Editorial

The Medical Professionalism Project and its Physician Charter:
New Ethics for a Political Agenda

Jerome C. Arnett, Jr., MD, FCCP


Changes in health care delivery threaten the values of professionalism and are tempting physicians to reject their commitment to the "primacy of patient welfare." So claims a new group, the Medical Professionalism Project, which is comprised of delegates from three medical organizations --- the American College of Physicians-American Society of Internal Medicine (ACP-ASIM) Foundation, the American Board of Internal Medicine (ABIM) Foundation, and the European Federation of Internal Medicine.

After several years of work they have developed a new code of ethics, the so-called Charter on Medical Professionalism, which they claim is necessary in order to "maintain the fidelity of medicine's social contract" and to encourage "collective efforts to improve the healthcare system for the welfare of society." This Charter has been published simultaneously in The Lancet and in Annals of Internal Medicine, the latter with a special introduction by the editor, Harold C. Sox, M.D.(1)

The Charter is a cleverly camouflaged political agenda whose objective is to replace our traditional individual-based medical ethics with population-based ethics. It claims to identify the "fundamental and universal principles and values of medical professionalism," and lists three principles and ten responsibilities as ideals to be pursued by all physicians. The principles are (1) primacy of patient welfare, (2) patient autonomy, and (3) social justice. The ten responsibilities (commitments) are: (1) professional competence, (2) honesty with patients, (3) patient confidentiality, (4) maintaining appropriate relations with patients, (5) improving quality of care, (6) improving access to care, (7) a just distribution of finite resources, (8) scientific knowledge, (9) maintaining trust by managing conflicts of interest, and (10) professional responsibilities.

The preamble states, "Professionalism is the basis of medicine's contract with society. It demands placing the interests of patients above those of the physician..." Medicine has no contract with society, but individual physicians do have contracts with individual patients. But the Charter does not consider the ethical values which support the life of the individual patient. Instead, like the Nazi doctor and the Soviet psychiatrist from a past era, paramount is concern for the health care system and for the "welfare" of society.

Two of the three "fundamental principles" conflict. The primacy of patients' welfare relies on the rights of individuals while "social justice" is based on the so-called rights of groups. But individual rights and group rights are mutually exclusive, so that they cannot coexist.(2) Physicians may follow one or the other of the principles, but not both.

Three of the ten responsibilities lead to ethical conflicts. Number six, improving access to health care, means "social justice," which is based on the absurd idea that forcing results to be equal --- that is, equalizing the distribution of wealth, of health care resources, or of any other good --- will correct for the shortcomings of "God, Nature, History and Happenstance."(3) History shows this idea has caused horrendous harm and suffering every place it has been tried.(4,5) It therefore is unethical.

Number seven, a just distribution of finite resources, means that someone instead of the patient is making decisions as to what is necessary or unnecessary. However, the patient is the only one who ethically can do this for her own care. Also, finite resources must be "justly distributed" only under government or corporate socialized medicine (socialism). This is the setting in which the provision of services to one patient might take away from those provided to another, as claimed in the Charter, but this certainly is not caused by our individual-based ethical code. Finally, a physician responsible for the care of a patient must not undertake responsibility for the rationing of health care. Some other member of the community must do this, not the physician.

Number nine, maintaining trust by managing conflicts of interest, is irrational. It is not ethical for physicians to enter into any arrangement that results in a conflict of interest. In a profession, as opposed to a trade, conflicts of interest cannot be managed, they must be avoided.

The principle of patient welfare, as Dr. Sox points out, dates from ancient times. So does the much-maligned concept of physician paternalism which, since the time of Hippocrates, has provided a very important and comforting support for the patient during frightening episodes of severe illness, thus strengthening the patient-physician relationship.

Yet physician paternalism is rejected supposedly because it interferes with patient choice, and instead, patient autonomy is promoted. But we have seen how patient autonomy (as part of the "Georgetown mantra" from the field of bioethics) has been used, falsely in some cases, to promote assisted suicide and euthanasia.(6)

Instead of physician paternalism, it is the Charter which takes choice away from the patient by insisting on altruism (the patient must place the needs of others ahead of her own needs) and by placing the needs of society above those of the individual patient. Both of these mean that some other person will make the choice for the ill patient. Who is this to be? How will this person be chosen? And why is this form of paternalism good if physician paternalism is bad?

Debasing our professional ethics in order to promote a political agenda is in itself unethical. Our time-honored, patient-centered ethics must be cherished and preserved with the same enthusiasm and pride that we apply to our sacred obligation to give the finest care possible to each of our patients.

From the physician immersed in patient care practicing front line medicine in the trenches, to the professors in our medical schools teaching medical students the failed ethics of "bioethics," to the leaders of organized medicine proposing a new ethical code for the entire profession, the same dictum must be followed --- primum non nocere. For the physician, first don't harm the patient but just as importantly for the leaders of the profession, don't harm the profession's ethical code.

This Physician Charter, a set of "fundamental principles," values and professional responsibilities, which places the needs of society above those of the individual patient, will increase suffering and death and destroy the patient-physician relationship. Designed to promote the interests of third parties, it will worsen, not improve, the dilemma faced by today's physicians, who already are challenged by new technology, increasing complexity of health care, changing market forces in medicine, and problems with health care delivery.

The political agenda behind this Physician Charter is the same as that behind the "Tavistock principles," proposed several years ago in an earlier attempt to destroy medicine's ethical code.(7) Tavistock principle number (1) proposed a new welfare right (an entitlement) to health care and principle number (2) proposed a population-based ethics. The "Tavistock principles" were rejected by every organized medical group which considered them.8 The same fate awaits this Physician Charter despite the years of wasted effort that these prominent members of organized medicine have expended to develop it.

References

1. Medical Professionalism Project. "Medical Professionalism in the New Millennium: A Physician Charter." Ann Int Med 2002;136:243-46.
2. Vazsonyi B. America's 30-years War: Who is Winning? Washington, D.C., Regnery Publishing, 1998, p. 79.
3. Ibid., p. 209.
4. Rothbard MN. Egalitarianism as a Revolt Against Nature and Other Essays. Auburn, Al., Ludwig von Mises Institute, 1974, pp. 18-20.
5. Vazsonyi, op. cit., pp. 37-39.
6. Smith WJ. Culture of Death: The Assault on Medical Ethics in America. San Francisco, Encounter Books, 2000, p. 111.
7. Berwick D, Hiatt K, Janeway P, Smith R. An Ethical Code for Everybody in Health Care (Editorial). British Medical Journal 1997;315:1633-34.
8. Arnett JC Jr. The 'Tavistock Principles' of Medical Ethics (Editorial). Medical Sentinel 2001;6(2):63-65.

Dr. Jerome C. Arnett, Jr., is a member of the Editorial Board of the Medical Sentinel, a medical ethicist, and a practicing pulmonologist in Elkins, West Virginia.

Originally published in the Medical Sentinel 2002;7(2):56-57. Copyright©2002 Association of American Physicians and Surgeons (AAPS).