Commentary on the Code of Medical Ethics and Deontology

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Chapter II: General principles

article 4.1. The medical profession is at the service of man and society. Consequently, respect for human life and dignity of the person and the health care of the individual and the community are the primary duties of the physician.

This article contains a dense and abundant doctrine, to such an extent that it can be said that the main principles of the whole of Deontology are recapitulated in it. In order to bring order to the following commentary, it will be useful to analyse the following five points in turn:

1. The service character attributed to the medical profession.

2. The individual and social dimensions of the medical vocation.

3. Respect as a fundamental ethical attitude of physicians.

4. The primary recipients of this respect: human life and the special dignity of man, especially the sick.

5. The duty to take care of health, both at the individual and community level.

1. The doctor's professional work is a service.

Medicine today has an incredible power to manipulate people. In the deontological context, however, the doctor Withdrawal becomes a dominator of his fellow human beings and establishes himself among them as a servant. His employment of time, his family life, his entertainment or his rest, yield to the needs of his patients, in order to be available to take care of their health. This commitment to serve appears in many fundamental ethical texts: "I solemnly promise to consecrate my life to the service of humanity" (Declaration of Geneva); "The physician should, in all types of medical internship , endeavour to offer his professional service with skill, full technical and moral independence, with compassion and respect for the dignity of man" (London Code); "It is the privilege of the physician to practise medicine in the service of humanity" (Declaration of Tokyo).

A doctor's service usually consists of the combination of availability, skill and respect, with which he goes to financial aid to those who need him; on extraordinary occasions, it must also be altruism, even to the point of risking one's own life to save the life of others. This disposition must never degenerate into servility, i.e. blind submission to the orders of others, whether they are the holders of political power, health administration bureaucrats, the wealthy, or patients who think of doctors as qualified technicians who carry out the orders they are given.

The physician's service to the sick recognises that patient and physician are of equal and identical dignity, and necessarily includes the science and conscience of a free man who, by vocation and voluntarily, serves his fellow man, whom he respects and who respects himself.

2. The individual and social dimensions of medical service.

Although the social obligations of physicians are dealt with in Articles 5.1 and 5.2, it should be noted here that physicians cannot limit their care to individual patients: they must also assume certain social responsibilities. In the vast majority of advanced countries, medical professionals, whatever their political and social convictions, have, through their participation, made possible the phenomenon of the socialisation of medicine. The medical profession has placed itself at the service of the community: this is particularly true of doctors working in public health area , those practising at the first level of attendance (family and community medicine), and those who collaborate with public administration in the organisation of attendance health care. Although, paradoxically, it has been said that medicine is too important to be left to doctors, it should be pointed out that medicine, even in its macroeconomic and general planning aspects, presents problems that require specific medical knowledge and the moral sense that professional ethics lends.

3. Respect, a fundamental deontological attitude.

The article states that the physician's primary duty, from which all other duties arise, is deontological respect. This includes the all-important manifestations of courtesy and good Education proper to civilised human coexistence. But it is much more, for it is like the nervous system of the moral organism.

The quality and abundance of moral life depends, in general, on the capacity to grasp and respond to moral values. Ethical respect sharpens our sensitivity to perceive them. Take, for example, the value of a patient's time. There are doctors who, through inadvertence, perhaps arrogance, think that the patient's time is worthless or of far less value than their own. These doctors make careless or untimely appointments for their patients and subject them to interminable waiting times: they do not realise that they are causing them discomfort, anxiety or humiliation. The waiting rooms of certain practices are a sample of deontological slovenliness.

Respect, as well as being a sensory organ, is a system that integrates moral stimuli, which selects the significant data from reality, charges them with meaning by applying the rules of ethics to them, and then makes a decision in the light of these rules. The ability to analyse, select and integrate these data depends, to a large extent, on the study of deontology, on the ability to reflect on the motives and consequences of our professional actions. There are doctors, and they are not few, who guide their conduct by intuition or almost automatic mimicry, who are incapable of giving a rational explanation for their decisions. Giving such an explanation is an expression of respect.

Finally, respect is the effector organ of moral conscience: its actions are proportionate responses to the moral values at stake, and have the richness of nuance that comes from familiarity with deontological reasoning. Respect makes it possible for the physician's response to the ethical demands of his patient to be an intelligent response, a service rendered to the patient's human dignity.

4. The primary recipients of respect: human life and the dignity of the person.

article 4.1 outlines these two well-defined primary objects in this regard. But there are many other important, albeit lesser ones, which are dealt with in Chapters III to V of the Code, which give rules respectively on the doctor's relations with his patients, professional confidentiality, and the quality of medical care; and, above all, Chapter VI, which deals with respect for the life and dignity of the person. It is interesting, however, to make a few considerations on respect for the human person in the particular situation of being ill. status .

In the deontological tradition, the relationship between patient and doctor has always been seen as an asymmetrical one, where weakness meets power, fear meets security, ignorance meets science. It has also been often repeated that it is the meeting of a trust with a conscience. In more recent times, it has been argued that the traditional paternalistic attitude of the doctor towards his patient is historically, psychologically and sociologically outdated and must be replaced by a relationship of equals, in which two human beings, two autonomous consciences, must seek a agreement.

Whether the more traditional or the more modern idea is followed, the doctor-patient relationship must in fact be governed by respect for the integrity of the person. This respect excludes any manifestation of superiority or arrogance on the part of either the physician or the patient.

Although the physician ordinarily occupies a position of authority, he cannot treat his patients as if they were things, or animals, or stupid human beings. He must bear in mind that his relationship with the sick has a medical purpose: to cure illness, to alleviate suffering, to improve health, to prevent death. That is his legitimate field of action. He will refrain from unnecessarily invading other areas of the patient's existence. The patient's condition staff obliges the physician to recognise him as someone who is intelligent and free: hence the physician's duty to inform him and to give his free consent apply for for diagnostic and therapeutic acts, and to do so in such a way that the patient understands his explanations and advice and can consent with the maturity of a moral adult being and manager.

In the doctor-patient relationship, respect for the integrity of the person is reciprocal: if the doctor is forbidden to impose anything on the patient against the latter's conscience, he or she also obliges the patient not to violate the scientific and moral convictions of his or her doctor. If, in the event of a serious difference of opinion, a mutually satisfactory solution cannot be found, mutual respect will lead to a polite fail of the doctor-patient relationship. Such an eventuality entails some discomfort and resentment, which is the price that doctor and patient have to pay for remaining self-respecting people who respect each other's freedom.

5. Individual and community health care.

Although physicians must first attend to the health needs of their patients on a one-to-one basis (according to 4.3, this duty takes precedence over any other convenience), they are simultaneously obliged to care for the health of the community, as stated in article 5.2.

It is very important for the physician to have a considered notion of what health is. From a medical point of view, the idea of health that emerges from the well-known WHO definition - health is a state of complete physical, mental and social well-being, and not merely the absence of disease or infirmity - is far beyond the present and future capabilities of medicine. Perhaps more acceptable - and also more internship- is the idea that health is living well, albeit with limitations. The doctor must strive to reduce ill health, the factors that threaten it, to reduce as far as possible the intensity and spread of illness and its residual effects: he or she must put the preventive and curative dimensions of medicine on internship , while avoiding inducing iatrogenic ills and financial aid to create a healthier social way of life. It should be noted that the Code accords the same dignity to Community health care as it does to respect for human life and the dignity staff of its patients.

article 4.2. Physicians must care for all patients with equal conscience and application without distinction as to birth, race, sex, religion, opinion or any other condition or circumstance staff or social status.

This article is a continuation of an old ethical tradition. There are very old and moving testimonies that show how doctors do not exclude anyone from their care: they do not find out beforehand what their patients' convictions are, in order to care for their co-religionists and reject those who do not think like them. Although in our times, coinciding with moments of politicisation of medicine, there have been moments of eclipse of this fundamental rule , this idea has never been so strongly affirmed as in the great modern deontological texts. One of the clauses of the Declaration of Geneva states: "I will not allow considerations of religion, nationality, race, party politics or social class to come between my professional duty and my patient". And article 1 of the Principles of European Medical Ethics proclaims that "The vocation of the physician is to defend the physical and mental health of man and to alleviate his suffering with respect for the life and dignity of the human person, without discrimination as to age, race, religion, nationality, social status or political ideology or any other reason, in time of peace as in time of war.

Thus, when facing his patients, the doctor rejects all factors of discrimination, whether external and goal (religion, race, nationality, economic or social status, etc.) or internal and subjective (the feelings the patient inspires in him or the illness from which he suffers), and obliges himself to care for all of them with due knowledge and conscience. The doctor does not do this because he is a committed pacifist, an eclectic cosmopolitan, or because he lacks convictions. He does it because the quality of his attendance requires him to be even-tempered, to control his feelings, to maintain an emotional detachment that allows him to act with serenity and prudence, because only then will he be able to provide proper care. Allowing phobias and antipathies to come between him and his patient, or, on the contrary, an excess of compassion and tenderness, can distort his work.

The essence of this duty not to discriminate is that the physician, once the therapeutic relationship has begun, should treat all his patients with the same technical skill , the same scientific quality and the same professional seriousness. No patient should feel slighted on account of any of his or her personal characteristics. It would be illusory, in view of the differences in the character and expressive capacity of doctors and patients, to claim that all doctor-patient relationships should have the same cordiality and the same affective temperature. It is enough that they have, as stated above, and this is no small thing, the same scientific quality and the same skill manager .

Compliance with this precept is facilitated when the patient enjoys the freedom to choose his or her physician, as well as when the physician may refuse, except in emergencies, to treat a patient because he or she considers that the necessary trust is lacking (see article 9). People have the right to choose according to their preferences and to relate agreement to their affinities, convictions or religion. For this reason, free choice is a basic principle of medical internship .

article 4.3. The physician's primary loyalty is to his or her patient, and the patient's health must take precedence over any other convenience.

One of the principles of medical ethics is formulated here: the principle of beneficence, which sheds much light on the doctor's moral judgement. In this principle, the deontological attitude (the physician is always obliged to seek the good of the patient) and the consequentialist attitude (we must produce the greatest possible benefit through our actions) go hand in hand.

The basis of the doctor-patient relationship is the conviction that everyone is convinced that it is good to go to the doctor, because it is taken for granted that the doctor has one dominant interest: the cure of the sick person, the preservation of his or her health. Although doctor and patient may have conflicting interests in any other field of human activity, everyone must be sure that the doctor will behave loyally and will not exploit his or her relationship with the patient for his or her own benefit and to the patient's detriment.

The patient must be given the opportunity to express his interests, to express his wishes on the points that he considers significant for him in his relationship with the physician. In the vast majority of encounters between physician and patient, the patient's wishes are obvious and do not need to be formulated: he or she comes seeking relief and healing. This is his or her sole interest and leaves it to the physician to decide, confidently and without constraint, by what means this is to be achieved. On other occasions, the patient demands that his or her personal or religious convictions be respected, which may condition the physician's actions (see in this regard the commentary on article 8.1 of the Code).

Medical loyalty consists in respecting each patient in his or her own peculiarities; in maintaining continuity of care until the end; in responding to the sometimes untimely calls of patients or their relatives; in proposing, or accepting, the enquiry with another colleague when circumstances dictate; in withdrawing when the doctor's physical or mental Schools begins to decline and then advising patients to go to another competent colleague. Loyalty lies in not giving in to the temptation to abuse prescribing for marginal financial gain through unnecessary visits, superfluous operations or any other subject disguised exploitation. Loyalty lies in communicating to the patient, with prudence and circumspection, the truth of his status and prognosis; in not becoming impatient with the patient's disobedience, and in helping him, as often as necessary, to modify his behaviour.

But loyalty to the patient does not oblige the physician to submit to the patient's abusive requests. It sometimes happens that, in order to obtain some unfair advantage, the patient pressures the doctor to issue prescriptions, certificates, sick leave or similar things, which may involve fraud on third parties. The physician may not agree to certify a non-existent disease, to declare someone unfit for a work who is not, or to over-evaluate a compensable bodily injury. The physician will firmly reject such abusive claims and refuse to be an accomplice with the patient against the business, the insurance institution or the public administration. Loyalty to the patient and protection of his or her interests have a limit: that of the illegal, abusive or unseemly.

article 4.4. The physician shall never intentionally harm the patient or treat him/her in a negligent manner; and shall avoid any unreasonable delay at attendance.

This article, in its first part, introduces into the Code the ethical principle of non-maleficence, which is presented in two complementary forms: as a positive precept of not causing malevolent harm and as a condemnation of negligent conduct. In its second part, it adds that the patient's time has ethical significance and must be respected.

1. Refraining from any harmful or negligent conduct.

Physicians may not harm their patients. This is a duty of the first rank, which appears already in medical ethics in its first Hippocratic moment ("...as regards diseases, you shall observe two things: to help, but, first of all, to do no harm"). Hence the expression "primum non nocere" was born. And when harm is unavoidable, it must always be justified by a well-founded hope of greater benefit to the patient. The International Code of Medical Ethics states: "When a physician administers professional care that might weaken the physical or mental condition of his patient, he shall do so only for the patient's benefit.

First, the physician must refrain from inflicting malicious, malicious, deliberate harm, which may amount to a criminal act, with the aggravating circumstance that the physician abuses his or her position of trust to harm or eliminate a patient. Such conduct can never be tolerated, even if its perpetrators subjectively describe it as compassionate or virtuous. It is ethically unjustifiable to conduct experiments on human beings without their consent, especially if they are dangerous; or to kill a sick person, even out of compassion; or to torture an enemy, for political reasons. The wrongfulness of such acts is not cancelled out by the desire to know and obtain interesting scientific data information, by the doctor's complicity with relatives, or by the implementation of certain political ideals.

Secondly, the physician is obliged to avoid or at least diligently reduce the harm resulting from his or her professional actions; that is, he or she will try to prevent iatrogenic harm as far as possible, to prevent the remedy from being worse than the disease. Many physicians tend to think that iatrogenic pathology is an inexorable companion of medical activity. But this attitude can be irresponsible: the prevention of iatrogenic harm is a deontological obligation.

Thirdly, the physician must protect his patient from harm and harm that may be caused to him by others or that he may cause to himself. The Declaration of the Central Deontology Commission on Freedom of Prescription of November 1984 states: "Physicians must be impervious to influences that may harm their patients, whether they come from the physician's own interest or convenience, from administrative impositions, from family or environmental pressures, or from the ill-advised demands of the patient himself". It follows from these words that physicians must act as advocates for their patients to ensure that their rights are not prejudiced.

Fourthly, negligent conduct by the physician is prohibited. internship The notion of negligence refers to reference letter to a lack of diligence, to the careless failure to use the knowledge and skills that the doctor possesses and that are necessary to prevent avoidable harm. From the point of view of Criminal Law and civil law, negligence is a very important element in the negligent or harmful conduct of physicians, and is present in many malpractice suits internship. From an ethical point of view, negligence is the neglect of the duty to provide proper care to the sick, whether or not significant harm is caused to the patient. The Code prohibits negligent care, which, through fatigue or lack of application and diligence, is not uncommon. This should not lead physicians to justify themselves or their negligent colleagues on the grounds that carelessness can happen to anyone. They should realise that negligent behaviour occurs in those who are distracted, or who follow the line of least effort, or who tend to forget that they are dealing with human lives, with human beings, and not with animals or things.

2. This article imposes the obligation not to unreasonably delay the patient's attendance . The ethical value of promptness in the doctor's response in emergency situations is dealt with in the following article . In the ordinary doctor-patient relationship, the physician's punctuality is not only a manifestation of courtesy and good Education: it is also a manifestation of ethical respect. It is inevitable that in a doctor's life there will be unforeseen events, urgent calls, patients who need much more time than calculated, interventions that become complicated. But these occasional circumstances do not justify the systematic neglect of punctuality for appointments, or the delay in sending reports to patients or colleagues.

The doctor must be sensitive to the value of other people's time. A delay in attending to an outpatient visit can be enough to cause a minor catastrophe in the daily routine of a housewife. A full conference room waiting room is no longer a sign of prestige and a large clientele, but a sign of carelessness or incompetence in coordinating appointments with patients. When a doctor is late for his or her scheduled schedule appointment, whether at the doctor's office or at home, he or she should apologise and give a reasonable explanation for the delay.

The work as a team requires extreme punctuality. This is required by a correct collegial relationship, but above all by the efficiency of group in relation to the patient. The delay of one person wastes the time of many: collective performance deteriorates and tensions arise in the mutual relationship. A surgical operation delayed for the convenience or whim of the surgeon causes economic damage (useless occupation of the operating room, loss of work performance of nurses, assistants and anaesthetist); psychological tensions in all of them, with the potential risk of harm to the patient; and in the patient and his family, gratuitous anxiety. Hierarchical superiors, team managers must be exemplary in this respect.

Delays in care can cause serious harm to patients, particularly when there is a need to consult with other specialists and delays are compounded. Degree The physician manager should take the utmost care to assess the urgency of the case and make it known to the colleagues consulted. Chain delays in matters that should have been taken seriously by doctors from the outset are not tolerable.

article 4.5. All physicians, regardless of their specialization program or the modality of their practice, must provide emergency care to the sick or injured person financial aid .

This article outlines the conduct to be followed by physicians in emergency situations. Two different general situations can be considered with respect to the provision of emergency medical services: one is that of the regularly established physician who is called to attend to a patient in urgent need of care; the other is that of the physician who fortuitously finds himself in a scenario (a traffic accident, an episode of illness occurring suddenly on a means of transport or in the street) in which someone needs urgent medical attention.

1. In the first status, it is clear that the doctor must pay as much immediate attention as possible to the sick or injured person, even at the cost of abandoning the work in hand. Logically, the doctor will be able to investigate whether the message that reaches him or her translates a real status urgency or whether it is the result of anxiety or whim. After this quick but diligent enquiry, and having formed his conscience about the case, he will have to decide on his conduct. As is easy to understand, ethical conflicts in emergency situations are not uncommon.

The emergency call to the doctor is often abused. Apart from the excusable situations born out of ignorance or fear, the emergency call is often used for convenience, to avoid the more or less lengthy wait imposed by the ordinary call. Some patients think that, since they pay their fees on time, they have the right to be seen without delay, and that they can exercise a more or less disguised control over the doctor's time.

In addition to the abuses mentioned above, there is no shortage of reasons for doctors to dismiss or delay their response to many emergency calls: the care of other patients who need them, the experience of previous useless calls, fatigue, ungodly hours, unpleasant weather, the distance to be travelled. All these circumstances can make the doctor's decision very difficult, especially when it is not the doctor himself who has received the call and it is no longer possible to make the necessary clarifications. In case of doubt, what the physician must do is very clear: the emergency must be dealt with by the physician who has been called or by a colleague who takes his or her place. It does not relieve the physician of responsibility to invoke a misunderstanding.

The obligation to provide care in an emergency has, apart from its ethical dimension, the character of a legal rule , in case the doctor is a public official. The offence of refusal of assistance, according to agreement with article 371 of the Penal Code, is committed by "a public official who, when required by a private individual to provide a service to which he is obliged by reason of his position in order to prevent a crime or other harm, refrains from providing it without just cause". It should be borne in mind that, for the purposes of criminal legislation, the concept of civil servant is very broad, as article 119 of the Criminal Code states that "A civil servant is considered to be anyone who, by immediate provision of the law or by appointment by the competent authority, participates in the exercise of public functions", so this concept can include doctors who occupy posts in public, municipal, provincial or regional services or institutions, those who work for Insalud, doctors in the armed forces, etc.

2. When the emergency status occurs in circumstances where the doctor is not practising his work (he is on holiday, travelling, or passing in the street) and someone calls loudly for a doctor's financial aid , the doctor must make himself known: he cannot shirk his moral duty to attend. He or she may not claim in order to abstain that his or her specialization program does not qualify him or her to provide the specific care needed by the patient, for article 4.5 specifies that the duty is imposed on the physician 'whatever his or her specialization program or the modality of his or her practice'. It seems to be assumed that the skill and skill of any physician to provide first aid or to mobilise the mechanisms for obtaining urgent financial aid should always and in any case be superior to those of any other person outside the profession. A clear consequence of this deontological obligation is that every physician should receive in the course of his or her programs of study training, and thereafter keep updated, a minimal but adequate training training in emergency medicine and first aid.

In parallel to the offence of refusal of assistance mentioned above, the Penal Code, in its article 489 bis, criminalises the offence of omission of the duty to provide assistance, which can be committed by any citizen and, a fortiori, by any doctor, whether a civil servant or not, who "fails to assist a person who is helpless and in manifest and serious danger, when he could do so without risk to himself or to a third party.... The same penalty shall be incurred by anyone who, prevented from providing assistance, does not urgently call for help from others". In a civilised society, no one, least of all a doctor, can remain indifferent to a human being whose life is in danger without giving him the help he needs financial aid .

article 4.6. In situations of catastrophe, epidemic or life-threatening situations, the physician may not abandon the sick, unless compelled to do so by the competent authority. He/she shall present him/herself voluntarily to assist in the relief effort.

There are many pages in the history of medicine that recount the heroic behaviour of many doctors who risked, and even lost, their lives to save those of the victims of epidemics and catastrophes. Nor has there been any shortage of doctors, including some notorious figures, who preferred to flee from danger and save their lives, betraying their duty to care for the sick and wounded. This article obliges the doctor to exercise altruism when, in carrying out his work, he finds himself in the position of risking his life and safety. This occurs on the occasion of very dangerous epidemics, for which no proven preventive means are available, or during and after calamities and catastrophes (mass accidents, floods, earthquakes). The rule imposed by this article results from combining the obligation of attend in cases of emergency, formulated in article above, with the duty of continuity of care, established in article 9 of the Code.

Although disaster medicine is acquiring the status of a medical subspecialty, all physicians should have a basic understanding of how to provide relief in such situations, knowledge . One element of this knowledge is to recognise that, both technically and ethically, the effectiveness of disaster medicine depends on the successful programming and coordination of medical relief. Isolated initiatives, however well intentioned, can be ineffective or disruptive. Physicians must not act on their own: they must offer to assist in the relief effort and perform the functions assigned to them. This subordination to the competent medical authority is based on the decisive role that proper coordination plays in the effectiveness of the outcome, which depends on the rigorous adherence of all to proven ways of searching for and transporting victims, and to effective protocols for triage of the injured, on-site provision of first aid, and orderly evacuation to nearby hospitals. There is, therefore, a particular obligation to obey the competent authority in such situations. It is only because of a serious professional conscientious objection that the physician may not accept the order of the authority.

article 5.1. Physicians must be aware of their professional duties to the community. He/she is obliged to strive for the greatest possible efficiency of his/her work and optimal use of the means that society places at his/her disposal.

The rules of the Code deal, for the most part, with physicians' relationships with individual patients. This article and the following one outline the physician's deontological obligations to the social community. Many physicians who are extremely individualistic have not bothered to reflect on the social responsibilities of the medical profession or on their own responsibilities. Deontology disapproves of such an attitude: The physician cannot remain oblivious to the social dimensions of medicine or to the effects of living in society on health.

No one lives and cannot live apart from society. The healthier society is, the better the health of each individual. Depending on the circumstances, social coexistence can be a decisive factor in promoting health or causing illness. All physicians should participate, to the extent of their skill, their specialization program and the modality in which they practise their profession, in social measures that promote health, prevent disease, contribute to the Education health of the population, evaluate the effectiveness of the health care system and draw attention to health care needs.

What, in particular, are the duties towards the community of which physicians must be aware, and how can they optimise their work and the means at their disposal? The physician's social responsibility will lead him or her, first and foremost, to ensure that quality medical care is available to all. group Physicians have a moral duty to participate, either personally or through their representative bodies (WTO, medical unions), in the study and implementation of programmes that seek a fairer distribution of resources, so that the public purse adequately finances health expenditure, so that each patient and each special population (pregnant women and newborns, the disabled and the elderly, the poor and the displaced, for example) receive, for reasons of distributive justice or subsidiarity, the health care they need.

At the same time, physicians will be concerned with eliminating waste in health care provision. They should have a clear understanding of the high performing of many preventive measures and encourage their patients to withdrawal or mitigate voluntary health risks. He/she should be aware that today physicians, particularly general practitioners, are both physicians of their patients and physicians of populations, and should therefore be efficient in their role as health educators, which is one of the most cost-effective ways to invest physicians' time and knowledge. He will participate in or promote scientifically, sociologically and ethically sound epidemiological and preventive programmes.

And finally, he or she will always pay careful, but also critical, attention to measures that seek to limit medical expense . Physicians need to be keenly aware of the economic cost to the health of the population and will strive to pay attention to the cost/benefit ratio of their interventions. The Code imposes a reasonable obligation on physicians to make the best use of the means and instruments at their disposal and entrusted to them. It is not ethical to distinguish here between public and private medicine: in both, the available resources must be distributed and used to their best advantage. The physician's freedom and individual initiative is an essential element core value, but his or her responsibility, including financial responsibility, is no less important. Physicians must love and practise justice: they must care for the facilities and resources of others as if they were their own.

The physician, while fulfilling his obligations to the community, is not disassociated from his responsibility to his individual patients. To them he owes his primary loyalty. In any organisational status he remains bound by his deontological duties and by his professional conscience.

article 5.2. Since the health care system is society's main instrument for health care and health promotion, physicians must ensure that it meets the requirements of quality, adequacy and the maintenance of ethical principles. requirements . They are obliged to denounce its deficiencies, insofar as they may affect the proper care of patients.

Today, in almost all advanced societies, the State provides its citizens with a more or less comprehensive health service, using Health Insurance to provide medical care to citizens and thus satisfy the right of all to the protection of health (established, for example, in article 42 of our Constitution). The socialisation of medicine has been one of the great achievements of social justice and the crowning glory of contemporary medicine. It is also an irrefutable testimony to the social responsibility of physicians. This article tells us about the deontology of physician participation in health systems.

1. requirements ethical demands to be placed on the health system.

In 1963, the World Medical Association ( association ) promulgated its Twelve Principles for the Provision of Medical Care in any National Health System, in which it set out the ethical requirements for physicians to provide their partnership services to national health systems. The best comment that can be made on the first part of this article is to summarise the contents of that WMA document, updated in 1983. It states, among other things, the following:

Any national health system, while providing state-of-the-art medical services, must show the utmost respect for the freedom of the physician and the patient.

The conditions for the participation of doctors shall be defined jointly with the representatives of the medical organisations agreement .

-Any health care system should allow the patient to consult with the physician of his or her choice, and the physician to determine the patients he or she wishes to see.

-Any health care system should be open to all qualified physicians.

Physicians should be free to practise their profession wherever they choose and to practise the specialization program in which they are competent. The medical organisation should, however, pay attention to deficiencies in the distribution of physicians throughout the country and seek to remedy them by providing appropriate incentives to physicians who will work there.

-The profession must be adequately represented in official bodies concerned with health and disease issues.

-The confidentiality of the doctor-patient relationship must be recognised and respected by all those involved in the patient's treatment and administrative control. This should also be supported by the authorities rule.

-The moral, professional and financial independence of the physician must be guaranteed.

The authority in charge of the financial management must pay adequate compensation to the physician, which cannot be determined solely by its financial status or by a unilateral decision of the government.

purpose -Inspection of medical services for the purpose of checking their quality, issue or cost, should be carried out only by medical doctors, and should be assessed according to local or regional criteria, not national standards.

-In the best interests of the patient, the doctor's right to prescribe the treatment he or she considers appropriate according to the medical criteria of the moment cannot be restricted.

There should be no difficulty in allowing doctors to take part in activities purpose to broaden their knowledge and improve their professional status.

Contractual or statutory relationships between ministries of health or social services and physicians have, on the whole, evolved unsatisfactorily. The text of the Twelve Principles reveals the extent to which these relationships have deteriorated. The Code therefore imposes a duty on physicians to persevere in their efforts to bring the health care system up to the required standards of quality, adequacy and ethics requirements .

2. The ethical obligation to denounce the shortcomings of the health system.

In the field of health care attendance , doctors must play the role of social conscience. This obliges him/her to denounce technical and moral deficiencies in the health care system. Articles 22.1 and 22.2 of the Code are also devoted to the duty to report. Suffice it to say here that whistleblowing must be done truthfully and without exaggeration. The public and individual patients need to know if they suffer from major deficiencies in the services they receive, or if there are lapses in preventive policies that may endanger their health. Medical reporting should always be positive in nature. It should seek to remedy deficiencies, never to overturn the health care system. Any complaint should be accompanied by the proposal of a solution, not utopian or impossible, but practicable and realistic.

employment It is interesting to note the use of the plural "the doctors" in this article, which contrasts with the use of the singular used in practically the rest of the articles of the Code. This points to the collective nature that the complaint must sometimes have and which will find its appropriate vehicle in the coordinated actions of the doctors of a health centre, of a collegiate section, of a high school or of the WTO itself. Unfortunately, too much experience has shown sample that doctors' complaints are not always well received by the public authorities, who not only ignore or scorn them, but sometimes take reprisals against the complainants. When status reaches the level of the intolerable, the possibility of a medical strike arises, the ethics of which are dealt with in the following article.

article 6. In the event of a medical strike, physicians are not relieved of their ethical obligations towards patients for whom they must provide urgent and urgent care that cannot be postponed.

It may happen that the working conditions of doctors who work for others, in public or private institutions, work , become unbearable, either because they do not have the material means to carry out their work competently, or because the moral or remuneration conditions to which they are subject are incompatible with professional dignity. Often it seems that the only way to force a satisfactory solution is to resort to strike action. Although this is a right guaranteed by the Constitution, in medicine it has very peculiar nuances.

There is no unanimity among doctors as to whether there are ethical reasons that ever justify the organised suspension of professional services. Some physicians deny that an ethically acceptable strike can occur in medicine because it necessarily entails a deterioration, with consequences that are difficult to calculate and justify, in the care of the sick, and because it can create, when it becomes severe, greater harm than the harm it is intended to alleviate. A physician can never knowingly cause harm to patients entrusted to his care. Other physicians argue that only a strike that seeks to correct serious deficiencies in the physician's diagnostic and therapeutic work is lawful, since it is an action taken on behalf of patients, not against them. status Finally, there are those who believe that seeking to improve an objectively unsatisfactory employment or remuneration situation for doctors constitutes sufficient ethical grounds for strike action.

But all agree that, in medicine, a strike can never be a protest action that is applied in an absolute manner and carried to its ultimate consequences. It therefore tends to become more of a symbolic gesture. The deontological duty to ensure the care of serious and urgent patients and the unpostponable diagnostic and therapeutic attendance , which is imposed in this article, together with compliance with the minimum services imposed by the Government tend to dilute the social discomfort created by the doctors' strike in such a way that it becomes inoperative as a means of pressure against the public administration or against the health employers: it is, in the best of cases, reduced to a means of giving advertising to the deficiencies of the system.

An eloquent demonstration of the intrinsic weakness of the doctors' strike is the text of the deontological rules that the committee Superior of the Belgian Order of Doctors established as obligatory in the event of a medical strike: "...It is ethically admissible to organise a collective suspension of the activity of doctors as long as it ensures:

1. for patients already in care, the necessary treatment;

2) to all, the attendance that the doctor deems indispensable according to his conscience".

Every strike leads to negotiation between the parties in conflict. skill In medicine, there should be arbitration mechanisms to prevent development conflicts, endowed with such moral and technical authority that their decisions are imposed by force of reason. Both medical unions or strike promoters and employers (Ministry of Health, insurance companies, private hospitals) are morally obliged, albeit by different degree scroll, never to lose sight of the particular obligation they have not to harm patients.