• applied and professional ethics

In her paper ‘Why Not Common Morality?’, Rosamond Rhodes argues (1) that medical ethics cannot and should not be derived from common morality and (2) that medical ethics should instead be conceptualised as professional ethics and the content left to the medical profession to develop and decide.1

I have considerable sympathy with the first claim and have myself argued along somewhat similar lines.2 I am, however, very sceptical about elements of the second claim and will briefly explain why (see my 2011 paper in a somewhat obscure journal for a more in-depth argument3).

The first part of Rhodes’s constructive argument is to show that practising medicine is not only a role, it is something more. Medicine is a profession and as such its members have to internalise and personally endorse a specific ethics. Rhodes is careful to state that more work is needed to complete the justification for this claim, but the arguments she does provide are strangely ahistorical. First, it is not that long ago that what we now conceive of as one profession was actually two very strictly separated professions, that is, university educated physicians and apprenticed surgeons. Can we really be certain that medicine is now one, unified profession¹? Second the way butchers, bakers and candlestick makers are traduced is also oddly ahistorical. It is only fairly recently in many countries that anyone can butcher meat, bake bread or make candlesticks and legally sell the product to the public. Historically these trades have in Europe not been mere roles, but skilled trades that could only be pursued after a long apprenticeship and acceptance into the appropriate guild after proof of competence in the trade. It still takes 3½ years to train as a butcher in my native country Denmark and even longer to become a baker; skilled candlestick makers are unfortunately extinct. That belonging to these skilled trades was, and is not a mere role is also substantiated by the fact that it comes with a set of normative commitments in terms of how the skill is practised and how customers are treated. A set of commitments that the skilled tradesperson has to internalise to carry out the trade in the right way. The distinction between roles and professions is thus not nearly as clear cut as Rhodes makes out.

The second part of Rhodes’ constructive argument is even more problematic. Let us accept that medicine is a learned profession. Why should that lead us to the conclusion that deciding the content of the normative commitments of the profession and its members should be solely up to the profession? Rhodes offers the following argument from standpoint epistemology:

Medical professionals are the ones who define professional duties because they are the only ones who adequately understand what is involved, appreciate potential risks and benefits of their services, and distinguish competent practice from unacceptable performance. Therefore, the ethics of medicine is internal to the profession: It is constructed by the profession, for the profession, and needs to be continually critiqued, revised, and reaffirmed by the profession. (1, p. XX)

The first problem with this argument is that we have absolutely no reason to believe that the epistemological premise is true. It is highly implausible that a medical sociologist who embedded herself in a medical setting could not ‘adequately understand what is involved’ in practising medicine; and we have good evidence that when medical sociologists and anthropologists do embed themselves in this way they discover important things about the practice of medicine that most (and perhaps in some circumstance all) medical doctors have never realised. Think for instance of the oeuvre of Charles Bosk or the studies of medical communication in different contexts by Atkinson4–9 and many others. In the legal arena many jurisdictions have also moved away from accepting the claim that ‘Medical professionals […] are the only ones who […] distinguish competent practice from unacceptable performance’. This claim would certainly also come as a surprise to nurses and other healthcare professionals as well as to patients. Specific individuals in these other groups may not be able to make the distinction across all areas of practice, but they can definitely make it in some with which they are familiar. And, in total there may be enough knowledge and expertise in groups outside of medicine to make this distinction without medical input in every area of medical practice.

The second problem is that even if the epistemological premise is true, it does not justify the conclusion that ‘the ethics of medicine is internal to the profession’. Medical practice does not occur in solitude or in a vacuum but in a set of relationships that involve many other stakeholders than the profession, for example, patients, other health care professionals, health care institutions, funders of treatment and so on. Let us for the sake of brevity here just focus on a cornerstone in the medical philosophy, ethics and law literature the ‘doctor–patient relationship’. If we accept that medical professionals are the only people who can adequately understand the doctor-side of that relationship for the reasons given by Rhodes, we also have to accept by the same reasons that the only people who can adequately understand the patient-side are patients. But the ethics of the doctor–patient relationship must necessarily be based on an adequate understanding of both sides of that relationship, or it will not be able to adequately resolve the ethical conflicts that may arise within the relationship. It might be counter-claimed that doctors can understand and represent the patient view, but that undermines the whole argument from standpoint epistemology.

A separate problem is that there are many learned professions in the modern healthcare system.². Without expanding the concept of a learned profession in any way it is clear that nursing, physiotherapy and occupational therapy are now also learned professions (and there may be many more of which I am unaware). If Rhodes’s argument for the autonomy of professional ethics holds for medicine it also holds for these other professions. Given that the epistemic standpoint they occupy is different from the standpoint of medicine they are likely to develop professional ethics with a different content; and let us just note in passing that if they develop an identical professional ethics to medicine it undermines the claim that medicine occupies a unique or special standpoint which justifies giving the medical profession the unfettered right to develop its own ethics. If we have several bona fide but different professional ethics in the healthcare system they may come into conflict, and if they are all justifiably autonomous we do not have the resources to resolve those conflicts conceptually. We might then resort to process, for instance by claiming that medical professional ethics is always determinative. But, nurses and other healthcare professionals are no longer the handmaidens of physicians, and from a purely numerical perspective maybe we should let nursing ethics be dominant in the healthcare system and decisive when conflicts arise! (see also10).