Bill 114: Who broke trust?
==========================

* Michael Gordon

Your editorial1 raises important questions about what it means to be a physician. These questions have a long history and often resurface when there are conflicts between individual physicians, medical organizations and third-party payers such as government and private insurers.

Ethical discussion surrounding such conflicts ranges from the view that individual physicians can choose when and how to work (such that a refusal to provide medical services does not reflect poorly on their professionalism) to the view that the duties and obligations of physicians are intrinsic to their professionalism and are a trust that they hold in the public interest.2,3,4 

In the latter view, the privilege of self-regulation implies a collective and intrinsic duty to provide care to individuals and the public.2,3,4 The fulfilment of this duty might be perceived as taking precedence over most other factors, sometimes including potential personal danger. From this perspective, a failure to provide emergency and other essential services does not meet society's acceptable expectations of the medical profession.

Most observers agreed that the Quebec government's handling of the potentially volatile situation there was likely to provoke strong reaction from physicians, who cherish their professional independence. On the other hand, the concept of the nonabandonment of patients is espoused by many as one of medicine's core values.5,6

Physicians in training and those already in practice should examine the implications of belonging to a self- regulating profession. Certain duties and obligations may result from our enviable status; these might include undertaking responsibilities that avoid putting individual patients and the public in general at untoward risk, especially during times of crisis.7

If we are willing to abandon our special duties and obligations as physicians, it is possible that we may inadvertently sacrifice some of the cherished ethical and professional values that we believe separate us from other members of society.

## References

1.  1. Quebec's Bill 114 [editorial]. CMAJ 2002;167 (6): 617.
    
    [FREE Full Text](http://www.cmaj.ca/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiRlVMTCI7czoxMToiam91cm5hbENvZGUiO3M6NDoiY21haiI7czo1OiJyZXNpZCI7czo5OiIxNjcvNi82MTciO3M6NDoiYXRvbSI7czoyNDoiL2NtYWovMTY3LzExLzEyMjguMy5hdG9tIjt9czo4OiJmcmFnbWVudCI7czowOiIiO30=) 

2.  2. Wynia MK, Latham SR, Kao AC, Emanuel LL. Medical professionalism in society.N Engl J Med 1999;341:1612-5.
    
    [CrossRef](http://www.cmaj.ca/lookup/external-ref?access_num=10.1056/NEJM199911183412112&link_type=DOI) 
    
    [PubMed](http://www.cmaj.ca/lookup/external-ref?access_num=10577119&link_type=MED&atom=%2Fcmaj%2F167%2F11%2F1228.3.atom) 
    
    [Web of Science](http://www.cmaj.ca/lookup/external-ref?access_num=000083717000012&link_type=ISI) 

3.  3. ABIM Foundation, ACP–ASIM Foundation and European Federation of Internal Medicine. Medical professionalism in the new millennium: a physician charter. Ann Int Med 2002;136:243-6.
    
    [CrossRef](http://www.cmaj.ca/lookup/external-ref?access_num=10.7326/0003-4819-136-3-200202050-00012&link_type=DOI) 
    
    [PubMed](http://www.cmaj.ca/lookup/external-ref?access_num=11827500&link_type=MED&atom=%2Fcmaj%2F167%2F11%2F1228.3.atom) 
    
    [Web of Science](http://www.cmaj.ca/lookup/external-ref?access_num=000173637400007&link_type=ISI) 

4.  4. Gordon M. Beyond the Hippocratic oath: ethical challenges in the care of elders. J Geriatric Care 2002;1:180-3.
    
    

5.  5. Quill TE, Kassel CK. Nonabandonment: a central obligation for physicians. Ann Intern Med 1995; 122:368-74.
    
    [CrossRef](http://www.cmaj.ca/lookup/external-ref?access_num=10.7326/0003-4819-122-5-199503010-00008&link_type=DOI) 
    
    [PubMed](http://www.cmaj.ca/lookup/external-ref?access_num=7847649&link_type=MED&atom=%2Fcmaj%2F167%2F11%2F1228.3.atom) 
    
    [Web of Science](http://www.cmaj.ca/lookup/external-ref?access_num=A1995QJ08500008&link_type=ISI) 

6.  6. Pellegrino ED. Nonabandonment: an old obligation revised. Ann Intern Med 1995;122:377-8.
    
    [CrossRef](http://www.cmaj.ca/lookup/external-ref?access_num=10.7326/0003-4819-122-5-199503010-00010&link_type=DOI) 
    
    [PubMed](http://www.cmaj.ca/lookup/external-ref?access_num=7847651&link_type=MED&atom=%2Fcmaj%2F167%2F11%2F1228.3.atom) 
    
    [Web of Science](http://www.cmaj.ca/lookup/external-ref?access_num=A1995QJ08500010&link_type=ISI) 

7.  7. Gordon M. Tensions between physicians' political goals and professional and ethical conduct. Ann RCPSC 1997;30:14-6.