The past 15 years or so have left the medical profession in a demoralized condition. Debilitating cuts in health care budgets, driven by fiscal uncertainty and neo-liberal politics, have been accompanied by creeping privatization (and profitization) and the replacement of the ideal of public administration with the ideology of business management. Physicians, at the hub of care provision, were seen as the cause of the “excess” spending in health care — an excess that justified the cuts — and as incompetent managers. Physicians-in-chief of hospital wards and departments were replaced by managers who had never seen the sick and dying, and any talk of professionalism was eyed suspiciously as thinly veiled self-interest.
Many physicians have reacted with frustration, anger and cynicism. Some have simply retreated from the debate. Medical schools graduate their students with a not-so-shiny degree, a $100 000 debt and some tutoring in the art of self-preservation — how to protect personal time, control working hours and put one's own needs on a par with (or even ahead of ) those of patients. The high-quality care that society demands, it is argued, itself demands the respectful nurturing of those who provide it. In Canada, for example, the CMA proclaimed a Charter for Physicians,1 which some critics viewed as a self-serving bill of physician rights2 and others as a necessary corrective to the erosion of “reasonable working conditions.”3
A third option is to leave this valley of darkness, climb to a mountain peak, and proclaim a new vision of things. This is what a group of European and North American physicians have done. The Charter on Medical Professionalism, proposed by the American Board of Internal Medicine Foundation, the American College of Physicians–American Society of Internal Medicine Foundation and the European Federation of Internal Medicine (see News, page 945),4 rises above disenchantment by refitting Hippocratic principles to withstand the corrosive effects of globalization, corporatism, privatization and greed.
The charter is based on 3 fundamental principles: the primacy of patient welfare; respect for patient autonomy; and a commitment to social justice. These principles entail 10 “professional responsibilities,” most of which are well articulated in the literature of medical ethics. The principle of social justice leads to 3 responsibilities with a distinctly contemporary cast: the just distribution of finite resources (with an emphasis on providing cost-effective care); improving access to care (by eliminating barriers based on educational, financial and social factors); and managing conflicts of interest, including relationships between industry and opinion leaders (such as researchers, editorialists, guideline-writers and even journal editors).
The charter will be criticized as being idealistic. It is. But the profession must remain idealistic and fundamentally altruistic if it is to survive as a profession and not as a servant of the notion that the market is capable of producing both prosperity and equity. The charter should be read, pondered and discussed. Its emphasis on social justice addresses a particularly modern and relevant set of concerns, and we hope that individual physicians and their professional organizations will embrace them. — CMAJ