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This page created August 2000 by Michael Wynne
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.
Graeme Samuel in his lecture to the World
Bank claims that "professional self-regulation, has robbed consumers
of sovereignty". he asserts that "Self-regulatory practices that have
developed essentially to serve the interests of service providers".
This is a reiteration of the views of Adam Smith, Friedman,
Califano
and Wooldridge.
This interpretation has been attacked and discredited by Wynia et
al.
(Wynia M.K. et al "Medical
Professionalism in Society" New Eng J Med 1999 -Vol. 341,No.
21)
Professionalism has protected people from exploitation for hundreds of years. It has sometimes failed - spectacularly in the USA. Professional principles have succumbed to contexts which threaten the welfare of professionals and their families. These contexts have sometimes challenged the continuation of professionalism as a guiding principle in health care. I am not trying to defend what has happened but to understand why it has happened. The argument is that if we consider the circumstances in which it now finds itself it is not surprising that failures have occurred.
When the underlying principles of professionalism are examined the criticisms of professionalism as such are simply not sustainable. This is particularly so when set against the disturbing principles of the marketplace and the consequences of replacing professionalism with market theory. The problems are intrinsic to marketplace patterns of thought. They are external to professional belief systems.
PROFESSIONALISM AND SELFISHNESS:- There is some truth when Samuel claims that professional processes have come to "serve the interests of service providers". This is particularly so in the USA. His claim needs to be more closely examined to see why a group which professes to put the interests of others before their own has in practice not lived up to this fundamental principle.
Professional bodies have a dual responsibility. First a duty to the community and to their patients. Second to attend to the affairs of their members and see that they are fairly dealt with. They cannot ethically attend to the needs of their members at a cost to the care of their patients or the welfare of the community.
The profession has been placed in a catch 22 situation in Australia. There are strong pressures from an increasingly commercialised context and intense criticism from politicians and economists. To meet the pressures and continue to act for patients they need to maintain their position in society, their morale and their defences. Self interest and social responsibility become congruent but there is a very fine line to tread. There are strong pressures to bend the line. I argue that the situation which has arisen and the professions responses are in large part a consequence of two factors - unionism and market pressures.
UNIONISM: - The rise of unionism in response to exploitation of workers by the marketplace brought with it into Australia a strong Marxist conflict model for resolving disputes. This has not always served equity well. The money goes to the strong and the organised. Those with power secure salary increases, those without are simply ignored. Professionalism and unionism are uncomfortable bedfellows. The paradigms under which they operate are not congruent.
Governments control medicare fees and the salaries of doctors in hospitals and universities. Governments have adopted the conflict model. They respond only to worker power. They have been hard nosed. As a consequence professional bodies have become de facto trade unions fighting to secure maximum benefit for members. This is a role which sits uncomfortably with professionalism and doctors have felt uncomfortable when forced to take industrial action.
Doctors are selected from students who have competed strongly and successfully. They come from the top 2-3% of school leavers. This is a group which is conditioned to expect a place in society. They can be expected to rise to the challenge presented by government, fight hard and succeed. This does not fit with the image of the health profession as a group dedicated to the welfare of others. The pradigm conflict causes a conflict in identity. Governemnt has responded by using this to attack the profession as selfserving.
PROFESSIONALISM UNDER ATTACK - CONSEQUENCES:- The unprecedented attack on professions and professionalism by market theorists and politicians has contributed to the problem for the professions. The market mode of thought is based on suspicion and distrust. This has generated uncertainty and doubt in the profession on the one hand and stubbornness on the other. Efforts are directed to confronting market critics and defending their position. It has fostered a laager mentality. This makes it difficult for the profession to lead the way in developing a more appropriate health system. There are risks to innovation. They are well aware that the politicians and economists wish to impose their solutions. They will exploit any opportunity they are given.
Professions operate within society. Values and ethical systems are fragile social structures that are maintained because they are valued and supported in the community as well as the professions. This gives them "legitimacy". People can identify with them and "internalise" them. In this professions are no different to other social groups, such as sportsmen/women and sportsmanship. The attack on professionalism "delegitimises" professional values and is therefore self fulfilling. If it is not valued then it will disappear. Fortunately much of society still values trust, empathy and integrity.
DEFENSIVE BEHAVIOUR:- Professional bodies have had to protect professionalism. To do so they must maintain the status of the profession in the community, and also the identity of members. They have been moderately successful in some but not all of this. Their commitment to the community has suffered. The perception is that professional associations are now more interested in the welfare of members than the public they serve. There is probably some truth in this but Samuel's glib phrases are not an adequate analysis.
Members of the profession are part of the society they live in and when their values are no longer seen as credible or relevant then they adopt society's values - or even that of the marketplace. Many doctors in the USA now do MBA's and become businessmen. The chairman of Columbia/HCA is an extreme example. This is how our society operates. This is the context within which members of the professions must actualise their lives and build identity. There is an acute paradigm conflict. This is the behaviour which we would expect in this situation.
CLICK HERE -- to go to a discussion about the relationship between context,paradigms and identity in health care. This will help if you are having difficulty with the arguments.
THE FAILURES OF THE MARKET AND THE FAILURES OF PROFESSIONALISM: - When we look at why the competitive market has failed so badly in health care in the USA then it soon becomes clear that there are fundamental problems in the whole idea of applying competition and market principles to health and aged care. Directors have a fiduciary duty to serve shareholders not patients. They cannot put patients first. Professionalism has an ethic committed to care. The market has an ethic which threatens it. These problems have been recognised for a long time - about 2000 years. This www site describes the unfortunate consequences and the reasons for this.
In the past professionalism has tried to shield itself from the pressures of competition and the marketplace. It has developed a system of ethics to do so and salesmen have been kept at arms length. This arms length relationship with commercialism has not been well maintained during the latter half of the 20th century, particularly in the USA. Medical Research gets much of its funding from commercial groups with a strong interest in getting the result they desire. Health care corporations of all sorts make their money from decisions made by doctors. Corporate behaviour when doctors display integrity and refuse to meet the expectations of their market masters is very disturbing.
Despite these failings the underlying values, and the core practices of professionalism remain sound. Unlike market paradigms they are directly applicable and relevant to health care. This is the context within which they developed. Market theory was developed selling commodities - toilet paper and condoms - a very different context. This context and the belief systems which it gave rise to have been imposed on health care from outside.
The major problems in the US system have arisen because the market has successfully overridden an already weakened professionalism. Professional people have been complicit with the market in doing this. Medicine as a profit making business became legitimate, in the USA at least long before corporate chains were founded. Professionalism has failed because the market has triumphed. The market has succeeded financially and failed society because professionalism succumbed.
WHY PROFESSIONALISM FAILS:- When professionalism and professional values lose the support of the community then the protection that they provide is lost. Members of the profession have difficulty in identifying with professional values and in acting out a professional identity. The values seem passe.
The pressures generated in the US health care marketplace operate no differently in this respect to fascism in Germany or apartheid in South Africa. In both countries sections of the profession slipped in their commitment to professional values. The majority did not slip as badly as in the USA. While the context in Germany and South africa challeneged professional values the threat to the welfare of the doctor and his family was not as great. You did not lose your job because you provided care to socially disadvantaged groups.
If we look more closely at why professionalism has failed, particularly in the USA where it has failed miserably we find that it has failed whenever it has lowered the shield which protects it from the the marketplace. Contracts of various sorts are at the heart of most arrangements between business and the professions. Corporations are interested in binding the profession to the corporate profit mission and contracts do this. Few if any of the terrible things which have happened in the USA could have happened had the profession been united and stood firm - refused to enter into contracts.
Walton and Moynihan describe the development of similar problems in Australia but we do not yet have a problem with corporate contracts, because our doctors have resisted them. Walton suggests that the solution is for doctors to learn to handle conflicts of interest in dealing with the market. Walton did not study the relationship of doctors with HMO's or with large business groups as these are not yet established in Australia. She has had no experience with them.
The experience described on this www indicates that the problems are much too deep to be handled in the way Walton proposes. They are much more than conflicts of interest. The risks to career and family, which we have seen in Tenet/NME, Columbia/HCA and managed care create pressures which cannot be resisted by unsupported individuals. It is not fair to expect them to do so. What Walton is suggesting is not a viable solution to the problems we face. She is fiddling at the periphery, trying to patch a system which needs to be changed.
(Walton M " The Trouble with
Medicine"
Moynihan R " "Too Much Medicine")
RE-ESTABLISHING PROFESSIONALISM: - What I have suggested as the way forward is a bringing together of the community and the professions to re-establish and reaffirm the value and validity of professional ethics and to set up a joint health care system built on these values - part of a civil society. This should address the needs and the opportunities presented by the modern era while re-establishing a sound arms length relationship with the marketplace.
CLICK HERE -- for another page which also explores issues surrounding professionalism, professional failure, the market and trust.
CLICK HERE -- for another page which examines "quality" and the health care professions
CLICK HERE -- to for more about professional independence