The American Journal of Bioethics 4.2 (2004) 17-18
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Deriving Professionalism from its Roots
Linda L. Emanuel
I readily sign on to Delese Wear and Mark G. Kuczewski's recommendations (2004) for additional attention to professionalism on the grounds that enhanced attention is much more likely to help than to harm.
However, I would urge the following perspective for consideration—both as part of the push to include more attention to professionalism and as part of the educational initiatives that might result from it. Consider that professionalism might be best understood as a philosophy, a behavioral disposition, and a skill set that result from one of the fundamental relationships in human interaction. That is, it is more than a social contract that can be constructed as participants see fit; it is an institution of relationships that protect an essential feature of what we human beings are (Pellegrino and Thomasma 1981).
These fundamental relationships are those of care during illness. These relationships have special standing or moral valence because of the vulnerability that illness brings and because that vulnerability goes to the core of our mortal, human condition. With the inherent connection to ultimate existential matters, the inherent vulnerability of illness, the need for special skills and standards of competence, and the need for pristine personal behavior, members of the professions have felt compelled to be able to profess competence and a specialized ethic. And these have come to characterize the standards of the medical profession with all its texts of knowledge and codes of conduct. This is to affirm rather than deny that there is a social contract between the professionals and the members of the wider society (Freidson 1970). But it is also to say that the social contract should be seen as a result of the need to protect an inherently special relationship in science: the care for the ill.
So when Wear and Kuczewski call for the "theory of professionalism [to] be constructed from a dialogue with those we are educating," I want to call out and say, "Okay, yes. It is important to reconstruct the model of professionalism so that it is true to the terms and contexts of today's young professionals. But do not risk encouraging an assumption that they should be constructing the very nature of professionalism de novo!" I do not doubt that Wear and Kuczewski understand this; their students and those of others who advance professionalism education should also. After all, it is so easy to arrogate the notion of professionalism to cover a multitude of differently motivated social contracts that can then undermine the standing of professionalism for those of us (that is, all of us) who need the kind of professionalism that protects our deep vulnerabilities (Starr 1982).
Similarly, when Wear and Kuczewski call for a deeper connection between professionalism and theories of social justice, a concern knocks on my mental door again. Not that social justice is an unimportant matter in healthcare. It is all-important. It is time that we all wake up to the realization that health is a form of social power, and political theory must include determinants of health and healthcare in its deliberations. But that is not the same as professionalism, which is justified with no reference whatsoever to theories of justice. The relationship between professionalism and theories of justice is interesting and should be explored (Wynia et al. 1999). So, as the young and lively-minded professionals of the future take their place in the classroom, by the bedside, and in the policy forums of the future, may they have partaken in lively discussions—helpfully instigated by Wear and Kuczewski and others—during their, one hopes, mandatory courses on professionalism.