Ethics and the Good Doctor

Character in the Professional Domain

Sabena Jameel, Andrew Peterson, James Arthur

• Publisher: Routledge
• Year: 2021
• eBook ISBN:
  9781000478877
• Topic: Education
• Subtopic: Medical Theory, Practice & Reference

Ethics and the Good Doctor brings together existing literature and an analysis of empirical research conducted by the Jubilee Centre for Character and Virtues to examine the ethical nature of medical practice and explore medicine as a virtuous profession.

The book is based on the idea that medical practice is an inherently moral profession, in which notions of trust, care and meaningful relationships form the foundations of being a good doctor. By taking into account the ethical dimensions of medical practice that have come under greater scrutiny and pressure over recent years, this book explores how personal and professional character is understood, enacted, and experienced by medical practitioners at various stages of their career.

Ethics and the Good Doctor situates and presents the empirical data in a way that is accessible to practicing doctors, medical students, and medical educators. Clear implications for policy, practice, and research are offered, ensuring this book will be of great interest to a range of stakeholders involved in medical practice, including those working in medical policy.

1 The professions and character

DOI: 10.4324/9781003137887-2

Introduction

Whether inspired by a desire to justify an occupation’s status as a profession (teaching and social work, for example) or by the need to re-assert precisely what lies at the heart of a long-standing profession in the wake of public concerns about standards (medicine and law, for example), the related questions of what constitutes a profession and what constitutes professional practice have received a great deal of attention over recent years. A core concern within this literature on the professions has been to highlight and seek to understand the ethical basis of professions, whether generally or specifically. Professions are deemed inherently ethical occupations because, and more so than other occupations, they place high moral demands on the conduct of workers. Indeed, these ethical and moral demands – which include care, integrity, fairness and diligence – are often viewed as the defining feature of many professions, including medicine, law and teaching, reminding us that professions are ultimately concerned with human actions and interactions. For example, in relation to medicine, the focus of this present book, Bontemps-Hommen et al. (2019) have suggested that morality is at the heart of medicine. As Oakley and Cocking (2001) also remind us, the focus of professional work is typically the provision of goods – such as health, education and justice – that are fundamental to flourishing individuals and societies. In specific relation to medical education, Brody and Doukas (2014) talk of medicine as both a ‘trust-generating profession’ and as ‘the application of virtue to practice’ (see also Rhodes (2020) on the importance of trust). Yet, and as various professional ‘scandals’ over the last 20 years have evidenced, every profession and professional faces ethical challenges and dilemmas as part of their work. Indeed, the very ethical nature of the professions entails that public mistrust and criticism results when conduct falls below the standards expected (Blond et al., 2015).

In order to examine the ethical nature of professions and the ethical dilemmas experienced by professionals, since its inception the Jubilee Centre has undertaken a number of empirical studies examining character, virtues and the professions. Some of these studies have concentrated on the professions generally (Arthur et al., 2019a), while others have focused in on specific professions: law (Arthur et al., 2014), medical practice (Arthur et al., 2015a), education (Arthur et al., 2015b), business (Kristjánsson et al., 2017a), nursing (Kristjánsson et al., 2017b), and the British Army (Arthur et al., 2018). More recently, through the project Practical Wisdom and Professional Practice: Integration and Intervention the Centre has built on this research to examine particular commonalities and differences across professions and professionals (Arthur et al., 2019a).

The purpose of this first chapter is to provide an initial survey of the existing literature on the professions. The first section considers briefly what constitutes a profession in general terms, before turning to the more specific ethical dimensions of professional activity. It does so in light of the now widespread trend towards managerialism, accountability and efficiency that has been witnessed across professions in a number of countries over the last 30 years (Berwick, 2016; Montori, 2017). In the second section, attention moves to consider the value of a virtue-based account of professional ethics. In this section we draw on the Jubilee Centre’s neo-Aristotelian approach to virtues and character in order to argue that professional ethics involves but also transcends reliance on rules and duties, thereby requiring professionals to act with professional wisdom and judgement.

What constitutes a profession?

While definitions of what constitutes a profession abound, certain features seem to be generally, if not universally, accepted (see, for example, Carr, 1999). These are that:

• a profession is a paid occupation;
• a profession requires formal qualifications, a high level of education and a prolonged period of training/induction;
• a professional possesses high level theoretical and practical expertise in a given discipline;
• a profession provides a public service;
• a profession is, and professionals are, held in high esteem within society;
• a professional acts with integrity, care, honesty and trust, exhibiting a level of professional autonomy and judgement;
• professional ethics is guided by a code of conduct specific to that profession.

The Australian Council of Professions,¹ which captures each of the features above, defines a ‘Profession’ as:

a disciplined group of individuals who adhere to ethical standards and who hold themselves out as, and are accepted by the public as possessing special knowledge and skills in a widely recognised body of learning derived from research, education and training at a high level, and who are prepared to apply this knowledge and exercise these skills in the interest of others. It is inherent in the definition of a Profession that a code of ethics governs the activities of each Profession. Such codes require behaviour and practice beyond the personal moral obligations of an individual. They define and demand high standards of behaviour in respect to the services provided to the public and in dealing with professional colleagues. Further, these codes are enforced by the Profession and are acknowledged and accepted by the community.

In seeking to establish a ‘working definition for medical educators’, Cruess, Johnstone and Cruess (2004: 75) offer the following:

An occupation whose core element is work based upon the mastery of a complex body of knowledge and skills. It is a vocation in which knowledge of some department of science or learning of the practice of an art founded upon it is used in the service of others. Its members are governed by codes of ethics and profess a commitment to competence, integrity and morality, altruism, and the promotion of the public good within their domain. These commitments form the basis of a social contract between a profession and society, which in return grants the profession a monopoly over the use of its knowledge base, the right to considerable autonomy in practice and the privilege of self-regulation. Professions and their members are accountable to those served and to society.

In the UK, various professions make clear the centrality of the ‘ethical’ to the nature of the profession. For example, in its Code of Ethics,² the British Association of Social Workers asserts that:

Ethical awareness is fundamental to the professional practice of social workers. Their ability and commitment to act ethically is an essential aspect of the quality of the service offered to those who engage with social workers. Respect for human rights and a commitment to promoting social justice are at the core of social work practice throughout the world.

The Law Society of England and Wales³ makes clear that:

The commitment to behaving ethically is at the heart of what it means to be a solicitor.

Ethics is based on the principles of:

• serving the interests of consumers of legal services
• acting in the interests of justice acting with integrity and honesty according to widely recognised moral principles

Ethics will help you respond in the right way to any moral dilemmas you might face at work.

Many more codes of conduct from other professions that similarly locate ethical conduct as fundamental to the profession could be cited. However, despite these reasonably well established and understood definitions, how best the ethical should be formulated conceptually and can be implemented practically, remains both disputed and challenging. Turning specifically to definitions of professionalism in relation to medical practice (which are examined in more detail in Chapter 2), Ong et al. (2020: 636) reflect both that rather than being static, ‘professionalism is an evolving, socioculturally informed, multidimensional construct’ and that ‘the concept of professionalism remains poorly defined’.

Clearly, ideas about what constitutes the ‘good’ professional transcend simply technical abilities and encompass notions of judgement, wisdom and care. However, further questions remain about the extent to which particular cultures, discourses and practices can put pressure on how professionals, particularly those working in the public sector, can act with (or indeed without) ethics and integrity (see, for example, Furlong et al., 2017). Indeed, various studies evidence the impact (whether positive or negative) of workplace conditions on professionals’ ability to exhibit ethical conduct (see, for example, Oakley and Cocking, 2001; RPS, 2011; OfSTED, 2019; Worth and Van Den Brande, 2019).

Discussions about the meaning and nature of ethical professional conduct and the effect of cultures, discourses and workplace practices typically concentrate around two particular considerations. The first is the impact, widely cited and critiqued in current literature on ethics and the professions, of the increased forms of managerialism and instrumentalism that have roundly been identified as detracting from the ethical and societal role of professionals. According to critics, the turn to managerialism across and within the professions has led not to a renewed form of professionalism but to a processes of de- and re-professionalisation through which the goals of general accountability (to service users and to government) and efficiency have actively worked against professional autonomy and judgement (Carr, 2011; Holbeche and Springett, 2004; Dixon-Woods et al., 2011). The second consideration is the extent to which professions, such as health, teaching and social work, have come under increased public scrutiny and accountability in the wake of various ‘scandals’ (Seijts et al., 2017; Arthur et al., 2019a). Over the last 25 years in England, for example, high-profile cases including the murder of Stephen Lawrence and resulting Stephen Lawrence Inquiry (known commonly as the Macpherson Report), the murder of Victoria Climbié, the death of Peter Connelly (also known as Baby P), the Mid Staffordshire hospital crisis and the Rotherham Child Sexual Exploitation scandal have all raised serious questions about what were significant failures in professionals’ ethical judgement and conduct.

In the context of managerialism, accountability, efficiency, public scrutiny and increased workplace pressures, professions and professionals need to (re)envisage the ethical nature of their work. This (re)envisaging by necessity includes paying attention to what a profession aspires to be, what constitutes professional practice – whether generally or specifically for that profession – and how external factors shape the standing and work of professions today (see, for example, Berwick, 2016). In the next section we start to examine these questions through a focus on a virtue-based approach to pro...

Table of contents

• Cover
• Half Title
• Series Information
• Title Page
• Copyright Page
• Table of Contents
• Acknowledgements
• Introduction
• 1 The professions and character
• 2 Ethics and medical practice
• 3 Medical practitioners: Personal and ideal character strengths
• 4 Medical practitioners, ethical dilemmas and the perspectives of medical educators
• Conclusion, recommendations and further research
• References
• Index