Social Justice and a commitment to a fair distribution of finite resources has always been a core of who we are as physicians and as human beings. With the renewed emphasis on professionalism in medicine, it is being reintroduced as part of the core of our values as physicians. This is very welcome, but does not sit so well with some of our more conservative colleagues, as you'll see below.
Medical Professionalism in the New Millennium: A Physician Charter -- Project of the ABIM Foundation, ACP–ASIM Foundation, and European Federation of Internal Medicine* 136 (3): 243 -- Annals of Internal Medicine:
"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. "
In the next section, A Set of Professional Responsibilities:
"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."
Response Letter in Annals of Internal Medicine, by Christopher Lyons, in part:
"In the charter's preamble, the concept of medicine's contract with society is discussed. To a large extent, the obligations of physicians to society in that contract are nicely laid out in the subsequent discussion. Given that a contract is usually created between two parties and each party has an obligation to the other, what is society's responsibility to physicians? As highly trained, caring members of society, aren't physicians entitled to certain assurances of financial stability? Should we be expected to withstand ongoing efforts to politicize the health care industry in attempts to garner votes while balancing the federal budget? Must we continue to withstand repeated attacks from trial attorneys who have little interest in the facts of a medical case and are interested only in the payoff? "
Another, by Jerome Arnett, in whole:
"I read with interest the article on medical professionalism in the new millennium (1), which proposed a new code of conduct for physicians comprising three principles and 10 responsibilities. As a proposed code of ethics, the charter is untenable for several reasons. Two of the three principles conflict. Patient welfare is predicated on individual rights while social justice is based on group rights (those of "society"). Since individual rights and group rights are mutually exclusive, the physician can follow one of these two principles but not both (2). In addition, at least 2 of the 10 responsibilities (public advocacy and just distribution of finite resources) place the interests of others ahead of those of the patient. Physicians will be less likely to subscribe to an ethical code that does not have the welfare of the patient as its highest objective.
"Equality of outcome is an undesirable and unattainable vision that invariably results in the loss of patients' rights. Only under socialism (government medicine or corporate socialized medicine) are health care resources finite, so that they must be rationed or justly distributed. Under other circumstances, the provision of services"necessary" or "unnecessary"to one patient does not diminish the resources available for others.
"The commitment to maintaining trust by managing conflicts of interest forbids physicians to pursue private gain or personal advantage. How then is it ethical for a group of physicians such as the Medical Professionalism Project to weaken our code of ethics in order to promote a political agenda (improving "the health care system for the welfare of society," promoting "the fair distribution of health care resources," or ensuring social justice)? These proposed changes in our time-honored, patient-centered ethics will worsen, not improve, the dilemma of today's physicians, who already are challenged by new technology, changing market forces, problems in health care delivery, bioterrorism, and globalization. But even more ominous, medicine without effective, patient-centered ethics is no longer a profession but merely a tradewhich was its status in ancient Greece before the Oath of Hippocrates.
Reference number 2 is:
2. Vazsonyi B. America's 30 Years War: Who Is Winning? Washington, DC: Regnery; 1998:79.
Two of the authors, Drs. Cruess and Cruess, reply, very diplomatically:
"IN RESPONSE:
"Although Dr. Arnett's points are well taken, the charter is not a code of ethics, nor is it intended to detract from or supplant the Hippocratic tradition that has long enriched medicine's history. It is a statement of contemporary responsibilities—medicine's understanding of its obligations under today's social contract. We strongly disagree that individual rights and group rights are mutually exclusive and that "the physician can follow one of these two principles but not both." We do not underestimate the difficulty of reconciling the two sets of responsibilities but believe passionately that medicine must attempt to do so. The alternative is for someone without medical knowledge or expertise to determine the societal rights in health care and how they are to be reconciled with the rights of individual patients. Do we really wish this to occur, or do we believe that it is better for individual physicians and their organizations to use their expertise to try to achieve the proper balance? The charter suggests the latter course. It does, however, state that physicians must put the welfare of the individual patient first, thus reaffirming our traditional fiduciary responsibilities. Our duties to individual patients must be carried out with a knowledge of the impact of our own decisions on the wider society, which we also serve. We also disagree that the allocation of resources to one patient does not diminish the resources available to others under a market-driven system. The attempts at cost containment seen throughout the world, no matter what the nature or structure of the health care system, indicate that this is not true. There is no question that contemporary physicians are expected to serve both their patients and society.
"A second point of some importance refers to "equality of outcome." We are not sure that equality of outcome can be termed "undesirable," as Dr. Arnett stated, but certainly such an objective is unrealistic. Nowhere does the charter advocate equality of outcome as an objective.
"Dr. Arnett interprets the charter as forbidding physicians' pursuit of private gain or personal advantage. Nowhere does it so state. The conflicts of interest section states that physicians must deal with these conflicts in an open and transparent way. We cannot eliminate conflicts of interest, but we must ensure that our integrity is preserved as we cope with and manage them and recognize the consequences of our decisions.
"We agree with Dr. Arnett that without effective patient-centered ethics, medicine is no longer a profession. As already mentioned, the charter is not a code of ethics but a freely given statement of medicine's commitments and responsibilities, essentially outlining where we should stand in complex times. It is aimed at restoring the feeling of pride in the profession and public trust that all observers have agreed is so essential to the proper functioning of a profession and distinguishes it from a trade."
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