William M. Sullivan. Work and Integrity: the Crisis and Promise of Professionalism in America

William M. Sullivan. Work and Integrity: The Crisis and Promise of Professionalism in America. 2nd ed. San Francisco, CA; Jossey-Bass, 2005.

Forward [Lee Shulman] Quotes an engineering student: “An engineer is someone who uses mathematics and the sciences to mess with the world by designing and making things that other people will want to buy and use – and once you mess with the world, you are responsible for the mess you’ve made.” Examples of this responsibility include matters of what to do with scrap from the production, disposal of parts following obsolescence, and what might have been done to make it better in the first place. “The moral challenge to the pedagogy [of professional education] is to guide the students through these increasingly responsible levels of practice, while sustaining the social contract with clients that guarantees zealous concern for their well-being and safety” (xi). Part of professionalism is to anesthetizeone’s natural moral equipment as a human being and replace it with a uniform code of conduct shared by one’s colleagues. “Unless you are confronted with the tensions inherent in the practice of any profession, the conditions for integrity are not present” Integrity is never a given, but always a quest that must be renewed and reshaped over time” (xiv).

Introduction: The Crisis and Promise of Professionalism. “Professions such aslaw, medicine, and academe have established for themselves shelters from pure market completion, a privilege granted on the basis of specific expertise. . . . But they have held such positionsof honor on the basis of a social contract with the public they serve. . . . Professions have received authority to control entry into their domains and key aspects of how they do their work” (2). “The public’s persistent worry about professions, often somewhat misleadingly described as a concern about profession ‘ethics,’ is in fact a suspicion that professionals have broken faith with the public” (2). Professions are distinguished from knowledge workers generally (computer programmers, researchers, help desk staff) on the basis of a pledge of public service. “The professions are publically chartered to make it their primary concern to sustain public goods” (5). The contract with the public must be two way: “In this book, the ideal of social reciprocity is called civic professionalism” (5). “One may question how well professionalism can function in a time when interest and participation in civic affairs continue to decline, while the conditions of even much professional work tend increasingly to link skills less with public purposes than with market advantage. So if the professions are not clearly obsolete in the new world of work, professional ideas are under sever strain” (95). [RB Reich.The future of success: Working and living in the new economy. New York, NY: Random House, 2000; P Osterman. Securing prosperity: The American labor market, how it has changed and what to do about it. Princeton, NJ: Princeton University Press, 1999]: The twentieth century was an economic abnormality with its rise and then decline in the statues of professions and constriction and subsequent increase in income disparities, including within the professions. Professionals today as experimenting with “how light they can travel”; which elements of the professional life are really essential. The trend is toward “technical professionalism”; “A redefinition of the professional as expert frees the most marketable members of a professional field to compete in an increasingly stratified and competitive marketplace, high-paying jobs, without being dogged by professions of social responsibility” (9). “At the same time, the collegial form of professional work is also under attack from those eager to bring expensive professional services under managerial control” (9-10). This trend is being exacerbated by massive funding of the professions by the government, including insurance, coupled with decreasing regulations. “Government professionalism,” such as the civil service, teaching, and regulatory positions such as the FDA have taken a hit. “Professionals’ greatest asset is this professional culture itself” (11). The more normative a knowledge mandate in the profession, the greater the profession’s social influence. “The narrowing of professional claims toward the purely the cognitive or technical in recent decades has contributed to the weakening of professionalism” (12). Even when employed, professionals can use claims of professional values and norms to shield them from influence by both managers and clients. “The popular image of the self-employed lawyer or doctor in solo practice is not the norm in any profession. Professional work has always been organized in guildlike networks of practitioners” (14). [BA Kimball. True professional ideal. In America: A history. Cambridge, MA: Blackwell, 1992]: “A profession is an occupation based upon formal knowledge and trainedskill, organized in a collegial or guildlike way, and carried on in a spirit of service” (16). “Professional service came to mean contractual relations between a professional and a client” (16). In America, freedom is defined negatively as lack of external constrain, individually defined. “As a model of work, professionalism questions the belief that consumer demand offers always and everywhere the best guidance for the conduct of social functions” (18). America is in search of “the terrific deal.” We want our needs satisfied now at the best price and with the least limitation on our personal effort, identify, or convenience. “The reward of the new economy are coming at the price of lives that are more frenzied, less secure, more economically divergent, more socially stratified. . . . As our earnings become less predictable, we leap at everychance to make hay while the sun shines” (19). The culture of the “terrific deal” includes unlimited free choice. “It is the notion of the detached self, a spontaneous series of choices through which the self comes to be the sum of its experiences. Perhaps the most influential manifestation of this belief in a detached self is in the popular equation of identity with consumer preference, as though a person really were just a sort of running tally (surreptitiously maintained in cyberspace by ‘cookies’) of clicks on a mouse, a ‘shopping cart’ of choices and experiences” (20). “A profession is a means of livelihood that is also a way of life. Professionalism seeks freedom in and through significant work, not by escaping from it” (21). There is also a “love this” dimension to professionalism. “American society needs the professions today. It needs them for what they do, certainly. But it also needs the professions as examples of ethical work” (22). “To become a professional is not only to join an occupation; it is to assume a civic identity. . . . What has been missing is action in which the professions take public leadership in solving perceived public problems, including the problems of abuse of privilege and refusal of public accountability” (23). “These trends toward increased commercialization seriously risk reshaping relationships between professionals and clients for the worse, substituting a calculus of cost and benefit for ethical relationships of care and trust” (24). “As the professional failures exposed by the collapse of Enron and WorldCom and their ilk have made vividly clear, codes and laws are not in themselves enough” (24). Professional education has become professionalized, but is still accredited and regulated by the professions. “Professions are set apart from other occupations by their public pledge to deploy technical expertise and judgment not only skillfully but also for public-regarding ends and in a public-regarding way” (27). The trend has been to divide professional education into specialized areas, separating the cognitive from the practical and ethical dimensions, in curriculum, faculty, and institutional locus” (27). “The book’s critical argument is that professionalism has proven an ambiguous good. The ambiguity stems in large measure from professionalism’s loss of direction. This in turn has been due to weakening connections between the professions and the culture of civic democracy. The culture is itself in crisis, so that the problems of professionalism emerge as tied up with the difficulties inherent in keeping the ideals of democracy and public service alive within an ever more complex but incoherent economic and social environment. Taken as a whole, this book makes the case that professional life can and needs to be restructured in ways that suffuse technical competence with civic awareness and purpose” (32).

Chapter 1: Professionalism. “A profession is typically described as an occupation characterized by three features: specialized training in a field of codified knowledge usually acquired by formal education and apprenticeship, public recognition of a certain autonomy on the part of the community of practitioners to regulate their own standards of practice, and a commitment to provide service to the public that goes beyond the economic welfare of the practitioner” (36). “Professionalism promises to link performance of special tasks with this larger civic spirit” (38). “Professional licensing and grant of control over recruitment and training of practitioners are part of a social contract between the organized field and society” (39). Professions “create goods that at some time are essential for everyone, and important for a society as a whole” (39). “The labor market puts pressure on professionals to behave competitively toward their peers, and to accede to the demands of profit when they conflict with professional standards of excellence. Indeed, it is in part to temper such market pressures that professional organizations exist. Yet, for a profession as organized interest, the aim at self-aggrandizement has proven to be perhaps stronger than it is for the individual” (40). This situation is complicated by professionals working in institutional settings. [We retain the myth of the individual, public servant professional in the face of an increasingly market driven organization system.] WS frames his analysis in terms of the tension between technical and moral standards for professionals. “When the academic guild is in charge, professional training emphasizes the cognitive and technical. In a situation in which the practitionersthemselves control education and licensing, performance and the culture of the guild tend to have much more importance as decisive standards of professional quality” (42). WS asks us to consider the thought experiment where “social and individual needs would be met more efficiently and effectively if ‘knowledge workers’ could compete for jobs now monopolized by licensed professionalson the basis of whatever skills and credentials consumers and employers decided were useful” (43). Journalism and business seems to fit this model [they also have strong codes and ethics education programs]. This approach will not work to the extent that relevant market information is unavailable. Hence medicine’s former antagonism to managed care. [The issue is who one chooses to partner with and what their value structure is.] “The authoritative model lurking in the background here is the ideology of deregulation currently in vogue. In this view, the only moral obligation of any enterprise is to maximize its economic well-being. By defining all public activities as self-interested, profit-oriented enterprises, this powerful trends works to strip away any moral understanding of the relationship between profession and society, or between professional and client, except that of commercial exchange” (44). Nobel laureate JosephStieglitz writes on the impossibility of deregulated economies in the face of restricted information, insider trading being a notorious example. WS explores the example of accounting that tried to establish itself as a top-tier profession by arguing that regulation should be pushed back in favor of trust. And then Sarbanes-Oxley in 2002 and the only hope for accounting firms being loose enforcement. “Such outcomes [loss of public confidence in professions] represent institutional failure as much as individual corruption” (50). Scrutiny and skepticism will do little to place the professions on a moral footing. We must find the systemic factors that drive the choices of individual professionals and modify them. Historically, the professions found advanced knowledge and skill (technical foundations) insufficient to establish professional status; they needed a contract with society and political and social arrangement. “The answer [to the dangers of misappropriating the social contract for personal advantage] is both strengthening accountability and a professional leadership attentive to public needs as well as attuned to practitionerwants, one concerned to improve standards and also to strengthen links between the profession and the public” (56). “The decline in medicine’s professional sovereignty began, paradoxically, with its greatest expansion during the burst of national enthusiasm for scientific progress that followed victory in World War II. In that era for the first time, organized medicine accepted government as a partner [for the money]” (57). Medicine, and other professions, now show up as line items in the budgets of other organizations such as government and business. In response, we have seen “the takeover of much of health care by for-profit managed care, with a high likelihood of some degree of government oversight and regulation, as yet to be determined” (58). Medicine finds for-profit management a better partner than government or the public generally. “The very success of the professions turned later-twentieth-century professional leadership inward toward building its own organizations and prestige. Claims to professional expertise displaced community trusteeship as the coin of legitimacy for most professional groups” (59). The new equation of “technical skill leads to profit” has replaced the equation of “public service leads to prestige.” This is a vicious cycle as privileging the technical dimension reduces the professions’ voice in public discourse, further insulating the professions. The Charter on Medical Professionalism was produced by the American Board of Internal Medicine Foundation and the American College of Physicians – AmericanSpecialty of Internal Medicine Foundation of the United States, together with the European Federation of Internal Medicine in the mid-1990s. In the preamble it states that “public trust in physicians turns on the integrity of both individual physicians and the whole profession.” “It is once again a serious question whether or not a profession can secure public recognition of its claims to traditional professional prerogatives on the basis of the marketability of its technical skills alone” (62). “As fields such as medicine come under the sway of larger market-driven organizations, it is far from clear that these fields will be able to sustain their social importance without reengaging the public over the value of their work to the society at large. If the professions are to have a future, they may need to make their case from a civic understanding, rather than a wholly technical one, of what it is that professionals are about” (62). [DL Rhode. In the interests of justice: Reforming the legal profession. New York, NY: Oxford University Press, 2000]: “Commercialism and incivility are increasing; collegiality and collectiveresponsibility are in decline. The priority of profits and the resulting sweatshop schedules have squeezed out time for public service and familycommitments” (p. 208 in Rhode). “The public is deliberately kept at arm’s length and denied input into professional decision making and self-discipline. The consequence is the paradox of a prominent and influential profession whose members feel; powerless in the face of the profession’s most crippling ills” (63). “This sense of powerlessness lies not in weakness of character on the part of individual lawyers. It stems from weak professional solidarity, manifested in the failure of the organized bar to take leadership in reform” (63). “What is needed, then, is collective empowerment of practitioners, guided by accountability to the public. Taken together, the experience of medicine and law suggest that professionalism flourishes only if key players within a profession take leadership in enforcing high standards of practice, while inviting public response and involvement in the profession’sefforts to clarify its mission and responsibilities” (63). “The most constant tension, as we have seen, is between a technical emphasis stressing specialization – broadly linked to a utilitarian conception of society as a project for enhancingefficiency and individual satisfaction – and a sense of professional mission that insists upon the promise of the ethical and civic dimensions of the enterprise” (64).

Chapter 2: The Evolution of the Professions – From professions of office to organized professions. America has always struggled with the tension between egalitarianism and individuality. “Since a professional career has always been a route to individual success, professions have been a focus point in the struggle to balance democratic openness to individual achievement with the need for the professions to be trusted to work for the benefit of others, in pursuit of agreed-upon, common ends” (67). “The human capital of professionals, however, is peculiarly dependent upon public, legal acceptance of the value of services offered by the professional” (67). “The professional (including the group of professionals providing a certain service) must persuade clients to accept the professional’s definition and valuation of that service, even as the clients must acknowledge and trust the competence of the provider” (68). This is a two-way process that includes political elements. In Europe, professional means publicservant; in America it designates independent status. In colonial times, ministers were elected and paid by the community. With the Revolution it was assumed that the professions, an elite, would naturally transform into a civic role. With the Revolution, the professions were forced to seek independence from the state and thus were called the “free professions,” even while remaining largely the province of otherwise wealthy gentlemen. They had strong local attachments. Andrew Jackson set all of this on its ear. He was literally out to get the wealthy New England gentlemen, urban interests,any form of specialization, and moneyed interests. In the name of protecting the independent farmer he closed the national bank and ended licensing of the professions such as medicine. He considered plantation owners honest laborers and protected the interests of slave owners. De Tocqueville sawdemocracy as a mixed blessing: society must commit to maintaining the conditions necessary for individual freedom. “De Tocqueville believed that in a commercial society individuals, now free from dependence upon social superiors, would define theirliberty in mostly material terms, taking security and comfort as their defining life goals, . . . thus undermining the very moral capacities that gave meaning to the idea of freedom” (78). De Tocqueville thought markets would be driven by “the look of brilliance” rather than quality [smile design]. “The common problem for the free professions was – and is – to establish and safeguard standards of practice that ensure public authority and confidence” (82). Following the Civil War, American began to lose its rural individual character (accept for the romantic ideal) and became more urban, with concentrated wealth in corporations, and entrepreneurial. Corporate capitalism was “a form of organization designed to accumulate large amounts of capital, resources, and labor and apply them to the rational, planned conduct of economic activity through a division of labor and bureaucratic routine” (83). We begin to have the notion of a “career.” Professionalism grew during this age of the expert – someone who knew how to get things done. Technical know-how grew more quickly than did the understanding of how best to useit. Much of the organization of professions was voluntary and local. Frederick Taylor, just before the 1920s was the first to “deskill” work to the point where we began to think in terms of a profession of managing work. One of the effects of this line of analysis was division of tasks into specialized activities to be performed by skilled individuals but managed by a separate group of individuals who specialize in how to put things together. The new university, Johns Hopkins being the first, modeled on the German system of science and preparation of individuals for government positions, began to appear. But unlike the European system, American universities were funded privately rather than by the government to a notable extent. This created the conditions for professions to base their authority on technical skill rather than participating in the social contract. Corporations tended to colonize small populations (towns) rather than partner with them. By the end of the nineteenth century industry defeated agrarian populism.