Medical Professionalism: A Charter for the 21st Century

What is or makes a physician? What should be the physician's responsibility? What should be the physician's goals? These and many other questions physicians and the public should ask and be educated. For this reason, I have taken the liberty to copy and publish here on a bioethics blog a very important document prepared by the Foundation of the American Board of Internal Medicine in partnership with the American College of Physicians Foundation and the European Federation of Internal Medicine.

There has been much discussion on various threads on this blog about how doctors behave. Well, this Physician's Charter should tell how the profession should expect them to behave. Do you agree? ..Maurice.

MEDICAL PROFESSIONALISM IN THE NEW MILLENNIUM:
A PHYSICIAN CHARTER


Preamble


Professionalism is the basis of medicine’s contract with society. It demands placing the interests of patients above those of the
physician, setting and maintaining standards of competence and integrity, and providing expert advice to society on matters of
health. The principles and responsibilities of medical professionalism must be clearly understood by both the profession and
society. Essential to this contract is public trust in physicians, which depends on the integrity of both individual physicians and
the whole profession.
At present, the medical profession is confronted by an explosion of technology, changing market forces, problems in health
care delivery, bioterrorism, and globalization. As a result, physicians find it increasingly difficult to meet their responsibilities to
patients and society. In these circumstances, reaffirming the fundamental and universal principles and values of medical professionalism,
which remain ideals to be pursued by all physicians, becomes all the more important.
The medical profession everywhere is embedded in diverse cultures and national traditions, but its members share the role of
the healer, which has roots extending back to Hippocrates. Indeed, the medical profession must contend with complicated political,
legal, and market forces.Moreover, there are wide variations in medical delivery and practice through which any general
principles may be expressed in both complex and subtle ways. Despite these differences, common themes emerge and form the
basis of this charter in the form of three fundamental principles and as a set of definitive professional responsibilities.

Fundamental Principles

Principle of primacy of patient welfare. The principle is based on a dedication to serving the interest of the patient. Altruism
contributes to the trust that is central to the physician-patient relationship. Market forces, societal pressures, and administrative
exigencies must not compromise this principle.
Principle of patient autonomy. Physicians must have respect for patient autonomy. Physicians must be honest with their patients
and empower them to make informed decisions about their treatment. Patients’ decisions about their care must be paramount, as
long as those decisions are in keeping with ethical practice and do not lead to demands for inappropriate care.
Principle of social justice. The medical profession must promote justice in the health care system, including the fair distribution
of health care resources. Physicians should work actively to eliminate discrimination in health care, whether based on race, gender,
socioeconomic status, ethnicity, religion, or any other social category.

A Set of Professional Responsibilities
Commitment to professional competence. Physicians must be committed to lifelong learning and be responsible for maintaining
the medical knowledge and clinical and team skills necessary for the provision of quality care.More broadly, the profession as
a whole must strive to see that all of its members are competent and must ensure that appropriate mechanisms are available for
physicians to accomplish this goal.
Commitment to honesty with patients. Physicians must ensure that patients are completely and honestly informed before the
patient has consented to treatment and after treatment has occurred. This expectation does not mean that patients should be
involved in every minute decision about medical care; rather, they must be empowered to decide on the course of therapy.
Physicians should also acknowledge that in health care, medical errors that injure patients do sometimes occur.Whenever
patients are injured as a consequence of medical care, patients should be informed promptly because failure to do so seriously
compromises patient and societal trust. Reporting and analyzing medical mistakes provide the basis for appropriate prevention
and improvement strategies and for appropriate compensation to injured parties.
Commitment to patient confidentiality. Earning the trust and confidence of patients requires that appropriate confidentiality
safeguards be applied to disclosure of patient information. This commitment extends to discussions with persons acting on a
patient’s behalf when obtaining the patient’s own consent is not feasible. Fulfilling the commitment to confidentiality is more
pressing now than ever before, given the widespread use of electronic information systems for compiling patient data and an
increasing availability of genetic information. Physicians recognize, however, that their commitment to patient confidentiality
must occasionally yield to overriding considerations in the public interest (for example, when patients endanger others).
Commitment to maintaining appropriate relations with patients. Given the inherent vulnerability and dependency of patients,
certain relationships between physicians and patients must be avoided. In particular, physicians should never exploit patients for
any sexual advantage, personal financial gain, or other private purpose.

Commitment to improving quality of care. Physicians must be dedicated to continuous improvement in the quality of health
care. This commitment entails not only maintaining clinical competence but also working collaboratively with other professionals
to reduce medical error, increase patient safety, minimize overuse of health care resources, and optimize the outcomes of care.
Physicians must actively participate in the development of better measures of quality of care and the application of quality measures
to assess routinely the performance of all individuals, institutions, and systems responsible for health care delivery.
Physicians, both individually and through their professional associations, must take responsibility for assisting in the creation and
implementation of mechanisms designed to encourage continuous improvement in the quality of care.
Commitment to improving access to care. Medical professionalism demands that the objective of all health care systems be the
availability of a uniform and adequate standard of care. Physicians must individually and collectively strive to reduce barriers to
equitable health care.Within each system, the physician should work to eliminate barriers to access based on education, laws,
finances, geography, and social discrimination. A commitment to equity entails the promotion of public health and preventive
medicine, as well as public advocacy on the part of each physician, without concern for the self-interest of the physician or the
profession.

Commitment to a just distribution of finite resources. While meeting the needs of individual patients, physicians are required
to provide health care that is based on the wise and cost-effective management of limited clinical resources. They should be committed
to working with other physicians, hospitals, and payers to develop guidelines for cost effective care. The physician’s professional
responsibility for appropriate allocation of resources requires scrupulous avoidance of superfluous tests and procedures.
The provision of unnecessary services not only exposes one’s patients to avoidable harm and expense but also diminishes the
resources available for others.
Commitment to scientific knowledge. Much of medicine’s contract with society is based on the integrity and appropriate use of
scientific knowledge and technology. Physicians have a duty to uphold scientific standards, to promote research, and to create
new knowledge and ensure its appropriate use. The profession is responsible for the integrity of this knowledge, which is based
on scientific evidence and physician experience.
Commitment to maintaining trust by managing conflicts of interest. Medical professionals and their organizations have many
opportunities to compromise their professional responsibilities by pursuing private gain or personal advantage. Such compromises
are especially threatening in the pursuit of personal or organizational interactions with for-profit industries, including medical
equipment manufacturers, insurance companies, and pharmaceutical firms. Physicians have an obligation to recognize, disclose
to the general public, and deal with conflicts of interest that arise in the course of their professional duties and activities.
Relationships between industry and opinion leaders should be disclosed, especially when the latter determine the criteria for conducting
and reporting clinical trials, writing editorials or therapeutic guidelines, or serving as editors of scientific journals.
Commitment to professional responsibilities. As members of a profession, physicians are expected to work collaboratively to
maximize patient care, be respectful of one another, and participate in the processes of self regulation, including remediation and
discipline of members who have failed to meet professional standards. The profession should also define and organize the educational
and standard-setting process for current and future members. Physicians have both individual and collective obligations to
participate in these processes. These obligations include engaging in internal assessment and accepting external scrutiny of all
aspects of their professional performance.

Summary
The practice of medicine in the modern era is beset with unprecedented challenges in virtually all cultures and societies. These
challenges center on increasing disparities among the legitimate needs of patients, the available resources to meet those needs, the
increasing dependence on market forces to transform health care systems, and the temptation for physicians to forsake their traditional
commitment to the primacy of patients’ interests. To maintain the fidelity of medicine’s social contract during this turbulent
time, we believe that physicians must reaffirm their active dedication to the principles of professionalism, which entails
not only their personal commitment to the welfare of their patients but also collective efforts to improve the health care system
for the welfare of society. This Charter on Medical Professionalism is intended to encourage such dedication and to promote an
action agenda for the profession of medicine that is universal in scope and purpose.

2004❧ ABIM FOUNDATION ❧ ACP FOUNDATION ❧ EUROPEAN FEDERATION OF INTERNAL MEDICINE