Systems of service: reflections on the moral foundations of improvement

Providing clinical care is above all a service; in that sense, the medical profession aspires to Aristotelian phronesis, or prudence—being ‘capable of action with regard to things that are good and bad for man.’ This intense commitment to service encourages healthcare providers to gravitate towards one or another epistemology as their preferred moral pathway to better care. One such epistemology, the ‘snail’ perspective, places particular value on knowing whether newly devised clinical interventions are both effective and safe before applying them, mainly through rigorous experimental (deductive) studies, which contribute to the body of established scientific knowledge (episteme). Another (the ‘evangelist’ perspective) places particular value on the experiential learning gained from applying new clinical interventions, which contributes to professional know-how (techne). From the ‘snail’ point of view, implementing clinical interventions before their efficacy and safety are rigorously established is morally suspect because it can result in ineffective, wasteful and potentially harmful actions. Conversely, from the ‘evangelist’ point of view, demanding ‘hard’ proof of efficacy and safety before implementing every intervention is morally suspect because it can delay and obstruct the on-the-ground learning seen as being urgently needed to fix ineffective, inefficient and sometimes dangerous existing clinical practices. Two different moral syndromes—sets of interlocked values—underlie these perspectives; both are arguably essential for better care. Although it is not clear how best to leverage their combined strengths, a true symbiotic relationship between the two appears to be developing, one that leaves the two syndromes intact but softens their epistemological edges and supports active, close, respectful interaction between them.