Editorial
The Charter on Medical Professionalism: an important issue that concerns us all

Several scientific journals, such as the Lancet, Journal of the American Medical Association, Annals of Internal Medicine, Medical Journal of Australia and Obstetrics and Gynecology, have published, particularly in the last 2 years, editorials and series of articles on professionalism and the new Charter on Medical Professionalism. In fact, since 1999 a group of 20 health care professionals from Europe and North America have been working on the so-called Medical Professionalism Project. The project can be characterized as an attempt to redefine and modernize some old philosophies, particularly the medical code of conduct, to reflect the new challenges facing medicine today.1–3

The main result of the work of this group, which includes representatives of the American College of Physicians, the American Society of Internal Medicine and the European Federation of Internal Medicine, is the Charter on Medical Professionalism. This charter outlines 3 principles and 10 commitments that define what a medical professional should stand for.

According to Dr. Richard Cruess, a former dean of medicine at McGill University, Montreal, and a member of the international group working on medical professionalism, “the Charter is a public statement that this is what the medical profession believes it should stand for in a new and complicated society. On the one hand, the Hippocratic Oath is a public profession of a commitment. On the other hand, you have codes of ethics which are really guidelines for conduct, and they are based on experience and other basic ethical dilemmas that health care professionals face in their day-to-day lives.” The Charter complements both.1,3,4

In a recent article in the Medical Journal of Australia Dr. Sylvia Cruess and coauthors 5 set the stage for the establishment of a new set of rules for the medical profession such as the Charter on Medical Professionalism. The authors discuss the physician’s dual role as healer and professional, concluding that the roles are linked by codes of ethics governing behaviours and are empowered by science. The authors also observe that physicians, being part of a profession, are bound by a contract with society. The profession grants a monopoly over the use of a body of knowledge and the privilege of self-regulation. In return, the professional should guarantee competence, integrity and the provision of altruistic service to society.

The authors also discuss many factors that have threatened professional values, including increasingly critical societal attitudes toward physicians’ pursuing their own financial interests and failing to self-regulate in a way that guarantees competence, and, probably most important, factors related to changes in health care delivery in the developed world. For the ideal of professionalism to survive in this modern era, physicians must understand their role in the new social contract. They must meet the obligations necessary to sustain professionalism and ensure that health care systems support a behaviour that is compatible with professional values.1,3,5 Cruess and coauthors 5 emphasize that the conditions of medical practice are tempting physicians to abandon their commitment to the primacy of patient welfare.

The three fundamental principles of the Charter on Medical Professionalism are the principle of primacy of patient welfare, the principle of patient autonomy and the principle of social justice. These principles set the stage for the core values of the Charter, the 10 commitments: a commitment to professional competence, to honesty with patients, to patient confidentiality, to maintaining appropriate relations with patients, to improving quality of care, to improving access to care, to a just distribution of resources, to scientific knowledge, to maintaining trust by managing conflicts of interest and to professional responsibilities.3–5

Altruism is also important in relation to the primacy of patient welfare. Altruism contributes to the trust that is central to the physician–patient relationship. Market forces and social pressures and requirements must not compromise this principle. It is also commendable that while discussing the principle of social justice, the Charter insists that the medical profession must promote justice in the health care system, including fair distribution of health care resources. Physicians should work actively to eliminate discrimination in the health care system, whether based on race, sex, socioeconomic status, ethnicity, religion or any other factor.4,5

The Charter on Medical Professionalism has been sent to most medical associations, schools and licensing bodies in North America and Europe with the expectation that it will be adopted in some official capacity.

Questions and objections, particularly regarding the feasibility and universal applicability of such concepts, will likely be forthcoming from all areas of the political spectrum of the health care system. Nevertheless, the importance of such an initiative should not be undermined. Medical students, young physicians, and health care providers will bring their fresh view to this crucial debate. With their youth, they will bring the ideals that should have remained untouched with all of us throughout our careers. In discussing this issue — via email — with my daughter Julia, a health sciences student at Queen’s University, in Kingston, Ont., I received a quote from her that I would like to share with you. These words may serve as an antidote to skepticism regarding the feasibility and applicability of the Charter: “Through the effort of people with open minds and values, the world has only the path of betterment and equality to journey; this belief is neither naïve nor too optimistic — it is, in fact, essential and certain.”

The discussion of the new Charter on Medical Professionalism is extremely relevant and important to ophthalmologists and all vision care providers. The CJO should and will participate in it.

Miguel N. Burnier, Jr., MD, PhD
Editor-in-Chief

REFERENCES

1. Promoting professionalism. McGill Reporter 2002;34(12): 1–2.
2. Nusinovich Y. Charter on Medical Professionalism: putting the charter into practice. Ann Intern Med 2003;138(10): 855.
3. ABIM Foundation; ACP–ASIM Foundation; European Federation of Internal Medicine. Medical professionalism in the new millennium: a physician charter. Obstet Gynecol 2002;100(1):170–2.
4. Gruen RL, Pearson SD, Brennan TA. Physician–citizens — public roles and professional obligations. JAMA 2004; 291(1):94–8.
5. Cruess SR, Johnston S, Cruess RL. Professionalism for medicine: opportunities and obligations. Med J Aust 2002; 177(4):208–11.