The quality of the professional relationship between Canadian physicians and their patients is being progressively eroded by the unrealistic promises of politicians and the contorted efforts of bureaucrats to achieve the impossible. Stories abound in every province of physicians who are thrown into the conflict of advising their patients of needed treatment and then apologizing for a system that cannot provide that treatment in a timely fashion. Waiting lists attest to the gap between needed care and available resources. Struggling to meet the needs of their patients and their obligations to themselves and their families, physicians are leaving the country, surrendering their privileges, seeking alternative niches in which to deliver care or just burning out.
The political pipe-dream that unlimited high-quality services can be provided with limited funds can no longer be sustained by the extorted good will of physicians and other health care professionals. This is why, in 1996, as it passed the latest revision of the CMA Code of Ethics, the CMA's General Council voted nearly unanimously to develop a physicians' charter. Over a 2-year period the Charter was developed and revised with input from every provincial, territorial and professional affiliate and from the public. The final revision [1] was supported overwhelmingly by the CMA Board and approved at the meeting of the General Council in 1998 by 124 votes to 51.
The purpose of the Charter is to clarify for physicians and the public the circumstances that physicians need in order to give their best to their patients and their profession. One of the strongest arguments for the Charter was the well articulated concern of the provincial Colleges with regard to the deteriorating mental and physical health of practising physicians. [2] Physicians who are denied professional satisfaction through intolerable call schedules, isolation and exclusion from health care planning are limited in their ability to provide effective patient care.
The critique of the Charter by Dr. Nuala Kenny and colleagues published in this issue (page 399) is misleading, for it applies the word "rights" to the Charter and thus alters its character and distorts it to meet the definition of the attack. The Charter that the CMA General Council overwhelmingly voted for is a statement of needs, not a declaration of rights. The question of whether a traditionally conservative group such as the CMA should produce a document like this was, quite appropriately, the subject of debate by General Council. Some ambivalence was expressed about early drafts and preambles, but extraordinary support emerged for virtually all the articles in the final version. Kenny and colleagues' objections that a charter should be reserved for an oppressed group or be developed with the involvement of those who would deny our profession are difficult to take seriously. In answer to the first, I would suggest that preventing oppression is surely better than reacting to it; as for the second, we need only remember that the coal miners of Cape Breton did not ask permission from their employers prior to seeking tolerable working conditions.
The needs expressed in the Charter are real and pressing. For example, the relevance of the Charter's call for physicians to have the freedom to advocate improvements in health care funding was manifested recently in Nova Scotia, where the silence of physicians on matters of funding policy was sought as part of a contract between the Nova Scotia government and the provincial medical society. The resulting arbitration order stipulates that "The Medical Society will not publish opinion articles or letters to the editor in newspapers decrying government funding of physicians" and that "Any negative communications, including posters from previous communications programs should be taken down if still displayed in doctors' offices." [3]
Nor are the terms of the Charter in the best interests of physicians only. Kenny and colleagues' criticism of article 6 implies, quite incorrectly, that physicians may never refuse or end a therapeutic relationship, even under the special circumstances stipulated in the CMA Code of Ethics. Most practising physicians know of circumstances in which the continuation of a physician-patient relationship serves neither the best interests nor the safety of either party. Article 11, which invokes the need for physicians to be able to inform patients of all appropriate treatment options, recalls how patients and physicians have joined in the United States to resist health maintenance organizations that sacrifice the needs of both by limiting therapeutic choices. Furthermore, one of the recommendations in discussions of the Charter was the development, in concert with other groups, of a charter for patients.
Kenny and colleagues' suggestion that physicians adopt altruism as a solution may appeal to governments, but for physicians, other health care professionals and patients fruitlessly seeking the treatments they need, it rings hollow. However, their critique has at least one thing right: respect must be earned. Many opinion polls have confirmed that Canadian physicians individually and collectively have long earned respect. But now the time has come for physicians to insist on reasonable working conditions under which they may retain that respect. It is in the best interests of our patients that care be provided by an independent profession striving to assure quality and access, and that it not be reduced to the level of other overburdened and overregulated government services. We may hope that the Charter will help us to achieve that goal. But the worth of the Charter, like that of the Code of Ethics, will be measurable only after Canadian physicians have made it a living document by using it to improve the quality and availability of health care in Canada.
Dr. MacCarthy is a Member of the Board of Directors of the CMA and has recently become Director of Professional Relations, British Columbia Medical Association, Vancouver, BC.
Competing interests: None declared.
Reprint requests to: Dr. Dan MacCarthy, British Columbia Medical Association, 115-1665 West Broadway, Vancouver BC V6J 5A4; fax 604 736 4566; [email protected]