Ethics and Growing Legal Crisis in Medicine Frank A. Chervenak, Laurence B. McCullough 1 Department of Obstetrics and Gynecology, The New York-Presbyterian Hospital, Weill Medical College of Cornell University, New York, NY; and 1 Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, Tex, USA Abstract This essay presents a preventive ethics to hidden aspects of the professional liability crisis, which is now affecting physicians throughout the world. It draws on the concept of fiduciary responsibility and its four professional virtues of integrity, compassion, self-effacement, and self-sacrifice to identify preven- tive ethics approaches to the professional liability crisis for practicing physicians and physician leaders. Physicians should adhere to integrity in clinical practice and testimony, to compassion and self-sacri- fice by focusing on patients rather than their own needs, and to self-effacement by not allowing risk of litigation to influence patient care. Physician leaders should create organizational cultures to support physicians in this important work. Fiduciary responsibility and professional virtues should guide prac- ticing physicians and physician leaders in creating best-practice models to improve organizational cul- ture and influence health policy. The legal crisis concerning malpractice and professional liability affects physicians and physician leaders in many countries around the world either as an existing or emerging issue. Much attention has appropriately been given to public policy issues such as tort reform and insur- ance reform. At the level of clinical practice, pro- posals have been made about improving commu- nication, documentation, adherence to practice guidelines, consultation, and even weeding out bad doctors (1). Such policy and clinical proposals will not in all cases be implemented and those that are will take considerable time to have an effect. Meanwhile, as recent work stoppages in the Uni- ted States indicate, among physicians and physi- cian leaders there is great frustration, anger, and even despair about the future of medicine. At this time of crisis, economic survival has become paramount for many physicians. Older physicians are considering whether early re- tirement is as attractive as or even more attractive than continuing to practice. Younger physicians worry that insurance costs may not permit a fis- cally viable practice. Physician leaders wonder whether medicine is entering a world in which there is no margin and therefore no mission. As a result of these responses to the pro- fessional liability crisis, economic and other forms of self-interest can become dominant and displace fiduciary professionalism from its central place in the moral lives of physicians and physician lead- ers. The purpose of this paper is to provide physi- cians with preventive ethics tools to deal effec- tively in their own practices and in organizational culture with this hidden ethical professional liabil- ity crisis (2-4). This paper draws on our previous work on this topic (5). The historical, sociocultu- ral, and economic circumstances of different countries will shape this emerging crisis in distinc- tive ways but the ethical challenges, we believe, are transcultural. 724 www.cmj.hr FORUM Croat Med J 2005;46(5):724-727