by Kenneth Sharpe
Making ethical choices in the everyday work of doctoring and nursing is like playing jazz: Moral Jazz. Doctors and nurses are not just “making it up,” any more than a good jazz musician is making up music. Moral medical practice starts with ethical guidelines and professional norms. But these rarely tell precisely what to do, and so the capacity for moral improvisation is integral to everyday practice.
Respect patient autonomy; don’t be paternalistic. But is this patient too fearful or sick or ambivalent to choose? And what if she wants to leave the decision to the doctor?
Engage in shared decision making. But how do you teach the patient to make these decisions? Good counseling requires the ability to read an uncertain and ambiguous context and figure out what to say or do on the fly. Inevitably you will nudge the patient by how you frame the issue, and by your very body language. So how much do you want to nudge and how much do you want to share?
Be empathetic: good listening is the key to a good history, a good diagnosis, and a treatment regime that a patient will actually follow. But how do you learn to listen to patients that are shy and fearful, or overly talkative; how do you balance empathy with fairness when you have other patients waiting?
Be compassionate: understanding and love are sometimes the best medicine for those with chronic or terminal illnesses (and for the rest of us too). But how do you balance compassion with the detachment needed for rigorous diagnosis—and needed also to prevent practitioner burnout?
Such professional norms and guidelines are like the opening melody of a jazz piece, with the creative interpretation left to the wisdom of practitioners.
Jazz saxophonist Stan Getz said that jazz is “like a language. You learn the alphabet, which are the scales. You learn sentences, which are the chords. And then you talk extemporaneously with the horn.” Good improvisation is not making something out of nothing, but making something out of previous experience, practice, and knowledge.
Being a good jazz musician doesn’t just require the technical skill to play the sax or horn well; it doesn’t just require reading notes and following the rules. It requires the skill to listen well, to adapt, to imagine quickly. It’s about being relational, perceptive and discerning: a good jazz musician needs to adapt to a changing situation. They learn to be resilient, and when to take risks by trying and failing. And, like every doctor-patient interaction, each piece is a unique improvisation. Good jazz can’t be written down any more than a physician can simply follow a script.
Paul Haidet stressed this point when writing about the importance of improvisation in both the medical encounter and in jazz. Physicians follow biomedical patterns of inquiry, he says, but patient-centered care demands leaving space for patients to organize their unique narratives. Figuring out when and how to interrupt, to slow down, to be silent, to change the subject—these are the kinds of improvisation a jazz player makes all the time.
Can doctors and nurses learn the wisdom to engage in moral improvisation? The moral jazz of medical practitioners demands a sense of inner purpose; practitioners need to find meaning in their work, be passionate about what they do, and feel compassion for their patients. They also need to learn to work harmoniously with others on their team—like playing well in a jazz ensemble.
Moral jazz is at the heart of the professional formation of a good doctor. It can’t be “taught” any more than jazz can be “taught.” But we can encourage it to be learned. That’s what many med schools are beginning to aim at with their courses on “patient-doctor relations” or “the profession of medicine.” That’s what Schwartz rounds, narrative medicine, and longitudinal integrated clerkships aim at. Such pedagogies rightly presume that the moral skills and virtues needed to practice patient-centered medicine are learned—like jazz—through practice. And that practice has to be smartly designed.
At the heart of such educational design are situations where students learn to listen to each other, and to care about their patients. By practicing improvisation, they learn the courage and resilience to improvise. They learn to listen to the nuances of the body language of their patients and colleagues by actively practicing this listening. They learn to take risks when given a safety net by their expert teachers. At the heart of this is not what senior doctors and nurses tell young doctors and nurses, but what they practice with them: what they coach and how they mentor. As Stan Getz put it, “You can read all the textbooks and listen to all the records, but you have to play with musicians that are better than you.”
The practical wisdom of doctors and nurses sometimes depends on rules and principles—like the basic melodies in jazz. But rules alone can’t do the job. Moral improvisation is the interpretative tune we play around these notes and melodies, in order to do the right thing in the right way at the right time.
Kenneth Sharpe teaches at Swarthmore College and is co-author (with Barry Schwartz) of Practical Wisdom: The Right Way To Do The Right Thing (Penguin/Riverhead). He is currently working under a grant from the John Templeton Foundation to study how to better design the institutions professionals work in so as to encourage the learning and exercise of practical wisdom.