The American Journal of Bioethics 4.2 (2004) 33-36
[Access article in PDF]
The Social-Contract Model of Professionalism:
Baby or Bath Water?
Jacob E. Kurlander
Matthew K. Wynia
We commend Delese Wear and Mark G. Kuczewski (2004) for drawing attention to the need for a considered and consistent approach to developing professionalism. However, their discourse analysis would benefit from first articulating an explicit model of professionalism that acknowledges both the range of stakeholders involved and the severity of the challenges in medicine today. The contractual model of professionalism can serve to illuminate some of the authors' recommendations, which are otherwise interesting but weakly grounded.
The social contract has long been the basis of statements of medical professionalism, starting with the American Medical Association's (AMA) 1847 Code of Medical Ethics, the first-ever national code of professional ethics, [End Page 33] which notably captured many of the qualities called for by Wear and Kuczewski (Bell and Hays 1999). For example, the 1847 Code was organized according to physicians' occupational relationships and lists concrete responsibilities to patients, other practitioners, and the public. More recently, the social contract has informed the American Board of Internal Medicine (ABIM) and American College of Physicians-American Society of Internal Medicine's (ACP-ASIM) "Physician Charter" (ABIM Foundation, ACP-ASIM Foundation, and European Federation of Internal Medicine 2002) and the AMA's "Declaration of Professional Responsibility" (2002), both civically-oriented statements.
The social contract captures something fundamental about healthcare—it is a valuable social good (or service) necessarily provided by independent and expert practitioners. The same can be said of other goods entrusted to professions. Society has an interest in guaranteeing that these goods are of high quality, reliably supplied, and equitably distributed, assurances that traditional market-based and regulatory distribution mechanisms cannot provide. It is a truism that the market ethos should not prevail in settings like the clinic. Physicians do not simply provide what patients want, the sine qua non of the service industry, they provide what patients need. And because professionals must possess specialized knowledge, have flexibility in decision making, and deal with uncertainties, they are poor candidates for external regulatory oversight. In short, the most appropriate and competent party to oversee a profession is the profession itself. Hence society forms tacit agreements with select occupations to provide these necessary assurances. But self-regulation is not nonregulation; reliable frameworks for self-regulation must be established and monitored.
The emergence of self-regulation is not a simple causal story. A profession's explicit commitment to some social good evolves in tandem with the public trust, and from their convergence is born the privilege of autonomy, sometimes taken to be the defining characteristic of professions (Latham and Emanuel 1999). Self-regulation, in part reflected in codes of conduct, ties the essential attributes of a profession together. As an ideal type it confers three distinct monopolies: the political (to speak on public affairs within the profession's area of expertise), the supervisorial (to establish work standards and to direct and evaluate work), and finally the economic (to control recruitment, training, and credentialing) (Friedson 1994). For agreeing to abide by explicit ethical standards, starting with a commitment to a socially valued good (e.g., health), professionals are granted rewards of status and money.
In keeping with the social contract, professional norms are subject to negotiation with society, but their ultimate approval depends on the profession itself. Although professions do not have privileged access to moral standards, they gain a unique perspective through their education and practice (Latham and Emanuel 1999). Professional ethical standards therefore reflect the qualitative demands of the occupation itself and the obligation to negotiate for specific social priorities. Medicine, for example, must be especially attentive to the nature of the clinical encounter, in which Pellegrino (1991) notes "a peculiar constellation of urgency, intimacy, unavoidability, unpredictability, and extraordinary vulnerability within which trust must be given" (84).
Wynia and colleagues (1999) identify three core elements of medical...