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Beyond Professionalism

Beyond Professionalism

I am worried about the future of the profession of medicine in general, and of psychiatry in particular. Behind my anxiety is a series of 3 disturbing occurrences—the subject of this column—in which I sense a gradual but palpable shift in the identity of physicians, both those in training and those in practice.

Several times a year, I teach a seminar in public health ethics for fourth-year medical students in which we discuss the myriad of ethical dilemmas associated with pandemic flu. Among the most debated is what ethicists call the "duty to care," which is the obligation for physicians and other health care providers to risk their health and even lives to serve and save the sick. I ask the students whether they believe they would come to work during a pandemic, and in some classes almost no one raises their hand.1 While their reasons reflect important values—the need to care for a partner or children, or fear of dying and depriving their family of livelihood—their choices are the reverse of what has historically been expected of medicine. True, there were cowardly physicians who fled to the relatively safe country during the black plague, but there were many more clergy and doctors who perished while tending to the dying. Similar heroic examples from our own day occurred during the severe acute respiratory syndrome (SARS) outbreak.1

This change in conceptualization was also reflected in the comment of one of my most respected colleagues, who told me that he had 2 sons and that he would do anything he could to dissuade them from becoming physicians because medicine was no longer a profession but a business.

In the final disturbing incident, more than two thirds of the residents in my own academic institution, the University of New Mexico, voted to unionize. Many of the most idealistic trainees who supported the union believe it is paradoxically the last bastion of professionalism. Others would say more pragmatically that the business of medicine is a fait accompli and that unions represent the most fair means of obtaining humane working conditions, which will, in turn, safeguard the quality of patient care from being reduced to the lowest economic denominator. Far better ethicists than I have held that unionization is not consonant with the historic understanding of a profession.2

At this point, it is important to stop and remind ourselves of the definition of a profession, so that we can better judge what actions and attitudes threaten and support the concept. While there is considerable debate about the exact contours of the definition, the basic shape of a profession has retained the lineaments of Flexner's formulation during the reformation of American medical education. A contemporary statement is that of Arnold and Stern: "Professionalism is demonstrated through a foundation of clinical competence, communication skills, and ethical and legal understanding, upon which is built the aspiration to and wise application of the principles of professionalism: excellence, humanism, accountability, and altruism."3

Almost everyone would agree that this is not a description of a business but of something qualitatively in a different moral universe. This is not to say that businesses cannot adhere to the highest ethical standards of their respective domains, nor even that some corporations are not engaged in the public form of altruism, philanthropy, or are not organizationally accountable to the environment and their own employees and customers. This is only to say that the sine qua non of a business is profit and production for those who have invested in it and own it--not the service of others beyond all other interests, which has been the goal of medicine since Hippocrates. In fact, the Hippocratic school began as a protest against the commercialism of health care practitioners of the period and amounted to a moral revolution in the practice of medicine that was reflected in the ideals of the famous oath.4

It would be illogical and presumptuous to claim that doctors could not provide competent, even dedicated, treatment of illness and injury as employees or managers. Many of the most progressive initiatives in health care delivery are derived from business, such as performance improvement, quality assurance, and systems analysis.5 There are health care entities operating today whose leadership and staff understand and present themselves as the "health care industry," and many patients, including psychiatric patients, actually prefer the moniker "consumer." Policy analysts and economists have argued that the comprehensive transformation of medicine into a business is the only means of controlling cost, ensuring equitable access, and maintaining high standards. From the ethical perspective, if medicine were to become a business and not a profession, it would resolve a number of pressing and thorny conflicts of interest, especially for psychiatry, such as the role of the pharmaceutical industry in education and research, self-referral to imaging facilities, and the perennial struggle with government funding.6,7


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