AMA Journal of Ethics^®

More ES. The remains of the profession, or what the butler knew. Ann Intern Med. 2001;134(3):255-259.

In The Remains of the Profession, or What the Butler Knew, the author attempts to answer the above questions by reflecting on the actions of Stevens, the butler in Kazuo Ishiguro's award-winning novel, The Remains of the Day. By way of comparison with Ishiguro's work, the author argues that as physicians lose control over the ends of their work -- patient care and well-being -- and disclaim responsibility for the uses to which their work is applied, their professionalism erodes. As their sense of professionalism erodes, physician-employees of health care organizations may identify increasingly with their colleagues and employers, become emotionally disconnected from patients and, worst of all, fail to develop their capacity for individual moral agency. Like Ishiguro's butler, physician-employees may end up only mimicking professionalism as they work for employers who value them only as servants.

Questions for Discussion

1. The author believes that professionals must not abrogate their core duties "to make sound and ethical judgments and to acknowledge the responsibility for having made them." Is it possible for physicians to exercise these "core duties" under the conditions imposed by contracts with managed care organizations?
2. Is the recent establishment of physician unions connected in any way to the eroding of professionalism the author describes?
3. AMA policy as promulgated in its Code of Medical Ethics maintains that physicians' professional duties to patients should not be altered by the system of health care delivery in which they practice. How can physicians avoid conflicts between their responsibilities to patients and their responsibilities to provider organizations to whom they are under contract?