Pellegrino defines professionalism as “those qualities and modes of conduct proper to professions.”1 In each patient encounter, the physician, as a professional, “professes” both technical competence and a commitment to use that competence in the patient’s best interest. A good physician is therefore characterized by virtues that enable him or her to achieve what he or she professes: benevolence, confidentiality, compassion, and courage are just a few examples.1 Specific to family medicine, Dr Cal Gutkin, Chief Executive Officer of the College of Family Physicians of Canada, has identified 6 “key principles and actions” of professionalism, including knowledge, commitment to ongoing education, evidence-based practice, liability, self-regulation, and the provision of “ethical” and “altruistic” care.2 Given that the qualities described above are noble and worthy of emulation, one might wonder why FPs do not agree on what professionalism is.
One explanation is the abstract nature of these qualities.3 The proper translation of them into practice is subject to both context and individual interpretation.
To whom do FPs owe duty?
Problems in clinical practice rarely have black and white solutions. They are often fraught with struggles to balance competing duties. In the case of filling out forms for limited-use medications, it is not uncommon to see FPs “stretching” criteria so their patients can obtain a more effective medication otherwise unattainable because of high cost. Some might argue that this represents a commitment to the patient’s best interest, but is it professional? Many FPs would say no. They would consider it an unjust allocation of resources and a threat to the sustainability of Canada’s health care system, not to mention that the practice involves lying.
The limits of altruism
Family physicians who worked on the front line during the SARS (severe acute respiratory syndrome) outbreak despite not having adequate information or protective gear are obvious examples of altruism in family medicine. Should all FPs be held to the same standard during future disease outbreaks in order to be considered professional? Some might consider it a necessary duty, but many will probably say no. It is not hard to conceive that some FPs might refuse to do so solely out of desire for self-preservation; nonetheless, many others might consider such a duty, although honourable, to be unreasonable—akin to expecting firefighters to go fight a fire without appropriate equipment.
Mediating the boundary between altruistic and reasonable behaviour can also prove challenging in seemingly mundane daily family practice. A typical example is the “1 problem per visit” rule implemented by some FPs as a necessity, not only for financial reasons, but also as a means to provide equitable access.4 Other FPs deem this practice unprofessional, as it violates the duty to care; they feel that a physician should just work longer hours or be content with suboptimal remuneration. Then there are urgent cases to be addressed, such as patients with acute illnesses or letters advocating delays in deportation, that get squeezed in through lunch or after hours. How much does a physician need to forgo his or her own interests to be considered professional? There is clearly no consensus on this question.
Checking values at the door?
Prioritizing competing values is inherent in every family medicine encounter. It is often recognized that patients and physicians might have different values relating to what is considered “good” or “good care.” The same differences also exist among FPs and can manifest as variation in services provided, such as the willingness or declination to perform or refer for procedures such as abortions, hymenoplasties, or cosmetic “enhancements.”
In 2008, the College of Physicians and Surgeons of Ontario’s draft policy “Physicians and the Human Rights Code” generated vigorous debate on whether physicians who decline to refer their patients for procedures contrary to their moral beliefs should be considered unprofessional.5 There are FPs who welcome this draft policy, as they believe that it will further the reproductive rights of women. The ability to control one’s fertility on demand is a “good” in this value system. To these FPs, the fetus is the woman’s property and its fate should be solely dependent on the disposition of its owner. Nonreferral for abortion is seen as an impedance of a woman’s autonomy and thus as unprofessional.
To FPs who believe that life begins at conception, for scientific or moral reasons, the fetus is not an “it” but a “him” or “her.” These physicians decline to perform or refer for abortions, as they feel an obligation to care for 2 patients—the mother and fetus—instead of the woman alone. To have to refer for abortion is to knowingly disregard that duty and intentionally inflict harm onto a patient by participating in the taking of his or her life. In this value system, one’s obligation to nonmaleficence trumps respect for autonomy. This is an example in which there is a stark contrast between what is considered professional between 2 groups of FPs.
Bottom line
Family physicians do not agree on what professionalism is. While some disagreement is based on self-preservation or health system reasons, some is a result of a genuine struggle to balance competing values and the ultimate desire to provide “good” care. These differences in concepts of professionalism should not be ignored but cherished as a part of the diversity in Canadian society.
Acknowledgment
I would like to thank the members of the Ethics Committee at the College of Family Physicians of Canada for their valuable ongoing discussion about ethical issues concerning professionalism in medicine.
Notes
CLOSING ARGUMENTS
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The lack of consensus on the definition of professionalism among FPs is multifactorial.
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Genuine struggle to balance competing values often underlies professionalism debates.
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Family physicians’ duties to individual patients and society can at times be at odds.
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Prioritizing these obligations on a case-by-case basis can produce varying responses to these dilemmas.
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Value systems with divergent concepts of “good,” “good care,” and “personhood” can lead to contrasting de nitions of professionalism. These differences are reflective of the diverse nature of Canadian society and should be cherished.
Footnotes
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Cet article se trouve aussi en français à la page 973.
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Competing interests
None declared
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