Charter on Medical Professionalism
Medical Professionalism in the New Millennium: A Physicians' Charter
Physicians today are experiencing frustration as changes in the health-care delivery systems in virtually all industrialised countries threaten the very nature and values of medical professionalism. Meetings among the European Federation of Internal Medicine, the American College of Physicians and American Society of Internal Medicine (ACP-ASIM), and the American Board of Internal Medicine (ABIM) have confirmed that physicians' views on professionalism are similar in quite diverse systems of health-care delivery. We share the view that medicine's commitment to the patient is being challenged by external forces of change within our societies.
Recently, voices from many countries have begun calling for a renewed sense of professionalism, one that is activist in reforming health-care systems. Responding to this challenge, the European Federation of Internal Medicine, the ACP-ASIM Foundation, and the ABIM Foundation combined efforts to launch the Medical Professionalism Project (www.professionalism.org) in late 1999. These three organisations designated members to develop a "charter" to encompass a set of principles to which all medical professionals can and should aspire. The charter supports physicians' efforts to ensure that the health-care systems and the physicians working within them remain committed both to patients' welfare and to the basic tenets of social justice. Moreover, the charter is intended to be applicable to different cultures and political systems.
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 globalisation. 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.
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.
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.
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.
Medical Professionalism Project* Lancet 2002; 359: 520-22
*Members listed below.
Published simultaneously in Ann Intern Med 2002; 136: 243-46.
Correspondence to: Linda Blank, ABIM Foundation, 510 Walnut Street, Suite 1700, Philadelphia, PA 19106, USA (e-mail:firstname.lastname@example.org)
Members of the Medical Professionalism Project
ABIM Foundation--Troy Brennan (Project Chair), Brigham and Women's Hospital, Boston, MA, USA; Linda Blank (Project Staff), ABIM Foundation, Philadelphia, PA, USA; Jordan Cohen, Association of American Medical Colleges, Washington, DC, USA; Harry Kimball, American Board of Internal Medicine, Philadelphia, PA, USA; and Neil Smelser, University of California, Berkeley, CA, USA.
ACP-ASIM Foundation--Robert Copeland, Southern Cardiopulmonary Associates, LaGrange, GA, USA; Risa Lavizzo-Mourey, Robert Wood Johnson Foundation, Princeton, NJ, USA; and Walter McDonald, American College of Physicians-American Society of Internal Medicine, Philadelphia, PA, USA.
European Federation of Internal Medicine--Gunilla Brenning, University Hospital, Uppsala, Sweden; Christopher Davidson, Royal Sussex County Hospital, Brighton, UK; Philippe Jaeger, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland; Alberto Malliani, Università di Milano, Milan, Italy; Hein Muller, Ziekenhuis Gooi-Noord, Rijksstraatweg, Netherlands; Daniel Sereni, Hôpital Saint-Louis, Paris, France; and Eugene Sutorius, Faculteit der Rechts Geleerdheid, Amsterdam, Netherlands.
Special consultants--Richard Cruess and Sylvia Cruess, McGill University, Montreal, Canada; and Jaime Merino, Universidad Miguel Hernández, San Juan de Alicante, Spain.