The American Journal of Bioethics 4.2 (2004) 36-38
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Professionalism and Discourse:
But Wait, There's More!
Jamie L. Shirley
Stephen M. Padgett
We commend Delese Wear and Mark G. Kuczewski (2004) for noting that recent calls for increasing professionalism within medical training have too often been composed of recycled platitudes and have ignored both internal contradictions and larger issues of social justice. Additionally, we concur that the analysis of discourse is a useful and illuminating means of interrupting current trends in professional education. Discourse analysis—in all its many versions—is an underused resource within bioethics, and it is disappointing that few who have commented on Wear and Kuczewski's paper have addressed what we took to be one of the authors' central points. Indeed, a more extensive application of linguistic theory would strengthen Wear and Kuczewski's critique and (we believe) reframe their conclusions. For this we need a more robust sense of discourse and of the assumptions that surround its use in contemporary theories of language.
Wear and Kuczewski remind us that language is a process of linking signifiers with concepts to create meaning. Languages are networks of these signifiers, referring not so much to solid objects as to other signifiers, a chain of words pointing to other words (Van Dijk 1997). The problem arises when there is no consensus within a community about what the terms mean.
Languages are not composed only of words and concepts, however, but also of the practices and institutions of a particular social community, within a particular historical and cultural context. In turn, these languages help to reproduce those social practices and institutions. Languages, in this conception, are constitutive of a way of being in the world—as Wittgenstein (1958) said, a form of life. Language is what we do, not merely how we talk about what we do (Shotter 1993).
In contemporary linguistic shorthand, "discourses" are particular languages organized around sets of practices, ideas, and institutions. Within the broad and complicated discourse of "medical practice," for example, the discourses of midwives, perinatologists, genetics counselors, and (various groups of) pregnant women are distinct, yet overlapping, ways of constructing the events of pregnancy (Rapp 1997). These discourses represent not just different words for the same things, but different experiences, different cultural practices, and different kinds of power.
There are always multiple (and sometimes contradictory) discourses available to speakers—for example, patients can invoke one or more of the discourses of professional judgment, consumer skepticism, self-help, and religious faith, among others—but these discourses are not equally powerful. Not only are discourses differentially available to speakers, but some are more effective than others in obscuring competing discourses. The more hegemonic discourses (those produced by and reproducing powerful social institutions) accomplish this by making their assumptions seem natural and unmarked.
With these brief comments on our understanding of discourse, we now turn to the discourse of professionalism as a case in point.
As we have said, one of the characteristics of dominant discourses is their ability to marginalize or obscure alternative ways of naming things—to make those things literally unsayable. As Wear and Kuczewski point out, the professionalism discourse has "defined, organized, contained, and made seemingly immutable a group of attitudes, values, and behaviors" [emphasis added]. In ironic confirmation of this, while many of the other respondents to this article discuss, for example, which virtues belong within professionalism, none question whether professionalism is itself a good thing. In contrast, we would argue that professionalism is no longer helpful as an organizing ethical framework—that it is too deeply entangled with physician privilege and power, too limited in its concept of normative responsibilities, and too diffuse in the ways it has been deployed within the healthcare system.
Though medical-professionalism advocates like to portray an unbroken chain back to Hippocrates, contemporary understandings of what it means to be a professional and medicine's claims to that status are of far more recent vintage and...