Second Opinion: ‘Professionalism’ - No Substitute for Medical Ethics

March 1, 2008

Pulmonologist Jerome Arnett Jr. on the folly of so-called medical “professionalism.”

“Paging Dr. Hippocrates” (October, 2007) is an excellent and timely article that explores physician dissatisfaction, an important problem for today’s physicians.

But the article advocates exactly the wrong prescription in suggesting that physicians embrace the concept of “medical professionalism” as a solution to this discontent. Medical professionalism is described as a “large concept” whose principal tenet is “selfless concern for patient care.” In the article, Christine Cassel, MD, president and CEO of the American Board of Internal Medicine (ABIM) and the ABIM Foundation, noted that physicians “don’t feel like they are doing the right thing.” They have a perception that they are failing their patients. Her solution is to “create systems” so that doctors can “spend more time on the tasks that the doctor ought to be doing …”

According to the article, physicians may become cynical because they are not paid fairly for their work, or because they have lost control over medical decision-making, or because they are corrupted by conflicts of interest inherent in systems such as Medicare, Medicaid, and private insurance. But, in fact, it is our medical ethics - not medical professionalism - that provides us with a code of values so we can choose right from wrong in order to successfully deal with conflicts of interest.

Medical professionalism is not a code of ethics - and the distinction is vital. Physicians are ethically required to reject any scheme, however well-meaning, that comes between them and their patients. The concept of medical professionalism, as outlined by ABIM and described in your article, is such a scheme.

Here’s why.

Each profession or trade has a different ethical “highest value,” or goal, and each embraces virtues to achieve its goal. In science, for example, the goal is to discover truth. The essential virtues are honesty, integrity, and objectivity. In medicine, the goal always is the good of the patient. The primary virtue is trust.

As physicians we cannot ethically accept limits of any kind on our judgments regarding patient care. This means we can allow no third party to come between the patient and the physician, including third-party payers. Such schemes are defended as being necessary for “the good of society,” and physicians are often open to this argument. But because the good of the patient is the highest goal in medicine, the “good of society” cannot be physicians’ primary goal.

In 2002 Harold C. Sox, then-editor of Annals of Internal Medicine, introduced in that journal a set of guidelines for physicians: “Medical Professionalism in the New Millennium: A Physician Charter.” The principles outlined in the charter included “social justice,” and it implored physicians to dedicate themselves to “collective efforts to improve the healthcare system for the welfare of society.”

By embracing such collectivism, the professionalism charter doesn’t address the conflicts of interest that are at the root of physician dissatisfaction. The charter was described by two of its authors as “not a code of ethics, but is aimed at restoring the pride and public trust … that distinguishes [a profession] from a trade.” But history shows us that what distinguishes a profession from a trade is not “pride and public trust,” but is, in fact, a code of ethics.

The idea that technology (information technology or electronic medical records) can solve the problem, as suggested in “Paging Dr. Hippocrates,” or that a mental attitude (such as “mindfulness”) can help, is not convincing. Nor can the problem be solved by using corporate business models such as “appreciative inquiry” or “lean management” to streamline services. Only an objective medical ethics can show us what we must do to prevent conflicts of interest. We may not need to “create [new] systems” at all, but instead merely return to our validated Hippocratic ethics, which support the individual patient, and reject the collectivist principles of the politically motivated “Medical Professionalism Charter.”
Jerome Arnett Jr., MD, is a pulmonologist who lives in Helvetia, W.Va. He can be reached via editor@physicianspractice.com.

This article originally appeared in the March 2008 issue of Physicians Practice.