Lost Virtue: Volume 10

Dedicated to

No topic in medical education has received more attention and generated more discussion in recent years than that of “professionalism”. In many ways, this should come as no surprise in light of the dramatic technical and scientific advances in medicine, the changing, and often confounding, roles of physicians in complex health care systems, and the growing expectation throughout society that physicians should provide more effective, patient-centered care. Any of these factors alone is sufficient to create anxiety and confusion about basic duties and responsibilities of physicians to patients, the medical profession and to society. In this complex, demanding, commercialized and yet, values-laden, world of health care it is an understatement to say that there are fundamental challenges to what it means to be a medical professional in today's society.

Public and profession alike are troubled by what they perceive as a loss of professional status in medicine. Can it or ought it be retrieved? How? These questions cannot be answered without understanding what a profession is, what professing medicine entails in the way of character traits, and whether, and how, these traits can be taught. Answers are sought in the phenomena of the physician–patient encounter, the theory of virtue ethics and its implication for character formation. In addition, the moral attitudes and practices must also be supportive of the idea of a profession. Courses in professionalism might help but the problem is first of all a moral one.

Professional formation and evaluation in medical education lacks a reliable conceptual foundation. This shortcoming results from an insufficient appreciation of the history of medical ethics as the source of the concept of medicine as a profession. This chapter therefore explores the medical ethics of the Scottish physician-ethicist, John Gregory (1724–1773) and the English physician-ethicist, Thomas Percival (1740–1804), who between them invented the concept of medicine as a profession. Three components of this concept are identified: the commitment to scientific and clinical competence; the commitment to protect the patient's health-related interests; and passing on medicine as public trust, not merchant guild.

This chapter questions the role of virtues in health professional medical ethics. It distinguishes between the ethics of conduct – usually expressed as moral principles – and the ethics of the character – expressed as virtues. It questions whether virtues are intrinsically valued or valued instrumentally as the means to right conduct. It poses two problems for virtue theory: (1) The “naked virtue” problem – whether instilling virtues increases the probability of correlative morally right conduct, and (2) the “wrong virtue” problem–which of many sometimes controversial virtues should be promoted. The chapter ends by arguing that these are less serious problems for the morality of conduct.

This chapter reviews the evidence of the development of ethical decision-making competencies of medical professionals. Selected studies are reviewed that use a theoretical framework that has shown the most promise for providing evidence of character formation. The evidence suggests that entering professionals lack full capacity for functional processes that give rise to morality (sensitivity, reasoning, motivation and commitment, character and competence). Further, following professional education, considerable variations in these abilities persist. Whereas many perceive that role modeling is the most effective way to teach professionalism, there is no empirical evidence to support the role of modeling in professional development. The chapter concludes with suggestions for facilitating character development resistant to influence by negative role models or adverse moral milieu.

Disillusionment among doctors is common. It is not uncommon for even highly successful doctors to say they wish they had gone into another field or that they would not encourage their children to go into medicine. In this chapter, I explore why this might be so. For many, medicine has become just another job dominated by technical skill and technology. I suggest that educating for professionalism as the remedy for this disillusionment is almost certain to fail as the issues are as much sociological as personal and professional. Perhaps disillusionment is a clue to a much more complex reality for modern medicine.

This chapter argues for appreciating the distinctiveness of medical ethics. If the ethics of medicine is different from the ethics of everyday life, it follows that the character of physicians is and should be different from the character of others. Molding the character of future physicians therefore becomes an important matter for the attention of medical educators. In that light, this chapter explains the appropriate goals for such an educational program and discusses the means for teaching and inculcating the principles, attitudes, and behaviors that physicians need to embrace in order to fulfill their special social role and professional obligations.

One way of defining the character of clinicians is to examine their moment-to-moment actions during the course of clinical care. These small actions, cumulatively, describe the clinician as a practitioner and moral agent. In this chapter, using clinical examples, I explore the possibility that professional competence and virtue are based, in part, on clinicians’ ability to engage in a “mindful” practice in which they can be attentive to their own actions, curious enough to examine them and present and flexible enough to change them.

Fostering the development of professional character in student physicians remains the most essential, yet challenging and sometimes elusive goal of those in medical education. Current understandings and contemporary approaches to learning and teaching can provide perspectives that may inform our thinking. In this chapter, learning with and from others is explored along with approaches that form the foundation for the development of professional character that integrates moral conduct into professional practice. The implications for both teaching and learning and the importance of the learning environment are discussed. Education as a moral endeavor and values-based practice is emphasized.

Recent accreditation standards have changed for all US and Canadian medical schools and residency programs. Newly mandated knowledge, skills, behavior, and attitudes required of the learner to become a medical professional are permeated with professionalism and associated curricular themes. The art of medicine now emphasizes humanistic skills, ethical precepts, and principle-based values. To this end, this chapter calls for enhanced learner collaboration with educators, as well as a required longitudinal ethics curriculum and medical apprenticeship for all phases of medical education. These efforts can thereby result in greater moral reflection on professionalism and its successful assimilation into clinical practice.

The resurgence of interest in professionalism necessarily focuses us on the moral core of medicine and the character of the good doctor. While medical education reform projects aimed at educating for professionalism are replete with lists of laudable virtues necessary for the doctor, we have made little progress in mapping those character traits, values and behaviors to admission procedures, curricular reform and faculty development. If educating for professionalism is to be effective, medicine must re-claim the moral core of professionalism and identify clearly the fundamental traits, values and virtues necessary for good medical practice in the twenty-first century.