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The Death Of Hippocrates

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, [email protected].

*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