Jan Hartman
Principia, 31-044 Kraków, ul. Grodzka 52

Bioethics and the Issue of Professional Competence

In the present world, where the sphere of knowledge and social relations have become extremely complex, the problem of insufficient competency and inability to manage efficiently the cumulation and distribution process of various professional skills, has grown very urgent. Paradoxically, the insufficient knowledge, lacking skill or competence may be advantageous. To a certain extent, it reduces the threat of arrogant technocracy and meritocracy, while supporting innovation and creative search process, in which the burden of excessive erudition has often slowed down progress. Yet, obviously, the uncontrolled incompetence is dangerous in general, and particularly in all those cases when incompetent persons are entrusted with extensive responsibility and authority.

In general, two distinct forms of incompetence exist. The former one is a self-controlled incompetence, enlightened with the Socratic awareness: “I do know that I know nothing.” The latter, is an uncontrolled and uncontrollable incompetency, which shows no sign of self-awareness. To the contrary, it is convinced of exceptional erudition and ability.

Similarly to all other complex and science-related fields of social life, in medicine and health care incompetency is very common, and-understandably-very hazardous. The dramatic status of this problem in medical practice is underlined by the fact that the social function of medical doctor relies strongly on social confidence: particularly in the less affluent and tradition-oriented nations. More or less justifiably, doctors and medical officials generally believe that all cases of acknowledged incompetence, errors and insufficient skill cases tend to undermine such social confidence. It is true that the self-critical declaration of incompetence may lead to positive impression only in the most culturally advanced and educated societies. In typical societies, i. e. poor and uneducated, if such declarations are made at all, they result usually of the opportunist reasons, i. e. as justification necessary to avoid responsibility for given patient or bureaucratic difficulties and pass it over to others.

I would like to indicate here some of those areas where the issue of incompetence does appear in medicine and health care, i. e. those areas where the improvement of “incompetence management” mechanisms is necessary in order to anticipate and neutralise possible negative effects. Besides, I mean to point out an interplay between two stages of the competence/incompetence complex-the professional and the moral ones.

The primary area where both the insufficient competence, and inability to acknowledge it, emerge in the field of medical education, i. e. medical studies, hospital internships, medical specialisation, and academic career. The huge scope of contemporary medical knowledge results in the situation when it is absolutely impossible for medical universities to provide students with anything more than general introduction to medicine. Yet, those academic institutions are still pervaded with the conviction about allegedly professional knowledge inculcated into every general practitioner or specialist doctor. However, the structure of obtained knowledge is typically amateur, though supported by everyday practice and vocational experience relying on intuition rather than profound knowledge. That is why the training of physicians should gain a lot by applying extensively the methods used in amateur education, or popular practical instruction, rather than upholding the non-realistic and conceited ethos proclaiming the professionalism of every medical doctor. Paradoxically, the educational techniques applied in popular courses emphasise the self-awareness of incompetency, and the readiness to search for knowledge in reference books, to a much greater extent than classical academic education. The half-professional character of medical practice in poor countries leads to the situation when doctors are reluctant to learn anything at all, despite news on drugs, and draw their knowledge exclusively from the instruction leaflets accompanying newly developed pharmaceuticals. The illusion of scientifically sound knowledge wielded by doctors has been reinforced by the behaviour of academic scientists: In fierce competition for available financial grants, they have grown extremely reluctant to acknowledge incompetency or research failures. Paralely the pressure grows to mask and deny negative research results, which leads at best to the information chaos and missleading optimism in many areas of medicine. Thus, an extremely poor example is given to emulate by rank-and-file practitioners.

Health care management has been another area breeding insufficient competence and related hazards. In poor countries, the plight of health care system has been made more dramatic by the fact that -due to overall corruption-the awareness of the relative separateness of managerial and medical expertise fields has been obliterated or marginalised. In result, physicians, usually those of inferior stature, who were unable to pursue purely medical or academic career, manage almost all health care units.

The above mentioned areas of medical life necessarily rely on a certain moral and normative order. Also this moral sphere requires a definite level of competence. Such competence is based on the awareness of certain moral imperatives, the knowledge of specific obligations and liabilities expected from the medical and administrative staff. Yet, the level of moral awareness prevailing in the medicine practised in poor countries is generally very low. In fact, it is practically reduced to the conviction that certain regulations exist which ought to be followed if possible, and it is morally correct to follow them, in general; occasionally, there may appear exceptionally complex situations causing conscience dilemmas. In such rare situations the “voice” of individual conscience or religious convictions may matter. Yet, this sphere is considered entirely private and excluded from public scrutiny. The atrophy of elementary moral language and total neglect of moral standards related to medical vocation, lead to desperate corruption and demoralisation of professional relations. Unfortunately, this demoralisation has been reinforced by the unlimited authority, or even cult of medical doctors, typical for poor nations, which have been exposed to powerful processes of modernist secularisation producing as a side-effect a phenomenon of medical doctors increasingly assuming the social stature of traditional clergy.

The moral sphere, more distinctively than the technical-professional one, unveils mechanisms and the true sense of the comeptence partition and dispersion. On the simpliest level we see quite commonly how in everyday diagnostic and therapeutic practicies, involving medical knowledge, the responsibility for a patient is being shifted by doctors to other doctors as well as to the technical diagnostic processes that can be continued pratically endlessly. In other words, a difficult patient is often “thrown over” to another place, possibly far from my own office-to the specialist in other field, to the higher rank specialist in my field, to another lab for new tests. This way of conduct is basically always formally correct-from both, professional and moral, points of view-since expression of carefulness and uncertainty, like “we have to check also this” or “we need to exclude also that possibility” seem to pass for a measure of professional honesty. However, such a “competent incompetence,” ambigious expression of the responsibility on the one hand and, perhaps, of avoiding difficulties and circumstances that may unveil our ignorance on the other, obviously has its morally frustrating aspects. It comes out just of this vague and slow dispersion of responsibility and slips down to a sort of generalisation and depersonalisation of responsibility for a patient in a technocratic, totalist and proud world of the medical practice and knowledge that develops in the countries under modernisation. If a strictly professional competence is usually in this or that way quantifiable or divisible, then, on the contrary, the moral competency, the virtue, just dies “through partition.” Dies together with any responsibility that may exceed anyhow the legal understanding of this term. Of course, no social mechanism of avoiding individual responsibility for a patient’s fate does not really neutralise this responsibility, but instead of this, it undermins and puts into doubts moral competency of medical societies. It refers specially to some poorer countries, where all sorts of problems, also moral ones, can pass for explained when related to the shortage of money, reforms or to the bad system functioning. In opposition to the technical-professional expertise, which when acknowledged, sometimes can even contribute to the doctor’s prestige, any open declaration of moral incompetency socially compromises the given individual and seem hardly possible. We do sometimes confess sins, however we never say: “I regret very much, but I have not sufficient moral faculty in order to bear responsibility for my profesional practice to the expected extent.” This quite essential “metaethical” condition turns out to be a major obstacle for the moral improvement of the medical societies and the sad consequence of this state of the matter is that in this moraly loose atmosphere also the typycally professional-technical incompetences become less and less discernable as causing any moral disorder. What’s more, this is just the method of a “competent incompetence”-a proud way of declaring one’s lack of a special knowledge of some kind-which allows us to avoid direct responsibility and more: to avoid any moral burden, any questionability of one’s conduct. We come then to the deplorable conclusion that at least in the less developed countries the scietific and technical progress of medicine not only supports dispersion of responsibility for a patient, but destroys public sense of the moral among medical professionals, corrupts the sense of the special moral vunerability of medical practicies.