Clinical reasoning as a hermeneutic arc: teleology, narrative, and practical wisdom in patient care

Clinical reasoning is often described through partially independent frameworks, including causal explanation, probabilistic inference, ethical deliberation, and narrative understanding. What remains insufficiently clarified is how these dimensions are structurally integrated in the care of a particular patient. Drawing on Paul Ricoeur, this paper argues that clinical reasoning is best understood as a hermeneutic and practical movement structured by three interrelated arcs: an epistemological arc (from naive understanding, through explanation, to informed understanding), an ethical arc (from teleology, through deontology, to practical wisdom), and an anthropological arc (from suffering, through cultural works, to renewed acting). Within the epistemological arc, explanation unfolds through four modes of intelligibility-causal, probabilistic, teleological, and narrative-and is coordinated by the clinical skill of scale shifting. The paper's central claim is that teleology mediates between diagnosis and ethics: first as a mode of intelligibility that discloses what is at stake in the patient's life, and then as a normative orientation guiding deliberation about action. Narrative, in turn, does not replace causal, probabilistic, or ethical reasoning, but configures these heterogeneous elements into a meaningful whole and renders them appropriable within the patient's lived world. Finally, this paper presents a fictional clinical case to show how clinical explanation may support patient self-understanding and renewed agency.