Professionalism: a contract between medicine and society

The past decades have been characterized by an increasingly diverse society that has questioned both traditional values and societal structures. All professions, including medicine, have seen their stature diminish, and because of the increasing intrusion of government and the private sector into health care, medicine has lost both autonomy and influence throughout the world1 and in Canada.2 These changes have led to a recognition that medicine needs to re-examine its role so that it may best serve both individual patients and society. During recent medical history, there have been periods of introspection and discussion, but the dialogue has generally been among physicians, or between society and licensing bodies or medical associations. There has also been a dialogue among social scientists studying medicine, and between them and society. Unfortunately, there has been little communication between physicians and social scientists, 2 groups that share many interests, including the welfare of society. To understand better its role and values, medicine must listen to those who have studied and considered the professions, in particular the medical profession. This is why it is so satisfying to see the article by William Sullivan, a sociologist and philosopher, published in CMAJ (see page 673).3

There has always been a strong link between medicine's traditional values and the concept of professionalism. Physicians fill the role of healer and professional simultaneously,4,5 roles that have different origins and traditions. The healer, which is what individual citizens and society require, comes to Western culture from the Hippocratic tradition. The role is reasonably well understood and has had an important place in the medical curriculum for a long time. Professionalism, on the other hand, arose in the guilds and universities of the Middle Ages1 but had little impact on society until modern scientific medicine developed. As the delivery of health care became increasingly complex, Western society chose to use the concept of the profession as a means of organizing the delivery of health services. The professions were granted a considerable degree of autonomy in the Anglo-American world. As industrialized societies became wealthier, the professions were granted status, prestige and substantial rewards on the assumption that professionals would be altruistic and moral in their day-to-day activities. This formed the basis of the social contract between medicine and society, and functioned relatively well as long as both the profession and society were reasonably homogeneous and shared many values. In those simpler times professionalism was transmitted by respected role models to both students and the wider community.

The concept of professionalism came under intense scrutiny during the 1960s and 1970s. The belief that physicians would be altruistic was greeted with scepticism by social scientists, and medicine was accused of putting its own welfare above that of society.1,6 This occurred as the government or the private sector took control of the medical marketplace throughout the world.1 The intellectual basis for the criticism was articulated largely in the sociology literature, not readily available to physicians. The impact of this work on public policy was substantial. Medicine's response was defensive, which gave some further credence to the criticism itself.

Since the late 1980s, there has been a change in the opinion of the social scientists, with most commentators now being supportive of the concept of professionalism.3,7 Part of medicine's problem stemmed from the fact that it had been blamed for defects in the health care system. With the diminishing influence of the profession on public policy, the blame has shifted to those primarily responsible - the government or the private sector - and professionalism as a concept appears to be respectable once more.

There appears to be a window of opportunity8 to redefine medicine's contract with society. This window exists because of public dissatisfaction with the way nonphysician managers, either in government (in Canada) or in the private sector (in the US), are managing health care. The public is asking for a return of medical professionalism, with its core values of scientific expertise and altruism. However, this must be a professionalism that meets contemporary requirements and is understood by both the medical profession and society, because many of society's expectations depend on medicine meeting the obligations that are drawn from the traditions of the professional. This is why a knowledge of work by Sullivan and other social scientists is so important to Canadian physicians.

Sullivan's concept of "civic professionalism" offers medicine a future in which the values we cherish are central. In addition, the objectives that he proposes, including commitment to service, are achievable. We will be able to look ahead with some confidence, rather than with the pessimism that is so often articulated. He has much to teach us, and we have much to learn.

The authors are with the Centre for Medical Education, McGill University, Montreal.

Competing interests: None declared.