The American Journal of Bioethics 4.2 (2004) 26-27
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Integrity in the Relationship between Medical Ethics and Professionalism
Denise M. Dudzinski
Delese Wear and Mark G. Kuczewski's criticisms (2004) of the professionalism movement could be recast as the "potential dangers of renam(ing) what has been called medical ethics as professionalism." I discuss two dangers of categorizing medical ethics as a subset of professionalism, both of which are congruous with Wear and Kuczewski's arguments. First, ethical principles and ideals may be concretized to meet dominant goals and interests of a privileged profession. Without more critical reflection on the implicit values of medicine, the profession risks marginalizing vulnerable patients, minority and underrepresented students and physicians, and women. Second, complex virtues such as integrity might be oversimplified in the attempt to better measure outcomes.
To be sure, there are important ethical dimensions of professionalism, but we must be careful not to subjugate medical ethics to professionalism. The discipline of ethics brings philosophical, theological, and sociological perspectives and methodologies to bear on medicine. These orientations, informed by nonmedical professions and scholarship, offer critiques to the values and culture of medicine. These critiques are imperative for fostering critical reflection, social justice, and respect for persons.
Wear and Kuczewski observe that medical education encourages scientific rigor without always requiring that students critically engage and question the hidden values in clinical medicine. Medical professionals emerge from training with a variety of professional beliefs and values. However, there is a dichotomy between the explicit values of practicing medicine (empathy, compassion, and altruism) and the tacit values embodied in professional behavior (detachment, self-interest, and objectivity) (Coulehan and Williams 2001). The best way to address the dichotomy is to help physicians become comfortable with self-scrutiny and to encourage them to critically examine professional commitments. Such critical reflection improves clinical practice and fosters respect for patients. When not brought to consciousness, "physicians' personal attitudes, biases, fears ... and moods can interfere with their abilities to arrive at an accurate diagnosis, prescribe appropriate treatment, and promote healing" (Novack, Epstein, and Paulsen 1999, 517). Not only physicians but all of us must examine our biases, prejudices, and fears as we strive to be more respectful of others and to promote social justice.
Self-reflection is also required if physicians are to be culturally sensitive. Despite the promise and preponderance of cultural sensitivity training (Lum and Korenman 1994; McGarry, Clarke, and Cyr 2000; Robins et al. 2001), Beagan (2003) discovered that medical students were largely blind to cultural differences. Most failed to recognize or denied effects of gender, race, class, culture, or sexual orientation on their experiences in medical school. Not surprisingly, minority students described racism and women described sexism, but their classmates often did not recognize the discrimination. And many students thought the patient's class, race, gender, culture, or sexual orientation made no difference to "real" clinical practice. Members of the Institute of Medicine's Committee on Understanding and Eliminating Racial and Ethnic Disparities in Health Care also discovered that sociocultural differences between patient and provider are rarely recognized or critically examined by physicians (Institute of Medicine 2002). How can we expect students and residents to be culturally sensitive when they do not recognize the influence of their vocational culture?
Taylor (2003) suggests that medicine is a culture with no culture—"a community defined by the shared cultural conviction that its shared convictions were not in the least cultural, but, rather ... truths" (605). This belief might be an outgrowth of the privilege enjoyed by medical professionals. Medical students and physicians are privileged because they are well-educated, accustomed to feeling safe in their work and home environments, financially secure, and enjoy more clinical power and influence than any other healthcare profession. Such power allows the culture of no culture to go largely unchallenged. Privilege also influences a profession's understanding of and commitment to social justice. It is only by taking Wear and Kuczewski's advice to invite minority and underrepresented students, professionals, and patients to teach us...