The American Journal of Bioethics 4.2 (2004) Web Only
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Professionalism and the Social Role of Medicine
Peter L. Twohig
There is much to commend in Wear and Kuczewski's "The Professionalism Movement: Can We Pause?" (2004). The reforms they suggest are generally progressive. However, we identify three significant failings in the article. The first is the adoption of a relationship-centered approach to professionalism, which fails to acknowledge that the profession is more than a collection of individual relationships. Second, Wear and Kuczewski focus on only the academic medical environment, to the exclusion of nonacademic clinical care. Finally, Wear and Kuczewski's failure to recognize the complexity of the question of the social role of medicine leads them to endorse, too uncritically perhaps, a social-justice perspective for individual physicians. Indeed, all three failures arise from Wear and Kuczewski's failure to recognize the complexity of the question of the social role of medicine.
Professionalism under Seige
Medicine regards itself as a profession under siege. The President of the Australian Medical Association declared in 1995 that new "threats" appeared on a weekly basis, from "government, bureaucracy, or allied health groups wanting some of our territory" (Weedon 1995). States are actively shaping delivery models, rationalizing resources, facilitating the introduction of new kinds of providers, or expanding the scope of practice of existing providers. The social organization of healthcare workers is now characterized by integrated care models, multidisciplinary teams, or other such innovations (Cott 1997; Jenkins, Carr, and Dixon 1998). There is, therefore, some need to understand how various political processes, social contexts, and financial constraints shape professional relationships and health policy.
The dramatic changes to the social organization of healthcare have prompted a number of statements on professionalism to be issued. For example, the Medical Professionalism Project (MPP), launched in 2000 as a joint initiative of the American Board of Internal Medicine Foundation (ABIM) and the European Federation of Internal Medicine (see http://www.abimfoundation.org/mpp2003/index.html), poses the question "why is raising awareness about the core value of medical professionalism important?" Their response invokes the accelerating pace of change within healthcare and its broad scope and, more specifically, issues such as the rise of managed care, unionization of residents and physicians, and the role of the pharmaceutical industry. The MPP concludes that "medical professionalism is universally endangered" and that a "united front to influence and inform the culture and context of both clinical practice and medical training are particularly timely, appropriate and needed."
It is clear that the terms of the social contract between professional medicine and the people it serves are changing in response to changes in knowledge (such as the rise of evidence-based medicine), technological innovation, and the organization of health services. Among the most important transitions in clinical care has been the rise of the "patient-centered" approach. Patient-centered care seeks to create "expert" patients and to develop shared approaches to the management of disease (Stewart et al. 1995).
Wear and Kuczewski's position extends the patient-centered model to a relationship-centered model of professionalism. That is, they claim that medical students and residents will learn more about professionalism through its daily enactment with particular patients than through "abstractions." The difficulty with this "relationship- centered professionalism," as McCullough (2004) points out, is that it inevitably leads to individual practitioners starting "their reflections from scratch," without reference to the prior knowledge, debates, or theory of professionalism in medicine. This does damage to the notion that the medical profession is grounded in a body of shared knowledge. Further, the focus on individuality is at odds with our best understanding of professional ethics: the moral foundation of professionalism is the shared ethical standards of the professional group, decided on collectively and enforced through self-regulation and peer review. This implies an important role for "abstract" notions such as duty.
A strategy of relationship-centered professionalism would do little to invigorate professionalism in medicine at a time when "the...