The Professional Status of Bioethics Consultation - Springer Link

DEBORAH CUMMINS

THE PROFESSIONAL STATUS OF BIOETHICS CONSULTATION*

ABSTRACT. Is bioethics consultation a profession? With few exceptions, the arguments and counterarguments about whether healthcare ethics consultation is a profession have ignored the historical and cultural development of professions in the United States, the ways social changes have altered the work and boundaries of all professions, and the professionalization theories that explain how modern societies institutionalize expertise in professions. This interdisciplinary analysis begins to fill this gap by framing the debate within a larger theoretical context heretofore missing from the bioethics literature. Specifically, the question of whether ethics consultation is a profession is examined from the perspectives of trait theory, Wilensky’s five-stage process of professionalization, Abbott’s interdependent system of professions, and Haug’s deprofessionalization thesis. While healthcare ethics consultation does not meet the criteria to claim professional status, neither could most professions pass these ideal theoretical standards. Instead of a yes or no dichotomous response to the question, it is more helpful to envision a professionalization continuum with sales clerks or carpenters at one end and medicine or law at the other. During the past decade healthcare ethics consultation has been moving along this continuum toward greater professional status. KEY WORDS: bioethics, clinical ethics, code of ethics, deprofessionalization, ethics consultation, health care ethics, professionalization, professional status, professions

INTRODUCTION Is bioethics consultation a profession? The impetus to professionalize would be superfluous if bioethics consultation existed only within the paradigm of medicine, that is, if only physicians offered healthcare ethics consultation.1 In that case, physician-ethicists could create a sub-specialty of ethics within medicine, but there would be no need to debate the merits of establishing a new profession. Likewise, professional credentials are less important to part-time ethics consultants under a multidisciplinary paradigm in which the ethicists’ primary identities as nurses, social workers, attorneys, or clergy are already well established. Because physician-ethicists, attorney-ethicists, or nurse-ethicists have a previously recognized professional status and a place in the hospital environment, they can function in the clinic as colleagues alongside other professional healthcare providers. Theoretical Medicine 23: 19–43, 2002. © 2002 Kluwer Academic Publishers. Printed in the Netherlands.

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On the other hand, full-time ethicists who have been educated as philosophers, humanists, theologians, historians, or, more recently, as bioethicists, have a stronger need to justify their presence “at the bedside” to clinicians. Some have argued that the perceived need for credentials and/or licensing originated out of a growing necessity to disqualify charlatans and to gain acceptance by other professionals in healthcare.2 As clinical ethicists have achieved greater independence and recognition, they have sought a larger measure of control in choosing colleagues and successors, as well as a clearer distinction between those who can claim to be healthcare ethics consultants and those who can not. Discussions about professionalizing bioethics emerged first in the hospital setting. So long as most nonclinician bioethicists limited their role to teaching in academic classrooms, the question of whether bioethicists should work toward professionalization remained moot. As more nonclinician ethicists began practicing in hospitals as consultants, the issue became more pressing.3 Judith Wilson Ross has observed that some bioethicists desired professional standing because of increased interactions with other licensed professionals.4 For members of this group, a degree, a license, or another type of credential would certify their expertise in healthcare ethics consultation and legitimate their claims as advisors who can help resolve problems that occur during the medical decision-making process. In this paper, I examine the question of whether bioethics consultation is a profession from a theoretical and sociohistorical perspective. I want to be clear that the focus of this analysis is on bioethics consultation, whether practiced by individuals, teams, or committees, and not the entire field of bioethics. With few exceptions, the arguments and counter-arguments about whether healthcare ethics consultants should seek professional status have ignored the historical and cultural development of professions in the United States, and the ways that social changes have altered the work and boundaries of all professions. Additionally, the discussion to date has failed to consider the vast literature on professionalization theories that explain how modern societies institutionalize expertise in professions. This paper begins to fill this gap by framing the debate within a larger theoretical context heretofore missing from the bioethics literature. I first examine the question of whether bioethics consultation is a profession from the perspective of trait theory, by comparison to Harold Wilensky’s model of professionalization, and in the context of Andrew Abbott’s system of professions. Recognizing that professions do not emerge in a vacuum and that the social and political environment that pushed many occupations to become professions in the past has changed, I also explore whether Marie Haug’s deprofessionalization thesis has

PROFESSIONAL STATUS OF BIOETHICS CONSULTATION

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a bearing on the status of bioethics consultation. While the trait theorists, Harold Wilensky, Andrew Abbott, and Marie Haug have published extensively on the subject of professions; to my knowledge, they have never published anything on the subject of bioethics consultation. I have borrowed their concepts for this analysis of the professional status of healthcare ethics consultation. Please also note that in this essay I am using the terms bioethics consultant, ethics consultant, healthcare ethics consultant, and clinical ethics consultant interchangeably.

TRAIT THEORY OF PROFESSIONS Eliot Freidson, who has generally been regarded as a major analyst of the profession of medicine, once observed “it would be folly to be dogmatic about any definition of ‘profession’ or to assume that its definition is so well known that it warrants no discussion.”5 In keeping with Freidson’s advice, this analysis begins with a brief discussion of key characteristics identified with professional status by most trait theorists. At the most basic level, a profession is an occupation that is set apart from other occupations. But what features, traits, or characteristics set it apart? For many decades, discussions among trait theorists have focused on how professions should be defined, which occupations could legitimately be called professions, and what criteria should be used to support this judgment. Many social theorists believed that the way to determine if an occupation could be categorized as a profession was to determine how closely it resembled known professions, such as medicine and law. In early articles on the professions, social scientists summarized the history of an occupation as a case study, reviewed a list of essential traits of a true profession, and then decided whether a particular occupation was a profession based on how many of the essential traits it possessed.6 Numerous lists of the attributes of professions were created and multiple definitions were reported in the literature.7 Specialized Knowledge as a Trait of All Professions Max Weber was one of the first theorists to compile a list of traits to describe professionals. He emphasized that professionals have a high degree of knowledge, and the ability to apply this special body of knowledge in a way unique to a particular profession. Therefore, Weber’s list of professional traits, as well as most other lists that followed, included the use of a specialized vocabulary and the possession of technical knowledge.8 For Weber, all of human history could be conceptu-

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alized as the progressive rationalization of the world. He therefore envisioned professionals in increasingly formal, bureaucratic, and hierarchical environments working to achieve the ultimate goal of maximum efficiency. Weber theorized that professionals would use their specialized knowledge to enable persons to function in an increasingly bureaucratic and dehumanizing society. Contrary to the esteem accorded to professionals in subsequent decades, Weber had little regard for these professional experts whom he described as “specialists without spirit, sensualists without heart.”9 In later decades, the perception of the professional improved, but a core attribute remained the possession of specialized knowledge and skill validated by a community of their peers. Moreover, society must value and depend upon the professional’s specialized knowledge. Paul Starr later argued that the power of professionals originates in our dependence upon their knowledge and competence to interpret our understanding of the world and our own experience.10 Other Professional Traits: Service Orientation, Lengthy Training, and Self-regulation Talcott Parsons’ list offered the following characteristics as means to differentiate professions from occupations. First, professions must possess an orientation toward the collective good; second, professionals require a long period of adult training, and third, professional organizations must have the ability to set their own professional standards regarding membership requirements.11 In a similar formulation, William Goode identified the two core characteristics of a profession as: a prolonged specialized training in a body of abstract knowledge, and a collectivity of service orientation.12 From these two core characteristics, he derived ten additional characteristics, several of which cluster around autonomy. These include: the ability of a profession to determine its own standards of education, the capacity to self-regulate entry into the profession by having members of the profession serving on licensing and admission boards, and the power to be relatively free of lay evaluation and control. Although theorists continued to debate about the priority of one trait over another and have argued about which additional traits are required to constitute a profession, there is an underlying agreement that professions must have specialized knowledge, a service orientation, lengthy training, and the power to self-regulate. Professional Dominance and Vocational Status Suggested as Traits of Professions Freidson began his discussion of the medical professional with the broad distinction between professional and amateur, a distinction which Freidson


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viewed as that between work, tied to its exchange or market value, and non-work.13 Like Goode, he defined a profession as an occupation that has achieved autonomy, that is, achieved the ability to independently manage both the clients and their problems in its own way. He also placed primary importance on obtaining a dominant position within a hierarchical division of labor, thereby achieving self-direction and a reputation as the most reliable authority in one’s field. Freidson also recognized that the word “profession” has two meanings: it refers to a special occupation, and to an avowal or promise. He argued that professionals must embody both meanings. Everett Hughes agreed and further stipulated that genuine professions are vocations, or callings, in which special knowledge is applied to the affairs of others14 Hughes wrote, “In the classic sense being a professional implies a publicly declared vow of dedication or devotion to a way of life. It implies a special knowledge not available to the average person; it is an unequal relationship.”15 Thus, for many trait theorists, a profession was more than a job or an occupation; it became a way of life that provided an identity and increased status for the professional.

The Professional “Mystique” Consensus grew around some traits, such as specialized knowledge, training, autonomy, and a service orientation, and these characteristics were repeated on many different lists. In 1982, Starr synthesized these traits into the following definitional statement: A profession is: “an occupation that regulates itself through systematic, required training and collegial discipline; that has a base in technical, specialized knowledge; and that has a service rather than profit orientation.”16 However, many theorists noted that some occupations possessed all of the traits on a list yet they were unable to achieve professional status. Some theorists began to search for that elusive, distinctive trait that, when combined with other known characteristics, would tip the scales. An example of one unique trait proposed by some theorists to delineate professions from occupations is “professional mystique.” Moore has claimed that professionals strive to maintain secrecy over the exact procedures and knowledge they use to increase their power over laypersons. “The physician uses mysterious procedures in diagnosis and therapy, . . . the chemist performed experiments of mystifying complexity; . . . and social scientists, [are] perhaps most vulnerable to the charge of deliberate mysticism.”17 Similarly, Peter Cleaves has argued that this mysterious power is more than the obvious knowledge gap between the lawyer and client, or the doctor and patient. Professional mystique refers,

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instead, to the way that laypersons think of a particular profession as something beyond their comprehension. The importance of this “mystique” to the profession of medicine was explained to a medical student by the Chief of Medicine in the first chapter of Howard Brody’s The Healer’s Power. People are not supposed to be able to understand miracles; and so a place in which they can hope for a miracle must be a place shrouded in mystery. . . . Our talk must be mysterious; our writing must be mysterious and illegible as well. We must walk down the hall as if we were always pondering mysteries or on our way to perform miracles; no one must be allowed to ask us a question or engage us in light conversation without worrying whether some other poor mortal is being allowed to creep a bit closer to the brink of death because our tasks were interrupted18

Cleaves, Moore, and other trait theorists have claimed that mystery surrounds professionals in medicine, science, law, and religion, because these are the subjects that shape our world and deal with matters beyond our control and comprehension. Cleaves summarized this belief when he wrote, “a profession is a privileged occupation with mystique.”19 On the other hand, deprofessionalization theorists such as Haug (discussed later in this paper) argue that professions have lost their mystique in today’s society. Does Bioethics Consultation Possess These Professional Traits? Many overlapping inventories of the elements, traits, and attributes of professions have been created. No single authoritative list has emerged, yet the previously described traits – specialized knowledge, lengthy training, service orientation, autonomy, professional dominance, a vocation or calling, and professional mystery or mystique – have repeatedly occurred on multiple lists. I now ask, does the practice of bioethics consultation possess these seven professional traits? If the answer is yes, can it then claim professional status? First, a common body of knowledge has been accumulating in the field of bioethics over the past two decades. Landmark court cases, ethical theories and principles, and facilitation techniques are part of the specialized knowledge of bioethics consultation. Second, many practicing bioethics consultants have undergone years of lengthy training in graduate and postgraduate education and training, but there is not yet any requirement that all must do so. Some bioethics consultants begin practicing with only minimal training, or by completing an informal education program or a program of self-study. The third trait is evident. Because practitioners serve the interests of clients, patients, or others, healthcare ethics consulta-


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tion is an activity that embodies a service orientation, as contrasted to a profit motive. Fourth, has the practice of bioethics consultation achieved professional autonomy? Professions with autonomy are self-regulated; the members set their own standards of education and training, and control who can practice. As an organized group, healthcare ethics consultants do not have autonomy, but neither have they been denied autonomy; that is, no outside group is imposing standards on bioethics consultants. I can only conclude that, at this stage of development, it is too soon to know whether clinical ethicists will achieve professional autonomy. Fifth, it is also not yet known if ethics consultants will emerge professionally dominant over competing paradigms. For example, if either the medical profession or the discipline of philosophy were to gain control over the practice of bioethics consultation, then it would become a subspecialty with no possibility of professional dominance. Sixth, modern professions do not typically invoke the language of a vocation, or calling. Nonetheless, members of professions have continued to make lifelong commitments to its activities, values, and principles. Thus, professionals acquire an enduring identity and status. While it is true that some healthcare ethicists have taken on the identity of a professional bioethics consultant; it is also certain that in this multidisciplinary practice, most practitioners consult as a peripheral activity, or as a vaguely defined extension of roles in their primary profession, which might be as an attorney, physician, or educator. Bioethics consultants would acquire a distinct mode of thinking and a unique perspective if the various disciplines would become integrated into a new creation with an agreed upon set of skills, standards, education, training, and practices. Finally, what mystery or mystique is part of the practice of healthcare ethics consultation? What is there that bioethicists do or know that laypersons would regard as “beyond their comprehension?” This trait, professional mystique, may be the most controversial because, in a democratic society, ethics is everyone’s responsibility. So, in the sense that we are all called upon to make moral choices, how can there be anything mysterious about it? However, it is not the role of the healthcare ethics consultant to make moral decisions, rather, she must acquire the skills necessary to facilitate moral discussions, to interpret participants’ positions to each other, to discern the values at stake, and to assist others in making medical moral choices. Consequently, one role of the bioethics consultant could be stated as that of demystifying medical authority. How this is done may seem somewhat mysterious to laypersons. I conclude, therefore, that the evolving practice of bioethics consultation possesses some but not all the traits thought to be needed to become

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a recognized profession. In my judgment, so long as bioethics remains multidisciplinary, it cannot strive for separate professional status because it will not have a unique identity necessary for professional autonomy. On the other hand, even if bioethics consultation possessed every trait on every trait theorists’ list, professional status would not be guaranteed. As previously noted, trait theorists have had difficulty denoting a clear boundary that separates occupations from professions.

WILENSKY’S PROFESSIONALIZATION MODEL In “The Professionalization of Everyone,” Harold Wilensky asked, “What are the differences between doctors and carpenters, lawyers and autoworkers, that make us speak of one as professional and deny the label to the other?”20 Harold Wilensky observed that while the same traits were on most lists, they could not be used to accurately determine which groups had professional status. He therefore chose the different strategy of examining the process of professionalization.21 Instead of a focus on the individual characteristics or traits of professionals, Wilensky turned his attention to a search for a common story that all occupations could tell about how they had become a profession. He began with the premise that thousands of occupations sought professional status but only a few attained it. He attempted to discern a pattern that mapped the professionalization route. Wilensky wrote: Can a comparison of the few occupations which are clearly recognized and organized as professions tell us anything about the process of professionalization? Is there an invariant progression of events, a path along which they have all traveled to the promised professional land? Do the less-established and marginal professions display a different pattern?22

Wilensky generated a model consisting of the following five stages: (1) working full-time, (2) establishing training and education requirements, (3) forming local and national professional associations, (4) being licensed by states, and (5) formalizing a code of ethics.23 Comparing Bioethics Consultation to Wilensky’s Model How does the practice of healthcare ethics consultation compare to Wilensky’s model? The first stage, according to the model, is that members of a profession work full-time “at the thing that needs doing.”24 This criterion was designed to separate professionals from amateurs, or from ancillary members in a field. Wilensky defined professions as fulltime occupations that provided “the principal source of their members’


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incomes.”25 Yet, relatively few bioethics consultants are employed fulltime as consultants. The majority are either unpaid volunteers, adjunct ethics committee members, physicians, nurses, or social workers who do consultations “on-the-side,” humanists who are teachers or researchers first and consultants second, or hospital chaplains. This first criterion has not been met. Wilensky’s second stage was that professions established requirements for training and education. He contended that all professions possessed specialized or esoteric knowledge or skills that were acquired through training or education of lengthy duration. There are numerous training programs in bioethics consultation, but no established educational requirements. Even though the SHHV-SBC Task Force issued a report on core competencies for healthcare ethics consultants, it only called for voluntary compliance to the guidelines.26 Consequently, there is great diversity and no clear standard from institution to institution. For instance, while some healthcare ethics consultants are trained in one-year or two-year postgraduate fellowships, others may only attend a two-week intensive seminar. Additionally, the Task Force Report acknowledged that “core competencies can be acquired in various ways” and specifically rejected the need to recommend establishing a certification process for individual ethics consultants, or an accreditation process for programs that train clinical ethicists. In my view, the practice of bioethics consultation does require special knowledge and extensive training, but unless the educational and training requirements are institutionalized in some way, it will not meet Wilensky’s second criterion. Wilensky’s third criterion was that professionals create local and national associations and engage in an explicit attempt to separate competent practitioners from incompetent practitioners. “Members of professions organize associations to serve two purposes: to protect and enhance their own interests and to establish and uphold standards to protect the public.”27 A national organization for ethics consultants, the Society for Bioethics Consultation, was created in 1986. In 1998, it merged with two other national bioethics associations, the Society for Health and Human Values and the American Association of Bioethics, to form the American Society for Bioethics and Humanities. While it is true that consultation no longer has a separate national organization; it is equally true that merging three distinct groups into one professional organization can be interpreted as strengthening the professional identity of bioethics. However, no attempt has been made to restrict membership in any of these organizations on the basis of competence in bioethics consultation.

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Fourth, Wilensky’s model stipulated that states establish licensing regulations for professionals. No states require bioethics consultants to obtain licenses. Legal regulation of a profession is a way for society to recognize the value of the service provided by the profession, as well as a means to limit who can practice.28 At present, there are no plans for states to license healthcare ethics consultants. And, fifth, according to Wilensky’s model, all professions establish a formal code of ethics. Although bioethics consultants have not adopted a code of ethics, the topic has sparked a debate among bioethicists, which I examine in the next section. Giles Scofield, an attorney, has written that bioethics consultation appears to be headed toward professionalization and questioned whether this was a self-serving act by bioethicists, or for society’s benefit. Scofield wrote: With the proliferation of programs that train clinical ethicists to be consultants, the emergence of the Society for Bioethics Consultation, and the creation of the Journal of Clinical Ethics, ethics consultants look, sound, and act like true professionals. It is only a matter of time before the need to accredit teaching programs, credential graduates, license practitioners, and grant staff privileges to ethics consultants surface as serious questions. Each of these questions raises a larger one, which is whether society should recognize ethics consultants as the professional experts they claim to be29

Acceptance by society is indeed an important issue. Recognition by others, particularly official societal institutions, would strengthen a claim of professional stature. Cultural legitimation plays a central role in the professionalization process.30 To summarize, Harold Wilensky enumerated a process of five steps in an occupation’s quest to achieve professional status. Bioethics consultation has not fulfilled several of these conditions. It should be kept in mind, however, that Wilensky never intended this model to be used as a litmus test for professions. In fact, he noted exceptions in both directions, and provided examples of established professions that did not fulfill all five steps, and occupations that did complete each step but never achieved professional status. Thus, any expectation that forming a unified national organization, establishing educational standards, writing a code of ethics, and so on, will automatically result in the professionalization of healthcare ethics consultants is misguided.

A CODE OF ETHICS FOR ETHICS CONSULTANTS? In general, professional codes of ethics are designed to promote exemplary behavior, discourage inappropriate practices, and protect the recipients of the services being rendered. Professional codes of ethics are not


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intended to convey ultimate truth or provide ready-made answers for ethical dilemmas. Whether a code of ethics specific to healthcare ethics consultation should be established is a subject that has received considerable attention among bioethicists. Benjamin Freedman was one of the first scholars to argue for the formulation and adoption of a code of ethics for healthcare ethicists.31 His proposal has generated significant discussion within the bioethics community. Some bioethics consultants have asserted that because they belong to other professional organizations with well established codes of ethics, there is no urgent need for an additional code of ethics written specifically for ethics consultation. In my view, relying on codes written by the “feeder” organizations of consultants (i.e., medicine, law, nursing, etc.) is inadequate because these codes do not address particular concerns related to the evolving practice of bioethics consultation. Michael Yeo, in “Prolegomena to Any Future Code of Ethics for Bioethicists,” took the position that adopting a code of ethics for healthcare ethics consultants should be delayed until a day in the future, after a consensus is reached on a multitude of unresolved issues related to ethics consultation. Yeo wrote, “Although I am open to the idea of a code of ethics for bioethicists, I am concerned that adopting a code might bring about a premature closure on certain important questions that have not yet been sufficiently explored.”32 I disagree. Yeo’s concern that it would be unwise to adopt a code before issues are settled is not entirely valid because codes are not static and can be revised as new concerns arise. The primary reason for establishing a code of ethics for healthcare ethics consultants would be to establish ethical criteria for a practice that places its practitioners in relationships with patients, families, healthcare providers, and managed care organizations, among others. In the consulting role, bioethicists are expected to put the interests of others ahead of their own motives, needs, and interests. Additionally, healthcare ethics consultants have access to privileged and confidential information. Developing a statement with direction about these and other issues would provide guidance from the larger group to individual practitioners. One outspoken critic of this failure to establish a code of ethics is Scofield. He commented, “Ethics consultants do not even have a code of professional ethics, which makes it impossible to know how trustworthy and honest they expect themselves to be, much less to determine whether the standards they set for themselves are acceptable to society.”33 This view fails to consider that it would be possible to set standards without writing a code of ethics.34 In a response to Scofield, John Fletcher agreed that bioethics consultants should establish standards, but he objected to

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the idea of writing a code of ethics “because professions or subspecialties may have such codes, and clinical ethics is neither.”35 While Fletcher is correct in observing that professions and (medical) subspecialties have codes of ethics, it is equally true that many other groups, such as newspaper editors,36 little league baseball coaches,37 and magicians,38 have also adopted formal codes of ethics. Thus, an organization is not required to establish itself as a profession prior to adopting a code of ethics; nor will adopting a code of ethics decide the question of whether an occupation is a profession. Rather than perceiving the code of ethics as an indicator of professional status, Starr has suggested that formulating a code of ethics is a means of achieving solidarity among practitioners.39 My position is that the American Society of Bioethics and Humanities should explore with its members the possibility of establishing a code of ethics that would include ethical standards, principles, and guidelines for healthcare ethics consultants. ABBOTT’S SYSTEM OF PROFESSIONS Both trait theory and Wilensky’s professionalization model have been criticized for describing “ideal” images which do not resemble professions or professionals in “real life.” These methods give tacit support to the images which professions project of themselves, and obscure the ways that the professions engage in turf battles, or act as agents of social control. I next examine the practice of healthcare ethics consultation within the framework of a professionalization theory that will address these concerns. In recent years, Andrew Abbott has suggested that the search for a firm definition of professions should be abandoned in favor of studying the jurisdictional disputes and struggles for control over arenas of work which he regarded as the defining events in the study of professions.40 In his theory, professions make up an interdependent system. Each profession has activities that fall under its jurisdictional control. To maintain control of the expert knowledge and its application means dominating “outsiders” who attack that control. Jurisdictional boundaries between professions are perpetually in dispute, and competition is the “fundamental fact” of professional life. “Professions develop,” according to Abbott, “when jurisdictions become vacant, which may happen because they are newly created or because an earlier tenant has left them altogether or lost its firm grip on them.”41 Abbott rejected the traditional argument that occupations follow a certain sequence of development culminating in professional status. Instead, he demonstrated through case examples that jurisdictional claims


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furnish the impetus and pattern for new professions to develop. Abbott wrote, “It is the history of jurisdictional disputes that is the real, the determining history of the professions.”42 Professions begin with these jurisdictional disputes. When these disputes are placed in the larger context of the system of professions as a whole, one can understand the factors related to the development of that profession. Illustration of Abbott’s Hypothesis According to Abbott, the tasks of all professions are “human problems amenable to expert service.”43 To illustrate, multiple experts (professionals) have claimed jurisdiction over the problem of alcoholism as it has been interpreted and reinterpreted as a sin, a crime, and a disease.44 Ministers were the professional experts who attended to the problem of alcoholism when it was conceptualized as a social and moral weakness. In the late nineteenth century, alcoholism became a legal problem under the jurisdiction of laws and the courts. The boundaries changed again when alcoholism was reformulated as a disease and the medical profession gained control over the problem of alcoholism. Each reinterpretation of alcoholism – from a moral weakness to a criminal act to a biological disease – redefined the jurisdictional boundaries of the profession that controlled the problem. “Reinterpretations are normally part of larger jurisdictional claims, claims not only to classify and reason about a problem, but to take effective action towards it. The final tests of such claims are their practical results.”45 Shifts from one professional jurisdiction to the next are gradual, so for a period of time, both or several groups will claim jurisdiction until one eventually wins out over the other. A profession is always vulnerable to changes in its tasks; thus “professions both create their work and are created by it.”46 Today, for example, it could be argued that alcoholism is a problem which falls outside the domain of professionals and is instead dealt with in the realm of nonprofessional social support groups such as Alcoholics Anonymous. Applying Abbott’s Theory to Bioethics Consultation If Abbott’s theory is correct, then healthcare ethics consultation will struggle to gain its own territory as it develops into a profession. Boundaries will shift between healthcare ethics consultation and other professions. For example, the presence of bioethics consultants in the medical decisionmaking process has intruded on professional territory previously assigned to physicians. One study has already documented how practitioners in medicine and ethics “posture to maintain disciplinary turf.”47 Frank Marsh, an attorney-ethicist, commented on this power dispute

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between medicine and bioethics: “My quarrel with medicine stems from its tenuous attempt to maintain a position of power in a rapidly changing healthcare system and the misguided belief that this power is now being encroached upon by third parties under the guise of bioethicists.”48 Boundaries between Ethics Consultation and the Courts Abbott’s theory further suggests that medicine will be just one of several professions that this multidisciplinary practice will challenge for control over arenas of work. Another jurisdictional dispute is ongoing between bioethics and the court system. At issue is how much authority should be granted to decisions made by ethics committees. Law professor Diane Hoffman has noted that ethics committees are being given tasks that previously were entrusted to courts. “There have also been some murmurings recently by members of the judicial and legal communities that the role and authority of ethics committees be expanded to allow them to substitute for judicial decisionmaking in certain cases.”49 Professor Hoffman illustrated this point by describing the case of a patient, pregnant with a viable fetus, who was unable to decide the course of medical treatment for herself. Ultimately, federal Judge Terry of the United States Court of Appeals for the District of Columbia handed down a ruling in this case but he also concluded that it would be better if these “complex medical and ethical issues” were not decided by judges called to patients’ bedsides.50 Instead Judge Terry encouraged the establishment of “another tribunal,” that would be more appropriately qualified to make these decisions. In line with this suggestion [from Judge Terry], members of the Health Law Section of the Maryland State Bar Association recommended recently that the state adopt legislation that would expand the authority of ethics committees by allowing them to substitute their views for judicial decisionmaking in cases where patients are in a persistent vegetative state and family members or healthcare providers wish to terminate or withhold life-sustaining treatment.51

Although not exactly a “tribunal,” hospital ethics committees were established in the state of Maryland as the humane yet fair alternative to a bureaucratic and adversarial judicial system. Prior to Judge Terry’s ruling, both establishing and utilizing hospital ethics committees had always been voluntary. However, in July 1987 Maryland became the first state to require that all hospitals establish “patient care advisory committees.”52 This Act established mandatory ethics committees. It has been modified twice; and each time the responsibilities and authority of ethics committees functioning as ethics consultants have increased.53 The first change mandated that, in addition to hospitals,


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all licensed nursing homes in Maryland would be required to establish ethics committees. The second modification contained the following stipulations: (1) certain types of disputes involving the medical treatment of individuals with life-threatening conditions “must be referred to the institution’s ethics committee;” and (2) healthcare providers have the authority to follow a committee’s recommendation for medical treatment without first obtaining “the appropriate consent” from family members.54 This experience in Maryland lends credence to the speculation that professional boundaries between bioethics consultants and courts of law are shifting. The court system is, to use Abbott’s term, ‘losing its firm grip’ in the area of decision-making authority on behalf of patients. Perhaps this trend began in the 1970s with the well-known case of Karen Ann Quinlan whose family requested termination of life support through the court system. At that time, the New Jersey Supreme Court recommended that in comparable cases “a practice of applying to a court to confirm such decisions would generally be inappropriate [and] impossibly cumbersome.”55 Chief Justice Hughes further advised that decisions involving similar issues and disputes should be made, not in a courtroom, but by hospital ethics committees as “a general practice and procedure.”56 In 1976, at the time he rendered this decision, less than 1% of U.S. hospitals had ethics committees of any kind. They have since rapidly proliferated. My purpose in raising this issue was to illustrate a jurisdictional boundary dispute, consistent with Abbott’s perspective, between bioethics consultation and well-established court precedents, not to debate whether courts or ethics committees are better qualified to make these determinations. Professor Hoffman, too, expressed a similar concern about these shifting boundaries, “The more controversial question . . . is not whether ethics committees should be mandated but whether their role should be expanded to allow them to substitute for judicial decisionmaking in some cases.”57 As responsibilities regarding the practice of healthcare ethics consultation continue to be defined, long-held beliefs about the appropriate use of the court system in life and death medical decisions also will be challenged. During this unstable transitional period, diverse practices are found. Thus, in most states, hospitals are still able to choose for themselves whether to establish an ethics committee but in Maryland and New Jersey it is mandatory.58 In most states, physicians are always liable for their actions; however, in Hawaii, if they follow the advice they receive from an ethics consultation committee, physicians and healthcare providers have been granted legal immunity. “Hawaiian legislation grants full decisionmaking authority in patient care to ethics committees and provides for

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broad legal protection for physicians who participate with committees and implement their regulations.”59 Conferring immunity on decisions made by ethics committees simultaneously increased bioethics consultants authority and diminished the role for the courts. Jurisdictional Claims of Bioethics Consultation Abbott’s theory also asserts that professionals must maintain an optimal level of abstraction that clearly differentiates them from closely allied occupational groups struggling to increase their status. However, he documented that much of this abstract knowledge is irrelevant, and the notion that only one specific profession can help in a particular case is, in his view, a public fiction, or part of a strategy for maintaining the publicly clear picture of jurisdictional claims.60 Thus, professions experience varying degrees of success in establishing jurisdictional control over competing occupations in contiguous positions in a division of labor.61 In the case of healthcare ethics consultation, ethics consultants are now competing for control over the knowledge and skills needed to make complex medical and ethical decisions. The medical profession once monopolized this control; then it reluctantly shared its authority with the courts. Now, “strangers” from the humanities have challenged both of these professions for jurisdiction in this arena. According to Abbott’s interdependent system of professions, the boundary lines between professions are never permanently drawn, and the farther one is from the center of a profession’s domain, the more likely one is to encounter competition over specific responsibilities. Facilitating ethical decisionmaking at the bedside of patients is a core concern for healthcare ethics consultation, but it is only peripheral to medicine and to the court system. Thus, if I am correctly interpreting Abbott’s theory, the conditions exist for jurisdictional boundary disputes between ethics consultation and medicine, ethics consultation and the courts, and possibly ethics consultation and other contiguous professions. If we accept Abbott’s claim that professions begin with these jurisdictional disputes, then bioethics consultation has begun the process toward professionalization. Boundaries have begun to shift but at this early stage, the outcome of these jurisdictional disputes cannot be predicted.

HAUG’S DEPROFESSIONALIZATION THESIS In the 1960s and 1970s, there was a trend in the United States toward occupations becoming professions that formed the genesis for articles


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such as the previously discussed Wilensky’s “The Professionalization of Everyone?” The climate is different today and instead of creating more new professions, many scholars have taken the position that existing professions are instead becoming more like occupations. The deprofessionalization thesis, or the argument that the professions are losing their position of prestige and trust, is associated most closely with the work of Marie R. Haug.62 Haug’s position is that the professions have lost so much of their power that they have become subject to the same formal, hierarchical lay controls as other occupations. Haug identified three important attributes of professions that, in the past, accounted for their status and respect. First, professionals possess a monopoly over a body of knowledge that is relatively inaccessible to lay people; second, they have a positive public image that stresses altruistic rather than self-serving motives; and third, they have the power “to set their own rules as to what constitutes satisfactory work.”63 In her view, all three of these characteristics have begun to disappear for all professions. Professions are losing status. Recent changes in the practice of medicine, for example, illustrate this transformation. Marsh observed, “Physicians who once engaged in the art of medicine are now perceived by many to be largely highly skilled medical technicians who ply their trade in an ever increasing array of medical technology.”64 Professionals are losing their monopoly, their altruistic image, and their self-governing power. Consequently, professionals are becoming mere secular experts who are no longer protected from the necessity of negotiating and compromising with a skeptical clientele. Threats to Professional Monopoly over Knowledge According to Haug, there are three sources of threats to the professions’ monopoly over defined bodies of complex knowledge and skill. First, insofar as a profession’s formal knowledge can be stored in a computer, it loses its esoteric character because anyone can retrieve it. Second, as the lay population becomes better educated they will rely less on the specialized knowledge of professionals. And, the third threat to a profession’s monopoly over specialized knowledge is the result of the increasingly complex division of labor within which professionals work.65 Each of these threats will be discussed. Haug has written extensively about the loss of esoteric knowledge in the information age of the computer and she has argued that greater access to information is a serious threat to professions.66 An example of how computer technology has changed another profession can be found in medicine. Because the public has greater access to medical informa-

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tion through computer databases and media sources, many patients enter their physicians’ offices with requests for specific treatments, or specific medications. Indeed prescription pharmaceuticals are advertised directly to consumers with the tag line, “ask your doctor.” In some cases, the individual patient no longer relies exclusively on her physician’s knowledge of what medications should be prescribed for her benefit; rather, she demands treatments. Greater access to information is also affecting bioethics consultation. For example, a computer program, Dr. EthicsTM , has been marketed “to help ethicists and future ethicists alike in their encounters.”67 According to the sales brochure: “Dr. Ethics is a unique computer program that can analyze the ethical implications of case studies in clinical medicine . . . Dr. Ethics will expose the ethical dimensions, ask for responses and/or decisions and present its recommended resolution . . . easily and effectively . . . Dr. Ethics is so easy to use that there is virtually no training time or manuals needed.”68 If one could solve ethical dilemmas by using a computer program then there would be little need to consult a professional ethicist. Haug’s second identified threat to the professions’ monopoly over specialized knowledge stems from the lay population’s increasing level of education. She believes that a more educated populace will be less inclined to see professional knowledge as mysterious and more likely to be critical and challenging when dealing with professionals. This threat is closely related to her first point. The combination of an educated public with greater access to information from computers diminishes the need to turn to professionals to solve problems. The result is that patients and clients become consumers in the marketplace. Haug has predicted that, “In a time when professionals offer only expert information, with the client in a position to seek alternatives, we will begin to see a consumer model, rather than a patient or client model, of the entire transaction and the concept of profession as now formulated will be indeed obsolete.”69 She concludes that these first two threats have combined to narrow the knowledge gap between professionals and clients and therefore professions will become obsolete. I would instead argue that these significant developments will transform professional practices rather than eliminate professions completely. First, consider that not everyone in the public will achieve the educational level to understand professional knowledge, thus professionals would still be necessary for those less educated. Second, even among those who could comprehend the knowledge and information, not all will pursue it. Some will still prefer to trust professionals to handle the details. Finally, even


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though the formal knowledge is accessible via computer or other sources to lay persons, it will still fall to the members of a profession to generate the new knowledge, to determine what is to be stored, and to effectively interpret the information and knowledge that is retrieved. Freidson, too, denies Haug’s thesis that the knowledge gap has narrowed.70 He argued that the quantity and quality of specialized knowledge has increased even as the capability of the average patient or client to evaluate more technical knowledge has grown. Thus, the professions, according to this view, continue to possess a monopoly over at least some important segment of formal knowledge. Haug’s third and final explanation for why professions are losing their monopoly status refers to the increasingly complex division of labor within which professionals work. Early theorists emphasized the positive benefits from an ever more highly specialized division of labor to both professionals and to the larger society. For example, in a series of lectures at the turn of the twentieth century, Durkheim developed the idea that professional organizations and associations might help the larger society develop new forms of social solidarity through their propagation of values, through their devotion to improving their craft, and through their encouragement of high ethical principles in relation to their work. His basic insights were that individuals would have a strong level of identification to their professions, similar to one’s family identity, and, that the newly developing professional associations would create an additional source of values.71 Whereas Durkheim’s division of labor theory stressed cooperation among professions, Haug’s more recent analysis highlights competition. She has asserted that the current specialized division of labor makes professionals dependent on other specialists in new fields who will then claim more authority for themselves. These new specialists contest control over some portion of the formal knowledge and skill that the established professions formerly monopolized. I suggest, in accordance with Haug’s thesis, that healthcare ethics consultants could be construed as one more group in a series of specialists who are claiming control from medicine over new knowledge and skill. If, for example, bioethical questions emerged partly as a result of new technology in medicine, then it could also be said that bioethics consultants emerged as the perceived specialists in this new field. This conclusion is consistent with DeRenzo’s observation: “Why then do we need bioethics consultants? The reason is in large part because we have recognized that physicians do not necessarily have the specialized knowledge and skills to ascertain what is in a patient’s best interests within the context of the patient’s personal value system.”72 By developing training programs, educational degrees, clinical

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fellowships, peer-reviewed journals, and written standards adopted by a national organization, healthcare ethics consultants are claiming specialized knowledge and skills that, following Haug’s thesis, should result in increasing authority for bioethics consultants and diminishing authority (in this area) for physicians who will become increasingly dependent on these new specialists in this new field. Challenges to the Professional’s Fiduciary Role Finally, Haug has claimed that the climate of public opinion has become increasingly hostile and distrusting of professionals’ alleged altruism and fiduciary responsibilities in a professional-client relationship. If true, this would significantly alter the concept of a profession because a fiduciary relationship has historically been a central feature of professions. Everett Hughes, a scholar of the professions, wrote: Thus is the professional relation distinguished from that of those markets in which the rule is caveat emptor, although the latter is far from a universal rule even in exchange of goods. The client is to trust the professional; he must tell him all secrets which bear upon the affairs in hand. He must trust his judgment and skill. In return, . . . only the professional can say when his colleague makes a mistake.73

McCullough has defined the professional’s fiduciary role as having a duty “to act primarily for another’s benefit in matters” connected with the actions created by the profession.74 He is one of several authors who have recently written that medicine is increasingly perceived as a trade in which physicians pursue economic self-interest rather than acting for the patient’s benefit. “Indeed, we may be living at a time when the moral life of the physician as fiduciary will be easily destroyed by the voluntary choices of physicians and healthcare institutions not to preserve it.”75 A decrease in trust in professionals creates greater demands for accountability and for the protection of clients’ and patients’ rights. Clarifying these rights further contributes to the professions’ loss of trust and prestige. Haug argued that the concept of a profession will become obsolete and that instead of relationships with clients or patients, the consumer model will prevail. Rather than accepting Haug’s argument that all professions are disappearing, I am offering the alternative interpretation that the bioethics consultation ‘profession’ began because of this climate of distrust and demands for patients’ rights. Haug may have correctly assessed the sociohistorical changes but incorrectly predicted the outcome. Haug claims that the public has become increasingly hostile and distrusting of professions and professionals. Rather than considering this point solely in support of the elimination of professions, I am suggesting that it could be a motivation to create new professions, like bioethics consulta-


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tion, to mediate between a distrusting public and established professions. Instead of all professions becoming obsolete, as she predicts, perhaps new professions or new forms of professions will emerge. SUMMARY In this paper, I considered issues related to the professional status of healthcare ethics consultation. I examined the question of whether bioethics consultation is a profession in a theoretical and sociohistorical context heretofore missing from the bioethics literature. I specifically looked at trait theory, Wilensky’s five-stage process of professionalization, Abbott’s interdependent system of professions, and Haug’s deprofessionalization thesis. I concluded that healthcare ethics consultation, according to both trait theory and Wilensky’s five stages, does not meet the criteria to claim professional status at this time. Furthermore, in my view, bioethics consultation will never become a full-fledged profession as long as it remains a multidisciplinary practice in which the majority of its practitioners are engaged in other professions or occupations most of the time, and are ethics consultants on a part-time or volunteer basis. However, this does not prevent healthcare ethics consultants from establishing a code of ethics. Given that bioethics consultants assist patients, families, physicians, and other healthcare providers with complex medical moral decisions, it makes sense for them to have some agreed upon guidelines or principles. Andrew Abbott has posited that professions make up an interdependent system in which jurisdictional boundaries are always in dispute. According to this theory, professions begin with jurisdictional disputes, and shifts from one professional jurisdiction to the next are gradual so that several groups can simultaneously claim jurisdiction until one eventually wins out. I argued that healthcare ethics consultation is, at a minimum, competing with medicine and the courts for control over claims to the expert knowledge needed to facilitate medical and ethical decisions. Boundaries are shifting as each group struggles to gain territory, but the outcome cannot yet be predicted. It is possible that bioethics will emerge with jurisdictional control, but the issue is unresolved. No discussion of professionalization issues would be complete without acknowledging that external conditions are not as conducive to establishing professions as they have been in past decades. Marie Haug has claimed that all professions are disappearing and becoming more like occupations. She also claimed that the public has become increasingly hostile and distrusting of professionals. Rather than considering this latter point solely in support of the elimination of professions, I suggest that it

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could be a motivation to create new professions, like bioethics, to mediate between a distrusting public and established professions. The question, “Is healthcare ethics consultation a profession?” is complex. The simple answer is no. It is not a profession. There is no theory or definition that permits us to unconditionally declare the practice of ethics consultation to be a profession. Nor could most professions pass these ideal theoretical standards. However, a yes or no dichotomous response may not be appropriate for the complex issue of professionalization. Instead, imagine that a continuum exists with occupational jobs, such as sales clerk or construction worker, placed at one end and well established professions such as medicine and law located at the other extreme. During the past decade, in my judgment, healthcare ethics consultation has been moving toward greater professional status. It has not achieved professional status, and the trend could reverse, but it currently is moving toward professional status.

ACKNOWLEDGEMENTS The author would like to thank W.J. Winslade, E.S. More, R.A. Carson, Patricia Sokul, and three anonymous referees for their helpful comments on earlier drafts of this article.

NOTES AND REFERENCES ∗ The views expressed in this article are those of the author and may not reflect the opin-

ions of the American Medical Association or the Institute for Ethics. An earlier version of this paper titled, Is bioethics consultation a profession?, was presented at the American Society of Bioethics and Humanities (ASBH) Second Annual Meeting, October 1999 in Philadelphia, PA. 1 LaPuma J. Schiedermayer DL. Ethics consultation: Skills, roles, and training. Annals of Internal Medicine 1991; 114: 284. They argue that only physicians should be ethics consultants, which would result in all ethics consultants being licensed professionals. 2 Lilje C. Commentary: Ethics consultation: A dangerous, antidemocratic charlantry. Cambridge Quarterly of Healthcare Ethics 1993; 2: 440. 3 Yeo M. Prolegomena to any future code of ethics for bioethicists. Cambridge Quarterly of Healthcare Ethics 1993; 2: 403. 4 Ross JW. Commentary: Why clinical ethics consultants might not want to be educators. Cambridge Quarterly of Healthcare Ethics 1993; 2: 445. 5 Freidson E. Profession of Medicine: A Study of the Sociology of Applied Knowledge. Chicago: University of Chicago Press, 1970: 4. 6 Carr-Saunders AP. Wilson PA. The Professions. Oxford: Oxford University Press, 1933.


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7 Millerson G. The Qualifying Associations: A Study in Professionalization. London: Routledge, 1964; Abbott P, Wallace C. The Sociology of the Caring Professions. New York: The Falmer Press, 1990. 8 Waters M. Collegiality, bureaucratization, and professionalization: A Weberian analysis. American Journal of Sociology 1989: 94: 945–972. 9 Weber M. The Protestant Ethic and the Spirit of Capitalism. NY: Charles Scribner and Sons, 1958 [1905]. 10 Starr P. The Social Transformation of American Medicine: The Rise of a Sovereign Profession and the Making of a Vast Industry. New York: Basic Books, 1982: 4. 11 Parsons T. The sick role and the role of the physician reconsidered. Milbank Memorial Fund Quarterly Summer 1975: 257–278. 12 Goode W. Encroachment, charlatanism, and the emerging profession: Psychology, sociology, and medicine. American Sociological Review 1960; 25: 902–914. 13 Freidson E. Professional Dominance: The Social Structure of Medical Care. Chicago: Aldine, 1970. 14 Hughes EC. Professions, in On Work, Race, and the Sociological Imagination. Chicago: University of Chicago Press, 1994: 37–50; reprinted from Daedalus, Journal of the American Academy of Arts and Sciences. Chicago: ASA, 1963. 15 Orr RD. Personal and Professional Integrity in Clinical Medicine. Update 8, 4: Loma Linda, CA: Loma Linda University Center for Christian Ethics 1992. 16 Starr, 15. 17 Moore WE. The Professions: Roles and Rules. New York: Sage Foundation, 1970: 226–227. 18 Brody H. Healer’s Power. New Haven, Ct: Yale University Press, 1993: 7. 19 Cleaves, P. Professions and the State: The Mexican Case. Tucson: University of Arizona Press, 1987: 9. 20 Wilensky HL. The professionalization of everyone? American Journal of Sociology September 1964; LXX(2): 138. 21 Wilensky, 137–158. 22 Wilensky, 142. 23 Wilensky, 142–146. 24 Wilensky, 142. 25 Gallessich J. The Profession and Practice of Consultation. San Francisco: Josey-Bass, 1982: 367. 26 Aulisio MP. Arnold RM. Youngner SJ. Health care ethics consultation: Nature, goals, and competencies. A position paper from the society for health and human values – society for bioethics consultation task force on standards for bioethics consultation. Annals of Internal Medicine 4 July 2000; 133(1): 59–69. 27 Gallessich, 367. 28 Garcia A. An examination of the social work profession’s efforts to achieve legal regulation. Journal of Counseling and Development May/June 1990: 492. 29 Scofield G. Ethics consultation: The least dangerous profession. Cambridge Quarterly of Healthcare Ethics 1993; 2: 417. 30 Bledstein BJ. The Culture of Professionalism: The Middle Class and the Development of Higher Education in America. New York: W.W. Norton & Co., 1978. 31 Freedman B. Bringing codes to newcastle. Clinical Ethics: Theory and Practice, Hoffmaster, B., Freedman, B., Fraser, G., eds. Clifton, NJ: Humana, 1989: 125–139. 32 Yeo, 404.

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33 Scofield, 420. Scofield also complains about the field’s lack of a code of professional ethics in other articles, including, Is the Medical Ethicist an Expert? ABA Bioethics Bulletin Winter 1994; 3(1): 9. 34 The 1998 SHHV-SBC Task Force Report, Core Competencies for Health Care Ethics Consultation – adopted also by the American Society of Bioethics and Humanities (ASBH) – is a beginning to the process of establishing standards. 35 Fletcher JC. Commentary: Constructiveness where it counts. Cambridge Quarterly of Healthcare Ethics 1993; 2: 430. 36 A code of ethics for the American Society of Newspaper Editors can be found in Codes of Professional Responsibility Second Edition, Gordon RA. ed. Washington D.C.: The Bureau of National Affairs, 1990: 135–138. 37 Codes of Ethics for Little League Managers and Coaches, Little League Players, and Little League Parents are found on the worldwide web at http://www.tcfn.org/ rcll/cethic.html [coaches’ ethics]; http://www.tcfn.org/rcll/plethic.html [players’ ethics]; and http://www.tcfn.org/rcll/pethic.html [parents’ ethics]. 38 There are three different codes of ethics for magicians: one adopted by the Society of American Magicians (S.A.M.); one adopted by the International Brotherhood of Magicians (I.B.M.); and a Universal Code of Ethics jointly endorsed by both organizations. S.A.M. Assembly 206, Program handout. Austin Tx: Aug. 21, 1997. 39 Starr, 15. 40 Abbott A. The System of Professions An Essay on the Division of Expert Labor. Chicago: University of Chicago Press, 1988. 41 Abbott, 3. 42 Abbott, 2. 43 Abbott, 35. 44 Abbott, 35–38. 45 Abbott, 38. 46 Abbott, 316. 47 Perkins HS. Saathoff BS. Impact of medical ethics consultations on physicians: an exploratory study. American Journal of Medicine 1988; 85: 761–765. 48 Marsh FH. Why physicians should not do ethics consults. Theoretical Medicine 1992; 13: 286. 49 Hoffman DE. Regulating ethics committees in health care institutions – Is it time? Maryland Law Review 1991; 50(3): 749. 50 Judge Terry’s decision from In re A.C. 573 A.2d 1235, D.C. 1990, as cited by Hoffman, 749–750. 51 Hoffman, 750. 52 Hoffman, 751. 53 Fletcher JC, Hoffman DE. Ethics committees: Time to experiment with standards. Annals of Internal Medicine 1994; 120: 335–338. 54 Fletcher and Hoffman, 335. 55 Chief Justice Hughes, Matter of Quinlan 355 A. 2d 647: 27. 56 Hughes, 29–30. “We repeat for the sake of emphasis and clarity that . . . they shall consult with the hospital ‘Ethics Committee’ or like body of the institution.” 57 Hoffman, 790. 58 Ethics committees were legally mandated in Maryland in 1987, and in New Jersey in 1990. 59 Fleetwood J. Unger SS. Institutional ethics committees and the shield of liability. Annals of Internal Medicine 1994; 120: 320.


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60 Abbott, 68. 61 An example of a profession establishing jurisdictional control over a competing occu-

pation in a contiguous position in a division of labor is medicine and pharmaceutical interests. Starr describes how medicine initially gained control of pharmaceuticals in the early 1900s in Social Transformation, 127–134. But, according to Abbott’s interdependent system of professions, the issue can return so it is an open question whether medicine will continue to successfully control pharmaceutical interests. 62 Haug MR. Deprofessionalization: An alternative hypothesis for the future. Sociological Review Monographs 1973; 20: 195–211; and Haug MR. The deprofessionalization of everyone? Sociological Focus 1975; 8: 197–213. 63 Haug, Alternative Hypothesis, 196. 64 Marsh, 286. 65 Writings about the specialization of labor date back to the late eighteenth century. Durkheim’s classic work, Division of Labor in Society, posits that societies generally develop from a simple, “mechanic” form of solidarity to a more complex, “organic” form of solidarity based on occupational specialization. Writing at the turn of the last century, Durkheim envisaged a society in which most traditional forms of social connection would be eliminated by an impersonal market economy and an ever more highly specialized division of labor. Durkheim E. The Division of Labor in Society. Halls, WD. trans. NY: Free Press 1984 [1893]. 66 Haug MR. Computer technology and the obsolescence of the concept of profession. Work and Technology 1977: 215–228. 67 McGee G. Phronesis in clinical ethics. Theoretical Medicine 1996; 17: 321–322. 68 McGee, 322. 69 Haug. Computer Technology, 226. 70 Freidson E. The changing nature of professional control. Annual Review of Sociology 1984; 10: 1–20. 71 Durkheim E. Professional Ethics and Civic Morals. Brookfield, C. trans. Glencoe, IL: Free Press, 1958 [1897–1899]). 72 DeRenzo EG. Providing clinical ethics consultation. HEC Forum 1994; 6(6): 387. 73 Hughes, 37. 74 McCullough L. John Gregory (1724–1773) and the invention of professional relationships in medicine. Journal of Clinical Ethics Spring 1997; 8(1): 12. 75 McCullough, 19.

Institute for Ethics American Medical Association 515 North State Street Chicago, Illinois 60610 USA E-mail: [email protected]