What Is Wrong with the Physician Charter on Professionalism

In 2002, the American Board of Internal Medicine Foundation collaborated with the American College of Physicians-American Society of Internal Medicine Foundation and the European Federation of Internal Medicine to write a document titled "Medical Professionalism in the New Millennium: A Physician Charter." 1 The charter set outs three main principles, which require that physicians be guided by (in order): 1) patient welfare; 2) patient autonomy; and 3) social justice.¹ The principles are very similar to those of the Belmont Report, the 1979 report by the National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research.² The three ethical principles of the Belmont Report, in lexical order, are: 1) respect for persons; 2) beneficence; and 3) justice.

There are two important differences between the three principles in the Belmont Report and those in the Physician Charter on Professionalism. One is the change from respect for persons to respect for autonomy. The second is the lexical ordering of the principles. I believe that the changes are more substantive than might appear on first blush and reflect systemic problems in modern medicine and in the new charter on professionalism. I will argue that it is incumbent on medicine to reestablish its professional responsibilities by reembracing the notion of respect for persons.

What Is Respect for Persons?

The principle of respect for persons used in the Belmont Report is similar to the principle of respect for persons expressed as the second formulation of Kant's Categorical Imperative: "Act in such a way that you treat humanity, whether in your own person or in the person of another, always at the same time as an end and never simply as a means."³ This means that you should always treat others as rational beings with their own goals and purposes, and never simply use them for your own purposes. What the principle does not mean is also crucial. It does not say that you can never treat another as a means for your own purposes. It states that you can never treat another solely as a means. It is not wrong to enroll a healthy adult to serve as a research subject for a study on drug metabolism for a drug that he does not need, but it is wrong to do so without his permission. The healthy adult may agree to participate because of his belief in the research or because he needs the $100 incentive that you offer. Thus, his participation serves his own ends as well as those of the researcher.

For Kant, "person" is a technical term and is not coextensive with human beings. For Kant, persons are individuals who have the ability to reason and to participate in meaningful relationships. Kant's principle of respect has been interpreted to exclude children who are not full persons.⁴ And yet, while the principle of respect for persons does not apply to nonpersons, Kant argued that those individuals deserved our protection as a sign of our own humanity.

By contrast, the principle of respect for persons in the Belmont Report is understood to incorporate two distinct ethical convictions. The first conviction is that "individuals should be treated as autonomous agents," and the second that "persons with diminished autonomy are entitled to protection."⁵ An individual is an autonomous agent if he is "capable of deliberation about personal goals and of acting under the direction of such deliberation."⁶ In other words, autonomous agents should make decisions based on personal health care goals, and they should consent or refuse to participate based on this deliberation.

Individuals with diminished autonomy may not understand the decision that needs to be made or the risks and benefits that might persuade one to consent or refuse to participate. Their diminished autonomy may be due to youth, cognitive disability, or mental illness. For some the diminished autonomy may be temporary; for others it is permanent. The Belmont Report is clear that 1) "Respect for the immature and the incapacitated may require protecting them as they mature or while they are incapacitated"; 2) "The extent of protection...