The professionalism movement: can we pause?

The topic of developing professionalism dominated the content of many academic medicine publications and conference agendas during the past decade. Calls to address the development of professionalism among medical students and residents have come from professional societies, accrediting agencies, and a host of educators in the biomedical sciences. The language of the professionalism movement is now a given among those in academic medicine. We raise serious concerns about the professionalism discourse and how the specialized language of academic medicine disciplines has defined, organized, contained, and made seemingly immutable a group of attitudes, values, and behaviors subsumed under the label of "professionalism." In particular, we argue that the professionalism discourse needs to pay more attention to the academic environment in which students are educated, that it should articulate specific positive behaviors, that the theory of professionalism must be constructed from a dialogue with those we are educating, and that this theoretical and practical discourse must aim at a deeper understanding of social justice and the role of medicine within a just society.     

医患关系的本质:医生的专业视角及其伦理意蕴

力图从为西方医学领域已完善发展及广为接受的专业(Professional)视角对医患关系(Patient-professional Relationship,以下及正文中皆简称为PPR)的伦理意蕴做探讨.简要追溯了现代医护专业精神的起源,说明了道德责任之所以是专业这一概念的重要组成部分的原因,并且指出为病人最大利益着想是医护专业最根本的道德规范与责任,亦是医患关系不可缺少的伦理基石.     

Physician Involvement in Torture: An Ethical Perspective

Evidence proves that physician involvement in torture is widely practiced in society. Despite its status as an illegal act as established by multiple international organizations, mandates are routinely unheeded and feebly enforced. Philosophies condemning and condoning torture are examined as well as physicians’ professional responsibilities and the manner in which such varying allegiances can be persuasive. Physician involvement in torture has proven detrimental to the core values of medicine and has tainted the field’s commitment to individuals’ health and well-being. Only when this complex issue is addressed using a multilevel approach will the moral rehabilitation of medicine begin.     

Professional Education and Professional Ethics Right to Die or Duty to Live?

Despite the undeniable ethical dimensions of paid occupations — trades and services — other than the traditional professions, it is still natural to associate courses of professional ethics with medicine, law, nursing or teaching, rather than auto-repair, supermarket assistance or window-cleaning. Indeed, it seems plausible to hold that if there is anything more to the traditional distinction of professions from trades or other services than considerations of social and economic status, it might well reside in the distinctive ethical or moral character and implications of such occupations as medicine, law and education. This paper undertakes to explore, via examination of some of the commonly suggested criteria of professionalism, the nature of such implications and the extent to which they justify continued deployment of a distinctive occupational category of 'profession'. On the assumption that they do, however, the paper is also concerned to examine critically the consequences for education in professional ethics of any such distinctive ethics of profession.     

The nature of illness experience: a course on boundaries

With the Accreditation Council for Graduate Medical Education's designation of "professionalism" as one of six core competencies in residency medical education, some educators of residents and medical students believe that the concept of professional role is too restrictive and narrow for grappling with the complex dynamics of professional-patient relationships. The ethical quandaries of abortion and physician assisted suicide illustrate how individual personal values cannot be ignored in the dynamic relationship between health care professional and patient. This article describes a medical school course where students are paired with "patient mentors." Within the dynamic and intimate relationship that unfolds over several months, students explore the "experience of boundaries," and are invited to use this experience to consider their evolving professional identity.     

Trainees with Competence Problems in the Professionalism Domain

Increasingly, professionalism has been recognized as a core competency for health service professionals and is the domain in which vexing competence problems are observed in trainees. We begin by describing manifestations of problems of professionalism in accord with the values that fall within the rubric of this multifaceted construct. We provide an approach for evaluating problems of professionalism and discuss intervention for trainees with mild, moderate, or severe problems in this domain. We propose implications for training focused on enhancing the culture of programs; bolstering the education, guidance, and mentoring provided related to professionalism; and encouraging best practices for addressing trainees with problems of professionalism. We conclude by sharing ideas about defining professionalism, identifying problems of professionalism, strengthening our approach to assessing professionalism and intervening when problems are evident, developing strategies for preventing professionalism problems, and ensuring that psychologists take seriously their responsibility to address professionalism concerns with colleagues.     

Towards a Confucian Virtue Bioethics: Reframing Chinese Medical Ethics in a Market Economy

This essay addresses a moral and cultural challenge facing health care in the People’s Republic of China: the need to create an understanding of medical professionalism that recognizes the new economic realities of China and that can maintain the integrity of the medical profession. It examines the rich Confucian resources for bioethics and health care policy by focusing on the Confucian tradition’s account of how virtue and human flourishing are compatible with the pursuit of profit. It offers the Confucian account of the division of labor and the financial inequalities this produces with special attention to China’s socialist project of creating the profession of barefoot doctors as egalitarian peasant physicians and why this project failed. It then further develops the Confucian acknowledgement of the unequal value of different services and products and how this conflicts with the current system of payment to physicians which has led to the corruption of medical professionalism through illegal supplementary payments. It further gives an account the oblique intentionality of Confucian moral psychology that shows how virtuous persons can pursue benevolent actions while both foreseeing profit and avoiding defining their character by greed. This account of Confucian virtue offers the basis for a medical professionalism that can function morally within a robustly profit-oriented market economy. The paper concludes with a summary of the characteristics of Confucian medical professionalism and of how it places the profit motive within its account of virtue ethics.     

Reflective Writing about Near-Peer Blogs: A Novel Method for Introducing the Medical Humanities in Premedical Education

Narrative analysis, creative writing, and interactive reflective writing have been identified as valuable for professional identity formation and resilience among medical and premedical students alike. This study proposes that medical student blogs are novel pedagogical tools for fostering peer-to-peer learning in academic medicine and are currently underutilized as a near-peer resource for premedical students to learn about the medical profession. To evaluate the pedagogical utility of medical student blogs for introducing core themes in the medical humanities, the authors conducted qualitative analysis of one hundred seventy-six reflective essays by baccalaureate premedical students written in response to medical student-authored narrative blog posts. Using an iterative thematic approach, the authors identified common patterns in the reflective essays, distilled major themes, coded the essays, and conducted narrative analysis through close reading. Qualitative analysis identified three core themes (empathic conflict, bias in healthcare, and the humanity of medicine) and one overarching theme (near-peer affinities). The premedical students’ essays demonstrated significant self-reflection in response to near-peer works, discussed their perceptions of medical professionalism, and expressed concerns about their future progress through the medical education system. The essays consistently attributed the impact of the medical student narratives to the authors’ status as near-peers. The authors conclude that reading and engaging in reflective writing about near-peer blog posts encourages premedical students to develop an understanding of core concepts in the medical humanities and promotes their reflection on the profession of medicine. Thus, incorporating online blogs written by medical trainees as narrative works in medical humanities classrooms is a novel pedagogical method for fostering peer-to-peer learning in academic medicine.

     

Autonomy and coercion in disease prevention and health promotion

Most of the attention regarding the balance between autonomy and paternalism has been focused on the therapeutic relation. Much less attention has been devoted to the problem of autonomy in the application of medical knowledge for preventive purposes. Here, because the good to be achieved is social as well as individual, an unavoidable dilemma ensues. Effective preventive measures of benefit to all must necessarily limit autonomy and involve some coercion. I argue that there are principles which can be established to guide society in a moral use of coercion. The question of employing medical knowledge is not, as it is in therapeutic medicine, to preserve or enhance autonomy. Rather its aim is to enhance voluntary co-operation. Principles for moral use of coercion must thereby be derived from health as a moral value.     

Mental state attributions and the side-effect effect

The side-effect effect, in which an agent who does not specifically intend an outcome is seen as having brought it about intentionally, is thought to show that moral factors inappropriately bias judgments of intentionality, and to challenge standard mental state models of intentionality judgments. This study used matched vignettes to dissociate a number of moral factors and mental states. Results support the view that mental states, and not moral factors, explain the side-effect effect. However, the critical mental states appear not to be desires as proposed in standard models, but rather ‘deeper’ evaluative states including values and core evaluative attitudes.     

Toward a reconstruction of medical morality

At the center of medical morality is the healing relationship. It is defined by three phenomena: the fact of illness, the act of profession, and the act of medicine. The first puts the patient in a vulnerable and dependent position; it results in an unequal relationship. The second implies a promise to help. The third involves those actions that will lead to a medically competent healing decision. But it must also be good for the patient in the fullest possible sense. The physician cannot fully heal without giving the patient an understanding of alternatives such that he or she can freely arrive--together with the physician--at a decision in keeping with his or her personal morality and values. In today's pluralistic society, universal agreement on moral issues between physicians and patients is no longer possible. Nevertheless, a reconstruction of professional ethics based on a new appreciation of what makes for a true healing relationship between patient and physician is both possible and necessary.     

医学专业精神的初步研究

由于历史和社会文化的差异,中西方对医学专业精神有着不同的理解。在中西不同语境下,分析了“Profession”和“Professionalism”这两个核心概念的涵义,并从中西对比的视角,对中西方医学专业精神所面临的几个共同问题进行了初步研究,包括医学专业核心道德价值观念、利益冲突、行业自治等。在此基础之上,还对我国医学专业精神的发展提出建议。     

Laying medicine open: understanding major turning points in the history of medical ethics

At different times during its history medicine has been laid open to accountability for its scientific and moral quality. This phenonmenon of laying medicine open has sometimes resulted in major turning points in the history of medical ethics. In this paper, I examine two examples of when the laying open of medicine has generated such turning points: eighteenth-century British medicine and late twentieth-century American medicine. In the eighteenth century, the Scottish physician-philosopher, John Gregory (1724-1773), concerned with the unscientific, entrepreneurial, self-interested nature of then current medical practice, laid medicine open to accountability using the tools of ethics and philosophy of medicine. In the process, Gregory wrote the first professional ethics of medicine in the English-language literature, based on the physician's fiduciary responsibility to the patient. In the late twentieth century, the managed practice of medicine has laid medicine open to accountability for its scientific quality and economic cost. This current laying open of medicine creates the challenge of developing medical ethics and bioethics for population-based medical science and practice.     

Toward a Reconstruction of Medical Morality

At the center of medical morality is the healing relationship. It is defined by three phenomena: the fact of illness, the act of profession, and the act of medicine. The first puts the patient in a vulnerable and dependent position; it results in an unequal relationship. The second implies a promise to help. The third involves those actions that will lead to a medically competent healing decision. But it must also be good for the patient in the fullest possible sense. The physician cannot fully heal without giving the patient an understanding of alternatives such that he or she can freely arrive—together with the physician—at a decision in keeping with his or her personal morality and values. In today's pluralistic society, universal agreement on moral issues between physicians and patients is no longer possible. Nevertheless, a reconstruction of professional ethics based on a new appreciation of what makes for a true healing relationship between patient and physician is both possible and necessary.     

Why be a good Human Being? Natural Goodness,Reason, and the Authority of Human Nature

The central claim of Aristotelian naturalism is that moral goodness is a kind of species-specific natural goodness. Aristotelian naturalism has recently enjoyed a resurgence in the work of philosophers such as Philippa Foot, Rosalind Hursthouse, and Michael Thompson. However, any view that takes moral goodness to be a type of natural goodness faces a challenge: Granting that moral goodness is natural goodness for human beings, why should we care about being good human beings? Given that we are rational creatures who can ‘step back’ from our nature, why should we see human nature as authoritative for us? This is the authority-of-nature challenge. In this essay, I state this challenge clearly, identify its deep motivation, and distinguish it from other criticisms of Aristotelian naturalism. I also articulate what I consider the best response, which I term the practical reason response. This response, however, exposes Aristotelian naturalism to a new criticism – that it has abandoned the naturalist claim that moral goodness is species-specific natural goodness. Thus, I argue, Aristotelian naturalists appear to face a dilemma: Either they cannot answer the authority-of-nature challenge, or in meeting the challenge they must abandon naturalism. Aristotelian naturalists might overcome this dilemma, but doing so is harder than some Aristotelians have supposed. In the final sections of the paper, I examine the difficulties in overcoming the dilemma, and I suggest ways that Aristotelians might answer the authority-of-nature challenge while preserving naturalism.     

Toward a reconstruction of medical morality

At the center of medical morality is the healing relationship. It is defined by three phenomena: the fact of illness, the act of profession, and the act of medicine. The first puts the patient in a vulnerable and dependent position; it results in an unequal relationship. The second implies a promise to help. The third involves those actions that will lead to a medically competent healing decision. But it must also be good for the patient in the fullest possible sense. The physician cannot fully heal without giving the patient an understanding of alternatives such that he or she can freely arrive—together with the physician—at a decision in keeping with his or her personal morality and values. In today's pluralistic society, universal agreement on moral issues between physicians and patients is no longer possible. Nevertheless, a reconstruction of professional ethics based on a new appreciation of what makes for a true healing relationship between patient and physician is both possible and necessary.     

Teaching suffering: The testimonial-commentary method

Attempts to define professionalism and humanism suggest that qualities such as compliance to values, patient access, doctor-patient relationship, demeanor, professional management, personal awareness, and motivation are prominent thematic components. In this communication, we present a method for instruction in the values of humanism that may help to overcome the "curricular inertia that plagues medical education." Our approach is structured around a technique of testimonial-commentary as a novel approach to teaching humanism that does not rely upon the traditional role-modeling format. To develop effective medical school curricula for teaching humanism, we cannot rely upon the textbooks of normal and abnormal human anatomy and physiology. We must delve into the "unscientific" realms of human identity ranging from sensuality to brutality: self-preservation to sacrifice. Underneath it all, we must acknowledge that there are the ties that bind us together as people. The Seminar on Human Suffering challenges medical school educators to work with the community at large to insure that physicians will be able to serve those that seek their counsel.     

Understanding the Trusted Doctor and Constructing a Theory of Bioethics

This paper offers a constructivist account of bioethics as an alternative to previous discussions that explained the ethics of medicine by an extrapolation of principles or virtues from ordinary morality. Taking medicine as a higher and special calling, I argue that the practice of medicine would be impossible without the trust of patients. Because trust is a necessary condition for medical practice, the ethics of the profession must provide the principles for guiding physician behavior and the profession toward promoting trust and being trustworthy. In a phrase, that principle is “seek trust and deserve it.” I sketch out how the concept of trust provides a different justification for common sense principles of bioethics and explain how the concept of trust provides reasonable guidance for resolving moral conflicts within medicine. The trust-seeking approach provides a new and unexpected ordering of some traditional medical values, it reveals the weightiness of previously undervalued bioethical precepts, and illuminates the centrality of some largely ignored obligations of medicine. It also has the power to guide clinical practice and to inform the profession about standards for medical institutions. This revised version was published online in August 2006 with corrections to the Cover Date.     

诊断脑死亡的伦理思考

随着医学的进步和社会的发展,死亡的定义、诊断标准和医生道德责任有了新的内容,脑死亡就是生命终结已为医学界普遍接受.诊断脑死亡是非常专业的技术性工作,有权进行脑死亡诊断的医疗单位和医生必须达到相应的资质要求.确诊和宣布脑死亡应遵循的伦理准则包含多方面的内容,如家属应有死亡标准选择权、脑死亡的诊断程序、脑死亡诊断结果的宣布和生效等方面的问题.