The American Journal of Bioethics

The broad goal of medical education is to provide students with professional training; that is, to produce graduates with the knowledge and skills they will need to be good physicians. This entails helping students (including residents) to understand the content and the justification of their special responsibilities as physicians as well as to accept their professional responsibilities as important and overriding. It also involves promoting the development of habits of disposition and attitude that are essential to performance as a good physician; that is, the character (i.e., virtues) of a good physician and the development of skills to communicate competence, caring, and respect in their interaction with patients. In other words, medical education must acknowledge that its mission includes nurturing and evaluating medical professionalism and integrating ethics into clinical skills development (Moros and Rhodes 2002; Pellegrino 2002).

In that light, we agree with several of the points made by Delese Wear and Mark G. Kuczewski (2004). They are correct to note that reports arising out of the au courant interest in professionalism have produced lists of abstract characteristics that "have failed to create pedagogical practices" that are effective in promoting professionalism. Also, the reports do not provide "a curricular theory of professional development," and they do not address the importance of "the learning environment for professional development." Nevertheless, we take issue with Wear and Kuczewski's view of how to identify an appropriate theory and how to use it to guide medical education.

The Ad Hoc Approach

Wear and Kuczewski start by criticizing the ad hoc approach of distinguished medical societies in developing lists "of attitudes, values, and behaviors" that are essential components of professionalism. Specifically, they complain that these lists include "too many abstractions." To remedy these shortcomings, they suggest enlisting medical students and residents in the development of new ad hoc lists. We see no reason to expect novices to have greater insight than the experienced leaders in the field or any reason to expect a theory to emerge from a process designed to elicit a list.

Even though the lists developed by expert physicians do capture important and traditional values of the profession, we share Wear and Kuczewski's doubts about the experts' approach to articulating the content of professionalism. The reports by the learned medical societies inadequately explain the moral necessity of the attitudes and behaviors they identify. A theory is needed to provide an account of which characteristics are essential and why. The coherence conferred by theory also provides a means for resolving inevitable conflicts between principles and serves as a guide for nurturing professionalism.

Virtues

We take the core of Wear and Kuczewski's complaint about "abstractions" to be that the lists fail to distinguish general characteristics (i.e., virtues) that are ethically crucial for everyone from virtues that are particularly related to the ethical practice of medicine. Virtue is the inclination to feel and act as one should. Some virtues are necessary for moral action in general; others are special responsibilities for some, such as those in a profession (Pellegrino and Thomasma 1993). For example, everyone with enough understanding of the world to appreciate its inherent dangers can recognize that some degree of courage is required to do almost anything. Courage is needed by ordinary citizens (e.g., to fly in an airplane), by patients (e.g., to submit to endoscopy), and by physicians (e.g., to treat patients with SARS). Similarly, integrity, the virtue of abiding by one's moral commitments, is the mark of every morally upright individual. Integrity supports the person who donates blood, the patient who abides by disease-containment measures, and the physician who resists pressure to discharge patients prematurely. We certainly want doctors, like everyone else, to be courageous people of integrity. Yet, without some special justification, there is no...