The authors of an international physicians' charter say the new document is an attempt to recoup aspects of professionalism that doctors have lost in the wake of growing government and private-sector control over medicine.
Two of the coauthors told CMAJ that the Charter on Medical Professionalism is not intended to replace either the CMA Code of Ethics, the CMA's Charter for Physicians, or the Hippocratic Oath. Instead, it is designed to complement existing codes by articulating 3 principles and 10 professional responsibilities that address issues ranging from the primacy of patient welfare to the just distribution of finite resources and the disclosure of errors.
“The medical profession is clearly worried about its place in society and its values,” says Dr. Richard Cruess, a former dean of medicine at McGill and one of 18 coauthors from around the world. “We believe the majority of doctors are unhappy because they feel powerless to bring about change to make things better.”
By using this new tool, “we may be able to make changes to preserve the values of medicine.”
Dr. Charles Weijer, a bioethicist at Dalhousie University, Halifax, says the charter “relies on the language of physician responsibility rather than rights, and … radiates a clear commitment to the patient, first and foremost. You read it and say, ‘Wow, this is what it means to be a doctor.’ I love it.”
The charter was initiated 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 (www.professionalism.org). It was published in February simultaneously in the Lancet and in the Annals of Internal Medicine (www.annals.org/issues/v136n3/full/200202050-00012.html).
Weijer says it's an idealistic document that has arrived when the “profession needs more ideals injected into the contemporary debate. The public has become somewhat jaded about the role of physicians in society because they don't hear doctors articulating these ideals.”
He says physicians could use the document to defend the health care system and the primacy of patient welfare.
Dr. Sylvia Cruess, the other Canadian coauthor, says it could be used for teaching professionalism and evaluating students. “It has the potential to be powerful,” says Sylvia Cruess, former medical director at Montreal's Royal Victoria Hospital. Weijer plans to use it for teaching his first-year medical students next year.
In Canada, where almost all relevant medical bodies already employ the CMA Code of Ethics, all 16 schools of medicine and licensing bodies have received the charter and been asked to adopt it. (The CMA published its own Charter for Physicians in 1999. See CMAJ 1999;161[4]:430-1.) The new charter is being distributed in the US and UK, and will soon be published in Europe. No time frame has been set for its adoption.
The CMA's 1999 Charter for Physicians contains 30 clauses in 5 different sections: the physician–patient relationship, professional integrity, fairness, quality of life and health care system.
“The new charter is consistent with the CMA's own work on medical professionalism, which is currently the main priority of the Committee on Ethics,” said Dr. John Williams, the association's director of ethics.
“The CMA published a discussion paper, Professionalism in Medicine, last year, and the committee expects to finalize its policy on ‘medical professionalism’ for consideration by the CMA board this May. Sylvia and Richard Cruess have provided invaluable comments on these documents, so the CMA has benefited from the work that went into the ACP charter.”
The registrar at the College of Physicians and Surgeons of British Columbia says the new charter attempts to return physicians to their basic responsibility to patients. “There are more and more complaints that doctors are acting in the interest of the bigger picture instead of the patient,” says Dr. Morris VanAndel. “The main message here is the responsibility to the patient.” He says the college council will discuss the charter.
Richard Cruess acknowledges that some may not favour the charter's emphasis on social justice and the fair distribution of resources. “It's something to work toward,” he says.
“Physicians know the impact of the use of resources better than anyone else, so they have to be involved in it,” adds Sylvia Cruess.
Another potentially contentious issue is the commitment to inform patients of medical error, a move the authors strongly endorsed. The charter also advocates full disclosure of conflicts of interest in order to maintain public trust. “We've got to manage them as openly and best we can,” says Sylvia Cruess. Weijer describes the charter's stand as “courageous” and says it could have a profound effect.
Sylvia Cruess says the demise of professionalism stems from the loss of control to the corporate and government sectors, a loss that now “threatens physician practice and their ability to determine their own career.”
In Canada, says Richard Cruess, this has created tension between the “obligation to the patient and the obligation to society and limited resources.”
He says the new document is an attempt to help physicians regain some control over the debate by making them expert advisers.
“We have to negotiate more than ever because we don't control the marketplace, but in order to negotiate we have to be recognized as putting the welfare of society first, just as individual doctors have to be recognized as putting patients first,” he says. — Barbara Sibbald, CMAJ