Ancillary Health Care Professional Definition Essay

Professionalism as a Virtue

When I wrote the book Public Virtues[1], I included professionalism among the virtues that characterize our current era. I believed that professionalism was a value on the rise and was highly regarded in societies where knowledge had and would continue to play an increasingly crucial role. Nonetheless, my view of professionalism as a virtue was formulated more that fifteen years ago and with a question mark. My reasoning was based on the feeling that the sense of professionalism most commonly exhibited these days is far being what we could consider a moral virtue. More and more, the concept of a good professional tends to be linked to that of an expert, a person who is competent in a certain field of knowledge, and not the ideal of a person who is committed to and morally responsible for the functions or activities they carry out. I am speaking of something I wrote some time ago, as I mentioned before. If I bring it up now, running the risk of sounding immodest by beginning this reflection by quoting myself, it is only to corroborate that I maintain my point of view as expressed then. Indeed, the common popular definition of professionalism, or even of professional excellence, regardless of the profession in question, is related to scientific and technical competence, to possessing knowledge and set of specific skills and abilities. A good professional is, above all, an expert; not a person who is morally committed to what they do and, by extension, to society as a whole.
 
This definition of professionalism-or professional excellence, which is really the same-reveals the reductionism and simplification typical of a world that judges a person's behavior more on its results than on the principles they should follow and serve. In a way, professionalism is equivalent to a job well done. However, the concept of work has also been reduced to a certain technical skill, a practical ability, which does not go beyond doing things materially well. A good architect should design buildings that do not fall down; a good engineer should build bridges that do not collapse: a good teacher should know how to pass on knowledge to their students; a good doctor is one that can correctly diagnose and treat patients. In any case, having the necessary scientific and technical competence is, undoubtedly, the first moral duty of a professional. However it is not the only one, as professional responsibility requires something more. It requires more in all professions, regardless of their projection and social density, but particularly in those whose aim and purpose is the quality of human life, such as the healthcare professions. In this article, I intend to define the elements of this moral plus required of professional excellence in general and, particularly, in the healthcare field.

It is not difficult, in principle, to assign a plus of moral excellence to healthcare professions. Medicine was the first profession to create a code of ethics, in a time when the profession did not even exist as such. The Hippocratic oath [2] does not only lay out medical prohibitions, it is also a personal code of conduct derived from the concept of medicine as an "art" (techné) based upon observation and specific cases. The Hippocratic texts, in theory, shape a physician's ethos, their method. This behavior must focus not only on the patient's best interests, but also on upholding the physician's reputation and that of the profession. Due to the complexity of the art in question, this behavior must take into account all those affected.

Life is short, and the Art long; the occasion fleeting; experience fallacious, and judgment difficult. The physician must not only be prepared to do what is right himself, but also to make the patient, the attendants, and externals cooperate.
(Hippocratic Treatises, "Aphorisms")

Chinese philosopher Confucius wrote: "Medicine is a human art". It should not be understood only as a means to cure, but as a moral commitment to preventing all avoidable suffering. A practice based on love and respect for others that, as in the Hippocratic oath, should be ruled by the principle of not harming and doing good, respecting patients without discrimination. More than a practice based on laws, Confucius and his followers understood medicine as a practice based on the cultivation of virtue, which, in turn, is nurtured by feelings such as piety, shame and respect.

We should treat the patients as our mothers.
(Tianchen Li, Ming Dynasty)
 
Whoever comes to seek cure must be treated like your own relatives regardless of their social status, family economic conditions, appearances, ages, races, and mental abilities.
(Simiao Sun, Tang Dynasty) [3]

Since such ideas were written twenty five hundred years ago, in general, the goal of medicine has not changed. On one hand, the patient must be cared for, preserved from harm, avoiding corruption and injustice. On the other hand, a good collaborative relationship with other members of the profession must be established. Although Hippocrates had already mentioned that one of a physician's aims is to preserve their good reputation, it was Thomas Percival (1740-1804), a philosopher and physician famous for his moral tales for children and author of codes of medical ethics, who stressed the need to go beyond individual actions in professional practice. In his view, a professional must be able to put the patient's interests and those of the general public before their own. The positive public image of medical practice is as important as dedication to the patient.

The theory is rarely questioned, but practice is still a long way from truly reflecting this. In real life, scientific excellence does not always go hand in hand with ethical excellence because personal interests take precedence over general interests or the interests of others. The dangers of medical practice laid out in the great classics of medical deontology are exacerbated as the profession becomes more commercial and knowledge more specialized and technical. Max Weber (1864-1920), in his theory of the profession, a term he compared to "vocation", warned of the first of these threats. The word Beruf, used by Weber to refer to different human occupations or activities, can mean both "divine calling" and "human profession". The idea came from Luther in his translation of the Bible, where he compared contemplative monastic life, which he himself held in low esteem, to professional life in order to highlight the importance of the latter as an explicit expression of love for one's neighbor. The duality of profession and vocation allows Weber to express the loss of vocational spirit in human activities, reducing them to mere professions in which bureaucracy and profit seeking inhibit any other purpose. This is yet another aspect of the disenchantment of the world which he refers to throughout his work. Linked to the idea of vocation, to the idea of commitment or mission, a profession requires dedication to its own ends, which should go beyond private interests. However, despite the theory, Weber [4] regrets that earning money has become the goal of professions; that accumulation of wealth has become an end in and of itself. It seems that our capitalist system and the economic subordination of all activities make it impossible to recover professional ethics. In the end, everything is a business.

Similar to Weber, American sociologist Talcott Parsons (1902-1979) [5], referring specifically to medicine, insists that this profession should be understood as "an ideology of service" and not as pure business, since it deals with a social problem such as health. Undoubtedly, both cases postulate an idealized professionalism, which is driven by altruism rather than profitability. This idealization is a far cry from reality, but should perhaps be maintained as an ideal if we want to discuss a professional excellence that is not limited to material aspects but encompasses a clear moral dimension. Beyond rhetorical idealizations, the concept of vocation that is implicit and inseparable from that of profession would always take into account Weber's final conclusions in his splendid lecture "Politics as a Vocation" [6]. In these conclusions, he demanded that politicians-and, by extension, anyone who feels called to do something interesting in this word-know how to set their own limits when prevented by circumstance from maintaining ethical principles.

However, it is immensely moving when a mature man -no matter whether old or young in years- is aware of a responsibility for the consequences of his conduct and really feels such responsibility with heart and soul. He then acts by following an ethic of responsibility and somewhere he reaches the point where he says: "Here I stand; I can do no other."
(Max Weber, "Politics as a Vocation").

In addition to the reigning materialism and economism, yet another aspect has come to distort, in our time, the sense of professional excellence we would like to maintain even if only as a regulatory idea: what Ortega denounced as "specialism" [7] when referring to the one-dimensionality of scientific and technical knowledge. It so happens that, in this case, we face an obstacle that is not only unavoidable but also necessary for the development of knowledge. Only specialization and division allow knowledge to progress. On the other hand, however, the moral dimension that should be inextricably linked with professional excellence is closer to humanistic knowledge than to that of a pure scientist. In the case of healthcare professionals, their aim goes beyond mere "diagnosis and treatment", as philosopher Hans George Gadamer [8] explains. The professional is not only required to have sound scientific knowledge, but should also know how to "restore" harmony, to "treat" a human being, to "help" them live differently, to "advise". Another widely read sociologist, Zygmunt Bauman, regrets that we are living in a society of experts, which in itself is unfit to cope with a complex world [9]. In such a society, the "person as a whole" is seldom deserving of attention: we are organs whose functions require care.

Health depends on many different factors and the final goal is not so much regaining health itself as enabling patients once again to enjoy the role they had previously fulfilled in their everyday lives.
Hans George Gadamer, The Enigma of Health.

The "specialism" denounced by Ortega, the scientific obsession derived from a positivism that requires proof (evidence) and figures, lead C.P. Snow [10], more than fifty years ago, to call for the fusion of the two cultures: humanist and scientific. These two cultures were born and developed in unison, although they were later so definitively separated as to make communication between the two nearly impossible. In a way, the birth of bioethics responds to the need to recover the lost unity between science and humanities. A unity without which, in the words of Wittgenstein, the most vital questions remain un-posed.

We feel that even if all possible scientific questions be answered, the problems of life have still not been touched at all.
Ludwig Wittgenstein, Tractatus Logico-Philosophicus  [11]

Professions nowadays have become, in short, well or poorly executed "careers". To have a successful professional career has become synonymous with success in a profession, which itself is synonymous with achieving a level of excellence that, frequently, is equivalent to getting rich. Success today is more related to money, fame and material success than to excellence derived from good practice, which is not always acknowledged by society or the profession itself.

In short, the commodification of the profession, which impedes us from looking beyond mere private material interest, and the technical reductionism derived from knowledge specialization are two great obstacles to healthcare professionals acquiring and implementing a moral dimension in their work. Without it, the two goals set by both ancient and modern classics of medical deontology will be missed: patient welfare and cooperation in building a positive image of the profession. Professional ethos, if reduced to a mere mercantile and bureaucratic ethos, does not cultivate the values or virtues that healthcare practice should display. Marañón [12] wrote that physicians did not need to be trained in ethics because their vocation would lead them naturally to behave virtuously from a moral point of view. But Marañón was mistaken in this particular aspect because, just as has happened in other professions, including the most highly renowned (which used to include medicine, in addition to priesthood and judgeship), healthcare professional have lost their vocational dimension or, at least, said dimension has been inhibited by other more pressing or attractive needs and interests. Other interests, it should also be said, that are more highly renowned and applauded by society. However we look at it, it seems difficult to speak of excellence without assigning this word a moral significance. The term "excellence", as I will explain shortly, comes from the Greek areté, which can be translated as "virtue" or "excellence of a thing". Thus, if we want to recover the idea of professional excellence, we must analyze which virtues, which qualities, define said excellence. The next section is devoted to this topic.

To conclude this initial approach to healthcare professionalism, we should state that the dimensions of said professionalism, if what we seek is excellence in its fullest sense, should cover the following objectives:

- Patient's best interest as a priority.
- Cooperation with other healthcare professionals.
- Concern for the profession's good image.
- Openness to humanist knowledge.

 
Virtues of Healthcare Professions

In the previous section, I have tried to explain that professionalism may be considered a virtue or an ethical value if it meets certain requirements. Generally, such requirements have to do with the professional's open-mindedness regarding ethics and their empathy towards other people, beyond the scientific competence an expert is assumed and required to have. However, what we have covered so far must be specified further. To do this we will return to our discussion of virtues, now looking at those virtues that are intrinsic and specific to healthcare professions. To this end, we must begin by clarifying this insistence on discussing the concept of virtue.

Any person well trained in philosophy, as I am afraid I am, cannot avoid associating the term ‘excellence' with areté, the Greek term that is usually translated as "virtue". This is because Aristotle [13], the great theorist of virtue as the core of ethics, defines virtue precisely as the excellence of a thing. Everything in this world has its virtue, which consists of the faithful achievement of the object's assigned or foreseen end. The virtue of a musical instrument, a racehorse or an Olympic athlete lies in fulfilling, respectively, the functions of a musical instrument, a racehorse or an Olympic athlete. By analogy with certain realities whose ends are clearly defined, Aristotle poses a more complex question, which is the starting point of his ethics: what is man's intrinsic function or end and which virtues must he have to achieve it? The first part of the question, in his mind, needs no discussion: the goal of human life is happiness. However, the complicated part is not stating that a being human's goal is to be happy, but specifying what one must do or how one must behave in order to achieve this. Hence his treatises on virtues, namely Nicomachean Ethics and Eudemian Ethics, in which he lists the virtues a free man requires order to achieve his end.

Every virtue or excellence both brings into good condition the thing of which it is the excellence and makes the work of that thing be done well; e.g. the excellence of the eye makes both the eye and its work good; for it is by the excellence of the eye that we see well. Similarly the excellence of the horse makes a horse both good in itself and good at running and at carrying its rider and at awaiting the attack of the enemy. Therefore, if this is true in every case, the virtue of man also will be the state of character which makes a man good and which makes him do his own work well.
Aristotle, Nichomachean Ethics.

Some of the virtues Aristotle proposes as qualities of an excellent human being are still current today and can help us contextualize healthcare professionalism. However, above all, what really helps us deal with this issue is the concept of virtue itself as those qualities a person must acquire in order to do what they are intended to do well. I do not see a better way, then, to raise the issue of excellence in healthcare professions than by analyzing which virtues such professionals should have. Because their goal, in this case, has already been defined. The goal is patient welfare. This aspect is not subject to debate. However, what should be discussed is the way in which it is achieved and the way the contradictions that may come up are dealt with. Aristotle also had an opinion to this respect: we deliberate not about ends-happiness, patient welfare-, but about the means with which to achieve them. In our case, we will deliberate on the virtues of healthcare practice. What are these virtues?

Several contemporary scholars have worked on this issue. The evolution of bioethics, with the aim of defining the fundamental principles of healthcare ethics, has helped analyze which key values professionals must hold in order to maintain said principles. James F. Drane [14] suggests the main virtues of medical practice should be benevolence, respect, care, truthfulness, friendliness and justice. Edmund Pellegrino and Thomasma [15] also mention truthfulness, respect, compassion, justice, integrity and self-effacement. Finally, to cite only three examples of renowned authors in this field, Marc Siegler [16] believes that respect for others is an essential virtue of healthcare practice, which in itself includes compassion, truthfulness and trust. We should also say that both Pellegrino and Tomasma and Siegler add another virtue: prudence or phronesis, which they understand to be the synthesis of all other virtues, and so indeed it is. Later I will refer extensively to this virtue, which I consider fundamental. As for the others, it is not difficult to see them as the translation of values implicit in the celebrated principles of bioethics into personal attitudes, particularly the more modern ones, such as autonomy and justice.

Indeed, respect and sincerity are two ways of taking into account a patient's autonomy, their freedom of choice and right to be informed as to what is happening. Justice, in itself, has been one of the fundamental virtues since antiquity. It also constitutes the essential obligation of all healthcare policies in a welfare state, and this is contemporary not ancient. And if justice is an essential obligation of the social state, its implementation likewise depends on the behavior of healthcare professionals with regards to non-discrimination, but also to altruism and professional integrity, which should always put public interest before private interest. With regards to benevolence, the virtue of compassion, of empathy, is perhaps the best disposition to seek patient welfare, which is what the principle of benevolence prescribes.

The value or virtue of care deserves a separate paragraph. Although not all of the aforementioned authors take this value into consideration, it is nonetheless among the most promoted values within the realm of virtues in general, and particularly among those of the healthcare professions. Since Florence Nightingale took it on herself to define the work of nurses, caring has been the most specific goal of nursing. It is still so, although caring has become much more relevant as the result of a healthcare sector that focuses more on caring than curing. American philosopher Carole Gillian [17] was the first to highlight the existence of care as an ethical value, a value that is parallel and complementary to justice, and that had been ignored in a world made up exclusively of men. It is true, justice has always been the center of moral concern, ever sincePlato's Republic, but this morality structured around justice has looked down on or silenced another value that just as essential as justice: the value of care. That care has been overlooked can be explained by the fact that a willingness to care for others has always been more a feminine than a masculine trait. Historically, women have typically been the ones to care for children, the ill and the elderly. This is the why nobody has paid serious attention to care as a value. It was seen as a task that belonged exclusively to the realm private life, with little or no professional status. But this is no longer the case. Not only has care been professionalized, it has also become one of the main goals of healthcare professionals in general. At least this is what is said in the renowned article published by the Hastings Center, The Goals of Medicine [18]. One of these goals is, precisely, to care for all patients, especially those who cannot be cured. One must hope that the obvious feminization of medical practice will help bring an end the marginalization of care, giving it the central position it deserves.

I have mentioned above that it is also necessary to talk about prudence, another virtue that, in my mind, is essential to understanding medical practice, particularly if we want to frame it in an ethical context. Being prudent, in the classical sense, means nothing more than knowing how to appropriately apply a rule. Healthcare professionals must care for people or individuals with distinctive characteristics and situations. In a way, each case to be treated is unique. Thus, it is clear that, in the professions of medicine and nursing, automatic application of rules or protocols does not work. Aristotle used the good physician as an example of a prudent man. This is-he said-the one that succeeds in curing the patient, not always the wisest, although knowledge of medical science in this case is taken for granted. Professional excellence includes, thus, the prudence to focus on the specific case at hand, even breaking from normal rules if the case so requires, but only if necessary. A prudent decision is not reached only by applying the previously learnt formula. It is the personal decision of a good professional. Mark Siegler, who also rates prudence above any other virtue, refers to Plato's Laws to explain it, which recommends an adequate contextualization.

Schematically, since the explanation of each of the previously mentioned virtues could lead to a whole treatise, and without any intention of being exhaustive, healthcare professionals seeking excellence should acquire the following virtues:
 
- Benevolence.
- Respect.
- Care.
- Sincerity.
- Friendliness.
- Justice.
- Compassion.
- Integrity.
- Self-effacement.
- Prudence.
  
Theory and Practice

So far, we have discussed professional ethics, the virtues healthcare professionals make their own. But ethics always faces a problem that we cannot fail to consider. Ethics is theory and professional excellence is shown through practice. Thus, in moral philosophy there is no other option than to deal with the question of the relationship between theory and practice: Does professional ethics, the discourse of virtues, actually influence medical practice? What can be done to make this influence real?

Virtues are more than just rational decisions a person takes when facing a conflict. Both reason and feelings play a role in acquiring these virtues. Because virtues are a disposition to act; they are attitudes; they are acquired through habit; they are a way of being; and they forge a person's character. In other words, they are not rules to be obeyed. Aristotle conceived of a virtuous life as the construction of a sort of second nature, what the Greek called ethos, character. Nobody is born being nice or sincere or just, nor will they take on these characteristics simply by following a list of rules on occasion, sporadically. A person is virtuous because they are used to acting virtuously; being just, nice, sincere or respectful is part of their character. A virtuous person does not believe they must comply with some duty: they act this way spontaneously; we could say because they feel it. Therefore best practices, what I have called "virtuous" practices, are not achieved through theoretic classes on professional ethics. They are acquired in day-to-day practice, based on having to resolve everyday problems and conflicts.

Our aim is not to know what justice is, but to be just.
(Aristotle, Eudemian Ethics)

Knowing about virtue is not enough, but we must also try to possess and exercise virtue, or become good in any other way
(Aristotle, Nicomachean Ethics)

This does not imply that theoretical knowledge of values and ethical principles of healthcare practice are worthless. They are not at all, of course. But theory does not suffice. I discussed above the virtue of prudence. Well, there is no better way of teaching what the virtue of prudence means than by showing the example of a prudent person. The best pedagogy is practice, which serves as an example. This does not mean that theory should be underestimated. Bioethics, as a reflection on healthcare practice, has greatly increased awareness among healthcare professionals of the moral dimension of their profession. This increased awareness has come about in both universities and hospitals as the concept is introduced, through slowly and with difficulty it must be said. However, above all, what the presence of bioethics in the clinical arena has done, and continues to do, is to help create a culture that focuses on the more human aspects of clinical practice. James Drane aptly defines bioethics when he states that its function is to prevent healthcare conflicts from always ending up in court. Bioethics could prevent this by mediating in the conflict, by helping see that the professional doesn't shirk their responsibility but assumes it and helps find a conciliatory solution.

One way of connecting theory and practice consists in avoiding the legal reductionism that currently threatens all professions. The origin of the concept of profession is religious. Hence the term "profession", which refers to belief in a certain religious faith. It is this origin Max Weber plays on so brilliantly when equating profession to vocation. In Foundation and Education in Bioethics, Diego Gracia [19] explains how this religious origin resulted in professional practice taking on a more ethical than legal responsibility. It has only been since the 19th century and the constitution of states of law that tend to see all professions as equal, leaving no transgression of the required ethics unpunished, that ethical responsibility has been reduced to legal responsibility. This is a far cry from the parameters established in the first deontology codes of professional associations that Thomas Percival referred to, in which the ideal was the virtuous physician, a "minister of the ill".

Consolidating Trust
            
Trust is one of the virtues mentioned by philosophers when referring to healthcare professions. I believe this virtue deserves a separate chapter, since, if consolidated, it addresses all other existing challenges and trials healthcare professions face.

The proposed title for this article speaks of "healthcare professions", in plural, which is a symptom of the complexity that currently surrounds the approach to the whole issue of illness. We are not only referring to medicine, nor even to medicine and nursing, but to the whole range of professions, occupations, tasks and activities that play a role in curing and caring for the ill [20]. Cooperation among all healthcare professionals is essential for two main reasons: knowledge is highly specialized, as I have mentioned previously, and professionals must take into account a new kind of patient. Patients nowadays are not only aware of their own autonomy, capacity and right to be informed, to express an opinion and to decide, but are also more active and demanding than ever before, and know their rights as a person and demand to be treated accordingly.

The new model of patient is probably the most defining and the newest feature of the current concept of healthcare professions. This is due, above all, to the fundamental value given to individual freedom in liberal societies. However, this is not the only change healthcare professions must face. Another new feature is the value given to justice, equal opportunity and non-discrimination, which imply a public healthcare system that must treat all members of society equally. The development of biomedicine, in turn, is generating great expectations, which should be addressed with prudence and common sense, not only because many of them call into question essential ethical principles but also due to the fact that scarcity of resources makes it impossible to address everything and, at the same time, protect the individual right to healthcare. The more knowledge advances and technological possibilities increase, the more difficult it is to make decisions, foresee the consequences of such decisions and make them compatible with human rights. Such an arduous task requires the cooperation of all those involved, particularly of those professionals who are most familiar with the issues at hand.

Not to mention other changes, such as the ageing population that has led to new concepts of illness and, in a way, requires us to complement the traditional concept of curing with one of caring. Only recently has our society admitted that taking care of dependants is to be considered a top priority. Recognition of this dependency, therefore, can in no case be seen as disrespect for basic human dignity. Finally, and without any intention of delving into all the new issues that must be faced, migratory movements also bring us in contact with concepts of medicine and nursing that are different from our own, force us to come to terms with the differences and accept different types of behavior. This in no way means, however, that we should renounce the fundamental principles and rights established in our Constitution.

So, all these changes reinforce the need for something that healthcare professions, at least in theory, have never doubted, although it doesn't hurt to repeat it until it becomes a reality: The need to face the ethical and humanistic sensibility that must be a part of healthcare practice. At the heart of this change lies the need to accurately correct the paternalistic perspective that lasted for centuries. This correction should not be contractual, but should focus on establishing a relationship based on trust. I don't see trust as merely a virtue professionals must acquire; it is a value that the relationship between patients and healthcare professionals should be able to generate. For Jovell and Navarro [21] trust implies "competence and commitment". Scientific and technical competence, of course, because patients basically want to be treated by a professional who knows what they are doing, but also commitment on behalf of the professional to the patient's welfare and best interest, which in itself implies a certain degree of altruism, solidarity and compassion, as well as respect and sincerity. The group of virtues, in short, discussed previously as the core of what has been called "patient-oriented professionalism".

Professionalism and Citizenship. Self-Regulation

In the three dense chapters Durkheim devotes to "Professional Ethics" [22], he develops the theory, very much in line with his sociological thinking, that professional associations are essential as a source of solidarity and morality, in order to fight against the anomie that threatens liberal societies. Only collective power can legislate over the individual who, once free of social constrictions, also sheds any type of moral constriction. Thus, Durkheim conceives of professional morals as the prologue to civic morals, which go beyond personal or family morals. And he believes that professional ethics is possible, except in the case of a market economy, given that this activity has always been the bastion of liberty and is resilient to any sort of regulation, even that coming from its own agents.

The problem, however, is that the economy's resistance to regulation have an effect on other professions insofar as these become ever more dependant on the economic industry and come to be seen as merely business. Healthcare is no exception, as shown by the language we use to refer to its workers: doctors and nurses are mere employees and patients are no longer the ill or patients, they are healthcare clients, users or consumers. Albert Jovell refers to the "McDonaldization" of medicine and to the consequences that forcing the healthcare system to fit the mould of any other industry will have on adequately meeting patient needs and expectations. The paternalism that has, so far, dominated clinical relationships, tends to be corrected and abandoned. But we are heading towards a contractual relationship, typical of a business-oriented model. By recognizing that patient autonomy is at the heart of healthcare ethics, we have moved the relationship between healthcare professionals and patients towards the commercial paradigm, when real progress would lie in building a fiduciary relationship, in which trust would be acknowledged as the ideal form of communication between professionals and patients.

The arena of healthcare protection is currently a complex network in which a variety of stakeholders play a role, in addition to those known as "healthcare professionals". Management and research structures, the pharmaceutical industry, these multiple providers make up an organizational complex that cannot remain indifferent to the values and principles that ensure good professional practice. This is the reason why the deontological codes that summarized professional obligations at the dawn of the bureaucratization of medicine are no more than a partial and insufficient expression of what professional excellence should be. Moreover, left to stand alone, deontological codes run the risk of being seen as an instrument for masking other interests. What used to be labeled "professional deontology", which was set in codes of conduct written basically by professional associations, is now little more than a substitute for legislation, thus nurturing this type of responsibility which I believe we must overcome or complement because is it merely legal.

Assuming professional responsibility is also a way of assuming the duties and obligations of citizenship. And this is one of the issues our liberal democracies have yet to address. Developing the aforementioned virtues, as qualities a professional must display, is part of taking responsibility for one's own actions in a wider sense, beyond scientific and technical competence. Therefore, of all the virtues discussed, the most fundamental is still prudence, which I would call the "capacity for self-regulation". If a person is unwilling to take in the true spirit of these virtues and apply them appropriately in each case, there is no law or deontological code that can make them do so. This is exactly what Aristotle demanded from the prudent, meaning virtuous or excellent, politician, judge or physician. A prudent person possesses the "practical wisdom" to understand what is best for the patient in each case, which is the only goal of healthcare professions. It is necessary thus to discuss the means, we said, as the goal is clear and undisputed. So, the prudent professional has acquired the ability, the experience and the knowledge needed to discuss the means; they know how to do this.

Discussion implies dialog. The absence of dialog is also a shortcoming of our current democracies. I mentioned at the beginning the two objectives repeated in the first medical ethics texts, those by Hippocrates and Confucius. On one hand, patient welfare; on the other, cooperation with other professionals involved. The sense of community is essential because, in professional practice, not only personal reputation is at stake, but also that of the profession as a whole. One has a responsibility to oneself and to the profession and, of course, to the society one serves. Hence, ethics has an inalienable public dimension, because, in the end, public interest should take precedence over personal and private, or even corporate, interests. And these considerations bring us to understand professional practice as an expression of citizenship. Being a citizen is more than voting and paying taxes. It is being a member of a community that shares common interests and which demands that its members make an effort, in line with their functions and abilities, to help achieve them. In this article I have tried to show how professionalism should overcome its tendency towards technical, economic and contractual reductionism. It must be a civic-minded professionalism, one that serves the community.

Medicine should rethink its characterization of itself as simply a branch of applied science, which causes it to lose sight of the complexity of healing as a human practice that requires not just expert knowledge but the context of a dedicated professional community.
W.M. Sullivan. "What is Left Of Professionalism After Managed Care?" [23]

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Bibliographical References

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Humanidades Médicas, No. 21, November 01, 2007

Translated by Susana Torres

The healthcare workforce accounts for the greatest proportion of spending, and holds the key to the quality of healthcare delivery (WHO 2000, JCAHO 2001). Yet despite the importance of the workforce, there is a lack of a coherent theory to underpin workforce development. This paper aims to contribute to the current understanding of workforce development in Anglo/North American countries by describing ways that the healthcare workforce can evolve as a result of the pressures on interprofessional boundaries.

Why is the workforce changing?

The past century has seen the growth and transformation of existing professions and the introduction of new workers (Larkin 1983, Willis 1989, Johnson 1972). These changes are believed to be the result of developments in technology, education, research evidence and new systems of purchasing, organising and regulating the workforce (Cooper 1998, 2001, Salsberg 2002). Recently, disciplinary boundaries have come under new pressures as a result of staffing shortages in medicine, nursing and the allied health professions (Richards et al. 2000, Department of Health 2000c, Appel and Malcolm 2002). Additionally, neo-liberal managerial principles have led to a redistribution of resources on the basis of professional accomplishment rather than the historical workforce hierarchies and roles (Hughes 1994, Stone 1995, Barrados et al. 2000, Exworthy et al. 2003, Borthwick 2000). Neo-liberalism has been reinforced by the strength of the consumer movement. For instance, the growth of patient-centred care emphasises the needs of the service user, rather than the needs of professional groups, and has created a need for flexibility in both working practices and service organisation which presents significant challenges to professional power (Hurst 1996, Department of Health 2000c, Nancarrow 2003, Freidson 2001).

These changes have a number of implications for traditional workforce boundaries. Unskilled workers such as healthcare assistants and support workers are taking on tasks previously only performed by professionals (Cooper 2001, Richardson 1999, Buchan and Dal Poz 2002, Heckman 1998). Professionals are delegating tasks to other disciplinary groups, such as the prescribing of medication by practice nurses (Appel and Malcolm 2002, Weiss and Fitzpatrick 1997, Britten 2001). Increasingly, healthcare providers are working within inter-professional teams and receiving training in programmes that promote inter-professional education (Barr 2000). Service users are becoming more empowered through the consumerism of health which has resulted in better access to information and user consultation in service development and delivery (Germov 1998). Each of these factors has the potential to influence the roles of existing professional groups, and presents a challenge to workforce planners.

Orthopaedic surgeons in the United States are a good illustration of the dynamic nature of professional boundaries. There are approximately 20,000 orthopaedic surgeons in the United States. Some claim that this number represents an over-supply of between 20 and 50 per cent (Anonymous 1998). The vice-president of the American Academy of Orthopaedic Surgeons stated:

a decade or two ago, when we were fat and sassy, we decided to limit our practices to those aspects that were fun and well remunerated. We chose not to counsel little old ladies about the prevention and treatment of osteoporosis; we chose not to provide foot care services in our offices (Heckman 1998: 6).

Other providers, including podiatrists, internists and emergency medicine physicians, filled the void created by the contraction of the services of orthopaedic surgeons. A similar picture has been painted within the orthopaedic community in the UK (Klenerman 1991). The oversupply of clinicians created competition between orthopaedic surgeons and a subsequent need to reduce supply, increase demand or reclaim an area of their traditional scope of practice. Heckman suggested:

Perhaps we should get out of bed at night and come back to the emergency room to treat the patients who are now being managed by others in primary care and emergency medicine. Perhaps we should train our cast technician or office nurse to trim corns, calluses and toenails, and maybe we should take the time personally to instruct our patients in rehabilitation principles following shoulder and knee surgery rather than delegating all of that responsibility to the physical therapists (1998: 8).

This description of discarding unwanted, lower status or less well paid roles during a time of prosperity, and then a desire to reclaim these roles, or at least control certain tasks when circumstances change, illustrates the impact of competitive market forces on health service provision; the possibility of substituting roles from a more highly trained provider to a less specialised, or differently trained workforce; and the willingness of other practitioners to adopt the discarded jobs. It also demonstrates Hughes's (1958) division of labour based on ‘dirty work’, where those with high professional standing retain the more desirable work, delegating the less pleasant or stigmatising work to others with less standing. It reinforces the model of medical dominance in that it assumes that once professional turf has been ‘given away’, it can later be reclaimed, either by the medical profession, or by other providers under the control of the medical profession. In other words, professions can gain privilege by successful claims to ‘jurisdictions’, but can also lose privileges too (Abbott 1988). Recourse to ‘powerful elites’ in support of these moves are usually necessary, as illustrated in the elimination and re-introduction of dental assistants in the UK, under the watchful eye of dentistry in the mid-1950s (Larkin 1980).

The importance of workforce flexibility is receiving increasing international attention resulting in widespread policy level support for boundary renegotiation. Rural workforce shortages in Australia have resulted in proposals to remove legal and professional barriers to practice so as to promote flexible service delivery (Office of Rural Health 2001). Recent UK policies actively endorse the notion of workforce flexibility both to address workforce shortages and enhance patient-centred care (Department of Health 1985, 2000a, 2000c, 2002). In the US, the demands of third-party payers have resulted in the rapid growth of new workers and have increased the scope of practice of non-medical providers (Cooper 1998, 2001, Salsberg 2002).

Historically, workforce planning has been uni-disciplinary, ignoring the interrelationship between disciplines (De Geyndt 2000: 33). However, the promotion of workforce flexibilities and inter-disciplinary care demand an increasing interdependence between different types of service providers. How these will be translated in practice remains an interesting conundrum, bearing in mind the competitive, exclusionary basis of modern professionalism (Abbott 1988, Parkin 1979, Freidson 2001). Perhaps a reconfigured form of profession is already emerging, shifting away from exclusivity and autonomy, towards a ‘culture of performativity’ (Dent and Whitehead 2002). These changes are not unique to the health workforce and are being seen in the legal sector, engineering and the built environment and education (Oxley 2002, Kritzer 1999).

There is not yet a clear theory to describe the current changes to the healthcare workforce. The concepts of proletarianisation (McKinlay and Stoekle 1988), deprofessionalisation (Haug 1973) and post-professionalism (Kritzer 1999) attempt to describe and explain the challenges to traditional professional power. Proletarianisation predicts the decline of medical power as a result of deskilling and the salaried employment of medical practitioners (McKinlay and Stoekle 1988). Deprofessionalisation describes ‘a loss of professional occupations of their unique qualities, particularly their monopoly over knowledge, public belief in their service ethos and expectations of work autonomy and authority over clients’ (Haug 1973: 197). Post-professionalism is the loss of exclusivity over knowledge that is experienced by existing professions. Post-professionalism arises because of the growth of technology and access to information and differences in the way that knowledge is applied through increasing specialisation (Kritzer 1999).

The purpose of this paper is not to debate these theories, but to examine and describe the directions in which the healthcare workforce can change in an attempt to develop a taxonomy around these concepts to enhance future debate. The terms ‘diversification’, ‘specialisation’ and ‘substitution’ are widely used in health workforce planning, but their significance for the changing boundaries of the health workforce have not been systematically examined. Additionally, this paper aims to clarify the interrelationship between different types of healthcare provider boundaries, and the potential for changing roles and career development opportunities arising from these changes.

Professional ‘fusion and fission’

Several phases in the emergence and transition of professions have been described. The phenomenon of occupational transition is receiving increasing attention. Freidson (1978) developed a model that considered the differing features of the social and economic organisation of occupations, acknowledging the existence of both formal and informal work, and the means by which occupations might pass from one form to the other. ‘Informal work’ is taken to encompass work which exists outside the official labour force, and which might, as a consequence of social or technological change, enter (or vanish from) official labour markets. For Freidson, it is the social rules that determine the formal or informal status of occupations, rather than the nature of the work itself. Freidson also draws on a more abstract distinction in defining subjective and objective occupations; the former constituting work which is productive but does not involve economic exchange (such as volunteer work), or where a surrogate occupation (which provides economic gain) renders invisible the subjective occupation for which the worker ‘labour[s] for love or glory’ (Freidson 1978: 5).

Dingwall (1983) provides further insights into the processes involved in the steps leading from the creation of an occupation to its formal recognition. Using health visiting as a case study, Dingwall highlights the stages through which an occupation may form, become formalised, or assume alternative modes of development. In the case of health visiting, both gender and class are considered relevant in the transition of informal, voluntary ‘sanitary mission’ workers into more formalised, credentialised, health visitors. Here the actual work tasks also assume importance in ensuring the transition, where an expanded role would include tasks which were ‘more “properly” the sphere of a domestic servant than a lady’ (1983: 613). Yet the trend is noticeably reversed when the emphasis is shifted in favour of credentialising tactics, a move that, in the care of health visiting, was facilitated by further segmentalisation and the incorporation of subordinate grades, comprising lower social class women to whom the ‘dirty work’ could be delegated (Dingwall 1983).

The notion of occupational ‘fission’ however, is augmented by further concepts that acknowledge the possibility of alternative outcomes for occupations in transition. Occupational ‘fusion’ and ‘capture’ offer a more comprehensive appreciation of the possibilities for developing fields of work; the former expressing a merger of disparate local organisational forms into a recognisably uniform occupational structure, the latter a gradual subsumption of one group by a more powerful neighbour (Dingwall 1983). Thus, the transition from subjective tasks, first to informal, then formal occupational structures, is mapped in a way which acknowledges the differing and dynamic trajectories possible in the life-cycle of occupations (Dingwall 1983). For established or aspiring professions, occupational strategies often centre on the protection and maintenance of boundaries, coupled with an ongoing campaign to expand areas of control (Macdonald 1995, Larson 1977). This is perhaps best understood in terms of Weber's concept of social closure, which acknowledges the way in which social collectivities act to ensure their status and position in society. This is usually achieved by the creation and maintenance of exclusive rights to key privileges whilst simultaneously engaging in further exclusionary or usurpationary strategies aimed at acquiring greater privileges, at the expense of other, competing groups (Macdonald 1995, Parkin 1979). The pursuit of a ‘professional project’ may thus include strategies that involve advancing the goals of professionalisation through legislative and regulatory control, and which are dependent upon access to relevant external power resources (Larkin 1983, 1993, 2002, Larson 1977). Also relevant are Kronus’ (1976) and Larkin's (1983) formulation of ‘occupational imperialism’, which illuminates the competitive stratagems and tactics adopted by professions in advancing their aims through the acquisition of high status skills and roles (‘poaching’ from other occupational groups) whilst delegating lower status roles to subordinate groups. These models are useful in that they acknowledge a dynamic capacity of professions to act, enforce and counteract exclusionary or usurpationary closure strategies, and seek to defend and expand role boundaries (Larkin 1983).

Abbott (1988) re-focused attention upon the importance of the acquisition and control of tasks in the workplace. For Abbott, professions engage constantly in jurisdictional disputes, in which occupational vacancies are created and occupied in a competitive, dynamic and inter-related system. Such a system allows for change in a non-linear way, where occupational ascendancy is not necessarily guaranteed or beyond effective challenge. Changes in the occupational domain of one profession have an impact on neighbouring professions, or in the genesis of new professions. Inter-professional conflict is, then, at the heart of Abbott's thesis, enabling an analysis that extends beyond the progressive acquisition of statutory and regulatory forms of legitimation (Abbott 1988). Abbott's ‘system’ has been criticised, however, for its failure to consider the motives and intentions of the actors involved (Macdonald 1995), an approach which is taken up by Burrage and Torstendahl (1990). Here, four ‘actors’ are identified who play a role in shaping the destiny of aspirant professional occupations: the ‘practising members’ (as distinguished from professional academics), the users, the universities and the state (Burrage and Torstendahl 1990). Viewed from an international, comparative perspective, the influence of each actor is examined for its impact upon the outcome of professional goals. Intra-professional conflict is also viewed as an inevitable outcome of the way professional organisations operate, in representing multiple interest groups, such as ‘generalists’ and ‘specialists’, or city versus rural based practitioners (Burrage and Torstendahl 1990). However, coupled with a common ideological stance, which ‘inspires practice and constrains practitioners’, professions also display the features of ‘persistence’ and ‘proximity’, enabling the professionals to share common aspirations consistently over time, and largely retain control over the regulation of professional behaviour (Burrage and Torstendahl 1990). Negotiations with the state vary not only over time, but also in different cultural and national contexts, although state interests tend to be similar in relation to professional occupations, where they may serve the state in a variety of ways (Burrage and Torstendahl 1990). It is the political process which is ultimately afforded the greatest importance in shaping professional development and change (Burrage and Torstendahl 1990); a conclusion which resonates with Larson's professional project, the ‘regulative bargain’ with the state which is integral to it, and the political culture upon which it depends (Macdonald 1995).

More recently, the literature has focused upon an increasing challenge to the authority and autonomy of the professions, most notably from the influences of managerialism and marketisation (Fournier 2000, Cox 1991, Boyce et al. 2000). For Fournier (2000) the construction and maintenance of boundaries is crucial to professional development, and demands constant ‘boundary work’ to preserve or expand them. The constitution of the professional field within a discipline into an ‘independent, autonomous and self-contained area of knowledge’ is instrumental in forging professions, and is achieved by constructing boundaries in three distinct arenas that separates the profession from other professions, clients and markets (Fournier 2000: 69). By constructing a field of expertise surrounded by an ideological cover that asserts a ‘natural’ basis for professional boundaries, the field is self-producing and therefore expandable and capable of re-definition (Fournier 2000). In her analysis of the impact of the challenge of the market, Fournier concludes that it may yet be premature to predict the demise of the professions, stressing the capacity of professions to reconstitute their knowledge and redefine their boundaries as they adapt to new realities. Malin (2000) however, does identify significant problems for the establishment of legitimate boundaries of care within community and social care, in an environment of state intervention centred on demands for employer-led training and the codification of knowledge through an imposed competence-based approach. In this arena, there is little possibility of self-determination when the development of knowledge is constrained by a managerialist agenda (Malin 2000).

Witz's (1992) elaboration of closure theory identifies ‘demarcationary strategies’ as those concerned with the creation and control of inter-professional occupational boundaries. In particular, she draws a distinction between her own interpretation and that of Kreckel (1980), who considered demarcation to represent a consensual or ‘horizontal’ shift in boundaries, based on mutual negotiation. In contrast, Witz (1992) regards demarcationary strategies to be more akin to the competitive, conflictual processes of occupational imperialism (Larkin 1983).

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