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In 1996, David Kern, MD, Assistant Professor of Medicine at Brown, Director of the Division of Occupational Medicine at Brown and the Occupational Health Clinic at Memorial Hospital of Rhode Island, submitted an abstract to the American Thoracic Society describing "flock workers' lung," a new occupational lung disease affecting workers in the nylon flocking industry.12 That report provoked controversy, not because of the quality of the methodology, but because of alleged conflicts between Dr. Kern, the local factory that was the site of the research, Kern's employer, Memorial Hospital of Rhode Island, and Brown Medical School, where Kern held an academic appointment.1 2

The hospital alleged that Kern had violated confidentiality agreements signed when he undertook his research. Brown reflected on the implications of confidentiality agreements, and the economic and legal risks physicians take when they sign such agreements, risks which may be shared by the medical schools that appoint those researchers. Kern asserted that the hospital may have been pressured by the factory, and that Brown had failed its academic mission by refusing to defend his academic freedom.

At the end of the controversy, Memorial Hospital did not renew Dr. Kern's contract and closed its Occupational Health Clinic, ostensibly because it had been losing money for years. A new non-profit academic occupational and environmental health center, the Occupational and Environmental Health Center of Rhode Island, opened in 2000 to continue Kern's work, spearheaded by a coalition formed by the labor movement, the medical community, and the Rhode Island Affiliate of the American Lung Association.

The Kern case illuminates contradictions in the social theory of medicine. The social theory of medicine views medicine as a profession from the perspective of the profession's role in the economic, legal and cultural life of the society as a whole, a role which is rarely explicated and poorly understood.1 From the vantage of social theory, the Kern Case pitted one party, which believed medicine was an owned industrial process, containing proprietary information protected by the laws which govern commerce, against another party, which believed medicine represented a covenant between a physician and the public, vesting physicians with unusual responsibilities and privileges that transcend those commerce-laws

In this paper, I will examine the social role of medicine, arguing that medicine as a profession is defined by the tension between its altruistic character, which uses oaths and covenants to insure that medicine is practiced for patients' benefit, and its marketplace role, where medicine is practiced wholly for the benefit of its practitioners. I will consider the role of advocacy in the context of the derived meaning of medicine as a profession, and then reflect on the Kern case in the context of the meaning of medicine as a profession.

SOCIAL CONTRACTS AND PROFESSIONALISM

Medicine exists in a complex, constantly changing society, with different actors and interests, roles and relationships. Medical Professionalism is a matrix that includes the participants and their perspectives, interests, relationships, personal covenants, and contracts. The social contract between society, individuals, and the profession as a class is the glue that holds the matrix together.

Physicians, as a class, accept certain unusual responsibilities. In exchange, physicians, as a class, are awarded certain unusual privileges. Individual physicians are judged by the extent to which they discharge the accepted responsibilities, and evaluate their participation in the social contract by the extent to which they receive the promised privileges.2,3,4,5

The social contracts that govern medicine as a profession are complex, and, like most social contracts, are rarely explicit. A few parts of the social contract have made their way to paper as law or regulation - the laws governing licensure, the laws governing commerce, the regulations of specialty societies, the staff-admitting regulations of hospitals - but most of society's expectations of medicine are not written: expectations about professional behavior, about diagnostic accuracy and therapeutic effectiveness, about the intensity of disinterested advocacy, about the care of the poor, and about the role of physicians in identifying and advocating for social interventions that reduce the social cost of disease and injury.

Of course, social contracts like these are fluid, changing as society changes, with expectations that are renegotiated in the public arena by a contest of wills and the tussle of competing interests.

SOME DEFINITIONS OF PROFESSIONALISM

In general, professions employ a body of knowledge or skill that they use for the good of others. The exercise of that knowledge or skill has inherent dangers to the community, because the quality of the service cannot be independently verified at the time it is performed, and is therefore not subject to the usual process by which the community evaluates a service or commodity-the process of comparison intrinsic to the marketplace. When a consumer buys a car, s/ he can quickly evaluate it ("caveat emptor"); the same does not hold for the patient undergoing a triple bypass.

The professions struggle to convince the community that their practice is performed free of self-interest. The community struggles to convince itself that professionals practice without self interest, so it can use the valuable specialized knowledge or skill provided by professionals without fearing that what purports to be disinterest isn't a fiction - that the physician does not share the same unbridled self-interest of the used car dealer.

Consider the Oxford English Dictionary definition of Profession (111.6): "The occupation one professes to be skilled in and follow. A. A vocation in which a professed knowledge of some department of learning or science is used in its application to the affairs of others or in the practice of an art founded upon it. Applied specifically to the three learned professions of divinity, law and medicine."6 Paul Starr also recognized the role of specialized knowledge and its application to the affairs of others, but included the need of professions to portray themselves as free of self-interest. "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 a profit orientation, enshrined in its code of ethics."7

Expectations about professional behavior derive from professionals' desire to convince others that they come from a social class which allows them to attain the requisite education and training, and from the professions' need to appear devoid of self interest. These expectations, which include expectations about dress and speech, extend to personal integrity.

Codes of ethics, oaths and covenants percolate through the professions, as they struggle to emphasize the dis-interested character of their practice. It is these codes, oaths and covenants, and the attempt to establish a space devoid of self-interest that gives rise to the notion of a Sacred Space, which will be discussed in detail below.

MEDICINE IN THE MARKETPLACE

Even though the specialized knowledge and skill of medicine makes its quality difficult to evaluate by the usual comparative judgments of the marketplace, and even though professionals struggle to appear devoid of self-interest to maintain their legitimacy, physicians do function in the marketplace, as they develop a product and merchandise that product, which is their skill, knowledge, and expertise. Indeed, in a consumer society, the rules of the marketplace dominate social intercourse, and the professions must live by those rules, even when the rules conflict with professional ethics.

Economists view the professions differently from the way the professions see themselves, focusing on the professions' monopoly of expertise, and their to stand behind the cloak of disinterested advocacy while performing like self-interested capitalists. "Skeptical economists view professions as state-- protected cartels whose primary purpose is to raise barriers to entry through education and certification requirements, to restrict competition from outsiders, and ultimately extract monopoly rents by combining to fix prices and the terms of service to clients."8