David B. Waisel, M.D.
Committee on Ethics
A resurgence of interest in professionalism in medicine has given rise to a number of papers and statements. I want to take this opportunity not only to introduce a new statement on medical professionalism but also to consider why such statements are written.
It was organized by the American Board of Internal Medicine, the American College of Physicians-American Society of Internal Medicine Foundation and the European Federation of Internal Medicine. The charter declares: "Professionalism is the basis of medicine's contract with society" and describes three fundamental principles and 10 commitments. These principles and the commitments are outlined in the table on page 32, and readers are encouraged to read the full, brief document.
Statements such as the charter tend to perturb people. Declarations about medical professionalism address us as people and as individuals, which is different and far more personal than addressing anesthetic practices. A reader may easily infer that authors, by advocating for basic ideas, are suggesting that the readers do not honor or value those beliefs. Further, these statements use powerful, unambiguous words such as "must," "should," "require" and "demand." Statements do not seem to consider – or at least do not overtly acknowledge – the real-world pressures physicians must balance constantly. Unfortunately, these distractions may overwhelm the reader to the point that the relevance of the statement is lost. Readers may gain more from these statements by taking a different approach to them.
Approaching Statements on Professionalism: Why Are They Written?
They are written as a reminder. Reminders serve an important purpose. Anesthesiologists are amply pressured to skirt professional behavior. As the charter states: "Changes in the health care delivery systems in virtually all industrialized countries threaten the very nature and values of medical professionalism." In many cases, anesthesiologists may perceive the conditions of daily practice as too onerous to actively consider professionalism. It is rare, however, that we have anything more than ourselves to remind us of the tenets of professionalism. Thus it is useful to have a reminder of those sober obligations in light of aggressively omnipresent, blaring daily pressures.
They are written to direct attention to areas that need work. The proper diagnosis and management of some professional issues are largely settled, such as in confidentiality, while other often more recent issues have not had proper approaches delineated. A purpose of statements such as the charter is to focus attention on those areas in which further theoretical and empirical research is needed to help develop pathways to resolution. Consider this analogy: The statement "manage the airway appropriately" is mostly an impractical goal without an understanding of airway anatomy, risk factors, difficult airways and management options. In the same vein, "commitment to maintaining trust by managing conflicts of interest" is of little benefit without being able to define "trust," identify conflicts of interest, avoid entanglements and resolve conflicts.
They are written to propose new areas of professionalism. A good statement brings forth new areas for consideration. The charter, perhaps reflecting its international nature, offers a new challenge for medical professionalism. The third principle put forth is the primacy of social justice [Table]. This continues to be defined in the 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."
Summary of Charter on Medical Professionalism
Principle of primacy of patient 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 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.
- Commitment to professional competence
- Commitment to honesty with patients
- Commitment to patient confidentiality
- Commitment to maintaining appropriate relations with patients
- Commitment to improving quality of care
- Commitment to improving access to care
- Commitment to a just distribution of finite resources
- Commitment to scientific knowledge
- Commitment to maintaining trust by managing conflicts of interest
- Commitment to professional responsibilities
I am unsure what to do with these statements. I agree that physicians should participate in public health to improve access to care and to eliminate barriers to access. The argument for individual physician responsibility for societal health and the practices of health care in part arises from the idea that medical training and practice are largely supported by society to serve the specific purpose of health care. Without this support, most physicians would be unable to become physicians or to practice high-quality medicine. It has been argued that legitimate reciprocity of this investment requires anesthesiologists to not only manage all issues related to anesthesia but also to ensure the further growth and development of the specialty.
However, I do not know whether this "should" rises to the level of an obligation, particularly "without concern for the self-interest of the physician or profession." That seems to be an excessive standard except in the most extreme circumstances. Further, even if it does rise to the level of an obligation, I am not sure if the prescribed path is proper. The mandate for professional participation in matters presumes expertise. Medical training does not prepare physicians for advocacy or for the complex reasoning and understanding necessary to consider public policy. While physicians have every right to participate in democratic decision-making, most physicians do not have the special knowledge that affords them the right to use their unofficial authority to influence policy.
The Next Step
Problems notwithstanding, statements such as the "Charter on Medical Professionalism" help provide necessary balance as we navigate daily practice. Anesthesiologists are encouraged to read them and consider them as reminders of core beliefs, guides to areas that need further work and proposals of new areas to consider.
- ABIM Foundation. American Board of Internal Medicine. ACP-ASIM Foundation. American College of Physicians-American Society of Internal Medicine. European Federation of Internal Medicine. Medical professionalism in the new millennium: A physician charter. Ann Intern Med. 2002; 136:243-246.