 Good afternoon. I'm delighted to welcome you to the second seminar in our year-long series on medical professionalism. We are absolutely delighted and honored that Dr. Ed Pellegrino, a professor emeritus of medicine and medical ethics at Georgetown University, is able to join us today. As many of you know, Dr. Pellegrino is simply the dean of American medical ethicists. He has worked in the field for many years, has been in medicine for more than 60 years, during which time he served as chair of departments, departments, deans of medical schools, vice-chancellors, presidents of medical schools, and recently served as the chair of the President's Council on Bioethics in Washington, D.C. He had been the John Carroll Professor of Medicine and Medical Ethics at the Kennedy Institute of Ethics at Georgetown and at the Center for Clinical Bioethics. Ed has been all of our teachers, whether we studied directly with him or as Dr. Salmezzi did, or whether we've learned from him from afar. It was in the early 1990s as the field of clinical ethics was being developed that Ed joined Peter Singer and me to write a series of five articles in the first five issues of the Journal of Clinical Ethics trying to lay out a framework and a foundation for the field. Ed's name associated with those papers and his contributions to the papers really helped establish the field in a way that otherwise would have been much more difficult to do. Dr. Pellegrino has written almost 600 articles, more than 20 books. He's the founding editor of the Journal of Medicine and Philosophy, a master of the American College of Physicians, a great nephrologist and internist who he tells me in the old days you couldn't be a nephrologist unless you were also trained in cardiology. So in the old days you did both cards and nephrology training before you got boarded. Well, I won't say anything more, it's a delight to welcome Ed. His title is slightly different, slightly different from the one in the brochure. The talk today is on professionalism, proletarianism or profession, which shall it be? Ed, it's a delight to welcome you to Chicago. It's wonderful to be back at the University of Chicago where I've been quite a few times and watched the growth of Mark Shigel. More ways than one. Well, I wasn't getting into that. He did grow laterally and longitudinally, but mostly cerebrally. And it's a place to talk to you about this particular subject, which is a very hot one right now. I didn't change my title. This is a subtitle. I'm approaching it from the point of view of professionalism, but where professionalism might go or could go. And I wanted to compare an ancient notion, a notion of profession, with the notion of professionalism and the possibility that professionalism may mutate into proletarianism if we don't watch what we're doing. So this is a kind of warning signal. Certainly it's acute, occurred to many of you, but I would like to explore it just a little bit if you would allow me. The life in medicine, as I've led it over the last 60 years, has been filled with nostrums, panaceas, methodic treatments for every ill that our profession is presumed to have manifested to the public, to other professions, medical schools, etc. And many of these panaceas have arisen from genuine problems in the changes in the profession itself over the years. I look at professionalism as one of those methodic treatments that needs to be looked at skeptically, and that's why I took this particular approach, because I see profession, what I call the act of profession, as the bedrock of our profession from the point of view of what it is, what it ought to be and what it should be doing. I see professionalism as a sociological look at what we do, and I see proletarianism as something which has occurred in some very, very nasty manifestations, as you undoubtedly have already thought, as you reflect on the notion, but also as a kind of thing we can slip into and not appreciate what's happening. So with that in mind, let me just do first. I thought I'd be frank and develop my line of argument from the beginning so you know where I'm going and what I'm doing. The intersection of ethics and sociocultural forces create a need for a rational set of interrelationships with individual physicians for more responsibility, whereas I come from, and responsibility to society and social needs and development and society around it. I want to take a position that professionalism does not address this problem adequately, and I'll tell you why, and that therefore I want to conclude that we do have a problem that's not imaginary, but we need to return to the focus of individual patients good, which is the concern of the physician, and a reality that will not disappear, no matter how we organize society, people will get sick, and they will get sick on the starship going to Galaxy 740293 Alpha. And we do, however, much more than ever in the past, need to focus on social good as well and on the profession as an organized body, and that's what I take to be the thrust of professionalism. As you know, there are a multitude of definitions. I happen to think that Elliot Freitzen, the sociologist, definition is the one that makes more sense rather than some of the multitudinous definitions we find in the multitude of papers that are coming out of institutions today, all of which have interesting things to say, but they say them in diverse ways and under different rubrics. So let me just quickly go over Elliot Freitzen's criteria. It's a specialized work to be a profession, recognized and grounded in a body of theoretical dictionary knowledge and skill. And its exclusive jurisdiction is under a particular division of labor and created and controlled by the occupational negotiation as a sheltered position in external and external labor markets. So all of these are sociological and I'm not going to argue for these, simply say I accept them as Elliot Freitzen's observations, which I think are reasonable. It has a formal training program lying outside the labor market. Number five is what I want to emphasize. This is what Freitzen says, that a profession is an ideology that asserts greater commitment to doing good work than to economic gain and to the quality rather than the economic efficiency of work. So what are the problems with that definition today? Not the definition itself, but with that last statement. As we look at those definitions of professionalism, here are some of the problems that I see that I'm going to be looking at. There's no agreed upon definition, as we've already said. You can define ideologically, define it as a social scientist would, and that's Freitzen and I have to believe that makes more sense than what the others have seen. And people are emphasizing on the one hand two things. One is the articulation of behavior and affect on the part of physicians. Behavior is relationship to each other and to patients. Effect is relationship to their values and how they see themselves. But there is no clear or firm articulation of ethics in most of the statements except one, and it's pretty confused in that one as I will say. I make that point because remember the last point of Freitzen was that all of the above had to be under the direction of ideology or it would not be, in his point of view, a professional and it would not be ideal professionalism. Emphasis on method and teaching, et cetera, et cetera, et cetera, without clarity of definition. Methods of measurement of behavior and of affect on what I take to be arguable grounds. I'm not going to weigh you out with all of these. The ABIM charter which most of you are familiar with particularly is a mixture of ethics and commitments, three freely asserted ethical principles with a series of freely asserted commitments to behavior and to dealing with the relationships and problems. It deals mostly with commitments versus obligations. There's very little word about obligation. There's very little deontology. I've read not all the literature, God knows, but I've read perhaps 50 papers and these observations I think apply to most of them. An unclear specification of roles of various health care professions who's in charge, who's my advocate, who will answer my questions. Those of you who are clinicians know when a patient comes that wants to know some very simple answers to simple questions. What's wrong? Is it serious? Can you do something about it? What are you going to do to me? Will it hurt? Will it cost? Put the long pole. That's what it's about at the front line. Those questions are very difficult to answer when you're talking about behavior of one relationship, this profession to the other one and so on. All of which is important, but it needs an organizing principle and professionalism is not an organizing principle with those two ends in view of A, responding to the needs of the patient, and on the other hand, meeting the new challenges that come from the social engagement of medicine, which is nothing wrong about this, nothing against that please. Let's not get into the dichotomy of these guys who are only on patients and are neglecting society or society and neglecting patients. Obviously that relationship has to be developed and that's part of the thesis we're talking about. It's a bit of overcrowding bedside, I still make rounds and especially when I'm making ethical rounds, it's hard for me to find out who's in charge because there is a small matter of the moral responsibility and legal responsibility which is defined as belonging to the position of record, just trying to find who the position of record is. Again, this is not criticism, it is dilemma that I'm confronting and some of you are confronting. That overcrowding is a bedside, I can't see the patient for the crowd. Most of the freely asserted commitments have some justification, but I doubt, but there's no order of priority for resolution of conflicts. So professionalism as defined by Freitzen is a real concept, it's a concept that has meaning, but as he says, and this is particularly interesting at the end of his book more or less, under the title of the soul of professionalism is ethics and what I think is being ignored somewhat. Okay, here's what he says and then this will be the last of Freitzen. I didn't realize this. At University of Chicago Press, I don't get any royalties for that. Freitzen does. Anyway, I'll read his words again, only because I want to tie it into what I think is a valid scientific definition of professionalism and the link between it and transcendent values, which I see very little of in the literature as I review it. Transcendent values, that's a pretty fancy word for what we're talking about, transcendent for philosophy or something bigger than that. But anyway, transcendent adds moral substance to the technical content of the disciplines. Professionals claim the moral as well as the technical right to control the uses of the discipline so that they must resist economic and political restrictions that arbitrarily limit benefit to others. I'm not going to spell out the implications. You're all well aware of what's happening in the world today. While they should have no right to be the proprietors, these are the professionals, no right to be the proprietors of the knowledge and technique of their discipline and one of my big fights over and over again is that people say, this knowledge belongs to me. I paid my tuition and I respond by saying, and what is the cost in that you would allow people to invade your body as our medical students do, because they have a social sanction to do so? And to that question, who owns it? So I come now to this very pithy statement of fights. While they should have no right to be proprietors of the knowledge and technique of the disciplines, they are obliged to be their moral custodians. Fightson calls this, as I said, the soul of professionalism, that it is an organized, well functioning, presumably not discipline, but a set of people involved in a discipline with a dedication, however, that goes beyond the discipline itself. That being the case, let me look at this other side, the other end, proletarianism, which he also addresses, but I'm very much concerned about. If the profession fails to be the, these are my words, don't blame these on Fightson, if the professional fails to be the moral custodian of the nature and usage of his technique, he becomes or she becomes a proletarian, someone to be used as an instrument to advance goals other than the moral obligations of the profession. I put the worst case scenarios there, obviously we're not, I think, heavens going in that direction, but proletarianism comprises the soul of professionalism if, if that soul is lost without dedication to a moral set of beliefs which divide and direct the use of the technique and the profession. So summarization of this piece of what we're talking about, there's nothing wrong with the idea of professionalism if it's defined promptly, it's a social phenomenon and I think that's quite correct, it's a social phenomenon that has a moral substance to it and that's what I'm going to be talking about. Let's turn to the idea of profession which is entirely different than professionalism. This is a very high-flown quote from the first mention of the word profession that is in the record coming from the first century AD but also probably older than that. It comes from someone called Scribonius who was a medical attendant to one of the Roman emperors for all things. Here's what he said about it. All men and gods, in fact, should despise any physician whose heart is not filled with humanity and mercy according to the purpose of his profession and for those of you who have Latin, you'll see the word profession, professor Jonas which I'll point out in the moment has a special meaning and we don't judge people by the worth of their bank account, or by their status or anything else in life. They offer to help all who seek it and promise never to injure anybody. Beneficence is ahead of non-malificence. Beneficence is the first principle. Just a minute again, profession. It means declaring a loud, announcing a loud, making a public commitment a promise. And that's what each and every one of us does when we address the patient and say, can I help you? What's wrong? What can I do for you? Etc. Put yourself on the gurney and someone on a white coat comes along with a stethoscope around their neck and says, how can I help you? What do you interpret that to be? You're in pain, you're anxious, etc. What does that mean? That is the word profession. The public promise that you make implicitly, if they didn't think that you were going to help them, they would certainly not submit or get off that gurney. So we're talking about a different kind of profession, that is to say in terms of the etymology of the word. It's the oldest one. I am not suggesting that everybody acted the way Scobonia suggested at the highest level. That's not the point. The point he made there was the use of that word profession. And it is not something that came into existence in the 18th and 19th century. That's somewhat implied. Now, to be truly an ethic, we'll be talking now, an ethic that's related to the promise of helping, of assisting. What does that mean? Let's look at that more carefully. Remember my line of argument. I'm going to hook the care of the individual patient with their societal needs. So to be truly an ethic, you have to have an established moral philosophy or an examination of the realities and phenomena of the physician-patient relationship. I'm going to choose number two rather than number one, which would be a more difficult assignment at this point. It also requires, however, what do we think medicine is, a moral philosophy of some kind, namely norms and virtues entailed by the phenomenology of clinical medicine. That's my phraseology. What I mean by that is that the obligations we have, and we're talking about not just medicine, but all the health professions. I'm using medicine as a shorthand only because, if I say something critical, it's going to be about medicine and not about anybody else's profession. But all of us have exactly the same commitment that action of profession. When the nurse comes to the bedside, when the physical therapist says, let me look at that knee, et cetera, et cetera, et cetera, the health professional has an orientation to the good of the patient. The good of the patient is the relief of what they consider and what they define as a problem, as illness for them. So, we're talking now about, therefore, an internal ethic of medicine. Not one taking off the shelf from some existing philosophy. That's the way most of medical ethics mean to us. But are you wrong with that? When you get to that level, but you start at the very ground, which is what is it all about? Now, all of you say this, or we've heard this before. Hold on for a moment. Let's see where we go with this. The active profession, can I help you? What does it say? It says, I'm competent. I will use my knowledge for your benefit, not the insurance company, not the hospital, not anything else. And trust me, aren't those the things that run through your mind when you're on the gurney? That's what I want you now. What are we looking for? We're looking for someone who can give you a technically correct and a morally good action. It should be decided for and with you, the patient. That's what you're expecting. And it's carried out efficiently, safely, and compassionately. All this seems to be laboring the obvious. But laboring is the obvious, and not to labor the obvious, is where we go wrong. And why this whole notion of professionalism and professionalization, even worse, idea, all of that, has significance, only if, just as Fraction said, and just as the facts say, only if it is enlightened by and based in an ethics, a moral. An ideology, I object to that, but that's okay. We know what we're talking about, and he's talking about ethics. So here are the things that are phenomenologically just some quick things that are phenomenologically true about that relationship. Don't worry, we'll come to society in a moment. When you become a patient, that's an existential change. You're sitting around now listening to me, probably wishing it would all be quickly, and I wouldn't blame you one bit, but nonetheless, you're in pretty good state of relationship to yourself and who you are and your identity. And as you're sitting there, you find a little nodule in your earlobe, being physicians and physician-related or other health professions and so on. You begin to think what's going on, what's happening. The questions I talk to you about. Your life has changed, like it or not, until you get some resolution to that problem. So you have a loss of your freedom and daily routine. You're environmentally vulnerable. You don't know what's wrong, even if you're a physician lying on that gurney, having been a physician on that gurney, I know that experience. You're anxious, you're fearful. There's a certain amount of hostility. You're mad at the problem and you get mad at the physician or the nurse or the allied health worker. It's a confrontation with your affinity. Now you know that's the possibility that you may even die. It's a threat to your self-image and your future. And all of this comes down to your ultimately having to trust this person who came to you and said, can I help you? You're in the most state of existence to be ill. Quick summarization, the empirical realities are there's predicament of illness, I've just talked about the change in existential states. The act of profession, your promise of help, you said, how can I help you, what can I do? And the act of healing, the decision that you will make a decision which is technically correct and morally right. What does that mean? This is a review only of medical ethics. We'll put it back into the line of argument very shortly. Certainly we talk about virtues. A great deal today, and I've written a lot about virtues, I'm not going to lecture on them. But you do expect things to be manifest to you in the way this person behaves toward you. Benevolence first, not respect for your autonomy. Benevolence first, fidelity to trust and promise, compassion, courage, honesty and suppression of self-interest. Frights and points that I was one of the elements of professionalism. Intellectual virtue, science. This is in the classical sense of knowing the knowledge that you'll be dispensing and working with. Technique prudence, the first and most important of the clinical virtues. The capacity to make the right and good decision in the face of uncertainty. Most of us make our important decisions without having all the facts and not being certain about what we make our treatment with absolute treatment. We know there are things we cannot predict and yet we must act. That's the difference of clinical ethics and this is the center of clinical ethics is not right. So, center of clinical ethics means how do we make decisions which are in the best interests of the patient. That's the virtue of prudence and it's the oldest of virtues and I'm not going to lecture on that either. Covering the background for where I'm going. That was part two. Part one was a little examination of the notion of professionalism. The second one was the idea of profession which is far older than the notion of professionalism. Now, medicine also has and so do all the other health professions let me say that over and over again not just medicine, social obligations. I put and that's dealing generally with justice, justice in the use of our technique and our knowledge. Commutative justice first. Commutative justice. That branch of justice that deals in one-to-one relationships, contracts, dealings that we go through every day with in-beings that active promise. We act as technical experts when it comes to policy decisions. We have to be and should be advocates for distributive justice. We should participate as private citizens indeed in some of the studies I've read in professionalism. There's been great emphasis in people and society wanting positions to be more active in the life of the community. Oh, leave that off for the moment. What have I said before you? A, a notion of professionalism which is a valid social notion but one which must have a moral foundation when we're in the health professions that moral foundation is that strongest focus on the promise we make to the patient as a group but particularly as individuals in moments of existential crisis. And then thirdly we have responsibilities to society and that side has been emphasized in professionalism and there's nothing wrong with it. What we need then and what some of us are working with is how to order these things one to the other. And I see in the case of professionalism an entire emphasis on the physician being trained or the nurse being trained in a milieu which emphasizes what a society want of us and so on how we should behave and what should our attitudes be important but they do not define the fundamental relationship which is the moral relationship of a promise we've made to act for the interest and the good of the patient. And therefore I think as we look more critically at the notion of look more critically at the notion of professionalism and begin to look at it from the point of view of what's missing particularly the notions of the relationship of the health professional to the person who needs their help and the moral responsibility and not in any way deviating for a very valid definition of professionalism which is frightsome namely it all depends on it all depends on having a moral orientation he makes that point that for him is the soul of ideal professionalism and so I would propose and not going to detail at this point giving you an opportunity to ask some questions I would propose that we yes should look at professionalism look at it from the point of view of how we take these questions and problems I've raised with it and put together and not abandon the patient in the interest of the community on the other hand who should do what and I'll argue further that we must remember that the heart of medical ethics nursing ethics the other health professions the patient that has to be done within the framework of what kind of society we live with and responsive to what people are asking but not designing and abandoning the technical and moral orientation we have because someone wants it this way or that way we have to justify it in an orderly systematic critical fundamental way and that is going to mean a much more serious kind of engagement than I think we're in now I think the way I see professionalism being written about is in ideology in the wrong sense that is a series of beliefs that are held strongly and powerfully but are not justified in any formally systematic critical way and so I would like to see added to our medical ethics and I've written about this and have an article in this direction medicine regarded and again nursing moral communities so that in addition to moral community as to say in addition to our acting the way we've been talking about with individuals we also act together as a body for the social good without going into finding that which is another series of discussions of another kind so that we divide these issues on the one hand dependence of the patient on or the sick person on individual health professional and the dependence of society for the changes that are being emphasized in professionalism those changes being part of the fact that we in the health professions each of us within our profession have also a moral community what do I mean by that and I'll be coming to the close by that I mean that we are committed as a group to the welfare of those we deign to treat and office ourselves to treat as a community we're not doing that our organizations always turn to the interests of our professions not to the interests of the community and society a moral community we're united together why because we have been educated together with a moral point of view not so much in the fact that we are all doctors all nurses or all allied health professions but rather the fact that we're united by a common and I'm not going to go through here because of time some kind of common common oath we've taken or a charter or what have you I think the charters have problems but we'll leave that aside at the moment thank you the professionalism movement maybe a sociological movement as you said but it's also heavily an educational movement an effort to transmit to the students behaviors, attitudes performance both in the technical realm and one would hope also in the moral realm of what it means to be a good doctor and to practice well your challenge though is really a very difficult challenge in asking in asking of educators to be able to transmit this sense of moral commitment so much easier to transmit a sense of how to perform how to behave what things are acceptable in the community it seems much more difficult to get at your wish for us that we train our people to become a part of this moral community can you give us any guidance there I mean is it the training process itself through 4, 8, 10 years of training that leads to that is it by example is it by role models how do we get there that's a long question I'll try to answer very very briefly because I've been involved in education for 6 or 5 years it's just as you know my problem is that when you start talking about teaching behaviors you have to have a foundation for a particular behavior we spoke of words of commitment commitment appears in many of these statements these charters why should I commit myself in that direction well I would like to convince if you want to talk about medical students or residents or myself what I would like to convince is that commitment is not a matter of choice it's not a matter of prestidigitation of what you feel you can do and you like to do it is what you must do and that's why I think the act of profession which commits you in this public way every time you meet a patient that can be taught only one way that weighs heavily on the medical teacher by example I can lecture for 6 weeks on medical ethics on medical comportment or any of these other things I'm talking about turn my back once at the wrong moment when I'm making rounds and I've blown the whole lesson out the window so we can talk about these behaviors the other point about the behaviors is the methods of measurement are dubious very dubious but it's much much more keeping a very similitude if you're standing there and you see someone do it the right way and you are then wanting to follow that person every medical student eventually every resident has a model someone they admire for their technical skill usually at the beginning and then they begin to pick up the habits within the non-technical realm and I think clinical teachers are not sufficiently aware of the fact that they transmit two things one how to do endocrine surgery and secondly how to treat the person who has a few chromosatoma and those two things don't always go together so I'm not opposed to having sessions in which we say what a society want of us and so on the point is how do you put those two things together and I don't think I don't think that emphasizing a list of behaviors or a list of relationships is going to take the place of a moral conviction and that moral conviction has to be actualized and concretized in the person of a clinical teacher teacher rather than going around Oprah Winfrey style I'm going to repeat your questions so that it's also recorded for the for the tape so if there are questions I'll be recognizing them and repeating them to what extent are the principles that have been articulated timeless and to what extent do they need to be adapted to particular structures in the current era economic strictures and things like duty hours well one at a time leave the duty hours for the second piece I don't think there's any conflict from what I've said because the way I would put it is if you're planning to meet an economic crisis in medical care why not do two things first ask yourself what are the requirements for an ethically defensible economic decision not let's make an economic decision and then decide where the pieces fall start with that question and I think that's a different way of approaching it you look at in the beginning what you're thinking about and the second thing is you follow what you've decided upon by examining again the ethical dimension and once the ethical dimension it's not something complicated is the change you've made beneficial or harmful and if harmful have we made a sufficient attention to preserving the good of the patient in the light of economics it's a not something you're going to get out of a mathematical formula I think that's what people are asking us what about X, Y and Z and how does that fit with our economic decision economic decision will be made I'm not someone who says well let's just forget about it that first and in the design of your system there's a great deal you can do at the beginning to look at what would be the impact on the good of the persons we are treating where do we go when some of our economic decisions fall as they might and I'm not making any political statements here at all they might on those on the margin of society what's the moral obligation of those who are writing the plan how do you balance those that's a prudential decision exactly what I was talking about but you have your ethical question preceding your economic question and then when you've made your economic choice what would be the dominant ethical point of view he said what about the persons on the front line who have not been involved in actually making those economic decisions but are simply confronted with them as facts particularly when they have to make trade-offs between the economic good of society and the good of the patient or confronted with a system of financial incentives that they didn't invent and weren't in the making process I don't think any of that changes what I said you're making a reality a reality I'm very familiar with I've been at the front lines I've been in the trenches presented with a certain set of facts which you said and I agree you're quite right with that but our job is to say what impact will that be and then think of the second thing as a profession when we suspect that a decision has been made economically is damaging to patients to people that's where the fact of being a moral community united for the good of the patient as well as individually as a group comes in and I've heard very little clear examination of the ethical implications of some of the things that are proposed without going into specifics to what extent is the individual clinician going to be beholden to third parties that have made decisions or have influence and interests in the decisions being made at the bedside beholden I think you're saying being put into a situation by those well again where are we in our answer to it where are we let's say there's no question these decisions being made away from us but where's our pushback that's what I'm talking about I'm preaching I guess revolution the question again for the tape should physicians become then activists and revolutionaries for the record Dr. Harmon for the case of for the sake of the record I'm not preaching revolutionaries however I'm using the word pushback I would like to see and I have not seen in my lifetime our profession saying look we have a common responsibility to act for the good of the patient on a one-to-one basis you can't do it as an individual but as a group and we haven't done that and that's what I'm talking about revolution is a strong word obviously but we have let me say this we have much more moral power than we've ever exerted again the comment is isn't as was said before by Dr. Chin the frontline physician who's operating within decisions that were already made by others outside the profession already proletarianized by your definition of proletarianism well as a matter of fact I didn't want to annoy you but you've come to the obvious conclusion yes that is why I put professionalism profession and proletarianism yes you're proletarian once you lose the capacity to determine how you're going to use your knowledge for the purpose that it's designed which for us should be the good of the sick person for the record the question is to what extent could physicians rather than simply responding to society actually engage with society particularly with patients in establishing the sorts of standards how much can the physician do not just the physician I remember I've confined myself to physician only because of the reason I gave you the beginning but I'm talking about all health professionals just think of the moral power 400,000 physicians 2 million nurses XYZ, dentists, etc who were really united by a moral commitment to the good of those they serve tremendous impact on society tremendous we still have some status left we're losing that status simply because we don't take that kind of position so I think we ought not to be throwing our hands up we have power and that's why I developed the notion here that on the one hand there's no question that we have to strengthen our commitment to what we do and secondly we have to be a moral community where all of us in the health professions push back when there's something that threatens the good of those we can treat maybe that's too such a dirtle I'm not preaching the point is I think that's our moral responsibility Dr. Pellegrino I was under the misguided impression that as people became more mature and senior in their standing they became more conservative your message to us is one of radical activism that changes my mind greatly but thanks so much for coming and talking to me just one comment activism but with a moral foundation yes very fabulous