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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. Specifi-
cally, 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 professional-
ization 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 multidisci-
plinary 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.
20 DEBORAH CUMMINS

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 char-
latans 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 nonclini-
cian 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 21

a bearing on the status of bioethics consultation. While the trait theo-


rists, 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 knowl-
edge 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 tech-
nical knowledge.8 For Weber, all of human history could be conceptu-
22 DEBORAH CUMMINS

alized as the progressive rationalization of the world. He therefore envi-


sioned 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 dehu-
manizing 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 member-
ship 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 character-
istics, 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 rela-
tively 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
PROFESSIONAL STATUS OF BIOETHICS CONSULTATION 23

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 divi-
sion 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 mean-
ings. 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,
24 DEBORAH CUMMINS

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 require-
ment 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-
PROFESSIONAL STATUS OF BIOETHICS CONSULTATION 25

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 disci-
pline 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 profes-
sions 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 multi-
disciplinary 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 consul-
tants 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 health-
care 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 demo-
cratic 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’ posi-
tions 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 consulta-
tion possesses some but not all the traits thought to be needed to become
26 DEBORAH CUMMINS

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 previ-
ously 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 auto-
workers, 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 profes-
sional 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 full-
time occupations that provided “the principal source of their members’
PROFESSIONAL STATUS OF BIOETHICS CONSULTATION 27

incomes.”25 Yet, relatively few bioethics consultants are employed full-


time 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 require-
ments. Even though the SHHV-SBC Task Force issued a report on core
competencies for healthcare ethics consultants, it only called for volun-
tary 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 educa-
tional 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.
28 DEBORAH CUMMINS

Fourth, Wilensky’s model stipulated that states establish licensing regu-


lations 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 emer-
gence 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 prac-
titioners, 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
PROFESSIONAL STATUS OF BIOETHICS CONSULTATION 29

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 consid-
erable 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 specifi-
cally 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, health-
care 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
30 DEBORAH CUMMINS

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 news-
paper 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 criti-
cized 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 juris-
dictions 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
PROFESSIONAL STATUS OF BIOETHICS CONSULTATION 31

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 (profes-
sionals) 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 crim-
inal 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. Bound-
aries will shift between healthcare ethics consultation and other profes-
sions. 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 practi-
tioners in medicine and ethics “posture to maintain disciplinary turf.”47
Frank Marsh, an attorney-ethicist, commented on this power dispute
32 DEBORAH CUMMINS

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 previ-
ously 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 estab-


lished 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 responsi-
bilities and authority of ethics committees functioning as ethics consultants
have increased.53 The first change mandated that, in addition to hospitals,
PROFESSIONAL STATUS OF BIOETHICS CONSULTATION 33

all licensed nursing homes in Maryland would be required to establish


ethics committees. The second modification contained the following stip-
ulations: (1) certain types of disputes involving the medical treatment of
individuals with life-threatening conditions “must be referred to the insti-
tution’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 determina-
tions. 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 consulta-
tion 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 decision-
making authority in patient care to ethics committees and provides for
34 DEBORAH CUMMINS

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 docu-
mented 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 inter-
dependent 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 jurisdic-
tional 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
PROFESSIONAL STATUS OF BIOETHICS CONSULTATION 35

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 deprofes-
sionalization 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 medi-
cine, for example, illustrate this transformation. Marsh observed, “Physi-
cians 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 special-
ized 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-
36 DEBORAH CUMMINS

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 indi-
vidual 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 effec-
tively . . . 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
PROFESSIONAL STATUS OF BIOETHICS CONSULTATION 37

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 knowl-
edge 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 profes-
sionals and to the larger society. For example, in a series of lectures at
the turn of the twentieth century, Durkheim developed the idea that profes-
sional 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 estab-
lished 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 ques-
tions 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 neces-
sarily 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
38 DEBORAH CUMMINS

fellowships, peer-reviewed journals, and written standards adopted by a


national organization, healthcare ethics consultants are claiming special-
ized 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. Clari-
fying 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-
PROFESSIONAL STATUS OF BIOETHICS CONSULTATION 39

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 health-


care 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 practi-
tioners 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 knowl-
edge 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 estab-
lishing 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
40 DEBORAH CUMMINS

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 prac-
tice 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 professionaliza-
tion. Instead, imagine that a continuum exists with occupational jobs, such
as sales clerk or construction worker, placed at one end and well estab-
lished 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.
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42 DEBORAH CUMMINS

33 Scofield, 420. Scofield also complains about the field’s lack of a code of professional
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Winter 1994; 3(1): 9.
34 The 1998 SHHV-SBC Task Force Report, Core Competencies for Health Care Ethics
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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
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39 Starr, 15.
40 Abbott A. The System of Professions An Essay on the Division of Expert Labor.
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41 Abbott, 3.
42 Abbott, 2.
43 Abbott, 35.
44 Abbott, 35–38.
45 Abbott, 38.
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51 Hoffman, 750.
52 Hoffman, 751.
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55 Chief Justice Hughes, Matter of Quinlan 355 A. 2d 647: 27.
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57 Hoffman, 790.
58 Ethics committees were legally mandated in Maryland in 1987, and in New Jersey in
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PROFESSIONAL STATUS OF BIOETHICS CONSULTATION 43
60 Abbott, 68.
61 An example of a profession establishing jurisdictional control over a competing occu-
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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
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62 Haug MR. Deprofessionalization: An alternative hypothesis for the future. Sociolo-
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63 Haug, Alternative Hypothesis, 196.
64 Marsh, 286.
65 Writings about the specialization of labor date back to the late eighteenth century.
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of solidarity based on occupational specialization. Writing at the turn of the last century,
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75 McCullough, 19.

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