer and Heidegger provides a
constructive means to reframe the relationship between care and technology
4 This reframing adds human subjectivity and reflexivity to purely instrumental ways of
defining technology
5 Extending the concept of technology as we suggest could make therapeia the ally of therapy,
philosophical practice the ally of clinical practice, and clinicians as well as patients the
beneficiaries of a humane as well as ‘effective’ practice of caring

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Chapter 19
Is Social Media Changing How We
Become Healthcare Professionals?
Reflections from SoMe Practitioners

Nabilah Yunus Mayat, Sarah Louise Edwards, and Jonathan Guckian

19.1 Introduction

Social media (SoMe) is everywhere, with an estimated 3.96 billion people using
SoMe worldwide at the time of writing (Statista 2021). With a use this pervasive,
it is hardly surprising that SoMe has been used professionally within healthcare
practice. Most frequently, this use takes the form of the development, creation, and
dissemination of a seemingly limitless pool of educational resources.
In more recent years however, there has been a significant increase in the use
of SoMe for socialising amongst healthcare professionals (HCP) in the form of
sharing and discussing ideas, thoughts, and experiences (particularly during the
recent COVID-19 pandemic—see Finn et al. 2020 and Brown et al. 2020). However,
despite this newfound prominence, and the evolution of the use of SoMe, there
has been little deep exploration of SoMe. Though we know SoMe is an all-pervasive
source of knowledge, and we could explore questions such as the reliability of knowl-
edge, a focus on knowledge would miss the social aspect of SoMe. Is SoMe merely an
expansion of educational resources, or is its use changing social relationships within
the health professions and health professions education? If SoMe is more than just a
place to go to learn an expert’s top tips on the management of, say, cholecystitis, then
just what is it? And could it be changing our thoughts and practice regarding what
professional identity and professional community mean within health professions
education? In this chapter, we explore these thoughts in greater depth, offering our

N. Y. Mayat (B)
Airedale NHS Foundation Trust, Bradford, UK
e-mail: n.mayat@nhs.net
S. L. Edwards
University Hospitals of Leicester, Leicester, UK
J. Guckian
Leeds Teaching Hospitals Trust, Leeds, UK

© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2022 279
M. E. L. Brown et al. (eds.), Applied Philosophy for Health Professions Education,
https://doi.org/10.1007/978-981-19-1512-3_19
280 N. Y. Mayat et al.

perspective as practitioners, educators, and researchers invested in SoMe as to what

its changing use means for learners and teachers in our field.

19.2 What Is SoMe?

SoMe is a medium in a constant state of flux. As a result, it is extremely difficult to

define (Pettman 2015). Those familiar with SoMe will have their own ideas of what
qualifies. Here, we offer our own thoughts as SoMe practitioners, and demonstrate
how these align with educational literature on the matter from adjacent occupational
fields.
SoMe platforms are driven by evolutionary pressures which include: social trends;
corporation profits; and political discourse (Hinton and Hjorth 2019). The overall
mission of SoMe is to incentivise users to remain within a community, using the
platforms, for as long as possible (Hinton and Hjorth 2019). Accordingly, tech-
nology must consistently adapt to these external forces. As trends, profits and polit-
ical discourse are not static beasts, SoMe is constantly in motion. If you think forward
to what SoMe might look like, or constitute, in the year 2025, it is likely your imag-
ination has taken you somewhere very far from what SoMe looked like when it
burst onto the scene of popular culture in 2005 (the authors encourage readers of a
certain age to take a moment to mourn the loss of Myspace, SoMe giant between
2005–2008).
There is reason to believe that the dynamic and exponential growth of SoMe
affects healthcare professionals and their practice, though we do not know in which
way. Many current medical students, for example, are of an age where many of them
will have never known a world without SoMe (and will likely shrug their shoulders,
adopt a look of confusion, or at least raise their eyebrows, at our mention of Myspace,
an older platform).
So that we can explore SoMe as a phenomenon more comprehensively, we first
must settle on a definition. Whilst we have demonstrated that SoMe is dynamic and
fluid, what we are yet to pay due heed to is the term ‘social’. This term is so critical
to SoMe that it finds its home in the term itself. The use of ‘social’ within the term
social media highlights the primacy of multi-directional user interaction with the
medium in question. Therefore, in the context of health professions education, we
define SoMe as:
“web-based technologies which facilitate multi-user interaction that goes beyond fact
sharing, for the purpose of content creation, curation or community.” (Guckian et al. 2021,
1227)

Inherent to this definition is the idea that SoMe is not only an educational resource
in the limited sense of existing for users to share facts and informational titbits with
one another. Instead, SoMe can be utilised for the purpose of forming, or engaging
in, a professional community. As SoMe practitioners, and so participants of SoMe
ourselves, we have both experienced and seen how healthcare learners become part of
19 Is Social Media Changing How We … 281

a wider social collective. Though some students may ‘lurk’ on SoMe as passive users,
any engagement in SoMe platforms, be it through viewing content or participating
more actively in discussions with other users, introduces students to a new multi-
professional healthcare community. Particularly for those engaging in discussion
across SoMe platforms, users take on rapidly fluctuating digital identities which
may develop before they even enter medical school and are introduced to what
it means to be and become a healthcare professional—we have seen how some
prospective students use SoMe to connect with those established in the healthcare
professions, seeking out role models suited to their preferences. Increasingly, we
note that healthcare learners possess advanced skills in wielding SoMe to support
their education. Further, some learners and trainees use SoMe to critique healthcare
and healthcare education in ways that were previously not possible, in part, due
to the existence of organisational and institutional hierarchies. What we encounter
now as healthcare educators, is a generation comfortable interacting with SoMe, and
engaging in its varied uses.
By way of this comfort and engagement, healthcare students and trainees (indeed,
even prospective ones as we have previously demonstrated) are introduced and
interact with healthcare professionals differently than how they might outside the
world of SoMe. We suggest that this has ramifications on the process by which they
become healthcare professionals themselves—it influences the way in which they
form their professional identities.

19.3 What Is Professional Identity Formation?

Though professional identity can be variously defined, a common definition in health

professions education is that it is ‘who we are and who we are seen to be’ in rela-
tion to one’s occupational role (Monrouxe 2010, 41). The topic is of increasing
interest in health professions education, as educators and researchers recognise the
impact of professional identity development on practitioner confidence and well-
being (Freedman and Stoddard Holmes 2003; Sabanciogullari and Dogan 2015).
For a thorough discussion of professional identity that offers a different view than
outlined in this chapter, see Chapter 3 (readers may wish to consider how the concept
of subjectification may apply to, or expand, the discussions outlined herein).
However, even if one accepts this common definition, professional identity can be
conceptualised from a variety of perspectives. These perspectives exist on a spectrum.
On one side of the spectrum, identity formation is conceptualised as a purely cognitive
pursuit—identity exists in, and is shaped by, solely the human mind. For cognitivists,
identity as a doctor or nurse or physiotherapist is the professional self-concept of
an individual grounded in their attributes, beliefs, motives, values, and experiences
(Jawed et al. 2019; Ibarra 1999). Social constructionists exist at the other end of the
identity conceptualisation spectrum (Rees et al. 2020; See Chapters 10 and 11 for
more on constructionism). In contrast to cognitive conceptualizations, they maintain
that identity is formed only when learners interact with, and relate to, the world
282 N. Y. Mayat et al.

around them (Goldie 2012). Professional identity cannot be formed in a vacuum by

any one person individually—instead, it is interactional, existing only within social
relationships.
Given that the formation of professional identity can be variously conceptualised,
it is important that we clearly consider how we have defined and conceptualised
professional identity within this chapter. We embrace a social constructionist view
of PIF, where we position identity formation as occurring only within interactions. As
healthcare learners connect with the social world that surrounds them, they develop
their sense of who they are in different contexts, and this influences how they act and
practice as students and, later, as qualified professionals. Sfard and Prusak (2016)
theorise iterative cycles of change to be inherent to the process of PIF—within health
professions education this would mean that PIF is constantly renegotiated as a result
of dynamic interactions between learners and those that exist in the social world of
medicine, healthcare practice, and health professions education. This dynamic cycle
of continuous development aligns with our social constructionist conceptualization
of professional identity and has informed the analysis and discussion within this
chapter.
In the case of healthcare learners, the dynamic cycle of their identity development
can occur through the dialogue of narratives (Sfard and Prusak 2016). Individuals
are immersed in a variety of social narratives—or stories—on entry to the field of
medicine. The stories they hear, see, and engage in ultimately influence their own
sense of how they fit into a professional community, and how they should act as
someone assuming the role of a particular healthcare professional. In this way, the
cycles of iterative interactions learners in healthcare environments experience that
influence the way in which their professional identities form are also shaped by the
social narratives of a community that inform the way in which individuals interact.

19.4 Where SoMe and PIF Meet

As SoMe is everywhere, those using SoMe are everywhere, too. SoMe has radically
changed the social landscape of our world, enabling connections between individ-
uals and communities like at no previous point in human history. As we become
increasingly connected, the way in which we are interacting with one another is
changing. We have demonstrated how identity can be conceptualised as a social
endeavour, formed and shaped in the social space of interactions. SoMe has changed
the social space of many of our interactions—how we engage with one another online
is different from how we engage and connect in purely physical spaces. We hypoth-
esise that this means the process of identity formation (a social process) for health
professionals (who are increasingly comfortable with SoMe) is influenced in some
way when learners engage with SoMe.
As we have previously discussed, in our experience, healthcare professionals are
increasingly using SoMe to interact with online communities, rather than simply
19 Is Social Media Changing How We … 283

as an educational resource. What we have not yet considered is how healthcare

professionals use SoMe to interact with one another.
Individuals may have separate professional SoMe accounts associated with their
professional title and role in their place of work e.g., Doctor, Nurse, Health Psychol-
ogist, etc. For some, their professional identity is less clearly divided – there are
profiles which are considered personal yet are also used to engage in professional
communities. Some healthcare professionals have amassed so many followers and
such notoriety that they have become healthcare ‘celebrities’ within, or across, partic-
ular SoMe communities or demographics. Within medicine and medical education,
for example, we have witnessed the rise of ‘Medical Influencers’, or ‘Medfluencers’,
often popular for their expertise, views, and due to the resources they create (Khamis,
Ang, and Welling 2016). It is interesting to note that ‘Medfluencers’ are usually
not popular because of (or, at least, not entirely because of), their formal creden-
tials—they develop credibility instead through their popularity (number of followers,
and so on). This professional community is different from the physical world for
several reasons. Physically, we are unable to completely separate our professional
and personal selves—we are whole three-dimensional beings, and usually avoid such
strict categorisations of ourselves as either personal or professional. Further, though
there may be role models we aspire to in our respective fields, SoMe often offers
greater insight into the thoughts, views, opinions, experiences and, ultimately, lives
of the ‘Medfluencers’ we follow and admire.
The complex web of interactions we see between and beyond healthcare profes-
sionals on SoMe raises new questions. We do not believe that health professions
education has taken enough time to consider what it means to be on SoMe as a health-
care learner, and how this influences the type the healthcare professional learners
become – in other words, how they form their professional identities. What impact
does separating professional and personal accounts have, and what are the social
narratives influencing whether someone chooses to do this, or not? If accounts are
blended for personal and professional use, what social narratives shape how people
use those accounts, and are there any aspects of the personal self that learners perceive
they cannot bring to their professional SoMe presence? How does the presence of,
and our relatively unfettered access to, ‘Medfluencers’ influence how we see our role
models, and how we work towards becoming more like them?
In the previous chapter (Chapter 16), Chin-Yee talks of how technology should
be understood not as value-neutral, material artifacts, but as a way of thinking and
interacting with the world that reflects a range of social choices, and human values. In
this chapter, we explore the various technologies of health professions education in
this way, by exploring SoMe as a technology influencing healthcare learners. SoMe
is not a value-neutral artefact—it is not as simple as saying that SoMe is Facebook,
or Twitter, or Myspace (sob!). Instead, SoMe is a new way for learners to think and
interact with the world of health professions education and healthcare in a more
general sense. In the remaining sections of this chapter, we explore an example of a
clearly demarcated SoMe professional community to consider how this community
may shape the way in which learners think and interact, and so the way in which
their professional identities come to be formed.
284 N. Y. Mayat et al.

19.5 #MedTwitter: A New, Virtual Community Of

Practice?

To do so, we offer the example of #MedTwitter, a professional community formed

organically on the SoMe platform Twitter. We suggest that #MedTwitter represents a
virtual Community of Practice, a conceptualisation that then has significant bearing
on how we envision the impact of engagement with this community on learners’
emergent professional identities.

19.5.1 What Are Communities of Practice?

To demonstrate that SoMe communities can be Communities of Practice (CoP), and

so associated with the documented impact that involvement in CoPs has on identity,
it is first necessary to explore what constitutes a CoP.
The term ‘Community of Practice’ was first coined in 1991 by Jean Lave and
Etienne Wenger (Lave and Wenger 1991; Wenger 1998). CoPs are best defined as
a process of social learning that occurs when people who have a common interest
collaborate and interact in a group (Hopes 2014; Wenger 1998). Though conceived
as a theory of learning, involvement in a CoP influences participants’ identities as
participants engage in a process of ‘legitimate peripheral participation’ that moves
them from the status of ‘newcomer’ at the edge (or periphery) of the community, to
the status of ‘oldtimer’, engaged in, and central to, the community. As participants
engage in the practice of a community, they become increasingly integrated within
it, internalising and displaying behaviours learnt within a CoP through a process
of ‘enculturation’ which grants them status of a member, and moves them towards
‘oldtimer’ status.
Though CoP theory is popular within medical education, it is often misused, or
applied superficially. McGrath et al. (2020), in their critical review of the use of the
term within medical education, call for clarity when discussing what constitutes a
CoP. Initially, Wenger (1998) developed the concept of CoP to propose three defi-
nitional criteria communities must meet: mutual engagement; joint enterprise; and
shared repertoire. Mutual engagement is the basis for relationship forming—through
regular interaction, community members negotiate the meaning of practice within
their community. Through the sharing of practice in mutual engagement, individuals
create identities which function within the community. Joint enterprise maintains
the existence of CoPs—it is not only shared goals, but mutual accountability for
the negotiated enterprise that takes place within communities. Finally, shared reper-
toires include community routine, language, ways of working, and stories within a
community. Shared repertoires are generated through shared practice and meaning
making – something which suggests longevity, as repertoires tend to develop over
time. Later, Wenger et al. (2002) reframed these criteria to increase the applicability
of CoP theory as a management tool, naming them domain, community, and practice.
19 Is Social Media Changing How We … 285

Drawing on the above, we take that there are three criteria communities must meet
to warrant classification as a CoP:
• There must be mutual engagement or a common domain e.g., a group of paediatric
surgeons; MySpace fans; or pharmacists;
• There must be joint enterprise—in other words, a community must be established
through interaction between those within a common domain; and
• There must be the ability to practice. This involves the sharing of resources,
continued discussions about topics, and having a repertoire of methods to solve
these problems—developing shared repertoires through time (Hopes 2014; Lave
and Wenger 1991; Wenger 1998; Wenger et al. 2002).
Utilising the above criteria, the medical community can be seen as a CoP wherein
information is shared, exchanged, and debated. This pathway of information between
individuals enables the practice of learning, thus fostering the adaptation and devel-
opment of the professional identity linked to that common domain (e.g., linked to
the common domain of becoming or being a doctor, or nurse).
The increasing presence of HCPs on SoMe has led to the formation of communities
online (such as #MedTwitter) where HCPs interact with one another.
To determine whether the communities that exist solely on SoMe qualify as
Communities of Practice, we analyse the inception and dissemination of a podcast
entitled “Two Medics, One Mic” (Lasker and Gunawardena 2021). This podcast has
attracted significant attention as a creation, centrepiece, and aggregator of the growing
#MedTwitter community. Given this, we hope that analysing this podcast through
the lens of Communities of Practice theory may cast light on whether #MedTwitter
in its entirety represents a virtual community of practice. As previously, knowing
whether CoP theory applies to SoMe communities is important in discerning their
possible impact on the PIF of healthcare learners.

19.5.2 #MedTwitter and Two Medics, One Mic: A Case Study

The community of #MedTwitter consists of HCPs, students, and educators, all of

whom share a common interest in the world of healthcare, and are present on SoMe,
more specifically, on Twitter.
The podcast “Two Medics, One Mic” invites #MedTwitter community members to
speak about issues arising from contemporary (and often contentious) #MedTwitter
discourse, of which all speakers are a part. The fact that this podcast consists of
content generated through discussion of key topics arising as a result of interactions
between HCPs on the self-named #MedTwitter shows it to be a topic which would
classify as a common domain in itself.
This interaction between common members who are known to one another both
on Twitter, as well as on the podcast directly or indirectly, demonstrates that a sense
of community is often present within #MedTwitter, and between members. Members
often have shared jokes which spread throughout the community. Further, the fact
286 N. Y. Mayat et al.

that this group have named their own community ‘#MedTwitter’ demonstrates a
sense of unity and belonging under this label.
As such, discussion of topics seen on the podcast can be classified as a form of
practice that have arisen through #MedTwitter. Indeed, ‘Two Medics’ (Lasker and
Gunawardena 2021) is noteworthy for this very reason, as it transcends its recorded
setting and spills over into #MedTwitter discussion. The community appears to have
rallied around this podcast, inspired to create independent and interactive ‘Twitter
Spaces’ which feature its hosts and guests to continue debate. Subsequently the
community has begun to build and critique its own identity, often through debate and
challenge. This has not been without trauma, as those with values and ideals periph-
eral to that of the constantly evolving collective sense of identity with its implicitly
agreed social rules can feel judged by others and, at times, upon voicing dissenting
opinions, be banished—sometimes literally—to SoMe wastelands. Conversely, a
shared identity, centred around recognisable figures and examples of creation,
provides a clear roadmap for new peripheral participants to this CoP as they navigate
their own online identity (Lave and Wenger 1991; Wenger 1998).

19.5.3 Is #MedTwitter a Community of Practice?: Discussion

The case study illustrates how:

1. Members of #MedTwitter share a common domain (they are a group of
healthcare students, educators and professionals—most often from the field
of medicine and medical education—engaged in SoMe use and interested in
sharing opinions and experiences);
2. #MedTwitter is a community, in that its members interact, are often known to
one another, and there is a shared repertoire of jokes and language;
3. Discussions on SoMe can constitute the practice of a CoP. Such networking
results in the formation of relationships. Though we have offered up Two
Medics, One Mic as an example of this, there are many other ways these rela-
tionships can form. Indeed, the book chapter itself is another example of the
practice of #MedTwitter at work—we (the authors) all met and formed relation-
ships through #MedTwitter and were approached by the editors who knew of
us from #MedTwitter.
Given that #MedTwitter meets the three criteria we earlier set out as constituting
a CoP, #MedTwitter as a virtual community can be classified as a CoP with far-
reaching boundaries unlike those we may be accustomed to in our physical practice.
Indeed, in our experience, #MedTwitter has international reach, with participants
from across the globe. In analysing #MedTwitter against CoP definitional criteria
and showing that the community meets these, we have shown how it is possible for
SoMe communities to constitute a CoP—though we cannot say for certain without
further analysis that is beyond the scope of this chapter, it is possible (and likely)
that other SoMe communities may also function as CoPs.
19 Is Social Media Changing How We … 287

The fact that #MedTwitter warrants classification as a CoP has impact in reference
to the professional identities of its members. Whilst, according to current literature,
SoMe can be considered as a facilitator of the formal curriculum through the propa-
gation of webinars and other resources, if SoMe communities are also communities
of practice, fact exchange may not be the only form of education occurring amongst
participants of SoMe. Interactions with community members who share a common
domain of interest in healthcare operate as a social space in which participants’ iden-
tities are moulded. As previously discussed, interactions contribute to the dynamic,
iterative cycles of identity formation that move between individuals and the social
world. It is clear, now, that this social world constitutes not only an individuals’ phys-
ical experiences within educational and clinical environments, but also their online
interactions across SoMe platforms. Though we have demonstrated it is likely that
SoMe impacts the professional identities of its members, due to the nature of inter-
actions and because of the relationships that develop within SoMe communities, it
is difficult to know exactly what these impacts are without further study. It is crucial
that future research explores the nature of these impacts, examining the differences in
identity formation between physical and virtual CoPs. It is only through doing so that
we will be able to understand how to encourage a generation of healthcare learners
who are increasingly comfortable online to form robust professional identities in all
the social spaces they move in.
In the following section, we will walk with a learner as they enter and orient
themselves to the world of healthcare SoMe. In doing so, we map their trajectory
through SoMe as a virtual CoP, highlighting the process of legitimate peripheral
participation in action, and speculating as to the possible impacts of the process on
the identity formation of learners.

19.5.4 #MedTwitter as a Community of Practice: Mapping

a Learner’s Journey

As a healthcare learner, your first decision is whether to join SoMe (though you
may already be an active participant). The decision regarding which platform(s) to
join is one with no fixed answer. Across diverse platforms, a relatively common user
journey exists. Individuals sign up and build profiles on their chosen platform, sharing
variable personal data, before navigating to online domains of common interest and
sharing information in the form of micro-blogs, graphics, videos, or audio files.
Most platforms allow users to build on this information distribution through reaction
features, such as ‘shares’ or ‘likes’.
A relative divide exists amongst platforms: between public-facing, open commu-
nities such as Reddit or Twitter; and those designed to support private conversational
networks such as WhatsApp or Facebook Messenger. Whilst SoMe platforms such
as blogs or Instagram may consist of an individual showcasing their own views
and thoughts etc., platforms such as Twitter and Reddit have an aim of networking
288 N. Y. Mayat et al.

and communication between people. At their core, however, most platforms are
algorithm-dominated, designed to construct the illusion of a unique, personalised
experience. This personalisation extends to SoMe’s ‘dark side’, including targeted
advertising and data harvesting (Hinton and Hjorth 2019). The rapid rise of SoMe,
from Myspace in 2005 to complex applications which integrate privacy levels and
media sharing such as TikTok in 2017, has shaped our modern population of learners.
As previously, learners will likely be familiar, and comfortable, with one or more
SoMe platforms before they choose whether to engage in SoMe professionally, e.g.,
by interacting with the #MedTwitter community.
On their journey so far, our healthcare learner has begun to situate themselves
in an online social landscape. They must now decide whether to use SoMe profes-
sionally. If they do, they will be prompted to construct an online profile, through
which they will interact with others within a virtual landscape of practice. The
construction of this profile, being virtual, differs from a learners’ physical repre-
sentation. In the world of SoMe, learners have a chance to construct a profile with
far more wide-reaching possibilities than are available to them in the physical world.
Indeed, some learners opt for anonymous accounts linked to various healthcare
professional identities—a fictional example would be a Twitter account with the
handle ‘@TheMedicWhoBakes, through which its user shares their experiences as a
medic with a passion for the culinary arts. Learners may opt for anonymous accounts
for many reasons—in our experience, these often involve concerns regarding profes-
sionalism and identification, with an increased sense of freedom of speech facilitated
by anonymity. How learners choose to represent themselves on SoMe is interesting,
as different digital identities can result in a wide range of possible user experiences
and interactions. The effects on the user as a result of varying online interactions can
differ (Stets and Burke 2005). In the offline world, an individuals’ identity perfor-
mance is usually limited by an inability to control factors such as physical appearance,
social context, and non-verbal, subconscious communication. The online world, now,
provides an opportunity for learners to create an identity free of usual physical limi-
tations—they are empowered to control the narrative of their identity more than ever
before.
Once learners carefully craft their online profile, they will likely explore various
online communities they may choose to become members of on the platform they
choose, e.g., #MedTwitter. Initially on the outskirts of established SoMe commu-
nities, healthcare learners must partake in legitimate peripheral participation. This
is made possible as they share a common domain with established members (i.e.,
being a healthcare practitioner) which grants them legitimacy (Lave and Wenger
1991; Wenger 1998). Permitted to engage in the practice of the community, learners
dialogue with other members, becoming familiar with shared social narratives, ways
of working, and community repertoire.
19 Is Social Media Changing How We … 289

19.6 Engaging in SoMe

Given that engagement in CoPs is what allows participants to become familiar with
shared repertoires, to truly understand our learners’ experiences, we must, ourselves,
engage in SoMe. Osberg and Biesta (2008) suggest that knowledge emerges as a
result of participation. Only in participating in SoMe will we be able to comprehend
learners’ experience and appreciate how we may incorporate this new technology into
health professions education instruction, to facilitate robust identity development,
and perhaps even assessment (for a thorough description and analysis of the shifts in
assessment thinking and practice in our field, see Chapter 5; for an alternative view
regarding the practice of assessing behaviours and attitudes, see Chapter 6).
We offer an important proviso to our recommendation that educators and
researchers should engage with SoMe. That is: they should do so critically. Uncriti-
cally throwing oneself into SoMe is as poor practice as dismissing SoMe as a tech-
nology with purely negative impacts, or as something you do not wish to engage
with at all. But what does a critical approach to SoMe engagement look like? And
how can we use this critical approach to explore SoMe in relation to PIF?
We offer up the example of hierarchy to consider a critical approach to engaging
in, and exploring the impacts of, SoMe on the being and becoming of healthcare
professionals.

19.6.1 Critical Engagement in SoMe: Our Exploration

of Hierarchies as an Illustrative Example

One example of how the world of SoMe might be better understood through participa-
tion is found in considerations of the nature and practice of hierarchies. Many within
medicine and the health professions will be familiar with the concept of a hierarchy—
it is akin to a chain of command with higher- and lower-ranking individuals. Most
often, hierarchies are based on seniority, role, or status. Power is exercised through
hierarchies, with lower-ranking individuals subservient to higher-ranking ones (not
exclusively, and lower-ranking individuals do have the agency to exercise power,
though this is often more difficult for them to achieve) (Vanstone and Grierson 2021;
Brown and Horsburgh 2021).
However, within SoMe communities, we have observed that the hierarchies that
exist are different from those we have become used to in the clinical world. On SoMe,
everyone is within reach—most individuals can be messaged directly or publically,
and senior figures (using our traditional notions of seniority based on role or status)
seem to hold less sway based on these characteristics alone. It appears that SoMe
hierarchies are flatter than those that exist within the clinical world. Yet, the nuances
of this are underexplored—we hypothesise that, though traditional conceptualisa-
tions of medical hierarchies may not apply, different conceptualisations might, as
‘Medfluencers’ can wield significant power. Rather than a hierarchy founded on
290 N. Y. Mayat et al.

credentials, professional qualifications or expertise, our experience on SoMe tells us

that hierarchies may be based, instead, on communication, likability, and popularity.
Without our experience in this area, we are not convinced that we would have a
good sense of this issue, and of the way in which the concept of hierarchy may be
different online. It is through our participation in SoMe that this avenue for further
research has become clear to us. What is key is that our engagement has been crit-
ical – we have taken the time to reflect on the differences between our experiences
in the physical world, and online, and question established SoMe practices. In an
earlier draft of this chapter, we focused heavily on the notion of flattened hierarchies.
However, through supportive reflection and discussions we revised our thinking in
this area to our current view (that SoMe hierarchies may be flatter, but they are not
completely flattened). We took the time to question our positive regard for SoMe
as those who enjoy our time online. Reflexive engagement with SoMe is how we
recommend researchers and educators approach SoMe engagement critically.

19.7 Concluding Thoughts

In this chapter, we have considered the ubiquitous nature of SoMe, defining SoMe
as a dynamic and fast-moving new technology that goes beyond information sharing
to encourage the development of virtual communities of practice. Using a popular
podcast as a case study, we demonstrate how Lave and Wenger’s communities of
practice theory can apply to SoMe communities, reinforcing our suggestion that
SoMe is more than a resource, and allowing us to begin to speculate as to some of
the impact of these online communities on healthcare learners’ professional iden-
tities. Throughout, we have commented on the underdeveloped nature of empirical
scholarship in regard to the impact of SoMe on learner identities and, in the final
section of this chapter, considered why, as educators and researchers who are not
immersed in SoMe in the same way as their learners, we may be reluctant to engage,
or misdirected when we do engage, with the impact of SoMe on the process of student
identity formation.
We feel it is necessary to end this chapter with a call to action for health professions
practitioners, educators, and researchers. It may not surprise you that part of this call
is for further in-depth, high quality research regarding learners’ experiences of SoMe,
and the impact of these experiences on the professional they become. This research
is complex, since SoMe is an ‘unstable’ object of research that may have already
evolved by the time the research is published. Besides empirical research, we also
need to pay attention to the way SoMe may be uprooting our notions of what it
means to be a professional, where our community’is’, and whether this is changing
the nature of education—explorations that would benefit from philosophical and
media theory perspectives. To achieve this aim, we must avoid viewing SoMe as
something purely negative; we must listen carefully to our learners when they tell
us of their experiences; and we must critically and reflexively engage with SoMe
19 Is Social Media Changing How We … 291

Table 19.1 Practice Points

1 SoMe should be defined and treated as more than an educational resource that facilitates
information exchange. Instead, it includes the formation of communities that can have
meaningful impacts on the professional identities of their participants
2 Educators and researchers less familiar with SoMe must strive to ensure they don’t adopt a
potentially narrow view of the impact of SoMe platforms (either negatively or positively).
Questioning one’s experiences and beliefs in regard to SoMe can facilitate reflexivity
3 Educators and researchers should engage with various SoMe platforms themselves to better
appreciate their learners’ experiences. Engagement should be critical and involve questioning
of established online norms and practices. Group reflexivity discussions may assist in
developing a critical approach to engaging with SoMe
4 In tandem to engaging with SoMe oneself, educators and researchers must listen carefully to
the experiences of their students, keeping an open mind in the rapidly evolving landscape of
SoMe. Hosting discussions that help students reflect on, and so understand, their own
experiences and relationship with SoMe might facilitate professional identity formation
5 There are many avenues for future research—we have only scratched the surface in the form
of those we have highlighted throughout this chapter. Researchers may wish to consider how
healthcare learners’ interactions with others differ in the physical world, and on SoMe; how
learners’ perceptions of their online audience shape the identities they form; and how
hierarchies might differ online. We hope researchers will use this chapter as a springboard to
consider their own experiences, questions, and open avenues for further research

ourselves, so that we can better understand its impacts, and how these impacts might
be leveraged within health professions education (Table 19.1).
We would like to leave you with a quote from the American author Amy Jo Martin
that, we feel, captures the essence of much of our discussion:
It’s a dialogue, not a monologue, and some people don’t understand that. Social media is
more like a telephone than a television.

Acknowledgements We would like to acknowledge the help of many, without whom this piece of
work wouldn’t have been possible. Of note, we would like to thank Megan Brown and Mario Veen
for their help in the development of this chapter through editing. The help of Fred Hafferty, Simon
Fleming, and Camillo Coccia in helping conceptualise this chapter was invaluable. We would also
like to thank the editors of this book, without whom this opportunity and chance to learn and grow
wouldn’t have been possible. Lastly, not to forget, a big thank you to all our family, friends, and
supporters who believed and cheered us on through this authorship journey.

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Chapter 20
Phronesis in Medical Practice: The Will
and the Skill Needed to Do the Right
Thing

Margaret Plews-Ogan and Kenneth E. Sharpe

20.1 Introduction

Medicine is in a quandary. Despite remarkable advances in both diagnosis and treat-

ment, there is a growing discontent with healthcare—both from patients, and from
clinicians themselves. Indeed, despite advances, medicine has lost its grounding (Inui
2003). In Aristotelian terms one could argue that there has been a focus on the techne,
or the technical knowledge and expertise of medicine, but a failure to develop the
phronesis or practical wisdom necessary to do medicine in the best way possible.
Practitioners need practical wisdom to make tough, everyday decisions in messy
situations where guidelines and checklists fall short (Kinghorn 2010). Medicine is
about quality of life, not just quantity of life years. It is about the health of human
beings who are not objects but choosers. Freedom and preferences are important. It
is filled with ambiguity, with difficult choices between competing values, and with
the complexity that comes with navigating the human mind, body, and spirit.
We all need practical wisdom, says Aristotle, because we are all choice making
beings with the potential to discern both what the right thing is to do and—
often far more complicated—how to do it. The choices we must make often occur
in ambiguous, complex, and contradictory circumstances where we rarely have
complete information. Rules and incentives are of limited use in getting practi-
tioners to act rightly and can sometimes even undermine their will and skill to do
so (Kinghorn 2010; Schwartz and Sharpe 2010). So, what helps us to make wise
choices in these complex circumstances? In this chapter, we seek to describe how
practical wisdom is necessary for every aspect of doctoring. Further, practical wisdom

M. Plews-Ogan (B)
University of Virginia School of Medicine, Charlottesville, VA, USA
e-mail: mp5k@hscmail.mcc.virginia.edu
K. E. Sharpe
Swarthmore College, Swarthmore, PA, USA
e-mail: ksharpe1@swarthmore.edu

© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2022 293
M. E. L. Brown et al. (eds.), Applied Philosophy for Health Professions Education,
https://doi.org/10.1007/978-981-19-1512-3_20
294 M. Plews-Ogan and K. E. Sharpe

is the uber virtue necessary for the application of all other virtues in the practice of
medicine.
We will sketch out some of the everyday decisions doctors make that require
practical wisdom and look at why the character virtues and moral skills constitutive
of practical wisdom are critical to practicing medicine well. This leads to the question:
how can such practical wisdom be learned in medicine? Current institutions which
unintentionally undermine practical wisdom can be re-designed to foster it.

20.2 Why Doctors Need Practical Wisdom in Their

Everyday Practice

The everyday choices made by medical practitioners involve figuring out what is
relevant, deciding how to balance conflicting goods, and grappling with how to do
the right thing. Such choices demand practical wisdom (Wallace 1988; Zagzebski
1996). A summary of these problems as they pertain to medical practitioners is given
in Table 20.1.
Choices about relevance, balancing, and how-to problems demand practical
wisdom because rules, standard procedures, and checklists—our standard decision-
making guides—are not enough. That is because:
• These choices are “characterized by multiple correct solutions, each with liabilities
as well as assets” and there are “multiple methods for picking a problem solution”
(Sternberg 1998, 347).
• These choices are context dependent and there is often no clear rule, procedure,
or best practice guideline for that context.
• The choices are not pre-packaged textbook problems but are “unformulated or
need reformulation” (Sternberg 1998, 347). So, medical professionals need to
figure out the best way to frame the diagnosis, treatment options, and likely
outcomes.
• The evidence for these choices is incomplete or ambiguous but was the best that
could be had at the moment the choice needed to be made.
• The choices are sensitive to patient preferences and the outcome was uncertain,
so the patient needs to figure out what risks to incur.
• Even when the medical practitioner knew what the right thing was, it was truly
difficult to know how to do it.
In such circumstances it is phronesis that enables medical practitioners to discern
the right thing to do and equips them with the skills to do that right thing. What, then,
does practical wisdom require? In addition to technical skills and medical knowledge
practitioners need certain character virtues and moral skills to make these decisions.
We will look at these and then ask: how can health professions education encourage
such practical wisdom to be learned?
20 Phronesis in Medical Practice … 295

Table 20.1 Problems requiring practical wisdom

Problem Description
Relevance problems Medical practitioners are always making decisions about what is most
relevant for a particular patient in particular circumstances at a
particular time. Which of a patient’s major complaints are their chief
concern? Is that chief concern really the most urgent? What are the most
relevant clinical symptoms for a correct diagnosis—does someone’s back
pain indicate a malignancy, or bad ergonomic conditions at work? How
much does a patient want to hear and how much do they need to hear? Is
medical information relevant to this patient at this moment or is tough
love, or reassurance? What is most relevant about this patient in creating a
treatment plan this patient will follow?
Balancing problems Often more than one thing is relevant, and sometimes they are in conflict.
Sometimes the right medical choices must be balanced with the pressures
created by scarce resources, demands for profit, and bureaucratic rules. So
medical practitioners are frequently balancing conflicting goods
Such balancing problems are built into medical practice. Among other
examples: how do you balance what the patient wants to choose (patient
autonomy) with what the medical professional thinks is best
(beneficence—or paternalism)? And what does patient choice mean if she
does not want to make the choice, or he does not really understand the
situation or is hazy or upset? How do you balance scarce time when the
patient load is high? How do you balance the needs of a patient versus the
needs of one’s own family, or even the need to care for oneself? These
tough choices always demand practical wisdom
How-to problems Knowing what the right thing is still leaves tough choices about how to do
it in the right way. How to deliver bad news to each particular
patient—what to say, how much to say, and how to say it? When and how
to make an issue of a patient’s racism, homophobia, sexism, or religious
intolerance directed at a practitioner? How to empower a patient to choose
when the very way a doctor frames the diagnosis and treatment options, or
presents the statistics and survival rates—even the very tone of voice and
body language of the doctor—always nudges the patient to choose one
way or another? How to respond to a medical error: when and how to
report it, how to talk to or help the family or patient, how to set up a
system to avoid it in the future—and help doctors deal with mistakes they
have made (Plews-Ogan and Beyt 2013)?

20.3 The Crucial Virtues and Moral Skills Practical

Wisdom Demands

20.3.1 Virtues

Medical practitioners cannot make these tough decisions without certain virtues
which give them the will to do the right thing. Aristotle argues for the importance of
such virtues and sees them as learned habits or dispositions (hexis). They are “affec-
tive” in that they motivate practitioners to do the right thing: to be courageous and
296 M. Plews-Ogan and K. E. Sharpe

compassionate we need the disposition to act courageously and compassionately.

They are also cognitive: we need to know what compassion and courage are—to
recognize them, to know why they are important. A short list of virtues essential for
good medical practice would also include empathy, honesty, detachment, and fair-
ness. A longer list would include being resilient (having fortitude), being humble,
mindful, curious, open to criticism and feedback, self-effacing (disposed to place the
patient’s interests over the doctor’s self-interest), and faithful to the trust a patient puts
in a doctor. Also important are the desire to continuously learn and improve, having
the willingness to accept responsibility for one’s actions, to be open-minded (a dispo-
sition to suspend immediate judgment), and having the disposition to collaborate with
and learn from others (Pelligrino and Thomasma 1993).
These virtues are deeply embedded in the very nature of medical practice. To say
a person lacks compassion, is a coward, is unempathetic, is unreflective, and is not
disposed to be detached and to also say that this person is a good doctor, or even a
doctor, would seem strange to many both within and outside of the profession. That is
because medicine is not just a set of technical skills: it is a practice that aims to serve
patients, and that telos or purpose includes restoring to health and reducing suffering
and harm. These virtues are not optional. They are essential to achieving the aims
of the practice. A skilled medical technician might be competent to remove a mole;
a good doctor must also be able to have a compassionate, trustworthy conversation
with the patient when the pathology reveals melanoma.
There is legitimate concern that these virtues are vastly under-valued, and even
corroded, in medical schools and practice. Later, we will look at examples of
two medical schools that have tried to reverse this erosion by restructuring their
curriculum and teaching.

20.3.2 Moral Skills

Such dispositions or virtues give practitioners the moral will to practice well, but
to exercise these virtues they also need to gain the capacity (some might say the
competency) to actually act: the know how to be compassionate, empathic, detached,
courageous, mindful, and reflective, and to balance different ‘goods’ when they
inevitably come into conflict. Compassion demands more than the desire to alleviate
a patient’s suffering; it demands the capacity for empathy (understanding how the
patient is thinking and feeling), and the skills to engage that empathy even in situations
where the patient is belligerent, angry, or violent toward the doctor; it demands the
know-how to figure out what the patient wants and then to balance that with what
the patient needs and what the medical possibilities are. Without such moral skills,
compassion deteriorates into feel-good incompetence. Similarly, courage demands
more than fearlessness or the willingness to act in the face of fear: it demands the
technical skills of diagnosis and treatment, knowing how and when to take risk, and
the emotional self-regulation to control both anger and fear; otherwise, would-be
courage degenerates into foolhardiness.
20 Phronesis in Medical Practice … 297

This capacity to act—to bring these character virtues to bear on medical deci-
sions for this particular patient at this particular moment to achieve the purposes of
medicine—demands what theorists since Aristotle called practical wisdom. It is the
will and the capacity to do the right thing in the right way at the right time. None
of the character virtues so essential for being a good doctor can be translated into
action without the master virtue of practical wisdom.
A list of some of the closely related skills or capacities necessary for practical
wisdom are listed and described in (Fig. 20.1).

Fig. 20.1 Related skills or capacities necessary for practical wisdom

298 M. Plews-Ogan and K. E. Sharpe

It is important to note that there is a reciprocal relationship here between char-

acter virtues and practical wisdom: you can’t have good character without practical
wisdom, but you also can’t have practical wisdom without good character. Practical
wisdom is not simply a skill or technique that can be learned. It’s not simply learning
how to reason, how to analyse, how to do a logical deduction, how to surgically repair
a broken appendix, or sew a suture. A doctor can only have practical wisdom if she
has developed the virtues that motivate her to do the right thing—and she can only
do the right thing if she can exercise good judgment. Aristotle ([350 BCE] 1999)
himself emphasized that no one can have the moral virtues without phronesis and
anyone with phronesis has the moral virtues:
It is plain, then, after what has been said, that it is not possible without practical wisdom to
be really good morally, nor without moral excellence to be practically wise. (30)

20.4 What’s up with the Tattoo? An Illustrative Case

If medical choice making demands practitioners with practical wisdom—with the

character traits and moral skills we have been discussing—how might that look in
practice? In our research we have been asking physicians to talk about experiences
that they felt would illustrate practical wisdom. Dr. S tells us this story in the Case
Study box below.

Case Study Box 1 Dr. S’s Story: What’s Up With The Tattoo?
JT had been beaten most of his life. He was a patient in a homeless shelter. Mean.
Tough. The first day I saw him, he looks at my name. (Dr. S, a typical Jewish
last name) …that’s your name? He rolls up his sleeve. There is a huge swastika
tattoo and it’s dripping with blood. I said: “what’s up with the tattoo?” He said:
“Well…. I think you know.” I just by-passed the remark and went on with the
medical exam. [Dr. S commented to those of us in the group hearing this story
that seven of his grandmother’s children were killed in the German camps].
This patient came in many times…….and his sleeve was rolled up….and after
many visits, I noticed that his sleeve was not rolled up….and he sent his children
to me. Fast forward 11 years later. His last visit. I looked at JT’s arm and it
was all inflamed where the tattoo had been. I said: “JT: you have dermatitis on
your arm, and it looks terrible.” I asked him: “what’s up?” He bit his lip again.
He says: “since I met you, I have been trying to rub it off….”
I don’t know if I did anything for his health…. But it was about the most
meaningful thing that happened in my professional life. It’s calling to us to be
in the moment, to be our best selves in terms of the other….

Dr. S told this story to a small seminar (of mostly physicians) exploring practical
wisdom in medicine. It did not at first seem as if there were a lot of tough choices here,
20 Phronesis in Medical Practice … 299

but, as our group listened and reflected, we imagined the complexity of the choices
Dr. S was making. Before reading our reflections, see what choices you notice, and
what virtues and moral skills—the practical wisdom—Dr. S exercised.
Here are some of the things we noticed. Because these traits and moral skills
are necessarily interwoven, we will signal the character traits in bold type and the
fundamental moral skills using italics.
At the start of the exam, Dr. S first had to notice that he had a situation of moral
conflict, and to notice that he had several choices in how to respond. He could
have ignored the outthrust swastika and started the exam. He could have challenged
JT’s anti-Semitism. He could have told JT that he found his tattoo and comment
threatening. He could have told JT what feelings this evoked, given what happened
to his family in Nazi Germany and used that to critique the patient’s anti-Semitism
and make a point about justice and bias. He could have said “Oh, that’s a well-done
tattoo” and gone on with the examination.
His choice was to neither ignore nor confront. Instead, he turned the out-thrust
swastika into a question: “what does that mean?” Here, too, he had choices, like
his tone of voice. The tone he repeated to us was open, inquisitive, and non-
confrontational. He could have said the same words with a very different meaning.
And when the patient responded “you know what it means…. your name is S (a
Jewish name), isn’t it,” Dr. S had to make another choice: to engage or to ignore. He
chose to simply continue with the exam and work on the health issue the patient had
come in with. That patient, of course, had choices too: he could have walked away,
or escalated the confrontation, but did not.
Buried in these visible choices are multiple underlying, more subtle choices. For
example, Dr. S needed to decide whether the tattoo was a central issue in caring for
this patient—was it relevant to diagnosis and treatment? To developing a therapeutic
relationship? To helping this patient achieve well-being? In solving the relevance
problem, Dr. S. had to focus on the purpose of his activity at that moment. He was
not a teacher with a group of 10-year-old school kids confronted by a man flaunting
his swastika tattoo in a public place. He was a doctor whose aim was to deliver
knowledgeable, skilled, compassionate person-centered care.
Dr. S also had to make a quick judgment about the kind of threat this was. He had
perceived—probably intuitively and not consciously—that this patient was being
threatening but was not a threat. Such perception was rooted in Dr. S’s ability to
discern the context. The patient’s body language and tone of voice, and where he
was: in a homeless shelter with indigent poor people, with a variety of problems,
psychological, social, and medical.
We noticed that, in the few seconds that Dr. S had to react, there was little time for
conscious, deliberative reflection. He could not have laid out four options, weighed
the pros and cons of each one, and picked the best.1 Reflection was crucial for Dr.
S. after the fact when he had time to think about what he did and what else he could

1On naturalistic decision making and intuition see also Gary Klein, Sources of Power, How People
Make Decisions (Cambridge: MIT Press, 1998); and Daniel Kahneman, Thinking Fast and Slow.
(New York: Farrar, Straus and Giroux, 2011)
300 M. Plews-Ogan and K. E. Sharpe

have done, a ‘reflective practitioner’ in a post-game analysis (Schon 1983). This

fast, intuitive way of choice-making raises other issues about how practical wisdom
is learned. Intuitions are not inborn. They are learned. Intuitions can be educated.
This was Aristotle’s insight in the Nicomachean Ethics when he emphasized the
importance of developing the right habits before practical wisdom is possible. One
lesson here for teaching is to help young medical practitioners recognize the myriad of
moral choices they are making in even the most ordinary patient encounters. Another
is the importance of a medical education that helps students move step by step from
being novices to being experts (Dreyfus 2004), not only in terms of technical skill,
but in terms of moral skill.
Dr. S did not react immediately with the common emotions of anger or defen-
siveness. Dr. S. cannot remember exactly his emotions at the time. One possibility is
that Dr. S. felt anger and pain about the bias and anti-Semitism. Another possibility
is that Dr. S. did not feel anger or hurt because of the way he perceived the situation
(JT is suffering) and because of his deep compassion (I am here to help relieve that
suffering). Another possibility is that Dr. S’s habit of wonderment and curiosity
and problem solving kicked in: what drove JT to get this tattoo and why is he saying
this to me now?
Empathy and compassion were clearly at the heart of this story (for a thorough
discussion of empathy, see Chapter 5). Dr. S. needed some sense of what the patient
was thinking and feeling, and that demanded certain moral skills. He had to be a
good listener: he needed to read the body language, hear the tone of the words, and
to listen carefully to what was medically wrong with this patient. He needed to be
open to hearing what was on the patient’s mind (and in the patient’s heart) which
meant that he had to have the capacity to suspend judgment at least for the moment.
To be empathic, Dr. S. also needed to be a good communicator. He needed to know
when and how to use his own body language and verbal language to elicit what the
patient had to say. Thus, his opening question: “what’s up with the tattoo?” He also
needed the capacity to tolerate ambiguity and complexity and to live (at least for a
while) with uncertainty (can I go ahead with treatment even though I do not quite
understand what is happening here?) (See Chapter 4 for further detailed discussion
regarding the nature of ambiguity within health professions education).
Developing habits and feelings of compassion are an important part of encour-
aging practitioners to develop practical wisdom but health professions education must
also include fostering the motivation to act when compassion is absent. Imagine a
doctor who felt baffled, angry, or hurt by the flaunted swastika; or a doc who intensely
disliked this patient; or a doc who could not fathom how someone could think or
feel the way this patient did. This doctor-without-compassion might still have given
good care in this case because of the habit of duty or his commitment to the Hippo-
cratic oath or a larger faith or some other larger purpose2 (See also Chapter 5 in this

2 In a wisdom study Plews-Ogan carried out, this learning process was described by both patients
and physicians: at times ‘a moral context’ or a ‘professional code’ helped physicians to go through
the right motions, even when they weren’t feeling it. M. Plews-Ogan M, J. Owens, N May, “Wisdom
20 Phronesis in Medical Practice … 301

book for a more sceptical view of acting compassionately and empathically without
feeling in these ways).
Dr. S.’s story underlines another character trait that all doctors need in far less
threatening circumstances: the willingness to take risks, to fail and try again. Such
resilience and courage are not so much the overcoming of fear but the willingness
to act well in the face of it. JT flaunted his swastika tattoo to be provocative, even
threatening. But courage, like the virtues of empathy or compassion or patience,
demands not simply the willingness to act in the face of a strong feeling like fear
but also the moral skill to choose the right action. Courage demanded the capacity
to imagine the possible scenarios that could have developed with this person in
this shelter at that moment—and thus rule out any immediate danger. Dr. S needed
the capacity to assess the relevance of what he saw: that the patient was, in fact
suffering; that the threatening words were not, in fact, an immediate threat in these
circumstances. Dr. S.’s fearlessness could have led to recklessness instead of courage
had he not had practical wisdom.
In deciding how to treat this patient, Dr. S needed to balance good things that were
in conflict. There was no simple rule or principle or best practice that told him how
to rank order, prioritize or balance. Standing up against bias and injustice is a good
thing—something we expect good doctors to do. Being honest with patients is a good
thing. Diagnosing and treating them to relieve pain and suffering is a good thing to
do. Protecting one’s integrity is a good thing to do. Preserving one’s health and safety
so that you can continue doctoring is a good thing to do. In making the choice about
whether and how to respond, Dr. S. was weighing these things and finding the right
balance for this patient, and for himself, in this context. This capacity to balance
and weigh frequently underlies the everyday choices doctors make: this capacity is
one of the markers of practical wisdom in a doctor.

20.5 Designing for Wisdom

How then can practical wisdom be fostered? Classroom courses can teach about
practical wisdom just like they can teach about ethics. However good character,
good purpose, and good judgment—like good technical skill—cannot be learned
without experience. But not any experience will do: it must be well-designed. The
extensive literature about the informal or hidden curriculum in medical school has
demonstrated how bad mentoring and role modelling, and ill-structured experiences
in classrooms, wards and clinics have eroded the empathy, compassion, noticing,
and good listening of students (Hafferty and Franks 1996; White, Kumanai, Ross
and Fantone 2009). Two examples of institutional re-design provide provocative

through Adversity: Growing and Learning in the Wake of an Error,” Patient Education and Coun-
seling 91 (2) (2013): 236–242; and M. Plews-Ogan, N. May, J. Owens, M. Ardelt, J. Shapiro, S.
Bell, “Wisdom in Medicine: What Helps Physicians after a Medical Error,” Academic Medicine 92
(2) (2016): 233–241.
302 M. Plews-Ogan and K. E. Sharpe

illustrations of how to encourage the learning of practical wisdom and virtue, as well
as medical knowledge and technical skills.
One example is the reorganisation of the third-year program at the Harvard
Medical School-Cambridge Integrated Clerkship (CIC) at the Cambridge Health
Alliance (CHA) (Ogur et al. 2007; Hirsh 2014). Led by doctors like Malcolm Cox
(then dean of medical education at Harvard Medical School), David Bor, Barbara
Ogur, and David Hirsh, a major aim was to reverse the well-documented moral
erosion and decline of empathy among medical students during their third year of
medical school (Hojat et al. 2014). What students saw modelled by many doctors was
exhaustion from being overworked, little time to mentor students, a focus only on the
disease process rather than the person experiencing the disease, demeaning language
which de-humanized the patients, and encouragement to get the answers right for
the wrong reasons—to please or impress the resident or attending, not because it
really mattered for their care of the patient. The CHA faculty totally redesigned the
third year of medical school so students learned the medical science, the clinical
judgment, and the dedication, compassion and wisdom to stem ethical erosion.
At the heart of the program was designing continuous—longitudinal—relation-
ships: between doctor-teachers and students, between students and patients, and
amongst students. The 15 students had their own workspace and meeting area with
faculty offices nearby. They met every day at 7:30am for morning rounds together.
Instead of a training model based on immersion in hospital wards all day, the students
spent every morning in four out-patient clinics (internal medicine on Monday, psychi-
atry on Tuesday and so on) working one-on-one with the same doctor for the whole
year. And each student was assigned 75 patients for the year, drawn from these
out-patient clinics.
Their doctor-mentors in the clinic guided the students as they first learned to do
patient histories, then how to ‘work up’ the patients prior to examination, and then
how to do diagnoses and treatment recommendations themselves with their doctor-
mentor checking back in at the end to hear the students explain, in front of their
patients, what they found. Making these students responsible for actual patients in
this environment taught them to care by caring, taught them the hows and whys
of listening and empathy and good communication because these virtues and skills
were not theoretically important but actually important for their patients.
The organizing principles of the integrated clerkship program at the CHA are
replicated in a growing number of LICs – Longitudinal Integrated Clerkships (Worley
et al. 2016).
In our second case these principles were expanded to all four years of medical
school: the Phronesis Project at the University of Virginia School of Medicine (UVA).
Originally piloted by Dr. Margaret Plews-Ogan and her colleagues, it was designed
to foster capacities for wisdom formation from the beginning of medical training.
It emphasized character formation, listening, and noticing skills, and reflective and
deliberative practices creating three kinds of long term and continuous—“longitudi-
nal”—relationships for their entire medical school experience: a team of students, a
mentor-coach relationship with a faculty member, and a relationship with a patient
and their family. In most medical schools, students care for a particular patient for a
20 Phronesis in Medical Practice … 303

few days, at most a few weeks. At UVA, students care for their patients for four years,
and a lot happens to people in four years. They get sick, they get well, sometimes
they die, and the students experience this alongside their patients, with their mentors
coaching them throughout it all.
The student’s first task is to take a narrative history of their patient: not their
illness but who they are, what is important to them—a context in which to develop
an empathetic and compassionate relationship with this patient. Then they begin
accompanying their patients in medical encounters. Experiencing these encounters
through their patient’s eyes students learn to practice perspective taking, another
wisdom capacity that is then re-enforced in their seminars. Students also serve as
advocates for their patients in an attempt to overcome socioeconomic barriers to
health. Discussions in their weekly seminars include the role of physician advocacy
in achieving the greater good for society. By the end of their first year, students begin
in-depth clinical discussions of their patients with their mentor and each other: what
is going well, what is particularly challenging, what has worked, and what is not
working? Their clinical role expands in the second year as they are assigned tasks
such as helping their patients adhere to treatment plans which in turn involves under-
standing the obstacles to such “adherence” because of health literacy, belief systems,
culture, economic and social barriers. In the third and fourth years, students meet
monthly with mentors to discuss their patients, their experiences in the clerkships,
and their moral and clinical conundrums. They are encouraged to challenge each
other, and themselves. They are encouraged to see their failures as critical oppor-
tunities to mature as clinicians. Their mentors are encouraged to share their own
failures and limitations, and how they balance competing goods and uncertainties.

20.5.1 Wisdom-Generating Design Elements

These cases indicate some of the important design elements that can generate the
learning of practical wisdom.

20.5.1.1 Role Modelling, Coaching, and Mentoring

In the formal curriculum, teachers teach the ideal. Evidence suggests that the hidden
and informal curriculum is where students develop habits and character traits of
ethical practice by observing closely what the teachers and head nurses and doctors
actually do in practice and trying to align that with what they have learned in the
formal curriculum (Hafferty 1998). That process need not be left to chance. Coaching
and mentoring, if longitudinal—consistently done over time—can help students
to unpack those experiences (Maini, Saravanan, Singh and Fyfe 2020). They can
then realistically reflect on what is needed to live out wise action even in tough
circumstances (Sharpe and Bolton 2016).
304 M. Plews-Ogan and K. E. Sharpe

To offer one example, Vanessa’s (a student in the CIC programme) doctor-mentor

in the internal medicine clinic at CHA, Dr. Pieter Cohen, had her review out loud,
in front of each patient, what she diagnosed and what she would prescribe. He not
only told her stories from his own experience, but routinely asked her questions to
help develop her ethical sensitivity: How do you think the patient felt when you gave
the diagnosis? How did you feel? What kind of response did they make (in words
or body language)? How much truth should you tell this patient and when? Why
did you nudge the patient this way (toward drugs and not diet; toward wait and see
instead of surgery)?

20.5.1.2 Reflective Practice

The kinds of questions that Dr. Cohen asked Vanessa are at the heart of an experi-
ential learning cycle designed to teach reflective practice, Experience/Practicing→
Reflection → Deliberation and Learning → Experience/Practicing Again. This is
illustrated in Fig. 20.2.
Note that this is not a linear path but a circle—a kind of virtuous upward spiral, and
the starting place of this learning cycle depends on the subject matter, the practice and
people’s learning styles. The “practice” generates the urgency, and the ‘realness’ of
the learning. Reflection demands nurturing the capacities for learning how to notice.

Fig. 20.2 Experiential learning cycle

20 Phronesis in Medical Practice … 305

Deliberation demands figuring out what worked and didn’t and why—and what to try
next. Students learn ethical judgment the same way they learn technical judgment: in
an environment which allows for trial and error without putting the patients at risk.
The CHA and Phronesis project set up environments in which the practice generated
the urgency—the realness of the learning and the need for reflection and deliberation.
They were also environments of trust and curiosity, rather than judgment or shaming.
As one CHA student put it:
There are so many ways to get it wrong when it comes to counselling a patient, to figuring out
how to get them to accept treatment, to allaying their fears, to giving them hope, to helping
them make good choices – knowing when to choose for them, knowing when to let them
choose, and helping them make those choices. These are the kinds of daily ethical questions
so important for good doctoring.

John, a pseudonym for a student in the Phronesis Project, remembers how stunned
he was when one of his patients used a racial slur—how conflicted he felt between
his duty to treat the patient with compassion and the duty to treat all people with
respect. He said nothing. Neither did the nurse who witnessed the encounter. But he
was able to talk with his coach, unpack his assumptions, and think through possible
responses– to such a patient and to the nurse.

20.5.1.3 A Focus on Teamwork and Intra-Professionalism

The practical wisdom of modern medical practice is no longer a solo act: increasingly,
wise decisions about the treatment of chronic illnesses or complex psycho-social
problems depend on teams learning the skills to work together to see the different
aspects of the context and the different interrelated problems of the patient and
come up with wise suggestions, delivered wisely, for this particular patient. Both
the CHA and the Phronesis Project intentionally designed learning environments to
encourage medical students to work in teams, to listen and communicate, to dialogue
and brainstorm.
The students in the CHA clerkship team each take turns presenting a case from
one of ‘their’ clinic patients during morning rounds with their doctor-coach. The
doctor-coach has modelled the steps of a differential diagnosis but over the weeks
increasingly sits back to let a student present and the team work it out—coming
in at points to push and nudge: “I want you to be more like lawyers here…. push
back….what’s missing…what’s the story of the case….can you tell another story?”
Each student has two morning sessions to present their case—and can’t reveal
the actual diagnosis the first day. The first session leaves the team—the class—
puzzled. Their mission is to figure out the diagnosis and the treatment for the next
day—and test their ideas against what actually happened. The students learn the
skills of listening, empathy, cooperativeness, and collegiality necessary to work as a
team.
306 M. Plews-Ogan and K. E. Sharpe

20.5.1.4 Continuity of Relationships over Time

Undergirding many of the design elements above is continuity: allowing young

practitioners a continuity of experience over time with their mentors, patients, and
colleagues. The experience of such continuity over time encourages reflection. It
allows practitioners to learn how to understand the thoughts and feelings of patients.
Continuity also encourages the experience of trust building and loyalty among prac-
titioners which then allows a safe environment where learning can take place through
trial and error, and young practitioners have the opportunity to practice mindfulness
and be present.
At the CHA the third-year students work in their four weekly clinics with the
same patients and the same doctor all year. And every time one of the 75 patients
assigned to a student enters any part of the hospital or clinic system, the student’s
pager goes off. If at all possible, the student drops everything to accompany that
patient. In the Phronesis Program at UVA a medical student has the same faculty
member as mentor-coach for all four years and is assigned a patient (and family) to
follow from the beginning of the first year. This allows students to see how health and
treatment develop, understand a family’s joys and fears, learn how to adjust when
something does not work, and be able to advise or counsel the patient and other
doctors. Jeanne (a student pseudonym) was at the ER at UVA hospital when a patient
she had known for 3 years unexpectedly had a serious reaction in an infusion centre
and was being rushed to the ER. In 3 min, while waiting for the patient, Jeanne could
give a concise history of the patient’s medical care to the team (without even looking
at the records). After the patient passed away, she stayed another few hours with
the patient’s family who she had come to know. Jeanne called her faculty mentor:
“What do I do? I’ve never experienced this before…I’ve never talked to a family.”
Her mentor, who rushed over to accompany Jeanne as she talked to this family,
remembers: “it was stunning to see this student navigate this on behalf of the patient
and ultimately the family. I had been mentoring this student-patient relationship for
the last two years so she could call me: there was patient care continuity, there was
educational continuity. It was how it was supposed to be.”

20.5.1.5 Build Uncertainty Training Into Health Professions Education

Medical decision making often takes place in situations of uncertainty, ambiguity,

incomplete information, complexity (for more on ambiguity, see Chapter 4). Medical
practice during the COVID-19 pandemic was an extreme version of a common set of
circumstances: the limits of “standard operating procedures,” rules and algorithms.
Unlike medical school tests, there are no right and wrong answers. Yet, uncertainty
often rubs against the grain of a medical culture which encourages young doctors
to show their expertise by being decisive, by being certain. That is why attendings
often pretend to be more certain than they really are. So medical education needs
to be designed to train students in the character and the practical wisdom needed to
deal with decision making in complex and ambiguous circumstances – to encourage
20 Phronesis in Medical Practice … 307

students to practice the courage, patience and honesty, and the practical skills needed
to make decisions in the face of such uncertainty.
At the CHA and the UVA Phronesis Project, students are encouraged to learn
that when you think you have the answer that it’s not the whole answer. Often,
that becomes clear only with information gathered over time. At UVA, for example,
students are coached to spin out what they expect the results of the treatment plan
to be: if this is pneumonia and you treat with this antibiotic, what do you expect
will happen? The expectancies create the rules of the game going forward: there is
uncertainty until you see what happens—and if your expectations are not met, then
what will you do next? The students are encouraged to extend the uncertainties and
be prepared to alter their diagnosis and treatment plan. Each diagnosis and treatment
is a test situation because, until the patient recovers, there is still uncertainty, and
you always need to go through the process of reflective deliberation: what did I get
wrong, what do I see or notice now, what do I think it means, how do I test for it,
what do I try next? And how do I share this process with patients, to empower them
and to sustain their trust?

20.6 Conclusion

Medical knowledge, technical skills and phronesis are at the core of good medical
practice and health professions education. Phronesis rarely gets its due, even as
most health care professionals will give a nod to the importance of character and
good judgment in health care decisions. Too often, medical schools and health care
institutions ignore the importance of educating for practical wisdom; worse, the ways
their formal and informal curriculum are designed can erode the very wisdom that
good medical practice demands. That corrosive situation can be turned around by
designing for wisdom (Table 20.2).

Table 20.2 Practice points

1 Role modelling, coaching, and mentoring can generate the learning of practical wisdom
2 As reflective practice fosters phronesis, teachers must be conscious of how they teach
students to be reflective. The experiential learning cycle can be utilised to this end
3 Designing learning environments to encourage medical students to work in teams, to
listen and communicate, to dialogue and brainstorm fosters teamwork and
inter-professionalism which, in turn, facilitates practical wisdom
4 Relationships that endure over time with mentors, teachers, peers, and patients are critical
in providing students with the space to practice the necessary skills or capabilities that
make one practically wise. Programmes should be designed to foster such educational
continuity
5 Situations which encourage students to consider and be immersed amongst uncertainty
should be built-in to medical curricula
308 M. Plews-Ogan and K. E. Sharpe

Acknowledgements We would like to thank the John Templeton Foundation for research support
for this chapter. We would also like to thank three colleagues at the University of British Columbia
at the University of British Columbia for their critical comments: Dan Pratt, Glenn Regehr and
Maxwell Cameron.

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Chapter 21
In Pursuit of Time: An Inquiry
into Kairos and Reflection in Medical
Practice and Health Professions
Education

Sven Peter Charlotte Schaepkens and Camillo Quinto Harro Coccia

21.1 Introduction

In teaching and practicing medicine, there is pressure to work efficiently and be task-
focussed (Hodges 2010). Although there are only so many hours available in a day,
staff and trainees need to absorb the ever-expanding volume of technical knowledge
and manage an increasingly complex medical practice (Cunningham and Sutton
2008). In response, scholars have begun to rethink the meaning of ‘taking time’
and being a health professional in a demanding environment where time is precious
(Kumagai and Naidu 2021; Wear et al. 2015). Indeed, taking time is easier said than
done, particularly in reference to reflective practice: “for busy professionals short on
time, reflection runs the risk of being applied in bland, mechanical, unthinking ways”
(Bindels 2021, 8). Likewise, trainees who are task-oriented find little motivation
to voluntarily reflect (de la Croix and Veen 2018; Chaffey et al. 2012; Albanese
2006). Nonetheless, medical educators are encouraged to help trainees take time and
integrate reflection into the curriculum (Mann et al. 2007; Albanese 2006).
A lack of time challenges reflection because it is assumed that “taking time to stop,
think and evaluate” is a fundamental component of reflection, which could reduce
burnout (Lack et al. 2019, 228; Kuper et al. 2019).
Taking time to work through an experience that breaks in some way with the expected
course of things allows students to return to and begin to make sense of that which troubles
or delights them. (Wear et al. 2012, 608)

Similarly, medical staff need reflection time to process emotions to cope with work
pressure (McPherson et al. 2016). Therefore, at first glance, we ought to designate

S. P. C. Schaepkens (B)
Erasmus University Medical Centre, Rotterdam, The Netherlands
e-mail: s.schaepkens@erasmusmc.nl
C. Q. H. Coccia
University of Cape Town, Cape Town, South Africa
e-mail: camillo.coccia@uct.ac.za

© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2022 311
M. E. L. Brown et al. (eds.), Applied Philosophy for Health Professions Education,
https://doi.org/10.1007/978-981-19-1512-3_21
312 S. P. C. Schaepkens and C. Q. H. Coccia

specific portions of our schedule to document an appraisal of our day. Although this
is valuable, there are alternative ways to think about taking time and reflection.
Contemplation for early Greek thinkers was never seen as a task or activity, but as
precisely the opposite, as freedom from tasks and activities in order to think (Arendt
1958; Pieper 1963). In this chapter, we introduce the Greek notions of kairos, chronos,
and scholê to explore taking time to think without it being a scheduled task during
a busy day. Then, with Walter Benjamin’s work on time, we explore why kairos is
important to question an instrumental view of reflection as a task. Finally, we discuss
the practical implications of kairos for medical practice and education.

21.2 Experiencing Time

When we boot up our devices during our medical practice or at our medical schools,
a calendar app or other time management technology appears on our screens to
structure our day. They produce notifications that flag upcoming tasks, that we should
move along to our next meeting, or that patients are waiting. What can this experience
with time and calendars tell us about taking time and reflection?
Generally, calendars create order in an otherwise demanding environment. Such
technology provides a convenient overview of tasks and helps us keep track of our
day. Calendars divide tasks into manageable items that are either ‘to do’ or ‘done’.
They offer a gratifying sense of closure when something gets done, while they also
generate urgency, nudging us along to our next task. Presently, to imagine work
without the benefits of such organisational technology is hard. Its integration with
our daily tasks epitomizes and shapes the experience of our work as a sequence of
events that requires management (Giddens 1987).
Calendars provide a beneficial sense of control; however, they also require micro-
managing. Calendars divide time into distinct blocks by singling out individual
moments with abstract tokens like May 6th 2021, 08:30–09:15. As such, calen-
dars prompt what some philosophers call the ‘vulgar’ interpretation of time. Time is
an abstraction that exists independently of man and is measured by clocks (Keller
1999). Although measurement with clocks helps us ‘be on time’, its “increased accu-
racy leads one to become more and more concerned with ever smaller units of time”
(Keller 1999, 196). We divide our worktime with greater precision into neat, chrono-
logically organized blocks. We have one hour to finish task X, then twenty minutes
for meeting Y, fifteen minutes’ lunch, and afterwards ten minutes per consultation.
In sum, pre-allocated time slots dictate the pace of our work as an endless string of
loosely connected, sequential moments.
While we are very familiar with how calendars work and adapt to them, something
else happens when loved ones ask how our day was. We never list a perfect sequence
of chronologically transpired events as if we were calendars ourselves. We are not
objects “that correspond to statements about events occurring at various clock-times”
21 In Pursuit of Time: An Inquiry into Kairos and Reflection … 313

(Keller 1999, 240). For instance, the day was not hectic at 15:37; instead, I experi-
enced a hectic day because I was invested in doing my job and fulfilling my roles. I
will tell my loved ones a story about tensions, and that too many things converged
around midday, and how I was unable to cope with my responsibilities (Keller 1999).
These stories punctuate an otherwise abstract flow of clock-time, and illustrate how
we are deeply, personally invested in our surroundings.

21.3 Chronos and Kairos

The two aforementioned ways of time perception, time as a ‘chronological sequence

of events’ and as ‘lived experience’, can be put into perspective with the help of
an Ancient Greek distinction (Sipiora and Baumlin 2002). Greek thought offers the
notion of time as chronos: a destructive force of time, “an objective, measurable
time and a long duration of time” (Lindroos 1998, 11). Time is uniform with each
second, minute and hour lasting exactly the same amount since the beginning of
time. Such time is about “quantity of duration”, and prompts questions like “How
fast? How frequent? How old?” (Smith 2002, 47). Time receives order with ‘before’
and ‘after’ that provide a “grid upon which processes of nature and the historical
order can be plotted” (Smith 2002, 49). Our experience can, thus, be timed and
standardized, allowing us to date events, which is vital for how we organize life and
our historic understanding. In contrast, Ancient Greeks also know of time as kairos.
This notion is complex and multidimensional, since it was used variably throughout
Greek culture in epic literature and tragedy, and spanning among others Presocratic,
Platonic, Aristotelian, Sophistic and Stoic philosophy and rhetoric (Sipiora 2002;
Kinneavy 2002).
Generally, kairos is related to the meaningful moment, “the uniquely timely, the
spontaneous, the radically particular” (Miller 2002, xiii; Lindroos 1998). It is “the
right or opportune moment to do something, or right measure in doing something”
(Kinneavy 2002, 58). Rhetorically, kairos implies that one can learn theories and
strategies based on previously successful discourse, but theory cannot “cast a net
over the unforeseen, unpredictable, and uncontrollable moments” (Sipiora 2002,
6). Speaker and audience find themselves in a unique context that requires adjust-
ment and reinvention of discourse in the moment itself. As Aristotle argues, kairos
is situational (Kinneavy 2002; Kinneavy and Eskin 1994). Beyond rhetoric, kairos
spans many other dimensions of experience. Kairos particularly comes into play
when we face decisions in unique situations about means and ends, morals and
values “that cannot be a matter of law alone but require wisdom and critical judge-
ment” (Smith 2002, 56). To explore chronos and kairos for medical practice and
education, we turn to a personal experience of one author of this chapter, Camillo
Coccia.
314 S. P. C. Schaepkens and C. Q. H. Coccia

Case Study:
I was on a night shift in the Emergency Room and saw a new patient brought
in. Exhausted, I paged through a file and formulated the problem list: 26-
year-old, end-stage cervical cancer, now with loss of appetite. Working in
this particular Emergency Room, I had seen a multitude of patients with these
conditions and was already thinking of a possible differential diagnosis and a set
of investigational strategies for the particular pathology that might be present.
Then, I noticed the frontmatter of the file and was struck by recognition. I had
met this person before, but looking at her face now, she was unrecognizable.
Wasted and delirious, the patient did not resemble the memories I had of her.

We might not be so blithe as to justify Coccia’s bleak encounter as a mere learning

experience, but also perceive it as something much more profound and upsetting. In
Coccia’s case, the face of a suffering patient no longer disappeared behind the usual
signs, symptoms, and procedures that help ‘transform’ people into patients. Here, a
rupture occurred between kairos and reason (logos). Reason deals with generaliz-
able ideas and truths that are steady throughout time, whereas kairos represents “the
special occasion in the course of events when such truth must be brought to bear by
an individual somewhere and somewhen” (Smith 2002, 53). For Coccia, the patient
ceased to be just another scheduled patient who rationally represented a typical case
of cervical cancer. Kairos illuminated the contours of Coccia’s general ideas of ‘being
a doctor’ and ‘cervical cancer’ that normally guide him on the job (Dewey 1933;
Garrison et al. 2012). Moreover, the ideas partly failed him in this confrontational
moment. In unique situations, kairos-thinking emphasizes the individual and calls
for critical judgment “on the value and norm aspects of ideas” (Kinneavy 2002, 63).
Kairos provides particular constellations of events that create opportunity (oppor-
tunitas as the Latin translation of kairos) for a qualitative reappraisal of ideas or
transitions (Smith 2002). To make sense of such disruptive experiences, doctors and
trainees might need additional time to incorporate such confrontations with death
and suffering back into their clinical understanding, and we ask how kairos invites
further reflection.
The day can be divided in time at work and time off work or leisure time. Ancient
Greeks had a particular view of empty leisure time that contrasts with ours. Their
notion of leisure time was scholê, to which our word ‘school’ is etymologically related
(Skeat 2005). We might assume that scholê as leisure means time free from work, or
time spent away from specific commitments. In Greek thought, however, work was
a time during which scholê was impossible (Pieper 1963). The negative ascholia
describes everyday work activities and labour connected to the basic necessities
to sustain human life (Kalimtzis 2017). Ascholia contrasts with the more fulfilling
times of life in scholê, which is a conscious abstention from any such necessary
labour (Arendt 1958). Moreover, Aristotle saw scholê as an end in itself. It was not
leisure on the weekend as time off from work that had some specific goal, like resting
21 In Pursuit of Time: An Inquiry into Kairos and Reflection … 315

so we can improve our functionality when we go back to work (Zimmern 1911; de

Gennaro 2020). Neither was scholê a comfortable state of mindless relaxation or
consumption (Arendt 1958). On the contrary, lacking specific goals in scholê is what
is valuable, and does not make time spent in leisure void or pointless. Why is that
so?
Taking time without having a goal in mind can reinvigorate previous under-
standing and knowledge. The common formulation of knowledge and reflection in
health professions education is to understand phenomena in terms of their existing
purpose: ‘I reflect in order to improve myself at task X…’ (Kolb 2015; Coffield et al.
2004; Winkel et al. 2017; Roessger 2014; Nguyen et al. 2014). Teaching trainees
about these pre-existing purposes that are embedded in standard procedures, basic
facts, and learning goals is valuable. For instance, reflection during a pre-scheduled
reflection session on Thursday from 10:30–11:00 can prompt goal-oriented reflec-
tions that move within the regular parameters of work. A goal-oriented reflection
by Coccia could include evaluating how he can more effectively execute protocols
for cervical cancer patients or re-assess the adequacy of his doctor-patient commu-
nication when doctors know patients privately. Such reflections are important and
functional. Moreover, they are likely to occur within accepted parameters because
at work we are deeply invested in our roles and responsibilities that come with our
jobs (Keller 1999). However, Coccia could also focus on the shock and disruption
of the encounter; how someone’s personhood disappears behind a disease, medical
graphs, and symbols, and address the upsetting weight of the encounter in the face
of his medical task to deter death. It is in scholê’s absence of goals that reflections
could move beyond accepted reflective parameters that predetermine how we should
‘normally’ function and reflect during ascholia.
In sum, when we contrast scholê with our contemporary view of time, we see how
we presently divide time into periods of working and periods that are before or after
work. The periods that are within worktime are usually goal-oriented, organized by
the helpful chronos grid. From Greek thought we take that kairotic moments could
disrupt us from this way of working habitually and move us away from the grid.
We are, for a moment, not ensnared by our calendars to achieve our micromanaged
string of goals but receive the opportunity to question our ideas. Now, we can ask
why disruptions and questioning our ideas are valuable, for which we turn to the
philosophy of Walter Benjamin.

21.4 Walter Benjamin

When we commonly think about time spanning years, months, or even weeks, we tend
to use the following chronistic method of making sense of the present. A patient’s
history requires a general overview of many particular points of significance that
culminate in a timeline that explains the present. This method represents how all
these moments are (causally) interconnected and lead up to the present condition.
However, sometimes, a small piece of information can entirely reorganise the way we
316 S. P. C. Schaepkens and C. Q. H. Coccia

understand the timeline and radically alter our current understanding and diagnosis.
For instance, a doctor might presently notice an error, a missing piece of information
or uncover a lie from a patient which disguised a latent problem. For Benjamin,
an early twentieth century thinker, this was not exclusive to patient histories but
more fundamentally applicable to our historical understanding and personal lives.
However, Benjamin also noted a cultural trend that posited a current state of affairs
only as an inevitable result of the past – as if a series of events pointed unequivocally
to the present and on toward the future. This trend is widespread, and, we argue, also
prevalent in medical practice and education.
Born in Berlin in 1892, Benjamin was a member of a wealthy Jewish business
family. In 1940, he took his own life after a failed attempt at crossing the French-
Spanish border. His writing intertwines different disciplines and covers high and low
culture (Rosenthal 2014). His style is fragmentary and associative, which some call
kaleidoscopic (Lindroos 1998). Besides classically written academic work, many
manuscripts consist of assemblages of shorter texts, aphorisms, quotes, or vignettes.
They:
…provoke his reader to reject the idea of the linearity of the text, and to approach it as
separate pieces of thought, which, however, become bound together in the act of reading.
(Lindroos 1998, 32; Löwry 2005)

In the following, we explore some of his views on time in reference to his treatise
‘On the concept of history’ (1940) (Benjamin [1942, 2006b). We further elucidate
these with his biographically inspired vignettes from Berlin Childhood around 1900,
which he started writing in 1932 but was only posthumously published (Szondi 2006;
Cosma 2019; Steiner 2010). The breadth and depth of Benjamin’s work on history
and time is complex and extensive. Here, we only introduce his work for the sake of
medical practice, and it is by no means exhaustive.

21.5 A Boy in Berlin—A Man in Paris

It is 1932, and Benjamin tries to come to terms with his pending exile. He starts
writing about his earliest memories from when he was a boy in Berlin around 1900,
and once in exile in Paris in 1933, continues working on this project (Steiner 2010).
His aim is not objectively chronicling some facts about his Berlinian past; rather, his
descriptions cause images from past and present to clash (Cosma 2019). For instance,
in his vignette about the larder:
With what endearments the honey, the little heaps of currants, and even the rice gave them-
selves to my hand! How passionate this meeting of two who had at last escaped the spoon!
Grateful and impetuous, like a girl borne away from her father’s house, the strawberry
marmalade let itself be enjoyed here without a roll and, as it were, under the stars; and
even the butter tenderly requited the boldness of a suitor who found entry into its humble
quarters. Before long, the hand – that juvenile Don Juan – had made its way into every nook
and cranny, behind oozing layers and streaming heaps: virginity renewed without complaint.
(Benjamin [1950] 2006a, 128–129)
21 In Pursuit of Time: An Inquiry into Kairos and Reflection … 317

With these descriptions, Benjamin adds layers of meaning to a moment in the past
that encompass more than just grabbing food from a larder. Items become objects
of desire, hands turn into lovers, the larder is a place of excitement. Butter and
marmalade are no longer mere ingredients but come to life and act like willing lovers
who give themselves to an eager hand. No longer is slipping a hand through the
crack of the larder door an act of boyish thievery; it is a passionate meeting and
erotic exploration. The spoon, perhaps a symbol of restraint, correctness, and proper
etiquette, no longer constricts those who want to meet more intimately. Side-lining
the cutlery even underlines the physicality of the act of touching food with fingers,
or touching another’s naked body. Lovers find each other, unencumbered, and the
butter even rewards the carnal approach of the beloved. The boy’s hand transforms
into a bold Don Juan, who unveils and explores the lover’s body, encountering oozing
layers and streaming heaps in every fold and crevice, nook and cranny.
Benjamin’s larder vignette contrasts with the interpretation of the present as the
outcome of a string of past events. In short, Benjamin moves from understanding time
as an overly chronistic clock-time that is mechanical and linear, to a meaningful lived
moment filled with kairotic potential where past and present are not seen linearly
(Lindroos 1998; Kinneavy 2002). This vignette exemplifies this move, and is what
Benjamin calls a ‘dialectical image’. He understands an image in broad terms that
includes photographs or illustrations, but also mental images, memories, or knowl-
edge (Wiegel 2015; Lindroos 1998). Generally, we think of images as static objects.
Photographs or films freeze moments in the past, and memories could, likewise, be
seen to encapsulate past events that we carry with us into the present. Benjamin,
however, argues that images are not always purely static or unchangeable; images
can move, too (Lijster 2016). In the case of the larder, an image from the past (the
Berlinian boy) clashes with the image of the present (the man in Paris). How is that
odd clash visible in the vignette?
Benjamin’s vignette mysteriously ends with ‘virginity renewed’. This sentence
accentuates the collision of images, since we wonder whose virginity has been
renewed. It is unlikely that the nine-year-old boy in Berlin has lost his virginity,
or that he was overly conscious of any eroticism when slipping his hand in the larder.
Therefore, we might assume that it is not the boy whose virginity is renewed but
the man’s. By revisiting the image of a nine-year-old Berlinian boy from an adult
perspective in exile, the youthful act of breaking into the larder in the past collides
with an image of eroticism that only the adult Benjamin is conscious of. Something
erotic is revealed in the acts of a boy in the past, while something boyish simultane-
ously shows itself in an adult’s idea of eroticism in the present. In the confrontation
between past and present, Benjamin changed: his virginity was renewed.
Benjamin names this back-and-forth between past and present now-time, which
has two qualities. First, truth as we presently know it is no longer the result of a
stable progression of history. Conversely, truth for Benjamin is dynamic. Truth (re-)
establishes itself “in the right constellation of words and things, as a montage of
ideas, or as a (re)construction of previous truths” (Lindroos 1998, 63). For instance,
in the larder the ‘adult man’ and his understanding of his idea of eroticism and
virginity clashes with the boy’s world of stealing larder goods. In the present, these
318 S. P. C. Schaepkens and C. Q. H. Coccia

two merged and constitute new meaning. Similarly, in Coccia’s experience, seeing
a woman Coccia knew from the past clashed with the present wherein she appeared
as a patient whose personhood he barely recognized. For Benjamin and Coccia, past
and present came together and shifted their understanding. In Benjamin’s case it
shifted his idea about eroticism, and it made Coccia reconstitute his idea of being a
doctor deterring death.
The second quality of now-time is that it allows us to advance into the future
without being fully determined by our past, while we simultaneously hold some
connection with our past. Simplified, in now-time, one is not prompted to say:
‘because I am a doctor, I will always perceive every patient I henceforth encounter
in the ward as a patient.’ We simply do not function mechanically, and now-time
captivates the dynamic understanding of ourselves “by virtue of the interruptive force
[that images] are understood to impart to experience” (Osborne and Charles 2020).
Now-time loosens the tight, causal chain of history that one-directionally determines
the meaning of the present. In Coccia’s case, his past and medical surroundings
prompt him to predominately think and ‘be’ a doctor who treats patients, yet the
encounter with the cancer patient he once knew privately made him question this
truth.
Benjamin stresses the importance of upsetting any simplistic, chronological inter-
pretation of our (personal) history because we so easily explain our present as the
unidirectional result of our past. For Benjamin, the past is never settled, especially
when it clashes in kairotic moments with the present. These confrontations hold the
potential to change our understanding of ourselves and the ideas we inherit from the
past.

21.6 Historicism

Benjamin’s aim to upset an overly chronistic way of thinking about time is embedded
in his work on history and time in his Arcades project and in a series of theses ‘On the
concept of history’, written in 1940 (Steiner 2010). The war and political situation
prompted him to revise the traditional view of history that he labelled historicism,
which was conducive to the dire political situation (ibid). Historicism implies inter-
preting history as a linear evolution through time. Where we are today is unequiv-
ocally the product of our past, that steams onwards towards an inevitable future.
The causal chain of successive historic events determines us. A positive historicist
interpretation of history shows how we ultimately move towards utopia, whereas a
negative historicist interpretation shows how we end up in a dystopia (Lindroos 1998).
History becomes teleological; it moves towards its end-goal or final purpose that is
foreshadowed in the past. Historic examples include the arrival of true communism
or the Third Reich.
Benjamin does not question the truth of historic facts or their chronological order;
rather, he criticizes historicism’s way of relating to the past as a solely linear process
towards a certain future, and how we naively adopt such views elsewhere. Academic
21 In Pursuit of Time: An Inquiry into Kairos and Reflection … 319

ways of relating to history influence politics, culture, and trickle down to how indi-
viduals relate to their own personal time and work. For example, a historicist inter-
pretation of ourselves entails that ‘I am the product of (my) history, and as a doctor
I simply follow protocols handed down to me’. We do not imply that protocols
should always be questioned. However, “the uncritical reception of tradition implies
a problem, which is transferred into a ‘truth’ of this heritage and is conceived of
as temporally stable and non-transformable” (Lindroos 1998, 56). The past washes
over us like a big wave, and individuals can only undergo its advancement, act along,
or even use the past as an excuse to evade responsibility. The simplest version of
the latter would be insisting on ‘I did not have time to do it…’ Time becomes chro-
nistic and destructive: I lost my individuality to the progress of the past and even
clock-time itself (Lindroos 1998; Keller 1999). With now-time, Benjamin hopes to
rebalance past and present to provide an alternative to historicism that creeps up on
us in surprising ways, for instance, in medical practice and education.

21.7 Opportunities in Medical Practice and Health

Professions Education

Based on our outlined framework on time, we wish to address two issues in medical
practice and health professions education. First, the chronistic clock allows us to
seize control over our work, however, it also controls and dictates the lives of health
professionals and medical trainees. There is much to do in little time, and that requires
superb organisation skills, but kairos does not let itself be planned. We would not
deny that kairotic moments never occur during busy days. Rather, we point to kairotic
moments getting lost once they have occurred during a busy day because there is little
time to let the potential force of the kairotic moment land. This is why we support
taking time to reflect, for instance in scheduled ‘reflection groups’ (Veen and de la
Croix 2017; van Braak et al. 2021). However, from the perspective of scholê, we
must be aware that, at work, we are encapsulated in protocols, values, and norms
that dictate our goals. We wish to reach goals because at work we are very invested
in our roles as medical trainees or practitioners. This can invite typical (scripted)
reflections (de la Croix and Veen 2018) that abide by our prescribed responsibilities
at work (ascholia). Kairotic moments like Coccia’s disturbing one or more light-
hearted ones, signal opportunities to break free from the modus operandi. To pursue
such opportunities, we can keep the idea of scholê in mind. Contrary to ascholia, in
scholê we are freer from obligations and goals. We do not argue that this process is
binary. We suggest that pre-scheduled reflections during worktime can more easily
elicit reflections that stay safely within accepted parameters and socially desirable
outcomes (Hodges 2015), but that being vigilant about the latter might free reflection,
even when it is scheduled during work time.
The second point we wish to raise is related to the chronistic, linear and goal-
oriented perception of reflection and learning that is sometimes prevalent in health
320 S. P. C. Schaepkens and C. Q. H. Coccia

professions education. For instance, in health professions education David Kolb’s

‘learning cycle’ is a widely acknowledged model for learning and reflection and has
inspired other reflection and learning models (Veen and de la Croix 2017; Nguyen
et al. 2014; Roessger 2014). What is particularly puzzling in these models, but Kolb’s
work in particular, is the conception of learning as both static and flexible (Coffield
et al. 2004). They focus on learning as process, while simultaneously formulating a
historicist fixed end-goal once the models are applied correctly.
In Kolb’s model, learners initially belong to one of four learning styles. Any
progression requires cycling through four learning phases, and each is related to one
of four learning styles. Cycling through the phases successfully leads to expertise.
Put simply, learners need to make sense of past experiences by reflecting upon them,
then formulate a hypothesis, apply a technique to experiment, and assess its effect in
practice (ibid.). Being an expert means reaching the ‘integration stage’ and drawing
from all four learning styles (ibid.). Although Kolb’s model has received extensive
criticism (ibid.), in the case of skills acquisition one could assume that such a linear
approach to use the past in light of the future might be effective. Nonetheless, the
model becomes questionable because it also functions linearly on one’s professional
identity:
The process of socialization into a profession (…) instils not only knowledge and skills
but also a fundamental reorientation of one’s identity. (Kolb 2015, 261; See Chapter 3 for
in-depth discussion of professional identity formation and socialisation)

Kolb’s model and those that draw inspiration from it (Nguyen et al. 2014)
exemplify a historicist propensity. In the ‘integrated life style’ of the expert, Kolb
argues,
…we see complex, flexible, and highly differentiated life structures. These [high-ego-
development] people experience their lives in ways that bring variety and richness to them
and the environment. (Kolb 2015, 326)

Conversely, those who have not reached the integrated stage experience more conflict
in life, are less flexible, less creative, and bring less variety to their environment
because they are unable to integrate all four learning styles (Kolb 2015). Here,
historicism’s ‘utopic’ or ‘dystopic’ qualities are visible depending on one’s success.
On the one hand, the model provides some control over the learner’s development
if learners instrumentalize the past correctly; however, on the other hand, the model
exerts control over the learner. The utopic end-goal comes with many positive qual-
ities that any non-expert currently lacks. If learners fail to follow suit, they remain
stuck in a dystopic ‘low-ego-development’.
If we confront Benjamin’s criticism of historicism with the goal-oriented reflec-
tion and ideals surrounding professionalism, we argue that becoming a professional
is not as unidirectional as some theories would project it. One can schedule and
practice suture techniques, but scheduling ‘professionalism’ is much harder. Profes-
sionalism has a certain unplannable nature to it, and in the formative moments “truth
21 In Pursuit of Time: An Inquiry into Kairos and Reflection … 321

must be brought to bear by an individual somewhere and somewhen” (Smith 2002,

56). Becoming aware of kairotic opportunities helps disrupt solidified truths (about
ourselves, professionalism, doctors, and so forth) without unidirectionally projecting
new, fixed truths into the future. “This mental presence emphasises the ability to intu-
itively prophesise on the present, not through the past, but from the perspective of the
present” (Lindroos 1998, 40). Therefore, we suggest that we should speak, instead,
of professional (present-) awareness (Weigel 2015). Following Benjamin’s philos-
ophy, historic facts are not questioned, but the interpretation of those facts result in
ideas (about professionalism) that are reconstructed when past and present clash. If
one is alert to kairotic flashes of now-time, they provide us with opportunities to
either adopt or (re)constitute those inherited truths that make up medical practice.
Consequently, the image of the ideal, professional doctor does not exist as a stable
entity we inherit but is a contingent montage of images and ideas in the present
(Wyatt et al. 2021). Such (re)constitution could happen in the moment itself or could
be explored at a later point in time through reflection by oneself or with others to
become sensitive to kairotic moments.

21.8 Conclusion

In this chapter we have argued that there is a relation between chronistic and kairotic
experiences of time. Moreover, we have explained that there is a difference between
scholê and ascholia. We have further unpacked kairos with the help of Benjamin’s
criticism of historicism as a linear appropriation of the past that determines the
present and future. These considerations lead us to raise two issues within medical
practice and health professions education.
First, kairotic moments can occur at any time and are of value. However, there is
a danger that ‘taking time to reflect’ occurs only with predetermined goals in mind
for the sake of our responsibilities at work. Taking time as scholê is a way to break
free from this inclination. Faced with endless tasks and vast volumes of information,
opinion and demands for health care workers, it is labour that engulfs us. When one
task ends, the next one begins. By bringing tasks to an end and allowing ourselves
to come to rest in scholê, we might give ourselves time to rethink the purely goal-
oriented sequence of daily events that encapsulate us. Perhaps the kairotic moment,
when it strikes, is a call for inaction by setting aside the endless list of tasks and goals
and embracing freedom from tasks.
Second, we emphasise that kairotic moments can interrupt the tendency to reflect
on professional development and the development of medical practice in an overly
linear, deterministic, and teleological manner. Consequently, we recommend moving
away from terminology that shrouds models of learning and reflection in terms of
linear professional growth and development (Table 21.1).
322 S. P. C. Schaepkens and C. Q. H. Coccia

Table 21.1 Practice points

1. Learning theories, protocols, and strategies based on previously successful experiences are
valuable, but theory cannot always cast a net over uncontrollable moments which require
you to be open to unique circumstances
2. Institutionalized, goal-oriented reflection is valuable, however, dare to embrace the
opportunity kairotic moments provide you to reflect on your ideas that guide your everyday
habits
3. By bringing tasks to an end and allowing ourselves to come to rest in scholê, we might give
ourselves time to rethink the purely goal-oriented sequence of daily events that encapsulate
us
4. The image of the ideal, professional doctor does not exist as a stable entity we inherit from
the past but should be debated as a contingent montage of images and ideas infused by
kairotic moments in the present
5. Thinking chronistically isn’t wrong or bad, and we should not abandon it; we require
chronos for our organisational and historic understanding of our past, and it provides the
space for kairos and a qualitative interpretation of our time

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Chapter 22
The Application of Stoicism to Health
Professions Education

Alexander MacLellan, Megan E. L. Brown, Tim LeBon, and Neil Guha

22.1 Introduction

What do the alarm clock, the water mill, and the concept of democracy all share in
common? Though this may sound like the opening line of a critical political joke,
these inventions and concepts are factually united by their origin in ancient Greece.
Though, as a society, we consciously engage with and appreciate alarm clocks,
water mills, and democracy, there stand other facets of life in ancient Greece that
have not received the same degree of active attention. Stoicism, an ancient Greek
school of philosophy, is one such facet. A philosophy of life, Stoicism is a holistic
worldview, an ethic which offers guidance on ‘how to live’. The philosophy is widely
misrepresented, particularly within medical circles, as an indifference, a detachment,
a suppression of all emotions. This chapter challenges such interpretations, offering
an overview of Stoic philosophy as described by the ancient Stoics, and considers
how Stoicism may meaningfully inform health professions education and research
today. Through this chapter, we explore the applications of Stoicism to the health
professions, drawing upon this practical philosophy to offer concrete advice as to

A. MacLellan (B)
Department of Psychology, University of Bath, Bath, UK
e-mail: akem20@bath.ac.uk
M. E. L. Brown
Medical Education Innovation and Research Center, Imperial College London, London, UK
e-mail: megan.brown@imperial.ac.uk
Health Professions Education Unit, Hull York Medical School, University of York, York, UK
T. LeBon
TalkPlus (NHS IAPT Service), Farnham, UK
N. Guha
Nottingham Digestive Diseases Centre, University of Nottingham, Nottingham, UK
e-mail: Neil.Guha@nottingham.ac.uk

© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2022 325
M. E. L. Brown et al. (eds.), Applied Philosophy for Health Professions Education,
https://doi.org/10.1007/978-981-19-1512-3_22
326 A. MacLellan et al.

how concepts and practices in the field may be reconceptualised to advance education
and practice.

22.2 What is Stoicism?

If you search for a definition of Stoicism in the Online Oxford English Dictionary
(Oxford University Press 2021), two definitions are returned. The first considers
stoicism with a lowercase ‘s’, “the endurance of pain or hardship without the display
of feelings and without complaint”. It is a definition many will be familiar with,
particularly within the United Kingdom, where the British public are often portrayed
as a sober, unemotional people. The use of stoicism or stoic (utilising the lowercase
‘s’) in common parlance is at the root of misunderstandings of Stoic philosophy
within medicine and health professions education. The second definition provided
is more pertinent to our discussion within this chapter, describing Stoicism with an
uppercase ‘S’ as:
…an ancient Greek school of philosophy… the school taught that virtue, the highest good,
is based on knowledge; the wise live in harmony with the divine Reason that governs nature,
and are indifferent to the vicissitudes of fortune and to pleasure and pain. (ibid)

Stoicism, as we present it, therefore, is a philosophy advocating a happy and fulfilled

life is achievable by living virtuously.

22.2.1 History and Background

Stoicism is thought to originate around 300 BCE, with Zeno of Citium considered the
first Stoic philosopher. Whilst currently, philosophy is largely thought of as a pursuit
of a privileged few, Stoicism was a philosophy for the people. Taking its name
from the Stoa Poikile, or ‘painted porch’, the open-air market in Athens where the
philosophy was espoused, the Stoics thrust open the doors of happiness for everyone.
Exported from Greece, the philosophy gained popularity in the Roman empire, with
much of our current knowledge originating from the Roman Stoics. Over 500 years,
Stoicism grew into one of the most influential philosophies of the Western world.
Taught by freed slaves and practiced by kings, the fingerprint of Stoicism can be seen
in much of what we see in the world around us today.
Historically, Stoicism grew from the teachings of Socrates, espousing that moral
virtue is the highest good, and thus the path to happiness, or eudaimonia. Whilst
often translated as happiness, eudaimonia is perhaps more accurately translated as
‘flourishing’, a distinction that will carry importance. To the Stoics, the message
was simple: happiness and a good life can be achieved through the personal practice
of virtue. This message must have been an incredibly empowering thought to those
ancient Greco-Romans who would be regularly faced with pain, pestilence, poverty,
22 The Application of Stoicism to Health Professions Education 327

and death. Those suffering from the tragedies of the day were provided with a holistic
philosophy and structure to exert some manner of agency over their experiences in
a world which they had little control over.
It is thought many early and renaissance Christian writers were influenced by
Stoicism (Ferguson 2003). Later philosophers would draw upon, revise, and even
revile the Stoics, yet their cultural significance on Europe cannot be overstated.
Many of the teachings and practices of Stoicism influenced modern day cognitive
therapies (Robertson and Codd 2019). The world of the Classical Stoics would be an
alien one, yet with the philosophy undergoing something of a renaissance, it seems
to suggest the concepts remain relevant.
Since 2012, the Modern Stoicism movement, established by academics and
psychotherapists, has aimed to engage the public and lead research into the Stoic
philosophy, with annual ‘Stoic Weeks’ encouraging participants to engage with
Stoic ideas and practices for a week, conferences and publications (LeBon in Ussher
2014). More recently, Stoicism has been taught as part of professional development
for Cognitive Behavioural Therapy (CBT) therapists by one of the authors of this
chapter (TL) and has been found to improve rumination and resilience in anxious
populations by another (MacLellan and Derakshan 2021). It is perhaps understand-
able why there is a renewed interest in this philosophy, and though many ideas may
be disregarded as familiar, upon careful consideration they may offer a structure to
bolster wellbeing.

22.3 Core Tenants of the Philosophy

22.3.1 Dichotomy of Control

The simplest practical tenet of Stoicism is referred to as the dichotomy of control—

the assertion that an individual only has control over their thoughts and their actions,
and that it is, therefore, the primary concern of the individual to ensure these are
as ‘virtuous’ as possible. Epictetus, a key figure in the Roman Stoics, opens his
handbook with this very message, and an instruction: should something not be in our
control, we should be prepared to let it go. There are layers of complexity in these
few lines. Opinions, desires and even fears have been marked as directly under our
control, when they can often feel anything but; and things we find ourselves seeking
to influence, such as how others think of us or even our own physical health, have
been rendered largely incidental, though we shall return to this later. Epictetus, as a
former slave whose leg was cruelly broken by his master, was perhaps most sensitive
to the vagaries of fate. A good life is not to be found in a positive reputation, perfect
physical health, or substantial wealth, but in virtue and rationality. His guidance is
simple, rather than try to control things we can’t, focus on those things you can, and
you will find yourself in a state of tranquillity. Developing a recognition of what
328 A. MacLellan et al.

one can and can’t control, therefore, is a key practice for the Stoic, and one we shall
return to.

22.3.2 Therapy of Emotions

Contrary to current beliefs, the Stoics were not attempting to suppress emotions,
but rather engage with and surpass negative ones. Stoics took a cognitive view of
emotion, proposing that rather than an external event being the source of an emotional
experience, it is how we as individuals interpret that event that causes the emotion.
For example: we learn that a colleague has spoken badly about our abilities. A Stoic
would respond by recognising that we have been told this fact, we have not been told
we are harmed by it. If this idea sounds familiar, it may be because CBT re-labelled
this Stoic idea ‘cognitive restructuring’, making it one of the linchpins of its evidence-
based psychotherapy. This is far from the only technique used by the Stoics, with
Robertson (2012) naming eighteen techniques used by Stoics in the management of
emotions. Moreover, whilst modern CBT focuses more on factual misinterpretations
leading to negative emotions (for example, challenging the thought that “people will
ignore my colleague’s comments’) Stoics tended to place more emphasis on mistaken
value judgements (“even if they don’t ignore their comments, it can’t really harm
me”).
Many of the emotions the Stoics spoke of (often translated as ‘passions’) are
intrinsically linked with morality and were divided as either unhealthy or healthy
based on their relation to rationality and virtue. For example, the unhealthy emotion
of fear is rooted in the irrational expectation of harm, whereas caution, as the rational
avoidance of true harm, is seen as a healthy emotion. The aim for the Stoic, then, is
not to suppress, but to engage and understand.

22.3.3 The Virtues

The word ‘virtue’ has been used extensively thus far with little clarification. Virtue
in this sense carries no religious connotation, but rather describes the expression of
characteristics that we are uniquely able to display. The Stoics, therefore, would state
that a human has virtue when they exert their capacity for self-control and reason.
More specifically, the Stoics concerned themselves with the character virtues derived
from Plato, each seen as being essential for success as a human being (Gill, in Ussher
2016):
• Justice is required to live well in communities
• Temperance to manage our desires
• Courage to overcome our fears
• Wisdom to underpin each of the other virtues and use our ability to reason well
22 The Application of Stoicism to Health Professions Education 329

These are often considered broader categories, encompassing more specific, related
virtues, or character strengths.1 For example, Justice would consist of fairness and
equality, but also of kindness and philanthropy (Schofield 2003).
For a Stoic, the virtues act as a lens to view and regulate their own thoughts
and actions. It is through the contemplation and cultivation of these virtues that a
Stoic hopes to ultimately resist unhealthy emotional disturbance and navigate the
world as a positive and productive member of a society. Indeed, for the perfect Stoic,
living virtuously would ensure that one never had the temptation or the ability to
suffer from unhealthy emotions to begin with. The Stoic, therefore, is tasked with
developing a mindfulness not just of their thoughts, but of their character and through
the development of one, the other will follow. The goal is not to simply do good things,
but to be a good (or virtuous) person.

22.3.4 Moral Development and Cosmopolitanism

For the Stoics, acting virtuously was nothing more than acting according to nature,
both human and physical. They believed that humans have a natural disposition to
develop morally that is refined over the course of their life, as they gain greater control
and practice with their faculties for reason. This sense of moral development is tied
with the notion of oikeiôsis, translated as affinity or orientation. It is here, in this idea,
that the cosmopolitanism of Stoicism is most apparent. The philosopher Hierocles
writes of the development of morality as a process of achieving something akin to
consistency both internally and externally. All animals, including humans, begin with
an affinity with itself, the instinct of self-preservation. Further internal development
comes with developing an awareness of, and consistency with, the virtues.
However, it is with external development Hierocles has had the most influence
in the Stoic world. He proposed that the natural course of moral development was
to extend one’s affinity beyond just the self, to encapsulate wider and wider groups
of people, until the whole human race would be treated with the same care as one
gives to a family member. His advice included referring to those unrelated to you as
‘uncle’ or ‘sister’ (depending on their age and sex), at least internally, to engender
a greater affinity with them. In the health professions, a similar effect is encouraged
as trainees seek to develop an ability to connect with patients. With Stoicism often
considered a rather self-centred philosophy, this idea of cosmopolitanism being an
intrinsic part of moral development helps lend context to the politically active and
socially engaged Stoics of the Roman era and provides a useful reminder for us in
our daily lives.

1 The VIA Institute on Character classification of character strengths lists 24 such strengths grouped
into 6 virtues, which include the 4 Stoic cardinal virtues.
330 A. MacLellan et al.

22.3.5 Theory of Happiness and Eudaimonia

Happiness, or eudaimonia, therefore, is the product of sound moral development by

careful cultivation of the virtues. Although contemporary notions of virtue assume
a dichotomy between ethics and prudence, many ancient philosophers saw no such
division. Given the human condition, the qualities that are required both for personal
happiness and for being an excellent human being are identical, these being the
cardinal virtues. Virtue, therefore, is our best bet for happiness,2 and one that is
robust in the face of changing fate.
The Stoics recognised that when we place our idea of happiness in those things
outside of our control, our lives would be far more affected by changes in fate than
if we focused our concerns on those things within our control, namely cultivating
virtues. In a world where you were far more exposed to shifts in fate than at present,
the idea of gaining happiness from a possession would be a foolish one, when a storm
could render you destitute. Of greater difficulty is the desire for positive relationships,
respect, or physical heath.
The Stoic, then, is to accept both the positive and negative turns with equanimity.
This may seem a cold and reclusive idea. Are we, then, to withdraw from our friends
and family or possessions and the joy we derive from them as they may one day leave
us or break?
No.
The Stoics recognised that humans naturally desire these things. Rather than
change the nature of a person, they advise to consider what is being desired. Things
considered outside of our control were classified as either preferred or dispreferred
indifferents. Preferred indifferents are those which have some positive value (such as
health and wealth) and dispreferred being those that are negative (such as illness and
poverty). Should preferred indifferents come our way, we may enjoy them. Should
they not, we accept this too.
This allows a Stoic to enjoy a possession but to remind themselves that it may
break for it is fragile; to enjoy a relationship with a small reminder that it may end.
Rather than take a pessimistic view that knowledge of something’s impermanence
would sully it, knowledge of transience allows for a greater appreciation of it whilst
it is possessed. Happiness, therefore, is an acceptance of the things outside of our
control, and an appreciation for what is currently had.

22.3.6 Worldview

We have primarily considered Stoic ethics thus far. However, ancient Stoics had
much to say about Logic and Physics and embraced a worldview that may seem

2 Not only did the Stoics insist there was no tragic tension between prudence and morality, they
followed Socrates who argued in Plato’s Euthydemus that virtue was both necessary and sufficient
for eudaimonia.
22 The Application of Stoicism to Health Professions Education 331

strange to contemporary eyes. Most ancient Stoics were pantheists and determinists
who believed in providence. They would have agreed with statements such as “the
universe is a living thing” and “the universe is benevolent in its overall plan.” Modern
Stoics have debated how much of this worldview is necessary or helpful (Chakrapani
and LeBon 2021). Some, like Irvine (2008), have described a version of Stoicism
that does not rely at all on this worldview, and is the line taken in this chapter. Other
modern Stoics have reinterpreted “living according to nature” to mean living what
we understand the facts to be now (e.g., Pigliucci 2020). A reliable and readable
introduction to a version of Stoicism which incorporates more Stoic physics than
this chapter can be found in Sellars (2019).

22.4 Stoicism Within Health Professions Education

22.4.1 How Has Stoicism Influenced Health Professions

Education?

The popularity of stoicism as a term has led to the cartoonish view that Stoic philos-
ophy involves a cold, detached attitude to life and emotions—a ‘stiff upper lip’—
when, in actuality, Stoicism is a life philosophy that does not involve suppression of
all emotions—rather, it concerns control of the negative emotions one will inevitably
experience (Irvine 2008).
Unfortunately, within medicine, Stoic philosophy has been misrepresented as
lowercase ‘stoicism’. Though research drawing upon or referencing the philosophy
is uncommon, the work that has been done usually considers stoicism in regard to
patient experiences of pain, as a coping strategy in times of extreme physical distress,
or as a masculine characteristic that explains certain behaviours or outcomes amongst
men (Pathak et al. 2017). Such previous research is united by a conceptualisation of
Stoic philosophy as stoicism, an indifference to pain and distress, or a non-caring,
a nonchalance to serious issues of health. The Liverpool Stoicism Scale (LSS), a
validated psychometric tool developed in 1995 and used within health research to
measure ‘stoicism’ (Calderón et al. 2017), epitomises this cartoonish interpretation.
According to the LSS, stoicism involves a lack of emotional involvement, dislike of
emotional expression, and ability to endure emotion (Ribeiro et al. 2014). Indeed,
one of the scale items participants are asked to rate their agreement with is the state-
ment “one should keep a ‘stiff upper lip’” (Wagstaff and Rowledge 1995). Though
‘stoicism’ is used throughout literature concerning the LSS, the very same liter-
ature contextualises the scales’ use in the philosophy of the ancient Stoics. This
amalgamation of two very different definitions of ‘stoicism’ and Stoicism has led to
confusion within medicine at large as to the principles and applications of ancient
Stoic philosophy. Given such a narrow definition and interpretation, there is much
of the philosophy that is unexplored in relation to medicine, and which could cast
interesting, new light on issues of contemporary interest in the field.
332 A. MacLellan et al.

Within health professions education more specifically, Stoicism is largely unex-

plored in regard to the education and research of healthcare trainees and profes-
sionals. Where research has been conducted, this most commonly concerns Stoicism
as a coping mechanism in difficult situations. Research conducted by Taylor et al.
(2019) references stoicism with a lowercase ‘s’ briefly in regard to one way in which
medical students manage fatigue, whilst Papadimos (2004) explores Stoicism in a
way truer to ancient texts as a coping mechanism to help practicing physicians cope
with the emotional and social burden of caring for medical outlier patients. Recent
research conducted by three of the authors of this chapter (AM, MB, and TL) has
explored the translation of Stoic philosophy into psychological training for medical
students, with the aim of promoting empathy and psychological ‘grit’ (Brown et al.
2022). Taking a somewhat different approach, Patro (2015) speculates the relevance
of Marcus Aurelius’ writings on Stoicism to medical student leadership develop-
ment programmes, a hypothesis we could not see had been explored further. A lack
of research and theoretical commentary in this area is notable, with published work
sparsely cited, if at all. Similarly in regard to the field of medicine more broadly, there
are many principles of Stoicism that remain unexplored within health professions
education.

22.4.2 How Could Stoicism Influence Health Professions

Education?

Given a relative paucity of Stoic research and theorising within health professions
education, and the way in which the life philosophy has been misrepresented more
broadly within medicine, there are many, diverse ways in which Stoicism could
influence health professions education. For the sake of brevity, we consider three
case studies of situations within health professions education where the principles of
Stoicism we have outlined earlier in this chapter are relevant to considering contem-
porary practice, education, and research. All these case studies may be approached
with similar practices, and thus there would be a degree of overlap. However, for
clarity, we have restricted the practices explored to particular case studies.

22.4.2.1 Case Study 1: Dichotomy of Control and Theory of Happiness

Case Study 1: Sandra’s Story

Sandra is a newly qualified doctor in her first week of work, caring for a patient
with terminal cancer, Mrs Harrington. Mrs Harrington has no family or close
friends, and so Sandra finds time to speak to Mrs Harrington every day and
22 The Application of Stoicism to Health Professions Education 333

enjoys speaking with her about her interesting and varied life. Mrs Harrington
dies two weeks after first meeting Sandra. This is the first death Sandra has
ever experienced as a doctor. She struggles to cope with the death of Mrs
Harrington emotionally, thinking of her often and becoming upset regularly.
She feels angry that Mrs Harrington spent her final weeks in hospital without
receiving any visitors.

Sandra is struggling to adjust to an inevitable consequence of practice as a doctor—

the death of a patient. This, sadly, will be a case familiar to many healthcare profes-
sionals, such is the nature of working with those who are unwell or frail. There are
two core issues for Sandra here, 1. Dealing with death as an inevitable consequence
of being a doctor; and 2. Dealing with issues of empathy and emotional attachment.
This case study will focus on the application of the dichotomy of control and theory
of happiness within Stoicism to the way in which healthcare professionals learn to
deal with death.
Sandra is dealing with the death of a patient she has grown close to. We propose
that considering the principle of the dichotomy of control may help. Ultimately, the
death of some patients, particularly those with terminal diagnoses, is beyond the
control of an individual—beyond Sandra’s control. It may be helpful for Sandra to
reflect on what she can and cannot control. She cannot control that Mrs Harrington
has died, but she can control, with some support, perhaps, her own thoughts, fears and
actions. Reframing in this way may engender a sense of agency in Sandra and increase
her perceived sense of an internal locus of control, thereby increasing resilience in
future situations where she may be faced with the death of a patient.
Stoicism’s theory of happiness is also relevant. Firstly, as happiness is conceptu-
alised as a product of moral development and cultivation of the Stoic virtues, Sandra
may be reassured that engaging empathically with Mrs Harrison and taking the time to
connect with her were virtuous, moral things to do that may lead to place a fulfilment
in her professional future. Secondly, the Stoics conceptualise happiness as a product
of living in accordance with nature—with fate. Placing one’s happiness solely in
things that are outside of our direct control, such as the longevity of a terminally
unwell patient, leaves us vulnerable to being negatively affected by unpredictable
changes in fate. As discussed previously, the idea of accepting negative turns of fate
in regard to our relationships with other people may seem cold. The Stoics frequently
wrote of the idea of becoming at peace with death and loss, memento mori, learning
to view death as a neutral event. As a Stoic, Sandra would be advised to remind
themself of an inevitable end in order to fully appreciate relationships whilst they
are present and lessen the pain of their parting.
334 A. MacLellan et al.

22.4.2.2 Case Study 2: Virtue Ethics and Moral Development

Case Study 2: Daanesh’s Story

Daanesh is a nursing student on attachment to a hospital ward during the
COVID-19 pandemic in 2020. He is studying in an area with high rates of
COVID-19 hospitalization and death, prior to the development of an effective
vaccine. He lives with his mother who has significant physical health issues.
During COVID-19, the isolation of COVID-positive staff means that the ward
Daanesh is placed on is short-staffed, and he is asked to work additional shifts
to cover gaps in the rota. Daanesh is petrified of catching Covid and infecting
his frail mother.

Here, Daanesh is reflecting on and processing the difficulty in balancing his

responsibilities and duty of care towards his unwell mother, and the healthcare profes-
sion and community more broadly. In order to help Daanesh consider the difficult
situation in which he finds himself, we will consider the relevance of Stoic virtues
and the Stoic theory of cosmopolitanism to this case.
The notion of cosmopolitanism may be useful here. Exercises such as using Hiero-
cles’ concentric circles may ultimately help Danesh increase his affinity with those
he does not know and so make him more willing to make himself and his mother
vulnerable by working extra shifts. This could mean that he should work additional
shifts and treat the patients and staff on his ward with the same care he affords his
mother—yet, this is too simplistic.
Whilst Stoicism encourages people to extend their sympathies to others, unlike
utilitarianism, it is not so demanding as to insist that they treat strangers with the
same priority as those to whom they have closer affinity. There may be other ways
that Daanesh identifies he could help those on his ward through social or political
engagement.
In resolving his conflict, Daanesh may wish to reflect on the virtue of justice,
which is comprised of fairness, but also kindness and philanthropy. Daanesh may
consider kindness towards his mother, or philanthropy, as a sort of service towards
the healthcare community and patients during a time of crisis. The virtue of wisdom
may help Danesh reflect on which parties should take priority. Whilst this may
not simplify the decision, this process of reflecting on cosmopolitanism and virtue
may help Daanesh process his thoughts and reason his way through a troublesome
decision.
22 The Application of Stoicism to Health Professions Education 335

22.4.2.3 Case Study 3: Therapy of Emotions

Case Study 3: Ywain’s Story

Ywain is a registrar in medicine and has been a doctor for five years. They had
a serious incident which led to a complaint being made about them recently
from a patient. Even before this, they were having doubts about their career.
Ywain is not sure if they should continue with medicine as a career.

The above scenario shows Ywain struggling with a decision regarding their iden-
tity as a doctor, a situation rendered more complicated due to the complaint brought
against them. Whilst Ywain may have doubted their career choices previously, a
catalysing event such as a complaint can bring these, otherwise natural concerns, to
the fore, and cause personal distress. It is from this perspective we will consider how
the Stoic therapy of emotions can be of use to Ywain in resolving this conflict.
As mentioned previously, the Stoic view of emotion is broadly similar to many
cognitive theories of emotion, being that an external event (hearing a complaint
has been made about us) is not the cause of an emotional experience, but it is our
interpretation of that experience (‘I should not be a doctor’), that causes the emotion
(guilt and anxiety). Both Stoic and cognitive theories posit a largely uncontrolled
first response, with a second response that involves either cognitive maintenance, or
reappraisal. For example, upon hearing a complaint has been brought against them,
Ywain may feel an initial somatic sensation and experience of anxiety. In both Stoic
and modern cognitive models of emotion, Ywain may then maintain and reinforce
this state with negatively valenced cognitions, e.g. ‘I just do more harm than good’
or ‘I wish I could be like my friends who don’t appear to struggle as I do’.
As a Stoic, Ywain recognises their response is within their control. Their first task,
therefore, would be to reflect on whether their troublesome thoughts are factually
correct, and to engage in a process of self-questioning their emotional responses, their
motivations, and their assessments of these beliefs. They could ask those who know
their practices best how they rate their competence. Ywain could be helped further
by remembering that they can’t control what other people think, and to attempt to let
their opinion go. Ywain could contemplate their actions as either virtuous or not and
use their reflection as a springboard for professional development, or as a recognition
of an anxiety that needs addressing.

22.4.3 Stoic Research Tools

In this chapter we have endeavoured to showcase what Stoicism has to offer in

practical modern contexts, such as the health professions. However, this field is
still developing, and further research is required. Currently the Stoic Attitudes and
336 A. MacLellan et al.

Behaviours Scale (SABS) represents the best quantitative measure of Stoic ideation,
with validation currently ongoing.3 At present, qualitative methodology represents
the most reliable way to identify Stoic ideation in samples.

22.5 Practice Points

We hope this chapter has given you a working insight into how Stoicism might form
part of your personal philosophy in your healthcare profession, and wider life. We
also see transferability of these messages to educational practice, particularly within
the landscape of reflective practice. To assist, we propose 5 practice points which
may help you integrate some of the ideas we have discussed personally, but also
within educational settings.
1. Differentiate between Stoic philosophy and emotional suppression—Stoicism
as a philosophy has much to offer as an engaged practice, yet there is a require-
ment to distinguish and remove the stigma from the word due to the prevalence
of the lowercase form ‘stoicism’. This requires nothing but a mindful use of the
word and acquainting oneself with the philosophy, as introduced to you by this
chapter.
2. Reflect on what is in our control—with the dichotomy of control frequently
returned to in Stoicism, our recommendation is that a reflection on the limits of
one’s control may form the basis of Stoic practice. This need not be cumber-
some, but can be incorporated flexibly into a daily routine, or adopted as a
response to stress. Educators may wish to trial this type of reflection within
health professions curricula formally or informally.
3. Adopt a Stoic therapy of emotions—as detailed in the previous case studies,
the Stoics would propose to take a moment to pause when confronted with
distress and seek to understand the cognitions that play a role in their onset
and maintenance. We would propose the same when taking part in clinical
encounters, and in professional and personal reflection. Educators supervising
students participating in clinical encounters could help guide students in this
practice.
4. Look through a virtuous lens—the act of resolving both professional and
personal dilemmas can be eased by consideration of the four virtues and which
course of action best exemplifies them. This process may, again, find its place
in reflective practice.
5. Extending affinity with groups—our final point is to suggest a conscious exer-
cise of extending affinity to those in our professional lives. This may be done
during professional reflection or during a private moment, but to follow the
cosmopolitan ideals of the Stoic, one’s aim should be to view the belligerent
patient as a troublesome family member, or a frustrating colleague as one’s
difficult cousin (Table 22.1).
3 See www.modernstoicism.com/research for full details of the SABS v5.0 scale.
22 The Application of Stoicism to Health Professions Education 337

Table 22.1 Practice points

1. Differentiate between Stoic philosophy and emotional suppression
2. Reflect on what is in our control
3. Adopt a Stoic therapy of emotions
4. Look through a virtuous lens
5. Engage in the exercise of extending affinity with groups

22.6 Conclusion

This chapter set out to provide the reader with a primer in the philosophy of Stoicism
and highlight some of the ways it may be incorporated into health professions and
medical education. By necessity, much which may be of interest has been omitted as
it is beyond the scope of this introductory overview. It is our hope that this chapter is
the catalyst for further interest in Stoic philosophy. We would like to leave you with
this quote by the Roman Emperor and Stoic Marcus Aurelius ([161–180] 2006):
Objective judgment, now, at this very moment. Unselfish action, now, at this very moment.
Willing acceptance, now, at this very moment, of all external events.
That is all you need.

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Chapter 23
Teaching Dignity in the Health
Professions

Bryan C. Pilkington

23.1 Introduction

Ethics education within the health professions varies greatly, but two approaches
are most common: some rely on discipline—or profession—specific resources, such
as codes of ethics for particular sets of practitioners (e.g., the American Speech-
Language-Hearing Association code for Speech Language Pathologists or the Amer-
ican Medical Association’s code of ethics for physicians practicing in the United
States), others turn to the well-trodden arena of bioethics and (most often) adopt
some version of principlism (e.g., appeals to the principle of autonomy in many
medical school curricula).
This chapter offers to the reader a distinct approach, one rooted in the concept of
dignity, and argues that, by attending to this concept, there is the potential to widen
the ethical horizons of health professions students. An approach to ethics education
in the health professions that takes seriously the concept of dignity does four things:
first, it attends to the narrative nature of human beings and their self-conceptions,
that is, their stories; second, it engages non-standard cases (cases less commonly
discussed or cases considered to be at the margins of health ethics conversations);
third, it embraces analyses of complicated concepts; fourth, it attempts to unify broad
ethical considerations across the health professions and, in so doing, aims to serve
as a potential focal point not only for the ethics of particular health professions, but
also for interprofessional ethics.

B. C. Pilkington (B)
School of Health and Medical Sciences, Seton Hall University, Nutley, NJ, USA
e-mail: bryan.pilkington@shu.edu
College of Nursing, Seton Hall University, Nutley, NJ, USA
Department of Philosophy, Seton Hall University, Nutley, NJ, USA
Department of Medical Sciences, Hackensack Meridian School of Medicine, Nutley, NJ, USA

© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2022 339
M. E. L. Brown et al. (eds.), Applied Philosophy for Health Professions Education,
https://doi.org/10.1007/978-981-19-1512-3_23
340 B. C. Pilkington

23.2 Story-Telling Animals

The philosopher Aristotle ([350 BCE] 1999) famously claimed that human beings
were rational animals. Development within a broadly Aristotelian approach has
advanced this view and, borrowing from the work of ethicist Alasdair MacIntyre
(2007), describes human beings as story-telling animals. If this is correct, there
are implications for health, healthcare, and the training of members of the health
professions, e.g., in an encounter with a patient, reading their chart may be epis-
temically1 insufficient, a narrative medicine (or narrative health) approach might be
required. This is partly because human beings are not merely tellers of stories, but
they think through stories and—if MacIntyre is correct—find themselves embedded
within larger narratives through which they understand themselves or others and
which impacts their health and the health-related decisions that they might make.
This approach is also instructive for ethics educators of health professions students.
Students come to professional training with their own stories and as bearers of
particular and diverse traditions—family considerations, cultural traditions, personal
reasons for seeking out a particular health profession, et cetera. Conceiving of patients
and of students in this way can influence how education in health professions and the
treatment of patients is conducted. To be more specific, this framing is suggestive of
a principle, concept, or norm which ties not only to particular features of particular
persons, but rather one which engages the wholeness of persons, lest the complexity
of human life (and the relation of those many components of health) be missed. One
candidate to fill this role is the concept of dignity. In later sections of this chapter
dignity will be (briefly) contrasted with other approaches, but the aim of this chapter
is not to defeat and replace ethical approaches that are more dominant in the ethics
education of health professionals currently; rather, the aim of this chapter is to offer
an alternative approach which educators of the health professions might find valuable
in their teaching and in their practice.

23.3 The Concept of Dignity

The concept of dignity has a more international flavour and greater global appeal
than some of its counterparts. It plays a prominent role in many international human
rights documents and national constitutions, serving as the grounds for the treatment
of others. For example, the Universal Declaration of Human Rights specifies that “all
human beings are born free and equal in dignity and rights. They are endowed with
reason and conscience and should act towards one another in a spirit of brotherhood”
(United Nations 1948). The health and ethics implications for such claims follow
upon this acceptance of dignity and the framing of rights in terms of dignity. Addi-
tionally, Article 1 of the fundamental charter of the European Union states, “Human
dignity is inviolable. It must be respected and protected” (Schmitt 2008). Dignity, in

1 Of, relating to, or involving, knowledge.

23 Teaching Dignity in the Health Professions 341

serving as an ethical concept that grounds treatment of all people, applies inside and
outside of healthcare encounters. Attending to this concept refocuses our moral gaze
on the patients as persons, despite their vulnerable (or marginalized) status, because
they are members of the same moral community as health professionals and must
be treated accordingly. Something similar can be said of students and their teachers.
The humanity of both practitioners and teachers as well as patients and students does
the philosophical heavy lifting claims of dignity. As O. Carter Snead (2007) notes in
discussing the United Nation’s proclamations on the concept:
...‘human dignity’ denotes the concept that human beings are, by virtue of their humanity,
owed a special degree of moral care and concern. The “respect for life” is a corollary of this
principle, namely, that human dignity rightly understood imposes the obligation to act with
a high degree of care in matters touching and concerning human life and, at the very least,
enjoins harmful or exploitative practices in this regard. (54)

Three key characteristics define dignity. Attending to the dignity of patients

requires practitioners (and all members of the health systems) to avoid humiliating
patients, denying patients healthcare opportunities, and killing patients. In brief,
attending to considerations of humiliation forces us to recognize the vulnerability
(or marginalization) that patients bring to health encounters and serves as a resource
for the argument that such recognition is essential to caring well. For example, strictly
employing a “medical model” and conceiving of patients with, say, particular disabil-
ities, is a kind of humiliation which ought to be avoided. Such an approach assumes
the acceptability of certain societal structures as normative—it focuses on the land-
scape, not on the person. In a similar vein, classroom policies and practices which
seek efficiencies at the costs of individual student attention can fail to attend to the
anti-humiliation prohibition of respecting the dignity of health professions students.
‘No laptop’ policies with special exceptions or requirements to be “on camera” in
online instruction are two examples. Singling out students who may need a laptop
to read or ‘see’ the content or adopting a policy which forces students to open their
rooms or homes and transforming extracurricular space into classroom space are
measures that should be adopted with great care.
Denying people relevant opportunities is a second violation of dignity. This is
because attending to dignity draws attention to standards connected to what it is to
live a good human life, and from these standards, the necessary resources for the
realization of such a life can be garnered. Though there is some disagreement about
the content of those standards, a variety of approaches—such as Nussbaum’s (2008)
work on dignity and capabilities, Thomistic capacities-based approaches (George and
Lee 2008), or even practical social policy goals, like the United Nations’ Sustain-
able Development Goals (United Nations 2015)—are all examples of connecting
the treatment of people to the kinds of beings that they are and working—either
theoretically or practically—to ensure that the resources for this (or, negatively, to
prohibit violations against their realization) exist. A common theme amongst all of
these approaches is the importance of health, and so reflection on the concept of
dignity is a natural fit for education in the health professions.
Consider, for example, the philosophical idea of recognition. Recognition of
others as members, like oneself, of the same moral community is key to both
342 B. C. Pilkington

understanding and respecting dignity (to expand on this idea, see Chapter 5, which
considers the concept of ‘acknowledgment’, and Chapter 22, which considers the
role of affinity for others in Stoic philosophy). Because all human beings are such
members, they are all entitled to care. Thus, within the field of healthcare ethics,
special care is taken to avoid denying access to patients due to financial, social,
or geographic reasons because denying the opportunity to access health resources
that are needed for human flourishing is a violation of their dignity (for an expansive
discussion of social justice, see also Chapter 9). Dignity is tied to membership status;
it is not distinguished according to factors such as geographic location. This holds true
for classrooms, as well. Recognizing students as dignified members of an educational
community—and future members of a health profession—means offering flexible
content delivery and implementing various types of evaluations. Health professions
teachers should not seek to simply drop facts into the heads of students, but instead
should aim to place these individuals in the best situations to succeed for themselves.
Related both to ensuring opportunities and to prohibiting humiliation, health profes-
sions educators ought to shun as vigorously as possible old models of ‘hazing’ into
a profession.
The final key characteristic of taking dignity seriously is attending to the prohibi-
tion on killing. Because human beings are members of the same moral community,
they ought not—to take up the paradigmatic2 example of a violation of dignity—be
killed. This prohibition fits well with the care-focus of the health professions. To
kill another is, in many ways, to abandon care. Though life and death considera-
tions are not common within the daily practice of many health professions, it is still
important to highlight this characteristic in an overall account of dignity, and in the
teaching of dignity to health professions students. Patients are owed continued care
and health professionals are barred from concluding that obligation by themselves
ending a patient’s life or abandoning a patient in other significant ways. Though no
direct analogue exists in education, health professions educators ought to continue
to care—in a pedagogical sense—for students even if they have failed an exam,
plagiarized a paper, or acted dishonestly in a practicum. Jettisoning a person from
a program, for example, is appropriate in some cases, but should be used as a last
resort.

23.4 Murky Concepts and Getting Things Right

Dignity can be a tricky concept to teach. It can appear murky, or less straightforward,
in the fast-paced world of healthcare. In an attempt to clearly consider how we may
teach dignity, I reflect on dignity using the above description: 1. Broadly, as being
connected with the kinds of beings that humans are, and the resources needed for those
beings to flourish; and 2. Negatively, in terms of violations of dignity—humiliation,
denials of opportunities, and killing.

2 Serving as a typical example of something.

23 Teaching Dignity in the Health Professions 343

Though the aim of this chapter is to introduce dignity as a viable ethical concept
for health professions education and not to defeat other options, to motivate its
viability some comparisons may be useful. Some have argued that autonomy is the
most important principle in bioethics (Post and Blustein 2015), a field which—as
noted above—has had a great influence on healthcare ethics and ethical practices
within the health professions, and especially within medicine, over the last 50 years
(Evans 2014; for an in-depth review of the history of bioethics, particularly as it
pertains to climate change, see Chapter 18). In fact, some theorists have argued
against dignity in favour of autonomy on the grounds of the utility of each concept
(Macklin 2003). The charge of futility is levelled against dignity because it is said
to do no more than the concept of autonomy and, with Ockham’s razor hanging
overhead, it could be surmised that we might as well stick with what we know.
Though healthcare and instruction in caring for health have benefited from reflection
on autonomy—informed consent being the chief practical good derived—it is not
sufficient, nor are the other famous three principles of bioethics (justice, beneficence,
and non-maleficence) (Beauchamp and Childress 2019).
To illustrate this, consider a case of humiliating treatment: the all too common
case in medicine where, after seeing a patient and leaving the room, a physician
makes a joke about the patient’s appearance to the care team. They all laugh and
move to the next room. Most find this to be bad behaviour; some might describe
it as unethical, some as unprofessional, but it is not a violation of autonomy. It is,
however, a violation of dignity. This patient was thought of and treated as something
less than what they are—a human being—and though this may not affect their care,
it affects how they are seen and understood. Suppose that they were to come to learn
of the joke; this may negatively affect their self-conception and, potentially, impact
their overall health outcomes, even if it does not affect the healthcare they receive.
Even if they are aware of what was said and even if they are hurt by it, if they still
have decisional power over the kind of care they receive and if that care is available
to them, then this would not be a violation of autonomy (or of justice, beneficence,
or non-maleficence—at least as traditionally understood in this field). Similar cases
exist in education. Teachers who joke about their anonymous students’ performance
on exams or written assignments—“how could someone think x”—do not violate
a student’s autonomy. However, this kind of derision should be avoided because it
highlights that the educator is conceiving of the student not as a person, as a member
similar to themselves, but as an object of a joke. It raises—as it does in healthcare—
whether a proper relationship between teacher and student or practitioner and patient
exists.
Part of the challenge of introducing a new concept in ethics education in the
health professions is, as the aforementioned critics note, that there are other concepts
that are well known and understood to be useful. However, new concepts can bring
benefits of new realizations and of extending the ethical horizons of students. In the
very least, new concepts offer the ancillary benefit of welcoming consideration of
non-standard, or less commonly discussed, cases. It is to such a case that we now
turn to further illustrate the usefulness of dignity.
344 B. C. Pilkington

23.5 Non-Standard Cases and Spaces

Attending to the health of large groups, as opposed to particular individuals, is

an increasingly discussed task for members of the health professions and a great
deal of work in public health ethics exists to help guide this work. However, less
thought has been devoted to particular populations whose vulnerability is exacer-
bated during times of pandemic, e.g., incarcerated persons. Reflection on the position
of the subjects of mass incarceration—an especially ethically problematic situation
in the United States—is, though challenging and weighty, an excellent case study
for teaching dignity to health professionals. The othering that is involved in incar-
ceration, at least as it is practiced in the US, is both a violation of dignity and also
instructive to those interested in an ethic that takes seriously the vulnerable state
from which many patients seek aid from healthcare providers.
Incarcerated persons are often conceived of as mass and not as unique, individual
members of the human community. This was highlighted early in the COVID-19
pandemic when it was reported that:
… 1,828 people — or 73% of all inmates — have tested positive for COVID-19 at the
Marion Correctional Institute in Marion County, Ohio, according to the Ohio Department of
Rehabilitation [and] Corrections…At least 2,400 inmates across Ohio state prison facilities
have received positive diagnoses for COVID-19 since Ohio Department of Rehabilitation
[and] Correction began testing on April 11…As of April 22, incarcerated people make up
20% of the state’s entire coronavirus cases. 12 inmates have died. (Bates 2020a)

Systemic problems affect individual people (for more on the relationships between
individuals and groups, see Chapter 14 on the debate between individualism and
holism), and the failure to treat incarcerated persons as dignified, and so to attend
properly to their health, has plagued these individuals. One such person, Raymond
Rivera, was:
Arrested on a minor parole violation and sent to Rikers Island, where he waited months for
a final decision on his release. As his case dragged on the coronavirus spread through the
jail complex and he became sick. On Friday, state parole officials finally lifted the warrant
against Mr. Rivera as he lay in a bed at the Bellevue Hospital Center. He died the next day.
(Ransom 2020)

Spending time at the same complex led to the death of another man, Michael Tyson.
“He had been in custody at Rikers Island over a technical parole violation—a non-
criminal violation, like missing a curfew or failing to report an address change to
a parole officer” (Bates 2020b) for a month, when he contracted COVID and died.
This lack of attending to the health of dignified persons occurs in a context in which
others are treated differently. A final example highlights the othering of those who
are incarcerated in New York, and those New Yorkers who are not:
“The day after Gov. Andrew Cuomo ordered New Yorkers to stay home and maintain 6
feet of distance from one another, corrections officers handcuffed 33-year-old Jose Diaz to
another man by his wrist and ankle and put them on a bus headed to Rikers Island, where
the coronavirus had already infected more than three dozen detainees and jail employees….
The pandemic has hit Rikers harder than the rest of New York City. At least 91 inmates
23 Teaching Dignity in the Health Professions 345

for every 1,000 have tested positive for Covid-19, compared with 16 residents per 1,000
citywide. The top physician at the jail complex has called the situation a “public health
disaster unfolding before our eyes” and urged the release of “as many vulnerable people as
possible.” As another Rikers doctor put it, “The only meaningful intervention here would
be to reduce the jail population.” (Brown 2020)

It is complicated to address whether specific violations of autonomy have occurred

in these cases. This is because, in part, the autonomy of incarcerated persons is
restricted and understood to be so. However, as members of the same moral commu-
nity, the extremely risky health situations that persons were placed in is unethical.
Neither because their movements were restricted nor because their time was taken
from them, but because they were not afforded the necessary opportunities related
to their health that would allow them to flourish as human beings. Reflection on
non-standard cases3 like these has the potential to open up the horizons of health
professions students to attend more to the structures that either aid, or impinge upon,
their patients’ attempts to live healthy lives. The failure to attend to the dignity of
those mentioned in these cases was catastrophic: it left some dead, some without
opportunities to be safe and to thrive, and others in the humiliating position of being
at the whims of systems to which they had no recourse. Three specific lessons can
be drawn from a focus on dignity and reflection on the health-related situations of
persons residing in institutions of incarceration, and it is to those lessons that we now
turn.

23.5.1 Lesson One: Retaining Dignity

There are a variety of treatments which, though they aim at (and the hope is that
they will realize) health, place people in situations that are potentially humiliating,
reduce their opportunities, or risk their continued existence. These situations can
be exacerbated by the overarching power dynamic embedded within many health
encounters given the divergence in knowledge between patient and practitioner, and
the sheer fact of vulnerability and dependence of a sick person asking for aid from a
health professional. Informed by dignity, we might ask: can patients leave the hospital
experience, or complete the recommended treatment, with dignity? Such a question
might also be asked regarding certain “tough” or hazing-like practices within some
health professions in order that trainees will be able to “make it” through challenging
situations.
Health professions students and educators might consider Dirk van Zyl Smit’s
(2010) description of prison conditions and ask if the institutions and spaces in
which they work or plan to work allow for all patients to retain their dignity:
At its best, concern about prison conditions is motivated by the recognition that prisoners
as human beings have a right to dignity that should be recognized notwithstanding their

3Incarceration is a commonly discussed case, but in research ethics, not in ethics education in the
health professions.
346 B. C. Pilkington

incarceration. Regulation of prisons may seek to determine whether prison conditions are
such that prisoners can live in prison in a way that allows them to survive with their dignity
and humanity intact and, ideally, improve themselves in the process. (503)

23.5.2 Lesson Two: Undignified Treatments

Patient-centered care is a common mantra in the current healthcare landscape, but are
there procedures, policies, or healthcare structures which aim to benefit practitioners
at the cost of patients? The need for protection of practitioners, whether in terms
of their own conscience or their very bodily integrity (as the lack of PPE in some
places during the COVID-19 pandemic has made clear), is an accepted norm, but one
which must be justified when others bear the burdens of that protection. Secondly,
might there be particular kinds of treatment that simply should not be engaged?
Health professions students and educators should reflect on Priscilla Ocen’s (2012)
expressions of concern about labour and delivery in prison:
Even when pregnant prisoners are provided medical assistance during labo[u]r and childbirth
it is often at the expense of their dignity and basic humanity…Instead of approaching the
pregnancy and childbirth of incarcerated women with dignity and respect, the childbirth
process is often an occasion for particularized punishment, degradation, and humiliation.
Prison officials frequently justify the use of shackles on pregnant prisoners by citing concerns
for the safety of correctional officers and the public. (74)

Health professions students might reflect on Ocen’s description and ask if they are
truly hearing and seeing their own patients? Is their diagnostically essential skill of
listening as well-honed as the other tools in their diagnostic toolbox? In a health-
care landscape in which women and, in particular, mothers, are not as seen and as
heard due to obstacles such as structural racism (Smith 2019), does this example of
incarcerated women suggest any changes in the practices of the health professions?
Might reflecting on a case where the ethical issue is not simply that persons were not
allowed to make a decision about their care, but rather that they were humiliated and
treated in a way that does not befit the kind of beings they are, alter students’ outlook?
Health professions educators might ask structurally similar questions as they reflect
on their assignments, evaluations, and their overall pedagogical approach—are their
aspects of their curriculum which benefit them at the cost of their students?

23.5.3 Lesson Three: Recognition

Recognition of another person as a member of the same moral community, especially

while delivering news or engaging in shared decision-making, is essential for good
healthcare. Good and bad news is often delivered by health professionals and even
more prevalent are the opportunities to engage in shared decision-making about the
course of treatment and health goals. How news is delivered matters; how patients
23 Teaching Dignity in the Health Professions 347

are “consented” matters; and to do so well and ethically is aided by the recognition
that the patient is a member of the same moral community as the deliverer of the
news or the consenter. A useful analogue comes from Michael O’Hear’s (2012) work
on incarceration:
A large body of procedural justice research teaches that the process through which a legal
decision is made may matter as much, or even more, to the people affected by a decision
than the content of the decision. In particular, a legal process that treats participants with
dignity and respect may promote respect for the law and legal system, even if the substance
of the decision is adverse. (223, emphasis authors’ own)

Health professions students might reflect on how the recognition of the dignity of a
patient helps to reframe conversations in which bad news is shared, a medical error is
disclosed, or a costly but beneficial treatment is recommended. They might entertain
the classic philosophical question: could I have been someone else? Considering
such a question might aid students in adopting a different perspective. Recognising
another as similar to oneself in the relevant ways helps answer ethical questions about
error disclosure, the manner in which information is shared, and the importance of
shared decision-making because it raises a kind of reciprocity—not in terms of the
practitioner-patient relationship—but in terms of a deeper human connection within
society, wherein a health professional can see themselves as being on the other side
of the exam table. A similar question can aid health professions educators as they
teach students who may “come to age” in their shared profession in a different time
and context than they themselves did.

23.6 The Unifying Ethics of Dignity

Attending to the dignity of others in healthcare contexts refocuses the gaze of health
professionals from the treatment of an appendix in room 456, a torn anterior cruciate
ligament in room 789, or a case of autism in 123, to the treatment of someone like
them. The universality of this approach, dependent on the idea that all human beings
possess dignity, is not without difficulty. There are two challenges to employing
this framework: first, given that patients, as all human beings do, vary greatly with
respect to their personal characteristics (for good and for bad), how can such a
universal notion be workable in healthcare? Second, given that the practices of health
professionals from physicians to athletic trainers, from occupational therapists to
nurses, from speech language pathologists to physical therapists, all vary—their
scopes of practices, histories of their professions, the areas of health and of the
physical person that they focus on—how can such a universally applicable notion as
dignity capture the nuance needed to inform health professional practice and to be
used in the teaching of health professions students? These are important challenges
to address. In some ways, they mirror the more standard ethical resource options—
principlism and disciplinary-specific ethics resources (e.g., a profession’s code of
ethics), respectively—available to the health professions.
348 B. C. Pilkington

The first challenge is a conceptual one, and a weighty one at that. In clearly
articulating an account of dignity and the standards of human flourishing by which
to understand health practices and applicable resources, we open up the concern that
people might not meet such standards. In some ways, this mirrors the debate over
rights to health and rights to healthcare. If the former cannot be guaranteed, does it
make such a right impossible or are many of us failing in our duties when someone
does not achieve health? Another way of describing this challenge is to ask how a
concept that is so particular, in applying to individual persons, can be universally
applied?4 Thankfully, in applying the concept to health professions practice and
education, additional resources are at our disposal. These resources are of two types.
First, in their focus on the physical and mental states of persons, the health professions
bring with them a conception of healthy human life. They need not entertain this
challenge internal to the concept of dignity for it to be a worthwhile concept to
reflect on and to guide their practice. Universality can be found in the athletic trainer’s
treatment of a patient’s broken leg on a practice field or the paediatrician’s treatment
of flu symptoms in a young child—though they are distinct persons, standards of
health can guide health professionals, especially once they recognize their patient as
like them.
This leads to a response to the second challenge, as well. Dignity is broadly appli-
cable to all humans and its prohibitions on humiliation, denials, of opportunities, and
killing are, as well. However, how each concept is actualized within different health
professions—and within ethics education therein—may vary. It may be humiliating
for an athlete, in certain circumstances, to be carried off a field, and so the athletic
trainer who upholds the dignity of her patient may seek additional persons to help
walk the patient away as opposed to calling for a stretcher. The speech language
pathologist who recognizes dignity in her patient may not take a young student out
of recess for therapy, but instead find a quiet time during the day to engage her
and avoid the humiliation that can accompany being “pulled out.” The occupational
therapist who recognizes the dignity in her patients may broaden her horizon and
work to alleviate negative social determinants of health or positively to empower
her patient to contribute to bettering the social structures that might restrict her.
Building a health professions ethics can, thus, be both universal and also particular.
Recognition of another human being is the foundation of this ethic and how it is
particularized is up to, in part, individual health professional practices as they treat
individual, unique persons. The same can be said of a classroom environment. It is
the treatment of human beings as less than what they are—as mere members of a
mass of othered individuals—which tempts many to ground treatment of others on
what Martin Luther King, Jr. ([1963] 2021) called the “solid rock of human dignity”.

4Elsewhere, I describe this tension between merit and equality. I argue that accounts of dignity
appeal to a concept with an inherent tension between an egalitarian notion that applies to all
persons and a meritocratic notion that highlights the best activities of persons or the best versions
of themselves.
23 Teaching Dignity in the Health Professions 349

Table 23.1 Practice points

1. Consider employing non-standard cases and thinking from non-standard spaces in health
professions education
2. Reflect on the humiliation prohibition of dignity in your teaching and practice
3. Aim to place patients and students in positions to flourish by affording them more
opportunities, not fewer
4. Reflect on the abandonment of care prohibition in your teaching and practice
5. Promote dignity in your teaching and your practice

23.7 Conclusion

This chapter offers a new approach to ethics education in the health professions. It
suggests framing ethics content in terms of dignity and, in particular, urges health
professionals to avoid three violations of dignity—treatment that is humiliating,
denies opportunities, and kills. Dignity’s applicability is broad enough (with its focus
on human beings) to be relied upon in the ethics education of a variety of health
professions, but also specific enough (with the three prohibitions) to supply useful
content for the practice of individual health professions. The details of this application
must be put into practice by health professionals themselves as they realize dignity
in their daily work. An important and ancillary benefit of this taking up a new
approach to health ethics education is its suggestion of non-standard cases and spaces
for reflection; this chapter focused on situations of incarceration to elucidate three
lessons for health professional, which centered on practices that retain dignity, avoid
undignified treatment, and call for recognition (Table 23.1).

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Chapter 24
The Ambiguities of Humility:
A Conceptual and Historical Exploration
in the Context of Health Professions
Education

Barret Michalec, Frederic W. Hafferty, Nicole Piemonte, and Jon C. Tilburt

24.1 Introduction

…there are little things that instructors would say here and there that encourage you to
remember the greatness of what you’re doing or how serious it is that you can take someone’s
life in your hands. And those things are true I guess but it breeds a sense of greatness that’s
just kind of gross, you know. It’s just sort of sickening, and a huge turn off in medicine in
general. But you’re around that all the time and the fact of the matter is that you do have
people’s lives in your hands so to not feel that way at all is difficult.
First Year Medical Student, quoted in Michalec (2012, 8)

The quote above from Michalec’s (2012) study of socialization processes within
medical education indirectly highlights the concept of humility. Although (as we will
discuss later) humility has been linked to patient health, the limits of care delivery, and
to patient-centered care, the role(s) of humility within health professions education
has yet to be fully unpacked. We suggest that this hesitancy may stem from a lack of
clarity regarding the concept of humility and what it means to be humble. Within this

B. Michalec (B)
Edson College of Nursing and Health Innovation, CAIPER, Arizona State University, Phoenix,
AZ, USA
e-mail: barret.michalec@asu.edu
F. W. Hafferty
Division of General Internal Medicine and Program in Professionalism and Values, Mayo Clinic,
Rochester, MN, USA
e-mail: fredhafferty@mac.com
N. Piemonte
School of Medicine, Phoenix Regional Campus, Creighton University, Phoenix, AZ, USA
J. C. Tilburt
Division of General Internal Medicine, Mayo Clinic, Scottsdale, AZ, USA
Biomedical Ethics Research Program, Mayo Clinic, Rochester, MN, USA

© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2022 351
M. E. L. Brown et al. (eds.), Applied Philosophy for Health Professions Education,
https://doi.org/10.1007/978-981-19-1512-3_24
352 B. Michalec et al.

chapter, we examine the socio-historical evolution of the concept of humility in order

to lay the foundation for future humility-oriented research and program development
within health professions education.

24.1.1 The Ambiguities of Humility

Amongst contemporary scholars, there appears to be general agreement that humility

is a socially valuable attribute. Not only is being seen by others as being humble or
having humility perceived as socially beneficial, but humility is also seen as related
to other positive attributes such as empathy, generosity, and open-mindedness, and to
promote social cohesion (Snow 1995; Bollinger and Hill 2012; Exline and Hill 2012;
Nadelhoffer et al. 2017; Weidman et al. 2018; Worthington et al. 2018). Yet, humility
has a darker side to its apparent social desirability. Humility is also associated with
self-abasement, low self-opinion, a sense of worthlessness, incompetence, small
mindedness, shame, servility, lack of self-confidence, and a lack of ambition (Wright
et al. 2018; Tangney 2000; Roberts and Cleveland 2017; Exline and Geyer 2004).
Taken together, these countervailing views suggest that humility possesses a
conceptual duality, or, at the very least, a significant degree of conceptual ambi-
guity. What are the historical roots of the concept of humility, and where do these
ambiguities of humility arise? Moreover, and specific to this chapter, how is humility
discussed within the healthcare fields and within health professions education? How
is humility presented and taught (informally and formally) to health profession
students?
In this chapter, we address these questions by providing background on the
conceptual and theoretical foundations of humility specifically related to philos-
ophy and philosophical inquiry. Although we spotlight the prominent backdrop of
virtue and virtue ethics as it relates to humility, we also examine the potential “costs”
associated with humility, particularly as they pertain to health profession students. In
doing so, we explore the current focus of humility in healthcare and health professions
education, with particular attention to the arena(s) of interprofessional education.
In his recent chapter, “I am so Humble!”, Robinson (2020) meticulously dissects
the ‘Gordian Knot’1 of paradoxes associated with humility, including the apparent
dichotomy associated with humility regarding low self-assessment and inattentive-
ness to one’s status. In the same spirit, we suggest that exploring the dynamic history
of the concept of humility through antiquity, the enlightenment and today is much
like unraveling an intricate string of Christmas lights. You unravel a few sections
only to come upon compounded knot after knot…after knot. Aside from carefully
dissecting particular positions and deciphering complex prose about humility, it is
essential to inspect specific challenges to scholars’ readings of texts. Therefore, in

1The term “Gordian Knot” is often used as a metaphor for a complex, intricate, perhaps unsolvable
problem. It is featured in a myth associated with Alexander the Great (i.e., “cutting the Gordian
knot”).
24 The Ambiguities of Humility … 353

order to provide a grounding to our exploration, we begin by presenting the current

general understanding of humility. We then travel through time to briefly examine
how prominent historical and contemporary thinkers discuss humility and/or similar
constructs. Our goal within this chapter is to advance the examination of humility as
it relates to health professions education and cultivating the healthcare workforce of
the future. Therefore, by providing a firm “base camp”, while addressing the ambigu-
ities associated with humility, we can then explore if, and how, humility is discussed
within healthcare and health professions education.

24.2 Current Perspectives on Humility: A Grounding

To date, the conceptual and theoretical applications of humility have primarily been
conducted through the disciplines of philosophy, theology, and psychology, with
newer fields such as positive psychology and leadership science expanding this
base (Alfano et al. 2020; Worthington et al. 2017; Tangney 2000; Sousa and Van
Dierendonck 2017). This chapter will focus primarily on philosophical approaches
to humility. However, across humility’s multidisciplinary landscape, prominent
scholars have provided historical explorations of humility with detailed accounts of
its conceptual and theoretical evolution, evaluations of contemporary measurement
techniques, as well as discussions outlining similarity and differences to related
concepts (i.e., modesty, empathy, gratitude, etc.), along with the development of
conceptual-cousins such as intellectual humility, cultural humility, and relational
humility (see: Snow 2020; Davis et al. 2010; Van Toneren et al. 2019; Tervalon and
Murray-García 1998; Foronda 2020; Wright et al. 2016, among others).
Across this landscape, Worthington Jr. et al. (2017) note, there is no universal defi-
nition of humility, and all definitions of humility are “up for debate” (344). Regarding
a cohesive conceptualization of humility however, we can turn to psychology and
subdisciplines therein. Tangney (2000), for example, provides a widely accepted
broad overview of the key elements of humility that include: the accurate assess-
ment of one’s abilities and achievements as well as the acknowledgement of one’s
limitations and gaps in knowledge. In addition, being humble involves a relatively
low self-focus, appreciation of others’ contributions, and recognition that one is but
a part of a larger universe (Tangney 2000). Similarly, Peterson and Seligman (2004)
conceptualize humility as a process of self-evaluation that involves a non-defensive
willingness to see oneself accurately (in regards to strengths and weaknesses) and
the ability to transcend beyond self-focus and understand or view oneself from a
broader perspective.
At the same time, as noted earlier, these more positive renderings of humility
are not the only framing, and thus we must account for this bifurcation. Although
there is evidence of the ambiguities of humility in psychology, sociology, and other
disciplines, philosophy and philosophical inquiry, especially related to virtue-ethics,
provides a roadmap of sorts to how the concept of humility evolved over time, and
spotlights key transitions and “reversals” that lend to the ambiguities of humility. We
354 B. Michalec et al.

now step into our time machine to briefly connect with historical philosophers and
spotlight their perspectives on “humility”.

24.3 Historical Explorations of the Humility Concept

24.3.1 Classic Greek

Although Socrates (through Plato) never uses the term “humility” explicitly, Rawson
(2005) provides a detailed discussion of Socrates’ notion of “human wisdom” and
its potential connection to our current understanding of humility.
Taken aback by an oracle’s suggestion that no one was wiser than Socrates,
Socrates sets out to have meaningful discussions with reputable politicians, play-
wrights, and others known for their moral and scientific wisdom to showcase how
others are, indeed, wiser than he. Through his pressing interviews however, Socrates
exposes holes in their logic and their explanations of beliefs. Rawson (2005),
explains:
The more expertise people claimed about the most important things in life – justice, virtue
and the best way to live – the less they could justify their claims. Even the knowledge some
people did possess, like the art or science of their trades, was overshadowed by their mistaken
belief that they were also qualified to tell people how they should live. (31)

Socrates concludes that the key distinction between those he has met with and
himself is that, whereas they believe they know something and clearly do not, Socrates
knows nothing and knows it. In turn, Socrates interprets the oracle’s comment to mean
that the wisest is the person who is fully self-aware of their lack of wisdom—like
Socrates. Socrates then sets out to promote this humble self-knowledge as he debates
teachers, statesmen, and other prominent scholars of the time, cross-examines them
with cutting questions and exposing their inconsistencies. In this sense, Socrates,
without directly raising the concept of humility, may serve as a prime exemplar
of humility (specifically intellectual humility, which we will discuss later), and his
notion of “human-wisdom” as reflective of humility in its opposition to arrogance.
This caution against going beyond one’s limits (i.e., keeping within human bounds
broadly speaking) and avoiding hubris (or “hybris”) is a consistent moral and theme
throughout classic Greek writings. From Icarus flying too close to the Sun, Narcissus
drowning in the lake, to Homer’s Odysseus and his arrogant triumph over the Cyclops,
it is clear that classic Greek thinkers valued the notion of accurate self-judgement
and understanding (and accepting) one’s limitations. According to Chappell (2020),
although the term “humility” is absent within classic Greek philosophy, it is this
avoidance of overreaching or overstepping one’s bounds that rings closest to our
current notion of humility. Yet, within classic Greek philosophy, there also is an
ideological distance between arrogance (i.e. overstepping or stepping outside of
one’s human bounds) and proper pride and honor, and it is this ideological distance
that problematizes humility during this era.
24 The Ambiguities of Humility … 355

One aspect of this distance is apparent in Aristotle’s discussion of virtues in Nico-

machean Ethics. Although the virtuous man is aware of his constraints, the temporary
nature of his achievements, and to some extent his privilege, Aristotle also argues
that presenting or promoting oneself as less-than is insincere and in opposition to
magnanimity—which he held in the highest of regards (Chappell 2020). According
to Roberts and Cleveland (2017), Aristotle’s notion of magnanimity (i.e., “mega-
lopsychia”) is somewhat akin to pride and “makes people sufficiently attentive to
the honors that are due them for their greatness…” (38). In this sense, magnanimity
serves as a middle-ground between arrogance/vanity and smallness/lowness. In this
way, those who present themselves to peers as less worthy of honor are to be consid-
ered small-minded and the opposite of the “great-souledness” that is aligned with
the virtue of magnanimity.
This notion echoes through ancient Greco-Roman ethics. To some extent,
‘humility’ is equated with an avoidance or dismissal of honor, a downcast of
pride, and, within this frame, in opposition and detrimental to human potential and
achievement.

24.3.2 Christian Philosophy

Continuing our (excellent) adventure through time, to the ancient Romans, merit-
based pride, power, and honor were the highest of attributes and to be celebrated
privately and publicly. In turn, humility (and related concepts therein) was related to
shame, weakness, and abasement.
Yet, within ancient Judeo-Christian texts, there is evidence of a shift in the utili-
sation of term humility (Dunnington 2016). To this point, one may speculate that the
term humility may have been purposely “reversed” by Judeo-Christian leaders (from
Greco-Roman “paganism”) to promote and encourage the oppressed, marginalized,
and humbled Judeo-Christian people. This possible “reversal” within the Judeo-
Christian philosophy and theology denotes a key shift in the use of humility as
a positive attribute. Moses, a figure of authority and prominence, is venerated as
“…very humble, more than all men were on the face of earth” (Numbers 12:3). And
within classic Christian theology, perhaps no act is portrayed as more humble than
Jesus’ death—in fact, the acts and personification of Jesus as told through Judeo-
Christian texts, are described as models in humility that followers should embrace
and emulate. Moreover, within these writings, humility is framed as the antithesis
to pride—with pride now conjoined with arrogance, envy, and conceit. Humility, in
ancient Judeo-Christian philosophy, is framed not only as the antidote to pride, but
also as an essential virtue.
For classic Christian philosophers, humility is necessary to be receptive to divine
action. As Saint Augustine (Augustine of Hippo) states,
if you should ask me what are the ways of God, I would tell you that the first is humility,
the second is humility, and third is humility. Not that there are no other precepts to give, but
356 B. Michalec et al.

if humility does not precede all that we do, our efforts are fruitless. (St. Augustine, cited by
Dormor 2019)

Dunnington (2016) states,

for Augustine, humility is fundamentally the embrace of radical dependence. Radical depen-
dence is the will to receive completely one’s being from the generosity of another and the
will to give of oneself completely for the being of another. (27)

Dunnington goes on to state that for Augustine, humility is the transformation of

one’s will, to “desire differently”. Augustine suggests that it is through humility in
which all other virtues are cultivated and that humility, not pride, leads to excellence
and happiness (McInerney 2016). For Augustine, humility is the centerpiece for
virtue, and argues that ‘pagans’ (i.e., ancient Greco-Romans) cannot be genuinely
humble as they are victims of various vices resembling pride. Of note, while the
Romans used the cross as a tool to humiliate, Christian theologians utilize the cross,
and the notion of Jesus’ death on the cross, as the ultimate greatness and the true
symbol of humility—and this is reflective in Augustinian philosophy (Dunnington
2016).
Further reflecting the central role of humility for Augustine is his commentary
on the story of David’s slaying of Goliath, “Humilitas occidit superbiam”—humility
has slain pride. Augustine’s approach to humility, as one of the highest of virtues,
heavily influences how humility is perceived, and it in turn utilized in future Christian
philosophical work. Although prevalent in other Judeo-Christian texts, Augustine
consistently and emphatically distances humility from pride, presenting pride as the
opposing force of radical dependence—and in turn an anchor keeping from divine
connection. Augustine states (McInerney 2016):
We are striving for great things; let us lay hold of little things, and we shall be great. Do
you wish to lay hold of the loftiness of God? First catch hold of God’s lowliness. Deign
to be lowly, to be humble, because God has deigned to be lowly and humble on the same
account, yours not his own. So catch hold of Christ’s humility, learn to be humble, don’t be
proud. Confess your infirmity, lie there patiently in the presence of the doctor. When you
have caught hold of his humility, you start rising up with him. (2)

This notion of being subjugate in order to ascend is also prominent in the works of
Saint Benedict (Benedict of Nursia), who suggests humility is the ladder to which we
ascend into heaven, a ladder that we must first descend. The 12 rungs of the ladder
are discussed in the Rule for monastic life and are framed by Porter et al. (2017) as:
…submission of one’s will to divine commands, regular confession of one’s shortcomings
to a trusted elder, a grateful acceptance of one’s work assignments, and food allotments, and
the strategic use of silence geared toward cultivating solemnity. (57)

A strong supporter of Benedicts’ 12 degrees of humility, Thomas Aquinas sustains

the virtuous nature of humility, but presents it more as a restraint of sorts, a model of
temperance to navigate our appetites (i.e., urges, desires, concerns) in a reasonable
and moderate manner. Humility keeps us in-bounds, prevents us from going beyond
our limits, and is a reminder of divine rule and reverence for and subjugation to God.
24 The Ambiguities of Humility … 357

Put simply, to Aquinas, humility pulls the reins back on pride. Again, we see this
notion of humility as tether, keeping us within our limits—keeping us grounded. For
Aquinas, “Humility is a limiting mechanism, like a governor on a gasoline engine that
prevents it from being revved up beyond safety standards…” (Roberts and Cleveland
2017, 39).
However, in addressing Aristotle specifically, Aquinas also argues that humility
and magnanimity are actually complimentary virtues (Newman 1982).
Here is Aquinas’s paradox: no humility, no true or full magnanimity; no magnanimity, no
true or full humility. Demean or jettison humility, then, and regardless of your intentions
you have dealt a deathblow to greatness of soul. (Keys 2008, 218)

Moreover, Aquinas argues that humility is good for society in that it promotes the
common good and civic engagement. This notion also echoes the works of St. Bernard
of Clairvaux who suggested that humility is true self-knowledge, and that the recog-
nition of our own flaws and limitations (through humility) endear us to be beneficent,
forgiving, and gentle with other people.
As Newman (1982) notes, “In analyzing humility, Aquinas and other religious
philosophers emphasize the importance of subjection to God. In their view, all
humility is rooted in this basic subjection” (282–3). In this sense, Christian philos-
ophy frames humility as the converse of pride, vanity, and conceit, and ties humility
directly to a submission of the self to God. Dunnington (2016) argues that the
notion of humility emerged from a Jewish-Christian outlook, and that a “…chal-
lenge confronting secular philosophy is to give an account of humility that does
not rely on presuppositions unique to a religious outlook” (19). This “challenge” is
somewhat more evident among contemporary philosophers (as we will discuss later
in the chapter), as prominent scholars emerging from the Enlightenment appear to
take substantial efforts to untangle humility from its Judeo-Christian roots, even to
a dramatic extent in certain cases, and in turn, further cultivate the ambiguities of
humility.

24.3.3 The Enlightenment

The Enlightenment represents less of an aggressive or hostile attempt to eradicate

religion from socio-political thought and practice, than it does a collective effort to
emphasize and promote human potential and capability. This shift from the sacred to
the profane is well reflected in the use of and perspectives on the concept of humility
in the philosophical writings of the time.
According to Cooper (2010), Thomas Hobbes engages with the concept of
humility from a socio-political framework, situating humility as a stalwart for durable
social stability in that it is through humility that all humans are acknowledged as
equal—through an awareness and appreciation of human capabilities and limita-
tions. In Leviathan, Hobbes makes a distinction between confidence and pride (i.e.,
358 B. Michalec et al.

glory in one’s former actions), and “vainglory” or an inaccurate self-estimate. More-

over, within this conceptual framework, humility for Hobbes is an awareness of one’s
own vulnerability and finitude, and by association, the acknowledgement of other
humans as naturally equal. Although Copper highlights Hobbes’ empowering frame
of humility, she also credits Hobbes with the new/next “reversal” of how humility is
utilized in philosophical writings through his need to extract religious-based notions
of humility from how humility can exist within socio-political philosophy. Dunnigan
(2016) outlines Copper’s stance noting that for Hobbes, humility is no longer a virtue
that “…facilitates divine-human relationship”, but rather is framed as a vehicle “…to
inculcate the knowledge of finitude that Hobbes thought was a precondition for the
sustainable collective agency” (30).
Whereas Hobbes’ writings may present a somewhat favorable view of humility
(albeit from a socio-political standpoint), David Hume truly “…vilified humility as
keeping people mired in weakness and inaction” (Worthington Jr. 2017, 79). Hume
frames humility as limiting and undercutting ambition and attempts to reinstate pride
as a key virtue that fuels human agency and purpose. Hume refers to humility as a
“monkish virtue”, a term he uses for various traits associated with self-denial such
as celibacy, fasting, silence, and solitude that masquerade as virtues (Davie 1999).
Hume argues that these traits are in opposition to the flow of human life, and in
turn, humility should actually be considered a vice, an “…‘indirect’ passion of self-
deprecation” (Keys, 2008, 218). However, Burch (1975) argues that, “By ‘humility’
Hume means the feeling of humiliation, embarrassment, or shame. He does not mean
the character trait of humbleness or modesty” (177). Burch suggests that it is from
this framework that Hume positions humility and pride as opposing forces.
The positionality and role of humility in Immanuel Kant’s moral theory are not
only challenging to decipher but, in turn, also debated within the philosophical liter-
ature. Although not often considered a “virtue theorist”, Kant argues that pride is
essential to moral virtue, and although he connects humility to desirable aspects of
self-esteem, Kant is vehemently opposed to the false-humility of servility, as well as
Christian accounts of humility in general (Grenberg 2005; Louden 2007). An advo-
cate for the centrality of humility in Kantian ethics, Grenberg (2005) argues that Kant
viewed humility as the “..meta-attitude which constitutes the moral agent’s proper
perspective on herself as dependent and corrupt but capable and dignified rational
agent” (133). In fact, Grenberg argues Kant’s stance on humility can be interpreted
as: since inaccurately assessing oneself (i.e., self-aggrandizement) is at the heart
of social ill, then constraining over self-valuing and appropriate reassessment (i.e.
humility) is positive for societal function. For Kant, true humility (i.e., “humilitas
moralis”) follows from our comparison of ourselves with the moral law (rather than
moral agents such as Jesus), and our embracing of and respect for the moral law.
Furthermore, from this internalization of moral law stem “feelings of inner worth”
and self-esteem (Louden 2007, 632).
Like Hume, Friedrich Nietzsche is adamantly consistent and complete in his
rejection of humility. Humility is at the heart of morality of servitude and unnatural
devotion, a self-protective instinct of the weak and powerless (i.e., “slave moral-
ity”) (Nadelhoffer et al. 2017). For Nietzsche, humility serves as a barrier against
24 The Ambiguities of Humility … 359

humanity’s progress as it leads us astray from noble powers of mastery and under-
mines the raw nature of our wills to dominate (i.e., ‘master morality’). Nietzsche
explicitly problematizes the Christian stance on humility, even stating that the reli-
gions of the world that tout humility as a virtue were propagating a lie that it is
virtuous to not strive to your fullest potential to not embody greatness (Bollinger
and Hill 2012). Bollinger and Hill (2012) frame Nietzsche’s perspective:
Since these less fortunate individuals cannot attain the power and resources needed to obtain
happiness, they twist their powerlessness into a virtue and proclaim it as a desired end in
itself. In this way the weak try to stymie the strivings of the strong by proclaiming that
humility, not power, should be the desired goal. (31)

From Hume and Nietzsche, we see the de-virtueing of humility—tying humility to

weakness and subservience, and even categorizing humility as a vice, arguing that
it thwarts human progress and potential. Although the Enlightenment-era “reversal”
of the conceptualization of humility is quite clear with Hume and Nietzsche (feeding
the ambiguities of humility), the shift for humility as a vice back to a virtue (i.e., the
general common understanding of humility) is not so obvious. Yet, the humility-as-
a-virtue position is a consistent and persistent stance within the current philosophy
literature—which, yet again, further cultivates the ambiguities of humility.

24.4 Contemporary Accounts of Humility

Garcia (2006), Snow (2020), and Roberts and Cleveland (2017) each provide
condensed profiles of prominent contemporary philosophers’ primary stances
regarding humility, as well as evidentiary fodder for a broader glimpse into their
reasoning. Nonetheless, and because of the nuances nested within the variety of
current humility conceptualizations, we will present a general overview of a few key
voices in the field, then outline the consistencies among these conceptualizations that
may bring us to the current general understanding of humility that we offered at the
beginning of this chapter.
For Snow (2020), Taylor (1985) serves as a likely bridge between historical and
contemporary perspectives on humility. Channeling Aquinas, Taylor argues that
humility serves as a restraint for humans to not overstep or overreach their human-
bounds. For Taylor, having humility and being humble means an acceptance of one’s
lowly position, but does not include self-abasement. Moreover, Taylor (1985) does
not extract pride from humility:
The humble who occupy and accept a lowly position on some hierarchical scale may be
merely poor and meek. But to be virtuously humble is not to accept meekly just any sort of
inferior position. (17)

Norvin Richards (1988, 1992) rejects Taylor’s account of humility arguing that
if only those who accept a lowly position can be considered “humble” then those
who have attained a high position are excluded from being “humble”. For Richards
360 B. Michalec et al.

(1988), humility “…involves having an accurate sense of oneself, sufficiently firm

to resist pressures toward incorrect revisions” (254) (i.e., thinking too highly of
oneness). Richards emphasizes the need for knowing oneself so well that you have
no motivation to exaggerate yourself. In short, with Richards’ notion of humility,
you can avoid thinking too highly of yourself without the nasty after-taste of low
self-respect.
Utilizing modesty and humility somewhat interchangeably, Julia Driver (1989)
suggests that modesty, which from her perspective relies on ignorance, is “…a
dogmatic disposition to underestimation of self-worth” (378). To Driver, the
modest/humble person is someone who not only ignores their good qualities and
achievements but is also ignorant of them. Put simply, modesty to Driver (2001) is
almost an absent-mindedness to one’s own merits and abilities—a self-forgetfulness
and an un-noticing.
According to Snow (2020), humility is “…the disposition to allow the awareness
of and concern about one’s limitations to realistically influence one’s attitudes and
behavior” (11). Snow’s approach to humility is more concerned about awareness
and acknowledgement of one’s weakness, rather than an accurate understanding of
one’s strengths. Through her two types of humility, she outlines how humans can be
appropriately concerned with the flaws associated with the self (narrow humility) as
well as taken aback by limitations associated with acknowledging human existence
in the broader sense (existential humility) (Snow 1995, 2020).
Garcia (2006) states that humility is virtuous as long as stems from desired self-
improvement and/or proper acknowledgment of others’ deeds and merits:
The humble are those who are unimpressed with their own admired or envied features...those
who assign little prominence to their possession of characteristics in which they instead might
well take pride. They are people for whom there is little personally salient in these qualities
and accomplishments. (417)

Like Garcia, Roberts and colleagues (Roberts and Wood 2007; Roberts and Cleveland
2017) promote an understanding of humility through what it is not: pride, self-
importance, envy, conceit, and self-righteousness:
The virtue of humility is intelligent lack of concern for self-importance, where self-
importance is construed as conferred by social status, glory, honor, superiority, special
entitlements, prestige and power. (Roberts and Cleveland 2017, 33)

Roberts and colleagues believe that someone can be humble and acknowledge their
greatness—it is the lack of concern for this greatness (the void of self-importance)
that is the key.
Despite variations, there are certain consistencies within contemporary philo-
sophical approaches to humility. These conceptualizations often tout a heightened
awareness and knowing of the self, along with a willingness to be open to one’s own
limitations (and strengths). Taken together, these conceptualizations also speak to an
accurate and congruous understanding of one’s flaws and merits, but also a sense of
security in one’s vulnerabilities.
Thus far, we have engaged with classic and contemporary philosophy to explore
the journey of the concept of humility, and to better understand the ambiguities of
24 The Ambiguities of Humility … 361

humility through apparent “reversals” of humility that have, in turn, shaped its more
contemporary conceptualization. But how is humility applied and activated within
the health profession fields and health professions education?

24.5 Humility and Health Professions Practice

and Education

The majority of discussions of humility within the health professions literature

(practice and education) are commentaries, editorials, and snapshots of practice-
based experiences that are framed as reflections on practicing humility and/or being
humbled. These offerings typically highlight the beneficial nature of humility in care
delivery, nesting it within “professionalism” and praising humility as an important
trait to teach (formally and informally) to health professions students (Li 1999; Hader
2008; Oxman 2012; Mammas and Spandidos 2019; Caruso Brown 2019; Petriceks
2020). Although there have been efforts to extrapolate and apply the concept of
humility within the realm of care delivery (Crigger and Godfrey, 2010; Cleary et al.
2014; Zinan 2021), and most recently care delivery during COVID-19 (Cosgrove
and Herrawi 2021; Décary et al. 2021), it was not until recently that the impact of
practitioner’s humility on patient health began to be explored (Ruberton et al. 2016;
Huynh and Dicke-Bohmann 2020; Watkins Jr. and Mosher 2020).
Regarding conceptualizations of humility offered within the fields of care delivery,
Coulehan (2011), presents an idea of humility through four attributes: unpreten-
tious openness, avoidance of arrogance, honest self-disclosure, and modulation of
self-interest, and suggests that, within medicine, humility “…manifests itself as
unflinching self-awareness; empathetic openness to others; and a keen appreciation
of, and gratitude for, the privilege of caring for a sick person” (Coulehan 2010, 200).
In his discussion of the feedback processes related to Competency-Based Education
(CBE), Gruppen (2015) highlights the role of humility,
Humility is a willingness to acknowledge the possibility that you are fallible and may be
wrong, that you need guidance or help from others on occasion, that you can benefit from
feedback, and that you need to make changes in your performance. (6)

Chochinov (2010) defines humility by what it is not, “Being humble, however,

does not mean embracing mediocrity or indecision, any more than clinical confidence
need be conflated with arrogance or hubris” (1218). Following Crigger and Godfrey
(2010), Dameron (2016), suggests, “Humility is not about being self-critical. Instead,
it is about an honest appraisal of our faults and shortcomings” (9). Notably, particular
voices in these fields, such as Crigger and Godfrey, Paine and colleagues, Grouper,
and Coulehan, among others, do refer to humility as a virtue which not only aligns
with various contemporary philosophical perspectives, but echoes classic Christian
theology.
Given psychology’s strong presence in the evolvement of humility as a concept,
humility theory, and the measurement of humility, it is not surprising that there is an
362 B. Michalec et al.

active conversation within the practice of psychology and psychotherapy regarding

the role of humility in patient care and mental health services (for review see:
Worthington Jr. 1998; Paine et al. 2015; Davis and Cuthbert 2017; Sandage et al.
2017). Moreover, Paine et al. (2015), offer the concept of Clinician Humility,
…the evolving inclination toward accurate self-assessment, recognition of limits, the regu-
lation of self-centered emotions, and the cultivation of other-centered emotions in a clinical
setting. (10)

According to Paine et al., clinical humility (as well as humility in general), like
other virtues can be practiced and honed—they suggest through deliberate reflection,
study, and practice.
Another fruitful humility-oriented arena within health professions literature has
been discussions of humility’s conceptual cousin Cultural Humility. Distinguishing
cultural humility from cultural competence, Tervalon and Murrag-Garcia (1998, 117)
state that cultural humility is:
…a lifelong commitment to self-evaluation and critique, to redressing the power imbalances
in the physician-patient dynamic, and to developing mutually beneficial and non-paternalistic
partnerships with communities on behalf of individuals and defined populations. (117)

Smith and Foronda (2021) offer “ground rules” to teaching and cultivating cultural
humility within the classroom, and although their proposal is directed primarily at
nursing and nursing education, their approach could certainly be expanded to include
students of other health professions. Relatedly, Agner (2020), as well as the Amer-
ican Occupational Therapy Association (2020), outline the value and importance of
practicing (and teaching the tenets of) cultural humility within Occupational Therapy.
Moreover, Foronda and colleagues continue to explore and expand the conceptual,
theoretical, and operational parameters of cultural humility (Foronda et al., 2016,
2021; Foronda, 2020).
Intellectual humility, however, has received far less attention within the health
professions fields. We briefly raised the concept of intellectual humility earlier in
this chapter in our discussion of Socrates and his notion of “human wisdom”. Davis
et al. (2016) state that intellectual humility “…involves (a) having an accurate view
of one’s intellectual strengths and limitations, and (b) the ability to negotiate ideas in
a fair and inoffensive manner” (215). Of note, Gruppen (2014), connects the notion
of intellectual humility to elements of the Hippocratic Oath and highlights the value
of respecting the skills and knowledge of colleagues.
Within the broad fields of healthcare delivery and health professions education,
there appears to be a consistent stance that humility is valuable to patient care and as
a trait (perhaps even skill) to cultivate among current and future practitioners. More-
over, there appears to be alignment between these conceptualizations of humility
within these fields and the conceptualizations stemming from the contemporary
philosophers provided earlier (e.g., Richards, Snow and Roberts)—perhaps even
hints of Christian philosophical approaches to humility as well in the framing of
humility as a virtue. Nonetheless, there is a dearth of research and theoretical and
conceptual explorations of humility (in the general sense) within the healthcare
24 The Ambiguities of Humility … 363

fields. There is an abundance of research and conceptual explorations associated

with empathy (Sulzer et al. 2016; Michalec and Hafferty 2021), so why is humility
being humbled? Crigger and Godfrey (2010) offer two possibilities: (a) if under-
stood in the narrow sense of humility as lowliness and unworthiness, this conflicts
with modern societal conceptions of self of having value and importance, and (b)
the potential linkage of humility in the religious sense (i.e., Augustinian-Christian
frame) may stifle empirical engagement with the concept of humility. Below, we
offer an additional hypothesis—given humility’s implicit and explicit tether to social
status (Michalec et al. 2021), and the volatile nature of status dynamics as they
relate to practitioner-patient and practitioner-practitioner interactions, humility is a
sticky-wicket for scholars in these fields to navigate.
Relatedly, many scholars offer examples of organisational, and even national-
level, barriers to cultivating and practicing humility within the healthcare fields such
as: challenges embracing “medical uncertainty”, perceived power and control in
decision making, a national culture that values individualism and hubris, embedded
informal and formal competition (associated with exam scores, placements, opportu-
nities, etc.), a “publish or perish” culture within organisations regarding job security,
the imperial status of clinical knowledge, structures that implicitly and explicitly
discourage collaboration, and an overarching culture that dissuades vulnerability and
openness (Gruppenf 2014, 2015; Chochinov 2010; Coulehan 2010, 2011; Li 1999;
Zinan 2021). There are also individual and interpersonal-level challenges nested
within the healthcare fields and educational systems therein that may stifle the culti-
vation and practice of humility among providers and students. Gruppen (2014, 56)
suggests, “Cognitively, humility comes at a price of confidence and clarity. The task of
perpetually entertaining the possibility that one is wrong is demanding” (56). More-
over, although humility is generally understood as a positive social attribute, given the
ambiguities of humility there is the possibility that humble people might be perceived
by others as unassertive and lacking confidence and in turn, have their work mistak-
enly attributed to others (Owens et al. 2012). Furthermore, as Michalec et al. (2021)
argue, there are informal and formal social expectations regarding who should be
humble and when individuals should exhibit humility (i.e., regarding race, ethnicity,
gender, socioeconomic status, among other status characteristics), and failure to
follow these expectations could have dire consequences regarding (social) sanctions
such as isolation and withholding of various resources.
Overall, humility is still very “young” in the health professions and health profes-
sions education literature, specifically in regard to measurement, evaluation, and
impact on patient health outcomes. Within this burgeoning scholarship, in regard to
the conceptualisation of humility, there appears to be implicit (and perhaps explicit)
nods to classic Christian philosophy (e.g., Aquinas), as well as more contemporary
philosophers such as Richards, Snow, and Roberts among others—yet the “voice” of
specific Enlightenment thinkers, such as Hume and Nietzsche, is somewhat muffled,
if not absent. Moreover, there is no evidence of “ambiguities of humility” within this
particular scholarship, as there is apparent consensus within the health professions
364 B. Michalec et al.

literature that humility is a positive attribute (perhaps even a virtue), and a practice-
based skill to cultivate and promote. However, the “how” aspect of promotion, partic-
ularly given the traditionally high value (perhaps even virtue) of confidence within
the culture of medicine (i.e., “fake it ‘til you make it”) renders the picture still more
opaque than clear. As noted above, our goal within this chapter is to advance the
examination of humility as it relates to health professions education and cultivating
the healthcare workforce of the future by examining the socio-historical evolution
of the humility concept. However, given the relative “new-ness” of humility within
the fields of care delivery and health professions education, we encourage continued
excavation and exploration of not only the what, but also the when, where, and how
of humility. Below, we offer some potential next steps to address these questions.

24.6 Moving Forward

Along with current recent efforts regarding measuring the impact of providers’ degree
of humility on patient-related outcomes (Huynh and Dicke-Bohmann 2020; Ruberton
et al. 2016), and the effectiveness of particular humility-based interventions on indi-
viduals’ attitudes and behaviors (Watkins Jr. and Mosher 2020, 2017; Lavelock et al.
2014; Ruberton et al. 2017; McMahon 2020), we suggest three other areas that are
ripe for future humility exploration.
First, there is abundant literature regarding the nature of feedback in health profes-
sions education. In line with current research on the processes, techniques and
best practices associated with feedback, scholars can explore if and how humility
is utilised by both interaction parties to facilitate feedback, as well as differences
related to cultivating humility and improperly ‘accepting’ humiliation, especially as
it relates to health professions education and students’ wellbeing (Shah et al. 2020;
Kupfer 2003). Similarly, future research in this area can examine potential connec-
tions between humility, feedback and shame, belittlement, and bullying. Moreover,
such research could be expanded to include how tenets of humility (and being humble)
may be reflected in reflection and reflection-based processes frequently touted within
health professions education.
Second, there is a great deal of attention and voice paid to the influence of the
imposter phenomenon (or ‘imposter syndrome’) on health profession students’ and
young professionals’ socio-emotional well-being and productivity (Prata and Gietzen
2007; Christensen et al. 2016). Because the imposter phenomenon’s foundational
focus is an inaccurate view of oneself, their accomplishments, and their knowl-
edge, future work should examine the potential connection between humility and the
imposter phenomenon (Slank 2019).
Finally, given that team-based, collaborative care promotes more effective and
efficient care delivery, it is important to explore how health professionals and
health profession students learn to respect, value, and appreciate those outside of
their own discipline/practice. Somewhat similar to Paine et al.’s notion of clinical
24 The Ambiguities of Humility … 365

humility, Michalec attempts to expand the concept of humility to the interprofes-

sional realm and has recently proposed a ‘Professional Humility’ concept (Michalec
2020). Professional humility represents a consistent ability and willingness to: (a)
evaluate, account for, and respond to the occupational status hierarchy within health
professions (and health professions education), (b) understand the strengths and limi-
tations of one’s own profession, and (c) accept and acknowledge the qualities, skills,
knowledge, and aptitudes of health professions and care team members including
patients and caregivers. Michalec’s professional humility addresses individual and
organisational-level challenges to humility, while also situating it in advancing the
practice of team-based care and interprofessionalism.

24.7 Conclusion

Like a feather in the wind, the concept of humility is subject to both light breezes
and blusterous gusts within the realm of philosophical inquiry. However, as Chappell
(2020) suggests, “…because in investigating any virtue, humility included, we must
always keep in mind that real virtues are not timeless essences but sociological and
psychological realities” (188). In addition, Chappell advises readers to examine the
context of how time-specific socialization processes and mechanisms may influence
our understanding of ‘virtues’. This points directly to the nature of the ambiguities
of humility and how shifts and reversals in how humility is conceptualised speaks to
larger socio-cultural factors. In turn, perhaps the most important thing to remember
regarding humility in care delivery and health professions education is not its status
as a virtue, but rather how humility is perceived within practice and education. How
humility is referenced within lecture halls and clinical sites may reflect time- and
location-specific notions of ‘professionalism’ as well as serve as a canary for organ-
isational culture as suggested in the quote that opened the chapter. Hence, exploring
philosophical perspectives of various topics in health professions education not only
highlights gaps in our understanding, but also the ambiguities of particular attributes
and traits that we may often take for granted (Table 24.1).
366 B. Michalec et al.

Table 24.1 Practice points

1 Given the ambiguities of humility, explicitly unearth how humility is conceptualised within
your organisation. How does organisational leadership and faculty perceive humility as it
relates to patient care—and how does this conceptualization trickle down to students and
their professionalization
2 Decide within your organisation if humility is a valued trait/process for health profession
students to learn and cultivate—and if so, develop formal programs of practice to promote
humility among leadership, faculty, and students
3 Explore if and how humility is reflected within interprofessional settings (including
interprofessional education courses and programs)—this may resemble intellectual humility
and/or professional humility
4 Take note of biases and stereotypes associated with humility and being humble as they relate
to gender, race, ethnicity, socioeconomic status, and other status characteristics—as they may
influence how particular students are treated, evaluated, and promoted (or not)
5 Advance the scholarship associated with humility and care delivery and health professions
education. Use this chapter as a stepping stone to examine various social situations where
humility and being humble may be active or necessary. Such research can further expand our
understanding of what humility ‘looks like’ in various situations as well as identify other
barriers and facilitators to humility (and being humble) among practitioners and health
profession students

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Chapter 25
Concluding Remarks

Megan E. L. Brown, Mario Veen, and Gabrielle Maria Finn

Each of the chapters in this volume has examined how a philosophical perspective
can be applied to an area in health professions education (HPE). These chapters have
not been exhaustive but provide an accessible introduction to HPE in three ways.
First, each chapter stands for a whole field in philosophy that could be drawn on to
illuminate a HPE theme and has hopefully provided suggestions for further study
and exploration. For instance, there is much more to be said about bioethics as well
as climate change, but in this volume, both are addressed in Chapter 16 as green
bioethics, and in Chapter 15, which focuses specifically on how to integrate ethics
teaching in education. Second, each chapter is necessarily the application of one
philosophical perspective, where there could be many other ways of addressing that
issue. For instance, there are any number of educational philosophies that could be
applied to the philosophy of education, just as there are perspectives besides Stoicism
and Existentialism that could illuminate identity in HPE. Third, the list of topics
that could—and arguably should—be addressed is not exhausted by the chapters
in this volume. While our chapters did address social justice and feminism, we did
not address LGBTQIA+ issues explicitly. From the perspective of philosophy, the
chapters in this book have emphasized continental philosophy more than analytical
philosophy, and Western philosophy rather than Eastern philosophy.

M. E. L. Brown (B)
Imperial College London, London, UK
e-mail: megan.brown@imperial.ac.uk
M. E. L. Brown · G. M. Finn
Hull York Medical School, York, UK
e-mail: gabrielle.finn@manchester.ac.uk
M. Veen
Department of General Practice, Erasmus University Medical Center, Rotterdam, The Netherlands
e-mail: m.veen.1@erasmusmc.nl
G. M. Finn
University of Manchester, Manchester, UK

© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2022 371
M. E. L. Brown et al. (eds.), Applied Philosophy for Health Professions Education,
https://doi.org/10.1007/978-981-19-1512-3_25
372 M. E. L. Brown et al.

These omissions are inherent in the limitations of such a volume, as well as the
positionality of the editors and the selection of authors. In the following, we would
like to give a (again, non-exhaustive) summary of the themes addressed in the volume,
identify recurring/overarching practice points, and highlight some of the themes that
were threads journeying between our chapters. We will also offer thoughts regarding
themes that could benefit from additional perspectives, such as the ones we have
mentioned above.
This volume does not tell a single story, but rather takes the form of a dialogue:
between HPE professionals and philosophy, but also between the different chapters
in this volume. One way to illustrate this is by taking a single concept and exploring
its journey through the chapters. Here is one attempt to tell—not the story of this
book but a story—the story of agency.
The concept of agency denotes the difference between what is happening to me
and what is happening through me, between what I do and what is done to me. But,
in the health professions, it is also about how to relate to others’ agency, especially
when those others—students or patients, for instance—are in a dependent position
in relation to us.
The first four chapters are about education, which inherently poses a challenge to
agency because who is the agent in the original translation of education as ex-ludere
or ‘to lead out’: the one who is educated, or the educator? How do we reconcile the
goal of education to churn out autonomous, authentic health professionals with the
necessity that this imposes a structure on trainees that they have not invented them-
selves? Chapter 2 describes how these questions are resolved in the philosophical
concept of pedagogy, which creates meanings and indicates purposes, pointing in a
direction rather than laying out strict guidelines of what education should look like.
Pols and Berding conclude that one of the most important things HPE may learn
from philosophy of education is “the importance of trust in a student’s capability to
form themselves, the importance of self-activity, and of a safe place to be educated
in”.
In Chapter 3, Verwer and Van Braak further develop this notion of students’ agency
in education through critiquing the emphasis of Professional Identity Formation on
socialisation rather than what they call subjectification. In HPE, individual students
are trained to become qualified in health care practices and, in doing so, become part
of a community of practice. There seems little sense of agency in these two aspects of
education, because qualification means to meet a certain standard, becoming skilled
in a practice, and socialisation means becoming part of—and conforming to the
norms of—an “already existing order” (48). In contrast to these “pre-moulded trajec-
tories of development” (50) that conceptualize students as objects (‘identities’ to be
developed), they propose introducing the concept of subjectification in addition to
Professional Identity Formation to acknowledge students as beings in the process of
becoming a subject, that is, enacting agency.
But how do we enact agency—how are we free—in the context of the restrictions
imposed on us by the world? Chapter 4 explores how Simone de Beauvoir’s idea of
freedom as embracing ambiguity could serve as an alternative model for Professional
Identity Development. By reconceptualising ambiguity not as something to merely
25 Concluding Remarks 373

tolerate, but as something to embrace as the basis of any ethics or value system, Veen
and Brown describe how the highest stage of freedom for de Beauvoir “involves
social and political action to liberate the oppressed”. In other words, my agency
is contingent on the degree to which I promote others’ agency. This chapter on
existentialist philosophy lays out a number of issues that will need to be addressed
in order to truly develop this idea of agency, which are explored in subsequent
chapters: how can we address social justice in HPE?; what does this mean for the
physical aspects of HPE, such as learning to heal bodies?; how do we deal with
the ambiguity of technology in HPE as simultaneously creating new possibilities,
and hence promoting freedom, while also closing down these possibilities through
techniques and skillification?; and how do education and philosophy relate to the
factual, scientific, or ontological features of the world?
But first, Chapter 5 describes a practical approach to doing justice to ambiguity,
the need for subjectification, while enacting one of the central ‘skills’ (a concept this
chapter challenges) of HPE: empathy. De la Croix, Peters and Laughey argue that
“the life-giving gift of acknowledgement” (80) is a much-needed practice in HPE
because it does justice to the patient’s voice while simultaneously creating “a clear
space where students feel welcome as their whole selves, including their everyday
concerns and contingencies” (86).
They also, however, describe the tension between complex concepts such as
empathy on the one hand, and the requirement of HPE to assess students’ progress.
Indeed, the relationship between education and assessment has always placed tension
on agency. How can we say that, on the one hand, students need to develop their
identity on their own accord, being free and embracing their unique way of being a
healthcare professional, while also doing justice to the societal demand for qualified
professionals whose skills we can trust? Chapter 6 traces the philosophical shifts in
health professions assessment. Tavares, Pearce and Eva point to the fact that there
are always assumptions and intellectual frames underlying assessment, and that it
is never simply a manner of accurately representing a pre-existing state of affairs.
Being mindful and critical of our guiding assumptions underlying assessment also
means taking into account “the impressions of assessment recipients and the broader
social context in which the assessment takes place” (109) which could be seen as a
way of saying that assessment needs to acknowledge and be respectful of students’
agency: assessment not simply as something being done to them, but also through
them.
So far, issues regarding the broader social and political context in relation to agency
have come up several times, without explicitly being explored in depth. Perhaps
surprisingly, the concept that serves as a hinge to explore these issues is often seen as
the antithesis to concepts: the body. We largely treat the body as something that ‘is
what it is’. Nothing seems more obvious than the question ‘what is the body?’ —but
philosophy is a practice of questioning the obvious. In Chapter 4, we have already
encountered the ambiguity of the body: it is both the site of agency—the site from
whence I act—and an object being acted upon, for instance, in the case of surgery.
Acknowledgement and empathy in Chapter 5 are ways of recognising others as not
just a body, but a self. In Chapter 7, Finn, Hafferty and Quinton explore the role of
374 M. E. L. Brown et al.

the body in HPE. The basic idea that the body is a subject and a Self but also an
object and an Other has consequences for how discourses about sex, gender, science,
race, ownership and many other issues relevant to HPE intersect with it. They argue,
among other things, for “the critical engagement of health professionals and students
with their own orientation towards their body” (129).
But how do we promote such critical engagement with not just the body but other
social issues as well? How do we prevent the body—and other objects in HPE—being
seen strictly as scientific objects, as Finn et al. warn against? Chapter 8 outlines
Freire’s philosophical view of how education can promote critical consciousness.
Johnston, Hart and Manca argue that Freire’s pedagogy may be used in HPE to
transform it in a practice of freedom that flattens hierarchies, takes social and political
contexts into account, and promotes reflexivity by, amongst other things, using stories
as the center for teaching. This chapter itself can be used in dialogue with Chapters 3
and 6 to explore implications for subjectification and assessment.
But what are these social and political contexts that pose a threat to agency in
the context of HPE? One of these threats is the lack of inclusivity of HPE: who has
(more) agency? Dueñas, Politis and Danquah explore the concept of social justice
from a students’ perspective in Chapter 9. They do not only ‘discuss’ what critical
consciousness in relation to issues of race, ethnicity, gender and widening access
might mean for HPE, but also demonstrate it through analysing cases from their own
experience while continuously reflecting on their own positionality with regard to
these issues. Wånggren and Finn help us understand the “historical roots of gendered
inequalities in health” (195) in Chapter 10. They point to how “modern biomedicine
often comes to treat the patient as an object, infringing on the patient’s agency over
their health, this tendency has been critiqued especially by feminist health activists,
who highlight the silencing of women’s experiences in healthcare” (192).
In Chapter 11, Konopasky, Bunin and Varpio discuss another threat to agency,
which they call moral injury. During medical training, trainees often find them-
selves in situations where they are obliged to act according to guidelines that are
incongruent with their own values. What does it mean to exercise agency and main-
tain a sense of agency in these situations, and how can educators support them? In
placing the concept of agency centre-stage and distinguishing between the exercise
and the experience of agency, this chapter prepares the ground to go further down
the rabbit-hole of this concept. In this and previous chapters, different philosophical
perspectives have outlined the ambiguities and paradoxes of what is happening to me
and through me, between myself and others as a subject and an object, as both a free
agent and an identity operating in and constrained by a physical, social, and political
context. Taking a further step, we might ask—who decides what is ‘objective’ and
what is ‘subjective’? Who decides where the boundary lies and what the relationship
is between an ‘agent’ and the ‘external world’? Chapter 12 discusses ontology, the
branch of philosophy that is “the science of what is and the claims we can make about
the nature of being and existence” (222). Though this is perhaps the most abstract
type of philosophical inquiry, Wyatt, Ajjawi and Veen argue that to address some of
the issues that have been discussed so far, it is not only desirable but indispensable
that HPE professionals ask ontological questions. Since issues like educational value,
25 Concluding Remarks 375

social justice, professional identity development and assessment depend on how we

categorise and conceptualise the world we live in, and since the kind of assumptions
we make about the world are not obvious but always emerge from our freedom in
ambiguity, we are responsible for doing ontology. Doing ontology, as outlined in this
chapter, can create space for “trainees and physicians to bring their whole selves to
the profession” (234).
The subsequent two chapters discuss the main claimant to deciding on ontological
questions in HPE: science. In Chapter 13, Kehoe, Rothwell and Bluhm challenge the
view that the natural sciences should serve as the model for HPE. They offer a
basic introduction to philosophy of science within HPE, which can serve not just
to examine HPE and HPE research, but also the teaching of science within HPE
curricula. In this way, they enable HPE professionals to assert agency by being able
to consider and take responsibility for their philosophical orientations, questioning
the philosophical orientations that are handed over to them as ‘obvious’.
Chapter 14 explores one consequence of taking different philosophical orien-
tations to doing science in HPE. Crampton and Buckland consider the difference
between taking an individualist and a holistic perspective on social science in rela-
tion to the relationship between individuals and teams. In HPE, we mostly operate
in teams, but should these be considered as a social phenomenon (or ‘agent’) in
themselves, or as nothing more than the sum of individual agents? They argue that
not only is the answer to this question relevant for how we resolve practical matters
of education, but that agency is a criterion for determining which social phenomena
exist in (and thereby are consequential for) HPE.
The importance of ethical values for HPE was already clear from the chapters that
dealt with social justice (Chapter 9), feminist theories of agency (Chapter 10), and
the threat of moral injury to agency (Chapter 11). If the world HPE professionals and
students operate in is inherently ambiguous (Chapter 4), assessment in HPE depends
on philosophical assumptions (Chapter 6), and we cannot even depend on obvious
facts such as ‘the body’ (Chapter 7) or ‘science’ (Chapters 13 and 14), what should
be the guidelines for our actions? In Chapter 15, Pilkington provides a much-needed
introduction to ethics in HPE. Instead of looking for clear guidelines for how to act,
Pilkington argues, educators should not just teach professional norms, but employ
ethical theories while embracing their philosophical complexity.
One such issue that calls for an ethical approach is the question of how HPE profes-
sionals and students should relate to the reality of climate change. In Chapter 16,
Richie argues that climate change is indeed a pertinent ethical issue, because it goes
to the heart of the dictum to “do no harm”. But this chapter also agendises both
the complexity and necessity of asserting agency in a domain where questions of
clinical responsibility, bioethics, and social justice intersect. The way Richie argues
that the global ‘macro’ question of climate change is intimately related to the ‘micro’
interactions in the consultation room and is therefore a responsibility of future health
care practitioners, is an example of asking—and answering—ontological questions
in HPE (see Chapter 12).
376 M. E. L. Brown et al.

The question of climate change and green bioethics also calls attention to another
issue in HPE that is often overlooked, but which goes to the heart of agency: tech-
nology. The current climate crisis that found its roots in the industrial revolution and
our relationship to technology is an extreme example of what Chin-Yee outlines in
Chapter 17. We are used to thinking of ourselves as agents in relation to technology,
conceptualising technology as machines and tools that we manufacture and are in
control of. Chin-Yee, however, discusses philosophers of technology that have been
critical of the view that technology is a mere instrument that we are in control of. The
question of technology is an increasingly urgent issue in HPE, and another threat to
agency in addition to those outlined already, due to the rise of medical technology in
health care. Is technology an agent? If so, how does it relate to our own agency? How
is technology inscribed with values that may conflict with those that we subscribe
to in HPE? Chin-Yee outlines a nuanced approach to these kinds of questions that
succumb to neither technological solutionism nor technophobia.
Kelly, Dornan and Ruparell further take up the ambiguous relationship between
technology and care in Chapter 18, identifying technology as “a prime suspect for
the loss of care” (346) the latter of which was discussed in detail in Chapter 5. They
propose that philosophy can act as a therapy to balance technology and care and
transcend the instrumental ways of thinking that Chin-Yee discussed in the previous
chapter.
We may associate technology in the context of HPE primarily with medical tech-
nologies, i.e., relating to the skills and knowledge that students are trained in during
their education. But in Chapter 19, Mayat, Edwards and Guckian reflect on one partic-
ular form of technology that goes to the heart of a central concept that was discussed
in the first few chapters of this book. They argue that the rapid rise of social media
is changing what it means to belong to a community, particularly the community
of practice that is central to Professional Identity Formation. How is Professional
Identity Formation changing if my peers and role models during medical training are
not just the ones that I happen to end up with in my clinical placement, but also—and
perhaps more so—my social media ‘friends’ and the ‘Medfluencers’ I follow? This
is truly a philosophical question, in the sense that we cannot yet answer it because
social media is developing so rapidly that ‘traditional’ HPE research cannot keep up.
It would be interesting to explore how the previous two chapters (Chapters 17 and
18) could offer ways to further develop the notion of subjectification in addition to
Professional Identity Formation, in the ways suggested by Verwer and Van Braak in
Chapter 3.
The chapters so far focus on different aspects of HPE, as well as different philo-
sophical lenses through which important issues in HPE light up. The remaining
chapters of the book explore different relationships between philosophies or philo-
sophical concepts on the one hand, and HPE as a whole. The first of these, Chapter 20,
introduces the concept of phronesis as a way to combine issues of agency, science
and ethics in “practical wisdom”. Plews-Ogan and Sharpe argue that phronesis is a
much-needed addition to medical knowledge and technical skill.
In Chapter 21, Schaepkens and Coccia add a further dimension to the context in
which agency lives: philosophy of time—perhaps the most difficult philosophical
25 Concluding Remarks 377

topic besides technology. While in our everyday practice, time seems something
that is just passing (too quickly) or that tends to get booked up (in our schedules),
Schaepkens and Coccia argue that there are in fact two ways to relate to time. The
first is chronos, which is the kind of time that can be “measured, scheduled and
micromanaged” (389) and is discussed in time-management courses. The second is
kairos, which relates to the moments that matter most for HPE, those that stand out
from the unending stream of events and that have educational value. They suggest
that, in true philosophical fashion, we take the ancient Greek word for ‘school’,
scholê to conceptualize reflection in HPE not as yet another task or goal, but as time
free from any tasks and goal-orientedness. In terms of agency, scholê is time in which
we assert agency precisely by refraining from any action.
But how do we apply such a contemplative philosophy to HPE in practice?
Stoicism is a holistic philosophical approach that is a popular answer to this ques-
tion in contemporary medical practice, but it is often misrepresented. In Chapter 22,
MacLellan, Brown, LeBon and Guha provide an introduction to Stoicism and how it
can be practically applied in HPE. At the heart of Stoicism is a philosophy of agency,
that takes—among other things—reflection on what is within the reach of our agency
(or in our control) as a starting point for deciding between action and inaction.
The final two chapters of this book provide an in-depth exploration of what are
perhaps the two most relevant concepts in relationship to agency in HPE, which are
also at the heart of Stoicism and many of the other philosophical approaches outlined
in this book: dignity and humility. In Chapter 23, Pilkington argues that an approach
rooted in the concept of dignity can provide a practical and holistic approach to ethics
for HPE. Dignity means deep respect for another’s agency as well as one’s own, and
the concept is both broad and narrow enough to provide practical application—and
guide practical wisdom or phronesis—while also promoting continuous reflection on
our own philosophical perspective. The other concept, humility, is placed in historical
context in Chapter 24. Michalec, Hafferty, Piemonte and Tilburt provide a thorough
exploration of humility within the context of HPE and healthcare.
Humility brings together different threads in relation to agency. The agency of
healthcare professionals should always be characterised by humility and respect for
the dignity of others, because ultimately our ways of organising healthcare and HPE
are only our best responses to an ever-changing and ambiguous world. From the
philosophy of science, we know that we do not have one perfect system for gaining
knowledge, and from the philosophy of technology we know that we are not in
control. But from the philosophy of education, we can embrace humility from the
knowledge that another’s agency, that is, of the trainees, is both the central aspect
and beyond control of HPE. Acknowledging others, embracing ambiguity, and taking
responsibility for continuing to ask ontological questions all require humility. This
is evidenced by the fact that painful issues that none of us wish to be part of HPE
continue to exist despite our best efforts: social injustice, gender bias, and climate
change, to name a few.
Hopefully, the chapters in this book make one humble for two reasons: because
there are so many helpful philosophical perspectives and therefore so much left to
learn; and because none of these perspectives have been able to offer a definite
378 M. E. L. Brown et al.

answer or a once-and-for-all solution. Instead of even attempting to provide such an

overarching perspective, we hope that this example of mapping agency through the
chapters inspires the reader to do the same with the concept or object that interests
them most. For instance, other themes that could be tracked throughout the book
are the question of what constitutes meaningful education, how we relate the ethical
aspects of health professions education to its medical-technical aspects, or in which
ways we can stimulate reflection and critical thinking. But we would also like to
acknowledge that we, the editors, have been limited by our own social, political, and
philosophical positionality.
For one, we have focused almost exclusively on western philosophy, with an
emphasis on continental philosophy. There is a whole world of ‘non-western’ philos-
ophy left to explore. For instance, Buddhist and Taoist philosophy have much to
offer in relation to the crisis of stress and burnout but can also address ‘westernising’
practices such as what we now call ‘mindfulness’ by reuniting them with their philo-
sophical roots. Indigenous philosophies have much to offer to critically interrogate
the way we conceptualise the relationship between individuals and communities,
between ourselves and nature, and our relationship to our bodies. In addition to
philosophical perspectives, we have also been unable to address some topics that are
unquestionably relevant to HPE, for wont of space. Take mortality, which is perhaps
most often cited in any philosophical school as the start of philosophy. Or burnout,
stress, and reflection. And while we did include chapters about gender and social
justice, LGBTQIA + -related issues deserve more attention. Finally, though we have
attempted to include voices that are often marginalised in both HPE research and in
philosophy, and are proud to have several authors who are, at the time of writing,
students, or medical trainees themselves, in order to remain relevant for the future
of HPE, a greater proportion of our authors should, perhaps, have been trainees.
With these limitations in mind, we would like, in closing, to focus on what might
be the practical value of this volume, by looking at what the authors of all the chapters
have listed as practice points. As we have indicated in the introduction, we make no
claim to know what exactly philosophy ‘is’ and what its practical value for HPE
could be. Instead, we have performed a kind of experiment in which we invited a
range of experts in HPE and philosophy to apply one philosophical perspective to
one pertinent issue in HPE and close their chapter with five practice points.

25.1 Our Practice Points

Each chapter in this book offers practice points based on the discussion of some
key topic through a philosophical lens. We requested five practice points per chapter
from the authors to do justice to both the richness of philosophical perspectives
that cannot simply be summarized in one ‘call to action’, while also giving concrete
starting points to apply the subject matter in practice. It is important to note that there
are many more possible practice points for each chapter. The points each author or
25 Concluding Remarks 379

team of authors have provided are simply a starting point in applying the discussions
of this book to your own practice.
There are insights that span several chapters’ practice points. If you have chosen to
read this book cover-to-cover, you might have noticed that chapters on very different
topics, that approach these topics in very different ways, sometimes make similar
recommendations. This is interesting—despite diversity in perspective and approach,
there are some applications for practice that more than one philosophical approach
recommends. You may have your own thoughts on what these common themes are—
we offer ours, what we have noticed as threads which weave the tapestry of this book’s
practice points together into a cohesive whole.
First, we note that many chapters encourage their readers to engage in a process
of critical reflection. Some also encourage readers to prompt their students and
colleagues to reflect. These sorts of reflection involve considering one’s own perspec-
tive, experiences, or practice as a starting point for engaging with a new way of
thinking about a contemporary or side-lined topic in health professions education. In
Chapter 21, Schaepkens and Coccia consider the nature and practice of reflection, a
popular topic and practice, in our field. They argue that, in addition to goal-orientated
reflection (which, for example, might include reflecting on how you communicated
with a specific patient or colleague in your practice today), reflection without precon-
ceived goals is also valuable. As the chapters in this book prompt you to reflect, we
encourage you to reflect broadly, to give yourself the time and space to question the
taken-for-granted practices and ideas in our field. Think beyond reflecting only on
your own practice—what you do well, how you might improve—and consider how
the philosophical insights offered by each chapter might question the “unquestioned
heritage” (Schaepkens and Coccia 2022, 389) of our field.
Implicit in this commonality between practice points is an understanding that
philosophy can help us excavate, and then interrogate, the assumptions that we make
as we educate and research as health professions scholars. Chapter 13, which offers
an overview of the Philosophy of Science is an example of what asking such difficult
questions might look like in practice. Before I set out designing a health professions
education research project, I must consider my understanding of the nature of reality
(ontology), and of knowledge (epistemology). I should also examine how the question
I wish to ask, and so what I do to try to answer (at least in part) this question, align
with these understandings, to ensure robust research design. These can be difficult
practices to engage in—our field is steeped in a ‘natural sciences’ tradition, where
quantitative empirical research reigns supreme, and authors often approach research
questions best suited to different ontologies and epistemologies through a positivist
lens, which impacts the quality of the research we produce. Considering Philosophy
of Science, as Chapter 13 does, helps pick apart these sorts of considerations, guiding
us in asking these difficult questions of ourselves and our practice.
Also relevant to our ‘unquestioned heritage’ is the call many chapters make for
an increased awareness of the context in which we practice. Chin-Yee in Chapter 17
draws our attention to the fact that technology is not value-neutral. How artificial
intelligence operates in our field is shaped by context—by humans who are socialised
and politicised creatures at work in specific cultures. We would extrapolate this
380 M. E. L. Brown et al.

insight—nothing we do is value-neutral. Our actions—the way we design educational

programmes, our assessment practices, how we engage with students—are shaped
by social, political, cultural, and economic forces. Without examining this context,
we risk contributing actively to the marginalisation of certain groups, rather than
advocating against discriminatory practices. Chapters 4, 8, and 9 all highlight the
importance of focusing on freedom—for example, freedom for patients—as a driving
goal of healthcare. As educators and practitioners, this means we must critically
evaluate the way in which our pedagogy works (or doesn’t) towards challenging
oppression and promoting justice for the patients healthcare serves.
You might be thinking that this sounds challenging. We would be lying if we
said it was not. Institutional support is key to enabling the more radical pedagogical
change some chapters suggest (such as the call for climate change modules made
by Chapter 16, or the call for longitudinal education made by Chapter 20). Whilst
we encourage educators to engage with these calls and advocate for such changes
within their own institutions, we do acknowledge that in some settings educators
may feel they are fighting an uphill battle. Making small changes to their own prac-
tice might help educators keep faith whilst rallying against institutional barriers.
In Chapter 8, Johnston et al. offer examples of such small changes educators can
make to their own practice to facilitate dialogic learning and so contribute to critical
consciousness-raising. Through something as simple as taking charge of the furniture
in one’s educational space, educators can facilitate the transition of health profes-
sions education from a ‘banking’ model to a ‘problem-posing’ approach that allows
students to develop a sense of criticality. Both small-scale and large-scale changes
within our field are likely necessary in realising the vision of this book—in acting
on the beginnings of an applied philosophy for health professions education that we
have set out.
As a starting point for realizing both small-scale and large-scale changes, we might
close with a final recurring theme in the practice points. Instead of looking at HPE as
a collection of entities, we might look at it as being composed of relationships. This
includes human relationships, but also relationships to technology, and to forms of
knowledge, such as about assessment. Many chapters ask us to focus on important
aspects of HPE, such as the quality of education, the need for assessment, or the
patient’s body, but without losing sight of the fundamental human relationships that
are at the heart of HPE. For instance, we must trust students’ capability to form
themselves (Chapter 2) but can use narratives—which are all about relationships—in
teaching (Chapter 8), and engage in positive role modelling, coaching, and mentoring
to stimulate practical wisdom (Chapter 20). Other chapters point out relationships
that have been neglected, such as between the body and gender (Chapter 7). It seems
that many chapters are a call to focus—or re-focus—on the essence of that aspect of
HPE. In doing so, we focus on what truly matters, and allow that to inform both our
teaching and our conversations about change.