Thursday, August 09, 2007

Crisis in medical professionalism or 'professionalism" highjacked for social policy agenda

A commentary in the August 8,2007 issue of JAMA by an international group of authors (U.S.,England,Canada) presents the notion that the professional responsibilities that physicians are "honor bound" to fulfill are beyond the control of individual physicians and will require a "medical societal alliance". Only an extract can be found on line here. ("Alliance Between Society and Medicine",The Public's stake in medical professionalism", Cohen,J, Cruess, S and Davidson,C. JAMA vol. 208, no.6,p 670)

On first reading you have to wonder what the authors are taking about because when the basic ethical precepts of a physician come to mind no alliance of anyone to anyone else seems to be required or even makes sense. The physician is the one solely responsible for not harming the patient, placing the patient welfare first, honoring the patients autonomy and the confidentiality of the patient information.etc. So what are they talking about?

However, it is not the old but the new tenets of professionalism that the authors believe to be unworkable by physicians solely by their own efforts. You may ask when did we get new ethics and what was wrong with the old ones

The new ethical precepts were written in a joint effort several groups of internists (ACP,ABIM, and the European Federation of Internal Medicine) and was revealed to the world in 2002 in the Annals of Internal Medicine and spoke of three ethical principles:

Primacy of patient welfare.
Principle of patient autonomy
Principle of social justice, "to promote justice in health care including the fair distribution of health care resources"

The professional responsibilities that physicians cannot achieve by themselves in living up to the third principle are enumerated in the JAMA article and include the following all of which the authors say cannot be done without this alliance. (some have been paraphrased for brevity)

ensure that all have access to basic health care
provide an infrastructure to improve quality and safety
construct a medical liability system that encourages dissemination of lessons learned from medical error.
align payments with professional values and performance
provide medical education and research funding

The authors leave undefined the nature of this alliance but we are told it must "interrelate .. with the country's policy and decision making apparatus" ( I think this means government) and the primacy of public welfare,public accountability and social justice must prevail.

I have written before about the serious conceptual and ethical problems of inclusion of the concept of social justice into medical ethics before.

The JAMA article is basically the work of the same folks who gave us the new professionalism rules as it arose out of a meeting with the European internists and ABIM and ACP. Some of the same players (Dr. Casell of ABIM and Dr. Brennan of Aetna) wrote an earlier article in JAMA that may give us some hint about one road this alliance could take to make real many of its goals. That article,that I have written about before, speaks of large vertically integrated health systems that would be responsible for the health of groups-the so-called "accountable care organizations" or "integrated delivery systems". What better than a giant HMOoid organization could provide quality,cost effective, just, efficient,professionalism-promoting, conflict of interest free, patient centered, evidence based compassionate care and thus prevent the "public health crisis" that is brewing if we do not stop the erosion of medical ethics?

I cannot help but notice that is took five years for the folks who brought us the new ethics to realize ("on close reading'") that the precepts that this international consortium devised were in fact something that was beyond the control of physicians in the first place. Could the positioning of the concept of social justice into medical ethics serve to highjack medical ethics into promoting a social agenda and will the insurance companies not be in the wings ?

2 comments:

Anonymous said...

How is it that the ABIM through its ABIM foundation has taken on the role of keeper and legislator of medical ethics? For that matter how is it that three groups of internists appoint themselves to be in charge of ethics for all physicians? Do surgeons, family docs, etc etc not get to vote?
Talk about arrogance.

Anonymous said...

After the internists wrote the Charter, over the next several years scores of various specialty and sub-specialty medical organizations voiced their approval and endorsed the document.It looks like everyone in medicine has become an advocate for social justice.I'll wager that the members of those groups had about as much say in that as did the rank and file internists in the original document. I know I did not get to vote.