Medicine under threat: professionalism and professional identity

At this point, however, theories of professionalization divide in their way of characterizing professionalism and its history, falling into at least 3 distinct types. The first type of theory emphasizes the strategic side of professionalism: the use by professionalizing groups of claims for superior knowledge and special moral integrity as devices by which they could secure some measure of control over the market for their services. This view of professionalism as primarily a "project of collective mobility" also stresses the economic dimensions of the phenomenon of professionalization within the liberal capitalist order, with important variations in different nations.(f.2-4) Managed care would therefore be explicable fundamentally as a loss of guild monopoly in the face of more powerful market players, especially insurers and providers, legitimated as an advance of consumer sovereignty. For the third perspective on professionalization, however, the situation is more complex and external causes are more difficult to determine. Harold Perkin(f.10) argues that the spread of the idea of professionalism and its public legitimacy are inexplicable unless professionalism answers in some way to real social needs, which have become ever more pressing as the "post-industrial" or "knowledge" society has developed. "The whole point and purpose of professional society," writes Perkin, "is to apply knowledge and expertise to the production of enough sophisticated goods and services to meet the needs of every citizen ... so that for the first time in human history the economy is capable of producing enough 'created assets' to give everyone ... access to full range of satisfactions once open only to the rich and powerful." In this context the integrity of professional services becomes a key public good. To do this, medicine must take the lead in a public conversation about the profession's contract with society. If it does not, that contract is likely to be redefined in terms, and in a language, quite antithetical to the core concerns of medicine. The focus of this effort by the profession would be to give new attention -- and new importance -- to the spirit of professionalism, only a professionalism seen in specifically public-regarding, civic ways. A civic professionalism must seek to strengthen and extend the kind of fiduciary morality that has long been part of the ethos of medicine. But it must do this self-consciously and with explicit attention to how the relations