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The American Journal of Bioethics Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/uajb20
Getting Even More Specific About Physicians’ Obligations: Justice, Responsibility, and Professionalism Rebecca Bamford
a
a
Quinnipiac University Published online: 15 Aug 2014.
Click for updates To cite this article: Rebecca Bamford (2014) Getting Even More Specific About Physicians’ Obligations: Justice, Responsibility, and Professionalism, The American Journal of Bioethics, 14:9, 46-47, DOI: 10.1080/15265161.2014.935891 To link to this article: http://dx.doi.org/10.1080/15265161.2014.935891
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http:// www.tandfonline.com/page/terms-and-conditions
American Journal of Bioethics
Getting Even More Specific About Physicians’ Obligations: Justice, Responsibility, and Professionalism
Downloaded by [University of Connecticut] at 02:24 13 April 2015
Rebecca Bamford, Quinnipiac University Jon Tilburt (2014) explores a logical problem for the concept of professionalism in contemporary medicine, especially as this concept is articulated in the ABIM Physician Charter on professionalism (ABIM Foundation 2004). He argues that conflicting moral obligations produce a problem of dual agency for physicians: Professionals are expected to balance moral obligations regarding (i) the interests of individual patients with those regarding (ii) societal interest in the just distribution of finite health care resources. To respond to this dual agency problem, Tilburt affirms that physicians should adopt a “role morality” approach to professionalism, clarifying the moral obligations specific to the relevant contextual sphere of each of the many roles physicians may play in their careers. Tilburt is right that there is a problem with the professional expectations of physicians, and his concern to use logical reasoning to clarify the concept of professionalism is laudable. However, I think that Tilburt’s acknowledgment of concerns with role morality does not go far enough. Moreover, Tilburt pays insufficient attention to an important dimension of thinking about justice in contemporary health care. Tilburt’s analysis ultimately blurs the boundaries between physician and citizen-professional on which his recommendation of role morality rests. Tilburt claims that moral obligations in the roles of care provider and medical school faculty member can be separated out from one another, as well as from a further role he claims for physicians: a “‘profession-wide’ citizenship role in the sphere of public health and health policy” (34) that is distinct from clinical medicine. This profession-wide role is, Tilburt also claims, exercised by participation in relevant professional societies. But his argument includes the specific point that “individual physicians participate” and “defend the just allocation of health care resources as they see it” (35). On this account physicians seem to participate in what Tilburt calls the “collective medical profession’s citizenship” as distinctively individual physicians—they contribute to the relevant policy debates “as they see it.” The role of an individual physician on this account seems very close to the role of citizen-professional, even given Tilburt’s description of an individual professional as a “derivative” member of the medical profession. Tilburt claims that the
advantage of adopting a role morality approach to the dual agency problem is that it replaces a conflict in principles with a conflict in roles—physician, versus citizen-professional—though he acknowledges that his proposal lacks a way to prioritize these roles. I think we should consider a stronger version of this concern: It is not clear enough how the moral obligations relevant to the roles in question could be separated. Moreover, Tilburt’s position as described, which specifically incorporates the individual physician’s own views, does not seem to square with the Charter commitment to equity as involving public advocacy, promotion of public health, and preventative medicine “without concern for the self-interest of the physician or the profession” (ABIM Foundation 2004). Tilburt’s argument need not have presented the multiple roles played by physicians in strongly individualist terms. Analyzing the clinical ecology of surgical teams, Alan Bleakley (2006) recommends challenging a culture of “heroic individualism” in medicine that leads to error in surgery by employing a virtue-based approach to medical ethics and understanding desirable virtues as emergent properties of surgical teams conceived as dynamic systems (309, 311). Instead of seeing physicians as necessarily individuals playing discrete roles entailing competing moral obligations, Tilburt might draw from Bleakley’s work and reimagine virtuous professional behavior as an emergent property of care, faculty, and collective citizenship teams. Exchanging a framework of determining moral obligation for a framework of virtue-based ethics in health care might defuse the dual agency problem and open up space for an alternative way to characterize professionalism. Such a move may require critical engagement with the ABIM Charter (ABIM Foundation 2004). Furthermore, adopting role morality in medicine is not without difficulties. Tilburt considers some pragmatic and conceptual concerns with role morality: (i) Role morality may “functionally insulate” physicians from advocating for justice in care structures, because for “99%” of their time doctors are pursuing a patient care role rather than a citizenship role in the public health sphere; and (ii) adopting role morality replaces a conflict in principles with a conflict in roles (physician, vs. citizen-professional) with no way to prioritize roles. However, because his discussion
Address correspondence to Rebecca Bamford, Quinnipiac University, 275 Mount Carmel Avenue, Hamden, CT 06518, USA. E-mail: [email protected]
46 ajob
September, Volume 14, Number 9, 2014
Downloaded by [University of Connecticut] at 02:24 13 April 2015
Dual Agency and Expectations of Professionalism
is tied to a picture of physicians as individual professionals, Tilburt cannot do much more to resolve these issues. One way forward might be to explore two points from Kevin Gibson’s (2003) analysis of role morality. Gibson’s first point is potentially deflationary for Tilburt’s argument. Gibson contends that the concept of professionalism has no special moral significance in a role morality context; moral issues at work are merely one part of the “constellation” of moral demands that individuals must grapple with in their many roles (2003, 28). If Gibson is right, Tilburt’s recommendation of role morality to solve the dual agency problem would not work unless he sought to integrate physicians’ ethics across their personal and professional lives. Relatedly, as Gibson points out, one danger of role morality is that it may foster professional actions that individuals outside professional roles would not endorse (2003, 28). Gibson’s second point is that instead of thinking of people as professionals (for at least some of the time), we should think of individuals as people who are able to manifest power; the advantage of so doing is that assessment of individuals across personal and professional roles would be facilitated (2003, 28). This may be a better way forward and would, if coupled with Bleakley’s work, help Tilburt to pursue an account of the concept of professionalism as embedded in team and environmental systems. Tilburt’s exploration of the logic of professional expectations could also benefit from further analysis of the concept of responsibility, especially in connection to addressing social inequality in health care. In particular, Tilburt would have benefited from drawing on Iris Marion Young’s (2011) analysis of structural injustice and her social connection model of responsibility. Tilburt notes that improving access to care is specified in the ABIM Physician Charter on professionalism alongside pursuit of just distribution of finite health care resources. He also actively explores the need to ensure access to the benefits of basic health care for all via a sustainable and efficient model. Yet Tilburt’s acknowledgment that equitable distribution of finite resources and access to health care are both
important needs also seems to require that taking responsibility for structural injustice in health care is a professional ethical expectation for individual physicians (Tilburt 2014; Young 2011, 96). Young (2011) suggests that a social connection model of responsibility has a far better likelihood of dealing justly with social inequality than the more typical and individualist liability concept of responsibility, because the social connection model holds that all those who contribute to the relevant injustice share responsibility for it and are morally bound to join together to transform the unjust structures into just ones (96). In contrast, the liability model focuses on the relationship between individuals and harms (96). Young’s social connection model clarifies how social justice may be a reasonable professional expectation of physicians, and would address the functional insulation problem Tilburt (2014) identifies, as well as bolstering the significance and impact of physician advocacy and activism in and through professional organizations. &
REFERENCES ABIM Foundation. 2004. Medical professionalism in the new millennium: A physician charter. Available at: http://www. abimfoundation.org/Professionalism/Physician-Charter.aspx (accessed June 9, 2014). Bleakley, A. 2006. A common body of care: The ethics and politics of teamwork in the operating theater are inseparable. Journal of Medicine and Philosophy 31: 305–322. Gibson, K. 2003. Contrasting role morality and professional morality: Implications for practice. Journal of Applied Philosophy 20(1): 17– 29. Tilburt, J. C. 2014. Addressing dual agency: Getting specific about the expectations of professionalism. American Journal of Bioethics 14 (9): 29–36. Young, I. M. 2011. Responsibility for justice. Oxford, UK: Oxford University Press.
A Mask Tells Us More Than a Face John Banja, Emory University Oscar Wilde’s epigram (Redman 1959, 138) speaks directly to Jon Tilburt’s concerns about the sometimes contradictory obligations of professionalism (Tilburt 2014). On the one hand, “professionalism” is a mask that conceals the distressing reality of health providers occasionally withholding treatments from patients without the means to
pay. But state and federal legislatures may wear a more pernicious mask in handing down Medicaid budgets. Behind the masks of fiscal responsibility and individual accountability, legislatures pass Medicaid budgets whose limitations sometimes make it next to impossible for health professionals and their institutions to adequately care for
Address correspondence to John Banja, Emory University, Center for Ethics, 1531 Dickey Drive, Atlanta, GA 30322, USA. E-mail: [email protected]
September, Volume 14, Number 9, 2014
ajob 47
The American Journal of Bioethics Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/uajb20
Getting Even More Specific About Physicians’ Obligations: Justice, Responsibility, and Professionalism Rebecca Bamford
a
a
Quinnipiac University Published online: 15 Aug 2014.
Click for updates To cite this article: Rebecca Bamford (2014) Getting Even More Specific About Physicians’ Obligations: Justice, Responsibility, and Professionalism, The American Journal of Bioethics, 14:9, 46-47, DOI: 10.1080/15265161.2014.935891 To link to this article: http://dx.doi.org/10.1080/15265161.2014.935891
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http:// www.tandfonline.com/page/terms-and-conditions
American Journal of Bioethics
Getting Even More Specific About Physicians’ Obligations: Justice, Responsibility, and Professionalism
Downloaded by [University of Connecticut] at 02:24 13 April 2015
Rebecca Bamford, Quinnipiac University Jon Tilburt (2014) explores a logical problem for the concept of professionalism in contemporary medicine, especially as this concept is articulated in the ABIM Physician Charter on professionalism (ABIM Foundation 2004). He argues that conflicting moral obligations produce a problem of dual agency for physicians: Professionals are expected to balance moral obligations regarding (i) the interests of individual patients with those regarding (ii) societal interest in the just distribution of finite health care resources. To respond to this dual agency problem, Tilburt affirms that physicians should adopt a “role morality” approach to professionalism, clarifying the moral obligations specific to the relevant contextual sphere of each of the many roles physicians may play in their careers. Tilburt is right that there is a problem with the professional expectations of physicians, and his concern to use logical reasoning to clarify the concept of professionalism is laudable. However, I think that Tilburt’s acknowledgment of concerns with role morality does not go far enough. Moreover, Tilburt pays insufficient attention to an important dimension of thinking about justice in contemporary health care. Tilburt’s analysis ultimately blurs the boundaries between physician and citizen-professional on which his recommendation of role morality rests. Tilburt claims that moral obligations in the roles of care provider and medical school faculty member can be separated out from one another, as well as from a further role he claims for physicians: a “‘profession-wide’ citizenship role in the sphere of public health and health policy” (34) that is distinct from clinical medicine. This profession-wide role is, Tilburt also claims, exercised by participation in relevant professional societies. But his argument includes the specific point that “individual physicians participate” and “defend the just allocation of health care resources as they see it” (35). On this account physicians seem to participate in what Tilburt calls the “collective medical profession’s citizenship” as distinctively individual physicians—they contribute to the relevant policy debates “as they see it.” The role of an individual physician on this account seems very close to the role of citizen-professional, even given Tilburt’s description of an individual professional as a “derivative” member of the medical profession. Tilburt claims that the
advantage of adopting a role morality approach to the dual agency problem is that it replaces a conflict in principles with a conflict in roles—physician, versus citizen-professional—though he acknowledges that his proposal lacks a way to prioritize these roles. I think we should consider a stronger version of this concern: It is not clear enough how the moral obligations relevant to the roles in question could be separated. Moreover, Tilburt’s position as described, which specifically incorporates the individual physician’s own views, does not seem to square with the Charter commitment to equity as involving public advocacy, promotion of public health, and preventative medicine “without concern for the self-interest of the physician or the profession” (ABIM Foundation 2004). Tilburt’s argument need not have presented the multiple roles played by physicians in strongly individualist terms. Analyzing the clinical ecology of surgical teams, Alan Bleakley (2006) recommends challenging a culture of “heroic individualism” in medicine that leads to error in surgery by employing a virtue-based approach to medical ethics and understanding desirable virtues as emergent properties of surgical teams conceived as dynamic systems (309, 311). Instead of seeing physicians as necessarily individuals playing discrete roles entailing competing moral obligations, Tilburt might draw from Bleakley’s work and reimagine virtuous professional behavior as an emergent property of care, faculty, and collective citizenship teams. Exchanging a framework of determining moral obligation for a framework of virtue-based ethics in health care might defuse the dual agency problem and open up space for an alternative way to characterize professionalism. Such a move may require critical engagement with the ABIM Charter (ABIM Foundation 2004). Furthermore, adopting role morality in medicine is not without difficulties. Tilburt considers some pragmatic and conceptual concerns with role morality: (i) Role morality may “functionally insulate” physicians from advocating for justice in care structures, because for “99%” of their time doctors are pursuing a patient care role rather than a citizenship role in the public health sphere; and (ii) adopting role morality replaces a conflict in principles with a conflict in roles (physician, vs. citizen-professional) with no way to prioritize roles. However, because his discussion
Address correspondence to Rebecca Bamford, Quinnipiac University, 275 Mount Carmel Avenue, Hamden, CT 06518, USA. E-mail: [email protected]
46 ajob
September, Volume 14, Number 9, 2014
Downloaded by [University of Connecticut] at 02:24 13 April 2015
Dual Agency and Expectations of Professionalism
is tied to a picture of physicians as individual professionals, Tilburt cannot do much more to resolve these issues. One way forward might be to explore two points from Kevin Gibson’s (2003) analysis of role morality. Gibson’s first point is potentially deflationary for Tilburt’s argument. Gibson contends that the concept of professionalism has no special moral significance in a role morality context; moral issues at work are merely one part of the “constellation” of moral demands that individuals must grapple with in their many roles (2003, 28). If Gibson is right, Tilburt’s recommendation of role morality to solve the dual agency problem would not work unless he sought to integrate physicians’ ethics across their personal and professional lives. Relatedly, as Gibson points out, one danger of role morality is that it may foster professional actions that individuals outside professional roles would not endorse (2003, 28). Gibson’s second point is that instead of thinking of people as professionals (for at least some of the time), we should think of individuals as people who are able to manifest power; the advantage of so doing is that assessment of individuals across personal and professional roles would be facilitated (2003, 28). This may be a better way forward and would, if coupled with Bleakley’s work, help Tilburt to pursue an account of the concept of professionalism as embedded in team and environmental systems. Tilburt’s exploration of the logic of professional expectations could also benefit from further analysis of the concept of responsibility, especially in connection to addressing social inequality in health care. In particular, Tilburt would have benefited from drawing on Iris Marion Young’s (2011) analysis of structural injustice and her social connection model of responsibility. Tilburt notes that improving access to care is specified in the ABIM Physician Charter on professionalism alongside pursuit of just distribution of finite health care resources. He also actively explores the need to ensure access to the benefits of basic health care for all via a sustainable and efficient model. Yet Tilburt’s acknowledgment that equitable distribution of finite resources and access to health care are both
important needs also seems to require that taking responsibility for structural injustice in health care is a professional ethical expectation for individual physicians (Tilburt 2014; Young 2011, 96). Young (2011) suggests that a social connection model of responsibility has a far better likelihood of dealing justly with social inequality than the more typical and individualist liability concept of responsibility, because the social connection model holds that all those who contribute to the relevant injustice share responsibility for it and are morally bound to join together to transform the unjust structures into just ones (96). In contrast, the liability model focuses on the relationship between individuals and harms (96). Young’s social connection model clarifies how social justice may be a reasonable professional expectation of physicians, and would address the functional insulation problem Tilburt (2014) identifies, as well as bolstering the significance and impact of physician advocacy and activism in and through professional organizations. &
REFERENCES ABIM Foundation. 2004. Medical professionalism in the new millennium: A physician charter. Available at: http://www. abimfoundation.org/Professionalism/Physician-Charter.aspx (accessed June 9, 2014). Bleakley, A. 2006. A common body of care: The ethics and politics of teamwork in the operating theater are inseparable. Journal of Medicine and Philosophy 31: 305–322. Gibson, K. 2003. Contrasting role morality and professional morality: Implications for practice. Journal of Applied Philosophy 20(1): 17– 29. Tilburt, J. C. 2014. Addressing dual agency: Getting specific about the expectations of professionalism. American Journal of Bioethics 14 (9): 29–36. Young, I. M. 2011. Responsibility for justice. Oxford, UK: Oxford University Press.
A Mask Tells Us More Than a Face John Banja, Emory University Oscar Wilde’s epigram (Redman 1959, 138) speaks directly to Jon Tilburt’s concerns about the sometimes contradictory obligations of professionalism (Tilburt 2014). On the one hand, “professionalism” is a mask that conceals the distressing reality of health providers occasionally withholding treatments from patients without the means to
pay. But state and federal legislatures may wear a more pernicious mask in handing down Medicaid budgets. Behind the masks of fiscal responsibility and individual accountability, legislatures pass Medicaid budgets whose limitations sometimes make it next to impossible for health professionals and their institutions to adequately care for
Address correspondence to John Banja, Emory University, Center for Ethics, 1531 Dickey Drive, Atlanta, GA 30322, USA. E-mail: [email protected]
September, Volume 14, Number 9, 2014
ajob 47
