The Charter on Medical Professionalism:
The New Hippocratic Oath?

by Jay Johansen
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For almost 2,500 years the Hippocratic Oath was held up as the standard for doctors. But in the last few decades its popularity among medical professionals and medical schools has declined. And so in 1999 a group of medical societies from the United States and Europe got together and set up a committee, the Medical Professionalism Project, to develop a new oath. The product of their labors was published simultaneously in the Annals of Internal Medicine in the U.S. and the Lancet in Europe in February, 2002. They called it, "The Charter on Medical Professionalism".

Nothing in the published documents that I have seen from this committee specifically says that their goal is to update or replace the Hippocratic Oath, but that appears to be what they're trying to do, and if their new "charter" becomes popular that would be the likely practical result. In any case, it's interesting to compare this modern oath to that of the ancient Greek. I encourage you to read both: the Hippocratic Oath and the Charter on Medical Professionalism. One can see difference in their views of the world and the medical profession.

For convenience, for the rest of this article I shall refer to these as the "Oath" and the "Charter".

Small but amusing points

  1. Hippocrates comes across as rather humble. He appeals to the gods to help him live up to his oath. A bit later he says that all medical students should adhere to "a stipulation and oath", but does not specify that all must follow his oath. While I presume he would not support an oath containing contradictory principles, he seems quite willing to accept the idea that his might not be the final word. On the other hand, the Annals of Internal Medicine article introduces the Charter with the assertion that "we will look back upon its publication as a watershed event in medicine" and "everyone who is involved with medical care should read the charter and ponder its meaning".

  2. The Charter is very socially conscious, indeed quite "politically correct" at points. Shortly after making the rather pretentious statement about how all the doctors in the world should "ponder [the] meaning" of this Charter, the editors themselves ponder if doctors from non-Western cultures might not have different standards, and suggest a "dialogue" on the subject. The Charter attacks "market forces" as a threat to good medicine that must be overcome, and frets about the impact of "globalization". They have a lot to say about "social justice" and discrimination. The Oath, on the other hand, makes no reference to larger social or political issues: it speaks only of what the individual doctor should and should not do.

More substantive issues

Similarities

  1. Both say that a doctor should always put what is best for the patient above his own personal gain.

  2. Both say that a doctor should not divulge private information about his patients. (The Charter adds an exception in cases of "overriding ... public interest", such as when a patient endangers others.)

  3. Both prohibit taking sexual advantage of patients.

Differences

  1. The Oath is very specific. For the most part, if someone claimed that a doctor had violated the Oath, the only thing to debate would be the facts: did he really commit the claimed violation or not? For example, the Oath prohibits a doctor from participating in physician-assisted suicide or performing abortions. These are specific acts: the doctor did one of these things or he didn't.

    The Charter is much more vague. It tells doctors to "promote justice in the health care system", to be "dedicated to continuous improvement in the quality of health care", and to "provide health care that is based on the wise and cost-effective management of limited clinical resources". Even if you knew exactly what a doctor did every minute of every day, it could still be quite difficult to say whether or not he had lived up to this Charter. Exactly what is an individual doctor supposed to do to improve the quality of health care ... "continuously"? How do we determine whether a given treatment plan is "wise" and "cost-effective"? There's lots of room for interpretation and judgement calls here.

    As an editorial in World magazine put it (March 9, 2002), "Whereas the Hippocratic oath is a succinct 364 words (in the English translation), the Charter is 1,445 words that say much less".

  2. The meaning and goals of the Oath are plain: Hippocrates opposed specific practices that other doctors engaged in or that he feared they might engage in, and he spells them out: euthanasia, abortion, sexual relations with patients, violating patient confidentiality, and failing to refer to a specialist. (That last one strikes me as being of a different character from the rest. I guess that he feared that a doctor, through arrogance and/or greed, might attempt procedures that he was not qualified to perform, with obvious potential harm to the patient.) (A tangential thought: I am, of course, referring back to the Oath as I write this to get the list right, and as I do so it suddenly occurs to me that the issues that concerned Hippocrates are almost all issues that are still in the news regularly today. Perhaps things haven't changed so much in 2,500 years after all.)

    The Charter, on the other hand, plays word games that leave us guessing what they really mean. The example of this that I find the most puzzling, perhaps disturbing: There is a section on respecting a patient's right to make decisions about his own care that concludes, "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". What in the world is "inappropriate care"? If we just take the ordinary, literal English meaning of these words, I guess it would mean, "treatment that is not a good idea". But then what are we left with? Something like: Doctors should not try to make medical decisions for a patient, but should give the patient whatever treatment he asks for ... unless the doctor thinks that the patient's decision is wrong, in which case the doctor should ignore the patient's wishes and do what he thinks is best. But then, how is that different from the doctor just doing what he thinks is best all the time? I'd be happy to promise anyone that I would obey every order he gives me as ... long as I agree that it's a good idea and it's what I would have done anyway. Thus, I can't help but suspect that "inappropriate care" is a code word. I notice a couple of other similarly vague statements that I can't help but wonder might be related, namely: Another section talks about "wise and cost-effective" health care and a "just distribution of finite resources". And in two places they warn of the danger that "market forces" might pressure a doctor to "compromise" his "principles". Put this all together and -- and I freely admit that I am speculating here, but it seems to fit -- I think what they mean is this: If a patient asks for life-saving treatment and the doctor decides that this patient is not worth saving, that his quality-of-life is too poor, or that further care is too expensive, then the patient's wishes should be ignored and he should be left to die. That would be "wise and cost-effective". The fact that the patient has insurance or personal financial resources to pay for treatment is irrelevant, because that would be allowing "market forces" to pressure the doctor into "compromising his principles". I'm not making this up out of whole cloth: the idea of rationing medical care -- with decisions made either by government officials or hospital ethics committees -- has been floated a number of times in the last few decades, perhaps most dramatically in the "Clinton health care plan" proposed in the US in the early 90's that would have made it a federal crime for a doctor to give a patient treatment that was not approved by the government. (The proposal labeled this "graft and corruption in medical care".) If you have another idea what this might mean, I'm happy to hear it.


Full text:

The Charter on Medical Professionalism

Physicians today are experiencing frustration as changes in the health care delivery systems in virtually all industrialized countries threaten the very nature and values of medical professionalism. Meetings among the European Federation of Internal Medicine, the American College of Physicians-American Society of Internal Medicine (ACP-ASIM), and the American Board of Internal Medicine (ABIM) have confirmed that physician 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 organizations 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 patient welfare and to the basic tenets of social justice. Moreover, the charter is intended to be applicable to different cultures and political systems.

Preamble

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 globalization. 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.

Fundamental Principles

Principle of primacy of patient 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 patient autonomy. Physicians must have respect for patient 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.

A Set of Professional Responsibilities

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 patient and societal trust. Reporting and analyzing medical mistakes provide the basis for appropriate prevention and improvement strategies and for appropriate compensation to injured parties.

Commitment to patient confidentiality. Earning the trust and confidence of patients requires that appropriate confidentiality safeguards be applied to disclosure of patient information. This commitment extends to discussions with persons 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 patient data and an increasing availability of genetic information. Physicians recognize, however, that their commitment to patient confidentiality must occasionally yield to overriding considerations in the public interest (for example, when patients endanger others).

Commitment to maintaining appropriate relations 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 patient safety, minimize overuse of health care resources, and optimize 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 one's 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 physician experience.

Commitment to maintaining trust by managing conflicts of interest. Medical professionals and their organizations 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 organizational interactions with for-profit industries, including medical equipment manufacturers, insurance companies, and pharmaceutical firms. Physicians have an obligation to recognize, 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 maximize patient 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 organize 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.

Summary

The practice of medicine in the modern era is beset with unprecedented challenges in virtually all cultures and societies. These challenges center 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.

Source: "Medical Professionalism in the New Millennium: A Physician Charter", Annals of Internal Medicine, 5 Feb 2002, 136:3, pp 243-246.


Posted 6 Mar 2002.

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