Trumping Professionalism

If "professionalism" as a "core" of medical education curricula is here to stay, then there is little fault to be found in Delese Wear and Mark G. Kuczewski's article (2004) pushing us to be more thoughtful educators. Surely we need to be careful with and reflective about the concept of professionalism, and Wear and Kuczewski's reflections are insightful and important. However, we find troubling the normative position ceded, of late, to professionalism, and we contend that medical school and residency faculties—gatekeepers of the profession—give up too much if they give in to professionalism as a "core competency."

Ours can be a difficult position to articulate and defend because it involves an intricate balancing act. Like Wear and Kuczewski, we too would not wish to lose or undermine the ideals highlighted by the turn toward professionalism. We applaud groups like the Accreditation Council for Graduate Medical Education for acknowledging that the values captured under "professionalism" are central to medical practice. Further, a professionalism perspective brings some practice issues—for example, dealing with colleagues, developing care teams, the role of medical students and residents in patient care—into much stronger relief than other perspectives have done. At the same time, though, talk of professionalism, unfortunately and mistakenly, threatens to replace talk of moral excellence and social responsibility. We maintain that this incorrectly puts the cart before the horse.

As Wear and Kuczewski are correct to point out, one danger of a focus on professionalism is that medical education will be content to claim that already existing medical ethics curricula will do the trick. In fact, they cannot. However, this is not because professionalism is a higher-level consideration but because ethics is. Excessive focus on the details of a professionalism curriculum—developing lists of "right practices" and tools for assessing the presence of virtue—distracts us from the great variety of needs that must be fulfilled by an ethics curriculum. Moral development is largely the development of good habits of practical thinking—habits that involve taking other persons fully and appropriately into account, habits that should be adequate to the great variety of contexts in which our actions bear on the lives of others. In other words, ethics is essentially about responsible deliberation; it requires that as we look for ways to meet our own needs or reach our own goals—as physicians, citizens, community members, parents, lovers, or friends—we do so in a way that appropriately weighs both our commitments and the needs, goals, and commitments of other people. Professionalism presupposes the acceptance of some particular understanding—however arrived at—of how all of these morally significant factors are to be balanced in the professional's life. Ethics education encourages students to be attentive to considerations that might be morally relevant and to take care when thinking practically. It prepares students to articulate their reasons for choosing one course of action over all others and to comprehend the reasons others might have for choosing otherwise. It asks them to think about what it is to live well in general and to develop this understanding for the peculiar context of being a doctor. Professionalism, by contrast, asks students to adopt a special stance when making decisions as physicians. It requires that they accept an established set of values or a series of rules, and it suggests that doing so is part of becoming what they had not been. "Think what you will about morality; here is what doctors do."

We in no way wish to deny that the distinctive role of the physician creates distinctive moral challenges. Medical ethics education that gives priority to the development of good ethical deliberation over the imparting of moral truths can, in fact, give medical students and professionals the tools they need to work through many concerns in professionalism. What is called for by many medical educators who have accepted the centrality...