Prudence and Contemporary Gerontology

By Charles Zola, PhD

In elder care, prudence is ultimately focused on promoting elders' quality of life and is primarily concerned with determining the best ways to achieve this goal and ensure the objective is achieved.

Caring for the elderly involves numerous ethical issues that arise for both professionals and family members. Solving moral dilemmas is not always easy because of competing values and goals. These circumstances often result in frustration and second-guessing for decision makers. Perhaps one of the best yet least understood ways to resolve ethical issues arising in elder care is through the virtue of prudence.

Virtue ethics, a moral theory rooted in ancient Greece and formally developed by Plato, Aristotle, and the Stoics, is advocated by many contemporary ethicists and continues to enjoy widespread appeal. For example, the famous medical ethicist Edmund D. Pellegrino advocated that acting with virtue was the highest moral standard for physicians, surpassing two lower levels of moral conduct: adherence to legal standards and compliance to basic medical ethical norms and principles, such as respect for the right of autonomy and the obligation of medical confidentiality.

Virtue, defined as excellence in acting or thinking, is the term from which the English word virtuosois derived. For example, a piano virtuoso demonstrates expertise through a well-executed musical performance, and a scientist demonstrates excellence in the pursuit and discovery of new knowledge. According to virtue theory, the striving to achieve perfection in a particular task is a reflection of individual moral character. Pellegrino observes: "The more we yearn for ethical sensitivity, the less we lean on rights, duties, rules, and principles, and the more we lean on the character traits of the moral agent." In virtue theory, a moral agent is considered a morally good person insofar as one strives to do his or her best at a specific task.

What is unique about the virtue or prudence is that it occupies a kind of middle ground between thinking and acting, requiring the use of both intellectual and practical abilities. For health care professionals, this distinction is readily apparent because achieving quality care requires both an excellence in knowing what care is best and knowing how to deliver it effectively. For this reason, prudence is commonly defined as 'right reason in acting.'

Acting Prudently
The distinction between the knowing and acting aspects of prudence is clearly evident in the medical, nursing, and social work curricula. In addition to formal academic study, students in these disciplines are required to engage in clinicals or internships that demonstrate their ability to connect theory to practice. Knowledge about sickness and treatment of disease is futile if professionals do not know how to apply such knowledge to patients. For this reason, acting prudently is an essential feature of health care ethics. In fact, quality health care depends upon this twofold approach.

To act prudently requires other ancillary virtues. Philosopher and theologian Saint Thomas Aquinas described prudence in terms of a house. A house is a single entity but is comprised of walls, roof, and foundation. Likewise, prudence is a single moral excellence, but it is comprised of several other virtues. This article will examine these virtues and propose how practicing each can help professionals better meet the needs and interests of elderly patients and clients.

Exactly how does prudence operate, and how can a clearer understanding of its role help elders' caregivers deliver better quality care? In elder care, prudence is ultimately focused on promoting elders' quality of life and is primarily concerned with determining the best ways to achieve this goal and ensure the objective is achieved.

To do so, health care professionals first must have a clear vision of what can be realistically achieved. Prudence literally means to 'look ahead.' A cloudy or ambiguous perspective from the outset often results in negative consequences. A poor understanding of the nature of a disease or condition limits the ability to offer productive corrective options and care management plans, ultimately reducing care quality or jeopardizing the life of an elderly individual.

Virtue is especially important when there are two or more equally good ways to achieve a desired end. Prudence enables health care providers and their patients to engage in a deliberative process by which ethical means of treatment are proposed and decided upon. 

For example, consider an elderly cancer patient who faces several viable options for treating the disease. Each option poses benefits and risks, and each possibility has differing chances of success. Both the physician and patient need to determine how to proceed, but each will do so in his or her own way.

The physician might question colleagues about the best course of treatment or perhaps research therapeutic options. The patient may also act with prudence and seek the advice of other physicians and even family and friends about the matter. Eventually both clinician and patient (or the patient's surrogate) will need to reach a conclusion about the best course of action and make arrangements to implement it.

At this point both physician and patient are exercising the knowing or theoretical aspect of prudence as a deliberative or consultative process. Obviously, the ultimate goal of intervention or treatment is to provide a benefit to the patient; however, the means to that end can be ambiguous or uncertain. Prudence discovers the best means to reach the desired outcome.

This example illustrates another characteristic of prudence: Prudence determines the best way to achieve a particular beneficial outcome in a particular situation, at a particular time, for a particular person in specific circumstances. Prudence is not concerned with achieving the well-being of patients in general; rather, prudence is primarily focused on the needs and situation of a particular patient. In the case of two geriatric cancer patients, the good choice for one may not necessarily be the right choice for another due to differing circumstances and myriad variables. Making a prudent decision requires careful attention to the unique circumstances of the patient.

Both physician and patient must agree on the appropriate means of care and execute a care plan. It is in the treatment and care of the patient that the doingaspect of prudence is demonstrated. The best plan for health care means nothing if it cannot be carried out. The ultimate objective of prudent health care is to ensure that the proposed course of treatment is accomplished in practice, not simply on a chart.

As pointed out above, prudence requires an intricate confluence of several other virtues that are often referred to as the integral parts of prudence; some that are especially pertinent to gerontology are memory, docility, circumspection, and caution.

Other Aspects of Prudence
The theoretical aspect of prudence requires docility and memory. Docility refers to an eagerness to learn, and memory refers to the ability to learn from past experience. These positive qualities play a crucial role in geriatric care, and geriatricians have a professional and moral obligation to keep abreast of the latest developments and research in their particular area of specialization. Attendance at conferences and workshops is but one way to do so; another is periodic review of scholarly and professional journals. Elder care professionals keep abreast of the latest advances in pharmacology and best practices associated with elder care. Engaged dialogue with the gerontology discipline is an indicator of the caregiver's good moral character.

Memory plays a crucial role in prudent geriatric care and is especially useful in assessing present conditions and proposing a future course of treatment. Health care protocol requires taking an accurate and careful patient history. However, a geriatric patient is sometimes challenged in this area because of partial mental impairment or the onset of dementia. This presents a formidable challenge in patient care, especially in dealing with issues related to the end of life. In such circumstances, consultation with other family members or friends can often serve as a resource for elder care professionals.

In the absence of any formal advance directive or living will, a morally permissible way to determine a course of action is to ask a patient's family members to recollect the previously expressed preferences or attitudes of an elderly patient. Calling to mind these values can provide significant moral guidance for life-sustaining interventions and other similar matters.

Turning from the theoretical aspect of prudence to its active or practical character, there are the virtues of circumspection and caution. The former is concerned with paying careful attention to the execution of treatment; the latter refers to paying careful attention to situations that may arise to derail or interfere with care delivery.

Implementation of a course of care or treatment is often affected by variables, especially in elderly patients who experience comorbidities and are susceptible to a wide range of negative medical, psychological, and social threats. The virtues of circumspection and caution require that elder care professionals remain vigilant in providing care and prepare for any complications that may arise. This is true for all health care professionals, but it takes on significant meaning in elder care.

Elder care professionals exercise circumspection by paying careful attention to the changing needs of their patients. The elderly population is especially prone to both sudden and subtle changes in both physical and psychological well-being. These can be dramatic instances such as breaking a hip, slipping on a carpet, or momentary forgetfulness behind the wheel of a car that results in an accident. There is often subtle degeneration in the elderly, who are susceptible to gradual changes in eating and sleeping habits, mental competency, and physical decline. The effectiveness of improving or maintaining the quality of life of the elder requires dedicated and vigilant attention.

Many factors can interfere with providing care. The virtue of caution anticipates difficulties that may arise and ensures that the objectives of any treatment plan are realized despite them. Certainly this characterizes health care in general, but caution takes on special meaning when considering the elderly.

Often marginalized and neglected in society, the elderly likewise often experience similar treatment within the health care community. Elder abuse can occur in institutional settings as well as the home. The virtue of caution asks those dedicated to geriatric care to demonstrate the same concern and attention to the elderly as would be shown to any other patient or client within the formality of an institutional care or in society as a whole. Moral geriatric care demands due diligence in the performance of regular care and treatment by professionals.

Elder Advocacy
Tangentially related to this idea is patient advocacy, which is particularly relevant for older adults who are often disadvantaged through declining health and financial resources. Caution requires attentiveness and engagement with questions and debates related to social issues that are relevant in elder care: allocation of scarce resources, economic distribution, and elder abuse. Often these factors hinder quality care and lead to a diminishment of the value of elder life in society as a whole.

Cultivating the intellectual and practical excellences associated with the virtue of prudence is an essential way by which geriatricians are able to advance elderly patients' quality of life. Careful consideration of the means of care and how best to implement them optimizes not only the chances of successful aging, but also indicates the moral commitment that elder care professionals have for their patients and clients. Although no single ethical theory addresses every moral problem arising in elder care, because of its dual focus on theory and practice, prudence provides an invaluable rubric to guide elder care professionals in assessing the morality of their actions and help assure them that they are acting with moral integrity. 

— Charles Zola, PhD, is an assistant professor of philosophy and director of the Catholic and Dominican Institute at Mount Saint Mary College in Newburgh, New York. He previously served as the executive director of the Ethics Institute of Northeastern Pennsylvania at Misericordia University in Dallas, Pennsylvania.