This special section deals with the new professionalism movement. The interest in the term “professionalism” has been growing steadily in medicine, and the word now seems to be everywhere. However, bioethicists have lagged behind our colleagues in medicine and nursing in explicitly contributing to this movement. This special section adds to the effort to catch up.

There is a wind of change about to affect the training of all house officers in the United States. The Accreditation Council of Graduate Medical Education (ACGME) has promulgated a set of general competencies for all U.S.-trained residents, with a major thrust focused on bioethics and professionalism that will likely catch residency directors unaware. The ACGME's General Competencies document globally addresses many relationship-based ethical roles and responsibilities of house officers in healthcare. Of note, this document contains a specific section on professionalism. However, the entire document is woven with a sustained thread of medical ethics throughout its other sections. The intent is to imbue each physician with those skills, rules, and aspects of character that will be a foundation for humane, ethical, professional conduct. Professionalism does indeed go beyond ethical principles, accounting for competency and commitment to excellence and, most of all, implying a virtue ethics account of medical practice. The need to address the central place of virtue ethics in house-staff education is apparent, and we now have the right tool for the job—the ACGME General Competencies.

“Character counts at Central High” is the message frequently exhibited on the curbside marquee outside our local secondary school. Its meaning, however, is left to interpretation by those who happen to drive by the electronic display. More than likely, the deceptively simple declaration implies that Central's curriculum and associated activities are value laden, that they somehow address the collective and somewhat ambiguous set of traits we label “character.” It is a hopeful message to those who consider forming the character of the country's future workforce and citizenry to be an important goal of schooling.

Medicine is in a very self-reflective mood. There is a revival of interest not only in medical ethics (a.k.a. bioethics) but also in medical history, the Hippocratic corpus, and various kinds of literature that indicate physicians are reexamining the foundations of medicine and what it is that gives meaning to medicine. That is, they are reexamining the physician's vocation, in the true sense of vocation as a calling. This interest has coincided with the concern of third parties such as accreditation agencies about the professionalism of physicians.

Professionalism, like common sense, remains a timeless ingredient in the ethically successful practice of medicine in the twenty-first century. Professional ideals are particularly relevant in times of economic and social upheaval, medicolegal crises, provider shortages, and global threats to the public health. The American Board of Internal Medicine specifies professionalism as “constituting those attitudes and behaviors that serve to maintain patient interest above physician self-interest.” Because of its transcendent nature, professionalism, like ethics, is also considered “a structurally stabilizing, morally protective force in society.” Professions enjoy tremendous deference and autonomy in exchange for three unwritten but prerequisite promises: expert knowledge, self-regulation, and a fiduciary responsibility to place the needs of the client ahead of self-interest. Many educators suggest that professionalism includes additional characteristics such as honesty, altruism, temperance, commitment, integrity, and suspension of self-interest. However, there are large gaps in providing more user-friendly and operational models of professionalism to learners and evaluators at all levels of the academic hierarchy.

What do the terms “profession, professional, professionalism” mean in 2002? One dictionary defines profession as “a calling requiring specialized knowledge and often long and intensive academic preparation,” and it defines professionalism as “the conduct, aims, or qualities that characterize or make a profession or professional person.” These definitions are appealingly simple. Complexity arises when we add the term “medical” as in the medical profession, a medical professional, or medical professionalism; and, here a specific understanding of “the conduct, aims, and qualities that characterize” the field of medicine is required. To complicate matters, professionalism applies to both the profession as a whole as well as the individual professional persons, such as the physicians.

These CQ Sources were compiled by Bette Anton.

Although space limitations do not permit including all the responses received after the passing of David Thomasma, some representative expressions are included below. As these remembrances attest, Edmund Pellegrino spoke for all of us when he said at David's memorial service, “It has been said that we die only when forgotten; if so, David will live a long time. He remains a presence for his family, friends, collaborators, and all who met him.”

On September 4, 2001, press reports indicated that the Defense Intelligence Agency of the U.S. Department of Defense (DOD) planned to reproduce a strain of anthrax virus suspected of being held in Russian laboratories. According to the same reports, the Central Intelligence Agency (CIA), under the auspices of Project Clear Vision, is engaged in building replicas of bomblets believed to have been developed by the former Soviet Union. These small bombs were designed to disperse biological agents, including anthrax. Government attorneys were said to be confident that, because these projects were designed to develop defensive measures, they were not in violation of the 1972 Biological and Toxin Weapons Convention.

Over the past decade or so, the predominant patient-centered ethos in American bioethics has come under attack by critics who claim that it is morally deficient in certain respects, particularly when viewed in the context of acute-care decisionmaking. One line of criticism has been that the current ethic of patient autonomy gives an individual competent patient far too much decisional authority over the terms of his own treatment so that the patient is at complete liberty to neglect the ways in which his medical decisions can drastically and negatively affect the lives of other family members. Given that family members must help shoulder the financial, emotional, and rehabilitative burdens involved in the patient's care, it has been argued that they too have a legitimate interest in choosing what sort of medical treatment the patient eventually receives. Another closely related line of criticism is that the prevailing focus on patient autonomy gives short shrift to the moral significance of the family as a genuine community. Echoing a view of the person advanced by most communitarian political theorists, some commentators have argued that the patient comes to the clinic so thoroughly embedded in a complex web of familial relationships and obligations that it does not make sense to identify him as the only person in the family to make decisions about treatment.

The belated but formal acknowledgment of medical errors and their impact has been well documented. Curiously, the topic of management or executive mistakes in healthcare is not raised in professional meetings nor, until recently, addressed by an article in health administration journals.

Clinicians, operating within complex systems, make mistakes, as people do in every human endeavor, and when they do, patients are sometimes harmed. One important question is how we as clinicians can find resolution in the wake of an error. The published literature has divided errors into those caused by “systems” and by “individuals.” But whereas both “systems” and “individual” approaches are important in understanding the cause of an error, neither alone can fully lead to resolution once an error has occurred. Instead, both are necessary to understand, resolve, and prevent errors.

As medical students we were not discouraged from introducing ourselves by saying, “Hello, I'm Dr. So-and-so,” as opposed to identifying ourselves as students. If we happened to be doing rounds with an intern or resident, the physician would introduce himself or herself as “Dr. X and over here is Dr. Y”—indicating a student. When I introduced myself as a medical student, I got the feeling that people thought it was silly or unnecessary.

The challenge of determining that therapeutic intervention is futile is a recurrent ethical theme in critical care medicine. The process by which that determination is reached often involves demanding collaborative and interdisciplinary conversation and deliberation within the context of hospital policy, including ethics committee guidelines. The subsequent decision as to what happens next depends on resources, such as palliative care services, hospice, other hospital protocols, and, of course, family support.

This section is meant to be a mutual effort. If you find an article you think should be abstracted in this section, do not be bashful—submit it for consideration to feature editor Kenneth V. Iserson care of CQ. If you do not like the editorial comments, this will give you an opportunity to respond in the letters section. Your input is desired and anticipated.