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In this chapter, the authors present five changes in people’s attitude and behaviour, which not only can explain the decline of trust, but which must almost inevitably lead to a decline of trust. The first four changes may be summarised under the heading ‘loss of physicians’ authority’: (1) the discrediting of ‘professionalism’, which has led to a decline of professional authority; (2) the insistence on (and difficulty of) assessing physicians’ trustworthiness and the loss of merit-based authority; (3) a questioning of physicians’ medical authority caused by the disavowal of the basic tenets of scientific medicine (often referred to as the ‘crisis of modern medicine’); (4) increasing doubts regarding the physician’s agency and directive authority caused by the perceived commodification of medicine and a reconceptualisation of physicians as dependent employees. The fifth change refers to changes of risk perception and increasing risk-averseness. Contrary to what many believe, it is not risks which have increased, but uncertainty. Yet, people perceive this increase of uncertainty as an increase of risk – a risk which an increasing number of people are no longer willing to accept.
Here, the authors present two justifications usually cited as sufficient to warrant patients‘ trust in physicians: professional status and individual merit. Whereas in ‘status trust’ professionalism is taken as a guarantor of trustworthiness, in ‘merit trust’ a physician’s trustworthiness is assessed individually. On either account, trust is justified by the physician’s professionalism. ‘Professionalism’ may be defined as ‘acting trustworthily’ in exchange for autonomy of decision-making, whereas trustworthiness refers to ‘competence’ in terms of episteme (theoretical knowledge), techne (craft or skill), and phronesis (practical knowledge or experience), and ‘commitment’ as ‘to act in a way that the truster approves’. The authors argue that although in principle trust in physicians is justified, since both professionalism and individually assessed trustworthiness grant derivative authority, the reality is different. because an increasing number of patients reject the concept of professionalism and, accordingly, find it difficult (or even impossible) to assess physicians’ trustworthiness. Hence, they no longer believe that their trust in physicians is justified.
Introduction: Competence committees (CCs) struggle with incorporating professionalism issues into resident progression decisions. This study examined how professionalism concerns influence individual faculty decisions about resident progression using simulated CC reviews. Methods: In 2017, the investigators conducted a survey of 25 program directors of Royal College emergency medicine residency training programs in Canada and those faculty members who are members of the CCs (or equivalent) at their home institution. The survey contained twelve resident portfolios, each containing formative and summative information available to a CC for making progression decisions. Six portfolios outlined residents progressing as expected and six were not progressing as expected. Further, a professionalism variable (PV) was added to six portfolios, evenly split between those residents progressing as expected and not. Participants were asked to make progression decisions based on each portfolio. Results: Raters were able to consistently identify a resident needing an educational intervention versus those who did not. When a PV was added, the consistency among raters decreased by 34.2% in those residents progressing as expected, versus increasing by 3.8% in those not progressing as expected (p = 0.01). Conclusion: When using an unstructured review of a simulated resident portfolio, individual reviewers can better discriminate between trainees progressing as expected when professionalism concerns are added. Considering this, educators using a competence committee in a CBME program must have a system to acquire and document professionalism issues to make appropriate progress decisions.
In this article I investigate how a group of Black men in college worked together to learn and practice the professional pose—professional styles and behaviors meant to navigate professional settings. I argue that these behaviors were adopted to preempt any potential discriminatory acts and would ideally disassociate them from the negative labels associated with Black men. Specifically, I examine how leaders of the group Uplift and Progress (UP) prepared other members and recruits by teaching them how to present themselves as professional Black men who were familiar with White middle-class practices. To further encourage their success, group members sought out opportunities to practice these styles in public. By cultivating this professional pose, they were able to claim their place at a White institution and distance themselves from the unfavorable stereotypes of Black men. This strategy also bolstered their reputation on campus and would ideally prepare them for the predominantly White workplace.
This article describes the well-developed and long-standing medical ethics teaching programs in both of New Zealand’s medical schools at the University of Otago and the University of Auckland. The programs reflect the awareness that has been increasing as to the important role that ethics education plays in contributing to the “professionalism” and “professional development” in medical curricula.
This paper outlines a framework for explicitly including ethics in actuarial education. The framework includes integrity, the cardinal virtues (justice, prudence, self-control and courage), and vocation. It is based on a traditional understanding of ethics, and it is argued that it has the potential to be widely acceptable. Justification, from philosophy, is found mainly in virtue ethics, and the work of Alasdair MacIntyre. The framework is concerned with matters of character as well as behaviour and ultimate outcomes (which are the respective concerns of apparently competing deontological and teleological theories). Integrity and the cardinal virtues can be found within current professional standards or, it is argued in the case of courage, should be there. We come to appreciate and display the virtues as we are inducted into a professional community by teachers and mentors. Our view of ethics is incomplete, however, without acknowledgement of our own weaknesses and failures, and an understanding of the role of regulation. Such understanding should include insight into the way in which ideologies and institutions can pervert ethics for the benefit of vested interests. Finally, suggestions are made as to how the framework of the virtues can be included in the actuarial syllabuses.
According to the market failures approach to business ethics, beyond-compliance duties can be derived by employing the same rationale and arguments that justify state regulation of economic conduct. Very roughly, the idea is that managers have a duty to behave as if they were complying with an ideal regulatory regime ensuring Pareto-optimal market outcomes. Proponents of the approach argue that managers have a professional duty not to undermine the institutional setting that defines their role, namely the competitive market. This answer is inadequate, however, for it is the hierarchical firm, rather than the competitive market, that defines the role of corporate managers and shapes their professional obligations. Thus, if the obligations that the market failures approach generates are to apply to managers, they must do so in an indirect way. I suggest that the obligations the market failures approach generates directly apply to shareholders. Managers, in turn, inherit these obligations as part of their duties as loyal agents.
Although recent literature on professionalism in healthcare abounds in recommended character traits, attitudes, or behaviors, with a few exceptions, the recommendations are untethered to any serious consideration of the contours and ethical demands of the healing relationship. This article offers an approach based on the professional’s commitment to trustworthiness in response to the vulnerability of those seeking professional help. Because our willingness and ability to trust health professionals or healthcare institutions are affected by our personality, culture, race, age, prior experiences with illness and healthcare, and socioeconomic and political circumstances—“the social determinants of trust”—the attitudes and behaviors that actually do gain trust are patient and context specific. Therefore, in addition to the commitment to cultivating attitudes and behaviors that embody trustworthiness, professionalism also includes the commitment to actually gaining a patient’s or family’s trust by learning, through individualized dialogue, which conditions would win their justified trust, given their particular history and social situation.
With New Public Management came the idea that public organizations should be led by professional managers, rather than by professionals. This has been referred to as new managerialism. This article explores how new managerialism may affect professional autonomy in a public organization that enjoys a high – and constitutionally protected – degree of organizational autonomy. A framework distinguishing between organizational and occupational professionalism is adopted, in a 10-year case study of the Swedish National Audit Office (SNAO). The study shows how the autonomy of professionals at the SNAO was highly restricted, while management control systems were continuously expanded. At the same time, SNAO performance has been reduced. For example, the SNAO has been criticized for its high overhead costs. The study presented in this article, shows the complex interplay between professionalism, new managerialism, and organizational performance. Based on the findings from this study, the article maintains that it is equally important to consider how autonomy is distributed within agencies, as it is to consider how autonomy is distributed between the political sphere and the administration, when trying to explain organizational performance.
While the medical ethics literature has well explored the harm to patients, families, and the integrity of the profession in failing to disclose medical errors once they occur, less often addressed are the moral and professional obligations to take all available steps to prevent errors and harm in the first instance. As an expanding body of scholarship further elucidates the causes of medical error, including the considerable extent to which medical errors, particularly in diagnostics, may be attributable to cognitive sources, insufficient progress in systematically evaluating and implementing suggested strategies for improving critical thinking skills and medical judgment is of mounting concern. Continued failure to address pervasive thinking errors in medical decisionmaking imperils patient safety and professionalism, as well as beneficence and nonmaleficence, fairness and justice. We maintain that self-reflective and metacognitive refinement of critical thinking should not be construed as optional but rather should be considered an integral part of medical education, a codified tenet of professionalism, and by extension, a moral and professional duty.
This article presents empirical data on the limited availability of hospice and palliative care to the 6 million people of the English-speaking Caribbean. Ten of the 13 nations therein responded to a survey and reported employing a total of 6 hospice or palliative specialists, and having a total of 15 related facilities. The evolving socioeconomic and cultural context in these nations bears on the availability of such care, and on the willingness to report, assess, and prioritize pain, and to prescribe opiates for pain. Socioeconomics and culture also impinge on what medications and modalities of care are routinely available for pain or other conditions and can challenge professionalism, empathy, and responsiveness to patients’ unrelieved pain. Although all respondents report having a protocol for pain management, hospice, or end-of-life care, their annual medical use of opiates is well below the global mean. The International Narcotics Control Board (INCB), which monitors such use, encourages Caribbean and other low- and middle-income countries to increase their use of opiates to treat pain, and to overcome both unfounded fears of addiction and overly restrictive interpretation of related laws and regulations. Contextual considerations like those described here are important to the success of policies and capacity-building programs aiming to increase access to hospice and palliation, and perhaps to improving other aspects of health and healthcare. Exploring and responding to the realities of socioeconomic and cultural conditions will enhance public and policy dialogue and improve the design of interventions to increase access to palliative and hospice care. Improving access to palliative and hospice care in the Caribbean demonstrates beneficence and helps to fulfill human rights conventions.
The Chinese judicial system has long been influenced by a populist legal ideology that prioritizes public accountability and political legitimacy over professional autonomy. In recent years, however, the Chinese legal profession has begun to mobilize collectively, albeit episodically, to challenge this populism. Drawing on legal documents, interviews, media reports, and online discussions, this paper provides a scholarly analysis of the Li Zhuang case in 2009−11, in which the fate of an individual criminal defence lawyer was linked with the main ideological conflict in China’s legal system and the highest-level political struggles in the Chinese state. It demonstrates that, although populism remains an intimidating force in China’s judicial practice, lawyers, scholars, and other legal professionals may be laying a foundation for collective solidarity to pursue professionalism through their mobilization against populism.
In 2011 and 2012, the Supreme People's Court (SPC) published its first “guiding cases.” Guiding cases serve as decision-making models that must be taken into account by lower courts when deciding similar cases. This study argues that the establishment of a national formal legal mechanism to improve consistency in adjudication across jurisdictions and geographical boundaries will strengthen judicial professionalism. The guiding cases system provides the SPC with an instrument to steer adjudication in lower courts discreetly, thereby allowing it to exercise significant influence over legal developments. Given the complexity of cases, compared to law set out in statute, non-lawyers may have tremendous difficulty in understanding and assessing the effects of guiding cases; this in turn acts as a protective mechanism against extra-legal interference. The reform is an example of the SPC's delicate manoeuvring in order to retain judicial professionalism in a hostile yet politically conservative environment. It reflects an attempt by the SPC to strengthen its position vis-à-vis other actors of the party-state and to consolidate the judiciary's function as an adjudicative institution that works on the basis of formal legal mechanisms.
Integrity provides the foundation for most scholarly endeavours, including research and publishing. Authors, reviewers, and editors share responsibility for creating and maintaining the system in which we conduct and publish our work. However, research and publishing are complicated processes. A single research effort may involve multiple authors, hundreds of participants, and a variety of skills and tools that play out over the course of months or even years. Ethical challenges may arise at any point along the way, so it is not surprising that both new and experienced scholars often struggle to understand and maintain the ethical standards expected of them. This article highlights some of the main challenges scholars face and provides initial guidance for seeking solutions. But most importantly, it sets the stage for this Special Editors' Forum on research and publishing ethics.
Two significant people at the core of therapeutic encounter are the patient and the psychiatrist. The therapeutic encounter can establish a diagnosis and devise a management plan. The encounter lies at the core of clinical judgement. This chapter highlights the issues related to patient expectations of psychiatrists. A major task of the psychiatrist as a clinician is to come up to and understand what the patients and their carers expect from them. Patient expectations of the therapeutic encounter and what they want from their psychiatrist has to be seen in the context within which it is being carried out. Keeping up-to-date with knowledge, developing and setting standards and ensuring that these standards are met and kept, being ethical and possessing excellent communication skills are the key characteristics which patients and carers expect of their psychiatrists.
This chapter addresses the question of whether professionalism can be effectively taught, by examining what it means to teach professionalism, proposed strategies to teach it, evidence of effectiveness of interventions aimed at teaching or improving professionalism and evidence of ability to identify or predict unprofessional behaviour. In one of the primary texts on professionalism education, Hafferty notes that professionalism lies in an interface between possession of specialized knowledge, and using that knowledge for the betterment of others'. Learning the professionalism of Hafferty and Smith occurs in the culture of medical school and residency, where examples, narratives and role modelling occur. To improve this learning would require changes in the culture of medical schools. In addition to the efforts to teach professionalism to all students, many schools have programmes specifically to identify, presumably for the purpose of remediation, and students with unprofessional behaviours.
This chapter focuses on professionalism in psychiatry that is important to recall that unprofessional conduct by psychiatrists taints and undermines the trust that our patients have in us as individual psychiatrists as well as in the discipline of psychiatry and medicine in general. The Australian approach to professionalism is based on international standards of professional conduct in medicine and psychiatry. However, Australian psychiatry has been influenced by instances of unacceptable care, in which patients received care was neither medically competent nor professional. Australians seeking healthcare currently do so through public or private healthcare systems, and the universal public healthcare system is known as Medicare. Australians have historically demonstrated some indifference towards those institutionalized with mental illness, and in this context there have been a number of instances of institutional exploitation of mentally ill patients.
Experts in any field develop their expertise using both their training and experience. The nature of the expertise of the profession is a key essential of professionalism. The key to understanding professionalism is on two levels: first, what constitutes professionalism, and second, what gaps might highlight what a professional lacks, thus looking at expertise and professionalism both positively and negatively. In understanding the experiences, explanations and expressions of illness from the patient, the expert can engage with the patient, find common ground to explore, agree on goals of treatment and management plans and then keep these under review in regular discussions with the patient. This chapter shows that attitudes and professional attributes can be changed. Areas of expertise in psychiatry include culture; the ability to understand, co-ordinate and work co-operatively to provide comprehensive mental healthcare; the ability to understand ethical practice; and effective communication and education.
The challenges of professionalism are related to changing public and patient expectations, increased costs, conflicts of interest and consumerism. This chapter talks about teamwork. The essence of teamwork is the model used for crew resource management. Teams have been around for centuries, but healthcare teams are relatively new. They contrast with familiar congenial work groups that constitute the basic units of all hospitals. The integration of true medical teams into healthcare in several countries has occurred to varying degrees with different results. In the United States, the Accreditation Council for Graduate Medical Education (ACGME) has defined six competencies which form the basis of physician training. Two models that explain medical student cynicism include: the intergenerational model and the professional identity model. Teams serve the purpose of self-preservation by encouraging physicians to honour their ultimate fiduciary avowal, and to work co-operatively for the greater good of society.