Commentary on the Code of Medical Ethics and Deontology

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Chapter XII: Relationship with other institutions

This chapter deals with some specific ethical rules that affect doctors working in particular situations. Firstly, those who work for attendance medical institutions (hospitals, clinics), whether they are salaried or not. Secondly, those who provide special services to the State, to the administration of justice, to the armed forces, to insurance companies, etc.

Hospital medicine has reached an unprecedented development in our time. Hospitals and clinics employ a large issue number of doctors and treat a very high proportion of patients. It is not, however, this quantitative aspect that makes it advisable to regulate in the Code the specifics of medical ethics in health care institutions, but the fact that, in these institutions, inter-professional relations, and the doctor-patient relationship itself, take on features that require special treatment. Thus, for example, the doctor employed by a hospital must know how to combine his freedom to prescribe and his role as an advocate for the hospitalised patients with his loyalty to those who govern the hospital and to his colleagues who are part of a hierarchical organisation.

It is very important that there are doctors who work directly for certain public bodies, or who fulfil specific missions necessary for the proper functioning of society, such as inspecting the work of other colleagues, or assessing, as an expert and at the request of a magistrate, some medical-judicial problem that requires particular skill or expertise. In all these situations, the doctor-patient relationship or, as the case may be, the relationship between doctors, is modified by the fact that the medical expert or civil servant is affected by forces or interests that may interfere with ethical values. It is therefore understandable that attention is paid in the Code to the deontology of medical experts and civil servants.

article 42.1. Every physician is obliged to protect the prestige of the institution in which he/she works. He/she shall loyally follow the rules that tend to the best interests of the patients attendance . knowledge With equal loyalty, he shall inform the management of the institution of any deficiencies of any kind, including those of an ethical nature, that may be detrimental to this correct attendance, and shall report them to high school if they are not corrected.

This article imposes on physicians (1) the obligation to serve loyally the health care institution, public or private, in which they work, and to refrain from any careless or indifferent attitude towards it. And it points out (2) that the commitment to the best possible care of the sick attendance will sometimes lead him to denounce deficiencies.

1. When a physician is linked to a health care institution by a service contract, he/she must not forget that, over and above the terms and conditions of employment, his/her primary obligation is to look after the medical interests of the patient. There is only one code of ethics, regardless of the social-political context or modality, whether private or public, of professional practice. This deontology prohibits the physician from behaving as a mercenary. In all circumstances, the salaried physician will ensure that his or her work is of the highest technical and ethical quality and meets the criteria of efficiency and organisation of a modern, well-managed hospital.

The first loyalty that physicians owe to the institution in which they work is to respect patients and protect their rights. article 10 of the General Health Act 14/1986 states that some of these rights are specific to the patient in a health care institution. expense Hospital doctors, in private as well as public hospitals, should advocate for these rights, in particular when the interests of patients are threatened, for example, when health care containment plans are implemented, when clinical experiments of greater or lesser risk are carried out, when medical confidentiality is subordinated to bureaucratic convenience, or when patients are discriminated against because of the unequal geographical distribution of health care resources.

Respect for the rights of the sick can lead to an improvement in the environmental conditions in which the physician's relationship with the hospitalised patient develops. For this reason, as well as out of an obligation of loyalty to the institution in which he/she works, the physician will cooperate with the hospital's management and administrators to ensure its greater effectiveness.

2. The physician shall endeavour to correct any deficiencies that may be detrimental to the attendance of the patients. Through the hospital's Medical Committees, he/she shall inform the centre's administrators of all corrective measures that prevent the deterioration of medical services and attendance to individual patients. It shall ensure that the most efficient possible use is made of technical and human resources, that only those patients who should be admitted to the hospital are admitted, and that their stay is not unduly prolonged. His or her relations with the hospital's management and management shall be loyal and sincere, while maintaining his or her independence. The provisions on quality of medical care in Chapter IV of this Code, in particular Articles 29, 33, 34 and 35, apply here.

The article 42.1 invites the doctor, should his efforts to remedy the deficiencies be in vain, to put the status at knowledge of high school, who is obliged to use his social influence and his good offices to fulfil his statutory function of understanding "in all matters affecting or relating to the promotion of health or the attendance health" (article 34,k, of the EGOMC).

article 42.2. The rules of the institution shall respect the freedom of the doctor to prescribe and shall state that the doctor exercises, in the area of his skill, effective authority over the staff partner .

Whatever the legal form of the link by which the physician leases his services to any health care institution, he should bear in mind, when discussing the conditions of his work, that he is obliged to demand absolute respect for certain non-negotiable deontological conditions.

These are not capricious or haughty claims. They are requirements on which physicians cannot compromise, on which the human and technical quality of their work, and in particular their freedom and ethical responsibility, depend. Such demands do not arise from a selfish desire to preserve corporate rights or privileges, but from the need to safeguard the rights of the sick. In view of the tensions that often arise when individual or collective agreements are negotiated between doctors and hospital management, the committee Standing Committee of Doctors of the European Community, together with the association European Hospital Doctors, promulgated the Hospital Doctors' Charter as a term for reference letter. The knowledge of this Charter is essential to understand why hospital doctors cannot compromise on their demands for freedom and responsibility.

1. The freedom to prescribe is, of course, one of the most important of the hospital doctor's ethical requirements. To be independent is a general duty of the physician that permeates his entire activity in the service of the patient (cf. article 22.1 of the Code). The hospital physician must defend himself in good time against threats, large and small, to his professional independence. He or she must also ensure that the defence of his or her independence is rational and deontological, not an arrogant whim. Physicians cannot accept a work space in which their freedom of judgement and action is curtailed by clauses that limit or prevent their access to available diagnostic or therapeutic methods, that make the amount of their salary conditional on a certain 'productivity at low cost', or that oblige them to blindly comply with orders from superiors.

2. The second condition imposed by article 42.2 requires that the effective authority of the physician, in the area of his skill, over staff partner , be respected. The Annex to the Nuremberg Declaration on the internship of the profession in the countries of the European Community literally states: "2. Contracts, regulations and the law shall assure the physician: (...) 2.4. The functional authority and control of the staff placed at his disposal". What is said in Chapter VIII of the Code on the physician's relations with members of the other health professions applies here.

article 42.3. Any contractual, statutory or regulatory clause that recognises that a physician who is not competent to judge ethical disputes between physicians is prohibited.

The approach expressed in this article has come under heavy attack in the recent past and will continue to do so in the future. It has been regarded by some as an abusive privilege, more typical of the old political regimes partner than of the modern tendency to establish a single, equal jurisdiction for all. And yet this doctrine is enshrined in the basic documents of modern medical ethics. Thus, for example, the Declaration of Luxembourg (Annex to the Nuremberg Declaration of the committee Permanent of EC Doctors) states in its condition I that "respect for professional ethics implies the impossibility of imposing disciplinary sanctions for professional reasons without the intervention of the competent official professional jurisdiction. The latter must in all cases be independent of the contracting authorities".

In Spain, Decree 3160/1966, which approves the legal status of the Social Security medical staff recognises the validity of this clause, by establishing in its article 72, 1, that the disciplinary files and the appeals derived from them will be preceptively informed by the respective Provincial Medical Colleges. This rule exists, obviously, to facilitate the correctness of disciplinary measures that may be taken by non-medical directors of hospitals or similar institutions. The Colleges may not use this right to prior information to delay or impede the course of justice.

requirements It is not superfluous to insist once again on what has already been mentioned at purpose of article 35.4: that members are obliged to submit their work contracts to the approval of the Associations, in order to guarantee the minimum ethical standards and make them compatible with professional ethics and decorum. Failure to do so constitutes a less serious offence (article 64, 2. c, of the EGOMC).

article 43.1. Medical officers and those acting as experts shall also bring their professional activities into line with the requirements of this Code.

Once again, the unity of medical ethics is emphasised. There is no public function, judicial task, inspection or control activity that exempts the physician from complying with the rules of ethics, such as the duty of science, the duty of confidentiality, the duty to obtain the patient's free consent, and the duty to preserve the necessary freedom.

This obligation to comply with the precepts of the Code is also a legal obligation rule . Indeed, those who act as doctors in the service of public bodies, either because they are required by regulation to hold a medical degree ( degree scroll ) or because the function they perform involves the practice of medicine, are obliged to be registered. This is established in article 572, 2, of the Penal Code and reiterated in article 35 of the EGOMC.

This rule comes into play when there is any disparity or collision between the ethical rules and those imposed by the entity in whose service the doctor works. In such a circumstance, the member should inform the board board of high school, in order to receive committee and support, so that his or her rights are not violated.

In any case, the expert function imposes certain specific requirements. Of prudence: the doctor must consider, before accepting the expert assignment, whether he is really capable of carrying it out with skill and in the deadline indicated to him; if not, he must resign, and he will also do so if he considers that the questions put to him are foreign to the science or technique of medicine. Of impartiality, as set out in the commentary to article below. Secrecy with regard to all that he has been able to discern in the course of his investigations and which does not have to do with the strict mission statement that has been entrusted to him: he will therefore limit himself to giving a brief and specific response to the mandate he has received, excluding from his report collateral findings, in particular those corresponding to the sphere of privacy staff; he must keep reservation with regard to the expert assignments he is asked to carry out and will abstain from making any revelations about them to the media. Truthfulness in their certifications: given the particular relevance of the certifications issued by medical experts, it follows that the duty of objectivity is particularly demanding for them (see commentary on article 12).

article 43.2. Acting as an expert is incompatible with acting as a medical expert for the same patient attendance .

The expert's function is marked by motives and requirements (mandate from a third party, objectivity and independence of judgement, obligation to testify) that are very different from those of the ordinary doctor-patient relationship, which is more dependent on mutual trust. Freedom of judgement requires of the medical expert not only the absence of external coercion, but also the absence of subjective influences that could vitiate his free judgement. For this reason, the Code states that it is incompatible to perform both functions - doctor staff and medical expert - at the same time, as it is very easy for conflicts of loyalties to arise in such a circumstance.

It is to be expected that in the future the status envisaged in this article will become less and less frequent. It will also become rarer for a doctor, working in a public service, to be able to refer patients to his enquiry or private clinic, for self-interested purposes, who come to him when he is acting in his capacity as a civil servant. The latter eventuality is included (article 44, l, of the EGOMC) among the actions prohibited to doctors. It is unethical for a civil servant doctor to give the patient the impression that, if he were to go to his private enquiry , the care he would provide would be more careful and effective. It is even more unethical for a doctor to express a reluctance to perform an intervention, or even a conscientious objection, when working as an employee, whereas this reluctance or objection disappears at his private internship because of the incentive of receiving a fee.

article 43.3. The medical expert must first inform the person concerned of the degree scroll under which he/she is acting, the mission statement that he/she has been commissioned to carry out and by whom. If the patient refuses to be examined, the doctor shall waive the right to do so. Such non-cooperation is a matter to be settled between the principal and the person concerned.

The expert examination is a medical act and therefore requires the consent of the person to be examined (Articles 11.2 and 11.3 of the Code). The doctor must provide the person to be examined, before proceeding with the examination and so that the patient can decide freely, with the appropriate information: the degree scroll for which he/she is acting (forensic doctor, insurance company doctor, Social Security inspector, military doctor, etc.); the that he/she has been entrusted with ( ).); the mission statement that has been entrusted to him (assessment of a bodily injury, verification of the state of illness, incapacity to carry out some work work, etc.); and who has entrusted him with the expertise (the judge, the military authority, the director of the insurance company, etc.). Normally, the patient will not object to the examination, as it is often a condition for obtaining certain benefits. grade However, if the patient refuses, the doctor will respect the patient's decision and, taking into account the circumstances and the reasons given, will withdraw from the case and immediately inform the client of the relevant information.

The physician may try to persuade the patient to change his or her mind with relevant reasons, but he or she cannot force, let alone coerce, the patient to submit to the examination. The physician is not a judicial officer with a search warrant who can force someone against their will. A medical "frisk" cannot be carried out, as the human body cannot be subjected to such a command subject. Such a status would be close to torture.

It is up to the judge or the appropriate authority to obtain partnership from the patient. Only after this partnership has been obtained may the doctor act.