The Death Of Hippocrates

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Preamble

As
far as we know, our species is alone in this world. The Old Testament
tells us that God created man in his image. Although the laws of
nature allow us to predict events, it is self-evident to every one
of us human beings that we have free will. This paradox has been
at the core of a great deal of theological debate. Is sinful behavior
the result of free will? Are we the products of our biochemistry
and genes, or perhaps also of early psychological influences? No
one would not argue that behavior and temperament are modified by
our internal milieu. However, human behavior is not very predictable.
What of inspiration, intuition, inventions, and the ability to think
rationally? Are they manifestations of free will?

Groups
of humans live in a society. Intellectual contributions to our civilization
can last no more than a single lifetime without cooperation with
others. (Think of Mozart's sonatas). The most basic level cooperation
is based in the family, albeit for reproduction.

What
then is a society? It is the interaction of individuals,
families, and various-sized groupings, usually for maximal mutual
benefit. It is also self-evident that the best outcome for all
arises when the interaction is for mutual benefit. When interactions
are those of a despot and a serf, one benefits at the expense of
another. We might therefore divide the relationship between human
beings into two categories: a) Those where the interactions
are for mutual benefit, and, b) all the others. In most of
the others, the philosophic concept is that of a zero-sum-game.
The more sophisticated relationship of mutual benefit has
always existed in society, at least to some extent. The nuclear
family is a familiar example. Each family member contributes to
the well being of the family by his or her particular specialized
activities. (One should comment parenthetically here that many actual
societies are managed through a combination of a) and b) above.)
The standard of living might be said to be represented by: SL =
a/b. Familiar examples are the social-democrat parties in Europe.
One of the greatest discoveries of all times is the realization
that the interaction for mutual benefit can be facilitated through
a marketplace involving many individuals, entities, even countries.
The interaction for mutual benefit increases the wealth of all.
It is the antithesis of the zero-sum-game. This renaissance
discovery was codified first by Adam Smith in The
Wealth of Nations
(1776) and politically by Frederic Bastiat
in the book, The
Law
, in the years after the French Revolution. This discovery
codifies Western civilization.

The
Role of Medicine

Medicine
plays an important role in Western civilization. Medicine brings
together the interaction of the sum of human knowledge — of science
and the art of medicine as passed down through the generations —
to the benefit of each person when that person is sick — in exchange
for the fee which makes the livelihood of the physician and funds
the perpetuation of the profession. This perpetuation consists of
the storage of knowledge, the teaching of the trade, and the growth
of the profession.

Money

A
second part of the renaissance invention of laissez faire,
that of trade for the mutual benefit of all, is the invention of
money. In its pure form laissez faire is dependent on honest
money and honest merchants. Both are at risk of being corrupted.
Piecemeal corruption by thieves, charlatans, counterfeiters, and
quacks is a nuisance. However, when the corruption is institutionalized,
the mutual-benefit relationship is soon usurped by the zero-sum-game
relationship. These zero and mutual themes, philosophies,
politics, and traditions have been with us from the beginning. They
parallel the roles of God and the devil in Christian tradition.
(Never does the devil declare his motive.) Evil is always masked
and claims to be good. The attempt of the take-over of medicine
is not an exception. This article is an analysis of such an evil
attempt.

The
Potential of Medical Care

Doctors
have the ability to help the sick. In present times this exceeds
that of previous generations. They also have opportunity to harm
people more. There has also arrived an opportunity for large profits
through the practice of medicine mostly through the vicarious
practice of medicine by pharmacological establishments, the hospital
supply business, bureaucracies, and other politicos with motives.
Now, therefore, is a time during which the ethical practitioner
has to be on guard even more than before.

The
Tradition of Responsibility to the Patient/Customer Goes Back to
Hippocrates.

The
purpose of this essay is to review the new u201CCharter,u201D which has
been given to medicine. I shall be dealing presently with weasel
words. Before we proceed, let us, however, read Hippocrates' oath
in its best English translation. I will dwell on the highlights
and essential points in contrast to the new u201CCharteru201D as we go along.

THE
OATH OF HIPPOCRATES

I
swear by Apollo Physician, by Asclepius, by Health, by Panacea
and by all the gods and goddesses, making them my witnesses, that
I will carry out, according to my ability and judgment, this oath
and this indenture. To hold my teacher in this art equal to my
own parents; to make him partner in my livelihood; when he is
in need of money to share mine with him; to consider his family
as my own brothers, and to teach them this art, if they want to
learn it, without fee or indenture; to impart precept, oral instruction,
and all other instruction to my own sons, the sons of my teacher,
and to indentured pupils who have taken the physician's oath,
but to nobody else. I will use treatment to help the sick according
to my ability and judgment, but never with a view to injury and
wrongdoing. Neither will I administer a poison to anybody when
asked to do so, nor will I suggest such a course. Similarly I
will not give to a woman a pessary to cause abortion. But l will
keep pure and holy both my life and my art. I will not use the
knife, not even, verily, on sufferers from stone, but I will give
place to such as are craftsmen therein. Into whatever houses I
enter, l will enter to help the sick, and I will abstain from
all intentional wrong-doing and harm, especially from abusing
the bodies of men or woman, bond or free. And whatsoever I shall
see or hear in the course of my profession, as well as outside
my profession in my intercourse with men, if it be what should
not be published abroad, I will never divulge, holding such things
to be holy secrets. Now if I carry out this oath, and break it
not, may I gain forever reputation among all men for my life and
for my art; but if I transgress it and forswear myself, may the
opposite befall me.

In
order to follow my discussion, you will need to have the text of
this Charter. You will find it reproduced near the end of this review.
As it is this Charter which I am critical of I will proceed to critique
it as it unfolds. Let my introductory comments above stand as a
background for the considerations, which follow.

Authority
From Within Or Practice By The Grace Of Others?

The
new Charter is replete with the latter perspective. The second word
is professionalism. Why would the creators of this document
choose this word rather than say ethics or responsibility
or simply profess? Let us remind ourselves that the word
profess comes from the concept of commitment which is by
definition individual and responsible. The -ism contains the concept
of a system defined by others. The next words are u201Cin the new millennium.u201D
This is but a clich, a linguistic indication of un-focused thinking,
or parroting. What has the incident on the calendar, the change
in the fourth figure from the right, and the way we count years
have to do with individual responsibility? Invoking the millennium
is redolent of invoking the messiah. Most aggravating, however,
are the next words: u201Ca physician charter.u201D A charter is a
document wherein a sovereign assigns permission to a subject. In
it is contained the concept of sovereignty and fealty. In this case,
those who funded the American Board of Internal Medicine, The American
Society of Internal Medicine, and The European Federation of Internal
Medicine have presumed to own the authority to dispense permission
to the doctors to heal the sick. Within that usurpation is contained
the concept that these bureaucracies can also withdraw that permission
at will. This is not authority coming from within voluntarily by
oath, nor from spontaneous altruism or a desire to cooperate with
other professionals. This document does not start with I promise
or I take an oath or I deem it my responsibility having
professed to the trade, no — none of the above. It is given
unto us by the u201Cgreat-and-mightyu201D who provided the funds for this
project. We shall look into this presently a little more. We are
next told that it is published simultaneously in America and Britain.
The Anglo-Saxon tradition indeed stemming from a charter — the charter
King John gave to the people of England at Runnymede in June of
1215 establishing the rights of the citizens to equality under the
law. This Anglo-Saxon tradition of jurisprudence is challenged here.
The implication is that the doctors in the English-speaking world
have suddenly taken upon themselves to serve these new masters,
canceling the principle of individual responsibility we have held
since the first Charter. Thinking in clichs is apparent in other
phrases: u201CI hope that we will look back upon its publication as
a watershed event in medicine.u201D Well certainly I am not part of
this we, and how dare the author hope on my behalf? Here
I am using myself as an example of the freethinking independent
Hippocratic physician. Watersheds in mountain ranges demarcate
divergent directions of rainwater flow into rivers. It is often
used as a simile for something important. Ironically the author
has used this clich exactly for what it symbolizes — a divergence
from the principles which have been the ethics of our profession.
In the introduction we are told about the main premise: u201CChanges
in the health care delivery systems in countries throughout the
industrialized world threaten the values of professionalism.u201D We
are next told that this is self-evident. Well, indeed it is. The
last thing we need, however, is a fix from the perpetrators
of the problem. The fact that these authors recognize the problem
in general (without defining its cause – socialism) foreshadows
what indeed we find – more socialist solutions. The introduction
then pleads that our conscience, the conscience of each doctor,
should decide. Well, my conscience has little difficulty in deciding
that the fix that these people propose will aggravate the problem
they have identified but defined vaguely, probably on purpose.

Three
Principles

We
next come to the three principles. We are told that the patient
comes first. We are told the patient is autonomous. Finally, the
predictable thorn is stuck in our flesh, u201CThe Principle of Social
Justice . . . .u201D Plato believed that physicians have a primary responsibility
to society, to the Republic, as he called it, not to their patient/customers.
These latter day Platonists, or philosopher-kings as they should
be called (Plato's original term) are, however, up to one additional
trick. It is the implication that opposites can cohabit. This charter,
if taken seriously, will no doubt open a door to endless argumentation,
adjudication, and finally determination from above. What a contrast
with the Hippocratic oath where the individual physician voluntarily
and clearly professes. The next paragraph, which piously
asks for dialogue, is the u2018dress of false modesty.' Contrast this
u2018modesty' with the assumed authority of this u2018charter' and the cast
of characters responsible for it and their source of funding. More
on this issue presently. They tell us that u201CIt has taken the task
force years . . . .u201D There is no room for dialogue.

Fatal
Flaws

This
Charter is flawed in principle. It is flawed ethically. It is replete
with the dialectic. For instance, u201C. . . the challenge will
be to live by these precepts and to resist efforts to impose a corporate
mentality on a profession of service to others.u201D Do you see the
false argument? We are invited to choose between Corporate Mentality
(presumably following the orders of the HMO manager and the like)
on the one hand — and service on the other. Now it is true
that doctoring is a service, but it is not altruism. (Altruism
is service to others for its own sake forswearing any reward). It
never can be or should be altruism. As soon as it is imposed upon
the profession as altruism it will be corrupted. Imposed altruism
is serfdom. In other words, the sentence epitomizes the false
dichotomy, the dialectical process.

Dialectics

Let
us remind ourselves what the dialectical process is. It is the proposal
of a thesis and antithesis and then the drawing of the synthetic
conclusion, the pre-intended or predetermined outcome. An unwary
person subject to the dialectic process is apt to be duped. In the
context of this charter one presumes that the u2018herd' of medicine
is thinking: u201CLead me on. I'm confused but believe you because I'm
too afraid to say that I'm stupid and haven't noted the catch.u201D
Next, we are told that forces that are largely beyond our control
have brought us to circumstances that require a restatement of professional
responsibility. Please, Dr. Harold Sox, (who is the editor who wrote
this introduction) what are these forces? Are you speaking of the
advertising of drugs? Of the promotion of research by drug companies?
The promotion of pharmaceutical and surgical medicine through their
surrogate, the NIH and the Universities? Are you talking about the
Draconian bureaucracies, which inhibit doctors from using their
initiative and individual responsibility? Are you talking about
the Codex Alimentarius that will u201Charmonizeu201D America through
the WTO ? The codex alimentarius is already established in Europe.
It deprives citizens from choosing vitamins and nutrient supplements
in many categories. Whence these forces? These are not the forces
of increased knowledge, technology and science. These are the forces
of central bureaucracies. It is intimidating to a Hippocratic physician
to find you publish the charter in two journals, The Lancet
and The Annals of Internal Medicine. These forces are foreign
to the Anglo-Saxon tradition of individual responsibility and freedom.
Are they beyond our control? Do we live in democracies and republics
or are we serfs? Will the forces of commercialism, bureaucracy and
socialism defeat us? Are we hopelessly doomed in this quagmire?
Is this charter a sign of the re-birth of mercantilism? Our answer
has to be a resounding no. True leadership will rally doctors to
the Hippocratic tradition, not Plato's.

Doctors
are Frustrated

We
next read that u201C…physicians are experiencing frustration as changes
in the healthcare delivery systems in virtually all industrialized
countries are threatening the very nature and values of medical
professionalism.” Well, this is a second iteration of the same
business. The implication that because we are frustrated we should
abandon our principles of two and a half millennia is as ludicrous
as it is insulting. As for the claim that u201Cvoices from many countries
have begun calling. . . u201D This is an embellishment. Whose voices?
Those of us in offices and emergency rooms are calling for Hippocrates.
Get the bureaucrats off our back please. The existing frustration
comes from the first dose of the socialist medicine. The charter
would be the last and fatal dose.

Medicine
and Socialism

The
socialist experiment with medicine started circa 1885 with Otto
von Bismarck in Germany. In the USA it was accelerated during WWII
and again during the Lyndon Johnson administration with the advent
of Medicare in 1965. In historical terms it is new. However, people
nowadays have been so well acculturated to socialism in medicine
that many believe humanity could not exist without it. The communist
variety, as in the USSR, failed on all fronts. The fascist variety,
into which we are now entering in America, is very profitable to
the large mercantile companies in what is to be called Public-Private-Partnerships.
This method of socialism, correctly called fascism, is also inefficient
from the perspective of the user/consumer. It does, however rev
up the cooperation between bought politicos and the captains of
industry.

The
Charter

At
the beginning of the charter we find, u201CProfessionalism is the basis
of medicine's contract with society.u201D This is a classic example
of two package deals in one sentence; nay, three package deals.
Let's start with Contract. A contract is a binding arrangement
between two individuals or entities entered into voluntarily
and for mutual benefit. The vague term, Medicine, in the
sentence — is who? Is it I, a doctor in the office? If so, on whose
say so? I do indeed have contracts with each and every one of my
patients — contracts which I honor and for the fulfillment of which
I shall go to the end of the world — but society? Who is society?
What is society? Where is the demarcation? Am I responsible for
the murders of Christians by the war of Jihad in some remote place
in the world? Who is society? Where is the margin? There is no such
thing. There cannot be a contract between ill-defined or indefinable
entities. This is the Platonic problem all over again. Can a person
profess to a code of ethics and a pattern of behavior? Yes, a person
can, and I as a doctor do. The word professionalism, however, implies
that an outside entity has defined it for me. I don't think so.
We next read that we are to place the interests of patients above
those of the physician. That is not a contract. A contract is an
arrangement in which there is mutual benefit. From the very
second sentence of this preamble, we find a continuation of the
moral contradiction we found in the introduction by Dr. Harold Sox.
Quite predictably, it goes on to discuss maintaining and setting
standards of competence and integrity and, interestingly, u201Cproviding
expert advice to society.u201D Again this nebulous term. The merit of
the nebulous term from the socialist point of view that it is whatever
he chooses it to be and at any time. (God protect us from giving
our freedoms over to these rascals.) Next, we are told that the
contract depends on public trust. Well, trust between parties is
nurtured when they fulfill their obligations. If a contract cannot
be fulfilled, if it contains built-in seduction to corruption –
the service above self part – it is doomed by definition. No
doubt the predictable default will be grist-to-the mill of every
inspector and licensing board. A u201Ccontractu201D which is not voluntary
is serfdom.

Global
Talk

The
thinking in clichs strikes one in the next sentence. This you see
is the product of a selection of high profile doctors in many countries
who have u201Cworked on this . . . for years.” So, just listen
to the next sentence: u201CAt present, the medical profession is confronted
by an explosion of technology.” Why do they not use the word
in advance – increase, improvement – why the analogy to
a bomb? Well, we find the answer in the second half of the sentence,
which includes problems in healthcare delivery and most importantly
bio-terrorism and globalization. Well, the issue of caring
for a particular patient is a private one – and unconnected
with bio-terrorism or globalization. The risk that gangsters will
release biological hazards into the community is a political and
military one. If we have sick people we will need to treat them.
Preparing for hazards is common sense, but not an excuse for socialism.
As for globalization, well that is globalbaloney in the context
of discussing the moral principles to guide a profession. This clich
is, however, emblematic of the origins of the thought patterns from
the foundations whence the funding came for this document. The Robert
Wood Johnson Foundation's agenda is indeed that of globalization;
namely, of control of the people of the world. The next paragraph
is worrisome in a different sense. u201CThe medical profession everywhere
is embedded in diverse cultures . . . .u201D I take it
I am a plant that is embedded in the garden of America. There are
two implications: First of all, that I have some kind of solidarity
with other doctors in other cultures or to their keepers. The more
sinister is that these globalization enthusiasts are planning to
use the embedded doctors for their globalization plan. Alas,
we can see it coming. The verbiage which follows is so characteristic
of the u2018politically correct' language emanating from the foundations
that I won't comment on it more except to draw your attention to
the contrast with the Hippocratic oath. Please cast your eyes up
and read it again. As one might have predicted, under the principle
of social justice we are told that we are triage officers. It is
we who will determine who is to die. And just to enhance our insecurity
in this position we are told that we cannot make a decision based
on socioeconomic status, gender, and a whole list of the usual diversity
criteria. What is not on this list? The bourgeoisie, the politically
independent, he who abides by his own principles or takes them from
God. Politically principled doctors are not on the protected list.
Take note. Under a set of professional responsibilities, we soon
come to the favorite clich of the socialist-imposed Process
of Change.

Life
Long Learning

The
need for continuous revolution emanates from Antonio Gramsci, the
chief theoretician of the Communist International. We have read
about it in China – the Red Revolution – where the Intelligentsia
were placed in the fields for reeducation. Since 1985, America has
imported the Soviet method of education into the Federal Department
of Education. Is it surprising that it has arrived in the medical
u201Ccharteru201D we are now reading? Here it is: u201CPhysicians must be committed
to lifelong learning…u201D Who will determine what this learning
is? Well, you have guessed it. The same bureaucracies. Is my own
research valid? No, it is not, particularly if not sanctioned by
the Robert Wood Johnson Foundation and its cohorts in funding. What
did they choose? Is my judgment of the patient's account of his
illness relevant if it does not meet the standard of care or the
practice guidelines? No, it is not. How will it be inspected? Well,
that is a separate issue not dealt with in this Charter, but of
course it involves the transfer of all medical data to the bureaucrats
electronically all the time.

Honesty

I
must say that I have no argument with a commitment to honesty. The
implication, however, that there is no occasion where a physician
should adopt a paternalistic attitude is wrong. There are patients,
in clinical situations, in which what is now called full disclosure
amounts to nihilism. Human beings live by hope, and we, as physicians
have to remember that. Alienation of the physician from the patient
by this charter can easily be brought about by this u201Chonesty.u201D

Confidentiality

I
love the part about confidentiality, particularly as it arrives
exactly at the time when the new HIPPA law compels us to reveal
everything about all our patients all the time electronically to
Big Brother. We are told next about keeping appropriate relations.
Well, what is appropriate? And, who decides? What balderdash. The
rest of the material contains repetition of the same issues. I will
not bore you with repetition of the critique; however, toward the
end we do find a whip: u201CThe profession should also define and organize
the educational and standard-setting process for current and future
members.” In other words, if you don't abide by these rules,
you're out. Did you read anywhere in this Charter, u201C…according to
my ability and wisdomu201D? No. It all deals with set standards.

I
placed the phrase; Hippocrates is dead, at the top of this
critique. Unless every doctor in every office and every emergency
room and every operating room emerges to stand up against the socialist
takeover and to stand by the Hippocratic oath, the ethical relationship
between doctors and their patients is doomed. I admit, however,
that this charter is merely one step in the Socialist/Platonic plan
for the destruction of laissez faire.

The
Charter Givers

I
have pointed out that the Robert Wood Johnson Foundation (RWJF)
was instrumental in assembling the participants who signed their
names to this charter. Who are these people and how were they selected
and by whom? What is their motivation? That information is not disclosed
with the document. A little research on the World Wide Web yielded
some information which is summarized in the following section.

Relationships
and Interests of the MPP 2002 Participants and Associated Members

Members
of the Medical Professionalism Project 2002 appear to have overlapping
interests. Of the 18 members, 5 are affiliated with the ACP/ASIM,
6 are affiliated with the ABIM foundation, 2 are associated with
Brigham Women's Hospital (having over $240 million in grant monies,
two of which were provided by the RWJF for an unspecified amount),
4 are members of the EFIM, 1 is associated with ISIM and APOR (which
receives funding from RWJF), 1 is affiliated with AAMC (which has
received $2,628,870 in 1999, and $1,135,323 in 2000 in grants from
the John Hart Foundation and over $3,025,894 in grants from RWJF
active between 7/01 and 6/05).

Central
Player

Risa
J. Lavizzo-Mourey, MD is directly associated with the RWJF as the
current Senior VP and director of the Health Care Group. She and
two other signors of this project were also members of the Clinton
Task Force for Health Care Reform.,6

A
seeming overlap of interests is suggested when examining the academic
and professional history of Dr. Risa J. Lavizzo-Mourey, the current
Senior VP of the Health Care Group at the RWJF. Her academic and
career histories have created a network of contacts, many of which
are members of the MPP 2002. Of the total 18 members, Dr. Lavizzo-Mourey
is associated with 7. The remaining ten are from outside the USA.

The
MPP 2002 is a combined project fostered by the ABIM Foundation,
the ACP-ASIM Foundation, and the EFIM. Four individuals on the membership
board of MPP 2002 are directly affiliated with both the ABIM and
the ACP-ASIM.

It
appears that the member list for the MPP 2002 was created with the
motive of comprising a group of individuals, who having a friendly
association whether by education or career, are of particular interests
or having been backed by the same organizations. Then, that group
was combined with an international counterpart of medical representatives
who have knowledge of and demonstrated agreement of and with a more
socialistic medical practice than what the United States are accustomed
to. Dr. Richard Cruess is the Associate Director and Dean of McGill
University in Montreal Canada. u201CCanadiansu201D he suggests, u201Chave a
greater faith in government and more respect for authority than
is true in the U.S. It is generally recognized in Canada that government
is trying to produce the best health care for the least dollars
for the most people.u201D Sylvia, his wife and a major player in her
own right, adds: u201CCanadians are more willing than Americans to live
by and with the rules of the game.u201D

The
Foundation

The
Robert Wood Johnson Foundation (RWJF) itself was set up in 1973
by the then retiring scion of the Johnson family, son of the instigator
and builder of Johnson & Johnson Inc., in the 19th century.
The RWJF Board of Trustees is chaired by the former Vice Chairman
of Johnson & Johnson Inc., Robert E. Campbell, and includes
other board members with affiliations with J&J Inc. including
former PR agent of J&J, Lawrence G. Foster, and former Vice
President and General Counsel of J&J, George S. Frazza.

Financial
Connections

In
1999, the RWJF held approximately 61.7% of its 8.6 billion dollars
in assets, in Johnson and Johnson Inc., common stock.5

u201CMost of the Foundation's grants are multi-year awards. In any given
year RWJF supports about 2,300 projects."6

Johnson
and Johnson is one of America's industrial giants with profits in
the order of twenty four billion dollars a year.

Planned
Influence on a Profession?

Robert
Wood Johnson was described by his biographer as a complex personality
whose ideals moved toward socialism [not the term used by his biographer]
seemingly from his involvement in central planning under the presidency
of Franklin Roosevelt during WWII. It is doubtful if he planned
or envisaged the destruction of the Hippocratic ethic wrought by
the network of socialist apparatchiks his foundation has spawned.
It is, however, likely, that many of the players in this saga are
not quite cognizant that the thrust of their actions leads to the
destruction of medicine, nor that this mayhem is to be part of the
wider scene of the New World Order. A similar degeneration of principle
can be found through comparing the noble wishes of Cecil Rhodes
and the actions of the current Rhodes scholars under the umbrella
of the Council on Foreign Relations, etc.

The
chart below illustrates the main players in this scene and their
connectedness.

Key
to Legend in Illustration

AAMC

-
American Association of Medical Colleges

ABIM

-
American Board of Internal Medicine

ACP

-
American College of Physicians

APOR

-
Association of patient Oriented Research

ASIM

-
American Society of Internal Medicine

EFIM

-
European Federation of Internal Medicine

FACP

-
Fellow of the American College of Physicians

MACP

-
Master of the American College of Physicians

RWJ

-
Robert Wood Johnson

RWJF

-
Robert Wood Johnson Foundation

UEMS

-
European Union of Medical Specialists

 

The Charter

[Reproduced
from Ann Intern Med]

  5
February 2002 Volume 136 Number 3

PERSPECTIVES

Medical
Professionalism in the New Millennium: A Physician Charter

Project
of the ABIM Foundation, ACP–ASIM Foundation, and European Federation
of Internal Medicine*

Pages 243-246

Ann Intern
Med. 2002;136:243-246.

To our
readers: I write briefly to introduce the Medical Professionalism
Project and its principal product, the Charter on Medical Professionalism.
The charter appears in print for the first time in this issue
of Annals and simultaneously in The Lancet. I hope
that we will look back upon its publication as a watershed event
in medicine. Everyone who is involved with health care should
read the charter and ponder its meaning.

The charter
is the product of several years of work by leaders in the ABIM
Foundation, the ACP–ASIM Foundation, and the European Federation
of Internal Medicine. The charter consists of a brief introduction
and rationale, three principles, and 10 commitments. The introduction
contains the following premise: Changes in the health care delivery
systems in countries throughout the industrialized world threaten
the values of professionalism. The document conveys this message
with chilling brevity. The authors apparently feel no need to
defend this premise, perhaps because they believe that it is a
universally held truth. The authors go further, stating that the
conditions of medical practice are tempting physicians to abandon
their commitment to the primacy of patient welfare. These are
very strong words. Whether they are strictly true for the profession
as a whole is almost beside the point. Each physician must decide
if the circumstances of practice are threatening his or her adherence
to the values that the medical profession has held dear for many
millennia.

Three Fundamental
Principles set the stage for the heart of the charter, a set of
commitments. One of the three principles, the principle of primacy
of patient welfare, dates from ancient times. Another, the principle
of patient autonomy, has a more recent history. Only in the later
part of the past century have people begun to view the physician
as an advisor, often one of many, to an autonomous patient. According
to this view, the center of patient care is not in the physician’s
office or the hospital. It is where people live their lives, in
the home and the workplace. There, patients make the daily choices
that determine their health. The principle of social justice is
the last of the three principles. It calls upon the profession
to promote a fair distribution of health care resources.

There is
reason to expect that physicians from every point on the globe
will read the charter. Does this document represent the traditions
of medicine in cultures other than those in the West, where the
authors of the charter have practiced medicine? We hope that readers
everywhere will engage in dialogue about the charter, and we offer
our pages as a place for that dialogue to take place. If the traditions
of medical practice throughout the world are not congruent with
one another, at least we may make progress toward understanding
how physicians in different cultures understand their commitments
to patients and the public.

Many physicians
will recognize in the principles and commitments of the charter
the ethical underpinning of their professional relationships,
individually with their patients and collectively with the public.
For them, the challenge will be to live by these precepts and
to resist efforts to impose a corporate mentality on a profession
of service to others. Forces that are largely beyond our control
have brought us to circumstances that require a restatement of
professional responsibility. The responsibility for acting on
these principles and commitments lies squarely on our shoulders.

~
Harold C. Sox, MD, Editor

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.

Author
and Article Information

Requests
for Single Reprints:
Linda Blank, ABIM Foundation, 510 Walnut
Street, Suite 1700, Philadelphia, PA 19106-3699; e-mail, lblank@abim.org.

*This
charter was written by the members of the Medical Professionalism
Project: ABIM Foundation: Troy Brennan, MD, JD (Project Chair),
Brigham and Women’s Hospital, Boston, Massachusetts; Linda Blank
(Project Staff), ABIM Foundation, Philadelphia, Pennsylvania;
Jordan Cohen, MD, Association of American Medical Colleges, Washington,
DC; Harry Kimball, MD, American Board of Internal Medicine, Philadelphia,
Pennsylvania; and Neil Smelser, PhD, University of California, Berkeley,
California. ACP–ASIM Foundation: Robert Copeland, MD, Southern Cardiopulmonary
Associates, LaGrange, Georgia; Risa Lavizzo-Mourey, MD, MBA, Robert
Wood Johnson Foundation, Princeton, New Jersey; and Walter McDonald,
MD, American College of Physicians–American Society of Internal
Medicine, Philadelphia, Pennsylvania. European Federation of Internal
Medicine: Gunilla Brenning, MD, University Hospital, Uppsala, Sweden;
Christopher Davidson, MD, FRCP, FESC, Royal Sussex County Hospital,
Brighton, United Kingdom; Philippe Jaeger, MB, MD, Centre Hospitalier
Universitaire Vaudois, Lausanne, Switzerland; Alberto Malliani,
MD, Università di Milano, Milan, Italy; Hein Muller, MD,
PhD, Ziekenhuis Gooi-Noord, Rijksstraatweg, the Netherlands; Daniel
Sereni, MD, Hôpital Saint-Louis, Paris, France; and Eugene
Sutorius, JD, Faculteit der Rechts Geleerdheid, Amsterdam, the Netherlands.
Special Consultants: Richard Cruess, MD, and Sylvia Cruess, MD,
McGill University, Montreal, Canada; and Jaime Merino, MD, Universidad
Miguel Hernández, San Juan de Alicante, Spain.

Corruption

It
is the thrust of this review that doctors have been subject to an
intense corrupting pressure in the 20th century which can be summarized
with the word socialism. It has been brought on by the high
cost of inappropriate care with expensive drugs, hospitalization
and surgery. These have been promoted by research and advertising
from the commercial interests which are parasitic on the profession.
They include the pharmaceutical and hospital supply industries,
such as Johnson & Johnson. The creation of a rulebook, or charter,
codifying what is best encapsulated in the caricature term veterinarian
medicine will finally trap doctors into serfdom. Big business
often promotes government control. John D Rockefeller summarized
the idea with the famous phrase, Competition is a sin. When
the Hippocratic oath dies a standard bearer for liberty will be
lost. Ultimately patients will get the wrong care. Absent a genuine
market place for medical services no one will have any measure with
which to judge what is worthwhile, as medical services are no different
from other services in the economy.

We
also need to be concerned about the global agenda. The hidden strategy
of this program is not in keeping with Hippocratic medical ethics.

Conclusion

Doctors
should not let themselves be influenced by socialist/fascist propaganda.
In the case of this u201Ccharteru201D the nefarious motives become clear
when it is analyzed in light of the Hippocratic oath and the source
of funding is revealed.

June
10, 2002

Thomas
Dorman, MD, [send him mail]
edits Fact,
Fiction, & Fraud in Modern Medicine
.

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