To the Editor: Breen’s timely call for a reality check on medical professionalism noted major global changes that affect contemporary doctor–patient relationships: new technology, changing market forces, evidence-based treatment protocols, and resource-driven health services and policies.1 The call by our colleagues in the United States and United Kingdom to restore “trust that the public used to have in the profession” was urgent.

Breen’s thesis posits that lost trust is due to an “altered balance” of ethical issues faced by doctors because of a generational shift from the ethical principle of “beneficence” to “autonomy” to “justice” and “distributive justice”.

This view contrasts with Green and Bloch’s analysis of the mental health care system’s ethical concerns arising from an adherence to “efficiency-driven” policies that started in many countries during the 1980s.2 They suggest the system itself is flawed.

Green and Bloch suggested that the legacy of efficiency-driven policies created two current moral compromises for our profession: first, a threat to the “ethic of agency”; second, the constraints those policies imposed on ethical principles precisely because they were not based on justice, instead being created to meet wider socioeconomic and political considerations. Their views point to the heart of the matter, beyond Breen’s suggested remedy to be found in “stronger leadership”, which may be necessary, but is not sufficient without an urgent update on personal medical ethics.

At the individual doctor’s experience, Green and Bloch locate conflict arising from competing interest when doctors’ “principle of fidelity is juxtaposing their financial interests alongside patients’ needs”. In the US, a study found 28% of physicians receive direct payment for consulting, lectures or enrolling patients in trials, and 94% report “some type of relationship with the pharmaceutical industry”.3 To avoid the conundrum posed by the ethics of conflict of interests we face when confronted by these physician–industry relationships, or by efficiency-driven policies, risks perpetuating the very loss of trust that we need to restore.

Breen’s analysis, an important step in the needed debate on medical professionalism, should account for not merely shifts in the ethical balance, but also the incremental erosion of trust. As it stands, he expressed our very Australian attitude “she’ll be right”. Our overseas colleagues, as well as locals, have suggested that “she won’t be right, mate” when it comes to managerialism eroding the ethical foundations of medicine.4

In reply: My recent article was submitted under the category of “For Debate”, so it is pleasing that Halasz has joined the debate. I am disappointed that he interprets my view as “she’ll be right”. My point is that revising or repackaging existing ethical codes will not, on its own, fix any of the perceived problems of “managerialism eroding the ethical foundations of medicine”. Working constructively, consistent with existing ethical codes, within our health care system, as is also suggested by Green and Bloch,1 is more likely to achieve better outcomes for our community. As I stated and as Green and Bloch imply, this will not always be a simple matter.

I am in fierce agreement with Halasz over steps to reduce erosion of trust,2 but that was not the focus of my article.