PROFESSION AND PROFESSIONAL ETHICS

Among any society's most important institutions are the social structures by which the society controls the use of specialized knowledge and skills. This is particularly true when highly valued aspects of human life depend on such expertise, and all the more so if acquiring such expertise requires lengthy theoretical education and intensive training in its practical application under the supervision of those already expert, thus rendering the knowledge and skill in its application unavoidably exclusive.

Social control over the use of such knowledge and skills is important because the members of the expert group could use their exclusive expertise solely for their own benefit or even hold society hostage to their expertise. But those who might exert such control, if they are outside the expert group, cannot depend on their understanding of this expertise precisely because they lack the relevant knowledge and practical training. How, then, can a society control the use of important, specialized expertise and render those outside the expert group secure so that they will be able to enjoy the values that depend on it? One of the most important social structures developed to this end is the institution of profession.

In many people's minds, it is by publicly taking an oath that a person becomes a professional and acquires specifically professional obligations; and indeed the term profession does come to us from the Latin professio that comes in turn from the Greek verb prophaino, "to declare publicly." But it is not the oath that classically concludes professional training that creates professionals or produces their special obligations. It is in their presenting themselves to others as possessors and practitioners of a profession's expertise that they declare publicly that they are members of a profession and accept its ethical commitments as their own. The oath that many new professionals take is rather a reminder to those beginning professional practice that important ethical commitments go with it and a public assurance to the larger community by the new practitioners that they understand and accept this reality.

In the minds of many mature professionals, it was not the formal oath nor any other public activity that made them professionals, but rather their personal sense of vocation, of a calling or of being called, to this way of life. There is something truly admirable in this view of profession because professional practice is ethically challenging enough that only those with a deep sense of personal ethical commitment will manage its challenges well. But it would be a serious mistake to put all the focus on the person of the committed professional and none on the important social systems in which such a person functions. First, the content of the ethic of each profession—that is, the ethic that the committed professional is called to practice—is the content of an ongoing dialogue between the profession as a whole and the larger community within which it practices. Second, every professional's practice is necessarily practice in conjunction with someone served, frequently a capable, independent decision maker and always someone whose well-being is not fully defined by the values of the profession. The vocation or calling of the committed professional is precisely a social vocation, a calling to ethical relationships with those served in the context of the whole profession's proper relationship to the larger community.

The practice of specialized expertise and the special moral commitments associated with professional practice are what most differentiate a profession from other occupations. All the ways in which people spend their time earning a living involve skills and knowledge of value to others and involve relationships with others that have ethical significance, at a minimum the prohibition of coercion and the requirement that people honor their contracts that characterizes marketplace relationships. But the analysis just offered indicates that specifically professional practice involves a particular combination of institutionalized expertise and special ethical obligations over and above the obligations of the marketplace. It is these characteristics taken together that differentiate professions from other occupations.

The Key Features of a Profession

A few social philosophers and a large number of sociologists, following Émile Durkheim (1858–1917), a Frenchman, and Talcott Parsons (1902–1979), an American, have studied the institution of profession in depth and have attempted to identify its essential elements. This is not easy because so many groups have been eager to appropriate the title of profession in order to enjoy the social rewards that go with it. In addition, the terms profession and professional have both normative and descriptive uses in ordinary discourse. Nevertheless, by looking for common features among the most obvious examples of this institution, such as medicine, law, and dentistry, a useful listing of characteristic features is possible.

IMPORTANT AND EXCLUSIVE EXPERTISE. For an occupational group to be a profession, it must provide its clients with something the larger community judges extremely valuable, either because of its intrinsic value or because it is a necessary precondition of any person's achievement of valued goals, or both. Health and the preservation of life, to take two commonly identified goals of the health professions, are held by almost everyone to be values of the highest order, either as intrinsic values or as necessary preconditions of people's achievement of whatever else they value. In a similar way, security of one's property and person against the errors of others and against the adverse workings of government and the legal system, as one defensible description of the goal of the legal profession, is also widely valued as a precondition of achieving whatever other goals one has.

The expertise of a profession has both cognitive (theoretical and factual) and practical (the fruits of experiential learning) components that are of sufficient subtlety and complexity that only persons who have been specifically and extensively educated in them, by persons already expert, can be depended upon to bring about the relevant benefits for those whom the occupation serves. In the practical division of a society's labors, this makes possession of such expertise exclusive to a relatively small group.

Moreover, for the same reason, only persons fully educated in both knowledge and practice of a profession's expertise can be relied on to judge correctly the need for expert intervention in a given situation or to judge the quality of such an intervention as it is being carried out. Such judgments by those not so trained are not dependable. Because of the importance of what is at stake, it is not sufficient to judge the performance solely on the basis of its long-term outcomes, even when the nonexpert can accomplish such a judgment unaided. Long-term outcomes will not be known for some time, and the risk of negative consequences in the meantime, in a matter of great importance, is too great.

The expertise of a profession involves not only specialized and complex knowledge, both theoretical and practical, but also the application of this knowledge. This is the reason that mastery of a profession's expertise requires experiential as well as cognitive education. This is also why the members of a profession are said to "practice" its expertise. A profession is not made up simply of experts; it is made up of practitioners of a body of expertise.

INTERNAL AND EXTERNAL RECOGNITION. A profession, as an occupational group made exclusive by reason of its particular body of expertise, is also characterized by a set of internal relationships of which the most important is a mutual recognition of expertise on the part of its members. These internal relationships may remain informal or may become quite formal, as when a community of experts who mutually recognize each other's expertise establishes a formal organization. The expression "the profession of medicine" thus refers most properly to all those expert in the practice of medicine, mutually recognized as such by one another, within whatever geographic limits are relevant. This same expression is also used, however, to refer either to the chief national organization of such persons, the American Medical Association (AMA), or to some larger set of associations, including the AMA, to which physicians would likely belong. Nevertheless, it is not the formal character of association among experts, but the fact of their mutual recognition of expertise, that is most important here. Other expressions—for example, "organized medicine"—are available to refer to formally constituted groups.

The expertise of a profession is also recognized by the members of the larger community. This recognition may remain quite informal, or the external recognition of a profession's expertise may be expressed in formal actions of the larger community, such as certification, licensure, and so on, that confer formal authority in matters of the profession's expertise to an organized group of professionals. A group may be given, for example, exclusive authority to determine the degree of expertise needed by those who intend to practice it and to test the expertise of those who wish to do so. Such authorization often includes a grant of exclusive authority to train and certify new members of the profession as well. But, as with internal recognition, it is the reality of the community's recognition of the group's expertise that is essential to the character of a profession, not the degree to which it has been formalized.

AUTONOMY IN MATTERS OF EXPERT PRACTICE. Because the activity of a profession is so valued by those it serves, and because proper performance and dependable judgments about performance depend upon expertise that is unavoidably exclusive and therefore not available to the ordinary person, those served by a profession routinely grant its members extensive autonomy in the performance of the profession's practice. The term autonomy has a number of important uses in moral discourse and often appears when issues in bioethics are under discussion. Here, however, this term refers specifically to the acceptance by others of professionals' judgments as determinative on any matter that is within the range of the relevant profession's expertise. Such autonomy can characterize three kinds of judgments by professionals.

First, such according of autonomy depends on the assumption that each member of the expert community possesses the relevant professional expertise and is therefore a dependable provider of its benefits. Professional autonomy here extends to three arenas of professional practice: (1) determining the specific needs of the person seeking services in matters within the range of the profession's expertise; (2) determining the likely outcomes of various courses of action that might be undertaken in response to these needs; and(3) judging which of the possible courses of action is most likely to best meet these needs.

Consider, for example, the encounter between a physician or a dentist and a patient. The patient often accepts without question the doctor's judgments regarding these three things: (1) the nature of the patient's present condition and of the patient's need for care, if any (diagnosis); (2) the possible courses of action that might be undertaken in response and their likely outcomes (prognosis); and (3) the likelihood that one of these courses of action will meet the patient's needs better than the others (treatment recommendation).

In addition to these items, professionals also make judgments about the intermediate, instrumental steps involved in carrying out the chosen course of action. But these judgments can be and frequently are relegated to another party, such as a technician. Such a person, while capable of making judgments about properly applying instrumental actions already identified as needed, is not necessarily capable of dependably judging the need for these actions or which of the possible actions will best meet the need.

Although those who seek professional services ordinarily grant autonomy of this sort to the professional, they do not ordinarily do so simply on the basis of their individual judgments of the expertise of the individual professional. Instead they make their judgments on the basis of a more complex set of factors including the community's (external) recognition of the professional group's expertise and the professional group's (internal) recognition of the expertise of the particular professional. Thus, even though this grant of professional autonomy ordinarily takes place principally in the interaction of an individual in need and a particular professional, its full meaning can be understood only against the social background of the institution of profession.

A second kind of judgment sometimes accorded autonomy by the larger community concerns the various features of the situation in which the encounter between professional and the person seeking professional services takes place. Professionals often seek and the larger community and individuals seeking professional service often grant professionals considerable additional autonomy in determining the immediate circumstances of their practice.

The extent of this aspect of professional autonomy depends on answers to two questions: What aspects of the immediate circumstances of practice significantly affect the quality of professional performance? And what additional factors do members of the profession also prefer to control, either for their convenience or out of a conviction, possibly unexamined or even mistaken, that they affect the quality of professional performance?

For example, physicians, not their patients, typically control much of the daily routine of medical practice. In the marketplace, this control could easily be explained as the producers' control of the product they offer. But physicians ordinarily justify such preferred patterns on the grounds that they maximize their service to their patients. Patients in turn typically change their daily schedules accordingly even if they are doubtful that the inconveniences they accept are in fact the only way that physicians can best serve all of their patients.

Third, professionals' ability to make dependable judgments for their clients is also conditioned by other, still more remote situational factors over which professionals may seek, and the larger community may grant, some measure of control. To an even greater degree than autonomy in making practice judgments and in controlling the immediate circumstances of practice, autonomy of this third kind is ordinarily granted not to individual members of a profession but to organized groups of professionals.

For example, physicians' opposition to health insurance programs in the middle of the twentieth century and their later opposition to federally funded healthcare programs for the needy were efforts to preserve the medical community's then-preferred economic structure for healthcare distribution, namely, the fee-for-service marketplace. At one time, physicians also exercised almost total control over hospitals in the United States. They believed that their preferred economic and institutional arrangements for hospitals were the best way to produce healthcare for their patients. For a number of years, the larger community accepted this rationale and granted physicians a great deal of control of healthcare economics and healthcare institutions, with dramatic changes in this regard coming only in the last decade of the twentieth century. Regarding these changes, however, note that the lessening of physicians' control of these aspects of healthcare has not entailed any lessening of the professional autonomy of physicians in matters central to their expertise, the first category of professional autonomy discussed above.

THE OBLIGATIONS OF PROFESSIONS AND PROFESSIONALS. The final and, for present purposes, the most important feature of the institution of profession is that membership in a profession implies the acceptance by its members of a set of ethical standards of professional practice. Contrasting what may be termed a "normative" picture of a profession with what may be termed a "commercial" picture may make this point clear.

According to the commercial picture, practicing a profession is no different in principle from selling one's wares in the marketplace. The professional has a product to sell and makes the appropriate and needed agreements with interested purchasers. Beyond some fundamental obligation not to coerce, cheat, or defraud others, the professional would have no other obligations to anyone except those voluntarily undertaken with specific individuals or groups. According to the commercial picture, in other words, there are no specifically professional values or obligations in any profession. There is nothing to which a person is obligated precisely because she is a professional.

Some commentators consider the commercial picture to be an accurate description of what professions are like, whereas others maintain that professionals or the community at large would be better off if professions conformed to this view more thoroughly (Sade; Kuskey). But recall that all professional groups have a corner on some valuable form of knowledge within a society. Wherever this is the case, there is power—power to control the knowledge itself and, especially, power over the aspects of human life that depend upon this knowledge. Now compare how various powerful groups are dealt with in U.S. society. Contrast professionals with politicians, for example.

Experience has taught that politicians will be tempted to misuse their power. Consequently, Americans want to keep a close eye on them. This is arguably one reason why Americans accept without too much complaint the terribly inefficient system of periodic reelection, to take one example—the system enables the populace to keep close watch over those with political power. This may also be why Americans tolerate the excesses of a free press, because a free press means that it will be that much harder for politicians to misuse their power.

But the professions, though they do face some measure of regulation through licensing boards and the like, are subjected to remarkably little oversight in U.S. society. In fact, even when there is regulation, professions are generally regulated by their own members, not the larger community. How does the community assure itself that the power of the professions will not be misused? The answer is: by means of the institutions of professional obligation.

When a person enters a profession, he undertakes obligations, obligations whose content has been worked out and is continually being affirmed or adjusted through an ongoing dialogue between the expert group and the larger community. In other words, there are conventional obligations, over and above obligations incurred in other human relationships, that both individuals and groups have simply because they are members of a profession. Professions and professionals have obligations, and the content of these obligations for each profession comprise the "professional ethics" of that profession. In this way, the way in which a profession functions within the larger community is inherently normative. That is, the institution of profession is such that for each profession there are ethical standards that apply both to the actions of the whole professional group and to the actions of each member of the profession.

The Chief Categories of Professional Norms

Although most professions have articulated a code of ethics or other statement of the norms of their professional practice, such statements are never complete or fully authoritative. They are, at best, good partial representations of the content of the profession's norms and obligations. The full content of these norms is the fruit of an ongoing dialogue between the expert group and the larger community, on whose recognition of expertise and grant of professional autonomy the expert group depends for its status as a profession. Therefore, the effort to answer such questions as "What professional norms apply to this situation?" and "What is a member of this profession obligated to do in this situation?" must include asking what the larger community understands those norms and obligations to be, rather than looking only at the views of the professional group or some organization(s) within it.

Determining a profession's norms is therefore a much subtler enterprise than it might seem. Even the well-known moral categories of autonomy, beneficence, maleficence, and justice are only a useful starting point. Another way to examine a profession's norms is in terms of nine categories of professional obligation that have been identified from studies of numerous professional groups (Ozar and Sokol). Each of these categories provides a set of questions about a profession's norms for use in personal reflection on one's obligations, in scholarly study, and in professional ethics education.

Briefly stated, the nine categories of questions about professional obligation are:

1. Who is (are) this profession's chief client(s)?
2. What are the central values of this profession?
3. What is the ideal relationship between a member of this profession and a client?
4. What sacrifices are required of members of this profession and in what respects do the obligations of this profession take priority over other morally relevant considerations affecting its members?
5. What are the norms of competence for this profession?
6. What is the ideal relationship between the members of this profession and co-professionals?
7. What is the ideal relationship between the members of this profession and the larger community?
8. What ought the members of this profession do to make access to the profession's services available to everyone who needs them?
9. What are the members of this profession obligated to do to preserve the integrity of their commitment to its values and to educate others about them?

THE CHIEF CLIENT. Every profession has a chief client or clients, which is a category or categories of persons whose well-being the profession and its members are chiefly committed to serving. (The English language does not have a satisfactory generic noun to refer to the person or class of persons whom a profession serves. Beneficiary is etymologically correct but is clumsy and typically associated with trusts or insurance. Client is too commercial in its connotations, but it seems better than any other term for present purposes.)

For some professions, the identification of the chief client seems quite easy. Surely, one might say, the chief client of a physician and a nurse, for example, is the patient. But who is the chief client of a lawyer? Is it simply the party whose case the lawyer represents or to whom the lawyer gives advice? Lawyers are told and they announce in their self-descriptions and codes of conduct that they have obligations to the whole justice system; therefore, there are things that they as professionals may not ethically do, even if doing them would advance the situation of the party they represent or advise. So it appears that the answer to the question about the chief client of the legal profession is complex, involving not only the persons lawyers represent or advise but also the whole justice system and/or perhaps the whole larger community served by that system.

Once this sort of complexity about the chief client is noticed, even those cases that initially appear simple prove more complex. The physician and the nurse must attend not only to the patient before them, for example, but also to those in the waiting room or to the other patients on the hospital unit, and so on. In fact, they have some obligations to all the patients in the institution where they work, or to all their patients of record if they are in private practice. They also have significant obligations to the public as a whole; for example, they are obligated to practice with caution so as not to spread infection from patients they are caring for either to themselves or to other patients.

In all cases, this question about the chief client is one of the first questions that must be asked if a particular profession's obligations are to become clear: Whom does the profession principally serve?

THE CENTRAL VALUES OF THE PROFESSION. Every profession is focused only on certain aspects of the well-being of its clients. The professions' rhetoric to the contrary, no professional group is expected by the larger community to be expert in their clients' whole well-being or to secure for its clients everything that is of value to them. There is, rather, a certain set of values that are the focus of each profession's expertise, and it is the job and obligation of that profession to work to secure these values for its clients. These values can be called the profession's central values.

Most professions are committed to pursuing more than one central value for clients. For example, whatever other values are central for a given profession, the value of client autonomy is ordinarily a central value as well. Efficiency in the use of resources may have a similar standing. In any case, if there is more than one central value for a given profession, the question can then be asked whether these values are all equal in rank, or whether the members of the profession are committed to choosing them in some ranked order when they cannot all be realized at once.

For example, the values proposed as the central values that the dental profession is committed to pursuing for its patients, in order of decreasing importance, are: life and general health; oral health (understood as appropriate and pain-free oral functioning); patient autonomy (i.e., patient control), whenever practicable, over what happens to her body; preferred patterns of dental practice; aesthetic considerations; and efficiency in the use of resources (Ozar and Sokol).

Every profession needs to ask and answer the question: What are its central values? What specific aspects of human well-being is it the task of each member of this profession to secure for clients? And if there are more than one, which takes precedence?

THE IDEAL RELATIONSHIP BETWEEN PROFESSIONAL AND CLIENT. The point of the relationship between a professional and a client is to bring about certain values for the client that cannot be achieved without the expertise of the professional. To achieve this, the professional and the client must both make a number of judgments and choices about the professional's interventions. This third category of professional norms addresses the proper roles of the professional and the client as they make these judgments and choices.

At least four general models of such relationships can be distinguished:

1. In a "commercial model," only the minimal morality of the marketplace governs. In other words, neither party has any obligations beyond a general prohibition on coercion and fraud, unless and until individuals freely contract together to be obligated toward each other in specific additional ways.
2. In a "guild model," the emphasis is on the professional's expertise and the client's lack of it, so that the professional alone is the active member in all judgments and choices about professional services for the client.
3. In an "agent model," the expertise of the professional is simply placed at the service of the values and goals of the client without interference by any competing goals or values, including values to which the profession is committed from the start.
4. In an "interactive model," both parties have irreplaceable contributions to make in the decisionmaking process. The professional offers expertise to help meet the client's needs and has a commitment to the profession's central values, and the client brings his own values and priorities as well as the value of his self-determination. Ideally, the two parties judge together what professional interventions will most benefit the client and choose together to carry them out.

In addition, because the ideal relationship is described in regard to fully functioning adults, a profession's norms must also include how its members are to interact with clients who are not capable of full participation in decision making about professional interventions. Such clients might include children, the developmentally disabled, and persons whose capacity to participate is diminished by fear, illness, or other conditions.

SACRIFICE AND THE RELATIVE PRIORITY OF THE CLIENT'S WELL-BEING. Most sociologists who study professions mention "commitment to service" or "commitment to the public" as one of the characteristic features of a profession. Similarly, most professional organizations' codes of ethics and other self-descriptions give clients' best interests or service to the public a prominent place. But these expressions are subject to many different interpretations with significantly different implications for actual practice.

Consider, for example, what could be called a "minimalist" interpretation of this general norm. According to this interpretation, a professional would have an obligation to consider the well-being of the client as only one of the professional's most important concerns. This is called a minimalist interpretation because if any less consideration than this were given, the client's well-being could not be said to have any priority at all for the professional.

On the other hand, according to a "maximalist" interpretation, the professional has an obligation to place the well-being of clients ahead of every other consideration, both the professional's own interests and all other obligations or concerns that the professional might have.

It is doubtful that either of these interpretations accurately represents what the larger community wants or understands in this matter. Professional obligation almost certainly requires that members of a profession accept certain sacrifices of other interests in the interest of their clients. On the other hand, even if it were only for the sake of assuring a continued supply of professionals to meet its needs in the future, the larger community certainly would not actually require the commitment of a member of any profession to be absolute or to impose the utmost of sacrifices for the sake of the client's well-being in all circumstances. The actual content of professional obligation in this respect lies somewhere in the middle.

Each professional group therefore has, as an element of its obligations worked out over time in dialogue with the larger community, an obligation to accept certain kinds of sacrifices, certain degrees of risk in certain matters, and so on. For health professionals there is a degree of risk of infection, accepted in order to serve their clients. In other professions it may be primarily a risk of financial loss, social loss, or criticism. In any case, it should be a part of reflection on every profession's ethics and a part of all professional ethics education to raise this issue and to try to identify the kinds and degrees of risk that are part of that profession's obligations.

COMPETENCE. Every professional is obligated both to acquire and to maintain the expertise needed to undertake her professional tasks, and every professional is obligated to undertake only those tasks that are within her competence.

Competence is probably the most obvious category of professional obligation. It is also the easiest to describe in a general way. For if a professional fails to apply his expertise, or fails to obtain the expertise for undertaking some task, these failures directly contradict both the point of being an expert and the very foundation of the larger community's award of decision-making power to the professional in the first place.

But determining what counts as competence on the part of a member of a given profession, both in general and in relation to specific tasks, is a complex matter. In practice, and almost of necessity, detailed judgments about requisite expertise are left to those who are expert—to the profession itself. But the larger community usually requires that explanations be given regarding the general reasoning involved. In particular, the community should understand the risk–benefit judgments involved in every determination of minimal competence. For as the level of competence identified as the minimum acceptable in some matter is raised, the relative availability of that level of expertise to the profession's clients will fall, and these trade-offs should be made in dialogue with the larger community, not unilaterally by members of the profession alone.

IDEAL RELATIONSHIPS BETWEEN CO-PROFESSIONALS. Each profession also has norms, mostly implicit and unexamined, concerning the proper relationship among members of the same profession in various matters and also among members of different professions when they are dealing with the same client. Some elements of the proper relationship between a family practitioner and a renal specialist, for example, are not matters of etiquette, but they bear directly on the medical profession's ability to achieve its proper ends. The same is true of relationships between physicians and nurses, dentists and dental hygienists, dentists and physicians, and so on, when they are caring for the same patient, and between architects and engineers when serving the same client.

Some aspects of these relationships are dictated by each professional's obligation not to practice beyond her competence and so to seek assistance from other professionals when a particular matter requires expertise that the first professional does not possess. But other aspects of co-professional relationships are also governed by professional norms, though they are rarely explicit. For example, how should coprofessionals communicate with a client about their differing recommendations for the client when these differences derive not from differing interpretations of the facts, but from differing philosophies of practice within their different professions or from their professions' different or differently ranked central values?

THE RELATIONSHIP BETWEEN THE PROFESSION AND THE LARGER COMMUNITY. The activities of every profession also involve diverse relationships between the profession as a group, or its individual members, and persons who are neither co-professionals nor clients. These relationships may involve the larger community as a whole, various significant subgroups, or specific individuals. Every profession, precisely because it is permitted to be self-regulating, for example, owes the larger community the effort needed to carry out this task conscientiously. This includes providing and monitoring educational programs and institutions in which new members of the profession receive their formation as professionals; monitoring the collective activities of members of the profession in their various professional organizations to make sure that these organizations act in ways consistent with the other professional obligations of the members; and having measures in place to monitor and correct incompetent or other professionally inappropriate practice on the part of individual members of the group.

Each profession has an educational obligation to the larger community. The reason is that both through actions of its individual members and through collective actions, every profession functions as the principal educator of the community regarding those elements of the profession's expertise that the lay community needs to understand in order to function effectively in ordinary life. Thus, for example, the health professions have obligations regarding public education in matters of ordinary health self-care and hygiene; and the engineering and scientific professions have obligations to educate regarding safety practices that the lay community needs to know in daily life.

A more subtle kind of obligation in relation to the larger community has to do with the content of key value concepts that become part of the public culture and play crucial roles in people's private lives and especially in public policy, but whose content is significantly influenced by the members of a profession or of a group of professions. For example, the engineering professions have a powerful formative influence on the culturally dominant notions of safety and physical risk; the health professions are more responsible than any other group for educating the public about what it means to be healthy; and so on. This is an area of professional obligation to the larger community that has received little attention but is of continuing ethical significance.

ACCESS TO PROFESSIONAL SERVICES. Professional services are distributed within a society by a complex system of economic, legal, and social structures. These structures principally determine who in the society will have access to the services of the professions when they need them. But because every professional is committed to the values that are central to his profession, no professional can consistently be indifferent when a significant number of people in the society need professional assistance to achieve these values and their need remains unmet.

There is, however, no single best answer to the question, "What ought I do when the society's distribution system leaves people in need of my profession's services without access to them?" Individual professionals will respond to this aspect of their professional obligation in different ways. For some it will involve pro bono or charity service of one sort or another. For others it will involve advocacy for changes in the distribution system or for publicly funded programs to provide services for the underserved. Others may focus on the value judgments being made by public decision makers who are arguably giving too low a priority to the kinds of well-being the profession provides. But in any case, access to the profession's services on the part of those in the society who need them is a matter that deserves special notice and explicit attention in the articulation of every profession's ethic.

INTEGRITY AND EDUCATION. Finally, there is that very subtle component of conduct by which a person communicates to others what she stands for, not only in the person's acts themselves but also in how these acts are chosen and in how the person presents herself to others in carrying them out. The two words that seem to communicate the core of this concern are integrity and education, especially when the two words are paired.

Each profession stands for, or "professes," certain values that it is committed to bringing about both for its clients individually and for the community at large. But a professional's personal priorities may communicate a different set of values, even though the professional's choices of interventions for clients and his efforts to secure appropriate relationships with clients all conform to accepted standards. Concern with this kind of communication to their patients and to the general public, for example, motivates some health professionals to establish in their personal lives patterns of healthy living consonant with what they say to their patients. Failure to attend to this element of professional commitment also makes illegal personal activities on the part of lawyers somehow doubly wrong.

Professionals may be obligated, then, to do some things and to refrain from doing others in order to remain true to the values that their profession stands for and thereby to educate others in these values by their own example.

There are undoubtedly other useful ways of dividing the general topic of professional obligation besides these nine categories. The point is that conceptual tools such as the key features of the institution of profession and the principal categories of professional obligation can assist professionals in determining their own obligations in general and in particular cases, and can assist scholars and educators of professional ethics to gain a clearer understanding of professional practice and of the ethical standards that apply to it.

Alternative Views of Profession

The account just given explains the institution of profession in terms of its function in society, as a means by which a society secures the benefits of specialized expertise for its members and prevents or at least limits its misuse by those who possess it. Like every account of a thing's function, this account is both descriptive and normative. It describes how professions and their members act, at least for the most part, and it identifies sets of standards by which their successes and failures to act in those ways are to be judged.

The principal alternative ways of explaining the institution of profession can be described under four headings: historical, critical functionalist, radical democratic, and personalist. Each of these approaches separates the descriptive and normative elements that are interwoven in a functionalist account, with the first and second stressing the descriptive elements and the third and fourth the normative elements.

Historical explanations of the institution of profession identify, through historical study, a developmental pattern that brings an occupational group to the point of being considered a profession. This pattern is then used normatively to determine whether particular occupational groups qualify as professions and what patterns of conduct by these groups conform or do not conform to the pattern. Some historical studies of professions do not purport to explain the institution of profession, of course, but simply tell part of its story without attempting to draw normative conclusions. Historical explanations may depend, at least initially, on some functionalist account of profession or on the selection of certain occupations, in their contemporary form or otherwise, as endpoints or at least markers of the developmental process being studied. But once a developmental explanation has been formulated, it can then be offered to replace functionalist accounts on the grounds that these are excessively idealized and are not adequately descriptive of the current or historical conduct of relevant groups. For example, the medical profession in the mid-twentieth century has been described as the product of a process of monopolization, or gradual acquisition of control by an exclusive group over a segment of market activity over the years (Berlant). The institution of profession generally has been described as a specialized mechanism for maintaining economic power and class-based status and dominance (Larson).

Some critics of the professions formulate a functionalist account of the institution for themselves, or accept someone else's, and then use its normative content to critique current patterns of conduct of individuals and organizations within a particular profession or across the professions generally (Freidson). Other functionalist critics argue that currently accepted functionalist accounts are so idealized—that is, pay so little attention to the gap between what is described as the profession's function and the profession's actual conduct—that they leave unchallenged actual or potential harm to the community by the professions or at least do not call upon the professions strongly enough to correct their inadequacies for the community's sake. Therefore, an alternative account of the function of professions and professionals is proposed, and its implications for professional conduct are identified (Kultgen).

Radical democratic critics of the institution of profession believe that any society that accepts this institution makes a profound mistake. It is central to the institution of profession that the possession of expertise is a basis of power and that one element of that power is a grant of autonomy to those possessed of it. By institutionalizing deep inequalities of power and autonomy in this way, these critics argue, a society makes the achievement of genuine democracy almost impossible. According to the radical democrat, the failures in conduct pointed out by functionalist critics and the developmental patterns leading to monopoly and to other forms of economic and class-based inequality that the historical critics point out are not historically contingent events but the inevitable outcomes of the inherently undemocratic constitution of the institution of profession. For these thinkers the solution, on which the well-being of the human community depends, is to do away with the institution of profession and all other institutions grounded on undemocratic premises (Illich, 1973, 1976).

The personalist explanation of profession identifies the individual professional's act of personal commitment upon entering a profession as the basis of everything morally significant about the institution of profession. As centuries ago a solemn vow initiated a person's membership into a profession—a vestige of which remains, for example, in the ceremony in which new physicians speak the Hippocratic Oath—so today the act of personal commitment by each member of a profession is what brings the profession continually into being and gives it its character. The contents of a profession's norms are determined by the contents of these personal acts of commitment; and the professional who falls short in conduct fails above all to honor her own commitment to serve others, rather than failing to follow a norm created and sustained principally, according to the account proposed here, by the mutual effort of the profession and the community at large (Pellegrino; Pellegrino and Thomasma).

Each of these approaches stresses a feature of the institution of profession that standard functionalist accounts are held to overlook or underestimate: the developmental patterns by which professions and professionals are formed; the extent to which professions' and professionals' actual conduct falls short of the functionalist's proposed norms; the undemocratic character of exclusive expertise; and the centrality of the act of commitment by which a person becomes a professional. More complex functionalist accounts could incorporate much that is stressed in these other approaches, as more complex versions of each of them could incorporate emphases and concerns from the others. From the point of view of understanding professions as they exist, in other words, each of these approaches teaches something of importance and all deserve careful study.

Changing Times, Changing Standards, Changing Concepts

It is not only the conduct of individuals and groups, as measured by professional norms, that can fall short of what ought to be. Professional norms themselves can fall short of what they ought to be, particularly when important characteristics of a society undergo change. There was a time, for example, when the general level of education in the United States may well have justified an ethics in which the ideal patient–practitioner relationship for physicians and dentists conformed to the guild model rather than the interactive model, whereas the latter has become normative for these professions in the years since the 1970s.

A profession's norms and the institution of profession itself are human constructs and, like all things of human making, they can fall short of their intended goals, and the goals themselves can change with changing times. When norms and institutions are no longer able to do the tasks that a society needs them to do, then the society is justified in trying to change them. But social structures such as professions are inherently conservative, in the root sense of that word; they exist to preserve a mode of acting or of organizing conduct that has proven fruitful, and they preserve it by forming in their participants strong habits of perceiving, judging, and acting in ways that support it.

So when times and expectations change, or people's values or abilities change, or the surrounding social institutions change, then it is important to reexamine the relevant norms and institutions to see if they are still appropriate and to change them if they are not, even if this involves a major transformation of a particular profession's norms across many of the nine categories. One of the weaknesses of functionalist accounts of the institution of profession in the minds of critics is that such accounts seem to say that whatever is the case is what ought to be the case. But, like the other four approaches, the functionalist account is simply a conceptual tool whose purpose is to help a society understand what it has when it has a particular profession with a particular set of norms so that the society can then make a judgment on whether that is the profession that ought to exist.

In an analogous way, the new professional enters a profession whose norms are already in place. This does not mean that these norms cannot be changed, but they achieve their content by means of an ongoing dialogue between the profession and the larger community, and they change their content in the same way. So the new professional cannot create the contents of his professional obligations out of whole cloth. Yet, even in the individual case, the norms of the profession are not the ultimate determiners of right and wrong. If these norms are in conflict with one another or with other important moral considerations, or if they are severely defective in some way, then the professional must form his own conscience to decide how to act. Situations arise in which conscientious disobedience of a professional norm is what a person's moral judgment requires when all things about a situation are considered.

By what standards should a society judge a profession's norms when their adequacy to the society's needs is in question? By what standard should the institution of profession itself be judged? By what standard should the individual professional form her own conscience when conflict or severe doubt about the adequacy of a professional norm in a particular case suggests that conscientious disobedience may be the correct path? Surely not by the norms of the profession, because these are precisely what are being challenged when such questions arise. It is to the deeper values and standards of human conduct and social life that individuals must turn at such times, for it is upon them that the norms of professions rest for their moral force in the first place.

As is true for many other human institutions, if the institution of profession did not exist, it or something like it would need to be invented in order for people to live together effectively. For no one person can master all the knowledge and skills on which the achievement of so many important values in human life depend. But, like other human institutions, the institution of profession as a whole, and each individual profession, and each normative feature of each profession, requires regular ethical scrutiny to make sure it continues to fulfill the purposes for which it was made. One of the principal roles of the field of bioethics and its practitioners is to provide the members of the health professions and the larger community with effective conceptual tools to employ in this scrutiny.

david t. ozar (1995)

revised by author

SEE ALSO: Care; Compassionate Love; Competency; Confidentiality; Conflict of Interest; Divided Loyalties in Mental Healthcare; Impaired Professionals; Information Disclosure, Ethical Issues of; Informed Consent; Medicine, Profession of; Professional-Patient Relationship; Nursing, Profession of; Teams, Healthcare; Psychiatry, Abuses of; Sexual Ethics and Professional Standards

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