Commentary on the Code of Medical Ethics and Deontology

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Chapter XI: Relations of the corporation

It is surprising that in the Code of Ethics there is a chapter specifically devoted to dealing with the relationship of the Members with the medical corporation, as this is one of the most characteristic contents of the WTO General Statutes. But it is obvious that many statutory duties have a very strong ethical component, and should therefore be subject to deontological regulation. This Chapter XI considers, on the one hand, the duties of members in general (article 39), and, on the other hand, some specific responsibilities of members who, elected by ballot, occupy the executive positions of the Colleges and of the committee General.

article 39.1. It is the duty of physicians, regardless of their professional and hierarchical position status , to appear when called upon to do so by the Professional Associations.

There are, in fact, very few occasions on which the Colleges or the committee General can compel a member to appear. The Statutes generally state that the duties of members include "complying with any request made by high school or committee General, ..." (EGOMC, Art. 43, g). And the same Statutes include among the disciplinary offences classified as minor "failure to comply with the requirements or requests for reports requested by the high school" and, among those classified as serious, "deliberately rebellious indiscipline towards the collegiate governing bodies and, in general, the serious lack of respect due to them" (EGOMC, Art. 64.1.c and 3.a).

Relations between Colleges and Members must be based on mutual loyalty and respect, and on the common will to fulfil statutory and deontological duties. It would not be possible to achieve the aims of the Association if the Members were to ignore the call of the management when they ask them for information as experts on professional matters, demand their testimony as witnesses, request their partnership to form part of committees, or need their skill deontological as instructors in disciplinary matters.

The cooperation required by this article is, on many occasions, not only a duty, but also, and above all, a right that the member has to be heard, when his or her opinion or testimony may be of decisive value for the collegial management .

article 39.2. It is the obligation of the doctor to lend his partnership to corporate life and to contribute to the corresponding charges.

1. partnership and participation of the members.

It is undeniable that the attitude of the vast majority of members towards the WTO is marked by indifference, if not disdain. This article points out that active participation in WTO affairs is a moral obligation, as such indifference is clearly damaging to the WTO. The WTO, like any democratic entity, only has life to the extent that it is given by its members. The WTO's statutory aims are extraordinarily attractive, but they can only be achieved through the active participation of its members and the efforts of its elected leadership. One factor contributing to the perpetuation of indifference is, perhaps, the all too common absence among the leadership of the Colleges of members with solid professional prestige, with the capacity to govern and driven by ideals of service to the institutional aims and tasks of the WTO.

A fundamental way of collaborating with the WTO is for all members to participate responsibly in the election of College officers and to attend College Assemblies. These are moral obligations that flow from the democratic nature of the WTO and the loyalty owed to the institution. If participation in elections or Assemblies is leave, a vicious circle begins that slowly but inexorably kills the life of the corporation. leave This happens when the directors are elected with very little participation of the electoral body: it is then inevitable that they feel subjectively lacking in representativeness and the necessary moral authority, so that both their directive management and their deontological control of the professional practice tend to be marked by weakness and inaction. Governance lacking dynamism and moral authority spreads and reinforces the awareness that the Colleges, and ultimately the WTO, are inoperative, leading to greater indifference and a further decline in the rate of participation in subsequent elections. The vacuum created by the passive leadership of the Colleges is filled by the activism of general politics, the confrontation of different trade union tendencies. The deontological ineffectiveness is replaced by the activity of the courts of law. The ideal circumstances are thus created for these foreign powers - political, trade union and judicial - to increasingly encroach on the collegial space, which means the slow but inexorable death of the medical profession.

2. School fees.

Finally, this article refers to the obligation of the members to contribute to the financial expenses of the Associations and of the committee. The article 43, b) of the EGOMC imposes on members the duty to be up to date in the payment of their membership fees, while the article 51 of the same Statutes details the measures to be applied to members in arrears, measures which, although they include the granting of deferment of payment, also establish the possibility of fail of the professional practice of the member who refuses to pay their membership fees.

article 40.1. The Organisation shall strive to ensure that the ethical standards of this Code are respected and protected by law.

In this article, the WTO pledges to work with all its energy to ensure that the precepts of the Code of Medical Ethics and Deontology are not only not overridden or contradicted by legislation, but that legislation respects and protects them.

The EGOMC, in its article 2.2, states that the committee General, in the case of regulations for the State level, or the Colleges or their Associations, for the respective territorial scope, must provide a mandatory report on draft legislation and legal provisions of any rank that refer to the general conditions of professional practice and function. And article 3.4 of the same EGOMC establishes that one of the aims of the Organisation is "the partnership with the public authorities in achieving the right to health protection for all Spaniards and the most efficient, fair and equitable regulation of the health attendance and the practice of Medicine...".

It is therefore an obligation, and also an opportunity, for managers and members to demonstrate to the authorities and legislators the great social and professional values of rules and regulations deontology, so that they are respected and recognised by laws and lower-level provisions, and to prevent these from eroding the necessary freedom and the corresponding responsibility of doctors. rule It is true that the mandate of article 40.1 seems utopian at a time when governments and legislators tend to consider that the mandate they have received from the electorate confers on them such a broad and sovereign authority that they are dispensed from the elementary prudence of seeking the opinion of professional or social bodies on legislation being prepared. The WTO remains, however, obliged to defend and promote uphold ethical values. In order to be the valid interlocutor of patients and doctors before the public authorities, it needs to enjoy undisputed moral prestige in the eyes of society. It will only achieve this if it combines the quality of its reports on the professional issues raised with upright and impeccable conduct in the performance of the social function that society itself has entrusted to it.

article 40.2. The College shall defend Members who are harmed because of their compliance with ethical principles.

In this article the WTO is seriously committed to protecting the freedom of members who reasonably dissent or claim conscientious objection to provisions or orders that conflict with the ethical principles of the profession. Experience in other countries, and also in our own, sample unfortunately shows that, sooner or later, objecting physicians tend to be subject to pressure and discrimination by other colleagues or by those who run the institutions in which they work.

It is a basic principle in general ethics that there can be no moral life without freedom. It is also a basic principle of professional ethics that there is no responsibility staff without independence. Therefore, any action that seeks to diminish the freedom of physicians, whether it be their freedom to prescribe or their freedom of conscience, is unethical. When the Code obliges those who run the WTO to protect its members from harm because they are faithful to their ethical-professional convictions, it is not only applying Constitutional Law to ideological freedom (article 16 of our Basic Law: "The ideological freedom of individuals and communities ... is guaranteed .... of individuals and communities ... is guaranteed ... . No one may be obliged to declare their ideology, religion or beliefs") and to not be discriminated against on this basis (article 14: "Spaniards are equal before the law, and no discrimination may prevail on the grounds of birth, race, sex, religion, opinion or any other condition or circumstance staff or social"). It also does so in order to comply with the statutory duty of the Associations to "defend the rights and prestige of the members ... if they are the object of vexation, undermining, disregard or disrespect in professional matters" (article 34 of the EGOMC) and to protect the right of members "to be defended by the high school or by the committee General when they are vexed or persecuted on account of their professional practice" (Art. 42, b of the aforementioned EGOMC). To a certain extent, article 40.2 generalises, to other situations, what article 27.2 of the Code states about the protection of the conscientious objector to abortion and other interventions in the field of human reproduction.

However, it is not the blatant disenfranchisement that is most to be feared, but the subtle and refined ways in which the moral resistance of those who do not bow to the wishes of those in power is broken. There are legal channels to counteract serious reprisals (dismissals, transfers, opening of files). But there is no other channel than the deontological one to defend against subliminal forms of ideological torture or unscandalous discrimination, which depend on the discretionary decision of the system's administrators, such as the allocation of unpleasant schedules or tasks, or the preterition when it comes to distributing opportunities (leave for congresses, funds for research, participation in commissions).

The Spanish Medical Association is committed to providing support, through its legal advice and, above all, through negotiation, to those who suffer attacks on their professional freedom.

article 40.3. The Corporation has the duty to ensure the good quality of the teaching of Medicine, which must not lack the teaching of medical ethics. It must also do everything in its power to ensure that doctors can receive a continuous training .

The teaching of Medicine, its scientific and professional quality, is an issue to which the WTO cannot remain indifferent. It could not fulfil its fundamental aim of "promoting, by all the means at its disposal, the constant improvement of the scientific, cultural, economic and social levels of its members..." if it were to neglect (1) its initial level, which is that of the Education and training professional level of medical students, and (2) that of its consolidation and maintenance, which are the post-graduate Education and the ongoing Education of doctors.

1. The World Medical Association ( association ) promulgated a Declaration on Medical Education (Rancho Mirage, 1987), which emphasises that it is the individual responsibility of each physician and the collective responsibility of all physicians as members of the profession to maintain the highest standards of medical Education in two areas: in the application of the latest scientific advances to the prevention and cure of man's diseases, and to the alleviation of those that are now incurable; and in learning ethical standards of thought and conduct that emphasise service to others rather than personal advantage.

The partnership between Schools of Medicine and Medical Schools can lead to a very fruitful cooperation, of which there is already some evidence. The WTO has a particular interest in ensuring that medical students are taught the standards of the Code of Medical Ethics and the EGOMCs. Unfortunately, since 1975, the teaching of Deontology has been practically absent from the Study program of the vast majority of Spanish medical schools Schools , with the consequent massive prevalence, among the younger generation of doctors, of ignorance of statutory and ethical duties. degree scroll Royal Decree 1417/1990, which sets out the general guidelines for the plans for programs of study leading to the official university degree of graduate in Medicine, includes among the core subjects the block on "Legal Medicine and Toxicology. Deontology and Medical Legislation", which must be compulsorily included in the new Study program. This will come into force in October 1993.

2. The WTO also has a vital interest in promoting and cooperating in the continuing education of practising physicians Education . It is the Boards of Directors of the Colleges that must activate this function. The headquarters of the Colleges cannot lack a minimum infrastructure professor (classrooms, audiovisual materials, Library Services), to facilitate and host the very diverse programmes of update and recycling that doctors need to keep up to date. They should welcome initiatives in this field from public bodies, medical societies, professional groups or the Colleges themselves. It would be interesting if, as far as possible, the deontological aspects of the subject subject of each programme of Education could be dealt with.

article 40.4. It is the duty of the Collegiate Organisation to intervene in the health organisation of the country and in all aspects of civic life that affect the health of the population.

In addition to the individual duties of physicians towards society, discussed in Articles 4.1, 5.1 and 5.2, there are other corporate duties to be assumed by the WTO as a whole, and more specifically by its officers, towards the community: (1) to intervene in the health policy of the country, and (2) in the promotion of public health.

1. The public authorities should seek the advice of physicians in planning the equitable distribution of health care. The medical profession must remind the authorities that they must take their health policy commitments seriously. development "Technical progress, which is the basis of our industrial civilisation, and the economic growth that results from it, have as their principal aim to promote, thanks above all to health policy, the fullest possible physical and spiritual development of man, of all men", as stated in the final paragraph of the Declaration on the internship of Medicine in the Community Countries (Declaration of Nuremberg, 1967, article 57-3 of the Treaty of Rome). And, obviously, the fulfilment of these promises implies, in a modern society that wants to take care of all its citizens, an economic burden of enormous magnitude. apply for The medical profession should be called upon to advise on subject: "Budgetary decision-makers should first consult the experts at committee and it is precisely then that the medical profession should be consulted. Once a decision has been taken, the medical profession should make known its views on the consequences of such decisions," says the Declaration on Health Care Costs, which the committee Standing Committee of the Physicians of the European Community promulgated in Copenhagen in 1978.

2. The medical profession should also be involved in health issues affecting the population. In the broad field of public health promotion, there are technical tasks and committee tasks that only physicians can carry out with due skill: plans for health Education , vaccinations and the fight against voluntary health risks, civil protection, etc.

It is not easy to always remain loyal to the patient while serving the community and the state. It is not easy to always be fair in the allocation of money and services when some high-cost groups of patients (very low birth weight infants, chronic dialysis patients, certain types of transplants, AIDS patients, for example) may consume resources that could be used to improve the care of other, much larger groups. The Medical Corporation's duties to society constitute a field of high ethical tension.

The WTO is obliged to intervene. It is a corporation under public law, which "intended to collaborate in the realisation of the common good, shall enjoy the protection of the Law and recognition by the State" (article 2.4 of the EGOMC). It therefore has a place in the discussion of the broad lines of the health policy developed by governments, for which "it will relate to the State Administration, through the Ministry of Health" (article 2.1 of the EGOMC), or, where appropriate, the Colleges or their Associations will do so with the provincial or autonomous authorities (article 2.3).

article 41.1. All members who have been elected to position are obliged to conduct themselves and their decisions in accordance with the rules of the Articles of Association and ethics.

It is obvious that those who hold a position for which they have been elected and therefore enjoy the confidence of the electors are obliged to comply in an exemplary manner with the statutory and deontological rules specific to their position and function (detailed in Titles II and III of the EGOMC, in Sections 2, 3, 4 and 5 of the Statutes of the committee General, and those of this chapter of the Code), but also those common to all members. The Code and the Statutes are binding on them without mitigation. Being an officer does not confer deontological immunity.

This article is not a simple exhortation to good conduct addressed to the elected officials of the WTO. It points out that the task of leadership is not only a legal or statutory matter: it must be guided and inspired by ethical reasons and motives, and have the finesse of perception and responsibility which, over and above the legal and statutory, is demanded by the deontological rule . Fulfilling the obligations to ensure the quality of the professional practice of Members, to respond to the demands that society makes of the Colleges, and to exercise the power to initiate and sanction disciplinary proceedings in cases of conduct not in accordance with the Code and the Statutes, is no easy task, but it is the basis of corporate effectiveness: it is the price that the directors have to pay for the public prestige of the WTO.

It is possible, even inevitable, that the actions of some managers may be unwise. But it is a totally different thing for it to be unethical, done outside or contrary to ethics, and tolerating irregularities or unethical conduct in those who govern is tantamount to becoming an accomplice to very harmful abuses. The guilty manager must be denounced. Such whistleblowing is particularly incumbent on his or her colleagues in the governance task, as they may be more familiar with the performance and are more familiar with the statutory and ethical rules. The EGOMC (article 67) states that "the committee General shall have disciplinary functions in respect of the members of the Boards of the colleges and of committee".

article 41.2. Officers, even more so than non-officers, are obliged to promote the common interest of the Collegiate Medical Organisation, its high school, the medical profession and all members, to which they must subordinate any other particular convenience or the interests of group. Their conduct shall never imply favour or abuse of power, nor shall they give rise to any suspicion of doing so.

Two obligations are imposed on directors here: (1) to look after the general interest of the Corporation, above their own; and (2) to refrain from trafficking in the influence that position may give them.

1. The promotion of the general interest.

Managers are morally obliged to guide their decisions not by criteria that seek their own benefit or that of only a part of the members, but by broad considerations that take into account the consequences that their government actions may have for everyone and in deadline foreseeable consequences. For, although voted for by only part of the electorate, their decisions affect, at provincial, regional or national level, all the members. Once elected, they must be concerned, therefore, with looking after the common interests, not the private interests, whether these are personal, of the group that voted for them, or of the high school to which they belong.

It is not possible to give specific rules on this point. However, it should be pointed out that it is unethical to carry out the position leadership role with a systematic bias in favour of the exclusive interests of a particular group or tendency. Anyone who does so would alienate the support and loyalty of members who do not share his or her particularist aims, to the serious detriment of the Corporation. Indeed, much of the disinterest that many honest doctors have in the collegiate thing is due to the selfish politics practised by certain directors, who tend to forget that they have not been elected to defend and promote private interests, but to make a fair management with everyone: with those who share their ideas and with those who oppose them.

This does not mean that a manager, because he or she has been elected, should renounce having his or her own professional and corporate ideas. On the contrary, he/she should think that he/she has been elected precisely because he/she has certain ideas, but he/she cannot impose them on everyone: he/she must temper them and enrich them with the financial aid of the other managers, through the intelligent internship of collegial governance.

2. The prohibition of influence peddling. The holding of office may not be an instrument or occasion for gain staff, but rather an opportunity for altruistic and generous service to the members, to high school and to committee General. The main retribution of position is of a moral nature: social prestige in the eyes of the public and the Collegiate, the opportunity to carry out an honest and effective management . But the position shall never be used to benefit relatives and friends, or to support political or ideological party interests.

When a matter is being discussed, debated or voted on in which an officer may be involved or have a personal interest, that officer, as a sign of respect for the freedom of the other members of the governing body, shall absent himself from the session during the time when the matter is being discussed and decided. In doing so, the cause of the freedom and independence of the members and the other officers wins. The other officers, in turn, have a moral duty to judge in such a way that the interests of their colleague are neither scandalously favoured by attention nor unfairly discriminated against.

The manager shall refrain from exploiting for personal gain information that has come to his or her knowledge in the exercise of his or her duties position.

article 41.3. Officers shall not obstruct the lawful proceedings of Boards and Assemblies, nor shall they impede the free exercise of the right to decide matters by vote at manager .

By taking office at position, an officer assumes a duty to contribute to the proper functioning of the body he or she joins. The two essential elements of that duty are (1) to respect the right of all to discuss problems openly and politely, and (2) to accept a free vote as a means of deciding matters of governance.

1. College governance requires everyone to comply with the rules of procedure and to assume their responsibilities. The first of these is attend to duly convened meetings. Only in this way can the meeting be representative and achieve the necessary quorum. This is a serious obligation, as the EGOMC states in its article 18.1 that the unexcused absence of an executive from three consecutive meetings will be considered as Withdrawal at position.

There can, and should, be strong differences of opinion among managers on professional issues. It is natural for a democratic body such as the WTO to reflect the diversity of opinion found in civil society, a diversity which does not preclude, but rather reinforces, the obligation of management to participate in deliberations and to express its views. To do otherwise would be to disappoint the trust of constituents, and to deprive other executives of ideas or arguments that can help them to better decide on issues.

It is the particular duty of those chairing the sessions to make the necessary flow of discussion compatible with the exercise of everyone's right to express their opinion. There should be rules of procedure for sessions that indicate the order, issue and duration of the interventions of each member. It is true that any director has the means to hinder the progress of deliberations and, to a certain extent, prevent decisions from being taken, by demanding certain formalities from procedure, requesting technical opinions, or creating study commissions. This can prevent hasty or opportunistic decisions. Legitimate means of obstruction can be an efficient security mechanism, but it is never permissible to turn them into a procedure to paralyse government activity.

2. Once all those entitled to do so have had the opportunity to express themselves freely, the deliberation ends and it is time to resolve the question in conscience by voting.

Each governing body shall be free to determine its own voting rules. It should be noted, however, that apart from certain particularly sensitive matters, which may be decided by secret ballot, public and declared voting should always be preferred. The conference proceedings of the Sessions should record, on each issue, the vote of each of the officers, so that, if necessary, the collegiality can know the solidity of their convictions or their fidelity to their electoral promises.

article 41.4. The right to question managers by other managers or by the collegiate members must always be respected.

It is a tradition of the democratic system that the governed or the co-leaders of management can ask for clarification of decisions taken in office. No one can be annoyed by this, because, in addition to being a right of the governed, it is a circumstance that contributes to rationalising decisions and eliminates the risk of falling into caprice or laziness.

Everyone, both the questioners and the questioned, are ethically obliged to prevent the exercise of this right from degenerating into insults or verbal aggression, or from remaining at Fail because the person directing the discussion does not allow it to be exercised, or from becoming inoperative because the questioned person responds with evasions. Sometimes it will be necessary to postpone the response in order to be able to give it in a conscientious and documented manner.

In order to ensure that the question and answer session at meetings and assemblies is orderly and brief, it is highly recommended that those who wish to speak send the written text of their questions in advance. In this way, everyone can consider the need and measure the words they use. Although the President has discretionary powers to admit or reject the interventions that are subject to Question Time, he/she should always make accredited specialization of those that he/she has judged inappropriate to accept and the reasons that have led him/her to do so.

article 41.5. The directors shall keep secret the matters that have come to their knowledge in the course of their governance work .

Many matters to be decided by the board Board of Directors are not of a reserved nature: on the contrary, it is advisable to consult other colleagues or to seek the opinion of the members in order to reach a sound decision.

Other matters, however, are by their very nature confidential. In such cases, the manager is obliged to maintain the natural reservation confidentiality of all information passed on to him/her. They must not reveal, either by word or by their conduct, data of the files, the opinions of other executives or proposals for resolving the problems they have been asked to study. Any indiscretion on your part could damage the reputation of a colleague or make it difficult for other managers to act with independent judgement in dealing with the matter. If data were to be leaked to the media, the damage to third parties or to the institution itself could be irreparable.

article 41.6. The officers of the Collegiate Medical Organisation are obliged to maintain the deontological unity of the entire collegiate body.

In an entity as complex and diverse as the WTO, tensions and possible conflicts between local or group interests and general interests must be seen as a good thing, as a macrocephalic committee General absorbing the functions and responsibilities of the Colleges would be just as ineffective as disunited Colleges drifting in the direction of their own particular interests.

The unity of the WTO is strengthened by the good functioning and mature responsibility of each of the Colleges. It is in the WTO's interest that the Colleges achieve, each in its own territory, the greatest possible efficiency, following the path most in keeping with local traditions and with the choices made by the Colleges through the election of their officers.

The unity of the WTO is strengthened when the communication between the Associations and committee General is lively, circulates in both directions, and transmits sincere and complete information; when the Associations and committee respond to requests from data (administrative, deontological, professional) promptly and accurately. This reciprocal communication is essential for the WTO to be able to fulfil its institutional commitments.

written request Finally, it should be pointed out that, however broad the responsibilities that the WTO may consider it appropriate to transfer to the Associations of Colleges at subject , the right of all Members to appeal to the committee General on ethical matters must be preserved. development The annulment of this right would have two undesirable consequences: on the one hand, it would expropriate from Members a right they have always enjoyed: the right to appeal to committee General and to obtain a technically qualified opinion from its Central Ethics Committee, far removed from conflicts and possible local passions; and, on the other hand, it would prevent the creation of a national jurisprudence on ethics, which would set valid precedents and unify criteria for the benefit of Members and of the Associations themselves.