Medicine as a profession
Abstract
Over half a century ago, a Canadian judge defined a profession in a way that resonates still today, not only for lawyers and doctors, but for the current wide variety of professions and professionals. This article is a reflection on this definition. It briefly considers the historical context within which the knowledge base that characterises a profession evolved and what the various component parts of the judge's definition entail. A final consideration goes beyond the terms of the definition proposed – that of our ethical responsibility as professionals to stand up and be counted and, in the context of the disorder around us, to speak out.
In English the meanings of words evolve, changing with usage and nuanced by context. We may applaud a lawyer doing a thoroughly professional job, but less so membership of the oldest profession in the world. The same applies to the word amateur: though in living memory only lilywhite amateurs could represent their country in the Olympic Games, it's hard to think of a context where amateurish is used approvingly. It may thus be worthwhile exploring what lies at the core of a profession, what these core values entail, and how they inform the concept of professional ethics.
As a point of departure I would propose the definition put forward in 1951 by Peter Wright, a judge of the High Court of Ontario:
A profession is a self-disciplined group of individuals who hold themselves out as possessing special skills derived from education and training which they are prepared to exercise primarily in the interests of others.1
Wright's definition is very much worth pondering and parsing. ‘A self-disciplined group of individuals’ is ying and yang, thesis and antithesis; a profession must be self-disciplined, or big brother will do it for you. It must remain a ‘group of individuals’, not a caucus or a soviet. Lawyers and doctors generally relish the foibles and idiosyncrasies of their more eccentric fellows, evidence of the value they put on individuality.
‘Hold themselves out’ is a lovely phrase, fraught with overtones of hesitancy, vulnerability and the possibility of rejection. Those who consult a professional do not thereby undertake to engage him, but are explicitly free to seek a second opinion, free to accept or to go elsewhere. ‘Special skills derived from education and training’ is the defining knowledge base that the professional has to offer: the words education and training are key, particularly in an age where information – as opposed to knowledge – cascades at the touch of a computer key. ‘Which they are prepared to exercise primarily in the interests of others’ is again delicately put. A professional does not have to take a vow of poverty; on the other hand, if you are in it just for the money, you are not truly professional.
The knowledge base at the core of a profession has a number of consequences. The aphorism ‘knowledge is power’ was coined over four centuries ago, and was never truer than today. What is crucial to the meaning of profession is that the power that it brings is over disorder, not primarily over people. For the doctor it is the power over suffering, for the teacher over ignorance. When the first European universities started in the late 11th century, they had three faculties – canon law, civil law and medicine: canon law addressed spiritual disorder, civil law social disorder, and medicine disorders of the body. Today, in our knowledge-based service economies, it's not merely doctor/lawyer/priest; a vast array of occupations are professions in the true sense of the word.
That knowledge-based power is over disorder rather than people and is the basis of professional ethics. I was taught as a medical student that professional ethics was not examining a female patient without a nurse being present, and not charging fellow practitioners. The first is good sense, the other a courtesy: neither forms the basis for the ethical practice of medicine. Constantly asking the disorder versus people question, however, is the spell check of professional ethics on a day-to-day basis. We need it to inform our decisions, to remind us of our weaknesses and strengths, to assert the equality as human individuals of those on both sides of the desk. It is not always easy: the doctor may deal with psychotic or unconscious patients, the lawyer with clients who are distrait and confused, the teacher with teenagers. If what you do sounds the ‘power over people’ alarm, think again – you're not acting in a professionally ethical way.
The knowledge base also entails other ethical responsibilities. Knowledge is not static, frozen from the day of graduation: continuing education is a professional responsibility. The old surgical saw (metaphorical variety) ‘those who can't cut teach; those who can't teach do research’ is testimony only to intellectual defensiveness; those who transmit and expand the knowledge base, by teaching and research, ensure the future of a profession. Finally, on Karl Popper's criteria for research (hypothesis/testing/publication), publication is a professional responsibility for those in research. Patent as appropriate, but publish forthwith: as a research worker, your professional responsibility is to refine and extend the knowledge base.
It is difficult to see how Wright's definition of a profession could be substantially improved in a single sentence. What the etymology gives us, however, is additional insights into the ethical demands on a professional. The Latin verb ‘profiteor’ means to profess, to avow: thus a university professor, a nun making her profession of faith. The Latin in turn derives from the Greek verb ‘prophemi’, to speak out. The word that comes directly into English from this is ‘prophet’, commonly applied to somebody who foretells the future, as in a prophet of doom. In the Old Testament it is said that a prophet is without honour in his own country. The Hebrew prophets were without honour not because they foretold the future and got it wrong, but because they spoke out about the present, and got it right. In medicine we need to follow their example. The ultimate responsibility of a professional is to be prophetic: to speak out, to address the disorder around us, and to get it right.
- © 2010 Royal College of Physicians
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