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                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       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                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         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  | *This staff paper was discussed at the November               2007 meeting. It does not represent the official views of the               Council or of the U.S. government.*
The Council's Inquiry into the Healing Professions: Progress to               Date, Key Questions, and Possible Future Directions Staff Discussion PaperBy David G. MillerI. Introduction
This discussion paper summarizes the Council’s investigation to date of issues under the rubric of “the professions.” It examines the contemporary status of public and scholarly discourse regarding the concepts of “professions” and “professionalism.” Although the concept of “professionalism” is receiving increased attention both in the popular media and in academic discourse, it is not clear that such attention has been properly focused or clearly articulated. Thus, we suggest that in the interest of public education, the Council could bring conceptual clarity and order to the topic and explore several important related moral concerns. We further suggest that the best way to approach it would be to elaborate clearly the moral foundation of the healing professions and the potential implications for the practices of health care, health care education, and health care administration and policy.
II. A Brief History of the Council’s Inquiry into Professionalism
 The Council has heard from several guest presenters on the topic of “professionalism:” Dr. William Sullivan1 suggests that the professions are, in part, defined by—and should seek to renew—a dedication to professionalism for the public good since the profession’s “contract” with society is based in an ethic of service. On Sullivan’s view, the healing professionals occupy a position between corporation and state, in which they are granted certain privileges and encumbered with certain responsibilities in exchange for safeguarding and making available a particular social good: health care. Moreover, on those grounds, the professions are allowed monopolistic control over knowledge and skills to sustain, enhance, and transmit to future practitioners. Because health care professions are complex and entail the acquisition of a set of skills as well as a body of information, society charges the professions with certifying practitioners, regulating practice, and regulating access to procedures and treatments. Dr. Sullivan urged the Council to attend to the importance of professional civic engagement for the benefit of both the profession and society.

Dr. Lisa Day2 drew the Council’s attention to a number of issues in the field of nursing, issues that broadly affect nursing as well as the other healing professions. First, Dr. Day pointed to the ways in which ethical and clinical reasoning are inseparable in the healing professions, which makes the educational process a locus of moral formation and an abiding focus of deep moral concern. Drs. Jordan Cohen3 and David Leach4 reiterated that sentiment in their discussions of medical and graduate medical education respectively. Dr. Day also drew our attention to the tensions between various healing professions – e.g., nurses and physicians – and the ways in which such tensions may affect that healing relationship between patient and health care team. Finally, she pointed out a number of important problems facing the nursing profession: the shortage of nurses and nursing faculty; the multiple points of entry for nurses into the practice of nursing and the resulting disparity in knowledge and skill bases; the increasing number of nurses who have been trained in other countries and their unfamiliarity with our culture; the increased pressures on nurses to complete bureaucratic tasks; and the problem of low morale and rapid turn-over in the nursing profession. Dr. Day also suggested that the triumph of both “scientism” and “technologism” and the popularity of a “rescue mentality” in contemporary health care (of increased attention to “cure” with decreased attention to “care”) may also be undermining the provision of quality health care in America.

Dr. Arnold Relman5 drew the Council’s attention to the forces he believes are undermining medical professionalism: the commercialization of health care and bureaucratization of medicine; the way in which legal decisions have undermined professional associations’ ability to control commercialization; and corporate incursions by pharmaceutical and medical technology companies into medical practice, medical education, and continuing medical education. His strongest criticism is investors’ entering the medical care delivery system. He argues that medical professionals have an obligation to place their patients’ needs above their own and the infiltration of intermediaries who seek to make a return on their investment from the sick destroys the proper practice of health care.

Dr. David Rothman6 suggested that the Council would be best served by looking at what the future of the healing professions may hold rather than nostalgically looking at an imagined golden era of the past. He argued that medicine must focus on instilling professionalism, which he defines as an altruistic commitment to patients’ interests over monetary concerns. He worries that our society may focus on “professionalism lite” – on doctors’ attempting to seem better mannered – rather than on ensuring that they are more deeply committed to placing their patients’ interests first. Dr. Rothman also suggested that the medical profession must assert its own authority in determining how medicine is to be practiced – lauding the profession’s withdrawal from participating in executions as well as its resisting the “gag rule” requiring federally employed physicians from discussing the possibility of abortion with patients. 

Dr. Jordan Cohen discussed the Physician’s Charter of Medical Professionalism,7 promulgated by the American Board of Internal Medicine Foundation, the American College of Physicians Foundation, and the European Federation of Internal Medicine. The Charter enunciates three foundational principles (primacy of patient welfare, respect for patient autonomy, and respect for social justice) from which it derives ten categories of professional commitment (commitments to: professional competence, honesty, confidentiality, proper relationships with patients, scientific knowledge, professional responsibility, continuous improvement of quality of care, improvement of access to care, just distribution of resources, and the management of conflicts of interest). Dr. Cohen discussed each of those commitments and his view that the fundamental purpose of professionalism is to sustain the patients’ trust in physicians and society’s trust in the profession. One of Dr. Cohen’s primary concerns with respect to the teaching of professionalism to undergraduate medical students involves the “informal” or “hidden” curriculum, i.e., the learning that occurs through the experience of those behaviors displayed by—through exposure to the character modeled by—more senior clinicians. There is now a substantial literature that documents the chasm between the values and virtues embraced by the explicit, formal curriculum and those inculcated by the hidden curriculum.                Finally, the Council heard from Dr. Leach, whose work focuses on graduate medical education in medical residencies. Like Dr. Cohen, Dr. Leach also acknowledged the importance of character formation and the role of modeling in character formation, noting that the Accreditation Council for Graduate Medical Education has identified “professionalism” as one of six general competencies that graduate medical students are expected to demonstrate. According to Dr. Leach, character formation is important because the quality of a physician’s inner life affects the ways he or she cares for patients. He concluded by stating that, in today’s climate of team medicine, group formation (in addition to individual formation) is important to ensure good medical practice.                The questions the Council asked of the various experts and the discussions that followed those presentations reflected a sense of frustration with the ways the topic was approached. Although each presenter raised concerns and articulated positions that the Council affirmed as worthy of consideration, each presenter seemed to leave the Council with a form of confusion or misapprehension. That unease was expressed in a variety of ways, e.g., as a sense that the presentations were “too abstract,” that they weren’t clear about what professional character or professional behavior entailed or why “professionalism” would be of value. Council members also suggested that the presentations appealed to broad stereotypes or “caricatures” of ideal types and that presenters seemed to call health care professionals to commit themselves to high levels of civic engagement, altruism, and effacement of self-interest without offering a clear and compelling justification for holding professionals to standards higher than standards for non-professionals. 

Before discussing Dr. Pellegrino’s presentation to the Council and suggesting the ways in which it might allow us better to frame issues of professionalism, it will be helpful to examine the state of public discourse on the topic, which seems to exhibit a state of “abstraction” similar to that surrounding the Council presentations just reviewed.
III. The Current State of Public Discourse
Concerns regarding “professionalism” have been percolating in the public’s and the profession’s consciousness for at least the past two decades. As Dr. Cohen points out, although polls have indicated that people retain a high level of trust in their personal physicians, they have expressed declining trust in the profession as a whole.8 One source of increasing distrust is patients’ belief that financial incentives may encourage physicians to act in other than their patients’ best interests. Other sources of public dissatisfaction include the perception that physicians are spending less time with patients than they once did and that physicians have a higher allegiance to their own financial interests than they do to the interests of their patients.9

Articles in academic and professional journals reflect similar concerns among health care and medical education professionals. In 1995, a group of prominent physicians published The Patient-Physician Covenant, arguing that the covenant of trust that grounds medicine as a moral enterprise is at risk due to the threats posed by the “legitimation of the physician’s materialistic self-interest” and by “for-profit forces that press the physician into the role of commercial agent to enhance the profitability of health care organizations.”10 Three years later, in 1998, both the Association of American Medical Colleges11 and the Accreditation Council for Graduate Medical Education12 launched initiatives to redefine competence in medicine to include attributes of professionalism. And, in 2000, the American Board of Internal Medicine (ABIM) launched “Project Professionalism” to clarify the attributes of professionalism and to determine ways to enhance medical professionalism across medical disciplines.13 The ABIM’s “Project Professionalism” proposed a program of recertification for internists that would recognize the need for “continuous professional development.”14 These organizational efforts to develop and promulgate various definitions of professionalism were paralleled, in the literature, by numerous individual endeavors to explore the non-scientific and non-technical dimensions of health professional practice and to articulate the values, virtues, or attitudes upon which those dimensions depend.                 In addition to articles that specifically address defining professionalism, articulating standards of professionalism, and teaching and assessing professionalism in medical education, newspapers, magazines, and journals have also focused attention on what may be described as lapses in, and challenges to, professionalism: self-referral, corporate gifts and sponsorships, the commodification of health care, health care profiteering, depersonalization, technologization, overspecialization, over- and under-treatment, and any number of conflicts of interest and conceptions of the constituents of good health care.                 In short, both the general public and health care professionals, themselves, have voiced deep concern over the issues discussed by our expert presenters. But, just as the Council sometimes found the discussion regarding professionalism to be too abstract, much of the attention to “professionalism” in both the professional and popular media seems in need of more careful conceptual analysis and clearer articulation. We propose to use a framework anchored in the physician-patient relationship to provide that analysis and articulation.
IV. A Reorientation of the Inquiry into Professionalism: A Description of the Essential Features, the Universal Realities, of Medical Practice
At the Council’s September 2007 meeting, the final presentation on professionalism was made by the Council’s chairman. In that presentation, he articulated a vision of medicine as grounded in the foundational moral relationship between a healer and a patient, someone in need of healing. In further developing this description of the essential features of the practice of medicine (and by implication of the other health professions), he stated that a particular healing act begins when a physician offers to help someone in need of medical assistance. In offering to help, the physician implicitly15 or explicitly “professes” several things: she professes to have special knowledge and skills, attained through specialized training and education, which she will use in order to help restore or enhance the patient’s well-being. She invites the patient to trust that she will use her skills on the patient’s behalf. This is the meaning of being a “professional.”                For the patient’s part, accepting the physician’s offer and entering a healing relationship entails entrusting himself to the physician’s care and revealing his vulnerability: he is asked to disclose intimate information about himself and perhaps to permit physical examination and testing. Seeking medical help necessarily makes the patient acutely aware of his physicality, his embodiment, his finitude, and, thereby, his vulnerability and dependence. Because the patient’s capacity for self-efficacy is compromised by illness, the healing relationship always has the potential to affect the patient’s sense of self-worth or dignity. The medical relationship is, therefore, always laden with moral significance, a moral significance that figures prominently in the standards by which medical practice is to be judged. As Pellegrino and his fellow authors of the 1995 Patient-Physician Covenant argued, the relationship between patient and physician is grounded in a covenant of trust—a covenant rather than a contract because both acknowledge the inequality in the relationship, an inequality that requires the physician to promise not to take advantage of the relationship for undue benefit. 

The end of the relationship, according to Pellegrino, is a right and good healing act for the particular patient in his or her particular predicament; this is what the patient seeks and what the physician promises to seek on behalf of the patient as well. That is to say, the physician seeks to determine the state of the patient’s health, the possible ways in which that state might develop, and the possible interventions that might be attempted in order to change the course of development; then, the physician and patient attempt to determine which course of action to take in order to help heal the patient. Obviously, patients and physicians may disagree in their assessments of what ought to be done, and status of such disagreements and the ways in which they might be resolved is a central moral concern in the professional relationship – a concern that the Council may wish to investigate in more detail.

Although the moral center of professionalism is the physician’s offer to help a particular individual patient, the assistance that the physician qua physician offers is of a specific kind. It is informed by the physician’s education and training in the basic and clinical sciences, which are disciplines built up over centuries through the accumulating knowledge and experience, innovation and devotion, of healers, investigators, and patients themselves. It is a specific form of assistance that also requires skills in its application to a particular patient, in the performance of techniques for diagnosing and treating the ills that led him to seek that assistance in the first place. And it is a form of assistance that is sustained and perfected through the physician’s commitment to medical practice, not as a solitary or proprietary endeavor but as one that is collaborative and shared. This commitment to professional practice is inseparable from the physician’s commitment to the patient—from his promise to help, to heal, the patient.

This commitment to the practice of medicine is, or ought to be, an identity-conferring commitment.16 Professional identity, on this view, entails more than the mere having of an occupation; it entails personal identification with a moral community and a moral tradition in the pursuit of particular end, i.e., the sustenance and promotion of health. Medicine is inherently a moral enterprise that links patients with physicians and physicians with one another. Insofar as physicians bear a communal responsibility, that responsibility must extend to those who would enter the profession as well. The medical profession has an obligation to ensure that those who enter it, who become members of the moral community of medicine, are committed to the proper practice of medicine with the appropriate acknowledgement and respect for the moral relationship at its center. It is here that Drs. Cohen and Leach’s concerns about the moral formation of future physicians arise. (It also gives rise to concerns about character formation of those who are already members of the community and to the nature of the profession’s character, itself.)

Just as the physician incurs obligations to the profession that sustains his practice, so the profession, itself, incurs obligations to the society in which it practices. Society recognizes medicine as a profession that acts as a “trustee” for the knowledge and skills i.e., the technical expertise, that is valued so deeply by all members of society. Because medicine is based in a special body of knowledge and special technical skills that are best evaluated by practitioners, physicians are charged with credentialing those who enter the profession. The profession’s moral duty to maintain the integrity of the enterprise is institutionally recognized in its legal duty to regulate itself and refuse credentials to those who do not meet the standards of good practice.                Compared to any other group, medical professionals have a more thorough and intimate understanding of health and the conditions necessary to sustain and promote it. As professionals, they are entrusted to care for the health of individuals and of society. It may be argued that they have a particular moral responsibility to advocate for the sick and for policies that are most conducive to health. Some also contend that because most medical treatments and resources are prescribed by physicians, the profession has an obligation to advocate for just distribution of such resources. The Physicians’ Charter of Medical Professionalism seems to suggest such a position. On the other hand, the individual physician’s commitment to act in the best interest of her patients seems to militate against the physician’s participation in limiting one patient’s access to treatment due to concerns for the interests of society or for the interests of specific other patient.

In light of this discussion, we hope that it is apparent that public as well as professional understanding of the many issues that are now grouped under the broad umbrella of “professionalism” might benefit from reexamination in light of the act of profession, the nature of the practice, and the ends of medicine. In the public square as well as in more scholarly venues, discussion about the medical and other healing professions is often heated, but confused. The passion these topics arouse is understandable: the questions raised are important to everyone insofar as no one can avoid one or more of the array of ills to which the flesh is heir. No one can avoid the confrontation with human frailty and, ultimately, finitude. It is this facet of our humanity that is at stake in—that seeks and demands clarification in—the current debates regarding all of the issues of “professionalism”: the character and character formation of physicians and nurses; the financial and other conflicts of interest faced by health care professionals; the changes in the organization, delivery, and financing of health care; the evolution of cultural practices and beliefs that shape our concepts and expectations of medicine and health care; and the diversity and pluralism of our beliefs regarding the nature of health and health care. 
V. The Practice of Medicine as a Locus of Moral Concern
To that end, herewith are four themes that a report on professionalism must, almost necessarily, address: (1) the need to articulate a clear conception of the practice of medicine, its aims and obligations (2) the need to examine the virtues that ground medical practice and the ways to form and strengthen moral character in current and future medical practitioners, (3) the need to examine critically current threats to the moral ground of medical practice, and (4) the need to recognize challenges posed by differing understandings of health and health care.

**1. Medicine as Moral Practice**

*A. Distinguishing “Professionalism” from the Act of Profession*

Many articles on professionalism17 begin by stating that there is no agreed upon definition of the term. Moreover, because the title of “professional” often carries a sense of prestige, numerous occupational groups seek to expand the criteria and to be recognized as “professionals.”18 Nevertheless, a careful explication of the meaning of the term “profession” with respect to medicine (and health care professions, more generally) can help to differentiate the practice of medicine from other occupations and careers. Indeed, it may be best to avoid using the term “professionalism” altogether because the term can carry connotations of prestige or elitism or it can be somewhat narrowly or superficially construed as the etiquette and bedside manner of physician comportment. The Council’s discussion of the profession should hew more carefully to the act of profession in health care, that is, to the making of a promise to the patient, a promise that not only recognizes but also protects the patient’s vulnerability. Without explicit acknowledgement of the act of profession, the putative ideals of “professionalism,” “altruism,” and “beneficence” will seem unjustified and abstract. 

*B. The Possibility of a Division of Moral Labor in the Practice of Medicine*

Patients want competent, skillful, and knowledgeable physicians, but they also want, just as strongly, “someone who will care about them. They want a doctor with whom they can have some kind of human interchange…, someone who will show them sympathy.”19 The development of a caring relationship between physician and patient seems essential to building trust, but if there is a moral obligation to “care” rather than merely to “treat” patients, perhaps health care professionals can divide the “moral labor” involved in physician-patient relationships such that counselors, psychiatric nurses, social workers, chaplains, or others would be responsible for the “moral” or “emotional” work while the physician and other professionals would perform more “technical” tasks. Does the existence of professional “care-ers” reduce the physician’s obligation to demonstrate concern for his or her patient? 

*C. Interpreting Health Care Professionals’ Obligations*

Given the particular vulnerability of the patient, which is not limited to “merely physical” conditions but extends to the psycho-social and spiritual dimensions of his or her self-identity, and given the patient’s reliance upon the special knowledge and training of health care professionals, it is not difficult to discern the differences between the physician-patient relationship and other, perhaps more common, relationships, e.g., vendor-consumer or service provider-customer. What does the physician owe any particular patient and what are the limits of that obligation? Is “altruism” required or merely “beneficence,” and what are the differences between the two?20 Can the health care professional’s responsibilities be fully codified and enforced, or does medical practice require the exercise of practical reasoning that cannot be reduced to an algorithm or a flow-chart? What may be reasonably expected and what is supererogatory for the physician? What obligation, if any, does the patient have to the physician? 

*D. The Dynamic Nature of Identity, Relationship, Obligation, and Autonomy*

Of course, other related questions arise as these questions are examined: How are professionals to balance caring engagement with the need to protect their own emotional well-being? The practice of health care that derives from the act of profession clearly entails that the practitioner exhibit sympathy, empathy, and compassion at times, and distance, objectivity, and neutrality at others. What constitutes professional moral behavior will vary not only from patient to patient, but even with the same patient over time as his or her conditions change: the patient, the physician, and the physician-patient relationship are all characterized by dynamism. Even if a patient’s condition does not change, his or her understanding of and reaction to that condition may change. Human attitudes, behaviors, understandings, and identities change as do conditions, contexts, and relationships in which human beings are enmeshed. The Council may wish to reflect on what is stable and what is malleable both in the physician-patient relationship and in the individuals participating in that relationship. 

The patient’s capacity for autonomous choice and his or her desire to exercise choice will also change over time. For that reason, it is important to examine the appropriate way for physicians to demonstrate beneficence in trust,21 i.e., the physician’s obligation always to act in the patient’s best interests, respecting the patient’s autonomy when it is expressed, supporting autonomy by providing clear and understandable information as well as, when requested, advice based on the physician’s experience, and seeking to establish or restore the patient’s autonomy when it is compromised or not fully developed. The Council may choose to reflect on the ways in which patient autonomy is held, in trust, by those who care for him or her. While the well-established principle of respect for patient autonomy is admirable, autonomy takes many forms and admits of many degrees, and a discussion of those matters might serve the public well. 

**2. Moral Community, Character Formation, and Medical Education**

*A. Moral Community*

Another question that may be useful for the Council to address is: What is required of the profession? If medicine is a practice dependent upon a community rooted in shared history and identity,22 then in addition to individual physicians’ obligations to individual patients, the profession, itself, has an obligation to structure itself, to regulate itself, and to uphold standards that will allow it to pursue its moral ends. It has an obligation to structure itself so as to shape the character of its members, current and future, in an environment conducive to means and ends of this activity. The Council may wish to reflect on what encourages community, what encourages an individual to identify with a community, and what helps a professional community to sustain itself. 

*B. Character Formation and Assessment*

As decisive influences in the moral [or character] formation of physicians, undergraduate and graduate medical education offer up a wealth of possible themes for inquiry and exploration by the Council. At both levels, there are efforts underway to define, teach, and assess the so-called “elements” of professionalism, elements that are often listed but not necessary grounded in any more fundamental conception of medicine’s inherently moral nature. The Council could seek to redress this situation by articulating the challenge that confronts medical educators, if, that is, they take seriously the morally formative significance of graduate and undergraduate medical education. There are as well a number of long-standing observations that reveal the ambivalence with which many medical educators view this significance. For example, once admitted to medical school, it is exceedingly rare for a future physician to be seriously disciplined or dismissed, even in the face of strong evidence of poor character. Why is this so? Moreover, should the future physician’s character be assessed with the same rigor accorded to the evaluation of knowledge and skill? Can it be subjected to standardized “measurement,” or is character so fundamentally different from knowledge and skill that it calls for an altogether different approach to accountability? And what of the often described gap between the formal curriculum, with its much vaunted values and virtues, and the hidden curriculum, which is said to impart, far more effectively, the traits that are the mark of the successful physician? 

*C. Moral Psychology and Conflicting Professional Roles*

Of course, these questions echo more foundational questions that some Council members have raised in previous discussions: Is behavior determined exclusively, primarily, or secondarily by enduring character traits or exclusively, primarily, or secondarily by a combination of circumstance, context, and social pressure? The profession’s desire and obligation to bring vibrant and committed practitioners into the professional community would seem to demand some attention to questions of moral psychology, moral education, and character formation, as well as to ways to sustain and enhance moral community. Those concerns raise deeper philosophical questions regarding the nature of the obligation that health care practitioners have to their professional communities: How are professionals to form a community? How closely knit can or should professional communities be? In previous meetings, Council members have expressed concern about tensions inherent in a person’s occupying two or more roles – e.g., physician, educator, administrator, financial officer. Can the moral community of medicine fight the displacement of internal goods of medicine (e.g., the healing relationship itself; health; trust; shared humanity) by external goods (i.e., money), or is the displacement inevitable?

**3. Threats to the Centrality of the Patient’s Good as the   Foundation of Medical Practice**

Medical educators are not the only professionals confronting conflicting roles and responsibilities. Many of the challenges to health care professions are framed in terms of conflicting interests. How should health care professionals weigh or balance their commitments to individual patients, to their profession, to themselves, to their own financial and psychological well-being, to their families, their communities, and their society? The Council could choose to reflect on any of a number of conflicting interests that threaten to replace the patient’s good as the focus of medical practice. As Dr. Relman suggests, there is reason to be seriously concerned about such phenomena as the commodification of medicine, physician self-referral, and physician entrepreneurialism, because they encourage financial gain to supplant the patient’s good as the end of medicine. Corporate sponsorship of education, corporate gifts, and incentive systems that encourage over- or under-treatment threaten to cloud the professional’s judgment regarding treatment and care. The corporatization, bureaucratization, and proletarianization of medicine threaten to divert the professional’s attention from the good of the patient to the good of the institution or to the intellectual stimulation that medical practice provides. When they do that, they run the risk of seeing patients as interesting instances or “occasions” of illness or disease rather than as patient sufferers in need of caring and curing. This displacement of interest is a subtle way to sublimate their frustration at having to subvert their best judgment to standard policy. 

The Council may also wish to reflect upon the ways that our institutions structure our interpretations of morality and our conceptions of the proper practice of medicine. Have changes in the workforce and in our conceptions of what constitutes an appropriate commitment to work (the increasing demands for standardized work schedules, for limited work hours, for family leave) made the ideal of the physician-patient relationship untenable or even obsolete? Has specialization made continuity of care and of healing relationships impossible? Has the introduction of technology made interpersonal healing relationships less important? Is it possible for institutions, bureaucracies, and policies to encourage, rather than discourage, healing and healing relationships? By framing our examination of “professionalism” (with its sometimes superficial connotations) have we neglected the real threat – if the Council agrees that it is a threat – posed by conceptions of the practice of medicine that would ground the ethics of the profession in something other than a recognition of the vulnerability of the patient and the disparity between the patient’s need and the health care professional’s knowledge and skill? Are alternate conceptions of the relationship (as freely entered contract, as mere service, as commodity exchange, etc.) conducive to better care or do they subvert healing? 

 Not only have the administration, remuneration, and, perhaps even the understanding of the philosophical grounding of medical practice changed, so has the structure of medical practice. An immediately evident change in practice is the growth in the number of specialties and sub-specialties, paraprofessionals and non-licensed professionals. The swelling of the numbers of specialists at one end and of non-licensed assistants at the other end of the spectrum of health care “providers” provides additional impetus to depersonalization and an enhanced likelihood of discontinuity in care. Should such changes be accommodated, embraced, or resisted?

A recurring theme in Council discussion is one of conflicting worldviews and conflicting conceptions of the good and the right among groups within a particular society. Can -- or should -- medicine resist the greater contemporary American ethos of individualism, commercialism, scientism, technologism, entrepreneurialism, marketization, bureaucratization, proletarianization, etc.? Do those forces threaten the moral center of health care? Is it possible to buttress the profession and individual professionals against the intrusion of those forces into health care? Have our conceptions of human nature and our moral expectations altered so drastically that the ideas of “profession” or “vocation” are no longer meaningful? The Council may wish to reflect on whether to recommend resistance or acquiescence to what appears to be the direction in which our society is proceeding. How much accommodation, if any, is appropriate – and what grounds resistance, acquiescence, or accommodation? What is the appropriate response? Is capitulation to the market ethos a threat to the moral practice of medicine, or is it a change that the profession must accept and accommodate?

The good of the patient as the moral focus of medical practice is threatened by multiple interests at multiple levels, some of which might be seen best as subsidiary to the good of the patient, and some of which are antithetical to the patient’s good. The Council may wish to discuss whether the patient’s good is the sole or primary moral criterion for evaluating medical practice or whether it is simply one of multiple criteria that ought to be weighed in determining what constitutes good health care

**4. Challenges: Moral Pluralism, Disagreement, and Risk**

 There are a number of challenges to good medical practice that do not necessarily threaten to displace the patient’s good as the primary determinant of good health care. Instead, they are challenges to our conceptions of the patient’s good.

*A. The Relationship between Clinical and Public Health Ethics*

One source of tension that the Council may wish to focus on is that between clinical ethics (the physician caring for particular patients) and public health ethics (which focus on the population as a whole): recent scholarship has suggested that the traditional division of ethical concern between those two foci leaves an intermediary group invisible and marginalized – i.e., those with special needs who need special attention such as those with mental or physical disabilities, the poor, immigrants, children, undocumented persons, etc. Do clinicians have a special obligation to advocate for those who need medical assistance but also need assistance in making their need known? Do professional organizations have an obligation to work in health care advocacy? Can the individual patient’s good be defined without reference to the society in which he or she lives, and, if not, is the patient’s good determined or affected by the good of his or her community?

*B. Inter-Professional Tensions*

 Yet another challenge facing health care professionals is the inter-relationships among different health care professionals. Dr. Day raised concerns about the ways in which members of one group of health care professionals (physicians) relate to another (nurses). Do the various health professions have different moral cores that could help order their relationships and responsibilities? How ought health care professionals and professional organizations relate to one another? Does specialization exacerbate or mitigate tensions among the professions? If tensions between professions affect patient care or the proper functioning of health care teams, it might be wise for the Council to examine those situations.*C. Conscience and Moral Pluralism*

While human beings share a number of needs, desires, interests, and values – which sharing generally allows us to establish stable polities or social unions – we often differ in the ways we rank our values. Disparities in the ways we interpret and order our values are particularly evident and trenchant with respect to issues that are most intimately related to our sense of identity and autonomy. It is not surprising that our values concerning our bodies – issues of life and death, of physical intimacy, and of reproduction – are particularly important to our sense of moral identity, and it is not surprising that these issues are frequent sources of disagreement. It will, therefore, be quite important for the Council to explore the issues of professional conscience and integrity as well as the ways people of good will may differ in their interpretations of what constitutes a good life. Differences in our fundamental understandings of what medicine and health are and of what respect entails are important topics of moral concern.

If physicians commit themselves to acting in “beneficence in trust,” what ought to guide their judgments and actions – the patient’s desires, the patient’s best interests, the patient’s physical well-being? Who determines what constitutes the patient’s good? What should be done when the patient and physician disagree about what would constitute appropriate care, treatment, or practice? Is the physician morally obliged to provide care that he or she judges to be futile? Does cost or ability to pay play a role in determining what care will be provided? Can a physician refuse to refer a patient to practitioners who are willing to perform a service that he or she believes is immoral? 

While we are right to focus our primary concern on patients whose autonomy and sense of self-worth are threatened and/or compromised by their need for health care, we must also recognize that the physician’s autonomy and conscience are also deserving of respect and that the healing relationship cannot call upon the health care professional to violate his or her own conscience or to subjugate it to the will of another. It will be important, therefore, to articulate the circumstances under which a physician may withdraw from a relationship in order to protect his or her moral integrity and his or her professional judgment. A discussion of integrity, conscience, and respect will be in order: should a health care professional be compelled to provide services – or to refer to patients to physicians who are willing to provide services – that are legally permitted but which the medical practitioner interprets as immoral and antithetical to the ends of medicine The Council may also wish to discuss what constitutes “health” and what constitutes a person’s “best interest.”

Finally, the Council may want to consider the interesting issue Dr. Leach raised regarding the ways in which perhaps everyone sees himself or herself merely as a “renter” rather than a “co-owner” of the health care system. There are particular risks that arise when individuals come to identify themselves primarily as parts of a corporate entity: assigning and accepting personal responsibility becomes increasingly difficult. The Council may wish to reflect on whether the various participants in health care – which are, in reality, all of us, whether as patients, citizens, policy-makers, health care professionals, health care administrators, payers, insurers, members of plans, etc. – can find ways to encourage an appropriate and fair sharing or distribution of responsibility, an appropriate sense of “ownership” without such sharing becoming merely a reassignment of risk to those who are already at the greatest risk.                 In conclusion, we close with some observations: In the United States and perhaps throughout the developed world, we appear to be in the midst of a paradigm shift in our conceptions of the healing professions and the ideals that should shape the practice of medicine and nursing. Physicians and other healers were once conceived as professionals, defined by their obligation to perfect their knowledge and skills, their art, in the interests of serving the good of their patients; now, they tend to be seen as proletarians, workers, providers. Once a profession, medicine is now increasingly viewed as a job or occupation, comparable to any other. These changes are troubling, especially insofar as they adversely impact the moral reality of the professional-patient relationship, a relationship that is at once intimate and dependent upon trust—especially the patient’s trust in the professional’s promise to heal. In human experience, there are few relationships that are comparable, in terms of the inherent inequality, the intimacy, and the centrality of trust. These observations only accentuate the importance of how clinicians themselves and society at large understand the obligations of the healing professional for such an understanding will shape and determine behavior and expectations. As patients—and each of us will at some point be a patient—do we want to be treated and cared for by physicians or nurses who view themselves as having an occupation, just like any other -- as mere health care providers or health care workers? What can we retrieve or retain from the older concepts and ideals of medicine to help protect the bond of trust at the heart of the healing relationship between a patient, on the one hand, and a physician or nurse on the other? In the end, these are not questions of limited import for our answers to these challenges in medicine and the healing professions will have implications for the other helping professions and for society as a whole.

_______________________ 
FOOTNOTES-   William M. Sullivan, PhD, Senior Scholar, Carnegie Foundation for the Advancement of Teaching. 
-  Lisa J. Day, RN, CNS, PhD, Associate Clinical Professor, School of Nursing , University of California San Francisco . 
-   Jordan Cohen, MD, President Emeritus, Association of American Medical Colleges. 
-   David Leach, MD, Executive Director, Accreditation Council on Graduate Medical Education. 
-  Arnold S. Relman, MD, Professor Emeritus of Medicine and Social Medicine, Harvard Medical Schoo l . 
-   David Rothman, PhD, Bernard Schoenberg Professor of Social Medicine and Director of the Center for Medicine as a Profession, Columbia University . 
- Cf.  http://www.annals.org/cgi/content/full/136/3/243  for the Physicians' Charter and links to related articles in professional medical journals. Accessed October 16, 2007. 
- Cf.  Testimony by Dr. Jordan Cohen to the President's Council at  http://www.bioethics.gov/transcripts/sept07/session3.html  . See also J. Murphy, W.H. Rogers, H. Chang,  et al  ., "Trends in the Quality of Doctor-Patient Relationships: 1996-1999"  Abstr Acad Health Serv Res Health Policy Meet.   2000; 17: UNKNOWN. Accessed 10-09-2007 at  http://gateway.nlm.nih.gov/MeetingAbstracts/102272282.html  . 
-   See Lisa Sanders, "The End of Primary Care,"  New York Times Magazine  , 2004 Apr 18, pp.52-55; Health System Change: Tracking Report: " Who Do You Trust? American Perspectives on Health Care 1997-2001" accessed on 10-23-07 at  http://hschange.org/CONTENT/457/  ; Meg Bostrom, "Patients Before Profits: Reforming the American Health Care System, A Meta-Analysis of Public Opinion," ( Washington , D.C. : Frameworks Institute, 2002), n.58; Frank Davidoff, "Time"  An Int Med   1997 Sept 15: 127(6): 483-85; Maggie Mahar,  Money-Driven Medicine   (New York: HarperCollins, 2006). 
-  R. Crawshaw, D.E. Rogers, E.D. Pellegrino,  et al  ., "The Physician Patient Covenant  *"* Journal of the American Medical Association   1995 May 17: 273(19):1553. 
-   American Association of Medical Colleges,  Report I: Learning Objectives for Medical Student Education   (Washington, DC: Association of American Medical Colleges, 1998). 
-   Susan Swing, "ACGME Launches Outcomes Assessment Project,"  Journal of the American Medical Association   1998 May 18: 279(18):1492. 
-  http://www.abim.org/pdf/profess.pdf  . Accessed October 16, 2007. 
-  Stephen I. Wasserman, MD; Harry R. Kimball, MD; F. Daniel Duffy, MD, for the Task Force on Recertification, "Recertification in Internal Medicine: A Program of Continuous Professional Development,"  Annals of Internal Medicine   2000 August 1: 133(3):202-208. 
-   The terms "physician" and "medicine" will be used throughout the discussion recognizing that other health care professionals, practices, and professions stand in similar relationship to the patient. The inter-relationships among the professions and professionals may be a topic for further inquiry. 
-   Cf  . Bernard Williams, "Integrity." In J.J.C. Smart and Bernard Williams,  Utilitarianism: For and Against   (Cambridge: Cambridge University Press, 1973), pp.108-118. 
-   See, for example, Morris L.Cogan, "The Problem of Defining a Profession,"  Ann Am Acad Pol Soc Sci  . 1955: 297: 105-111. 
- Cf.   H. L. Wilensky, "The Professionalization of Everyone?"  Amer. J. Sociol   1964: 70:137-158. 
-   Carl E. Schneider,  The Practice of Autonomy: Patients, Doctors, and Medical Decisions   (New York: Oxford, 1998), p.195. 
- **Cf.  W. Glannon and R.F. Ross, "Are Doctors Altruistic?"  J Med Ethics   2002:28:68-69. 
- Cf.   Edmund D. Pellegrino and David C. Thomasma, Chapter Three in  For the Patient's Good: The Restoration of Beneficence in Health Care   (New York: Oxford, 1988). 
-  Alasdair MacIntyre's work on traditions, communities, practices, etc.  .  , could serve as a strong foundation if the Council chooses to pursue this line of inquiry. 

             

             

             

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