Called on by the Minister of Health to give its opinion on the report by Alain Cordier, entitled Ethique et Professions de Sante (Ethics and Health Care Professions), the French National Academy of Medicine endorses his analysis of the current situation, particularly regarding health care professionals' profound malaise and fears for their future, and the major changes that have occurred in the doctor-patient relationship. However, while it is true that " ethics is at the very heart of health care ", the National Academy of Medicine disagrees that the training of future physicians in humanism that must pervade their daily practice, in both the hospital and the community, is best assured by professional ethicists in the university setting. To ensure that medical students' initial appetite for ethical reflection persists and thrives, students must perceive, throughout their curriculum and particularly during their clinical training, that these considerations are held to be important by their superiors; they must also be encouraged to apply strong ethical principles as soon as they acquire responsibility for patient management on the hospital ward. Does this not imply that it is teachers themselves who must first be persuaded of this exigency ? And is it not they who must be offered appropriate training, in the form of short workshops where they have the occasion to debate with fellow doctors, philosophers, psychologists, sociologists and patient representatives ? In addition, time must be set aside on each hospital ward for discussions, based on concrete clinical cases, among qualified clinicians, trainees and other medical staff. Whenever a particular patient raises a difficult "ethical question ", such as a treatment indication or the choice of therapeutic approach, the entire team must be able to participate in the discussion, and must assist the doctor who has direct responsibility for the patient in his or her " humanly difficult " decision. The National Academy of Medicine feels that over-reliance on local ethics committees runs a risk of undermining physicians' sense of their personal responsibility. The Academy also considers that the situation might be even worse if the responsibility for medical decisions had to be deferred to a regional ethics committee, which is even more removed from daily medical exigencies and patients' individual experience. The respect of patients' human dignity should be a major objective criterion for assessing ward performance, and also an important link in the " systemic quality chain " that is so crucial for the renewal of hospital organization in France. It should be the responsibility of each ward director to ensure that ethical principles are taught and applied on a daily basis. And the choice of ward director should take into account the candidates' capacity to assure this aspect of their mission, in the same way as their scientific and pedagogic capacities. Successful enforcement of ethical standards should also be taken into account when assessing ward directors' performance.
