The article develops fresh perspectives on the normative practice model (npm) by extending its application to meso- and macrocontexts. Health care-related interactions, negotiations, and activities in these contexts have their own internal structure. One of the origins of the crisis in medical professionalism is the disregard for norms that shape health care conditions: efficiency standards, rules for policy making, quality measures, and principles of distributive justice. Disconnecting the professional from the moral purposes of health care was another source of the crisis. Doctors are not engineers; technocratic and scientistic views on professionalism detract from the vocation of the physician, which is to heal, to diminish suffering, and to console. The npm does not offer a blueprint—rather, it serves as a heuristic device that helps professionals and administrators to orient themselves both conceptually and normatively. Differences between contexts lead to different constellations of normative principles and to different descriptions of core responsibilities of stakeholders.
The normative practice model (npm) of medical practice (Jochemsen and Glas 1997; see also Hoogland et al. 1995; Hoogland and Jochemsen 2000; Jochemsen 2006) evolved out of discussions in an interdisciplinary group of philosophers, clinicians, and other scientists. Strijbos’s description of the medical relationship as a “contact” relationship (Strijbos 1988, 195) initiated the earliest exchange of ideas. After a couple of years, the discussants decided to focus on developing a normative structural analysis of the patient–physician relationship along the lines of Dooyeweerd’s analysis of types of individuality structures (Dooyeweerd 1953–1958, vol. 3). Members of the group had the impression that this analysis could inform and help orient moral reflection in medical practice. They saw their attempt as a way to circumvent a well-known problem in deontological and principle-based approaches to medical ethics, namely, that definitions of the norms, principles, and duties tend to be so general that they hardly offer any guidance with respect to specific medical ethical questions. The principle of beneficence, for instance, could be called upon to support both pro-choice and pro-life policies in medical ethics.
The npm describes medical practice as a normative practice with a structure and a direction. The terms structure and direction build forth on Dooyeweerd’s distinction between structural types and the religious dynamic that helps to bring a certain structural type to its destination. The simpler terms structure and direction became commonplace through the work of Wolters (1984) and Mouw and Griffioen (1993). Structure refers to the constitutive side of medical practice—i.e., to aspects of the practice of medicine that necessarily must be done justice to. Without compliance to norms that constitute medical practice, a practice cannot be qualified as medical practice. Direction aims at a regulative dimension—i.e., to the moral, spiritual, and religious values and spirit that guide medical practice.
In the context of medicine, the terms structure and direction were first used in a study on the relationship between professional autonomy and public demand for quality as well as cost containment in health care (Hoogland et al. 1995). Both in Hoogland et al. (1995) and in Jochemsen and Glas (1997), additional distinctions were proposed with respect to the constitutive side; to wit, between qualifying, conditioning (conditions-enabling), and foundational principles (or structures). Jochemsen and Glas (1997) associated the regulative dimension of medical practice with the ethos—the ensemble of core values and ultimate concerns—of the medical profession and of medical professionals (see fig. 1).
The aim of this paper is to develop the npm one step further by investigating the role of contexts in the definition of the different forms of normativity (see Mouw and Griffioen  and Verkerk et al.  for similar attempts). In most of its initial formulations (Hoogland et al.  is an exception, especially section 4.4 and chapter 10), the npm aimed at the individual professional–patient/client relation. In this paper, the perspective will be broadened by focusing on other actors in the field of health care—actors operating at meso- and macrolevels (e.g., institutions, policy making bodies, advisory committees, and government).
I begin with professionalism itself, because, as we will see, the notion of professionalism has historically evolved out of a responsibility that reaches much further than the individual doctor–patient relationship. After reviewing some definitions of professionalism, I will continue with a historical-sociological analysis of the concept. Next, I will discuss several contexts and analyze how they co-define roles and responsibilities. Finally, some suggestions will be made regarding the further development of the npm.
2 Professionalism: Definitions and Terms
He also emphasizes that the way we think about expert occupations transcends the confines of occupational sociology and comes close to a central theme in classical sociology, to wit, the emergence of modern society and culture as such.
Individually and, in association, collectively, the professions “strike a bargain with society” in which they exchange competence and integrity against the trust of client and community, relative freedom from lay supervision and interference, protection against unqualified competition as well as substantial remuneration and higher social status.rueschemeyer 1983, 41
Moore gives a practical overview and defines a professional as someone who has a full-time occupation, which sets his/her efforts apart from amateurism. The professional has a commitment to a calling: the fulfillment of the profession’s requirements is a response to a set of normative and behavioral expectations. Professions are set apart from other forms of occupation by various signs and symbols and are identified by their peers via membership of formalized organizations. Usually, the acquiring of skills and knowledge requires intensive and prolonged training. Professionals need to exhibit an orientation to service, they proceed by their own judgment and authority and are, therefore, professionally autonomous (Moore 1970, 5–6). Freidson’s more recent account enumerates similar criteria. He says that professionals have
How expert knowledge is deployed in different institutional forms, how it is controlled, how it is used as a resource of power and a basis of privilege, and how in turn different institutional forms of deployment, social control as well as individual and collective advantage, are affected by other and wider social structures and processes—inquiries into these questions tell us much about the structure and the dynamics of society as a whole.ibid., 38
1.specialized work in the officially recognized economy that is believed to be grounded in a body of theoretically based, discretionary knowledge and skills and that is accordingly given special status in the labor force;
2.exclusive jurisdiction in a particular division of labor created and controlled by occupational negotiation;
3.a sheltered position in both external and internal labor markets that is based on qualifying credentials created by the occupation;
4.a formal training program lying outside the labor market that produces the qualifying credentials, which is controlled by the occupation and associated with higher education; and
5.an ideology that asserts greater commitment to doing good work than to economic gain and to the quality rather than the economic efficiency of work.freidson 2001, 127
An important recent impetus for the study of professionalism is the educational reform in residency training programs. This reform has occasioned an upsurge of writings on professionalism as clinical competence and on the assessment of this competence. This body of literature focuses on the appropriate attitudes and behaviors of the physician, given her unique privilege of being a professional (see also Glas 2012). It also investigates how these attitudes and behaviors can be operationalized in a way that makes them suitable for clinical assessment.
Thus, being a professional consists in a unique combination of roles, excellence, and commitments. Note that in the quotation these commitments are positioned as basis for the social contract. It is not unusual to see the social contract described as legitimizing the exertion of certain skills, and to see commitments narrowed down to the duty of keeping the contract (e.g., to use these skills appropriately). The CanMEDS framework recognizes a broader embedding of the responsibilities and commitments. This is, of course, in line with one of the meanings of the word profession, which not only refers to a paid occupation but also to the vows people take—i.e., to what they profess at the occasion of entering a certain group. The Hippocratic Oath qualifies as a similar declaration of dedication on entering the medical profession.
Physicians serve an essential societal role as professionals dedicated to the health and care of others. Their work requires mastery of the art, science, and practice of medicine…. The Professional Role reflects contemporary society’s expectations of physicians, which include clinical competence, a commitment to ongoing professional development, promotion of the public good, adherence to ethical standards, and values such as integrity, honesty, altruism, humility, respect for diversity, and transparency with respect to potential conflicts of interest…. Professionalism is the basis of the implicit contract between society and the medical profession, granting the privilege of physician-led regulation with the understanding that physicians are accountable to those served, to society, to their profession, and to themselves.royal college of physicians and surgeons 2015, 26
In sum, all these definitions and their operationalization suggest that, rather than being solely based on the relation between a medical professional and an individual patient, the concept of professionalism is co-constituted and co-defined by the relation between professionals and society.
3 Professionalism from a Historical and Sociological Perspective
The social history of the concept of professionalism is complicated, which is reflected—among other things—by the fact that there is no single definition of it—not even for medicine as a profession. It is nevertheless not uncommon to see the sociology of professions described as having gone through at least three stages (Evetts 2003; Kanes 2010; Sciulli 2005).
The first functionalist or structural-functionalist phase started in the 1930s. The early studies give descriptions of the development of the professions and give a rationale for their emergence. Professionalism is generally seen as representing an outspoken, institutionalized form of division of labor. The term division of labor was not new at that time. It was, for instance, an important topic in the works of both Karl Marx and Max Weber, though, obviously, for different reasons. Marx considered the division of labor as an evil because it lies at the basis of class differences and of man’s alienation from the products of his hands. Max Weber, on the other hand, saw the division of labor as the inevitable counterpart of the process of modernization and rationalization of Western society. This process is characterized by the institutionalization of purposive-rational economic and administrative activities. These activities crystallize in two broad domains: the market (the capitalist enterprise) and the bureaucracy (public administration). Examples of bureaucratic control are activities of supervisory bodies, of authorities occupied with the enforcement of legislation, and of institutes that check whether certain standards are met. Characteristic for both domains are the functional and specific relations between providers and consumers, and between representatives of the bureaucracy and those who make use of its services, respectively. Other resemblances are the restricted domain of competence and power, and the application of universalistic, impersonal standards.
This first phase in the development of professions is usually seen as the expression of just another form of rational and functional division of labor, with traits of a bureaucracy. Leading sociologists such as Talcott Parsons (1963) emphasize not only the rationality of this process, but also its integrating function and uplifting potential. Professions have this integrative and uplifting role because their members are not only experts but also bound to certain norms and codes of conduct. These norms and codes embody goods that never would have been realized if professional–client relationships had been defined in terms of the market. Freidson suggests in his later work that the professional–client relationship conforms to a “third logic” (Freidson 2001), apart from the logic of the market (consumerism) and of the bureaucracy (managerialism). Most significant for professions is that they are permitted to regulate and control their own practices. Professions would lose all resemblance to their current manifestations if they became “mere casual labor in a spot market controlled by consumers” or “mere job-holders in firms controlled by managers” (Freidson 2001, 7; see also chap. 8). The third logic consists therefore in the specific form of giving and taking within the social contract that underlies the professions.
The second, critical phase (also called revisionist, ideological, or postmodern phase) in the sociological analysis of the professions puts emphasis on the negative effects of professionalism. The way these negative effects are described sometimes seems to echo Karl Marx’s objections against the division of labor: the professional is seen as someone who exploits his position of power to sustain his privileged, self-interested monopoly (Evetts 2003). Larson, for instance, one of the major voices in the critical camp, states that the medical profession in the u.s. has not shown the strength to safeguard its public mandate. Doctors have been more concerned with their own private interests than with pursuing the collective value of health. She deplores the lack of benefit the medical profession has yielded for the public good (Larson  2013; 2003, 460, cited in Kanes 2010). Illich (1976) goes one step further in his influential book Limits to Medicine by suggesting that the system of health care produces its own illness (iatrogenesis). Modern medicine disempowers people and expropriates them of their health. Such criticisms, however, are not restricted to the medical field.
Freidson mentions three general issues in what he calls the “assault on professionalism”: criticism on the monopoly of professions, on social closure, and on credentialism. These three issues are mutually related. The monopoly concerns the privileged position of professions in the market; i.e., their jurisdiction and exclusive command of how expert knowledge and technical means are put to use. Social closure refers to the claim that professions have the right to determine their own criteria for membership. Credentialism, finally, denotes the profession’s right to establish its own “credentials”—i.e., its standards of excellence and systems of accreditation. We live in a time of distrust in professions and a longing for deprofessionalization. This distrust can be understood as a result of societal criticism on the three self-ascribed privileges just mentioned.
Focusing specifically on medicine, Marmor and Gordon (2014) discuss a number of themes in the critical literature. Critics complain that the inherent inequality in terms of knowledge and skills has turned into misplaced superiority and display of authority (paternalism). Another issue is self-regulation, which has become a protective shield instead of a way to strike the balance between self-interest, service to the public good, and striving for the appropriate level of competence. This is the mild version of Larson’s criticism. Another issue is the traditional disdain of doctors for any form of competition and competitive commercialism. This disdain has sometimes turned into detrimental indifference to medical costs and the problem of controlling those costs. And, finally, the individual patient–doctor relationship has been focused on to such extent that it has led to a relative neglect of medicine’s role with respect to larger societal problems and public health concerns.
Such criticisms have caused some scholars to predict the decline and even the end of the professions (Broadbent, Dietrich, and Roberts 1997; see also Tallis 2004). Professional elites will become “proletarian” and this will dramatically change the profession, says Kaul (1986) about journalism. For a while the term proletarianism enjoyed some popularity as a way to describe the process of deprofessionalization. The idea is that, just as the proletarian has alienated from his labor, so the professional will alienate from his work. Krause (1996) states that professions behave like guilds and that, because they continue to do so, they will die out.
However, with the exception of some radical proponents of the free market, only a few scholars really believe that patients will behave like autonomous consumers and will, for instance, be able to gain all the relevant information and use it for their own benefit. The information that is available in the media and on the Internet is often incomplete or distorted because of the framing by interests groups. In other words, the “transaction costs” of deprofessionalization will be enormous: inexperienced service users need to work themselves up to a position in which they are able to assess the risks and benefits of the different options in a sufficiently realistic and adequate way. Many users will never reach this position or will simply not be willing to put in the effort required for this (Freidson 2001, 205).
The third phase in the sociological study of the professions began in the late eighties and early nineties of the previous century. This phase is characterized by a cautious reappraisal of the role of professions, by a search for balance, and a more empirical orientation (Irvine 2001). Abbott (1988), for instance, puts more emphasis on the internal dynamic within and between professions. Professions are not only interacting with governments and other bureaucratic agencies and financial partners, but also with each other: there are permanent negotiations between professions about their jurisdictions. Abbott also asks attention for the relation between kinds of professional work and the way the respective professions safeguard their credibility, accountability, and level of expertise. Different types of work require different credentials and different forms of education, quality control, and organization. Other studies point to the different ways of organizing work and how this has led to a plurality of professional styles, also in medicine. For medicine, Castellani and Hafferty (2006) mention seven of these styles: nostalgic, unreflective, academic, entrepreneurial, empirical, lifestyle, and activist. Bloom, Standing, and Lloyd (2008) see this plurality in the creation of new partnerships between states, market players, and civil society organizations. Given the larger role of formal and informal markets in the system of health care, the information asymmetry between experts and clients has become increasingly important. As a result of this asymmetry, additional regulatory arrangements are required to protect vulnerable consumers against exploitation, misinformation, and insufficient care. These new arrangements require new and targeted negotiations on specific aspects of the social contract. Today, these negotiations are more than ever mediated by non-market institutions such as public health bureaucracies, non-profit organizations, advocacy groups, and regulatory bodies.
4 Contexts of Professionalism: Levels and Kinds
The overall impression of this overview is that medical practice is evolving in an increasingly complex societal context, with many partners, with different mandates, jurisdictions, and responsibilities. In view of this increasing dominance and complexity, it is I think helpful to distinguish between levels and kinds of contexts. With respect to the levels (or strata) I will refer to micro-, meso-, and macrolevels of interaction. Individual patient–professional encounters are obviously located at the microlevel of interaction. Institutional factors belong typically, but not exclusively, to the mesolevel of interaction. Legal changes and other governmental actions take place at the macrolevel. With respect to the kinds of context I will discern economic, legal, institutional, and administrative forms of interaction.
Generally speaking, current medicine is characterized by a much larger impact of meso- and macrolevel factors on patient care and research than previous health care arrangements. Rather than discussing a list of all possible contextual factors, I refer to the tentative and incomplete overview in table 1 below, which gives an impression of the developments and factors with which current health care is intertwined.
To illustrate this with an example, let me briefly focus on the role of administrative factors, which form a considerable burden in many health care sectors today. The partially new forms of administration serve at least three goals: financial control, pursuit of safety, and warrants with respect to the quality of care. Note how these different factors refer to different stakeholders in the delivery of excellent and sustainable care. Financial control refers to the role of the government in maintaining the legal and economic framework of current health care. It also refers to the role of insurance companies, charity funds, and the industry in the financing of the system. Similarly, safety is not only a microlevel social issue but also typically an institutional (mesolevel) and public health (macrolevel) concern. It refers to the role of internal rules within health care facilities as well as to the role of all kinds of supervisory bodies. Quality of care, finally, is also increasingly defined in terms that transcend the individual doctor–patient relationship. The accessibility of health care facilities is one of the important items in quality assessments. Efficiency and accountability are two other important issues. The supervision and control of these different elements takes place predominantly at the meso- and macrolevels of interaction between stakeholders.
Counterproductive as most of these administrative requirements seem to be to the individual professional, they seem to be more or less inevitable from a broader perspective. It is at this point that two macrolevel developments intersect, namely, the profession’s attempt to regain trust, on the one hand, and the need to put an end to the spiraling costs of health care, on the other hand. Both developments reinforce each other in the sense that both lead to an increase of the administrative burden.
The weakening of trust in the medical profession can be at least partially attributed to individual scandals and improper behavior of individual members of the profession. The profession no longer succeeds in keeping up the image of impeccability and of the unconditional desire to put the patients’ interests above self-interest. As a result, the prestige of the profession has diminished. To regain trust, the health care sector needs to accept additional forms of regulation beyond its own self-regulation. Examples of such new regulations were already briefly alluded to above and can be found in the sphere of patient safety (medication use, prevention of physical harm), transparency (electronic records, standardization in the form of treatment protocols, digital prescription of medication, registration of compulsory measures in mental health care), efficiency (registering of the activities of doctors and nurses and the matching of these activities with treatment protocols), and efficacy (outcome monitoring, measuring of patient satisfaction). In spite of the intention of governments and other stakeholders to deregulate the sector, the new rules have laid the basis for a new bureaucracy.
This bureaucracy has in turn strongly increased as a result of changes in the financing of the system. These changes are simultaneous with the increase of bureaucratic control. Rising costs put the system under pressure. In many countries, market incentives have been allowed for the purpose of stimulating efficiency and efficacy. Markets, however, do not instill trust: in fact, they tend to have an eroding effect on trust, especially in non-profitable segments of the market (Polder, Hoogland, and Jochemsen 1996). As mentioned earlier, these segments need additional safeguards against exploitation, misinformation, and insufficient care. Today, these additional safeguards are abundantly—and disturbingly—present; for instance, in the form of rules aimed at the improvement of accountability, transparency, and quality of care. Such rules came on top of the rules just mentioned, which aimed at the reliability and transparency of the process of care. Because of these new rules, health care providers were obliged to monitor and report about the various elements of the new agreements.
The issue—increase of administrative burden—shows that there exists an underlying logic behind these developments. Table 1 helps us to understand how these various factors intersect. Very generally, we may conclude that, in terms of the npm, the conditioning aspects play a decisive role in the recent reforms of health care, both at the meso- and the macrolevel. There is a lively interaction between the legal, economic, and social kinds of normativity, and between these three and medicine as a larger societal good.
5 Professionalism is by Definition Related to Responsibilities in the Meso- and Macrosphere
This is a good point for a philosophical reflection on the issue of legitimacy and the notion of trust with regard to professional relationships. I will focus on two issues. I will go back to the individual professional relationship and discuss the role of expert knowledge in discussions about the legitimacy of medicine. Then I will return to larger contexts and discuss the impact of differences in context on the definition of the object, purpose, and legitimacy of medicine.
We have seen that the expert role is contested today. It is contested by strands within the service user movement. It is under pressure in commercialized sectors of the profession. And it is threatened by inter- and intra-disciplinary competition, loss of status, and fragmentation of the field of health care. Many of these developments are a byproduct of ongoing specialization and introduction of market incentives.
At a more fundamental level there are other issues influencing the very notion of expert knowledge and skills. It has, for instance, been suggested that the fortunes of professionalism are part of a more general and subtle change in our relation to knowledge and expertise as such (see Beck and Young , who refer to the work of sociologist Basil Bernstein), which consists in the fact that competence is no longer seen as “owned by” scholars and that professions are no longer conceived as embedded in scholarly contexts and traditions. Knowledge has been reduced to bits of information that are freely available to everyone, and skills are seen as more or less isolated abilities that can be appropriated where and when one wants and can be put to use deliberately. The relation between subject and knowledge and between practitioner and competence has become instrumentalistic (or, functionalistic). Knowledge and skills do not mean anything in themselves—they acquire meaning depending on their use. So, the best thing for a competence is to be transferable—i.e., effortlessly transferable from one context to another. Something similar goes for knowledge: it should be generic—i.e., general and suitable for use in as many contexts as possible. As a result, education and professionalism are no longer seen as embedded in practices with different styles, cultures, and implicit understandings of the world.
The ideology behind these suggestions and developments is questionable, however. There are at least two major drawbacks.
First, the instrumentalist approach to specialists’ knowledge and skills is too abstract. It is simply not true that competences can be operationalized apart from contexts. The competence of communication, for instance, involves quite different abilities that largely depend on the context. Talking with a severely psychotic and violent patient at a police station requires other communicative skills than psychodynamic psychotherapy. And negotiating with a patient at a closed ward about the level of restraint required for reasons of safety appeals to different collaborative skills than negotiating about treatment options with a fully competent anxiety disorder patient. So, competences such as communication and collaboration refer to a wide variety of skills that are highly context sensitive.
Secondly, the abstractness of the idea that skills can be separated from the persons who use them forms another drawback. The professional role is more than a set of loosely coupled skills. Professionals relate to their roles, and the manner in which professionals do this becomes part of their professional identity. Trainees need to grow into their future roles, and this growing requires that one is embedded in the relevant environments. These environments should, ideally, allow residents to discover their personal balance between who they are and who they are required to be in terms of knowledge, skills, and attitudes.
I readily admit that the relation of “postmodern” professionals to their knowledge and skills is changing. These changes are not new, or even “postmodern”: they are, in fact, predictable on the basis of Weber’s idea of an ongoing division of labor and of increasing interlacements between different spheres of life. However, these changes offer insufficient ground for a complete revision of the notion of professionalism, including a separation between the professional role, the context, and the professional as a person. It is the npm that suggests a different direction, to wit, a reinterpretation of transferability as “aiming at context-sensitivity.” The increasing complexity of current mental health care, both contextually and qua expert role, should not be addressed with a decontextualized concept of competence, but with a notion of competence that is even more contextually sensitive than it used to be. Transferability should not imply isolation and decontextualization. Ideally, it is accompanied by an increased awareness of the responsibilities of the different stakeholders (medical, legal, social, and administrative) and of the interlacements between micro-, meso-, and macroprocesses. This awareness is preferably guided by what one might call the principle of “simultaneous norm realization,” or some version of it (Van der Kooy 1964; Goudzwaard 1982).
The dominant role of contexts in the shaping of knowledge and skills also influences the assessment of the role of expert knowledge in discussions about the legitimacy of professionalism. What is it in expert knowledge that justifies its special role? And to what extent does the legitimacy of professionalism depend on the expert role?
One obvious position on this issue is that the authority of the professional solely depends on the expert role and, more specifically, on its being based on science and evidence-based interventions. This is what one might call a scientistic defense of the legitimacy of medical professionalism. We have seen that this position is ahistorical in the sense that it disregards the role of the social contract with its idea of a public mandate to serve some greater good in exchange for the relative independence of the profession. One-sided emphasis on the scientific foundation of professionalism, in other words, neglects the role of values (e.g., trustworthiness, honesty, altruism) in the very idea of being a medical professional. These values are not accidental—they form the basis for the social contract that undergirds professional activities. Moreover, another major drawback of such one-sided emphasis on the expert role is paternalism. If science determines what the “real” problem (or the real disease) is, then it is the professional, as representative of science and guardian of truth, who knows what is the matter and, consequently, who knows what is best for the patient. As a reaction to such paternalism, another extreme has emerged; namely, a devaluation of the expert role.
Both the scientistic adumbration of the expert role and the rejection of it by critical patient movements are related to the same improper valuation of science’s limitations and the same neglect of the distinctions between science, clinical practice, and worldview. The npm helps to provide a proper place for science and technology in medical professionalism. The scientistic defense of the legitimacy of medicine (and psychiatry) expects too much from science; namely, that science is or will be able to eliminate every uncertainty in the consulting room. The critical view assumes that expert knowledge belongs to a system with oppressive and disempowering traits. Both views fail to appreciate sufficiently the inherent limitations in scientific approaches to medical problems—limitations that follow from the abstract mode of observing and thinking of the scientist. Scientists may speak with authority when they respect the limitations of their methods and say no more than can be justified on the basis of their proper use.
That said, doctors as well as patients will always have to deal with what Gorovitz and MacIntyre (1976) have called the “inherent and necessary fallibility” of medical knowledge. Even in the ideal case of having complete knowledge of all the relevant causes and mechanisms, doctors will never be able to predict with 100% certainty what will happen in an individual case. There are therefore already on epistemic grounds good reasons to argue for a basis for medicine’s legitimacy that is broader than epistemic. Expert knowledge is important, even crucial—without it, there is no medical professionalism. That is what the npm means when it attributes a foundational role to scientific knowledge and technology. But science and technology cannot be the only or the ultimate ground for what doctors do.
- •Expert knowledge and skills deserve a special status because they are foundational for the practice of medicine.
- •The expert role functions in a broader framework of normative relations.
- •Contexts are part of this framework of normative relations; public responsibility of professionals (and of other stakeholders) is at the heart of professionalism.
- •Knowledge is never “just knowledge” but always part of a practice—a practice of knowing (as in science) or construing (as in technology) or predicting (as in policy making and treatment). All these practices have, as we have seen, normative dimensions.
Expert knowledge in itself cannot fully justify the authority of doctors nor undergird the legitimacy of what they are doing. Although expert knowledge is a sine qua non for medical professionalism, for the legitimation of the professional practice other norms are relevant, such as social, economic, and jural norms. These norms refer to the broader context in which medicine as normative practice is executed. In terms of the npm, doing justice to social, economic, and jural (i.e., conditioning) norms is the proper way to let the professional role take shape against the background of the broader contexts discussed above. Ideally, these broader normative dimensions assure that the expert contributes to the patient’s good—not only by opening up the clinician’s understanding, but also by attuning professional insight to what is good for this particular patient in this particular set of contexts.
6 Contexts and the Definition of Responsibilities and Jurisdictions
I will continue by making some remarks on the role of contexts in the definition of professional authority and jurisdiction. Do the roles and responsibilities of the professional and other actors in the field of health care differ depending on the level of context?
What follows is not an analysis of all the relevant elements for the discussion nor a systematic overview of all kinds of contexts, but a sketch of how the framework we have begun to develop may be filled in further. I will, moreover, only discuss levels of contexts and how they have an impact on professional responsibilities. Contexts are decisive for the definition of responsibilities.
Ideally, the discussion about duties and jurisdictions of health care professionals and other parties is settled on the basis of a realistic assessment of what can be demanded from the various partners given their competence, their social (contextual) horizon, legal constraints, and their specific role in the delivery of care. In practice the picture is much more messy, ambiguous, and characterized by unresolved tensions. Not only the content of care is negotiated—the “products,” so to say—but also the terms under which these products are delivered. These terms co-define the rights, duties, and responsibilities of the relevant stakeholders. There is no blueprint for the definition of these responsibilities. Bloom, Standing, and Lloyd (2008) discuss “new partnerships” between representative bodies within the state, market players, and civil society organizations. Castellani and Hafferty (2006) predict a proliferation of professional styles.
Blueprint or not, it seems obvious that the duties and jurisdictions of physicians at a microlevel differ from duties and jurisdictions of doctors at other social levels. Differences in duties and jurisdictions are based on differences in responsibility; these, in turn, are based on differences in domain (or object) and the type of good that needs to be realized in that domain. For example, a physician in the board of a regional hospital has other responsibilities than a physician in a private practice. Also, professionals involved in macrolevel policy making have duties and responsibilities that are substantially different from the duties and responsibilities of their colleagues in private practices and hospital boards. These differences can be traced back to differences in domain and in types of goods associated with these domains.
The domain of the hospital ceo (mesolevel) is twofold and concerns, broadly speaking, (i) the relation between the hospital and the practitioners to whom it provides employment; and (ii) the relation between the hospital as institution and other players in the field, both medical and non-medical, such as the state, the legal system, insurance companies, competing institutions, service users, and the public. Much of what the ceo does aims at the improvement and strengthening of the conditions under which practitioners deliver their services. This part of the job has an internal focus. Another part of it is externally focused and consists in negotiations with all relevant stakeholders about how to face health care needs at a regional level. The institution has as a purpose the creation of stable conditions for the delivery of these services. The duties and jurisdictions of the ceo concern, therefore, the norms, rules, and principles that regulate the “conditioning” aspects of medical practice. But the institution has also an externally focused purpose, namely, to adequately respond to the need for medical care in a given catchment area.
This implies four things. First of all, hospitals are not ends in themselves. They exist for a greater good—i.e., the care and treatment of people who suffer from illness and decline. Secondly, the focus on this greater good is not at odds with the idea that the primary responsibility of the hospital representative should be the managerial and economic side of the transactions that take place in order to fulfill health care needs. Thirdly, it also means that what ceos do is a good in its own right. Current medical practice is unthinkable without the guarantees the institutions offer: housing, administrative support, technical equipment, contracts with insurers, platforms for teaching and education, a living for its employees, and so on. So, the kind of good that is associated with the institutional domain and, more particularly, with the hospital as institution, is that it provides safeguards with respect to the conditions under which health care can be delivered. A fourth, more subtle implication is that conditioning norms are not self-contained but related to and determined by qualifying norms: the promotion of the conditions that make health care possible takes place with an eye to the main purpose of medical practice, which is to cure, to care, and to console. More technically phrased: the norms and principles of the conditioning aspects are “opened up” in the direction of the qualifying aspect of the constitutive side of medical practice.
Something similar holds for the macrosphere—that is, for the role of the state, advisory and supervisory boards, professional organizations, patient movements, and the legal system. The domain covered by these agencies is diverse and concerns, for instance,
- •the laws and agreements that help determine whose behaviors should be sanctioned as deserving professional attention;
- •the raising and framing of public awareness of health problems and of expectations about what health care can do (health education);
- •the registering and reporting of illnesses for public health purposes;
- •prevention; and
- •the raising of awareness of stigma and social exclusion.
Many of these activities are meant to provide the conditions that make health and health care possible. They can be grouped together and placed under the umbrella of medical practice itself with its own telos of serving the ill. This is another way of saying that doing justice to the conditioning aspects is intrinsically related to the moral meaning and purposes of health care. However, given this overarching telos, the focus of local actors will usually aim at the conditioning spheres themselves. The medical advisor at a ministry of health, for instance, can be convinced of the need for patient empowerment; but she will not undertake action herself (for instance, as campaigner) in this respect. Instead, she will maximally promote the conditions which make empowerment possible. This aim can be promoted by subsidies, legal reform, and additional regulations. Such financial, legal, and administrative measures are enabling: not a form of help in themselves, they enable the good cause of patient empowerment.
It is tempting to proceed from here to an analysis of the internal structure of the hospital, or of health care as a societal phenomenon. But this must be left to another occasion. My account so far has shown that, at the meso- and macrolevel, activities of stakeholders are ideally defined as taking place under the umbrella of healing, diminishing of suffering, and consolation. These activities can, in other words, still be understood from the perspective of the npm, taken in its broadest sense. However, these activities themselves are determined by non-moral types of norms—i.e., norms that are related to efficiency, sound policy making, and justice (e.g., fair distribution of means in a certain region). At the mesolevel of analysis, the emphasis is on adequately dealing with the need for health care services. At the macrolevel, the focus is on fair distribution of means and on protection of the general population—from natural disaster, epidemics, and general health risks.
The npm is not a blueprint of how reality in itself is, nor is it a model prescribing what professionals should do. It serves, ideally, as a heuristic device that helps professionals and administrators to orient themselves, both conceptually and normatively, in the field of health care. We have seen that variations in contexts lead to differences in emphasis in the pattern of normatively relevant aspects. This could eventually lead to new and more complex models. But as we have seen, the complexity of the current health care system can also be addressed with the existing npm (fig. 1), namely, by taking it as a point of reference; by relating the different normative dimensions to core responsibilities of other employees and stakeholders beside medical professionals; and by relating these core responsibilities to the relevant contexts in which these other employees and stakeholders are working.
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