The Theory and Practice of Professionalism

Introduction

Delese Wear and Mark G. Kuczewski (2004) maintain that the discourse of professionalism is imbued with too many abstractions. These abstractions, they claim, are at best "hazy" and at worst meaningless to the students we aim to teach about professionalism. The problem with abstraction stems from the fact that students do not see any connection between abstract attributes—such as being altruistic, knowledgeable, skillful, and dutiful—and their daily interactions in the clinical setting. To address this, Wear and Kuczewski propose placing the abstract language of professionalism in the context of concrete relationships. Such an approach, they argue, not only will rescue the discourse of professionalism from oblivion, it will simultaneously prevent professional attributes from taking on the appearance of ethical absolutes.

In response, I argue that Wear and Kuczewski fail todistinguish between the theory and practice of professionalism. In the clinical setting students and teachers of professionalism need to refer to the more specific and particular language that Wear and Kuczewski urge. Yet theoretical language cannot be simply dispensed with. The theory of professionalism can serve several important functions. It contributes to:

1. resolving ethical problems;
2. exposing invidious bias; and
3. gaining broader perspective.

Resolving Ethical Problems

Professionalism instructs students to develop a long list of attributes that seem, on their face, indisputably good. For example, professionalism extols attributes such as being knowledgeable and skillful; altruistic; respectful; honest; compassionate; committed to excellence and on-going professional development; and showing a responsiveness tothe needs of patients and society that supercedes self- interest. Yet these apparently admirable qualities can sometimes conflict. Thus, striving for excellence and on-going professional development in the conduct of scholarly research can come into conflict with putting the needs of patients and society above self-interest. After all, research into fundamental scientific knowledge might have little immediate value for patients and might be pursued with an eye to achieving career goals and progressing up an academic ladder. The individual researcher might bask in the attention and esteem bestowed by professional colleagues; seek and obtain the benefits of tenure and promotion in an academic setting; and gain the prospect of greater access to grant funding in the future. At the same time, patient care might take a back seat to research; and standards of excellence demanded in the clinical setting might not be fully met.

For example, consider the case of an individual who focuses tremendous energy on scientific research and becomes, over time, less knowledgeable and skillful about practical patient care. This person might not have read, for example, the latest studies about medical management of elevated cholesterol and might simply care less about the needs of patients because her or his attention is devoted elsewhere.

Resolving this dilemma might require recourse to the more theoretical language of professionalism. It will help little to simply repeat the practical dilemma: only so much time, too many demands on that time. Instead one needs to reflect upon the requirement of qualities, such as integrity, that map the moral domain in which the problem arises. "Integrity" is a description of one who acts from dispositions that are his or her own. It is not integrity perse that motivates action, it is one's virtues that motivate action. The role of integrity is to identify that a person who acts "from those dispositions and motives which are most deeply his, ... has also the virtues that enable him to do that. Integrity does not enable him to do it, nor is it what he acts from when he does so" (Williams 1981, 49).

What the researcher/clinician might discover about herself upon reflection is that she lacks strong first-order principles and dispositions, such as compassion and respect for patients, that would compel her to provide competent clinical care. The researcher/clinician may provide good care, but she cannot be relied upon to do so; sometimes she lacks the knowledge or skill to adhere fully to...