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This page created October 2000 by Michael Wynne
This page -- The medical profession has cherished and
protected its professional independence. There are pluses and minuses
to professional independence. On balance this independence has served
society well and should continue to do so. While it has bent to the
winds of change it has served democracy by keeping the embers of
community values burning in the face of totalitarianism and ideology.
The embers re-ignite as soon as the wind changes. Its response to
economic ideology is no different to its response to apartheid.
Professional independence has been a thorn in the side of almost every ideology which has sought to make health care subservient to its beliefs. In Australia the profession have opposed attempts to nationalise health care. They were attacked by politicians for doing so. Now they are opposing attempts to corporatise health care and to turn it into a market where marketplace success rather than community values will underpin health services. Once again they are being attacked and labeled by people like Wooldridge and Samuel
Samuel is critical of professional independence and talks of "anticompetitive provisions, often masquerading under the guise of "ethical" or "professional conduct" rules.
Samuel's frustration is understandable. While
the profession has often bent to ideology, professional independence
has been a sticking point- a brake on excesses. It has been a source
of continuous frustration to all those wanting to impose their belief
system and their ethics on medicine. Like all democratic institutions
there are plusses and minuses to professional independence.
The behaviour of the medical profession in South Africa is an excellent example of professionalism paradigms at work when they are in conflict with ideology. Doctors were part of this society and played their part in it. As a consequence the profession bent before the system and in many instances compromised its values. It has been rightly criticised for doing so.
While doctors adapted to live within the system and identified with it strong paradigm conflicts persisted. Professional paradigms exerted continuous pressure and doctors were among those who spoke out and were banned. Bill Hoffenberg who was subsequently knighted for his services to medicine in the UK was expelled from South Africa because of his involvement with Mandela. I knew him as a young physician, and again much later after his retirement.
The same patterns are being played out in the USA and in Australia today.
Professional ambivalence: - The South African Medical Association held their meetings on ocean liners sailing up the coast. This allowed them to escape the South African laws and protect their black colleagues from humiliation - having to use separate toilets, consume alcohol separately, and eat separately. They did so only when black doctors refused to attend meetings because of the humiliation.
Professionalism Resurfaces: - I returned to my Alma Mater, the University of Cape Town and Groote Schuur Hospital on studies leave in 1986, a time when rebellion against apartheid was growing. The university, the hospital and particularly its medical superintendent, Dr. Kane-Berman (one of my class at medical school) had been a constant thorn in the governments side. The doctors in the hospital, many friends from medical school days had unilaterally abolished the system of separate hospital wards. Black and white patients lay side by side. Many white patients had gone elsewhere and beds were empty. This illegal rebellion had the support of the Vice Chancellor, Professor Stuart Saunders, a doctor - another medical school colleague of mine. The government was threatening action and retribution.
I visited another old friend and colleague, by then a professor at the neighbouring Stellenbosch University and Tigerberg Hospital - the heartland of government theory. He assured me that government would soon put a stop to this. My Groote Schuur colleagues stood firm. The government shied away from a very public confrontation. Apartheid withered and died.
Taking Professional Values into the Community:- Professional independence has to draw a fine line between obeying the law, operating in a dysfunctional society, resisting social pressure and exerting democratic independence. To survive it must take its values into the community and gain its support. A system based on community values cannot survive in isolation.
Stuart Saunders piloted the University of Cape Town through the difficult years when it lived within the law but vigorously opposed apartheid. He walked a tight line supporting a militant antiapartheid student body while protecting his student charges from the wrath of angry authorities and a vindictive police force. He maintained his strong strong values and spread them through the university and the community by example. Frames of discourse were developed which embraced both human values and context. They were given identity and structure in his actions.
He groomed another doctor, Professor Mamphele Rhampele, a forceful and highly intelligent black colleague to succeed him when apartheid was abolished. She too trained as a junior doctor in another hospital where I worked. The discussions I had with this remarkable lady when we worked together helped me to understand apartheid without being judgmental - and so also corporate medicine. This does not mean that I necessarily share all her views, any more than I shared the views of my friend at Stellenbosch University when I met him in 1986.
The minuses of professional independence: - Like democracy itself, professional independence has plusses and minuses. It does permit and sometimes encourage dysfunctional practices. Its track record for self regulation is not good. It is prone to elitism. It can encourage a laager mentality and distance the profession from the community. This is the nature of society and any groups which lose contact with their "starting points" can behave like this. While they can hold out against society they can only be maintained by periodic reaffirmation in society. They can initiate this reaffirmation and in Australia there are citizens who are willing to do so.
Self correction: - The core values and
beliefs of professionalism are based on community and Samaritan
traditions - the foundations of a civil society. Because of the
profession can never maintain itself in isolation. It must return to
a dialogue with and a comfortable place within society. While there
will be conflict within the profession and dysfunctional behaviour,
as long as professionalism continues to exist, the underlying values
will reassert themselves. It is inherently self correcting. In this
it differs from marketplace ideology.
I am confident that the health professions in Australia and the USA will ultimately perform as well as my colleagues in South Africa, but there is a long and difficult path ahead. There will be lapses.
I am hopeful that members of the health care professions will form a hard core who will give meaning to the substance of community values. They will expose the claims to community values by market theorists as a facade - in conflict with their "starting points" so continuously at risk.
At the core of professionalism are the values which underpin a "civil society". I like to think that by engaging with the community in designing a health system doctors can take the lead in guiding society from economic ideology to a civil society. Health care is both the rock on which ideology flounders, and an ideal context from which to build a civil society. The primacy of community values are central to both. Saunders and Rhampele are good role models.
The medical profession in Australia has been marginalised by politicians and an acquisitive marketplace. It has temporarily retreated into isolationism. It needs to reestablish sound frames of discourse. It should get out there and lead the way out of the barren theoretical cul de sac in which we find ourselves - towards a civil society.
Universities: - It is sad that the universities in Australia have all abandoned their community values and embraced economic ideology. Perhaps this is because in Australia there are no doctors at the helm.
This absence of professional leadership in academic life may be because the frames of discourse which objectify professional and academic values have been "delegitimised" in public discourse. They should look to Cape Town and Witwatersrand universities, to learn how to live within the law while developing frames of discourse and fulfilling their responsibilities to society.
I quote from the Canadian John Ralston Saul's Massey lectures
We know that the universities are in crisis and are attempting to ride out the storm by aligning themselves with various corporate interests. That is short sighted and self destructive. From the point of view of their obligation to society, it is simply irresponsible. p177
What about Samuel's discomfort with
professional independence. Well as a new Australian embracing
Australian culture, its values and its idioms - "tough titties mate -
hopefully professional independence will be your nemesis!"
Trust,The Market and Professionalism
This page examines the way in which the market has corroded the values and ethics of the professions and induced doctors to place care for the corporation ahead of care for the patient.
CLICK HERE -- to examine the impact of the market on professionalism
This page acknowledges that professionalism has failed on a number of occasions and more so recently. It explores the reasons for this and argues that the meaning systems and the values which form the basis for professionalism are sound. Professionalism has failed when confronted by powerful forces which introduce meaning systems which are not congruent with professional values.
CLICK HERE -- to explore professionalism and the market at this level.
THE "CONSUMER", THE PROFESSION AND THE MARKET
This page explores the claims that in the market consumers would decide what care they were given, and that health care is currently organised for the benefit of the medical profession. It examines the way in which decisions about care are actually made in the marketplace. It does so by using examples.
CLICK HERE -- to explore the relationship between the "consumers", professions and the market.
Professionalism and Regulation.
This page examines the important regulatory role of professional values and ethics when contrasted with the ethic of the marketplace.
CLICK HERE -- for information about professionalism as a regulator.