I read with interest the paper by Quill and Cassel [1] and the accompanying editorial [2]. Although I agree with Quill and Cassel that the concepts they propose are of extreme importance, I can see why Dr. Pellegrino would object to lumping them under the term nonabandonment. Whereas Dr. Pellegrino raises objections about the dilution of the term itself, issues relating to its appropriateness at the level of a principle, and its insufficiency and confusion as an ethical foundation, I believe that an additional objection arises from the use of a negative term when a positive one is available.

Throughout the paper, Quill and Cassel refer to "nonabandonment" as a "commitment" to something. Why not express the operant ethical principle as a positive one, such as "commitment" or perhaps more specifically as "commitment to caring for the patient"? This would embody all that Drs. Quill and Cassel wish to express in a positive concept and would leave the already ingrained, negative, and narrower term nonabandonment to its traditional meaning, which is noted in the introduction to their paper. I believe that as physicians we can and should embrace this principle of commitment, which will no doubt create considerable conflict as we move more heavily into the managed care era, with its potential for provider contracts for physicians that change from year to year.

Indeed, in the American Board of Internal Medicine's recently completed project on professionalism in medicine, they state that "among the elements of professionalism required of candidates seeking certification" is "a commitment to sustain the interests and welfare of patients" [3]. A positive principle of commitment to caring for our patients is one to which people would relate more easily and is certainly one of which we need to remain mindful.