Medicine under threat: professionalism and professional identity.

T he professions have never been more important to the well-being of society. Professional knowledge and expertise are at the core of contemporary society. How such professional expertise is developed, how it is deployed, by whom it is deployed and for what ends are among the most pressing issues facing all modern nations. At the same time, many of the most distinctive features of the professions, especially their privileges of self-regulation and self-policing, are being curtailed. This is true even in countries such as Britain, the United States and Canada, where professions have historically been most autonomous and enjoyed the greatest social prestige. 1 To date, the efforts by professional groups to respond to these threats seem to reveal the weakness of appealing to expertise alone as the basis for professional control of medical services. Expertise does not provide much leverage for asserting traditional professional privileges in the face of calls for greater efficiency and cost reduction , let alone public demands for more personalized attention and care in dealing with complex technologies and more daunting social problems. What is missing from these ways of responding to contemporary challenges is precisely the moral core of professionalism: the contract between professional and society in which physician and patient are bound together within a larger " body politic. " What is professionalism? In Canada and the United States the social basis of the extraordinary grant of occupational authority and independence to professionalized occupations such as medicine and law has been a social contract between the profession and the public. Professionalism is the moral understanding among professionals that gives concrete reality to this social contract. It is based on mutual trust. In exchange for a grant of authority to control key aspects of their market and working conditions through licensing and credentialling, professionals are expected to maintain high standards of competence and moral responsibility. The work of the traditional learned professions has long been understood to require a significant domain of discretion in individual practice. It has therefore been thought to require a stronger sense of moral dedication than most occupations. A professional is not required to ignore material considerations but is expected to subordinate financial gain to the higher values of responsibility to clients and to the public interest. Contemporary students of professionalization have shown how, starting in the late 19th century, the development of professionalized fields modified the laissez-faire pattern of …