Medical professionalism in the new millennium:a physician
charter1, 2)
ABIM Foundation. American Board of Internal Medicine;
ACP-ASIM Foundation. American College of Physicians-American
Society of Internal Medicine;
European Federation of Internal Medicine.
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 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 patients' welfare
This 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 patients' autonomy
Physicians must have respect for patients' 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 patients' and societal trust. Reporting
and analysing medical mistakes provides the basis for
appropriate prevention and improvement strategies and for
appropriate compensation to injured parties.
Commitment to patients' confidentiality
Earning the trust and confidence of patients requires that
appropriate confidentiality safeguards be applied to disclosure
of patients' information. This commitment extends to discussions
with people 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 data on patients and an increasing availability of
genetic information. Physicians recognise, however, that their
commitment to confidentiality must occasionally yield to
over-riding considerations in the public interest(for example,
when patients endanger others).
Commitment to maintaining appropriate relationships 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
patients' safety, minimise overuse of health-care resources, and
optimise 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 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 physicians' experience.
Commitment to maintaining trust by managing conflicts of
interest
Medical professionals and their organisations 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
organisational interactions with for-profit industries,
including medical equipment manufacturers, insurance companies,
and pharmaceutical firms. Physicians have an obligation to
recognise, 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 maximise patients' 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 organise 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 centre 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. |