Three-year-old twins in Ontario urgently needed a liver transplant to save their lives. Both were born with Alagille syndrome, which creates liver disorder. Their father was a suitable donor, but could only save one. In a story subheaded âOne third of Canadians needing organ transplants never receive oneâ, Sagan (2015) shows how doctors caring for this and other such cases frequently face harrowing choices in responsibility that involve much more than rational decision-making and rules.
In another story with a twist, shared by Sørensen (2013), a ten-year-old boy facing amputation of a foot due to cancer became worried about what would happen to his foot. He didnât want to just have it disposed as tissue waste. What happened came about through a creative approach to responsibility generated by the medical staff collaborating with the boyâs family. A farewell dinner was held, then following the amputation, a formal funeral took place complete with vicar, small white coffin for the foot, burial in the cemetery and a wake â before the boy began his new life with a prosthetic foot.
Introduction
What does professional responsibility mean, in the escalating complexities and contradictory demands confronting todayâs professionals, such as those in the two stories opening this chapter? How is it enacted? Is there a single answer to either of these questions?
Of course not, is what I argue throughout this book. There are many influencing forces to consider and a range of defensible constructions of responsibility emerging in practice. There are different purposes for professional action. Uncomfortably, there also are different stakeholders often with conflicting perspectives, all of which have legitimate claims on professionalsâ responsibility. Further, we are witnessing important shifts in understanding what entails responsible professional practice in public service. What is responsible action when the needs of the many far outnumber the organ donors available, and when those many include potential recipients that the public are now beginning to consider as less worthy of state-funded health care, such as violent offenders or chronic alcoholics (Perry 2005)? Or, how should responsibility be determined in multi-agency and interprofessional practice, which is becoming the norm in many fields, when each occupation is governed by a different scope and standards of professional responsibility? Turning to issues generated by the increasing digitisation of professional work, what happens when assessments and recommendations formerly considered professional decisions are assigned to software algorithms and technological diagnostic instruments? Or in arrangements of co-production â another popular policy driver for public service reform where professionals are expected to work in equitable collaboration with families and clients to provide care â when bad things happen, who (or what) is responsible?
Interprofessional practice and co-production, new software code and big data, the press for innovation as well as for ecological responsibility, the growing obsession with assessment â these imperatives are all contributing to major shifts in professional work and responsibility. They can be viewed as regimes of governance. The argument here is that these regimes â particular aims, knowledges and practice bound together â act, in concert with other networks of market and measurement, as powerful influencers on professionalsâ ways of thinking, acting, engaging with the public and becoming âresponsibleâ. Professional workers, particularly those in public service, are increasingly subject to these forms and foci of governance. Each chapter in this book concentrates on one of these governing regimes to explore its implications for professional responsibility. The picture that emerges shows that professional responsibility is far from a singular concept. It takes multiple forms, and requires different processes of negotiation, deliberation and situated discretion.
This is not to imply that responsibility relaxes and âanything goesâ, according to the messiness of context and moment. On the contrary, this book generally follows the value commitments inherent in most public professionsâ obligations: to further a democratic, healthy world, address inequalities and engender respectful caring. But what is included in our understandings of democracy and caring? In most professions, human rights and needs have been central. However, many often undeclared dynamics â technological, bodily, political, managerial, environmental, affective â are mixed with actions and decisions of professionals struggling to enact these obligations. The first task is to recognise how these dynamics are entangled, and with what effects, in both the apparently human matters confronting professionals, and in professionalsâ scope of being and doing. The second is to consider what these dynamics mean for the commitments and possibilities of responsible professional action. Indeed, these considerations may entail rethinking what it means to be professional.
The opening examples of organ transplant and limb amputation help illustrate a further issue, which is the impossibility of separating discussions of responsibility from flesh, emotion, technologies and other materials. The boundaries between humans, and even between humans and non-humans, are not as distinct as we may be accustomed to believe. Is an amputated foot just disposable tissue, or a thing with an ethical claim for due care and respect, equivalent to what we may accord a human being? Some call this a sociomaterial approach to practice, which will be explained later in this chapter. This simply recognises that practice is an outcome of many social and material forces in turmoil. Practice is collective and distributed, not just an individual human person behaving in particular ways. This has powerful implications for how we understand responsibility. It also raises difficult questions about how to educate professionals in terms of professional responsibility.
Ultimately the arguments here are pinned to what they imply for purposes and approaches to professional education, where responsibility is fundamental, but taken to be sociomaterial and emergent, as well as urgent. There is justified concern about the growing control and standardisation of professional work exercised through external audits, alongside a certain devaluing and demoralising of professional responsibility caused through deep financial cuts in service, deregulation, new smart technologies, and declining trust in some sectors. However, critique can only take us so far in rethinking professional education. This book adopts an orientation of possibility, aspiring to what Braidotti (2013) calls an affirmative posthuman politics to construct sustainable alternative futures, in contemplating education for responsibility.
Conceptions of professional responsibility
I agree with Evetts (2013) that debates over defining âprofessionâ are not particularly useful. For the purposes of the bookâs discussion we may understand professions as âthe knowledge-based category of service occupations which usually follow a period of tertiary education and vocational training and experience ⌠[and are] extensively engaged in dealing with riskâ (Evetts 2013: 781). This book tends to focus most on professions engaged in public service, what some call the âpeople professionsâ, such as health and social care, policing and education.
Professional responsibility is often treated as a defining set of obligations for the nature of professionalism itself: obligations to the clientâs interests as well as the needs of society broadly (Freidson 2001). Both professionalism and issues of responsibility, sometimes blurred with ethics, today seem to command overweaning attention among employers, professional associations, the media and the public, judging by the volume of debate that continues to pour out of universities and blog posts.
Existing literature on professional responsibility, as shown in Chapter 2, tends to be characterised by a great deal of moral prescription, opinion and concern for methods to educate professionals to perform more responsibly. There is no shortage of pronouncements for practices that ought to constitute professionalsâ responsible practice in particular fields. Lists of ideal virtues defining proper professional conduct still circulate widely, even in professional education and assessment processes. These prescriptions may be stoked by complaints and public concern â heightened through periodic sensational âbad appleâ media stories â about professionalsâ perceived irresponsible practice and failure to appropriately regulate responsibility in practices such as medicine, finance, journalism, policing, social care and others. Before exploring new visions for educational responsibility offered by a sociomaterial sensibility, it is important to delineate more precisely what is meant by responsibility and what issues it bears.
Meanings of âresponsibility'
Conceptual discussions of responsibility are wide-ranging, from causal (who caused the problem) to consequential responsibility (who takes the blame); and from attributed (who is held accountable) to distributed responsibility (how accountability is apportioned among agents). Moral responsibility invokes notions of both obligation and moral decision-making. Obligation calls forth a sense of duty to care for self and others, extending beyond oneâs own self-interest, and accountability to others for oneâs actions. Others in this sense can be interpreted broadly: other human beings, other collectives such as community or national interests, authorities, tradition, animals or non-sentient beings of the natural universe, concepts or ideals. Moral decision-making to acknowledge and act upon oneâs responsibilities incites questions about the conception of the âgoodâ, the attendant criteria or âlawsâ that should guide individual action, and the extent of oneâs freedom to choose. Within all of this, as Gibbs (2000) points out, some view a distinction between responsibility as felt and responsibility as acted. For example, in education, there may be emphasis on raising learnersâ awareness of and personal commitment to civic responsibilities, as well as guiding them to enact their particular responsibilities as students.
In the field of ethics, critical debates have long swirled around the questions: who is responsible to whom, for what and to what extent? Responsibility has been developed within a tradition of rational philosophy as a question primarily of ethical decision-making. It also invokes issues of universal laws and the problem of the contingent particular situation, as well as bonds and obligations that inhere in an individual, which is usually conceived as autonomous, intentional and capable of acting independently of others. However, Levinas (1981) and educational philosophers who have taken up his conception of the ethical subject (e.g. Biesta 2006; van Manen 2000) do not accept the assumptions embedded in this rational tradition. Levinas stresses the relationships that enmesh human beings with one another beyond their conscious intention. He argues that ethical responsibility is moved by and enacted within moments of connection, participation with others that calls forth response. Derrida (1995), in his meditations on this work, shows the problem even of considering just who is âotherâ, e.g. who am I responsible to, when all are enmeshed? Any response to one particular âotherâ must often turn away from the call of someone else.
For an example, let us return to the issue of organ transplants and the ethical dilemma of deciding which little girl of a pair of twins will receive her fatherâs liver donation. An expert on applied ethics in transplants, Perry (2005) sets out the different considerations that doctors could consider in deciding which of the waiting many might receive the few available organs. The patientâs ability to pay is a factor in systems without universal health care provision. Preferences of the donor or kin may come into play. Some policies favour the citizens of oneâs own region and nation over immigrants, while others favour the most vulnerable. Benefits to non-recipients could even be a factor, prioritising those recipients whose contribution to other individuals or society in general is most needed. This moves into what Perry calls the âmerit or desertâ response, and he argues the importance of professionals acknowledging, however uncomfortably, any bias against people due to their own destructive behaviour. Patients are often prioritised by need; but if two or more are equally needy, should the decision be determined on a first come basis, by lottery, or other means? Priority also tends to be given to those who are most likely to thrive after surgery given age, health, support systems and so forth. In the case of the twin girls, where these factors are roughly the same, what is the responsible action? Clearly this is not something that can be decided by any one professional or individual, and the process of deciding reaches well beyond the rational assessment and balancing of the myriad dynamics involved.
These considerations shift the definition of responsibility from notions of felt duty to the active responding to others, broadly conceived, within complex webs of connection. A focus on response turns attention away from defining what is the good, and what ethical laws should guide action, toward questions about how response is excited, by whom or what, what forms it takes and what are its consequences. Thus responsibility is not necessarily an utterly rational construct, but can be a relational dynamic, which hearkens to sociomaterial worlds of emergent and entangled phenomena. In any case, the meanings of professional responsibility are tangled with issues of ethics, where some do seek a clear moral delineation of âgoodâ practice.
Responsibility and ethics
This book does not attempt to address the broad field of professional ethics. However, ethical considerations naturally come to the fore when considering what constitutes professional responsibility in practice, and three issues regarding ethics are worth explaining. First, ethics as a branch of philosophy tends to be concerned with right and wrong, the goodness and badness of action and its consequences and motives. In many professional disciplines, an official code of ethics sets out basic duties such as integrity, honesty, accountability, duty of care, and so forth. How professionals act upon this in different circumstances, and how they negotiate these duties in difficult dilemmas, is one subset of ethical concerns more broadly. This action increasingly is understood to be a pluralist endeavour, as explained in the next section.
Second, there are often conflicts between notions of ethics and of professional responsibility or professionalism. For example, professional codes of ethics in the public services, such as social care, tend to hold four principles at their core: autonomy, beneficence, non-maleficence and justice (McDermott 2011). Autonomy is about allowing individuals to retain control over their decision-making, free from intervention and interference. Beneficence is an obligation to promote individualsâ well-being. Non-maleficence is a professional commitment to act in ways that cause no harm to individuals served. The obligation of justice is to promote equality and ensure, as far as possible, fair distribution of scarce resources.
However as McDermott (2011) found in her study of practitioners working with older people living with âself-neglect and squalorâ, the complex situations facing these professionals every day created conflicts on a number of levels. To what extent should autonomy be preserved for individuals living in squalor posing health hazards, when they have the capacity to choose otherwise? One client lived in a small area surrounded by boxes piled to the ceiling. A housing professional determined that the boxes created significant fire hazard, which then invoked the needs of the wider community. However, the mental health professional determined that there was not sufficient risk to overrule the clientâs autonomy to decide how he lived. McDermott (2011: 55, 63) asks, to what extent should a reluctant client be persuaded to accept help? How far should a professional go to protect a person from risk? These are not simply rational decisions, a matter of choo...
