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Chapter four explores how educators might help cultivate the capacity for authentic patient care among doctors-in-training, including a comportment of humility, openness, and gratitude for patients. The argument is made that the curative ethos of medicine and its preoccupation with calculative thinking will persist until educators can cultivate within clinicians and clinicians-in-training the capacity to face their vulnerability and the reality of existential anxiety. It is through a pedagogy that values and fosters vulnerability and reflexivity that this capacity can be cultivated. Although recent trends in the professionalism movement, including that of “professional identity formation,” have made progress toward these ends, these movements actually may serve to reinforce calculative thinking, due to their focus on outcomes and assessment. This chapter looks critically at such trends in medical education and contends that ideas concerning professionalism can be enriched and expanded through an understanding of virtue ethics and the Aristotelian concept of phronesis, which emphasize personal development, experiential and habitual learning, and quality mentorship.

This chapter defines the various models of medical professionalism. The challenges to conventional notions of medical professionalism are addressed. The chapter shows that the consent model cannot convincingly be used to support the claim that physicians have a broad obligation to subrogate their personal moral beliefs in order to satisfy patient demands. It demonstrates that the gatekeeper model of professionalism is the only approach capable of laying a solid foundation for the maximum protection of both doctors and patients. In general, the models of professionalism explored in the chapter provide a significant perspective on the conscience clause debate, but only one of them can get out of the current stalemate and move toward a true balancing of interests.

For the first time in the history of bioethics, the possible contributions of ancient philosophy are receiving notable attention. The chapter contends that while this is all to the good, bioethicists’ focus on Aristotle’s notion of phronêsis(practical wisdom) is misplaced. In the meantime, the promise of Plato remains virtually untapped by those seeking collaborative models of the doctor-patient tie that avoid the pitfalls of paternalism and autonomy. In addition, Plato’s explorations of human nature and his political thought have much to offer bioethics right now in its probing of medical professionalism and medicine’s role in society. Though engagement with Plato will not resolve our own quandaries, his work, particularly the Laws, warrants greater attention from bioethicists than it has heretofore received.

This chapter explores the institutional roots of medical professionalism in the United States. It examines why the U.S. health care system delegates therapeutic authority to individual doctors and medical societies, with little centralized oversight in programs like Medicare. The chapter also presents findings from a national survey of physicians to gauge their views on the proper role of medical societies in medical evidence controversies. Although the tradition of professional autonomy places the physician at the center of the U.S. health care system, the survey evidence suggests that physicians do not recognize the important role their own beliefs (and potential misconceptions) about what constitutes good medical practice play in contributing to the problems of overutilization and inefficiency. The survey also reveals that doctors generally want their medical societies to forcefully defend treatments challenged by research. At the same time, the survey uncovers notable differences among the views of physicians based on both their medical specialization and partisan affiliation. Doctors who identify with the Republican Party place a somewhat higher priority on protecting clinical autonomy (and a somewhat lower priority on discouraging clinical interventions with minor or no benefits) than do doctors who identify with the Democratic Party.

Although Lipsky made few references to health workers, the autonomy historically associated with physicians' work implies that health 'policy' is significantly determined by the aggregate of individual clinical decisions, so that physicians can be regarded as street-level bureaucrats. However, developments in 'evidence-based medicine' and health quasi-markets have undermined the assumed indeterminacy of medicine upon which clinical autonomy is largely based, allowing clinical practice to be bureaucratised through incentivised clinical guidelines and 'patient pathways'. The English National Health Service evidences such bureaucratisation in primary care, though less clearly in secondary care. These developments do not constitute the imposition of 'machine bureaucracy' upon medicine, but do imply that Lipsky's criteria for the manageability of street-level bureaucracy are being approached. More generally, this chapter shows that the potential for bureaucratisation of clinical practice, though not unlimited, is somewhat greater than long-established theories about the esoteric and tacit nature of medical practice would suggest.

This chapter argues that there is a prima facie moral obligation to prevent and relieve suffering. Because pain and suffering are states that all rational people ordinarily want to avoid, this obligation does not derive from a specific view of life’s goods and evils. There are limits to the relief of suffering, but they are based on this same duty. Arguments against active euthanasia that point to euthanasia’s adverse long-term impacts on patients and society are examples. On the basis of this understanding, this chapter critiques religious views that appear to valorize suffering. It concludes with an examination of arguments that would limit medical interventions in the name of preventing the medicalization of suffering. Drawing on the concept of “malady” and its conceptually tight relation to suffering, the chapter argues that there are often good reasons for limiting the scope of medical professionalism to the prevention and treatment of diseases (maladies). The prevention and relief of suffering, however, sometimes counsel allowing physicians to assist patients seeking treatments for other, nondisease conditions.