Standards and accountabilities for professional resistance

As the concept of professional resistance ¹ is developed in Canadian medical education, we are concerned that the professional character of such resistance lacks grounding, which in turn undermines the profession as a whole. We therefore seek to clarify health professionals’ rights and responsibilities regarding acts of resistance, whether they involve visible protests or less visible acts of non-compliance.

In Canada, health professionals’ authority and privilege are grounded in state-authorized self-regulating professional bodies. When physicians claim professional authority to care for patients, advocate for community health, or engage in acts of resistance, they are granted that authority solely through their state-sponsored self-regulating college and have no right to invoke their professional titles beyond their membership in that college. Regulations under the Medicine Act define professional misconduct to include failures in clinical practice, financial misbehaviours, but also threats to professional integrity. However, standards for professional resistance have not been well-defined, communicated, or upheld, which has meant that health professionals engaged in resistance, and those who are confronted with professionals engaged in acts of resistance, have been obliged to rely on principles of freedom of expression, academic freedom, and legal expediency.

Principles of civil disobedience include an expectation of accountability and consequence. Medical professionalism requires analogous deference to state-sponsored regulatory and judicial processes, and willing accountability for one’s actions including acts of disobedience or resistance that are explicitly undertaken as a health professional. Acts of resistance that use anonymity to avoid accountability are therefore explicitly unprofessional. Resistance that leverages the authority of professional identity while denying the jurisdiction of professional bodies, or resistance that dismantles or disavows state-sponsored self-regulation is, we argue, inconsistent with the principles of a profession.

Setting and applying standards for professional resistance presents challenges. It can seem paradoxical to propose rules to define the limits of rule-breaking. The intent here is not to place boundaries on resistance within society at large—those boundaries are set by state laws and more broadly through the social contract. Instead, the goal is to characterize appropriate resistance for individuals who engage in resistance while claiming the unique privilege and power of membership in a self-regulated health profession. Being a health professional does not extinguish an individual’s right to a private life, but their actions in that sphere should not call their profession into disrepute.

Resistance to policies or practices that harm patients, providers, or learners may be considered more appropriate for professional resistance than resistance to issues that have no particular focus within health. That said, it is not difficult to link social policies with health, while “health in all policies” approaches could be used to legitimize health advocacy in any public debate.² Setting standards for professional resistance is not about patrolling the boundaries of health or asking health providers to “stay in their lane,”³ but rather about engaging meaningfully with resistance behaviours and actions that are intrinsically professional.

Clearly, healthcare professionals and trainees engaging in resistance need standards and accountabilities for their resistance to be understood and advanced as professional. Healthcare professionals who are identified as such and are engaged in resistance (or any other action) who reject or ignore the relevant standards and accountabilities should understand the consequences, which may include censure and exclusion from the profession. If the actions of professionals have no consequences, or if regulatory bodies take no action to patrol the boundaries of professional resistance, then the profession itself is in jeopardy. On graduation day, trainees can be left with the mistaken impression that the freedoms provided by academic institutions map to their professional freedoms as members of regulatory colleges. Where educational institutions take insufficient steps to delineate the boundaries of professional resistance among budding health professionals, they fail in the work of professional education and imperil the future of the profession itself.

The negotiation and application of standards for acts of professional resistance can build and strengthen the health professions, their absence could destroy them. Developing standards for professional resistance needs input from medical schools, regulatory bodies, professional associations, ethicists, and medicolegal experts, and most importantly from health professionals both in training and in practice. This is a long overdue conversation, but one whose time has come.

Edited by

Marcel D’Eon (editor-in-chief)