Global medical ethics
PAPER
The physician charter on medical professionalism from the Chinese perspective: a comparative analysis Pingyue Jin ▸ Additional material is published online only. To view please visit the journal online (http://dx.doi.org/10.1136/ medethics-2014-102318). Correspondence to Dr Pingyue Jin, School of Public Health, Chinese Academy of Medical Sciences & Peking Union Medical College, Room 833, T2 Office Building, Wangfujing Street 138, Beijing 100006, China; [email protected] Received 13 June 2014 Revised 3 September 2014 Accepted 3 October 2014 Published Online First 23 October 2014
ABSTRACT The charter of medical professionalism in the new millennium (Charter) has been endorsed worldwide, including by the Chinese Medical Doctor Association from 2005. Six years later, the association drafted a Chinese version of medical professionalism based on the Charter, the Chinese Medical Doctor Declaration (Declaration). This Declaration encompasses six tenets, which have large areas of overlap with the Charter. Meanwhile, certain differences also exist between the universal professionalism that the Charter aims to disseminate and the ideal Chinese professionalism that the Declaration endeavours to bolster. In this paper, we explore the unique aspects of the Declaration in contrast with the Charter to gain a deeper understanding of professionalism in the particular context of China. The Declaration may omit some valuable commitments found in the Charter, but it includes longstanding Confucian and cultural traditions of China, as well as consideration of current social circumstances. The Declaration thus reestablishes the ideal of universal professionalism in light of the Chinese context.
INTRODUCTION
To cite: Jin P. J Med Ethics 2015;41:511–514.
The Physician Charter on Medical Professionalism in the New Millennium (Charter) with its three fundamental principles—the primacy of patient welfare, patient autonomy and social justice—was intended to garner universal recognition and support1 and has been largely successful. To date, the Charter has been translated into 12 languages and endorsed by more than 130 professional organisations around the world.2 The triumph of the Charter represents a critical turning point in the development of professional codes of ethics. The ancient Hippocratic Oath along with more modern professional codes, such as the Declaration of Geneva adopted by the World Medical Association from 1948 and the Code of Ethics first published in 1847 by the American Medical Association,3 have emphasised the importance of medical professionals’ loyalty and responsibility to their patients. However, it was not until more recently that physicians have started to consider their broader social responsibilities, such as justice in health and protection of research subjects. Prompted by the Nuremberg trials after World War II and the exposure of the Tuskegee syphilis study, a series of ethics documents, including the Nuremberg Code, the Belmont Report and the Declaration of Helsinki, were published to regulate
medical research and the physician’s role in it.4 In the spirit of these ethics documents, the Charter takes on additional tasks of improving access to care and fair distribution of medical resources instead of merely focusing on individual patient well-being. The Charter therefore goes a step further than previous codes of ethics by calling on physicians to balance their commitments to individual patients and to social justice. Following this new development of professional codes, the Chinese Medical Doctor Association (CMDA), a national professional association of 2.1 million practising physicians in China, started to endorse and circulate the Charter of medical professionalism to its members starting in 2005.5 Although the Charter received wide acceptance among physicians in China, difficulties related to linguistic understanding and cultural differences emerged during the dissemination.5 Therefore, in September 2008 the CMDA invited a team of experts to draft the Chinese version of the Charter. They organised four rounds of discussion on the draft, which had been submitted to and reviewed by Zhu Chen, the Minister of Health at that time. Before the official publication, the draft was posted online to solicit public input and received extensive comments from health administrators, physicians, lawyers and journalists, which were taken into account in the final version.5 In June 2011, the Chinese Medical Doctor Declaration (Declaration) was published as a guide to the roles and responsibilities of Chinese physicians, regardless of their specialties or their ways of practising medicine. The Declaration offers a set of six tenets: equality and benevolence, primacy of patients, honesty and fidelity to promises, commitment to excellence and prudence, incorruptibility and impartiality, and lifelong learning. The issue of the Declaration not only contributes to the cultivation of the professional ethos of Chinese physicians, but also provides a unique opportunity to explore how medical professionalism is understood in different social, political and cultural backgrounds. In a sense, the Declaration represents how the universal ideal of medical professionalism is shaped by the particular cultural tradition and social context of China. It is of particular interest to study the Declaration and compare it with the Charter, especially since limited research exists on the interaction between medical professionalism and social context.6 In this paper, we discuss how universal professionalism is reframed in the Chinese context
Jin P. J Med Ethics 2015;41:511–514. doi:10.1136/medethics-2014-102318
511
Global medical ethics Table 1
Overlap of the Declaration and the Charter
Six tenets in the Declaration5 (original text in Chinese; translated by the authorii)
Corresponding tenets in the Charter
Equality and benevolence
Principle of primacy of patient welfare; Principle of social justice
Primacy of patient
Honesty and fidelity to promises
Commitment to excellence and prudence
Incorruptibility and impartiality
Lifelong learning
Physicians should be committed to the responsibilities of serving patients and society with the faith that medicine is a humane art. Physicians should care for patients in an equal manner, regardless of their nationality, gender, economic situation, religion and social status Physicians should respect patient rights and protect patient interests. Such respect persists in the right of patients and their family to decide the treatment option when they are sufficiently informed Physicians should be committed to honesty and integrity. They should also seek truth from the fact and have the courage to take the risk of medical treatments. Physicians should be able to communicate effectively with patients and inform them of the medical risks. They should never withhold information from patients or mislead them for any other reasons. They are also responsible for safeguarding patient confidentiality Physicians should adhere to active innovation in order to explore theories and methods to promote health and prevent diseases. Inspired by generosity and forgiveness, physicians should improve their skills by learning from others, and cooperate with colleagues to develop team spirit. Physicians should also follow rigorously clinical standards for diagnosis and treatment. They should practise medicine in a prudent way, without being ignorant and careless Physicians should be incorruptible, honest and upright. They should never be motivated by improper intention and make a profit in an illegitimate or immoral manner. Physicians should manage various interests and stakeholders appropriately and strive for elimination of barriers hindering justice in health. Physicians should make full use of the limited medical resources to provide patients with effective and proper care Physicians should continuously follow the development of modern medicine and update their medical knowledge and skills, striving for improvement of quality of care. Physicians should ensure the scientificity of medical knowledge and the rationality of the application of medical technology. They should also stand against pseudoscience and communicate the correct health knowledge to society accurately and actively
by comparing the Declaration and the Charter. Organised into a simple structure, our discussion starts by summarising the common characteristics shared by the two documents and then comparing their differences. This comparison is meant to facilitate understanding of the concepts of medical professionalism in China and contribute to the discussion of how different cultures and societies can develop their views on medical professionalism.
OVERLAPS Both the Declaration and the Charter open with a short preamble, calling on physicians to follow the basic principle of ‘the primacy of patient welfare, to develop the professional ethos of humanitarianism, and to be committed to the social responsibilities of preventive care, healing the wounded, and rescuing the dying’.5 The language of the preamble of the Declaration echoes familiar concepts of physician obligations in China, such as ‘to heal the wounded and rescue the dying’, which is a frequently mentioned obligation for physicians. After carefully examining and contrasting the Declaration and the Charter, we have found considerable overlap between these two documents, at least in a literal sense. These areas of overlap are presented below (table 1). As shown in table 1, all the tenets in the Declaration can be associated with several corresponding tenets in the Charter, and vice versa. Apart from these overlaps, one additional similarity deserves further consideration. Like the Charter and many other ethics codes,7 the Declaration does not provide much guidance when two tenets conflict in a practical situation or when an ethical dilemma occurs. For instance, if the husband of an unconscious pregnant woman constantly refuses the only effective operation, the attending physician and the medical team 512
Principle of patient autonomy; Principle of primacy of patient welfare Commitment to honesty with patients; Commitment to patient confidentiality
Commitment to scientific knowledge; Commitment to professional responsibilities
Commitment to a just distribution of finite resources; Commitment to improving access to care; Commitment to maintaining trust by managing conflicts of interest; Commitment to maintaining appropriate relations with patients Commitment to professional competence; Commitment to improving quality of care
cannot prevent the patient from dying with merely palliative care.8 In this case, physicians cannot follow both benevolence and the patient/family’s right of informed consent at the same time, and neither the Declaration nor the Charter gives clear direction on how to act when two tenets clash. However, we must admit that even the most perfect ethics code may not help us to escape the inevitability of ethical dilemmas. Ethics codes have to work together with careful analysis, thorough reflection, active exchange of ideas, and perhaps some practical wisdom in a given context. Despite the overlap between the two documents, some significant differences exist. On the one hand, the Declaration may fail to pay sufficient attention to some of the essential elements in the Charter; on the other, the Declaration includes some particular considerations that reflect Chinese cultural traditions and social situations.
DIVERGENCES One direct observation of the differences between the Declaration and the Charter is that the former is more virtuebased, with four of the six tenets in the Declaration delineating the ideal physician character including benevolence, honesty, prudence and incorruptibility. The Charter, on the other hand, is more responsibility-oriented.9 Further differences between the two documents are discussed below in order to gain a deeper understanding of medical professionalism in general and in the particular context of China.
Trust: central issue in the Charter but not directly addressed in the Declaration The Charter explicitly mentions ‘trust’ four times and describes it as a central issue for sustaining the physician–patient and Jin P. J Med Ethics 2015;41:511–514. doi:10.1136/medethics-2014-102318
Global medical ethics physician–society relationship. The Charter further stipulates that trust should be maintained by physicians through serving patients altruistically, informing patients sufficiently and honestly, protecting patient confidentiality, and disclosing and managing conflicts of interest.1 The Charter describes trust as contributing to the physician’s relationship with patients as well as the physician’s contract with society. In contrast, statements about trust and physician–patient relationship do not directly appear in the Declaration. Presumably, virtues such as benevolence and honesty advocated in the Declaration will cultivate trust and benefit physician–patient relationship. But considering the widespread distrust among patients toward doctors and hospitals and the tense relationship between physicians and patients in China,10 this omission of the centrality of trust may need to be revised in order to further develop professionalism and improve physician–patient relationships.
Social justice: important component of the Charter but not fully explained in the Declaration The Charter stands out among its predecessors partly because of the strong commitment that it makes to social justice. This focus on social justice, however, does not receive the same focus in the Declaration. Although the Charter’s tenets of ‘equality and benevolence’ and ‘incorruptibility and impartiality’ call on physicians to treat patients equally and to strive to eliminate barriers to achieving justice in healthcare, the concept of social justice in the Charter is a broader and more developed concept than that outlined in the Declaration. The Charter’s concept of social justice, as presumed in Western cultural tradition, should include fair opportunity and equal access to healthcare, priority-setting and rationing in healthcare resource allocation, and specific considerations of disadvantaged and vulnerable groups.11 The simple and unspecified account of justice described in the Declaration is, by contrast, inadequate considering its importance in the current context. Therefore the Declaration could benefit from giving more pre-eminent status to social justice through appropriate elaboration and explanation.
healthcare system. The Charter encourages physicians to engage in improving the healthcare system by assisting to establish mechanisms to improve quality of care and in eliminating systematic barriers to such improvements. It also calls on individual physicians to consider the profession as a whole, to strive for the quality of care, access to care, the development of medical science, and the high performance ensured by internal and external evaluation.1 Physicians’ participation in higher levels of the healthcare system, such as policy-making and mechanism design, can be very beneficial. First, this participation can utilise physicians’ practical wisdom and experience to facilitate the design of various mechanisms to eliminate structural impediments and to improve the health system; second, it can foster physician morale and enthusiasm for the new mechanisms that they had a say in developing. Given its potential to improve the healthcare system, physician engagement in higher-level healthcare system decision-making should be included in the Declaration. In addition, the Declaration says little about interaction between physician and society. This may be because the contract between physicians and society is not explicit in the Chinese social context. One important interaction that the Declaration stipulates, however, is physicians’ responsibility to communicate medical knowledge to the public. This communication was important in the past when physicians were involved in the movement against witchcraft and superstitions in Chinese society12 and remains important today to fight against poor healthcare literacy13 and inaccurate beliefs that could contribute to poor health. Proper health education through physician– patient contact is one of the most effective interventions in both health maintenance and disease prevention.14 It is thus an important task for Chinese physicians to communicate with and educate the public about the right way to take care of their health as indicated by the Declaration.
Confucian tradition in Chinese professionalism
Professionalism in a broader context
The Declaration represents an integration of the advanced development of Western medical ethics and the essence of Chinese cultural traditions. Based on the Charter, it further develops the tenets with regard to Confucian tradition, ancient Chinese cultural resources and current social circumstances. Here we highlight how the Declaration brings the Chinese perspective into the understanding of medical professionalism through the analysis of benevolence. The Declaration starts with the tenet of benevolence, which implies how significant it is. Benevolence or Ren in the Confucian tradition, meaning ‘to love the people’, occupies a central place in Confucianism as well as in ancient Chinese medical ethics.15 Confucian virtues, especially benevolence, had a profound influence on physicians in ancient times in China,12 and continue to influence them in modern times.16 Zhongjing Zhang (circa 150-219 AD), a well-respected physician as well as a ‘medical saint’, believed that physicians’ learning and medical skill practices should be inspired by their ideal of following Confucianism and being benevolent.15 In this way, the Declaration emphasises the primacy of patient welfare that appears in the Charter, but increases its meaningfulness by reframing it in terms of the more culturally familiar concept of Confucian benevolence.
Another aspect that the Declaration does not address adequately is physicians’ responsibility to the profession and to the
Cultural influence in Chinese professionalism
Explicit and implicit approach Compared with the Declaration, the Charter includes more detailed issues and specific guidance. For instance, it explicitly instructs physicians on how to confront medical errors and conflicts of interest. It also specifies cases that are exceptions such as when patient autonomy cannot be fully respected and when patient confidentiality may be violated to protect the public interest. Although such specific guidelines may inform many medical decisions, excessive detailed prescription in an ethics code may also prevent physicians from fully considering the particularity of the case.i For example, a very specific guideline, if put in an unsuitable situation, may be misleading and possibly result in rigid and unreflective responses from physicians. In contrast, the Declaration adopts a more general approach and covers the tenets of the Charter in a more concentrated manner. However, the general approach of the Declaration is not without problems, since it fails to give clear and practical guidance on some uncontroversial issues like the Charter.
i
I would like to thank one reviewer for pointing this out.
Jin P. J Med Ethics 2015;41:511–514. doi:10.1136/medethics-2014-102318
The inclusion of the patient’s family in the clinical decisionmaking process is also a unique aspect of the Declaration. Although autonomy indicating self-sovereignty —that is, 513
Global medical ethics ‘governance over one’s own agency’17—is the dominant doctrine in Western culture and modern biomedical ethics that serves as the justification of informed consent,17 the familydetermination model is favoured in the dominant culture of Confucianism in China.18 The family-determination model is also manifested in the Chinese legislation, ‘Law on Practicing Doctors of the People’s Republic of China,’ published by the National People’s Congress in 1998, which stipulates that ‘the physician should inform either the patient or the family member about the patient’s condition, and the informed consent for experimental therapy can be sought from either party’.19 Influenced by the family-oriented culture in China, the Declaration respects the patient’s family as an active stakeholder during the discussion of treatment options. Thus, the Declaration finds its own way to integrate the Chinese family-oriented culture and the Western individualistic model. The Declaration not only takes traditions into account, but also considers current social circumstances. One example is the emphasis it gives to the virtue of incorruptibility and integrity. Over-prescription, which is rooted in the fee-for-service payment system and distorts the regulation of price, remains a great concern for the public and policy-makers in China.10 20 In order to eradicate the problem of it being ‘too difficult to see a doctor and too expensive to seek healthcare’, it is not enough to only change the misguiding policy and the corrupted system, which certainly play a crucial role in solving the problem. Medical professionalism must also be integrated into the solution. It is a difficult yet critical task to re-establish professionalism in practice when physicians are greatly influenced by financial interests.21 The Declaration offers an important step to combating these issues by listing a number of ideal virtues and professional principles that physicians should have, emphasising incorruptibility and integrity.
to overcome physicians’ barriers to acting in the greatest interests of their patients and society. Acknowledgements I would like to thank Dr Verina Wild and Prof Nikola Biller-Andorno for their comments on the initial idea of this paper. I also thank my colleague Joelle Robertson-Preidler for proofreading the manuscript. Contributors PJ is solely responsible for the manuscript, including the initial idea, drafting and revision. Funding Part of this paper was created with the support of UFSPE, University of Zurich. Competing interests None. Provenance and peer review Not commissioned; externally peer reviewed.
REFERENCES 1
2 3 4 5 6 7 8 9 10 11 12
CONCLUSIONS The comparative analysis of the Declaration and the Charter in this paper serves as a response to the appeal of ‘whether the Charter represents the traditions of medicine in cultures other than those in the West’1 and the calling on ‘other cultures to develop their own unique perspectives on this important document’.6 We believe that the Declaration indeed shares common ground with the Charter, which aims to be universally applicable. Despite some differences in focus, both documents emphasise the importance of patient-centred tenets that advocate patients’ best interests, physicians’ scientific competency, physicians’ integrity and social justice. Although the publication of the Declaration will facilitate the process of refostering professionalism in China, the bigger challenge is yet to come. The most difficult task will be to transform the concrete virtues and professional principles into action and
514
13 14 15 16 17
18 19 20 21
ABIM Foundation. American Board of Internal Medicine; ACP-ASIM Foundation. American College of Physicians-American Society of Internal Medicine; European Federation of Internal Medicine. Medical professionalism in the new millennium: a physician charter. Ann Intern Med 2002;136:243–6. Physician charter on medical professionalism | ABIM Foundation. http://www. abimfoundation.org/Professionalism/Physician-Charter.aspx (accessed 2 Apr 2013). Davis M. What can we learn by looking for the first code of professional ethics? Theor Med Bioeth 2003;24:433–54. Markman JR, Markman M. Running an ethical trial 60 years after the Nuremberg Code. Lancet Oncol 2007;8:1139–46. Shi L. Background, content and social functions of Chinese Medical Doctor Declaration. Chin Hosp 2011;15:50–1. Jotkowitz AB, Glick S. The physician charter on medical professionalism: a Jewish ethical perspective. J Med Ethics 2005;31:404–5. Westerholm P. Codes of ethics in occupational health—are they important? Contin Med Educ 2009;27:492–4. Zhang X. Reflection on family consent: based on a pregnant death in a Beijing hospital. Dev World Bioeth 2012;12:164–8. Swick HM, Bryan CS, Longo LD. Beyond the physician charter: reflections on medical professionalism. Perspect Biol Med 2006;49:263–75. Hui EC. The contemporary healthcare crisis in China and the role of medical professionalism. J Med Philos 2010;35:477–92. Beauchamp TL, Childress JF. Principles of biomedical ethics. 5th edn. Oxford University Press, 2001. Guo Z. Chinese Confucian culture and the medical ethical tradition. J Med Ethics 1995;21:239–46. Li X, Ning N, Hao Y, et al. Health literacy in rural areas of China: hypertension knowledge survey. Int J Environ Res Public Health 2013;10:1125–38. Bai Y. Needs analysis on health knowledge and health education model in China. Chin J Health Educ 2007;23:701–3. Zhang D, Cheng Z. Medicine is a humane art the basic principles of professional ethics in Chinese medicine. Hastings Cent Rep 2000;30:S8–12. Fan R. Toward a directed benevolent market polity: rethinking medical morality in transitional China. Camb Q Healthc Ethics 2008;17:280–92. Eyal N. Informed consent. In: Zalta EN, eds. The Stanford encyclopedia of philosophy. 2012. http://plato.stanford.edu/archives/fall2012/entries/ informed-consent/ (accessed 21 Aug 2014). Fan R. Self-determination vs. family-determination: two incommensurable principles of autonomy: a report from East Asia. Bioethics 1997;11:309–22. Law on practicing doctors of the People’s Republic of China. http://www.gov.cn/ banshi/2005-05/25/content_973.htm (accessed 21 Aug 2014). Fan R. Corrupt practices in Chinese medical care: the root in public policies and a call for Confucian-market approach. Kennedy Inst Ethics J 2007;17:111–31. Hsiao WC. When incentives and professionalism collide. Health Aff 2008;27:949–51.
Jin P. J Med Ethics 2015;41:511–514. doi:10.1136/medethics-2014-102318
PAPER
The physician charter on medical professionalism from the Chinese perspective: a comparative analysis Pingyue Jin ▸ Additional material is published online only. To view please visit the journal online (http://dx.doi.org/10.1136/ medethics-2014-102318). Correspondence to Dr Pingyue Jin, School of Public Health, Chinese Academy of Medical Sciences & Peking Union Medical College, Room 833, T2 Office Building, Wangfujing Street 138, Beijing 100006, China; [email protected] Received 13 June 2014 Revised 3 September 2014 Accepted 3 October 2014 Published Online First 23 October 2014
ABSTRACT The charter of medical professionalism in the new millennium (Charter) has been endorsed worldwide, including by the Chinese Medical Doctor Association from 2005. Six years later, the association drafted a Chinese version of medical professionalism based on the Charter, the Chinese Medical Doctor Declaration (Declaration). This Declaration encompasses six tenets, which have large areas of overlap with the Charter. Meanwhile, certain differences also exist between the universal professionalism that the Charter aims to disseminate and the ideal Chinese professionalism that the Declaration endeavours to bolster. In this paper, we explore the unique aspects of the Declaration in contrast with the Charter to gain a deeper understanding of professionalism in the particular context of China. The Declaration may omit some valuable commitments found in the Charter, but it includes longstanding Confucian and cultural traditions of China, as well as consideration of current social circumstances. The Declaration thus reestablishes the ideal of universal professionalism in light of the Chinese context.
INTRODUCTION
To cite: Jin P. J Med Ethics 2015;41:511–514.
The Physician Charter on Medical Professionalism in the New Millennium (Charter) with its three fundamental principles—the primacy of patient welfare, patient autonomy and social justice—was intended to garner universal recognition and support1 and has been largely successful. To date, the Charter has been translated into 12 languages and endorsed by more than 130 professional organisations around the world.2 The triumph of the Charter represents a critical turning point in the development of professional codes of ethics. The ancient Hippocratic Oath along with more modern professional codes, such as the Declaration of Geneva adopted by the World Medical Association from 1948 and the Code of Ethics first published in 1847 by the American Medical Association,3 have emphasised the importance of medical professionals’ loyalty and responsibility to their patients. However, it was not until more recently that physicians have started to consider their broader social responsibilities, such as justice in health and protection of research subjects. Prompted by the Nuremberg trials after World War II and the exposure of the Tuskegee syphilis study, a series of ethics documents, including the Nuremberg Code, the Belmont Report and the Declaration of Helsinki, were published to regulate
medical research and the physician’s role in it.4 In the spirit of these ethics documents, the Charter takes on additional tasks of improving access to care and fair distribution of medical resources instead of merely focusing on individual patient well-being. The Charter therefore goes a step further than previous codes of ethics by calling on physicians to balance their commitments to individual patients and to social justice. Following this new development of professional codes, the Chinese Medical Doctor Association (CMDA), a national professional association of 2.1 million practising physicians in China, started to endorse and circulate the Charter of medical professionalism to its members starting in 2005.5 Although the Charter received wide acceptance among physicians in China, difficulties related to linguistic understanding and cultural differences emerged during the dissemination.5 Therefore, in September 2008 the CMDA invited a team of experts to draft the Chinese version of the Charter. They organised four rounds of discussion on the draft, which had been submitted to and reviewed by Zhu Chen, the Minister of Health at that time. Before the official publication, the draft was posted online to solicit public input and received extensive comments from health administrators, physicians, lawyers and journalists, which were taken into account in the final version.5 In June 2011, the Chinese Medical Doctor Declaration (Declaration) was published as a guide to the roles and responsibilities of Chinese physicians, regardless of their specialties or their ways of practising medicine. The Declaration offers a set of six tenets: equality and benevolence, primacy of patients, honesty and fidelity to promises, commitment to excellence and prudence, incorruptibility and impartiality, and lifelong learning. The issue of the Declaration not only contributes to the cultivation of the professional ethos of Chinese physicians, but also provides a unique opportunity to explore how medical professionalism is understood in different social, political and cultural backgrounds. In a sense, the Declaration represents how the universal ideal of medical professionalism is shaped by the particular cultural tradition and social context of China. It is of particular interest to study the Declaration and compare it with the Charter, especially since limited research exists on the interaction between medical professionalism and social context.6 In this paper, we discuss how universal professionalism is reframed in the Chinese context
Jin P. J Med Ethics 2015;41:511–514. doi:10.1136/medethics-2014-102318
511
Global medical ethics Table 1
Overlap of the Declaration and the Charter
Six tenets in the Declaration5 (original text in Chinese; translated by the authorii)
Corresponding tenets in the Charter
Equality and benevolence
Principle of primacy of patient welfare; Principle of social justice
Primacy of patient
Honesty and fidelity to promises
Commitment to excellence and prudence
Incorruptibility and impartiality
Lifelong learning
Physicians should be committed to the responsibilities of serving patients and society with the faith that medicine is a humane art. Physicians should care for patients in an equal manner, regardless of their nationality, gender, economic situation, religion and social status Physicians should respect patient rights and protect patient interests. Such respect persists in the right of patients and their family to decide the treatment option when they are sufficiently informed Physicians should be committed to honesty and integrity. They should also seek truth from the fact and have the courage to take the risk of medical treatments. Physicians should be able to communicate effectively with patients and inform them of the medical risks. They should never withhold information from patients or mislead them for any other reasons. They are also responsible for safeguarding patient confidentiality Physicians should adhere to active innovation in order to explore theories and methods to promote health and prevent diseases. Inspired by generosity and forgiveness, physicians should improve their skills by learning from others, and cooperate with colleagues to develop team spirit. Physicians should also follow rigorously clinical standards for diagnosis and treatment. They should practise medicine in a prudent way, without being ignorant and careless Physicians should be incorruptible, honest and upright. They should never be motivated by improper intention and make a profit in an illegitimate or immoral manner. Physicians should manage various interests and stakeholders appropriately and strive for elimination of barriers hindering justice in health. Physicians should make full use of the limited medical resources to provide patients with effective and proper care Physicians should continuously follow the development of modern medicine and update their medical knowledge and skills, striving for improvement of quality of care. Physicians should ensure the scientificity of medical knowledge and the rationality of the application of medical technology. They should also stand against pseudoscience and communicate the correct health knowledge to society accurately and actively
by comparing the Declaration and the Charter. Organised into a simple structure, our discussion starts by summarising the common characteristics shared by the two documents and then comparing their differences. This comparison is meant to facilitate understanding of the concepts of medical professionalism in China and contribute to the discussion of how different cultures and societies can develop their views on medical professionalism.
OVERLAPS Both the Declaration and the Charter open with a short preamble, calling on physicians to follow the basic principle of ‘the primacy of patient welfare, to develop the professional ethos of humanitarianism, and to be committed to the social responsibilities of preventive care, healing the wounded, and rescuing the dying’.5 The language of the preamble of the Declaration echoes familiar concepts of physician obligations in China, such as ‘to heal the wounded and rescue the dying’, which is a frequently mentioned obligation for physicians. After carefully examining and contrasting the Declaration and the Charter, we have found considerable overlap between these two documents, at least in a literal sense. These areas of overlap are presented below (table 1). As shown in table 1, all the tenets in the Declaration can be associated with several corresponding tenets in the Charter, and vice versa. Apart from these overlaps, one additional similarity deserves further consideration. Like the Charter and many other ethics codes,7 the Declaration does not provide much guidance when two tenets conflict in a practical situation or when an ethical dilemma occurs. For instance, if the husband of an unconscious pregnant woman constantly refuses the only effective operation, the attending physician and the medical team 512
Principle of patient autonomy; Principle of primacy of patient welfare Commitment to honesty with patients; Commitment to patient confidentiality
Commitment to scientific knowledge; Commitment to professional responsibilities
Commitment to a just distribution of finite resources; Commitment to improving access to care; Commitment to maintaining trust by managing conflicts of interest; Commitment to maintaining appropriate relations with patients Commitment to professional competence; Commitment to improving quality of care
cannot prevent the patient from dying with merely palliative care.8 In this case, physicians cannot follow both benevolence and the patient/family’s right of informed consent at the same time, and neither the Declaration nor the Charter gives clear direction on how to act when two tenets clash. However, we must admit that even the most perfect ethics code may not help us to escape the inevitability of ethical dilemmas. Ethics codes have to work together with careful analysis, thorough reflection, active exchange of ideas, and perhaps some practical wisdom in a given context. Despite the overlap between the two documents, some significant differences exist. On the one hand, the Declaration may fail to pay sufficient attention to some of the essential elements in the Charter; on the other, the Declaration includes some particular considerations that reflect Chinese cultural traditions and social situations.
DIVERGENCES One direct observation of the differences between the Declaration and the Charter is that the former is more virtuebased, with four of the six tenets in the Declaration delineating the ideal physician character including benevolence, honesty, prudence and incorruptibility. The Charter, on the other hand, is more responsibility-oriented.9 Further differences between the two documents are discussed below in order to gain a deeper understanding of medical professionalism in general and in the particular context of China.
Trust: central issue in the Charter but not directly addressed in the Declaration The Charter explicitly mentions ‘trust’ four times and describes it as a central issue for sustaining the physician–patient and Jin P. J Med Ethics 2015;41:511–514. doi:10.1136/medethics-2014-102318
Global medical ethics physician–society relationship. The Charter further stipulates that trust should be maintained by physicians through serving patients altruistically, informing patients sufficiently and honestly, protecting patient confidentiality, and disclosing and managing conflicts of interest.1 The Charter describes trust as contributing to the physician’s relationship with patients as well as the physician’s contract with society. In contrast, statements about trust and physician–patient relationship do not directly appear in the Declaration. Presumably, virtues such as benevolence and honesty advocated in the Declaration will cultivate trust and benefit physician–patient relationship. But considering the widespread distrust among patients toward doctors and hospitals and the tense relationship between physicians and patients in China,10 this omission of the centrality of trust may need to be revised in order to further develop professionalism and improve physician–patient relationships.
Social justice: important component of the Charter but not fully explained in the Declaration The Charter stands out among its predecessors partly because of the strong commitment that it makes to social justice. This focus on social justice, however, does not receive the same focus in the Declaration. Although the Charter’s tenets of ‘equality and benevolence’ and ‘incorruptibility and impartiality’ call on physicians to treat patients equally and to strive to eliminate barriers to achieving justice in healthcare, the concept of social justice in the Charter is a broader and more developed concept than that outlined in the Declaration. The Charter’s concept of social justice, as presumed in Western cultural tradition, should include fair opportunity and equal access to healthcare, priority-setting and rationing in healthcare resource allocation, and specific considerations of disadvantaged and vulnerable groups.11 The simple and unspecified account of justice described in the Declaration is, by contrast, inadequate considering its importance in the current context. Therefore the Declaration could benefit from giving more pre-eminent status to social justice through appropriate elaboration and explanation.
healthcare system. The Charter encourages physicians to engage in improving the healthcare system by assisting to establish mechanisms to improve quality of care and in eliminating systematic barriers to such improvements. It also calls on individual physicians to consider the profession as a whole, to strive for the quality of care, access to care, the development of medical science, and the high performance ensured by internal and external evaluation.1 Physicians’ participation in higher levels of the healthcare system, such as policy-making and mechanism design, can be very beneficial. First, this participation can utilise physicians’ practical wisdom and experience to facilitate the design of various mechanisms to eliminate structural impediments and to improve the health system; second, it can foster physician morale and enthusiasm for the new mechanisms that they had a say in developing. Given its potential to improve the healthcare system, physician engagement in higher-level healthcare system decision-making should be included in the Declaration. In addition, the Declaration says little about interaction between physician and society. This may be because the contract between physicians and society is not explicit in the Chinese social context. One important interaction that the Declaration stipulates, however, is physicians’ responsibility to communicate medical knowledge to the public. This communication was important in the past when physicians were involved in the movement against witchcraft and superstitions in Chinese society12 and remains important today to fight against poor healthcare literacy13 and inaccurate beliefs that could contribute to poor health. Proper health education through physician– patient contact is one of the most effective interventions in both health maintenance and disease prevention.14 It is thus an important task for Chinese physicians to communicate with and educate the public about the right way to take care of their health as indicated by the Declaration.
Confucian tradition in Chinese professionalism
Professionalism in a broader context
The Declaration represents an integration of the advanced development of Western medical ethics and the essence of Chinese cultural traditions. Based on the Charter, it further develops the tenets with regard to Confucian tradition, ancient Chinese cultural resources and current social circumstances. Here we highlight how the Declaration brings the Chinese perspective into the understanding of medical professionalism through the analysis of benevolence. The Declaration starts with the tenet of benevolence, which implies how significant it is. Benevolence or Ren in the Confucian tradition, meaning ‘to love the people’, occupies a central place in Confucianism as well as in ancient Chinese medical ethics.15 Confucian virtues, especially benevolence, had a profound influence on physicians in ancient times in China,12 and continue to influence them in modern times.16 Zhongjing Zhang (circa 150-219 AD), a well-respected physician as well as a ‘medical saint’, believed that physicians’ learning and medical skill practices should be inspired by their ideal of following Confucianism and being benevolent.15 In this way, the Declaration emphasises the primacy of patient welfare that appears in the Charter, but increases its meaningfulness by reframing it in terms of the more culturally familiar concept of Confucian benevolence.
Another aspect that the Declaration does not address adequately is physicians’ responsibility to the profession and to the
Cultural influence in Chinese professionalism
Explicit and implicit approach Compared with the Declaration, the Charter includes more detailed issues and specific guidance. For instance, it explicitly instructs physicians on how to confront medical errors and conflicts of interest. It also specifies cases that are exceptions such as when patient autonomy cannot be fully respected and when patient confidentiality may be violated to protect the public interest. Although such specific guidelines may inform many medical decisions, excessive detailed prescription in an ethics code may also prevent physicians from fully considering the particularity of the case.i For example, a very specific guideline, if put in an unsuitable situation, may be misleading and possibly result in rigid and unreflective responses from physicians. In contrast, the Declaration adopts a more general approach and covers the tenets of the Charter in a more concentrated manner. However, the general approach of the Declaration is not without problems, since it fails to give clear and practical guidance on some uncontroversial issues like the Charter.
i
I would like to thank one reviewer for pointing this out.
Jin P. J Med Ethics 2015;41:511–514. doi:10.1136/medethics-2014-102318
The inclusion of the patient’s family in the clinical decisionmaking process is also a unique aspect of the Declaration. Although autonomy indicating self-sovereignty —that is, 513
Global medical ethics ‘governance over one’s own agency’17—is the dominant doctrine in Western culture and modern biomedical ethics that serves as the justification of informed consent,17 the familydetermination model is favoured in the dominant culture of Confucianism in China.18 The family-determination model is also manifested in the Chinese legislation, ‘Law on Practicing Doctors of the People’s Republic of China,’ published by the National People’s Congress in 1998, which stipulates that ‘the physician should inform either the patient or the family member about the patient’s condition, and the informed consent for experimental therapy can be sought from either party’.19 Influenced by the family-oriented culture in China, the Declaration respects the patient’s family as an active stakeholder during the discussion of treatment options. Thus, the Declaration finds its own way to integrate the Chinese family-oriented culture and the Western individualistic model. The Declaration not only takes traditions into account, but also considers current social circumstances. One example is the emphasis it gives to the virtue of incorruptibility and integrity. Over-prescription, which is rooted in the fee-for-service payment system and distorts the regulation of price, remains a great concern for the public and policy-makers in China.10 20 In order to eradicate the problem of it being ‘too difficult to see a doctor and too expensive to seek healthcare’, it is not enough to only change the misguiding policy and the corrupted system, which certainly play a crucial role in solving the problem. Medical professionalism must also be integrated into the solution. It is a difficult yet critical task to re-establish professionalism in practice when physicians are greatly influenced by financial interests.21 The Declaration offers an important step to combating these issues by listing a number of ideal virtues and professional principles that physicians should have, emphasising incorruptibility and integrity.
to overcome physicians’ barriers to acting in the greatest interests of their patients and society. Acknowledgements I would like to thank Dr Verina Wild and Prof Nikola Biller-Andorno for their comments on the initial idea of this paper. I also thank my colleague Joelle Robertson-Preidler for proofreading the manuscript. Contributors PJ is solely responsible for the manuscript, including the initial idea, drafting and revision. Funding Part of this paper was created with the support of UFSPE, University of Zurich. Competing interests None. Provenance and peer review Not commissioned; externally peer reviewed.
REFERENCES 1
2 3 4 5 6 7 8 9 10 11 12
CONCLUSIONS The comparative analysis of the Declaration and the Charter in this paper serves as a response to the appeal of ‘whether the Charter represents the traditions of medicine in cultures other than those in the West’1 and the calling on ‘other cultures to develop their own unique perspectives on this important document’.6 We believe that the Declaration indeed shares common ground with the Charter, which aims to be universally applicable. Despite some differences in focus, both documents emphasise the importance of patient-centred tenets that advocate patients’ best interests, physicians’ scientific competency, physicians’ integrity and social justice. Although the publication of the Declaration will facilitate the process of refostering professionalism in China, the bigger challenge is yet to come. The most difficult task will be to transform the concrete virtues and professional principles into action and
514
13 14 15 16 17
18 19 20 21
ABIM Foundation. American Board of Internal Medicine; ACP-ASIM Foundation. American College of Physicians-American Society of Internal Medicine; European Federation of Internal Medicine. Medical professionalism in the new millennium: a physician charter. Ann Intern Med 2002;136:243–6. Physician charter on medical professionalism | ABIM Foundation. http://www. abimfoundation.org/Professionalism/Physician-Charter.aspx (accessed 2 Apr 2013). Davis M. What can we learn by looking for the first code of professional ethics? Theor Med Bioeth 2003;24:433–54. Markman JR, Markman M. Running an ethical trial 60 years after the Nuremberg Code. Lancet Oncol 2007;8:1139–46. Shi L. Background, content and social functions of Chinese Medical Doctor Declaration. Chin Hosp 2011;15:50–1. Jotkowitz AB, Glick S. The physician charter on medical professionalism: a Jewish ethical perspective. J Med Ethics 2005;31:404–5. Westerholm P. Codes of ethics in occupational health—are they important? Contin Med Educ 2009;27:492–4. Zhang X. Reflection on family consent: based on a pregnant death in a Beijing hospital. Dev World Bioeth 2012;12:164–8. Swick HM, Bryan CS, Longo LD. Beyond the physician charter: reflections on medical professionalism. Perspect Biol Med 2006;49:263–75. Hui EC. The contemporary healthcare crisis in China and the role of medical professionalism. J Med Philos 2010;35:477–92. Beauchamp TL, Childress JF. Principles of biomedical ethics. 5th edn. Oxford University Press, 2001. Guo Z. Chinese Confucian culture and the medical ethical tradition. J Med Ethics 1995;21:239–46. Li X, Ning N, Hao Y, et al. Health literacy in rural areas of China: hypertension knowledge survey. Int J Environ Res Public Health 2013;10:1125–38. Bai Y. Needs analysis on health knowledge and health education model in China. Chin J Health Educ 2007;23:701–3. Zhang D, Cheng Z. Medicine is a humane art the basic principles of professional ethics in Chinese medicine. Hastings Cent Rep 2000;30:S8–12. Fan R. Toward a directed benevolent market polity: rethinking medical morality in transitional China. Camb Q Healthc Ethics 2008;17:280–92. Eyal N. Informed consent. In: Zalta EN, eds. The Stanford encyclopedia of philosophy. 2012. http://plato.stanford.edu/archives/fall2012/entries/ informed-consent/ (accessed 21 Aug 2014). Fan R. Self-determination vs. family-determination: two incommensurable principles of autonomy: a report from East Asia. Bioethics 1997;11:309–22. Law on practicing doctors of the People’s Republic of China. http://www.gov.cn/ banshi/2005-05/25/content_973.htm (accessed 21 Aug 2014). Fan R. Corrupt practices in Chinese medical care: the root in public policies and a call for Confucian-market approach. Kennedy Inst Ethics J 2007;17:111–31. Hsiao WC. When incentives and professionalism collide. Health Aff 2008;27:949–51.
Jin P. J Med Ethics 2015;41:511–514. doi:10.1136/medethics-2014-102318
