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Medical Professionalism in Society

Article  in  New England Journal of Medicine · December 1999

DOI: 10.1056/NEJM199911183412112 · Source: PubMed

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 The Ne w E n g l a nd Jo u r n a l o f Me d ic i ne

Sounding Board the importance of professional self-regulation, espe-

cially in health care.19,21 Sociologists who study the
professions have become less cynically focused on
power. They have acknowledged that professional self-
regulation, although susceptible to abuse, serves nec-
M EDICAL P ROFESSIONALISM essary social functions.19,22 Still, the earlier attacks
IN S OCIETY on professionalism left this term with no coherent
meaning. Lacking systematic knowledge about pro-

T ODAY, at the dawn of a new century, genuine

medical professionalism is in peril. Increasing-
ly, physicians encounter perverse financial incentives,
fessionalism, many people use the term to refer to
ill-defined, sometimes self-serving, concepts.23-25 A
clarification of genuine medical professionalism is nec-
fierce market competition, and the erosion of pa- essary if the current unraveling is to be reversed.8,26-28
tients’ trust,1-7 yet most physicians are ill equipped to
deal with these threats.8,9 The role of professionalism PROFESSIONALISM IN SOCIETY
has been so little discussed that it has virtually dis- Medical professionalism is more than merely an
appeared in the battle between those who favor mar- activity that straddles market competition and gov-
ket competition in a trillion-dollar industry and those ernment regulation. Likewise, it is much more than
who seek greater government regulation.8 Physicians, a technical necessity for delivering a needed good or
feeling trapped between these camps, are turning to service, and it cannot be reduced to a “deal” nego-
unionization and other tactics.10 tiated with society. We think of professionalism as an
In the first half of this century, medical profes- activity that involves both the distribution of a com-
sionalism was generally understood according to the modity and the fair allocation of a social good but
structural–functional approach of Talcott Parsons and that is uniquely defined according to moral relation-
his school.11-13 This approach catalogued the distinc- ships.29 Professionalism is a structurally stabilizing,
tive characteristics of professions and then attempted morally protective force in society. Along with pri-
to discern the social function of each. For instance, vate-sector and public or government activities, it is
professional cooperation, rather than competition, a cornerstone of a stable society.
was seen as serving the public good by increasing Dramatic failures of medical professionalism to
the speed of dissemination of new information. Par- provide moral protection have occurred in recent
sons also believed that professionals were predis- memory, each failure marking a time of social disar-
posed to public service because they were less inter- ray or worse. Apartheid in South Africa overpowered
ested in amassing wealth than in achieving recognition core health care values,30 as did the Soviet Union’s
among their colleagues for doing good work.11 misuse of psychiatric diagnoses.31 The perversion of
Although their work was illuminating in many medical values, and the complicity of physicians and
ways, the structural functionalists failed to consid- other health care practitioners in this perversion, were
er the moral foundations of professionalism, and this an integral part of Nazism.32-34
failure resulted in a confusing conflation. Distinctive The social role of professionalism as a stabilizing
characteristics rather than moral premises were used force is not unique to the medical profession. Com-
to define professionalism. For example, self-regula- plex societies in different times and places have had
tion, which is a distinctive characteristic necessitated in common a need for meritocratic, dedicated sub-
by the nature of professional work, was understood groups that function to keep private interests and
instead as the essence of professionalism. In the ab- government power in balance through attention to
sence of an explicit moral base, critics could readily greater social goods. For instance, de Tocqueville re-
claim that self-regulation by physicians was nothing marked that American lawyers of his time served as
but a cover for the monopolization of trade. a stabilizing force in American society, tempering
In the 1960s, a critical academic literature seized the excesses of government and private industry.35
on this weakness, combined it with empirical evidence Similarly, the protected Mandarin class in pre-Com-
of professional self-interest, and asserted that profes- munist China served this role for many years, criti-
sional ethics were a cynical ploy.14-18 As Freidson not- cizing both the state and the private sector in order
ed, “When the leaders of the profession invoke ethics to protect vulnerable social goods.36
and the values of professionalism, [the] critics declare Professions protect not only vulnerable persons
it a self-serving ideology that masks the reality of na- but also vulnerable social values. Many values are vul-
ked self-interest.”19 Practical attacks on professional- nerable: individuals and societies may abandon the
ism gained strength from these criticisms. Through- sick, ignore due process in judging the guilt or inno-
out the 1970s and 1980s, claims that physicians were cence of a person accused of a crime, provide inad-
exploiting their trade monopoly led to the use of an- equate support for education, propagate information
titrust legislation against physicians.20 that suits those in power while stifling different per-
By the 1990s, many academics were reaffirming spectives, and so on. Values are so vulnerable that it

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 SOUND ING B OA RD

is hard to think of any society that has not at times of other goals. That is, physicians must be devoted to
lapsed in protecting them. Good civilizations, how- the work of providing health care.
ever, limit and reverse such lapses, in part by entrust- Physicians who value individual and public health
ing designated groups of people — physicians, law- more than other social goods remain motivated to
yers, teachers, journalists, and others — to safeguard work hard even when the financial rewards for such
the values. When professionalism in these core social work are not great. They criticize and police one an-
activities becomes unsteady, it marks the emergence other even when such actions have personal, social,
of societal problems. and financial costs. They offer high-quality services
That the need for professionalism is more than whether or not patients are capable of judging their
technical does not undermine the legitimacy of the quality. They continue to provide health care even
technical argument.19 In medical matters, neither pa- when, as during an epidemic, they risk their own
tients as consumers nor government regulators have health. And they maintain their obligations to care
sufficient training, experience, or time to assess ev- for financially disadvantaged patients.38-40 Today, the
ery health care product and service; the services pur- ascendance of marketplace values puts health care
chased are too complex, rapidly changing, and dif- for the poor at particular risk.3,41,42 Physicians should
ficult to correlate with measurable outcomes. Lay influence the organizations in which they practice to
medical education can alter the scope of needed pro- adopt policies that address the care of impoverished
fessional oversight, and this is desirable in many persons. Similarly, physicians must resist incentives that
cases. But illness will always limit the ability of pa- place the trust between patient and doctor and even
tients to “shop around” when important purchasing patient care at risk.5,43,44 Devotion to medical service
choices must be made.3 Professional groups, through is so important that physicians must avoid even the
the establishment of standards, education, and peer appearance that they are primarily devoted to their
review, can go a long way toward supplying quality own interests rather than to the interests of others.
assurance.37 Dramatic rises in physicians’ incomes over the past
In making a full case for professionalism, we do four decades have fostered the trust-destroying belief,
not wish to overstate the claim. In particular, we note whether true or not, that physicians as a group are
that respect for human worth, trustworthiness, and greedy and take advantage of patients.17,45-49
the protection of important values are not the exclu-
sive province of professionals; neither is competence. Public Profession of Values
But they are particular obligations of professionals. Physicians should speak out about their values. The
We also remain mindful that professionals, no less than word “profession” means, from the Latin, “speaking
entrepreneurs or government officials, can misuse forth.” Public avowal of values has been a distinctive
their power and have done so. The danger that pow- feature of the professions from before medieval times.
er will be misused is inherent in any system that as- Although acting on one’s professional devotion to
signs authority to a group of people to police them- medical service is a form of public profession of val-
selves. A full understanding of what professionalism ues, it is not enough. The unique nature of the re-
entails provides some protection against this danger. lationship between patient and physician requires an
explicit and professionally protected moral base so
A MODEL OF PROFESSIONALISM that there can be legitimate shared expectations,
Three core elements of professionalism, each dif- even in circumstances, such as emergencies, in which
ferent in nature, are necessary for it to work proper- individual relationships have not had time to ma-
ly. First, professionalism requires a moral commit- ture. The patient–physician relationship is based on
ment to the ethic of medical service, which we will shared experiences of vulnerability and the potential
call devotion to medical service and its values. This for health or illness and on a resultant respect for the
devotion leads naturally to a public, normative act: inestimable value of human life and health.50 Fur-
public profession of this ethic. Public profession of thermore, health care values focus on the public as
the ethic serves both to maintain professionals’ de- well as the individual. As Samuel Johnson noted, “A
votion to medical service and to assert its values in decent provision for the poor is the true test of civ-
societal discussions. These discussions lead naturally ilization.”51 Health care values reflect this assertion.
to engagement in a political process of negotiation, Through public profession of health care values, pa-
in which professionals advocate for health care val- tients and the public hear about these values as well
ues in the context of other important, perhaps com- as the standards that result from them. They hear that
peting, societal values. physicians’ commitment to such important standards
as never exploiting patients’ inherent vulnerability
Devotion to Medical Service and not abandoning patients is timeless. They hear
Physicians should cultivate in themselves and in that other, specific aspects of health care values are
their peers a devotion to health care values by plac- delineated in a continuous dynamic process with so-
ing the goals of individual and public health ahead ciety, to which physicians bring their training, profes-

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 The Ne w E n g l a nd Jo u r n a l o f Me d ic i ne

sional virtues, interprofessional relations, and above curred, for instance, in the difficult transition to man-
all, experiences in caring for patients. Finally, public aged care and at the start of the AIDS epidemic.
profession of values — for example, by participating Failure to profess health care values publicly may
in “white-coat ceremonies,” posting ethics codes in lead to uninformed, misinformed, or piecemeal pub-
waiting areas, and contributing to and espousing the lic policies. And failure to negotiate an acceptable
standards of a professional association — demands social contract leads the public to establish other
commitment.52,53 A public, collective commitment contracts in order to obtain what it needs and wants.
to fulfill legitimate expectations implies an accept- As one example, “alternative” practitioners and ther-
ance of accountability for one’s professional actions, apies become more attractive to the public when
as well as an acceptance of the shared standards of they provide something desirable that the profession
the profession, which may sometimes conflict with has ignored in individual or social negotiations. Yet
personal beliefs. negotiation does not mean simply giving the public
what it wants. An overemphasis on satisfying public
Negotiation Regarding Professional Values demands, without attention to core health care val-
and Other Social Values
ues, will ultimately leave both professionals and so-
Public profession of values inevitably requires pro- ciety unprotected. In addition, professionalism may
fessionals to engage with the public in negotiating be misused if physicians become devoted, as individ-
social priorities that balance medical values with other uals or groups, to values derived from other sources,
societal values. This political process of negotiation such as business values. Finally, an exaggerated de-
should lead to what is sometimes referred to as a so- votion to an ethic that is determined solely by pro-
cial contract between physicians and the public.54 fessionals may lead to paternalism or to the refusal
The process of negotiation not only clarifies legit- to consider other important perspectives.
imate public and professional expectations but can
also prevent counterproductive paternalistic behavior A SPECTRUM OF PROFESSIONAL
on the part of professionals. Individually, the process ACTIVISM
fosters patient-centered care by including each pa- With this model of professionalism as devotion,
tient’s health goals in decision making. Collectively, profession, and negotiation, exactly how, in a prac-
it can help accommodate a suitable social disposition tical sense, should physicians act on behalf of pa-
toward medical care. The process of negotiation can tients, the public, and health care values? What types
make clear professionals’ obligations to meet public of activity constitute professional advocacy?
needs, reminding the profession that it cannot have The advocacy activities of individual professionals
everything its own way and simultaneously demand- should fall along a spectrum, with more extreme ac-
ing appropriate advocacy. Tension may develop be- tions requiring more stringent justifications.57 At one
tween what society wants of physicians and physicians’ end of the spectrum is routine advocacy for patients
devotion to health care values. For example, portions and public health. Routine advocacy constitutes phy-
of society today favor intense market competition sicians’ regular daily activity. Physicians working in
among physicians as a way to lower the costs of care. health care delivery organizations — coordinating
But such competition encourages the development of care, working to improve practice guidelines, and so
trade secrets among physicians, such as proprietary on — should advocate health care values rather than
practice guidelines,55 and impedes the collegial in- government or corporate values, speaking on behalf
teraction and information sharing that are needed to of patients and health care. Occasionally, this type of
provide high-quality care. The challenge for physi- advocacy may be personally risky. For instance, phy-
cians is to be accountable to the public and its chang- sicians who appeal adverse coverage decisions on be-
ing values while protecting core health care values. half of their patients may put at risk their standing
with health plans.
An Archetypal Model of Professionalism If advocacy fails, physicians have an obligation to ex-
We propose that an ideal archetypal model19,56 of press internal dissent with regard to activities or pol-
medical professionalism entails the three elements of icies that undermine core health care values. This
devotion, profession, and negotiation. The model is responsibility is what distinguishes genuine profes-
ideal in that it is not descriptive of the reality today sionals from “company docs.” Although internal dis-
or in any other era. It is archetypal because it is in- sent is not always clearly distinct from routine advo-
tended to describe only core elements of profession- cacy, it is a negative form of activism that may go
alism. The purpose of the model is to provide a against an internal hierarchy. Internal dissent may re-
normative guide. quire courage and skill to achieve a positive outcome,
Each element may fail, may be misapplied, or may but it generally requires minimal moral justification.
not be in balance with the other two. A failure of Public dissent is next on the spectrum and should
devotion to the ethic of medical service leads to self- be used with more care. It may raise tensions and
protective behavior on the part of physicians, as oc- backfire, causing harm. For instance, the dissenter

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 SOUND ING B OA RD

may be demoted or fired, thereby perhaps harming a physician’s exit, so it must be justifiable on the fol-
patients’ care, or a point of dissent may become more lowing moral grounds. The harm to be prevented
difficult to resolve because publicity can provoke de- must be obvious and large; advocacy, dissent, and
nial or defensiveness. Public dissent is warranted only disobedience must have been tried; and there must
when internal dissent has demonstrably failed to rem- be a good prospect that health care overall will be
edy a harmful situation, when outside pressure is like- substantially better served if the professional makes
ly to be required to achieve change, when public a principled exit than if he or she continues to exert
silence allows the harmful situation to continue, and a strong voice for change within the organization.
when the potential harms to patients from public Because a principled exit is sometimes easier than dis-
dissent are relatively small. For example, the proposed obedience, particular care should be taken to avoid
closing of a clinic may justify efforts to galvanize com- distorted versions of it. A self-righteous exit helps no
munity support through public dissent. one in need (and actually does harm by eliminating
With direct professional disobedience, the fourth a potential source of advocacy) and primarily serves
form of activism on the spectrum, professionals act the dissenter’s self-image. This type of exit is an act
against authorities, publicly disobeying rules or laws of self-righteousness or even cowardice masquerad-
that are antithetical to health care. Direct profession- ing as professionalism. In the right circumstances,
al disobedience has a clear potential to harm patients, however, an exit may be both honorable and coura-
the profession, and professionals themselves. It should geous. In one very unusual circumstance, profes-
therefore be reserved for situations in which both sional disobedience and exit were chosen simultane-
internal and public dissent have failed, direct disobe- ously by a group of physicians as the only way to
dience is likely to be effective in remedying the prob- maintain the moral base of medical practice: Dutch
lem, the problem is very serious (preferably, its seri- physicians in World War II turned in their licenses
ousness can be documented empirically), and the but continued to practice underground, to avoid
action entails as little harm as possible.58 Surrepti- practicing under Nazi rule.34 The extreme nature
tious disobedience, such as secretly “gaming” a bill- of this example illustrates the burden of proof that
ing code to obtain coverage for services, is not jus- those who wish to exit must meet before claiming
tifiable as a form of direct professional disobedience, that such an action is necessary to maintain profes-
since it is neither public nor aimed at achieving sys- sionalism.
temic change.59 In contrast, delivering free care de-
spite a policy to the contrary, urging colleagues not CONCLUSIONS
to comply with California’s Proposition 187 (which We believe there is an essential role for profession-
called on physicians not to treat illegal immigrants), alism in society that market-driven and government-
and openly breaking a contractual “gag rule” are ex- controlled health care alone cannot provide, and we
amples of justifiable disobedience.60,61 propose three core elements of medical profession-
Indirect professional disobedience is the disobey- alism: devotion to service, profession of values, and
ing of otherwise unobjectionable rules in order to negotiation within society. Each element can be mis-
call attention to a wrong.58 Indirect actions become applied, but in balance they offer normative guidance.
appealing when it is not helpful to disobey directly. The model calls on physicians to engage in profes-
For example, physicians may not be effective in pro- sional activities along a spectrum of advocacy, there-
testing a health plan’s underprovision for the unin- by helping to preserve the decency and stability that
sured by directly caring for them — providing char- are essential to civilized society.
ity care is a normal part of professionalism and in an
open system it may even facilitate the injustice. But MATTHEW K. WYNIA, M.D., M.P.H.
an indirect action, such as collectively refusing to hon- American Medical Association
or a dress code, might call attention to the situation. Chicago, IL 60610
Although the danger of harm from such an action
may seem remote, indirect disobedience can be more STEPHEN R. LATHAM, J.D., PH.D.
harmful than direct disobedience, because in the lat- Quinnipiac School of Law
ter the action itself preserves patient care. Protestors New Haven, CT 06518
may also overestimate the effectiveness of their cam-
AUDIEY C. KAO, M.D., PH.D.
paigns.58 To be justified, the disobedient act should,
JESSICA W. BERG, J.D.
at a minimum, be clearly linked with the offensive
LINDA L. EMANUEL, M.D., PH.D.
situation, be seen as reasonable by the public, be un-
likely to result in greater harm to patients or others, American Medical Association
Chicago, IL 60610
and be likely to result in lasting positive change.
Finally, a principled exit from medical practice with- The opinions expressed in this article are those of the authors
in a health care system is justifiable in catastrophic and may not reflect the official policies of the American Medical
circumstances. Patients will frequently be harmed by Association.

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 The Ne w E n g l a nd Jo u r n a l o f Me d ic i ne

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