The recently developed charter on medical professionalism published simultaneously in Lancet[1] and Annals of Internal Medicine[2] represents the latest call for a renewed sense of professionalism in medicine. Jointly developed by the European Federation of Internal Medicine, the American College of Physicians-American Society of Internal Medicine, and the American Board of Internal Medicine, the document seeks to "encompass a set of principles to which all medical professionals can and should aspire." It succinctly presents three fundamental principles and a set of 10 professional responsibilities that form the basis of medicine's contract with society. The three fundamental principles are the principle of primacy of patient welfare, the principle of patient autonomy, and the principle of social justice. The set of professional responsibilities includes a commitment to professional competence, to honesty with patients, to patient confidentiality, to maintaining appropriate relations with patients, to improving quality of care, to improving access to care, to a just distribution of finite resources, to scientific knowledge, to maintaining trust by managing conflicts of interest, and a commitment to professional responsibilities. The need to emphasize professionalism is certainly timely, and all physicians should carefully read the document.
As a pediatrician, I share the concern and frustration that many have as I try to deal with the tremendous changes in health care delivery systems and the ethical dilemmas presented by new technologies. I applaud this heroic attempt to reconcile the need of medicine to reassert its professional status and to reject a corporate mentality. Yet there are several things worth reexamining in this well written call for a renewed sense of professionalism.
First, the document is structured as a contract of medicine with society. One must ask whether medicine is really in a contract with society? Or is medicine, in its essence, better understood as a relationship of an individual physician with an individual patient? Social contracts provide an excellent foundation for public health policies, but one could argue that these contracts cannot adequately address the needs of individual patients. Patient autonomy is always in a subservient role within systems based on social contracts.
Second, this document presents us with a contractual model for physician- patient relationships, not a covenantal model. In a contract, each party is concerned for his or her own welfare. Physicians have a technological advantage over patients because of their many years of training and specialized knowledge. Patients have medical needs, thereby resulting in a market for physicians= services. The market place mentality of social contracts drives them to place negotiation at the center of the physician-patient relationship. In contrast to this Physician Charter, The Hippocratic Oath[3] is a covenant. A covenantal relationship is one where the physician promises to put the needs of the patient over and above his own needs, his financial welfare, and the needs of others. In a covenantal physician-patient relationship, the practice of medicine becomes a moral commitment, not just a quid pro quo.
The physician-patient relationship is the final common pathway through which all care is delivered. Pondering the nature of that relationship and the nature of medical professionalism would be time well spent.
References
[1] Medical Professionalism Project. Medical professionalism in the new millennium: a physicians' charter. Lancet. 2002; 359(9305):520–2.
[2] Project of the ABIM Foundation, ACPBASIM Foundation, and European Federation of Internal Medicine. Medical Professionalism in the New Millennium: A Physician Charter. Ann Intern Med. 2002;136:243–246. Can be found on the web at: http://www.annals.org/issues/v136n3/full/200202050-00012.html (Accessed March 28, 2003).
[3] Hippocratic Oath. Translated by Heinrich Von Staden. Found on the web at http://www.indiana.edu/~ancmed/oath.htm (Accessed March 28, 2003).