professionalism: the emperor has no clothes!

I’ve long wondered about the dominance of “professionalism” as the guiding moral code for physicians, and I’m glad to have found this article via The Good Physician Project that explains why it’s such an uneasy stricture:

To defend its conclusions, each professionalism statement appeals to values that are supposedly inherent to the practice of medicine, and each statement presents itself as a consensus document about the virtues necessary for good medical care. But this is, at best, ironic: the very need for these statements, as well as the large amount of energy, time, and resources dedicated to producing them, betrays the fact that the described virtues are not shared by all physicians. There is, as Coulehan has described, a “hidden curriculum” deeply entrenched in modern medical practice, which in many ways directly contradicts the lofty ideals of the professionalism statements.^9,10 It is also unclear whether the professionalism statements have made any difference in the actual practice of medicine.

We fully support the various statements on professionalism with respect to patient care, and we agree with the sponsoring organizations that adherence to these standards is imperative for the proper practice of medicine. We further agree that adherence to these standards is not universal among physicians and that it is the responsibility of the medical profession to self-regulate and to mandate adherence to these standards. We do not believe, however, that these statements or the well-intentioned and well-organized movements that have produced them are likely to do much to correct the problem.

As with most large-scale moral endeavors taking place nowadays, professionalism in modern medicine is living off borrowed capital. Liberal, Western societies were formed by particular moral communities, but they have chosen to cut themselves from the religious traditions that sustained these communities in favor of fuzzier values and professionalism. It would be all well and good if moral formation for physicians (or anyone, really) was just a matter of consensus values — your consensus is going to be helplessly influenced by the broader power structures and fads of your day, but at least it’s easy enough to agree on a few basic things and let an ethics committee decide when there’s there’s not enough (or too much) autonomy to make a decision.

The problem, though, is that within medicine the “hidden curriculum” is so powerful that any values you want to promote (from patient dignity to anti-racism) are inevitably beholden to that hidden curriculum and the social and economic forces that sustain it. Without a thick moral community to form learners before they ever matriculate and then to sustain them once they are in the thick of things, the system will inevitably keep chugging along and learners within that system will learn to get along without resisting the everyday injustices. If you really want a healthcare system that trains people to work for justice in their communities, you need a moral and/or religious system stiff and cranky enough to resist injustice, no matter how difficult or how great the sacrifice. And a commitment to “professionalism”, however valuable, is not going to do the trick.

In a sense, the emperor of medical professionalism, as described in the various statements on professionalism, has no clothes. There is no common consensus or morality intrinsic to modern medical practice in which the professional virtues can be firmly cultivated and grounded. But our argument is constructive as well as critical. We believe firmly in the professional virtues, and we believe that the virtues have been, and can be, grounded and “clothed” in the rich moral, cultural, and religious traditions that make our culture so complicated, dynamic, and colorful. We propose a model of education that allows these colors to shine in their particularity by encouraging participation in communities of virtue that will allow the professional virtues to be cultivated from within rather than imposed arbitrarily from without. The emperor, we believe, has clothes, but we wonder: will he choose to wear them?