Medicine is, at its center, a moral enterprise grounded in a covenant of trust.  This covenant obliges physicians to be competent and to use their competence in the patient's best interests.  Physicians, therefore, are both intellectually and morally obliged to act as advocates for the sick whenever their welfare is threatened and their health at all times.

Today, this covenant of trust is significantly threatened. From within, there is a growing legitimization of the physician's materialistic self-interest; from without, for-profit forces press the physician into the role of commercial agent to enhance the profitability of health care organizations.  Such distortions of the physician's responsibility degrade the physician-patient relationship that is the central element and structure of clinical care.  To capitulate to these alterations of the trust relationship is to significantly alter the physician's role as healer, carer, helper, and advocate for the sick and for the health of all.

By its tradition and very nature, medicine is a special kind of human activity---one that cannot be pursued effectively without the virtues of humility, honesty, intellectual integrity, compassion,
and effacement of excessive self-interest. These traits mark the physicians as members of a moral community dedicated to something other than its own self-interest.
 
Our first obligation must be to serve the good of those persons who seek our help and trust us to provide it.  Physicians, as physicians, are not, and must never be, commercial entrepreneurs, gateclosers, or agents of fiscal policy that runs counter to our trust.  Any defection from primacy of the patients's well being places the patient at risk by treatment that may compromise quality of or access to medical care.
 
We believe the medical profession must reaffirm the primacy of its obligation to the patient through national, state, and local professional societies; our academic, research, and hospital organizations; and especially through personal behavior.  As advocates for the promotion of health and support of the sick, we are called upon to discuss, defend, and promulgate medical care by every ethical means available.  Only by caring and advocating for the patient can the integrity of our profession be affirmed.  Thus we honor our covenant of trust with patients.
                              Ralph Crawshaw, MD
                              David E Rogers, MD
                              Edmund D Pellegrino. MD
                              Roger J Bulger, MD
                              George D Lundberg, MD
                              Lonnie R Bristow, MD
                              Christine K Cassel, MD
                              Jeremiah A Barondess, MD

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Dr Crawshaw is in private practice in Portland Ore;  Dr Rogers, who died December 5th 1994, was the Walsh McDermott University Professor of Medicine at the New York Hospital-Cornell Medical Center;  Dr Pellegrino is Director, Center for Clinical Bioethics, Georgetown University Medical Center, Washington, D.C.; Dr Bulger is President, Association of Academic Health Centers, Washington, D.C.;  Dr Lundberg is Editor, JAMA, Chicago, Ill;  Dr Bristow is President- Elect, American Medical Association, Chicago, Ill; Dr Cassel is Section Chief, Department of Internal Medicine, University of Chicago, Chicago, Ill; and Dr Barondess is President, New York Academy of Medicine, New York, NY.
 
Correspondence to Ralph Crawshaw, MD, 2525 NW Lovejoy, Portland, OR, 97210.

The article above appeared in JAMA May 17, 1996--Vol 273, No. 19.  It is reprinted here without profit for those who have expressed a prior interest in such information for education or research.