Practically Wise

In “COVID-19 Through Time” (Issues, Spring 2021), Joseph J. Fins, a physician and bioethicist, describes how “the interplay of time, knowledge, judgment, and action is an essential determinant of how science works in the real world.” Fins notes that early in the pandemic, New York guidelines offered an approach to ventilator allocation for patients with respiratory failure due to COVID-19 infection based on then current knowledge and experience. However, with time, knowledge about management of COVID-19 patients with respiratory failure increased. It became apparent the guidelines were inappropriate. Fortunately, he writes, “tragic choices” of prematurely removing affected patients from ventilator support were not made. To Fins, “medical progress depended on the passage of time” during which clinical observations and research informed the treatment of patients with COVID-19 disease. He notes that this quantitative aspect of time—measured in minutes and so on—is what the Greeks called chronos.

Fins also highlights kairos, a qualitative aspect of time. Kairos, he writes, “asks us to appreciate the moral significance of the timing of our decision.” Is now the right time? Of course, chronos informs kairos. Yet throughout the COVID-19 pandemic, clinicians, health systems, and others have been “forced to contemplate kairos before having the benefit of … evidence provided by chronos.”

Indeed, as a physician, bioethicist, and leader of a regional health system, I can attest to the interplay between chronos and kairos and associated uncertainty during the pandemic. The following is a small sample of questions we have addressed with minimal evidence provided by chronos: What personal protective equipment should be worn when seeing patients without symptoms of COVID-19? How do we keep our hospital safe for patients, visitors, and employees? Will we have enough ventilators? (We also grappled with the matter of ventilator allocation.) Do we restrict visitors? How and where should we conduct COVID-19 testing? Who benefits from active treatment? How do we safely care for patients with non-COVID-19 diseases? How do we safely reopen the elective practices? Who gets a vaccine first? How do we ensure that vulnerable populations are vaccinated?

How does one make decisions in this midst of daunting uncertainty? I posit an additional Greek concept: phronesis, also known as practical wisdom or prudence. The bioethicist Edmund Pellegrino describes phronesis as “the capacity for deliberation, judgement and discernment in difficult moral situations” and the clinician’s “most valuable virtue.” It promotes wise decisionmaking. The bioethicist Lauris Kaldjian describes five elements of phronesis-based decisionmaking: worthwhile ends; accurate perception of concrete circumstances detailing the specific practical situation at hand; commitment to virtues and moral principles; and, based on these, deliberation and motivation to act in order to achieve the conclusions reached by such deliberation. Phronesis, in turn, informs praxis—doing what is best given the situation.

Our Hospital Incident Command System was activated for more than a year and met regularly to address the COVID-19 pandemic. Our deliberations, decisions, and actions have reflected Kaldjian’s framework. Communications to our patients, staff, and communities have been frequent and regular. We have articulated what we know, what we don’t know, and the rationale for decisions. Over time, chronos informed kairos and phronesis, and our confidence in managing the myriad effects of the pandemic, from patient care to public health efforts, grew.

Finally, I agree with Fins that a third dimension of time—the study of the past—should be embraced. I am also optimistic that, as he writes, “our efforts to achieve some imperfect, early measure of kairos in the present will be deemed prudent”—that is, practically wise.

Paul S. Mueller