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Thursday, June 28, 2007

Session 2: The Professions in Contemporary America: Promise and Peril

William M. Sullivan, Ph.D.
Senior Scholar
Carnegie Foundation for the Advancement of Teaching

CHAIRMAN PELLEGRINO:  When we began I forgot a very important official act, and that is to recognize Dr. Daniel Davis, the Executive Director of the Council, the man who makes things work.  It's important for this to be a government properly run meeting to announce him as the Executive Director and the official representative of government.  I'm simply a peon who gathers the group, but he is the Executive Director.

Thank you, Dan.

And this applies retrospectively.  The only power I have is to say my statement applies retrospectively.

This afternoon we pick up the program, and we're very, very grateful to Dr. William Sullivan for putting up with the rigors of air travel.  As I said at lunch, the motto for air travel these days is time to spare, go by air.  I hope you had some time to spare, but at least you're here with us, and we're very, very thankful.

Dr. Sullivan is Senior Scholar of the Carnegie Foundation for the Advancement of Teaching, and he is going to address the topic of professionalism from a more general perspective rather than in relationship to any particular profession or set of professions.

Dr. Sullivan.

DR. SULLIVAN:  Thank you very much for also the indulgence in rearranging schedules at the last minute.  This was a bit of an adventure for me, and I want to make it clear this was not an ill conceived idea for a dramatic entrance.  It was really due to United Airlines and some thunder storms in Chicago last night.

But it's actually a pleasure and certainly an honor to be invited to speak on the topic of professionalism, a topic that I think is of great contemporary importance before such a distinguished body, and I'm grateful for that opportunity and honored to have been invited.

The main theme that I want to stress this afternoon is what I want to call the practical necessity for professionalism, specifically for what I'm going to call a civic professionalism for the public good.

I think this argument supports a vision of the health professions, in particular, but I want to frame it in a way that applies more broadly to many professional domains, including law, the ministry, education, engineering, architecture, accounting, and the sciences.

I will proceed in three steps.  First, I want to provide a general characterization of the professions and the ethic of professionalism.

Second, I want to focus on professionalism in two senses, first as a heritage, and second as a moral source to guide thinking about contemporary professional work.

Third, I want to address the question of how to strengthen professionalism in today's climate.  Here I will talk briefly about the challenge of professional education.

Finally, I will conclude by underscoring the intrinsic good of civic professionalism as a complement to what I believe is its manifest practical utility.

So first, the professions and the ethic of professionalism; second, professionalism as heritage and as moral source; third, strengthening professionalism; and fourth, integrity and civic professionalism.

To assume a professional identify is not only to join an occupation.  It is to take up a civic role.  The core professionalism is that by functioning as a lawyer, engineer, doctor, accountant, architect, teacher or nurse, an individual carries on a public undertaking and affirms public values.

With this identity comes a certain public status and authority as is granted both by custom and the profession's social contract.  But professionalism also means duties to the public.  Chief of these duties is the demand that a professional work in such a way that the outcome of that work contributes to the public value for which the profession stands.

The larger public, I would submit, seems to understand this intuitively.  There is widespread expectation that professionals should be accountable beyond the measure of profit and loss because the professional ethic rests upon a fiduciary basis.

Amid the general outcry over the revelations of fraud and malfeasance as the financial bubble exploded in 2002, the sharpest outrage was directed at the law and accounting firms.  Quite correctly both officials and the public at large saw the leading lawyers and accountants of those organizations as guilty of an insolent repudiation of public trust.

They, therefore, judged those professionals corrupt and so more odious, if not more reprehensible, than your business leaders of companies like Enron and WorldCom.  Like hypocrisy, moral outrage is premised upon accepted standards of value.

The ideals bound up with professionalism have been only imperfectly realized in any professional field, but the persistence of these at least in the form of aspiration is noteworthy.

Summing up a large literature, the historian Shelton Rothblatt writes that professions can be defined by an ethic of service.  All agree that education, whether by apprenticeship or science, has been the central feature of professional identity.

Equally true, I think the professions can be seen as highly skilled occupations with a distinctive corporate form of organization.  But they are more than this.  In their corporate organization, they represent a project for bringing into the marketplace and society the spirit of public service.

Professions are organized so that individuals must submit to the corporate organization in order to acquire their specialized skills, and equally important, can only benefit personally from the employment of this human capital by applying it according to standards that are established and in aspiration, at least, monitored for the public benefit.

Of all job categories, professions and professionals have traditionally shown the greatest degree of involvement in their work, along with the largest attachment to its intrinsic rewards in contrast to the rewards of income and status.

In many ways then, the professions have, indeed, provided models of good work.

Professions operate within an explicit contract with society at large in exchange for privileges, such as monopoly on the ability to practice in specific fields.  Professions agree to provide certain important social services in exchange for the privilege of setting standards for admission and authorizing practice.  Professionals are legally obligated to discipline their own ranks for the public welfare.

The basis of these contracts is a set of common goals shared by the public and for which different professions undertake responsibility.  So medicine, nursing, and public health are, in effect, chartered for the maintenance and improvement of society's health, just as education exists to promote the goal of an educated citizenry, law to secure social justice, or engineers to insure safety.

The roots of this ethic, as I will try to show, lie deep in our society's religious and civil heritage, but these are public values.  In economic parlance, they are public goods, meaning that they are values from which all benefit and which depend upon everyone's cooperation, but to which no individual market actor has a strong incentive to contribute.  The professions are publicly charged to make it their primary concern to sustain such public good.  They are, therefore, in an important sense public occupations even when they work outside government or public supported institutions, such as schools and universities.

Like other institutions oriented for the public, professions depend upon trust and good faith on the part of both the public and the professional groups.

Now, it's this social contract, especially its larger implicit basis in social trust which has frayed, I believe, in recent decades.  There's ample evidence of the weakening of public trust in many professional areas, including the ministry, law, and teaching, as well as medicine.

Analysts, such as Derek Bok have pointed out the great shift in compensation and also prestige within professional ranks which has taken place since the 1970s.  The trend, according to Bok, has been away from public sector employment, such as government and education, toward the service of business and private sector activities.

One major result has been the growth in income disparity within professional ranks, directing the paths toward both wealth and prestige into the profit making arena and away from public institutions.

Sociologist Steven Brint has summarized these developments of movements away from what he refers to as an earlier form of professionalism as social trusteeship toward the embrace of a notion of the professional as the purveyor of expert services in an increasingly stratified and competitive marketplace.

I have referred to this as a shift from a civic toward a technical conception of the professional enterprise.  This social climate has put the professions on the defensive.  It has led many to question both the value and viability of the professional organization of work in many fields.  Indeed, the professions might be seen as facing a continuing low grade war of attrition. 

Professionals have traditionally been ascribed vocations, as well as careers or jobs.  However, while the value of having a calling is still respected today, it is seen mostly as applicable in very restricted spheres. 

So apart from the distinctly religious sense of calling, it is widely understood that both in the arts and in the sciences contributions of value require nothing less than the whole of a person's life and devotion. 

But the idea of institutionalizing vocation, of making it a regular established feature of daily work, as in professional occupations, is today a more questionable proposition.

To sum up, there has been some loss of both understanding and appreciation of the value of professionalism, but more serious is the erosion of the public's trust that professional groups are serious about these purposes.  It is not that assertions of good faith on the part of the organized bar or medicine, for example, have been lacking in recent years.  Rather, the public has seen these professions as gestures which must be redeemed by concerted action.

What seems missing is the public leadership involved in solving perceived public problems, including the problems of their own abuses of privilege and refusal of public accountability. 

Now, these issues point to the essential civic dimension of professional life, where the levels of trust, self-restraint, and degree of cooperation are high, where social interactions include most parts of a social environment on an equitable footing and are perceived as mutually beneficial.  Professional organizations and individual practitioners are more likely to behave as good citizens, taking responsible often leadership roles in the society's life.  This is the kind of thing which Brint's avocation of social trusteeship is a gesture toward.

In return, the professions maintain goodwill, public support and often prestige.  In such circumstances, individual professionals are likely to find their efforts of integrity recognized and rewarded.  These are the conditions of a society experiencing a kind of positive interdependence among its parts.

Conversely, however, where civic cooperation falters or becomes  sporadic, mediation between individual goals and social need is likely to break down, releasing aggressive efforts to escape social responsibility with all the corrosive effects this has upon democratic life.

A direct consequence of such circumstances is the worsening of possibilities for integrity in professional life.  Many of the disagreeable aspects of contemporary professional activity have their root causes, I believe, in this experience of negative interdependence.

From this perspective then, the professional enterprise is an important modern civic institution.  The professions have pioneered and continue to model a socially attuned way to organize work, thereby providing a potential resource through bringing the concerns of citizenship into a wide variety of specialized occupations.

The integrity of professional life — indeed, its future — is, I think, bound up with this civic enterprise.

Second, professionalism as heritage and as moral source.  Today the professions seem a natural and established feature of American society as in all developed nations.  In fact, however, the professions' achievement of social importance was hardly an expected or necessary feature of the development of the United States. 

There are ways in which the professions have fought an uphill battle against the ideals of individualism and egalitarianism so prominent in our democracy.

The conflict between the meritocratic ideals of the professions and a broader egalitarian populism has led to dramatic swings at one moment toward public recognition of the competence of certain specialized groups to regulate an occupational sphere, such as health care, while at other moments public opinion has stripped occupational groups of any special prerogatives or privileges.

Since the professional career has always been a route to individual success, professions have been focal points in the struggle to balance democratic openness to individual achievement, on the one hand, with the need for the professions to be trusted to work for the benefit of society in pursuit of agreed upon common ends.

Professionals take part, as I've argued previously, in commercial society, but they do so as the owners of a special type of property or capital of a peculiarly intellectual sort, the skills and knowledge acquired through their specialize training and experience.  This is sometime referred to as "human" as opposed to "physical" capital.

Like physical capital, human capital can be traded and like physical capital its security and negotiability depends upon a structure of legal definitions and procedures.

But the human capital of professionals is peculiarly depending upon the public legal acceptance of the value of services offered by the professional.  The professional's services are often beyond the lay buyer's ability to understand or fully judge.

There is, thus, an inescapable, reciprocal fiduciary relationship necessary between professional and client.  That is, the professional, including the group of professionals providing a certain service, must persuade clients to accept the professional's definition and valuation of that service even as the clients must acknowledge and trust the competence of the providers.

In this way, professionalism is always the result of a two-way process of social and political accommodation.  More than many other kinds of property, the human capital of professionals is visibly a social and, indeed, political artifact.  Hence, it can only be secured so long as, in the main, the terms of reciprocity seem fair to the public or the profession seems to be able to wield power to uphold its privileged position.

In this sense, the professions live a precarious existence in a democratic society, and I think it's for this reason that the ethic of professionalism has been so crucial in the development of professions in the United States.

It's Bruce Kimball who has traced the development of what he calls the true professional ideal through three historical stages, through a highly contingent process which only looks inevitable in hindsight.  Kimball shows how being a professional came to require the trades today most often identified by social scientists, for example, in studying professions.  That is, a profession is an occupation it's often said based upon formal knowledge and trained skill, organized in a collegial or guild-like way, and carried on in the spirit of service.

Kimball's work shows that the combination of knowledge and service came first, and this really lies in the fact that the first of the organized professions in America with high prestige, the one that approximated to what he calls "the true professional ideal in its time" was the ministry.  And this was in direct continuity with the medieval university, argues Kimball.

The minister in colonial and early republican America enjoyed high intellectual and social prestige and clergy were educated and credentialed in colleges such as Yale, Harvard, and what later became Princeton.  The ministry helped define what theologians at the time called dignified professions, continuing the medieval notion of profession as a religious calling to divine service.

In the new American republic, politics and law acquired enormous prestige through their central role in the new revolutionary order, and here Kimball argues we see a migration of the true professional ideal from the ministry to the law.  And it is from the law that the notion of vocation as marked by political and legal learning rather than theology derives.

In a constitutional order informed by theories of social contract, professional service came to mean contractual relations between a professional and a client.  The legal profession early organized itself into voluntary associations of the kind Alexis de Tocqueville saw as the distinctive feature of the American polity.  Yet it was still to be informed by the earlier ethic of selfless service.

These bodies of practitioners pledged themselves to both high standards of learning and to an ethic of public service.

The third stage in this development, Kimball argues, began early in the 20th century which saw a new configuration of prestige crystallizing around the natural and experimental sciences.  The sciences were then being institutionalized in the new American universities, and scientific expertise was beginning to shoulder aside legal and theological learning as the exemplary form of intellect.

As a result, first the professor as the expert within the new university system and then the scientifically trained physician emerged with new claims on the term "professional."  These claims were based upon the growing mystique of scientific knowledge.

In Kimball's account it was that notion of the professional which finally emerged a century ago that has become normative for Americans.  The professional, that is, was learned, but especially scientifically trained in a university setting, licensed, supported by a collegial organization of peers, and professed to an ethic of service both to clients, the legal inheritance, and the public, the inheritance of the ministry.

Now, these, of course, are ideal types.  They have never been realized in practice in any full sense, as I've tried to suggest.  But they have functioned, I think, as very important to the legitimation and, in fact, the guidance of professional life.  It's in that sense that they can be called moral sources.

The term "moral source" has been introduced by philosopher Charles Taylor, and I think it speaks well to the problem of professionalism today.  Taylor notes that increasingly modern moral problems involve not so much concern about heavy moral demands rooted in divine commands or nature, but rather the experiences of anomie and alienation when, as he puts it, the world seems to lose altogether its spiritual contour, producing a kind of vertigo, a fracturing of our world, even our sense of bodily integrity.

In order to maintain the sense of coherent identity and to act responsibly under such conditions, Taylor argues, it is essential to discover ways to articulate our sense of what is important and orienting for our lives, to articulate a sense of life, a framework for meaning.

Professionalism, as I've been arguing, is such a framework for meaning.  It provides an understanding of basic and determining values.  What professions should be, how professionals should conduct their lives; it provides the taken for granted expectations and norms about what is normal and desirable in the life of medicine, nursing, law, teaching, and so forth.

If Taylor is correct, the capacity of professionalism to inspire and guide individuals and professional groups depends upon its influence in shaping imagination and perception, in shaping the basic habits of professional life.  But normal sources become most effective when they function within ongoing institutions that echo and embody these moral meanings.  These institutions and their personnel become in a sociological sense carriers of the moral sources which they articulate.

What I have tried to suggest earlier is that it is just these institutions and their function as carriers of the ethic of professionalism which has been experiencing a kind of low grade erosion or slow crisis.

Therefore, my third point, the importance of strengthening professionalism.  It's not exaggeration, I think, to say that education remains a dominant feature of professional life even long after professionals leave the formal phase of training.  In order to make professionalism effective as a moral source revitalizing professional work, the connections between formal preparation and later experiences of practice have to be rethought for our time with perhaps a new emphasis upon the formative processes of professional life and education.

This will require more integration, more continuity between the concerns of the academy and those of the practitioner community.

In order to do this, however, it is important to recognize the complex and hybrid nature of today's preparation of future professionals.  The complexity of this problem, I think, can perhaps best be seen by recalling that professionals are trained in universities or university-like settings, and this is a process that began about a century ago, the movement of the professions into the university for reasons that Kimball's description of the new prestige of the universities and the sciences, I think, helps explain.

But it's important to recognize that once in the university, those who train future professionals now acquire a kind of dual identity, perhaps one might say a dual allegiance.  They are professors of law or medicine, but they are first and foremost professors of law or medicine.  As such, it is in many cases the values and the, to use another sociological barbarism, the career structure of the academy which dominates many professional lives.

This acquires importance because of the academy's own internal emphases.  The academy focuses, as I  think I don't need to elaborate, upon the development of systematic abstraction.  The great contribution of the modern university has been the development of modern science and a host of disciplines and subdisciplines in which this process of taking specific incidents and events and turning them into general rules and laws has been carried to an ever greater degree.

This is important, or at least we believe that it's important in most forms of professional preparation.  It's important to note, however, that professional education has its roots in a very different kind of experience, which is to say the experience of apprenticeship; that if we go back beyond a century ago — the case of medicine we actually would have to go a bit further into the 19th century, but in the case of law we don't have to go much further than a century — we discover that most professionals actually acquired their skills and knowledge and were admitted to their guilds largely on the basis of apprenticeship, which is to say that they learned and were socialized into their professions through the guild of practitioners.  In some nations this is still largely true.

In the United States, however, the practitioner guild, if we could call it that, has in many ways been held at arm's length by the academy.  This varies from field to field, but the mark of this, I think, is the enormous prestige given to academic research which in almost every field trumps clinical experience as the key denominator of prestige and importance.

So whereas once the aspiring professional met a kind of unified apprenticeship, often probably rather narrow and perhaps not enormously developed, today's professional student meets what I refer to as a kind of fractionated apprenticeship, at least three different kinds.

That is to say there is the apprenticeship of theory, which I've attempted to very briefly describe, but there is also very importantly the apprenticeship of practice.  And in medical education, this is very clearly marked by movement from one kind of educational experience to another, the traditional beginning of medical education in laboratory science and then the rather abrupt transition into the world of clinical practice.

But to this I think we have to add yet a third sort of dimension of apprenticeship, which was integral to the old unified form but which today is largely split off from both the academic or intellectual apprenticeship and the apprenticeship of skill in many cases, and that's the apprenticeship of professional purpose and identity.  This is the apprenticeship about which the public often is very concerned, but which necessarily, I suppose, in the logic of the academy, tends to receive the least attention.

So the argument I would like to put forward is that the route to strengthening professionalism and, therefore, of guiding or renewing the guidance of professionalism over professional life has to lie in the redevelopment and strengthening of the relationship among these three dimensions of today's professional apprenticeship.  And that is a task that will require the cooperation of both the academy and the practitioner wings of these fields.

Which brings me then to my conclusion, which for the sake of time I think I can state now rather quickly, namely, that in modern civil society no group or institution enjoys permanent guaranteed status.  Social relations remain open and fluid.  Professions compete with other professions and other organizations sometimes to the benefit of society and sometimes not, but what matters decisively is the prevailing climate in which this competition goes forward.

In this important sense, the whole, I think, is more than the sum of its parts.

The peculiar strength of strong civic cultures is, in fact, this holistic effect of widespread and pervasive forms of public cooperation.  The professions are integral parts of this process in the United States, and today's professions face, I think, not only changing domains of knowledge and shifting fields of practice, but also shifting conditions of practice within the dynamic and often confusing society.

Therefore, the horizons of the professions and particularly of the leaders of the professions need to be broad.  Petitioners must be able to think critically about their own situation and that of their field in relation to its defining purposes, and it is there that the ethic of professionalism and the elaboration or articulation of that ethic for new situations becomes critical.

To this end, the institutions or professional education, I think, must be made to model this and also to be better and more effectively linked to the later development of practice in its many dimensions.

So professionals above all need the ability to integrate a critical yet engaged standpoint into their guild's particular sense of knowledge, craft and attitude.

To preserve the professional social contract, we need to bring the perspective of the aware and critical citizen into the formation of the members of the community of practitioners.  The opposing poles of specialized expertise versus the broad sympathies needed for active citizenship define the tensions of professional life in our time.

But through its own inherent logic, a civicly attuned professionalism proposes an ideal of self which complements the need to achieve a positive outcome in today's growing social interdependence.  That ideal corresponds in one important way to the aspirations of the pervasive search for self-actualization and takes it beyond itself.  It demands of the individual a high degree of self-awareness and a major effort to develop one's powers, and these have been among the strongest contributions of professional life to our society. 

But then it demands more.  The goal of self-actualization itself must be transcended or perhaps better reoriented by integrating the goals of the individual practitioner with those of the larger professional community and, indeed, of the larger society.

The logical fulfillment of this process is a kind of character for whom what happens to these larger commitments is as important as what happens to the self or perhaps even more so.

This, I then would propose, is the outline of a kind of integrity of modern professional life, one which remains a viable possibility even if under heavy stress, and it's one that I think we have in time the opportunity to commit ourselves to anew.

Thank you.


CHAIRMAN PELLEGRINO:  Thank you very much, Dr. Sullivan.

We have asked first Carl Schneider to open the discussion.


PROF. SCHNEIDER:  First I want to say how very glad I am to have been asked to do this because I have been reading Dr. Sullivan's work almost since — this can't be true.  You're much too young for this — almost since I started teaching law.  Reconstructing Public Philosophy was a book that I read with pleasure and profit and still think about, which is remarkable considering how few of the books that I've read I can even actually remember how they read.

Let me start off.  I think I need to by saying that I believe in professionalism just as much as anybody in this room or this country, and that I believe it in many ways to be much more alive and well than many of the pessimists who have spoken so far today.  I know lots of members of both the legal and medical professions who strike me as embodying the nobler qualities that we look for in professionals.

I'm also puzzled that there is so much concern about how difficult it is to be truly professional.  It was never supposed to be easy.  Straight is the path and narrow the way.  Professionals always have operated under the kinds of economic pressures to go wrong that people are worried about now. 

Justice Holmes almost a century ago asked the graduating class at Harvard how they could hope to find a way of living greatly in the law when they to realize that law was a business, and he said it isn't easy, but it is possible.

The last prefatory remark.  I'm getting very nervous as a historian manqué about all of these historical generalizations.  I said something about it before lunch.  Let me say one more thing about it now.  I think in many ways the ethical standards we hold out for professions are higher than they used to be.  We may have just as many defaulters, but they may be defaulting from what is in some ways a higher standard.

Now, let me say that I'm responding here primarily to Dr. Sullivan's article "Markets v. Professions," because that's what I had to study before I came.  I want to suggest that the discussion may be helped by a higher degree of exactness, concreteness, and consideration of context.

So I'd like to begin by suggesting that one of the questions we need to be asking is: what is the problem that professions are facing exactly?  We have heard in a variety of forms, in the article I'm commenting on, and earlier today that the market is in some way disturbing our ability to be adequately professional.  But how exactly is that working?

One of the suggestions — this in the article — is that professionals have lost the confidence of the public and their trust, and that they are competing with people who are not members of the profession because professions have lost their professional authority.

Professionals have lost their professional authority.  Everybody has lost the trust and confidence of everybody else.  We live in a society in which people trust each other less and in which people trust institutions less and which people trust callings less.

I don't actually think that professions are particularly weakened in their ability to assert their authority as professionals.

The next suggestion is that professions are becoming businesses, and as I said before lunch,it's not so clear to me that there is actually any change.  I think it's very easy to perceive change because there is always an element of business and always an element of profession in any profession, and you look with dismay on the business side of it and forget that in the past that business side existed.

Now, the third possible thing that we may mean by the corruption of the market is that professionals are led to misbehave in some sort of way, and I take it that that is the purpose of the accountant example that Dr. Sullivan used.  And there are certainly misbehaving professionals. 

I remember just before I went to law school the problem with misbehaving professionals was Watergate.

The question then is what is the solution we're supposed to look to if professionals are misbehaving or otherwise being corrupted by the market, and this is where we have heard the invocation of the term "professionalism," a term that seems to me to have so many meanings that we can all love it, each in his or her different way.

I want to suggest that there are a lot of components that this professionalism might have, and here I'm just drawing on the article's apparent meaning in defining implicitly what professionalism might mean.

It might mean technical competence.  It might mean law abidingness.  It might mean obeying ethical rules.  It might be a concern with the just distribution of services, which we have a monopoly over.  It might mean participation as a citizen from the point of view of your profession.  It may mean sacrificing your client or your patient to some understanding of a broader public interest, or it may mean all of these things or some combination of these things or some combinations of these things plus some other things.

Dr. Relman correctly said this morning that any problem with professions is likely to be solved by a combination of three kinds of regulation:  self-regulation, government regulation, and market regulation.  None of these works very well.  Certainly none of them works across the board.

All of them have their virtues and all of them are present in the regulation of almost any profession I can think of.  There are a few exceptions.

We cannot avoid the market, as I think we agreed this morning, unless we return to the true meaning of an  honorarium, which was the amount of money that your client chooses to give you should your client choose to give you anything.

In the days before we had investors from the stock market investing in health care, we had doctors who were the investors in health care.  They were the ones who invested in themselves, who invested in their business and ran their business in order to get returns on their investments, and that produces its own kind of pathology.

And, indeed, we got to the managed care market because the fee for service market was seen to be injuring patients and society.

We are, in other words, driven to markets and to government regulation because the regulation of professions by professions has so often failed, almost necessarily fails because there is always a strong element of self-interest in the regulation of a profession when it's regulating itself.

Professions chronically and as nearly as I can tell universally, with one possible exception, do not discipline their own members with any kind of adequacy, do not get rid of the people who are incompetent and unethical with anything like the care that they should.

Professions speaking through their professional organizations regularly narrowly advance the interests of their own members, and Dr. Relman said earlier today that this may be doctors' last chance to really decide how their profession is to be regulated.  I believe they have already had their last chance.

Their last chance came probably decades ago.  I can  remember when I when I was a boy, since that is one of our topics of conversation, when the AMA made it clear that anything that moved toward socialized medicine was going to be opposed by doctors as vigorously as possible, and anything like any kind of insurance turned out to be a movement toward socialized medicine.

I think that when we think about why it is that government regulates professions, law and medicine particularly, more thoroughly through anti-trust laws, it is because the way that the professions behaved was not just regulating themselves in order to protect clients and patients.  It was using their ability of power over their members in order to keep prices up, in order to prevent groups of relatively poor people from forming groups to hire doctors on salary.

The case that people referred to this morning was a case in which lawyers were fixing the price of a very simple legal service across the board in that part of Virginia.

So I think that we have to face the fact that there are going to be regulations of professions in all of these kinds of ways, and the question then becomes what kind of balance do we have amongst these three kinds of regulations.

Now, the last question I think we have to ask is once we've decided on what kind of a solution to the problems of professions we want to adopt, we've got to decide how to implement that solution, and the modal answer to that question is education.  The modal answer to most questions in American life is education.

I am very touched and pleased at the confidence you all have in people who educate professionals.  I think it is a tiny bit exaggerated.  Let me try to suggest some of the reasons why you ought not to have so much confidence that I can fix things.

First of all, a lot of the problems with professions come because of external factors.  The market has been blamed for a lot of things.  In my instruction of my law students and my medical students and my undergraduates, I can't do anything about that.

Now, it might well be it's certainly more plausible to think that if the problem that we're really talking about here is a problem of professional misbehavior, of the Enron, Arthur Andersen, Watergate kind, that I ought to be able to do something about that by changing the attitudes that my students have.

But then I want to ask a couple of questions.  First, why is it that professionals do things that seem to us to be misbehavior?

Well, one of the reasons is because professionals being chronically in complicated moral situations often have to make choices in which they sacrifice some virtue.  In the accountant's and lawyer's situation and sometimes in the doctor's situation, you have to make a choice about whether to serve the moral duties you have taken on to your client or your patient or to turn you client or your patient into the law, and that is never going to be an easy kind of choice to make.

But that leads me to my second kind of problem.  One of the reasons that professionals misbehave is because people perceive the world in ways that are distorted by their own situation.  There is a very interesting and helpful article by a fellow named Bazerman called "Why Good Accountants Do Bad Audits," and he says that nobody who knows accountants thinks that the accounting profession is rife with crooks.  He says that the real problem is that if you are an accountant, you are very vulnerable to bias of an unconscious kind.  He says because of the often subjective nature of accounting and the tight relationships between accounting firms and their clients, even the most honest and meticulous of auditors can unintentionally distort the numbers in ways that mask a company's true financial status.

Even seemingly egregious accounting scandals, like Arthur Andersen's audits of Enron, may have at their core a series of unconsciously biased judgments rather than a deliberate program of criminality.

The third reason that professionals misbehave, I think, is because people respond to their situations more than they do to their own characters.  That is, I take it, one of the lessons of the famous studies that Stanley Milgram did, that people are much more motivated by the situation in which they find themselves and its incentives than they are by some character that they have.

Now, if those are some of the important, not all obviously, sources of professional misbehavior, it's worth noticing that these are sources that education can't do anything about.

Furthermore, the influence of education is limited in some important kinds of ways.  If you think that character is what is really important, you should realize that by the time I get them they're 25 years old, and their characters are probably shaped in very significant ways that I can't do a lot with.

Furthermore, however much I preach, however much I try to suggest to my students some of the important kinds of moral issues that will be at stake in their work, these will be abstract ideas that will very quickly be wiped away once the actual experience of practice starts, and I know of no evidence that the kind of professional education that we're talking about fixed professional misbehavior in either law or medicine, even though there have been serious efforts to make that kind of education work in both law and medicine for as much of history as I can personally remember.

I think that there is one way in which I might be able as a member of a law school to change people's behavior as incipient members of the profession, and that is by punishment.  When students cheat on exams, when students behave in seriously unethical ways, we could throw them out of law school and prevent them from becoming members of the profession, partly to eliminate people who will not be good members of the profession and party pour encourager les autres.  This is the last thing that an American law school is going to do.  It's the last thing that an American medical school is going to do.  It's the last thing that a profession wants to do with its own members.

So what I think would be the most important influence is the one least likely to be exercised.

I have to say that the calls for a broader kind of education, an education in liberal arts, an education that tries to get students to think about social justice in the broader moral aspects of their callings is a fine thing.  It's the way I try to teach, but if you think that that will make professionals the kind of people you want to see, then you should believe that we have now the kind of professionals that you want because that is exactly the kind of education that at least elite American law schools have been practicing at least 40 years.

The people who are lawyers now, the people who worked for Enron are the products of a system that educates people in the way that you're calling for.

That brings me back to professional autonomy and its failures.  Professions cannot reasonably be asked fully to regulate themselves, and that is why I think we need to think about what kind of balance of the three kinds of regulations you actually need in the specific context of each profession.

So I close as I started by saying I think we need to think with more exactness, concreteness, and more in terms of context about this problem than we have.

CHAIRMAN PELLEGRINO:  Thank you very much, Carl.

Would you like to respond, Professor Sullivan?

DR. SULLIVAN:  Very briefly because of the considerations of time.  Thank you very much for the very thoughtful response.

Just two points, I think.  The first is that I certainly don't want to imply that I'm opposed to a mix of regulatory strategy.  My purpose really was to defend the importance of professional revitalization, as it were. 

To put my cards on the table, the kind of problem which I was trying to suggest is more akin, I think, to the way in which we routinely think about other societies when we see them.  The classic case is always the description of old regime France where people say, "Well, it was just so venal and corrupt that they couldn't quite manage a reform."

And my fundamental belief is that the very nature of professional work is such that if there isn't, and I'm glad that we agree on this, that if there isn't a fair amount of this kind of sense within the profession, then really external regulation alone cannot do it.

So I was really only speaking of the professional part of that effort.  I mean, I think that that's a crucial and necessary one, and I think the second point I want to make is that I am not trying to make the claim that professional education sets people on a course for life which is going to be undeviating and uninfluenced by later development, but there is considerable empirical evidence that it's not so simple to imagine that students, as you said, arrive fully formed; that the best available evidence now is that that's really not so.

I mean, we know more and more about when people develop their (we would call it) moral conscience, and this even seems to be related to neurophysiological development, and it's interesting that the crucial moment for that actually is somewhere between 18 and 23, 24, where most societies have placed crucial things like ephebic training in ancient Athens and so forth, just at that point at which many people enter professional school.

So I wouldn't be so quick to dismiss that, and I think that if I was clear at all about the general view that I'm taking, you could begin to see what I meant about the way in which accounting, for example, could have gone wrong because of various influences that no one was perhaps individually to blame in a larger collective sense.

But there was a problem about not having the leadership or the conception of what they were doing that could have raised crucial flags, and I think the story that Paul Starr told 20 years ago about medicine has been borne out, that medicine's inability if not unwillingness, to really assume collective responsibility resulted in being regulated from outside.

DR. SULLIVAN:  I want to say thank you.

CHAIRMAN PELLEGRINO:  Thank you very much.

Are you responding, Carl?  I couldn't hear.

PROF. SCHNEIDER:  Oh, no.  I was just making a joke.

CHAIRMAN PELLEGRINO:  Okay.  I want to open it up to discussion now for the rest of the members of the Council.

Dr. Meilaender I saw first.

PROF. MEILAENDER:This picks up from a little different angle on Carl's request for specificity.  It's a little different angle, but there's a kind of a puzzle I have listening to your view, and one might put the puzzle simply by saying who is not a professional on your account. 

A professional presumably has something to profess, but it sounds as if what professionals profess on your account is just an ethic of  public service or something like that.

Almost everybody, I mean, you know, serving the public is not incompatible with making a living by doing it and so forth.  So you know, who claims to be interested solely in his own well-being?

The classical professions profess something much more specific than public service, you know, the good of health, the good of justice, the good of salvation, and so forth.

So that it just seems to me that if we're going to think about the professions today and whatever deformations they may have suffered, we need some more precise discussion of them than just the question of are they or are they not public spirited in order to kind of get at something.  It just seems too general to me in a way, but maybe I'm missing something.

DR. SULLIVAN:  That's a fair comment.  I was trying in a limited time to encompass a fair amount of territory.

In fact, you're right that these things have to be worked out within specific fields, but I do think that it's the case that the development of what we call the professions and which are recognized even in law in many cases as professions, in American history really does bear out the importance of this notion of public service.  It's public service precisely in responsibility for certain professions of purpose.

So I try to give illustrations about health and so forth.  So much so, I think, that to underscore a point I tried to make earlier, that it has been the organized health profession's apparent failure to, as it were, take leadership precisely around those issues that has annoyed the public in many cases; that it seems that the AMA, to take  a favor whipping boy of many people, which has actually lost membership in terms of the proportion of the profession who are now members, has simply been not a voice to talk about the larger functions of health in our society over the last 15 years, crucial years for the development of the situation of medicine in today's health care world.


PROF. MEILAENDER:If I may just briefly follow it up, I'm still not sure I see where this takes us.  You know, I don't do sociological studies of what people think, but I don't much care if my doctor makes more money than I do as long as my health gets taken care of, and I think there are rather a lot of people like that; that the problem they discern, they'll be concerned if something goes wrong with their health care, not with some general question about whether the profession of medicine is enriching itself.

So that it's a more specific focus on the quality of care than it is on, you know, being service oriented versus self-interest oriented.  I don't think that's what worries people.


PROF. DRESSER:  This is not your specific expertise, but it seems to me one of the worries in medicine today is about how industry, pharmaceutical companies and so forth through funding and other economic rewards to physicians and scientists have become part of the education and research missions of biomedicine.

It seems, based on my limited knowledge, to be a different kind of problem at a different scale at least than we've had in the past, but I'm not sure.  So I'd be interested in hearing comments about that.

But when industry inculcates itself into the training of professionals as well as how professionals carry out their work in research or medicine, is that something of special concern?

DR. SULLIVAN:  I think we have an expert witness.

CHAIRMAN PELLEGRINO:  We'll have to wait until tomorrow afternoon.

DR. SULLIVAN:  I can say one thing.  At the Carnegie Foundation my role really is to work with a variety of studies that the foundation has been doing on professional education, including the law and medicine, and that example is very striking.  Simply visiting a modern medical school, or for that matter a residency program, one of the most striking things to me was how much of the students and residents' lives were dominated, well, not dominated but let's say were accompanied by lunches and pizzas and all kinds of things provided, very clearly provided by what sometimes is referred to as "Big Pharma," and this is simply a part of the background of contemporary life, which suggests that at least to those corporations, professional education is very important for beginning to instill what they hope will be habits of connecting certain features of professional identity with their products over a lifetime.

CHAIRMAN PELLEGRINO:  If there are no other questions from the Council, Dr. Relman, I'll break a rule here if you'll be very, very brief.  The rule is that people who are not on the Council don't usually comment on the speaker, but I think because of this morning —

DR. RELMAN:  I don't want to violate your rule.  The question is: is it a problem that the pharmaceutical industry influences medical education at the graduate and postgraduate level?

I believe it's a terrible problem.  More than half of the cost of educating physicians in practice, so-called continuing medical education, now comes from the pharmaceutical industry.   Because of legal concerns about conflicts of interest and kickbacks, the pharmaceutical industry has been forced to separate its support of continuing medical education from the medical profession.

So in response to that need and in response to the opportunities for profit in health care, a whole new industry has arisen, one of the many new industries that has arisen around medical care.  They're called medical education companies, and there are dozens of them now.  They're sprouting all over, and their clients, their customers are the pharmaceutical industry.  They take money from the pharmaceutical industry. 

Company A says to Medical Education Company, "We would like to see you develop a program in the treatment of high blood pressure."  They happen to be manufacturers of pills to control high blood pressure.  "And so we'll give you the money, and we won't tell you what to do.  We won't tell what you should tell the doctors because that would be probably illegal now or unethical, but you understand," and the medical education company understands, "that if as a result of the money that we've invested in you in setting up that program, we don't see any effect on the sales of our product, we're not going to come back to you again."

So there's a very lively trade now.  I know a lot about this because I've devoted a fair amount of time watching it and seeing it.  There is clear evidence that this changes the behavior of doctors.  It changes the prescribing behavior of doctors, and it's a clear encroachment of the pharmaceutical industry on what should be the responsibility of the medical schools and the teaching hospitals.

I think it's a big problem.  I think it ought not to be allowed.  I've told the dean of my medical school that they shouldn't have anything to do with the pharmaceutical industry in this respect.  I've written about it.

The answer is money talks, and, "Dr. Relman, if we, the teaching hospitals and the medical schools and from the medical education companies and indirectly from the pharmaceuticals, who is going to pay for continuing medical education?"

That's the problem.  So thank you very much.


You had a comment?

DR. SULLIVAN:  No, thank you.  That was very well said.

CHAIRMAN PELLEGRINO:  Are there further questions?

(No response.)

CHAIRMAN PELLEGRINO:  If not, I think we will take a break for the next ten minutes because we have a program coming up and try to get back to our schedule.

(Whereupon, the foregoing matter went off the record at 2:37 p.m. and went back on the record at 2:51 p.m.)

  - The President's Council on Bioethics -  
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