On the relationship between medical ethics and medical professionalism.

The Journal of Medical Ethics strongly encourages contributions from medical students, and is one of the very few journals that retain a separate section for publishing student papers. Reflecting our desire as editors to showcase rigorous analyses of practically relevant ethical issues in healthcare, students are often ideally placed to identify novel concerns that may have been taken for granted by more senior colleagues, and to put forward ethical arguments that are acutely sensitive to the day-to-day realities of practice in which they are learning their trade. In this issue, the ethical reflections by a student on what might seem a rather innocuous act—kissing the head of a child patient to console him after a failed attempt at cannulation—reveals some challenging questions about what it means to act professionally in a healthcare role. The article by Alamri (see page 636) and the accompanying commentary by Kerruish and Anderson (see page 638) develop arguments and counter-arguments that connect a number of points about whether such behaviours are acceptable when they take place between a healthcare professional and a child patient. One point that is immediately striking when beginning to analyse this issue is the relationship between a claim about the ethics of kissing the patient, and a broader claim about the student’s professionalism. We might disagree about whether giving the patient a kiss would be ethically justifiable. Equally, we might disagree about whether such a behaviour could ever be justifiable when performed by a healthcare professional, even if we broadly agree that it was ethically defensible to kiss the patient in this instance. This relationship between ethics and professionalism in healthcare is a complex one, as the analyses of this case illustrate. However, despite such complexity, there is a growing trend (particularly within medical education) to conflate these two concepts. It is not uncommon to find medical ethics curricula expanding to include professionalism as an additional body of knowledge that should be taught to medical students alongside medical ethics by medical ethicists. Equally, there have been recent developments in the UK by the medical regulator, the General Medical Council (GMC), that seek to foreground professionalism as a key focus for medical education, 4 with medical schools taking very different approaches to developing professionalism alongside ethics as an integrated or distinct educational track. It is important, therefore, to get clear on how medical ethics and medical professionalism interconnect. Providing clarity about this relationship in the medical education context can also assist in clarifying how ethical and professionalism claims relate when they are invoked to analyse ethical issues in medical ethical scholarship of the kind presented in this issue. One way in which the relationship between ethics and professionalism might be understood is to claim equivalence between the two concepts. Understanding professionalism as the straightforward recasting of ethics would make most sense in the context of medical education where it would operate as little more than a marketing strategy. This strategy could be justified by observing that there can, on occasion, be the misperception amongst medical educators and students that ethics education involves little more than reflecting on cases in ways that take into account the different values held by individuals in the classroom. Labelling ethics as professionalism in medical training environments makes it absolutely clear that medical ethics is a particular kind of professional ethics; that students (and indeed their more senior colleagues) need to grasp the specific duties they have within their professional role as doctors, and that they need to be equipped to make judgements that invoke these duties in practical decision-making contexts. One immediate concern is that, in the recasting process, the content of medical ethics itself is reformulated in ways that undermine its core purpose and value. The GMC’s recent professionalism drive in medical education risks erring in this way if it is not implemented carefully by medical educationalists. Much of the motivation for placing professionalism at the centre of students’ education looks to be derived from the belief that students are not behaving as they ought, and that it is important to maintain standards of professional behaviour and fitness to practice. The risk here is that medical professionalism reinforces the idea that ethics education ought to be narrowly focused on ensuring that medical students behave in ways that comply with the standards set by the professional regulator, and in line with broader legal requirements. Whilst it is of course important to ensure that students recognise which actions are lawful and unlawful, acceptable and unacceptable, and that they behave accordingly, the requirements of medical law and professional guidance largely incorporate sufficiently flexibility to allow students to reason between competing values and to make practical judgements that are defensible on ethical grounds. Equally, abandoning the focus on fostering ethical sensitivity and reasoning skills in medical students in order to ensure that students simply know the basics of what they are permitted to do, would be to neglect our responsibilities as educators in this setting. In contrast with interpreting professionalism in terms of compliance, a more contentful approach to making sense of professionalism is to take seriously the idea that professional role morality, enacted and performed as it is in a variety of socially and institutionally diverse settings, is one that needs to be fostered in ways that extend beyond merely exposing students to knowledge about the ethical duties that apply to their practice. As Buyx and colleagues (2008) argue persuasively, this focus on the importance of inculcating professional role morality as a central component of medical education gives rise to new foci: i) the explicit fostering of personal attributes (or virtues) that are recognised as being crucial to students’ forging their identity and behaviours as healthcare professionals, and, ii) the development of personal strategies of resilience that enable students to maintain such attributes when buffeted by the different psychological, social, economic and moral challenges that arise in their varied workplaces and across their careers. Buyx et al. (ibid) advance i) fidelity to trust, ii) benevolence, iii) compassion, iv) intellectual honesty, v) courage, and vi) truthfulness as those virtues that are widely accepted as being constitutive of role morality in medicine. Correspondence to Michael Dunn, Department of Ethox Centre, University of Oxford, Headington, Oxford, OX3 7LF, UK; [email protected]