新世纪的医师职业精神—医师宣言
《新世纪的医师职业精神———医师宣言》是由美国内科学基金、ACP基金和欧洲内科医学联盟共同发起和倡议,首次发表于2002年《美国内科医学年刊》和《柳叶刀》杂志。到目前为止,已有包括美国、英国、法国、德国、加拿大等国在内的36个国家和地区的120个国际医学组织认可和签署了该宣言。中国医师协会于2005年正式签署该宣言,加入推行《医师宣言》的活动。
《医师宣言》为当代医师提出了21世纪医学职业道德的行为规范和行为准则。中国医师协会认为,《医师宣言》所提出的三项基本原则和十条职业责任完全符合世界各国医师职业道德要求;在医患矛盾突出的今天,实施《医师宣言》不仅是医师行业自律的体现,而且也有助于医师良好社会形象的树立。
本刊全文发表中英文《新世纪的医师职业精神———医师宣言》,希望它能作为医师职业道德的教材,贯穿在医学教育的各个阶段和整个过程,并最终体现在医学工作者的职业生涯中。“德为医之本,德高则医粹”。认真学习《医师宣言》,树立良好职业精神,既有利于医师职业生涯的发展,更有利于为人民的健康服务。做人民满意的医师是医学工作者的崇高目标,任重而道远,让我们携起手来,脚踏实地,为实现这一目标作出不懈的努力。
前言
医师专业精神是医学与社会达成契约的基础。它要求将患者的利益置于医师的利益之上，要求制定并维护关于能力和正直的标准，还要求就健康问题向社会提供专业意见。医学界和社会必须清楚了解医师专业精神的这些原则和责任。医学与社会达成承诺的本质是公众对医师的信任，这种信任是建立在医师个人以及全行业的正直基础上。
目前，医学界面临着科技爆炸、市场力量介入医疗体系、医疗卫生实施中存在的问题、生物恐怖主义以及全球化所带来的压力。结果，医师发现越来越难以承担他们对患者和社会所肩负的责任。在这种情况下，重申医师专业精神根本的、普遍的原则和价值——即所有医师追求的理想，变得尤为重要。
医学虽然植根于不同的文化和民族传统之中，但是医学工作者扮演的都是治病救人的角色，它的根源可以追溯到希波克拉底。实际上，医学界必须和错综复杂的政治力量、法律力量以及市场力量相抗争。而且，医疗的实施与实践具有很大的差异，任何普遍性的原则都可以因这些差异而表现出各种复杂而微妙的形式。尽管有这些差异存在，共同的宗旨仍然凸显出来并形成这一宣言的基础，它表现为3项基本原则以及一系列明确的职业责任。
基本原则
1、将患者利益放在首位的原则。这一原则是建立在为患者利益服务的基础上。信任是医患关系的核心，而利他主义是这种信任的基础。市场力量、社会压力以及管理的迫切需要都绝不能影响这一原则。
2、患者自主的原则。医师必须尊重患者的自主权。医师必须诚实地对待患者并使患者在了解病情的基础上有权对将要接受的治疗做出决定。只要这些决定和伦理规范相符合，并且不会导致要求给予不恰当的治疗，那么患者的这种决定就极为重要。
3、社会公平原则。医学界必须在医疗卫生体系中促进公平，包括医疗卫生资源的公平分配。医师应该努力去消除医疗卫生中的歧视，无论这种歧视是以民族、性别、社会经济条件、种族、宗教还是其它的社会分类为基础。
职业责任
1、提高业务能力的责任。医师必须终生学习并且有责任不断更新保证医疗质量所必需的医学知识、临床技巧和团队精神。更广泛地说，医学界作为一个集体，必需努力保证每一位成员都富有能力，而且有恰当的机制使医师能够达到这一目标。
2、对患者诚实的责任。医师必须保证在患者同意治疗之前以及治疗之后将病情完整而诚实地告诉他们。这一期望并非意味着患者应该参与到非常具体的医疗方案中去，而是指他们必须有权利对治疗做出决定。同时，医师也应该承认由于医疗而受到伤害时，应该立即将情况告知患者，因为不这样做将严重危害患者和社会对医师的信任。报告和分析医疗差错，为制定恰当的预防措施和改进措施提供了基础，并且也为受到伤害的患者提供恰当的补偿提供了基础。
3、为患者保密的责任。为了赢得患者的信任和信心，当提及患者的有关情况时需要有恰当的保密措施。当不可能获得患者自己的同意时，这一责任可以通过和代表患者的有关人员进行商谈来解决。由于汇集患者资料的电子信息系统的广泛应用以及遗传信息越来越容易获得，现在履行保密的责任比以往都更为迫切。但是，医师也认识到他们为患者保密的责任，偶尔也必须服从于公众利益的更高需
要(比如当患者危及其他人时)。
4、和患者保持适当关系的责任。由于患者固有的弱势和依赖性，医师和患者之间的某些关系必须避免。特别值得强调的是，医师绝不应该利用患者获取任何方面的利益，包括个人经济利益或其它的个人目的。
5、提高医疗质量的责任。医师必须为不断提高医疗卫生质量而努力奉献。这一责任不仅要求医师保持他们的临床技能，而且要求医师和其他专业人员通过合作减少医疗差错，提高患者的安全性，减少医疗卫生资源的过度使用以及优化医疗结果。医师必须积极参与建立更好的医疗质量衡量办法，并应用这些办法去常规评价所有参与医疗卫生实践的个人、机构和体系的工作。医师个人或他们的专业组织必须对帮助建立并实施这—机制负有责任，其目的是为了医疗质量的进一步提高。
6、促进享有医疗的责任。医师专业精神要求所有医疗卫生体系的目标是提供统一的、充分的医疗标准。作为个人以及作为整体，医师必须努力减少阻碍公平的医疗保健的障碍。在各种体系中，医师应该努力去消除那些基于教育、法律、财务、地域以及社会歧视的障碍。对公平负有责任而不考虑医师或行业的私利，不仅使公共卫生和预防医学得以提高，而且每个医师也因此而得到公众的拥护。
7、对有限的资源进行公平分配的责任。当满足患者个人的需要时，医师必须明智而有效地利用有限的临床资源为患者提供卫生保健。他们有责任和其他医师、医院以及医疗保健的付费方共同制定高效低耗的医疗保健指南。医师对合理分配资源所负有的职业责任要求他们谨慎小心地避免多余的检查和操作。提供不必要的服务不仅使患者可能受到本可避免的伤害，增加患者不必要的费用，而且减少了其他患者可以获得的资源。
8、对科学知识负有责任。医学与社会之间的关系绝大部分是以完整而合理地应用科学知识与技术为基础的。医师有义务赞同科学的标准、促进研究、创新知识并保证知识的合理应用。医学界对知识的完整性负有责任，而这种完整性则是以科学证据和医师经验为基础的。
9、通过解决利益冲突而维护信任的责任。医学工作者和他们的组织有许多机会因追求私利或个人的好处而危害他们的职业责任。当追求与营利性的产业相关时，包括医疗设备生产厂商、保险公司和医药公司，这种危害尤其严重。医师有
责任认识、向大众揭发并处理责任范围内或工作中产生的利益冲突。产业和专业领导之间的关系应该予以公开，尤其当后者为制定临床试验标准、撰写社论或治疗指南者，或担任科学杂志的编辑。
10、对职责负有责任。作为医师职业的成员，医师应该为最大限度地提高医疗水平而通力合作、互相尊重并参与自律，这包括对没有达到职业标准的成员给予纠正并为此制定标准。无论作为个人还是作为集体，医师有义务参加这些活动。这些义务活动包括参与内部评审并从专业工作的各个方面接受外界的检查。 总结
在所有文化和社会中，现代医学实践都面临着前所未有的挑战。改变医疗卫生体系与兼顾患者的需求，以及达到这些需求所需的有限资源都越来越多地依赖于市场的作用，其中以放弃将患者利益放在首位与传统职业责任之间的挑战最为突出。在这个经济迅猛发展的年代，为了维护医学对社会的承诺，我们认为有必要对医师重申医师专业精神的原则，并唤起他们的积极参与。这不仅要求医师个人对患者负责，而且要求他们作为集体去为社会的利益而努力，进而促进医疗卫生体系的改进。医师专业精神宣言的目的在于鼓励医师参与这项活动，并促进医学界制定一个统一的行动计划来达成这些责任。
Medical professionalism in the new millennium: a physicians' charter
Physicians today are experiencing frustration as changes in the healthcare delivery systems in virtually all industrialised countries threaten the very nature and values of medical professionalism. Meetings among the European Federation of Internal Medicine, the American College of Physicians and American Society of Internal Medicine (ACP-ASIM), and the American Board of Internal Medicine (ABIM) have confirmed that physicians' views on professionalism are similar in quite diverse systems of
healthcare delivery. We share the view that medicine's commitment to the patient is being challenged by external forces of change within our societies.
Recently, voices from many countries have begun calling for a renewed sense of professionalism, one that is activist in reforming healthcare systems. Responding to this challenge, the European
Federation of Internal Medicine, the ACP-ASIM Foundation, and the ABIM Foundation combined efforts to launch the Medical Professionalism Project () in late 1999. These three organisations designated members to develop a
healthcare systems and the physicians working within them remain committed both to patients' welfare and to the basic tenets of social justice. Moreover, the charter is intended to be applicable to different cultures and political systems.
Preamble
Professionalism is the basis of medicine's contract with society. It demands placing the interests of patients above those of the physician, setting and maintaining standards of competence and integrity, and providing expert advice to society on matters of health. The principles and responsibilities of medical professionalism must be clearly understood by both the profession and society. Essential to this contract is public trust in physicians, which depends on the integrity of both individual physicians and the whole profession.
At present, the medical profession is confronted by an explosion of technology, changing market forces, problems in healthcare delivery, bioterrorism, and globalisation. As a result, physicians find it increasingly difficult to meet their responsibilities to patients and society. In these circumstances, reaffirming the fundamental and universal principles and values of medical professionalism, which remain ideals to be pursued by all physicians, becomes all the more important.
The medical profession everywhere is embedded in diverse cultures and national traditions, but its members share the role of healer, which has roots extending back to Hippocrates. Indeed, the medical profession must contend with complicated political, legal, and market forces. Moreover, there are wide variations in medical delivery and practice through which any general principles may be expressed in both complex and subtle ways. Despite these differences, common themes emerge and form the basis of this charter in the form of three fundamental principles and as a set of definitive professional
responsibilities.
Fundamental principles
Principle of primacy of patients' welfare
This principle is based on a dedication to serving the interest of the patient. Altruism contributes to the trust that is central to the physician–patient relationship. Market forces, societal pressures, and administrative exigencies must not compromise this principle.
Principle of patients' autonomy
Physicians must have respect for patients' autonomy. Physicians must be honest with their patients and empower them to make informed decisions about their treatment. Patients' decisions about their
care must be paramount, as long as those decisions are in keeping with ethical practice and do not lead to demands for inappropriate care.
Principle of social justice
The medical profession must promote justice in the healthcare system, including the fair
distribution of healthcare resources. Physicians should work actively to eliminate discrimination in
healthcare, whether based on race, gender, socioeconomic status, ethnicity, religion, or any other social category.
A set of professional responsibilities
Commitment to professional competence
Physicians must be committed to lifelong learning and be responsible for maintaining the medical knowledge and clinical and team skills necessary for the provision of quality care. More broadly, the profession as a whole must strive to see that all of its members are competent and must ensure that appropriate mechanisms are available for physicians to accomplish this goal.
Commitment to honesty with patients
Physicians must ensure that patients are completely and honestly informed before the patient has consented to treatment and after treatment has occurred. This expectation does not mean that patients should be involved in every minute decision about medical care; rather, they must be empowered to decide on the course of therapy. Physicians should also acknowledge that, in healthcare, medical errors that injure patients do sometimes occur. Whenever patients are injured as a consequence of medical care, patients should be informed promptly because failure to do so seriously compromises patients' and societal trust. Reporting and analysing medical mistakes provides the basis for appropriate prevention and improvement strategies and for appropriate compensation to injured parties.
Commitment to patients' confidentiality
Earning the trust and confidence of patients requires that appropriate confidentiality safeguards be applied to disclosure of patients' information. This commitment extends to discussions with people acting on a patient's behalf when obtaining the patient's own consent is not feasible. Fulfilling the commitment to confidentiality is more pressing now than ever before, given the widespread use of electronic information systems for compiling data on patients and an increasing availability of genetic information. Physicians recognise, however, that their commitment to confidentiality must occasionally yield to over-riding considerations in the public interest (for example, when patients endanger others).
Commitment to maintaining appropriate relationships with patients
Given the inherent vulnerability and dependency of patients, certain relationships between
physicians and patients must be avoided. In particular, physicians should never exploit patients for any sexual advantage, personal financial gain, or other private purpose.
Commitment to improving quality of care
Physicians must be dedicated to continuous improvement in the quality of healthcare. This
commitment entails not only maintaining clinical competence but also working collaboratively with other professionals to reduce medical error, increase patients' safety, minimise overuse of healthcare
resources, and optimise the outcomes of care. Physicians must actively participate in the development of better measures of quality of care and the application of quality measures to assess routinely the
performance of all individuals, institutions, and systems responsible for healthcare delivery. Physicians, both individually and through their professional associations, must take responsibility for assisting in the creation and implementation of mechanisms designed to encourage continuous improvement in the quality of care.
Commitment to improving access to care
Medical professionalism demands that the objective of all healthcare systems be the availability of a uniform and adequate standard of care. Physicians must individually and collectively strive to reduce barriers to equitable healthcare. Within each system, the physician should work to eliminate barriers to access based on education, laws, finances, geography, and social discrimination. A commitment to
equity entails the promotion of public health and preventive medicine, as well as public advocacy on the part of each physician, without concern for the self-interest of the physician or the profession.
Commitment to a just distribution of finite resources
While meeting the needs of individual patients, physicians are required to provide healthcare that is based on the wise and cost-effective management of limited clinical resources. They should be
committed to working with other physicians, hospitals, and payers to develop guidelines for cost-effective care. The physician's professional responsibility for appropriate allocation of resources requires
scrupulous avoidance of superfluous tests and procedures. The provision of unnecessary services not only exposes patients to avoidable harm and expense but also diminishes the resources available for others.
Commitment to scientific knowledge
Much of medicine's contract with society is based on the integrity and appropriate use of scientific knowledge and technology. Physicians have a duty to uphold scientific standards, to promote research, and to create new knowledge and ensure its appropriate use. The profession is responsible for the integrity of this knowledge, which is based on scientific evidence and physicians' experience.
Commitment to maintaining trust by managing conflicts of interest
Medical professionals and their organisations have many opportunities to compromise their
professional responsibilities by pursuing private gain or personal advantage. Such compromises are especially threatening in the pursuit of personal or organisational interactions with for-profit industries, including medical equipment manufacturers, insurance companies, and pharmaceutical firms. Physicians have an obligation to recognise, disclose to the general public, and deal with conflicts of interest that arise in the course of their professional duties and activities. Relationships between industry and opinion leaders should be disclosed, especially when the latter determine the criteria for conducting and reporting clinical trials, writing editorials or therapeutic guidelines, or serving as editors of scientific journals.
Commitment to professional responsibilities
As members of a profession, physicians are expected to work collaboratively to maximise patients' care, be respectful of one another, and participate in the processes of self-regulation, including
remediation and discipline of members who have failed to meet professional standards. The profession should also define and organise the educational and standard-setting process for current and future members. Physicians have both individual and collective obligations to participate in these processes. These obligations include engaging in internal assessment and accepting external scrutiny of all aspects of their professional performance.
Summary
The practice of medicine in the modern era is beset with unprecedented challenges in virtually all cultures and societies. These challenges centre on increasing disparities among the legitimate needs of patients, the available resources to meet those needs, the increasing dependence on market forces to transform healthcare systems, and the temptation for physicians to forsake their traditional commitment to the primacy of patients' interests. To maintain the fidelity of medicine's social contract during this turbulent time, we believe that physicians must reaffirm their active dedication to the principles of
professionalism, which entails not only their personal commitment to the welfare of their patients but also collective efforts to improve the healthcare system for the welfare of society. This Charter on Medical Professionalism is intended to encourage such dedication and to promote an action agenda for the profession of medicine that is universal in scope and purpose.