Ethics and professionalism in a changing world

Abstract

While medicine is in a fairly constant state of change, the same could be said about the organisation and provision of healthcare, which can lead to conflicting obligations as regard ethics, professionalism and the standards to which clinicians are generally held to account. Additional complexity arises if there is confusion as to what these two domains comprise, and while there is plenty of literature on ethics and professionalism in medicine, much less has been written about the relationship between them. A lay observer could be forgiven for having little sense of where one ends and the other begins. It is also possible that few practicing professionals have pondered specifically on these issues, and not only should it help educators (whose task it is to design, implement and assess programmes and curricula) to have greater clarity on these issues, but it could potentially be of benefit to patients as well.

Ethics and professionalism are not the same, even though they are closely connected. If ethics and professionalism are to become part of the DNA of practicing clinicians, it should be clear to everyone of what the domains comprise, and what the terminology means. This could make a difference in how doctors behave towards each other, and more importantly, towards their patients; attitudes define behaviours, which in turn influence the way in which individual episodes of care are given, so this is far more than simply a question of semantics.

Resumen

La medicina se encuentra en un estado constante de cambio, y lo mismo podría decirse de la organización y la prestación de servicios de salud, lo que puede dar lugar a obligaciones contradictorias en cuanto a la ética, el profesionalismo y las normas a las que los clínicos generalmente se enfrentan. La complejidad aumenta si hay confusión en cuanto a lo que comprenden estos 2 dominios, y si bien hay mucha literatura sobre la ética y el profesionalismo en la medicina, menos se ha escrito acerca de la relación entre ellos. Un observador lego podría ser perdonado por tener poco conocimiento sobre dónde termina uno y empieza el otro; también es posible que pocos profesionales hayan reflexionado específicamente sobre estos temas, y no solo puede ayudar en el caso de los educadores (cuya tarea es diseñar, implementar y evaluar los programas y planes de estudios) para tener mayor claridad sobre estos temas, sino que potencialmente podría también beneficiar a los pacientes.

La ética y el profesionalismo no son lo mismo, a pesar de que tienen una conexión íntima, y si la ética y el profesionalismo se convertirán en parte del ADN de la práctica de los médicos, debe ser claro para todos los dominios que comprenden y lo que significa la terminología. Esto podría hacer una diferencia en cómo los médicos se comportan el uno hacia el otro, y más importante aún, para con sus pacientes; las actitudes definen el comportamiento, el comportamiento influye la forma en que se dan los episodios individuales de atención, así que esto es mucho más que simplemente una cuestión de semántica.

Introduction

It is often unclear where ethics ends and where professionalism begins, and this paper questions not only how the concepts are defined, but how they relate to one another in the rapidly changing world of medical practice. One reason why medicine continues to be afforded status as a profession is because it sets standards of conduct and technical expertise that patients and public can reasonably expect to be displayed by a registered doctor. However, not all countries work to the same standards or have fully functional mechanisms in place in order to uphold them.¹ It cannot simply be assumed, therefore, that standards are uniform or that they will apply equally in all different settings, even though one could argue that ethics and professionalism are about higher-level values that are immune from cultural difference and rise above the vagaries of individual healthcare systems.

Discussion

An important feature of professionalism is that it is outward-looking not inward-looking, having nothing to do with the self-serving interests of doctors and everything to do with protecting patients and members of the public.² While public protection and the provision of public service have long been embedded within the concept of professionalism, such concepts risk losing their meaning. Present realities of healthcare delivery mean that increasingly professionalism has less to do with public service, and more to do with meeting targets, even though in a country such as the UK, the tenet of public service is enshrined within a written constitution.³

It is fair to say that without a sense of public service, respect for the profession as a profession may not be entirely justified, since respect must be earned from colleagues and patients before doctors can reasonably expect to be afforded benefits that accrue from attaining professional status (such as higher than average earnings and social status within the community). Ethics and professionalism need to be relevant to the society in which medicine is being practised, and it is insufficient to rely on broadly defined universal principles unless they connect to the realities of modern practice.

While the connection between ethics and professionalism is close, the terms are not interchangeable. While many attributes of medical ethics pertain directly to professionalism, not everything in ethics is about professional practice, and not all points of professional practice give rise to matters of ethical concern. To avoid circularity, it is worth looking further at these relationships, and interdependence may be the best model to use, whereby ethics and professionalism could be said to comprise two equal but overlapping circles, i.e., being neither separate nor two fully integrated domains. Each has its place and each has relevance to the other.

If the Encyclopaedia of Bioethics is right, “the task of ethics (moral philosophy) is to answer systematically a range of questions concerning right and wrong conduct”⁴; while this is a useful description, it is hard to define ethics accurately other than by reference to its application. Similarly, the Stanford Encyclopaedia of Philosophy offers no single definition for ‘ethics’, choosing instead a list of applications, such as ‘business ethics, virtue ethics, feminist ethics’, and so forth.⁵ Therefore, it is unsafe merely to assume that doctors, patients and the public know what the term ‘ethics’ means, and above all, it has to be grounded in practice. Professionalism similarly acquires meaning through being applied, and when, where and how the concept is applied also influences how it is applied. Unless and until it can be demonstrated that theory translates into practice, each term will have limited relevance to day-to-day clinical practice.

The following may be taken as a working definition of professionalism: “A concept applying to a particular category of persons that includes attitudes and behaviours in and out of the workplace”, its opposite being unprofessionalism, which is about “behaviours that fail to conform to normative standards set by an independently regulated profession, such as medicine”.⁶ While “as yet there is no overarching conceptual context of medical professionalism that is universally agreed upon”,⁷ neither ethics nor professionalism can be pulled out of the drawer (or downloaded), and simply applied wherever or whenever medicine is practised. They need to be absorbed into the culture of medical practice to make a difference, and ethics and professionalism may need to be articulated differently according to local, geopolitical and legal factors.

Nobody expects the way in which healthcare is delivered to be the same, for instance, in Sub-Saharan Africa, rural India, Europe or North America; ethics and professionalism should not stand alone, and unless they can be absorbed into all areas of medical culture, they risk losing validity. Take the syllogism all doctors are professionals; all doctors are skilled at their job; therefore, all doctors are skilled professionals: one could rightly say that the conclusion is supported by the premises, but the premises themselves are untrue since not all doctors are equally skilled at their job, and not all doctors behave professionally all of the time. Technical skill is insufficient on its own just as behavioural attributes without the necessary technical competence are insufficient; both characteristics need to be present (and capable of being assessed) in order for a doctor to earn status that comes from being a medical professional. While training undoubtedly influences how clinicians do their job, other influences also play a part, including attitudes and behaviours exhibited by peers and seniors.⁸ Where professionalism is included in training programmes and medical school curricula,⁹ it is likely that it will also be assessed, and for this exercise to be worthwhile, the underlying concepts need to be both well-defined and relevant to modern practice.

When the American Board of Internal Medicine argues that “Professionalism is the basis of medicine's contract with society”,¹⁰ it does not of course say how that contract is defined (e.g., in the context of continual changes to the way that healthcare is delivered). Professional standards, in so far as they refer to ethical codes and norms, should not be divorced from social settings if they are to remain meaningful and relevant. Social context is influenced by many factors, including the culture of medicine, which may not always be benign, exerting a powerful but largely hidden influence.

Professionalism is about relationships: social relationships that determine an individual's position within society; clinical relationships that influence how a doctor interacts with patients; financial relationships that potentially influence motivations and behaviours, and inter-professional relationships that determine how a doctor interacts with colleagues and adheres to ethical standards. Core components of professionalism are commonly framed by reference to ethical norms, such as respect for confidentiality and patient autonomy, and behaving in an appropriate way towards one's colleagues³; however, it takes an expenditure of effort in order to ensure that these constructs are culturally and socially relevant. Contemporary society is rarely mono-cultural, and if standards are to enjoy any kind of moral validity, they need to be inclusive and applicable to diverse populations.

Social values vary within and between cultures, and similarly attitudes towards the rights of patients can vary between East and West. For instance, what is accepted as standard protocol in one country or social context could be considered unacceptable in another (e.g., as regard informed consent and the role of family).¹¹ In some cultural settings, the family is there in a supporting role with actual decisions being made by the competent patient. In other settings, the family plays a much more decisive role, and even patients with capacity may not be made aware of their diagnosis or properly informed about the available options.¹²

The World Medical Association Ethics Manual acknowledges the fact that ethics can change with time and that ethical values are susceptible to social and cultural influences,¹³ but such guidance is only really valuable if it translates into higher standards of practice. This is unlikely to happen if clinicians view such guidance as irrelevant, or worse still, if they are unaware of its existence. Stanton et al. are right to say that “the changing world is complex and often intimidating to professional norms”,¹⁴ and while professional standards should be clearly stated, they need to be able to respond to such complexity, which requires an expenditure of time, effort and resources.

Summary

Professionalism is capable of providing a useful framework for modern practice, but it risks being undermined through pressures that increasingly manifest themselves in everyday clinical practice. Unless frameworks and codes of practice translate in such a way as to influence clinical practice, then their core value risks being undermined. The concepts themselves should be clear and meaningful, and to this end, it might be useful to treat ethics and professionalism as comprising two distinct but overlapping domains.

Because social and cultural difference impacts on how things work in practice, professionalism needs to be sensitive to the environment in which it is applied, and thus, historical notions of ethics and professionalism should not be relied upon if they are no longer fit for purpose. To address these issues requires fresh thinking and a degree of determination, without which the future of medical professionalism, including the ethics that it embodies, could be open to question.

Conflict of interest

The authors have no conflicts of interest to declare.

Funding

No financial support was provided.

Acknowledgements

My thanks to Drs Richard Hays, Gregor Becker and Ming-Jung Ho for help and advice in relation to earlier drafts of this paper; my thanks also to members of the Program for Biomedical Ethics at Yale University, CT, and Meridian Health Program for Ethics and Humanism in Medicine, Jersey Shore University Medical Center, NJ, for contributions made at respective symposia on these topics.