Medical professionalism: is it really under threat?

Kerry J Breen
Med J Aust 2007; 186 (11): 596-598. || doi: 10.5694/j.1326-5377.2007.tb01062.x
Published online: 4 June 2007
Why is “medical professionalism” an issue now? Is the sky falling in?

A common perspective of the three recent publications appears to be that the medical profession in many countries is under siege. Wynia et al, writing from the United States, make the following opening statement in their 1999 article Medical professionalism in society:

In their opening sentence, the authors of Medical professionalism in the new millennium: a physicians’ charter declare:

They go on to state:

The summary of the more recent United Kingdom Royal College of Physicians document, Doctors in society: medical professionalism in a changing world, states that “the exercise of medical professionalism is hampered by the political and cultural environment of health, which many doctors consider disabling” and adds at the end of the summary: “our collective and abiding wish is to put medical professionalism back onto the political map of health in the UK”.3 The latter two publications also suggest that renewed medical professionalism will be one of the means of restoring the trust that the public used to have in the profession.

There have been enormous changes in the way medicine is practised and health care is delivered in industrialised countries from that which applied even a generation ago. In brief, these include:

I sense that these changes to the way in which health care is now delivered and funded have altered the balance of the ethical issues facing individual doctors. This is similar to the way that, three or more decades ago, the shift from a primary focus on the ethical principle of beneficence to a greater recognition of, and respect for, the autonomy of patients changed the way doctors approached their work. I believe that the medical profession (and especially its leaders) needs to examine and accept this altered balance and assist medical practitioners to work within this new balance. This is not to deny the importance of trying to define medical professionalism, debating its core principles and inculcating those principles into medical and postgraduate training.

In a forthcoming Australian Medical Council publication (Handbook of clinical assessment, in press), I state that:

Medical professionalism (also referred to as “professional and personal development” and covering such matters as communication skills, ethics and law) has become central to medical student curricula in Australia as one of the important outcomes of the reforms triggered by the Doherty inquiry into medical education of 1988.7 Recognised then by another name, it was also central to a “professional practice program” piloted for postgraduate medical trainees in Victoria in the early 1990s.8 Medical professionalism is now gradually finding its way into Australian postgraduate medical training programs.

This long history, together with a strong health consumer movement, community involvement in medical regulation, and a health care system which in most states and territories has been free of major scandals, may explain why medical professionalism is not under threat in Australia and why as an issue it has not gained attention. In addition, the Australian health care system, which combines genuine universal access with a strong private sector, probably insulates Australian doctors from the influences at work in some other developed countries.

The changing balance in application of ethical principles

I return now to my suggestion that changes to the way in which health care is provided, funded and organised have altered the balance in application of agreed ethical principles, and that the tension created by this changing balance is the source of the perceived threat to medical professionalism.

When I entered medicine, the central ethical principle that seemed to be lived out by my mentors was beneficence. In the space of one generation this was gradually overshadowed by the principle of respect for patient autonomy. Now I think we are moving into an era where the ethical principle of justice will become a more dominant influence, because of the evident need to use finite resources wisely. Putting this principle into practice is not a simple matter for individual clinicians, as the need to use resources justly is often in conflict with the need to act in what seem to be the best interests of the immediate patient (who, relying on the principle of autonomy, might be insisting on receiving treatment). Neither is it a simple matter for segments of the profession, where different groups fight for their own interests, sometimes disguised as the best interests of their patients. This ethical dilemma is not being widely acknowledged and discussed by the medical profession.

Ethical principles are a platform or structure upon which to base good clinical practice. While we in the developed world have grown accustomed to the four “pillars” of beneficence, autonomy, non-maleficence and justice, there are other ethical qualities — some call them virtues — that a competent practitioner should display, including compassion, fidelity and integrity. Tensions between principles applicable in any specific clinical situation have long been identified, as is implied by the balance between striving to help without causing harm, so it should come as no surprise that these tensions might change as circumstances change. Undoubtedly, circumstances have changed, as the complexity and costs of tests and treatments have increased and as the possibility of prolonging life (sometimes at unacceptable costs, whether measured in terms of intrusiveness and human distress, or in terms of financial costs) has also increased. In some clinical areas, such as neonatal and adult intensive care, clinicians are daily confronted with such ethical dilemmas.

Justice as an ethical principle when applied to health care means distributive justice or fairness in allocating health resources.9,10 This ethical principle comes into play at what have been termed “macro”, “meso” and “micro” levels in the health care system.11 At the macro level, the principle applies to decisions taken by governments and health departments as to how budgets are allocated. At the institutional or meso level (hospitals, health care networks, etc) administrators must take account of this principle in determining resource allocations. Less evident (or even denied by some doctors) is how this principle applies at a micro level in each patient–doctor interaction in daily practice. In simple terms, where health care budgets are finite, money spent on one patient means less money available to another patient. To date, the medical profession in Australia has been able to avoid engaging in a meaningful debate of these issues at the micro level and instead has emphasised the role of the doctor as the patient advocate, “fighting” for access to health care for “their” patients, using the notion of patients’ “rights to health care”.

If justice is becoming a more influential ethical principle, who should take responsibility to show leadership in helping the profession to adjust to this change? In my view, those appointed or elected to leadership positions in the profession must take this responsibility. The adjustment will not be easy, as most doctors are sincere in their role as patient advocates and have no access to information that meaningfully demonstrates the effects of their decisions about investigations and treatment of one patient on the entire health care system. Such leadership will take considerable moral courage, but to be responsible for a changed attitude that eventually makes it comfortable for any doctor to discuss resource issues in addition to rights and needs with their patients, as well as to be responsible for renewed community respect and confidence in the medical profession, will be the reward. Doctors who appreciate these ethical issues are also likely to be more confident and better equipped to participate effectively in working in teams and working with managers of health care institutions.

At the international level, an opportunity for such leadership has recently been missed. The World Medical Association released its Declaration of Geneva (Box) in May 2006 as a modern version of the Hippocratic Oath. Imagine how much more powerful the Declaration would have been if it had included the words:

  • Kerry J Breen

  • Melbourne, VIC.


Competing interests:

None identified.

  • 1. Wynia MK, Latham SR, Kao AC, et al. Medical professionalism in society. N Engl J Med 1999; 341: 1612-1616.
  • 2. Medical Professionalism Project. Medical professionalism in the new millennium: a physicians’ charter. Med J Aust 2002; 177: 263-265. <MJA full text>
  • 3. Royal College of Physicians. Doctors in society: medical professionalism in a changing world. Report of a Working Party of the Royal College of Physicians of London. London: RCP, 2005. (accessed Apr 2007).
  • 4. Reed RR, Evans D. The deprofessionalization of medicine. Causes, effects and responses. JAMA 1987; 258: 3279-3282.
  • 5. Relman AS. The new medical–industrial complex. N Engl J Med 1980; 303: 963-970.
  • 6. Carlson R. The end of medicine. New York: John Wiley and Sons Inc, 1975.
  • 7. Doherty RL (Chairman). Committee of Inquiry into Medical Education and Medical Workforce. Australian medical education and workforce into the 21st century. Canberra: AGPS, 1988.
  • 8. Plueckhahn VD, Breen KJ, Cordner SM. Law and ethics in medicine for doctors in Victoria. Geelong: VD Plueckhahn, 1994: xi-xii.
  • 9. National Health and Medical Research Council. Discussion paper on ethics and resource allocation. Canberra: AGPS, 1990.
  • 10. Kerridge I, Lowe M, McPhee J. Ethics and law for the health professions. 2nd ed. Sydney: Federation Press, 2005: 47-49.
  • 11. Breen K, Plueckhahn V, Cordner S. Ethics, law and medical practice. Sydney: Allen and Unwin, 1997: 131-132.


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