Professional Documents
Culture Documents
Perspective: Medical Professionalism in The New Millennium: A Physician Charter
Perspective: Medical Professionalism in The New Millennium: A Physician Charter
To our readers: I write briefly to introduce the Medical Pro- on the globe will read the charter. Does this document represent
fessionalism Project and its principal product, the Charter on the traditions of medicine in cultures other than those in the
Medical Professionalism. The charter appears in print for the first West, where the authors of the charter have practiced medicine?
time in this issue of Annals and simultaneously in The Lancet. I We hope that readers everywhere will engage in dialogue about
hope that we will look back upon its publication as a watershed the charter, and we offer our pages as a place for that dialogue to
event in medicine. Everyone who is involved with health care take place. If the traditions of medical practice throughout the
should read the charter and ponder its meaning. world are not congruent with one another, at least we may make
The charter is the product of several years of work by leaders progress toward understanding how physicians in different cul-
in the ABIM Foundation, the ACP–ASIM Foundation, and the tures understand their commitments to patients and the public.
European Federation of Internal Medicine. The charter consists Many physicians will recognize in the principles and com-
of a brief introduction and rationale, three principles, and 10 mitments of the charter the ethical underpinning of their profes-
commitments. The introduction contains the following premise: sional relationships, individually with their patients and collec-
Changes in the health care delivery systems in countries through- tively with the public. For them, the challenge will be to live by
out the industrialized world threaten the values of professional- these precepts and to resist efforts to impose a corporate mental-
ism. The document conveys this message with chilling brevity. ity on a profession of service to others. Forces that are largely
The authors apparently feel no need to defend this premise, per- beyond our control have brought us to circumstances that require
haps because they believe that it is a universally held truth. The a restatement of professional responsibility. The responsibility for
authors go further, stating that the conditions of medical practice acting on these principles and commitments lies squarely on our
are tempting physicians to abandon their commitment to the shoulders.
primacy of patient welfare. These are very strong words. Whether —Harold C. Sox, MD, Editor
they are strictly true for the profession as a whole is almost beside
the point. Each physician must decide if the circumstances of
practice are threatening his or her adherence to the values that
the medical profession has held dear for many millennia.
Three Fundamental Principles set the stage for the heart of
the charter, a set of commitments. One of the three principles,
P hysicians today are experiencing frustration as changes
in the health care delivery systems in virtually all indus-
trialized countries threaten the very nature and values of
the principle of primacy of patient welfare, dates from ancient medical professionalism. Meetings among the European
times. Another, the principle of patient autonomy, has a more Federation of Internal Medicine, the American College of
recent history. Only in the later part of the past century have Physicians–American Society of Internal Medicine (ACP–
people begun to view the physician as an advisor, often one of ASIM), and the American Board of Internal Medicine
many, to an autonomous patient. According to this view, the
(ABIM) have confirmed that physician views on profes-
center of patient care is not in the physician’s office or the hos-
pital. It is where people live their lives, in the home and the
sionalism are similar in quite diverse systems of health care
workplace. There, patients make the daily choices that determine delivery. We share the view that medicine’s commitment to
their health. The principle of social justice is the last of the three the patient is being challenged by external forces of change
principles. It calls upon the profession to promote a fair distri- within our societies.
bution of health care resources. Recently, voices from many countries have begun
There is reason to expect that physicians from every point calling for a renewed sense of professionalism, one that
www.annals.org 5 February 2002 Annals of Internal Medicine Volume 136 • Number 3 243
provement strategies and for appropriate compensation eliminate barriers to access based on education, laws,
to injured parties. finances, geography, and social discrimination. A com-
mitment to equity entails the promotion of public
Commitment to patient confidentiality. Earning the health and preventive medicine, as well as public advo-
trust and confidence of patients requires that appropri- cacy on the part of each physician, without concern for
ate confidentiality safeguards be applied to disclosure of the self-interest of the physician or the profession.
patient information. This commitment extends to dis-
cussions with persons acting on a patient’s behalf when Commitment to a just distribution of finite resources.
obtaining the patient’s own consent is not feasible. Ful- While meeting the needs of individual patients, physi-
filling the commitment to confidentiality is more press- cians are required to provide health care that is based on
ing now than ever before, given the widespread use of the wise and cost-effective management of limited clin-
electronic information systems for compiling patient ical resources. They should be committed to working
data and an increasing availability of genetic informa- with other physicians, hospitals, and payers to develop
tion. Physicians recognize, however, that their commit- guidelines for cost-effective care. The physician’s profes-
ment to patient confidentiality must occasionally yield
sional responsibility for appropriate allocation of re-
to overriding considerations in the public interest (for
sources requires scrupulous avoidance of superfluous
example, when patients endanger others).
tests and procedures. The provision of unnecessary ser-
Commitment to maintaining appropriate relations vices not only exposes one’s patients to avoidable harm
with patients. Given the inherent vulnerability and de- and expense but also diminishes the resources available
pendency of patients, certain relationships between phy- for others.
sicians and patients must be avoided. In particular, phy-
Commitment to scientific knowledge. Much of medi-
sicians should never exploit patients for any sexual
cine’s contract with society is based on the integrity and
advantage, personal financial gain, or other private purpose.
appropriate use of scientific knowledge and technology.
Commitment to improving quality of care. Physicians Physicians have a duty to uphold scientific standards, to
must be dedicated to continuous improvement in the promote research, and to create new knowledge and en-
quality of health care. This commitment entails not only sure its appropriate use. The profession is responsible for
maintaining clinical competence but also working col- the integrity of this knowledge, which is based on scien-
laboratively with other professionals to reduce medical tific evidence and physician experience.
error, increase patient safety, minimize overuse of health
Commitment to maintaining trust by managing con-
care resources, and optimize the outcomes of care. Phy-
flicts of interest. Medical professionals and their organi-
sicians must actively participate in the development of
zations have many opportunities to compromise their
better measures of quality of care and the application of
professional responsibilities by pursuing private gain or
quality measures to assess routinely the performance of
all individuals, institutions, and systems responsible for personal advantage. Such compromises are especially
health care delivery. Physicians, both individually and threatening in the pursuit of personal or organizational
through their professional associations, must take re- interactions with for-profit industries, including medical
sponsibility for assisting in the creation and implemen- equipment manufacturers, insurance companies, and
tation of mechanisms designed to encourage continuous pharmaceutical firms. Physicians have an obligation to
improvement in the quality of care. recognize, disclose to the general public, and deal with
conflicts of interest that arise in the course of their pro-
Commitment to improving access to care. Medical fessional duties and activities. Relationships between in-
professionalism demands that the objective of all health dustry and opinion leaders should be disclosed, espe-
care systems be the availability of a uniform and ade- cially when the latter determine the criteria for conducting
quate standard of care. Physicians must individually and and reporting clinical trials, writing editorials or thera-
collectively strive to reduce barriers to equitable health peutic guidelines, or serving as editors of scientific jour-
care. Within each system, the physician should work to nals.
www.annals.org 5 February 2002 Annals of Internal Medicine Volume 136 • Number 3 245
Commitment to professional responsibilities. As mem- available resources to meet those needs, the increasing
bers of a profession, physicians are expected to work dependence on market forces to transform health care
collaboratively to maximize patient care, be respectful of systems, and the temptation for physicians to forsake
one another, and participate in the processes of self- their traditional commitment to the primacy of patients’
regulation, including remediation and discipline of interests. To maintain the fidelity of medicine’s social
members who have failed to meet professional stan- contract during this turbulent time, we believe that phy-
dards. The profession should also define and organize sicians must reaffirm their active dedication to the prin-
the educational and standard-setting process for current ciples of professionalism, which entails not only their
and future members. Physicians have both individual personal commitment to the welfare of their patients
and collective obligations to participate in these pro- but also collective efforts to improve the health care
cesses. These obligations include engaging in internal system for the welfare of society. This Charter on Med-
assessment and accepting external scrutiny of all aspects
ical Professionalism is intended to encourage such ded-
of their professional performance.
ication and to promote an action agenda for the profes-
SUMMARY sion of medicine that is universal in scope and purpose.
The practice of medicine in the modern era is beset
with unprecedented challenges in virtually all cultures Requests for Single Reprints: Linda Blank, ABIM Foundation, 510
and societies. These challenges center on increasing dis- Walnut Street, Suite 1700, Philadelphia, PA 19106-3699; e-mail, lblank
parities among the legitimate needs of patients, the @abim.org.
246 5 February 2002 Annals of Internal Medicine Volume 136 • Number 3 www.annals.org