Medicine under threat: professionalism and professional identity

The professions have never been more important to the well-being of society. Professional knowledge and expertise are at the core of contemporary society. How such professional expertise is developed, how it is deployed, by whom it is deployed and for what ends are among the most pressing issues facing all modern nations. At the same time, many of the most distinctive features of the professions, especially their privileges of self-regulation and self-policing, are being curtailed. This is true even in countries such as Britain, the United States and Canada, where professions have historically been most autonomous and enjoyed the greatest social prestige.1

To date, the efforts by professional groups to respond to these threats seem to reveal the weakness of appealing to expertise alone as the basis for professional control of medical services. Expertise does not provide much leverage for asserting traditional professional privileges in the face of calls for greater efficiency and cost reduction, let alone public demands for more personalized attention and care in dealing with complex technologies and more daunting social problems. What is missing from these ways of responding to contemporary challenges is precisely the moral core of professionalism: the contract between professional and society in which physician and patient are bound together within a larger "body politic."

What is professionalism?

In Canada and the United States the social basis of the extraordinary grant of occupational authority and independence to professionalized occupations such as medicine and law has been a social contract between the profession and the public. Professionalism is the moral understanding among professionals that gives concrete reality to this social contract. It is based on mutual trust. In exchange for a grant of authority to control key aspects of their market and working conditions through licensing and credentialling, professionals are expected to maintain high standards of competence and moral responsibility. The work of the traditional learned professions has long been understood to require a significant domain of discretion in individual practice. It has therefore been thought to require a stronger sense of moral dedication than most occupations. A professional is not required to ignore material considerations but is expected to subordinate financial gain to the higher values of responsibility to clients and to the public interest.

Tensions within professionalism

Contemporary students of professionalization have shown how, starting in the late 19th century, the development of professionalized fields modified the laissez-faire pattern of American occupational life. When successful, efforts to professionalize occupations such as medicine and law provided their members with a degree of economic security and hope of "collective mobility" toward improved social and economic status. Fields less successful in their efforts at full professionalization (e.g., engineering, nursing and teaching) were correspondingly less able to provide their members with "market shelter" to escape economically precarious positions. Security of career and socioeconomic mobility, in other words, were directly dependent on the authority and prestige a given field was able to achieve.

At this point, however, theories of professionalization divide in their way of characterizing professionalism and its history, falling into at least 3 distinct types. The first type of theory emphasizes the strategic side of professionalism: the use by professionalizing groups of claims for superior knowledge and special moral integrity as devices by which they could secure some measure of control over the market for their services. This view of professionalism as primarily a "project of collective mobility" also stresses the economic dimensions of the phenomenon of professionalization within the liberal capitalist order, with important variations in different nations.[2–4] Managed care would therefore be explicable fundamentally as a loss of guild monopoly in the face of more powerful market players, especially insurers and providers, legitimated as an advance of consumer sovereignty.

The second type of theory emphasizes the issue of cultural and social authority, arguing that the market success of fields such as medicine have been ultimately, and crucially, dependent on their ability to establish their claims to possess the authority to define and control a specific area of expertise.[5–7] This approach sees the rise of the professions as closely linked to the progress of scientific and technical rationality in modern society. These interpretations of professionalization accordingly emphasize the role that claims to expert knowledge, especially scientific knowledge, have played in establishing professional autonomy in work and prestige in society. From this point of view, managed care represents a serious loss of legitimacy by a scientific elite to an economic one.

A third approach emphasizes instead the emergence of professionalism as an ideology of social reform, which could infuse social responsibility into the industrial division of labour. This ideology was developed by groups wanting to present an alternative to the dominance of competitive economic laissez-faire. From this point of view, professionalization has been both an expression of occupational self-interest and a movement with broader appeal to the middle classes. It has put forward a distinctive "social ideal" that has been crucial to such 20th century developments as the welfare state.[8–10] By focusing on the professionalizers' social criticisms and their formulation of new social goals, the third type of theory casts professionalization as a cultural and political development rather than seeing it as the outcome of struggle among economic interests or as an agent of the spread of scientific and technological rationalization.

Redrawing the contract: toward a civic professionalism

The ascendant ideology of the time promotes the efficiency of free markets in every area of social life. The underlying idea is that people will be better off if they are ceaselessly searching for the best "deal." This change in the larger social climate is already having significant - and often disturbing - effects on professional practice. The result, most evident in the US but not unknown in Canada and Britain, has been to transform the doctor-patient relationship by substituting questions of cost and benefit for traditional relations of care and trust.

In this redrawing of the contract between the medical profession and society, the stronger interests have prevailed, with the public reduced to bystander status and medicine itself more passive than active. Was this outcome inevitable? To those who view the professions as essentially "collective mobility projects" aiming at maximum autonomy, it seems so.3 In this context, scientific expertise can confer far less social power than adherents to the second, "rationalization" theory have typically thought.

For the third perspective on professionalization, however, the situation is more complex and external causes are more difficult to determine. Harold Perkin10 argues that the spread of the idea of professionalism and its public legitimacy are inexplicable unless professionalism answers in some way to real social needs, which have become ever more pressing as the "post-industrial" or "knowledge" society has developed. "The whole point and purpose of professional society," writes Perkin, "is to apply knowledge and expertise to the production of enough sophisticated goods and services to meet the needs of every citizen ... so that for the first time in human history the economy is capable of producing enough 'created assets' to give everyone ... access to full range of satisfactions once open only to the rich and powerful." In this context the integrity of professional services becomes a key public good.

Perkin therefore argues that realizing the potentials for individual freedom and development inherent in this kind of modern society requires a high degree of trust and cooperation among many specialized activities. In Perkin's historical perspective, then, professionalism functions to call attention to the priority of this kind of moral understanding to the purely technical understanding of specialized expertise. Professionalism thus reintroduces in a new way the idea of society as a "body politic" summed up in the "professional social ideal," a blending of social justice and economic efficiency, which Perkin finds at the core of 20th century social reform.9

The eclipse of that earlier, civically oriented notion of professionalism by a concept of the professional as simply a technical expert has made professionalism less effective as a claim to public legitimacy and at the same time has diminished the importance of the professional voice in public debate.[1, 8] Perhaps, then, the deflation of medicine's earlier pretensions may hold a positive potential. The contraction of medical autonomy at the hands of managed care may weaken the hold of the technical model of expertise, allowing the profession's "contract with society" to be recast on a different basis than either the old terms of professional "sovereignty" or the newer imperatives of state cost-control or corporate interests.11 It is once again a serious question: Can a profession secure public recognition of its claims to traditional professional prerogatives on the basis of its technical skills alone, or will public support and legal recognition for a profession increasingly require that it demonstrate significant contributions to advancing civic welfare?

The future of the professions may increasingly hinge on how professionalism is understood and practised. If the professions are to have a future, they may need to make their case on the basis of a social and moral rather than a wholly technical understanding of what it is that professionals are about.

Conclusion

Medicine depends on more than competence and expertise, essential as these are. It cannot function as an institution without good faith on the part of provider, patient and the public as a whole. The root of the public's trust is the confidence that physicians will put patients' welfare ahead of all other considerations, even the patients' momentary wishes or the physicians' monetary gain. It is the function of medicine as a profession to safeguard and promote this trust in the society at large. This point could be phrased as a maxim: "Medicine must always be treated as a public good, never as a commodity." In the present climate, which works against this trust in several ways, physicians will find themselves unable to sustain their important role as guardians of these values unless they can find ways to re-engage the public over the nature and value of their work for the society at large.

To do this, medicine must take the lead in a public conversation about the profession's contract with society. If it does not, that contract is likely to be redefined in terms, and in a language, quite antithetical to the core concerns of medicine. The focus of this effort by the profession would be to give new attention - and new importance - to the spirit of professionalism, only a professionalism seen in specifically public-regarding, civic ways. A civic professionalism must seek to strengthen and extend the kind of fiduciary morality that has long been part of the ethos of medicine. But it must do this self-consciously and with explicit attention to how the relationship between medicine and society needs to be recast to realize medicine's ideals, which are important components of the larger common good.

Competing interests: None declared.