Commentary on the Code of Medical Ethics and Deontology

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Chapter III: Physician-Patient Relationships

This is one of the richest Chapters of the Code. The understanding that medicine is a service has always been one of the most successful ways of giving ethical content to the physician's role. In the face of the suffering person, whose dignity is threatened by illness, the physician could adopt an attitude of superiority, since he or she has the science and the power. But deontological respect obliges us to see in each patient a human being whose moral value is immeasurable. This is why serving him is the attitude commensurate with the dignity that dwells in him.

The articles in this Chapter list a number of ethical features that should characterise physicians' relationships with their patients. Firstly, that of respecting the patient's freedom to choose a physician. Once the doctor-patient relationship has been established, the doctor is obliged to respect the patient's convictions, personal integrity and body; not to abandon him, giving the necessary continuity to his service; to inform him, so that he can assume his role as a mature and responsible person in the decisions that concern him; to tell him the truth with delicacy and circumspection. In addition, the physician is required to certify truthfully to protect the rights of his or her patients. Finally, physicians undertake to treat their patients in a personal and dignified manner at all times, and to keep and maintain appropriate medical records.

Article 7. The effectiveness of the medical attendance requires a full relationship of trust between doctor and patient. This presupposes respect for the patient's right to choose or change doctor or health care institution. Physicians must facilitate the exercise of this right on an individual basis and, as a body, shall endeavour to harmonise this right with the provisions and needs arising from health care planning.

This article opens with the assertion that trust is a condition of efficacy. It adds that such trust cannot come about without the freedom of choice of the physician for his patient, a freedom which is one of the rights of the patient. The article concludes by noting that, both individually and corporately, physicians should always advocate for the patient's right to free choice.

1. Trust, a condition for effectiveness.

It is a psychological necessity for the patient to place his trust in the doctor. No part of the doctor-patient relationship can be fully realised without this trust: the patient needs it in order to decide to go to the doctor, to tell him/her about the more or less intimate problems that affect him/her, to accept the advice and therapeutic measures, and to return to the doctor. Lack of trust is sufficient deontological grounds for fail such a relationship.

2. Freedom of choice, the patient's right.

Physicians must respect and enforce freedom of choice. It is natural that freedom of choice should be present, at least nominally, in the liberal practice of medicine. That it is present in the public practice of medicine is recognised by all truly progressive legislation. In fact, the need to guarantee this freedom of choice is an important reason for the coexistence of public and private medicine. The General Health Act 14/1986 recognises this principle in Article 10, 13, by including among the rights that everyone can invoke before the public health administrations the right to "choose a doctor and other qualified health professionals from agreement under the conditions set out in this Act, in the provisions issued for it development and in those regulating health work in Health Centres". Although, in practice, there is hardly any opportunity to exercise this right - even in primary care there are many geographical and functional limitations - it is nonetheless positive that it has received legal sanction.

Free choice is more an aspiration than a full reality, as it experiences in many circumstances unavoidable limitations. In sparsely populated rural areas or where, permanently or seasonally, communications are difficult, it is illusory to think of going to a doctor other than the local one. And people living in large cities cannot always be seen within a reasonable time by the doctor of their choice.

On the other hand, freedom of choice today often no longer has as its main object, as in the past, the doctor himself, but the institutions where medicine is practised. Among the socio-cultural transformations that contemporary medicine has undergone is the phenomenon of the progressive irrelevance of the doctor's personality and the growing importance that people attach to institutions. Many people do not now go to see Doctor Z, but go to Hospital Y or Clinic X, either because they have more confidence in technology and anonymous but efficient human teams, or because they have been won over by the advertising of the successes achieved in this or that care establishment. Or, on the contrary, they express their desire not to be taken to such an institution, because they think less of it. This preference or this condemnation affects, without distinction, all doctors working in these institutions.

In essence, freedom of choice is perhaps less about going to the doctor of one's choice than about rejecting a doctor in whom one has lost confidence. The patient should always be able to change doctors. And while it may be extremely painful for the physician to be rejected by a patient whom he or she has served with loyalty and self-sacrifice, the physician must, as Article 7 states, facilitate the patient's change. Ingratitude is one of the perquisites of official document. A physician should never be offended when a patient expresses a decision to leave him or her, nor should he or she put pressure on the patient to keep him or her. In this regard, it is worth bearing in mind what is said about the transfer of medical records in Article 15.5. These inconveniences are small in comparison to the limitations that would be imposed by a rigidly militarised medicine lacking these basic freedoms.

Article 8.1. In the exercise of his profession, the physician shall respect the convictions of the patient or those close to him and shall refrain from imposing his own convictions on them.

This article reflects the spirit and much of the letter of Article 3 of the Principles of European Medical Ethics, which states: "A physician, in the exercise of his profession, shall refrain from imposing his personal, philosophical, moral or political views on his patient.

1. Ethical respect for the convictions of others will manifest itself in different ways in different situations. Physicians should be attentive to the outward signs by which their patients show these convictions. Some may prefer to show indirectly, through non-verbal gestures, that they want their convictions to be taken into account, even if they prefer not to discuss them with doctors or nurses. At other times, physicians do not need to inquire about their patients' convictions because they legitimately presume them to be irrelevant, as is the case in most routine outpatient check-ups, vaccinations, care for acute illnesses of short duration and no risk, all of which affect the patient's existence epidermally.

On other occasions, on the contrary, respect requires an inquiry into the patient's religious or philosophical convictions, for it is only by knowing them that the physician will be able to respect them. Such a knowledge may not adversely affect the quality of medical care, since physicians are prohibited from discriminating between patients on the basis of such convictions (see Article 4.2). promote On the contrary, knowledge is intended to enrich the patient-physician relationship in a humane manner. Physicians should recognise that people wish to be true to their own beliefs and traditions and that they like to have them taken into account. Accordingly, physicians will refrain, as far as humanly possible, from applying or advising treatment that contradicts these convictions, thereby fulfilling their moral duty not to violate their patients' consciences and to respect the limitations imposed on them by their religious beliefs or cultural traditions. He shall offer the patient treatment alternatives which, although not ideal, are not repugnant to his professional conscience. If the patient's demands exceed the limits of what the physician in conscience considers rational, the patient-physician relationship should be terminated, as there is sufficient reason to do so (see Article 9). Neither can the physician do more to respect his or her patient, nor can the patient force the physician to violate his or her own convictions, scientific or conscientious. Physicians have the right to object scientifically or in conscience to irrational or anti-human demands of their patients.

Whatever the physician's views, he or she cannot ignore the important role that religion and cultural tradition play in the patient's adjustment to illness and acceptance of suffering and death. Out of humanity and tolerance, physicians must accede to all reasonable requests from patients for respect for their beliefs. Among other reasons, this respect is the patient's right. The patient also has the right to receive religious attendance , as recognised in almost all the Charters of Rights of hospitalised patients, which follow the World Medical Association's Declaration of Lisbon (1981), one clause of which states: "The patient has the right to receive or refuse spiritual and moral attendance , including financial aid from a minister of his own religion. Curiously, this right is not included in Article 10 of the current General Health Law 14/1986.

2. The physician's refraining from imposing his own convictions. The physician may not use his position to abuse his patients' convictions, either by mocking them or by trying to impose his own convictions on them by proselytising in a way that is disrespectful of the freedom of others. What is required here is, first and foremost, to exclude ideological manipulation, deception and mental abuse. As in the rest of society, there are some fanatical individuals among doctors. The physician will renounce any procedure, no matter how subtle, that would imply to the patient that the care he or she will receive will depend on his or her submission to certain ideological or behavioural guidelines imposed by the physician. It should not be forgotten that the opposite may also occur: that certain powerful and manipulative patients may try to ideologically dominate the physician.

This does not exclude that the doctor, after taking into account the patient's attitude and with a "religious" respect for his freedom, may not have, outside his professional relationship and even within it, if the patient accepts or wishes it, a conversation in which personal matters are discussed.

Article 8.2. The physician shall always act with propriety, respecting the privacy of his patient with sensitivity.

The obligation to treat delicately has a long tradition. It appears already in the clauses of the Hippocratic Oath ("I will always exercise my art with purity and sanctity" and "In whatever house I enter... I will abstain from all injustice or deceit, and from erotic actions on the bodies of men or women, free or slave").

1. The first manifestation of a doctor's correct treatment is to be sympathetic. The good doctor must have a very broad tolerance towards his patients, for some ailments upset the character of the patients, sometimes very deeply, and they become impertinent, rude, aggressive or distrustful. The unlimited capacity for disobedience shown by some patients towards the doctor's orders, or their flight towards marginal or folkloric forms of treatment, can exhaust the doctor's patience. The physician must then arm himself with a great deal of understanding and the ability to apologise. And when he can no longer give in, because the health of the patient or the dignity of medicine require it, he will try, firmly and without offence, to show his patients the minimum conditions he imposes on them in order to continue to treat them.

2. There is no need to repeat here what was said in the commentary on Article 4.1 on the contents of deontological respect. Physicians are obliged to treat their patients politely, complying with the norms and customs which, at any given time and in any given society, express mutual respect. The manifestations of medical propriety are manifold. Some, although Materials, are important: the dignity and cleanliness of the consulting room (see article 14), punctual compliance with schedule of visits or consultations (see article 4), the manner of dress and care for appearances. Others are more personal or vary in relation to local traditions, the age of the doctor and the patient, the existence of extra-professional relationships of friendship or kinship. Addressing each other as "usted" or "tutete", calling each other by their first name or by surname, are important details, as they show the notion that one has of the other. It is an important part of this duty of politeness to answer the patient's questions and to respond to his or her telephone calls or letters.

3. In a special way, the physician must respect the privacy of his patient. The doctor must not in vain invade the intimate, private world of his patient. He cannot abuse the trust that the patient places in him to enter his personal biography and turn the anamnesis into an opportunity to satisfy morbid curiosity. It is unethical to use enquiry to elicit from the patient information about his or her anxieties and weaknesses, family, business or financial conflicts, or sexual problems, when these are irrelevant to the medical orientation of the case. And it is seriously imprudent to record such information in writing.

The inviolability of the private personal and family world is not only one of the fundamental rights of the individual, guaranteed by Article 18.1 of the Constitution, but is also in line with the deontological precept of doing no harm. Only one reason authorises the doctor to access the patient's privacy: to know the patient in order to diagnose and treat him/her with professional skill and with human sensitivity (see Article 8.1). The ethical principle of parsimony, i.e. the rule of limiting oneself to doing everything and only what is necessary, is fully applicable here. The idea is very well expressed in Article 9 of the French Code of Ethics: "To the extent compatible with the efficacy of his care, and without neglecting his duty of moral attendance , the physician must limit his prescriptions and his actions to what is necessary". There are uninhibited, exhibitionist patients who want to take advantage of meeting with the doctor to tell medically irrelevant stories and gossip: they must be silenced.

4. There is also a deontological obligation to respect the body of the sick person which appears in all modern codes of ethics. In recent times, the philosophy and theology of human corporeality have been extraordinarily enriched, with the consequence that the human body has been revalued as a substratum and symbol of the person.

Respect for the person and his or her body takes on a very particular significance in the doctor-patient relationship and imposes specific precautions. For the duration of the physical examination or any other diagnostic or therapeutic intervention, the patient relinquishes his personal control over his body and agrees to turn it into an object on which the doctor applies his professional gestures. In the act of undressing, the patient manifests his transitory Withdrawal to human dignity and accepts that the doctor turns him into an objective reality that is scientifically evaluated. It is obvious that this treatment excludes any erotic intention: the doctor's visual inspection is never an exercise in voyeurism, nor does palpation have anything to do with caressing. The patient does not offer his body for the doctor's erotic gratification, nor can the doctor take advantage of the situation to sexually abuse his patient. And the reason for this lies not only in the general moral prohibition to abstain from illicit sexual relations: in the context of the doctor-patient relationship, any erotic abuse by the doctor of his patient's body is not only an indecent indecency, but also a grave injustice. rule As a precautionary measure, a third person (a nurse, another doctor, a relative of the patient) should always be present during the physical examination of the patient, in order to comply with the elementary prudence of avoiding unpleasant situations: the doctor is obliged to protect himself against his own weaknesses and against the fantasies or malevolence of some patients. This precaution is all the more necessary in certain situations such as genital exploration, psychiatric enquiry when the intensity of the therapeutic relationship may trigger sexual desires or needs, or when signs of sexual innuendo on the part of the patient have been observed. Indeed, the patient may take advantage of the particular circumstances of the enquiry or the doctor's visit to induce a sexual relationship. The deontological rule to abstain from sexual relations with patients is absolute. Such corruption is strongly condemned both for ethical reasons and for strictly professional reasons, such as the deterioration in the quality of care that occurs in such a situation that falsifies the aims of medicine.

The obligation to respect the body is all the greater the more helpless the patient is. If the patient is unable to take care of himself, as for example when he is under general anaesthesia, lying unconscious in an intensive care unit or unable to move in bed, the obligation to respect him is extended and intensified. Respect is not only obliged to protect his modesty, but also his bodily integrity. Bedsores or pain resulting from the incorrect positioning of body parts during anaesthesia are a clear indication of a lack of respect for the body.

5. There is also a duty not to intrude into the intimate sphere of the patient's family or social affairs. The great trust placed by a patient or an entire family in their physician may lead them to make him or her their advisor in matters that often have nothing to do with the specific professional skill that the study and practice of medicine gives. The doctor may then find himself playing two different roles: that of doctor on the one hand, and that of family friend and counsellor on the other. There is no objection to this, if the physician takes care to maintain a strict separation between these two roles, so that one and the other can always distinguish when he is acting as a physician and when he is acting as a friend.

The prohibition of meddling in family and professional matters includes two types of actions. On the one hand, the physician must refrain from using the trust he or she enjoys to take sides in family disputes, interposing his or her influence to the advantage of some and to the detriment of others, especially if he or she uses medical reasons, or unreasonable reasons, to do so. On the other hand, he should refrain from inquiring, out of gratuitous or unhealthy curiosity, to obtain information that he could use to his own advantage in the family or professional affairs of his patient.

Article 9. When a physician agrees to treat a patient, he undertakes to ensure the continuity of his services, which may be provided by fail if he is convinced that the necessary confidence in him no longer exists. He/she shall then inform the patient or his/her family of this fact and shall arrange for another physician, to whom he/she shall give appropriate information, to take over the patient's care position .

Continuity is a natural element of the ordinary physician-patient relationship and one of its most genuine manifestations. The physician responds to the patient's free choice or to a legal or regulatory requirement to treat him/her with a commitment to provide appropriate care for the necessary length of time. The patient, as a rule, does not wish to change doctors, nor does he/she wish to be changed.

The doctor-patient relationship must be a lasting one, despite the vicissitudes of the disease. The article states that the obligation of continuing care is established at the very beginning of the therapeutic relationship. Such a commitment is made at the moment of receiving the patient in the practice or going to the patient's home. The physician may refuse to see a patient because of lack of time and must then advise the patient to see another colleague. The same is true if, on his first visit to a patient at meeting , he feels that he is not able to provide the necessary care skill. But physicians cannot unilaterally abandon their patients while they are in need of their care. And when illness or other force majeure circumstances prevent him from doing so, he is obliged to find a colleague to take his place. financial aid Specifically, the Principles of European Medical Ethics state in Article 34 that "a physician who agrees to treat a patient undertakes to ensure continuity of care attendance and, if necessary, to request the assistance of physicians who are assistants, substitutes or associates from skill as appropriate".

Continuity of care is thus a serious obligation that a physician cannot fail on his or her own initiative unless he or she has sound reasons. This article refers to one of them: the loss of the minimal trust that should exist in any doctor-patient relationship, which occurs when the patient does not cooperate in treatment, or when he or she goes to another colleague for treatment of the same problem, or when there is an irreducible disagreement about the measures to be taken.

It is more difficult to fail the doctor-patient relationship than to initiate it. But it can never be a violent or irreversible rupture, or have the appearance of a withdrawal. When a break is unavoidable, the physician, in order to guard against legal action, will send a letter to the patient well in advance, stating that he or she will continue to provide services for a specified period of time, while the patient is able to find another colleague to care for him or her. He will offer to resume the relationship if the reasons for the break disappear. It does not seem necessary to state the reasons for fail in this letter, but if he does so, the reasons should be neither so general as to seem gratuitous, nor so specific as to be offensive that they could be used to initiate a lawsuit. The physician is obliged to provide the colleague chosen by the patient with the appropriate information (medical history, analytical data, treatments applied) to enable the colleague to continue the patient's care.

If the patient, duly informed, does not agree to undergo an examination or treatment that the physician considers necessary, or if the patient demands from the physician a procedure that the physician, for scientific or ethical reasons, deems inappropriate or unacceptable, the physician is released from his obligation to attendance.

This Article elaborates on some aspects implicit in the preceding Article. In particular, it sets out the conduct to be followed by the physician when there is an irreducible disagreement between the physician and the patient. Such a disagreement may arise from the patient's refusal, whether for economic, religious or simple opinion reasons, of the diagnostic plan or treatment proposed by the physician; or because the physician rejects the patient's demand as unacceptable (e.g., a complacency certificate , an unjustified work leave , or an abortion).

There are several social factors favouring this disagreement, the frequency of which is likely to increase in the future: society's growing ethical pluralism; the consumerist mentality spread among a greater number of patients, which tends to create the notion of "à la carte" medicine; the growing role of patients in clinical decision-making, which will increase as the health culture disseminated through the media grows; and, finally, the mistrust created by the denunciation of certain abuses, real or imagined, of doctors who have proceeded to carry out analyses or treatments without the patient's knowledge .

The physician should inform the patient of the reasons why he or she cannot afford to accede to the patient's wishes. If, after reasonable discussion, it is not possible to reach an agreement agreement, they should proceed to fail the relationship in a correct and polite manner. In contrast to the previous article, and by virtue of the special nature of the severance of the doctor-patient relationship contemplated here, the doctor remains free to decide in conscience whether or not to lend financial aid to the patient in the search for a colleague who is willing to accede to his or her wishes. Obviously, he is not obliged to do so. Nor can he do so morally, if for him such a financial aid is tantamount to cooperation with evil. There is, however, a widespread view that, in the event of a disagreement on moral grounds (e.g. abortion), the physician is obliged to tell the patient which other colleague can perform the procedure. In the Declaration of Oslo, the A.W.M. states: "If the physician considers that his convictions do not permit him to advise or perform an abortion, he may withdraw from the case provided that he ensures that a competent colleague continues to provide attendance medical care. This rule was established some time ago, for what was then called therapeutic abortion, because there was an idea, now superseded, that, in certain very serious and exceptional circumstances, it was necessary to perform an abortion to save the life of the mother. This rule is abusive and disrespectful to the conscience of the doctor, because he cannot live a double standard and judge that what he morally forbids himself because he considers it a serious breach of ethics, can be lawfully practised by other colleagues with more relaxed morals.

See also, on the deontology of withholding of care, Articles 27.1 (disagreement in matters of reproduction and abortion) and 6 (medical strike).

Article 11.1. Patients have the right to receive information about the diagnosis, prognosis and therapeutic possibilities of their illness, and the physician shall endeavour to provide it in the most appropriate words.

This imposes a duty on the physician to inform his patient of the most significant aspects of his illness, as a logical response to the patient's right to know about the nature of the symptoms, the diagnostic measures to be taken, the expected favourable and undesirable results of treatment, and the prognosis. The aim is not only to inform the patient, to alleviate anxiety, but to do so in such a way that the patient is involved in the decision-making process.

This article enshrines one of the most substantial advances in contemporary medical ethics: the patient's access to the status of a moral, free and responsible person, capable of consciously assuming his illness and its treatment, accepting it, refusing it or choosing, when possible, among the different options offered to him. It is the physician's duty to help the patient to weigh risks and benefits and to decide in a mature, conscious and responsible manner.

The moral maturity of the patient is source of many of his rights. Sections 5 and 6 of article 10 of the General Health Act include among the rights of all, in public as well as private medicine, the right "to be given, in comprehensible terms, complete information, verbally and in writing, about his or her condition, including diagnosis, prognosis and treatment alternatives" and the right to "free choice among the options presented to him or her by the doctor responsible for his or her case". The patient may waive this right, and the doctor must respect, as long as it is reasonable, the patient's wish to ignore it, which is often test of trust in the doctor's skill and honesty. However, either directly or through someone close to the patient, the physician will let the patient know what he or she cannot ethically ignore.

Information must be given in the most appropriate words: it must be simple and understandable, i.e. adapted to each patient, paying attention to what is important to the doctor and also, and not least, to what is of concern to the patient. It must be delicate so as not to harm the patient, either by its form or its content. It is incompetent for a physician to mislead the patient or make him more anxious. It is advisable not to use technicalities, which in the past could have served as a paternalistic resource or a means of suggestion. The exercise of the duty to inform should not assume a defensive, legalistic bias. On the contrary, it should take place in an atmosphere rich in humanity. This is also the subject of Article 11.4.

Where the proposed measures involve a significant risk to the patient, the physician shall provide sufficient and considered information in order to obtain the necessary consent for the measures to be carried out.

In most cases, the patient's oral consent to the plan proposed by the doctor is sufficient. If the therapeutic plan does not involve appreciable risks, it is not even necessary to mention consent: consent is assumed to have been tacitly granted by the patient simply by the fact that he or she went to the doctor.

However, if the measures proposed by the physician, whether diagnostic examinations or therapeutic interventions, involve significant risks, the physician is obliged to inform the patient about these risks, how they can be prevented or treated, and whether alternative measures are possible. Once the patient accepts the proposed plan, the physician shall obtain the patient's written consent. The document, signed by the patient, should not be too general. In many hospital institutions, the patient's signature is often provided with a consent form on which the patient gives permission for any diagnostic or therapeutic interventions that the physicians deem necessary to treat the patient's condition, including consent for an autopsy or for inclusion in an experimental protocol . Such a document is a kind of blank cheque that falsifies the true ethical nature of informed consent. Nor should such a document be too detailed. It should not include a detailed account of all possible complications, including the most rare and tragic ones. Some physicians provide their patients with comprehensive information leaflets about their illness and treatment to be read to them prior to the signature consent form. This approach is more for the physician's security against malpractice litigation than for the honest but compassionate and prudent information required by this article.

It is also necessary to record in writing the patient's refusal of the proposed treatment, especially when this refusal has not yet broken the doctor-patient relationship.

If the patient is unable to consent to medical treatment because he or she is a minor, incapacitated, or because of the urgency of the situation, and it is impossible to obtain the consent of his or her family or legal representative, the physician may and shall provide the care dictated by his or her professional conscience.

This article points out the exceptions to the patient's informed consent: the incapacity to consent, for which a vicarious authorisation must be sought, and the situation of urgency that obliges the physician to act without this ordinary requirement.

First of all, it specifies the circumstances in which, because the patient is not in a position to give consent, consent must be sought from the patient's closest relatives or legal representative: temporary loss of consciousness (traumatised and comatose patients, for example), loss of capacity to judge (but not affective or neurotic disorders), mental deficiency, infantile age. The ethical rule for obtaining consent overlaps with legal norms and follows the criteria of proximity and responsibility that govern substituted consent. There are, however, some peculiarities of ethical consent in medicine. Thus, for example, in paediatric medical practice, the custom is increasingly asserted of informing the child of the inconveniences, discomforts and results of the treatment he or she is to receive in order to obtain the child's cooperation. Such information to the child does not relieve the physician of the obligation to obtain the consent of the parents or apply for, or tutor, to treat the minor. Article 12 of the Spanish Constitution states that Spaniards come of age at the age of eighteen. In the UK, a shocking exception to the rigid obligation to obtain parental consent to treat children under the age of 16 (the age of minority limit) has been introduced: the administration of contraceptives or the performance of abortions on girls under the age of 16, when they object to report to their parents.

Secondly, it is pointed out that genuine urgency dispenses with the obligation to obtain consent. The duty to provide the means to save life or to avoid serious and irreversible harm is imposed on the physician above all other considerations. It is reasonable to assume that all those in a situation of extreme urgency wish to continue to live, so it can be presumed beyond reasonable doubt that they would consent to treatment. This applies to everyone without exception, including those who have attempted suicide. Experience shows that, in the vast majority of cases, the suicide attempter is grateful for the medical care that has rescued him or her from death. The obligation to treat in an emergency situation is not only ethical: it is a legal obligation, as noted in the discussion of Article 4.5.

In analogy with the emergency situation, the article states that the doctor will proceed to treat without consent when, after having sought it diligently and without result from a close relative or legal representative, the medical situation requires it. This may occur in various circumstances: because it has not been possible to talk to the person who should give consent, because there is an irreducible disagreement between those who have to decide, or because the doctor, having obtained consent for a certain intervention, is forced to substitute it with another, for which he did not have order authorisation. The article emphasises the obligation of the physician in such circumstances to follow the dictates of his conscience, which will determine the intensity and direction of his service to the patient.

Article 11.4. The physician shall, in principle, inform the patient of the diagnosis of his illness and shall inform him, with sensitivity, circumspection and a sense of responsibility, of the most probable prognosis. He shall also do so to the patient's next of kin or other person designated by the patient for this purpose.

This article deals with an important obligation of the physician: that of telling the patient the truth. This duty has already been mentioned in Articles 11.1 and 11.2, as an essential element in obtaining informed consent. But it is reiterated here in the context of the diagnosis and prognosis of serious or grave illnesses.

One way to respect the patient as a person is to tell him the truth. This is part of the ordinary doctor-patient relationship. Such matters as the diagnosis and cause of the disease, if known, and the prognosis, with regard to the restoration of health or the permanent limitations caused by the disease on the ability to work and relate to others, cannot be excluded from the information that is due. The physician should answer the patient's questions, as it is wrong to mislead the patient or to keep the patient in uncertainty as to how his or her condition may develop. It is an ethical obligation to answer reasonable questions from the patient or those close to the patient.

Such ordinary information should be given with sensitivity, circumspection and a sense of responsibility. Gentleness refers to the obligation to tell the truth without hurting: it has nothing to do, therefore, with benign deceit, a manifestation of bad paternalism, which assumes that the patient is incapable of assuming responsibility for his or her own personal destiny. Lying, even if it is pious, apart from being an ethical disgrace for the one who tells it, contributes to morally diminish the patient.

The article also discusses who the recipients of this information may be. In principle, it is the patient. As in the case of informed consent, other persons, the patient's next of kin or next of kin, or the recipient designated by the patient for this purpose, may act in the patient's stead. The patient may also prohibit the physician from disclosing this information to certain persons. The physician must follow the patient's wishes.

Article 11.5. It may be in the patient's interest not to communicate a very serious prognosis immediately, but this should be considered exceptional in order to safeguard the patient's right to decide on his or her future.

Telling the truth requires taking into account the circumstances of each case. It has been said that medical truth is an extremely potent drug that must be dosed over time. This is what this article alludes to when it states that, in certain cases, the physician must wait until the time is right to communicate a serious or fatal prognosis.

The doctor who fails to attend to the circumstances could bring about the moral collapse of the patient or his family with a truth administered in one fell swoop. He must determine what news to give and when. He must add to the simple and accurate truth a message of hope, for nothing is more fallible than blunt, fixed-term medical prognoses. The doctor cannot forget that patients have an incredible capacity to adapt to the limitations imposed by illness. And that the confidence to face the hard trials that the future holds rests in large part on the assurance that the doctor will remain at their side, will not abandon them in difficult times.

Basically, Article 11.5 states that there is no contradiction between sincerity and true compassion. Patients discover, more or less early on, the direction and course of their illness: they see it in the course of their symptoms and in the effects of treatment, and also in the face and gestures of the physician and family members. The physician will always prefer to tell the truth, out of respect for the patient as a person. The Code considers such a delay in reporting to be exceptional. To deprive the patient of the knowledge that his or her prognosis is unfavourable in the short term is an abuse, a professional failure, because it deprives the patient of his or her right to decide on the all-important end of life. The doctor, with his experience, will know how to choose the moments and the words to administer the doses of truth that the patient can assimilate at each moment.

Article 12. It is the right of the patient to obtain a certificate or report, issued by the doctor, concerning his state of health or illness, or concerning the attendance he has given him. The content of the opinion shall be authentic and truthful and shall be given only to the patient or to another authorised person.

The function of certify presupposes the physician's compliance with knowledge of this article and the relevant administrative regulations contained in Title VI of the EGOMC. It is established therein that the WTO is the only body entitled to issue and distribute the forms on which the certificates are to be issued, to fix their types and amounts, to inspect the use made of them and to establish the destination of the sums collected from the sale of the forms.

It should be noted that, although the official medical certificate and the medical report are of a different nature and have different legal and administrative effects, the ethical obligations of the physician are the same in both cases.

1. Article 12 imposes an obligation on the doctor to certify. The legal system stipulates that in order to acquire or consolidate certain rights, to obtain certain financial compensation or to justify absence from work, patients must present a medical certificate to third parties, attesting to certain points. From this legal or regulatory obligation that the interested parties have to present a medical certificate, it follows that the doctor has a legal and deontological obligation to issue the corresponding certificates, otherwise the doctor would cause them harm. The General Health Act includes among the rights of all users before the different public health administrations, that of "being issued with certificate accrediting their state of health, when this is required by a legal or regulatory provision" (Article 10, 8). The same right applies to patients who are treated in private medicine. However, the doctor can and should refuse to issue a certificate when he/she does not have knowledge direct knowledge of the matter on which testimony is requested, or when a biased certification is requested, because it conceals some substantive aspect of reality or because it attempts to defraud the public faith.

2. Secondly, Article 12 indicates the subjects covered by the certificate: the state of health or illness of the person concerned or the attendance medical care provided. It does not seem prudent, however, to issue certificates stating that someone is in good health: the doctor will simply state that he has not observed any pathological signs in each of the systems he has examined. With regard to the certification of illness, the doctor shall indicate the nature of the illness, the objective data on which the diagnosis is based and the significant circumstances - evolution, treatment, economic or otherwise subject- that are necessary for the addressee of the certificate to have the necessary elements of judgement. The doctor shall also certify the care provided to the patient, listing with rigorous precision the number of visits, the nature of the examinations or interventions carried out, the journeys made, so that the amount of compensation to be received can be assessed.

3. Thirdly, Article 12 states that the most important thing about certificate is that it is authentic and truthful. Authentic means here that it is authorised, that it is authentic. The physician should pay attention to certain formal details of the certificate (his or her name and registration number, the actual place and date on which the document is drawn up, the addressee and the effects of the document, signature authentic, clear and legible handwriting). The text, concise and unambiguous, must express what is strictly necessary and no more. A certificate that merely states the final diagnoses, which may be questioned by other experts, is inadequate. A good certificate describes the clinical or autopsy findings, the behavioural alterations, the actual results of the examinations carried out, with sufficient precision and detail, so that they can be interpreted by other experts.

certify means to make true, to confer the qualification of truth on what is affirmed. In making the certificate, the doctor acts as a notary, who attests publicly to what he or she states. As an expert, he enjoys the trust of society. It is unethical and shameful to abuse it and to put lies in the place of truth. It is also an injustice, because lying causes undue advantage to some and often gratuitous harm to others. In certain circumstances, the falsification of certificate is also a crime, according to article 311 of the Penal Code: "The doctor who issues a false certificate of illness or injury with the aim of exempting a person from any public service shall be punished with the penalties of major arrest and a fine of 30,000 to 60,000 pesetas".

It is not enough for the doctor to want to tell the truth. It is necessary for him to investigate it conscientiously, to verify each of the facts he certifies. He cannot make assumptions, however well-intentioned and sincere they may be, but they are not the objective truth; still less can he conceal a significant part of reality. He must clearly and unambiguously distinguish between what he observes in the subject in front of him and what the subject can tell him or relate. If it is not clearly differentiated on a certificate which things have been objectively verified by the doctor and which other things correspond to what the applicant of certificate subjectively experiences or declares, the inevitable result is confusion for those who have to interpret the content of the certificate. Ideally, the certificates should contain nothing more than data verified by the physician. The London Code states succinctly: "The physician shall certify only what he has personally ascertained".

4. The obligation to certify truthfully is confirmed by the penalisation of false certificate established by the EGOMC, which classifies as serious misconduct "the issuing of reports or certificates that are untruthful" (article 64, 3. e). It is therefore prohibited to issue complacency or false certificates. The certificate of complacency is a reflection of the moral climate that affects a large part of society. Many people in good faith, but ill-informed, believe they are entitled to economic or social advantages to which they are not entitled (absenteeism from work or school, financial compensation for injury or illness, facilitation of divorce, release from obligations) if they put pressure on the doctor to distort the reality to be certify: they project their own moral laxity onto the doctor and feel offended if the doctor does not bow to their demands. The doctor can never deliberately subscribe to a false certificate . He has an obligation to assist his patient in obtaining all the benefits and exemptions to which he is justly entitled, but he will not give in to their abusive demands. It is unethical to collude with a patient to defraud a third party.

Before sending his signature to certificate or report, the doctor should reread it carefully: in a document of such seriousness it is not admissible to include fictitious analytical data, lies in the designation and number of medical acts performed, slips in the amount of fees charged, and the like. Judges are entitled to interpret such distortions of the truth not as unintentional errors, but as result of moral impropriety. Every time a doctor certifies falsely, he or she also damages the moral prestige of all members of the profession.

5. At certify, the physician shall protect the confidentiality and safety of his or her patient. Only the patient, or anyone authorised by the patient, is graduate to apply for and receive the certificate. A physician may not accede to a request from anyone to certify the physical or mental state of health of one of his patients. When drawing up the certificate or report, he must bear in mind the purpose for which the document he is signing is to be used, which will be expressly indicated by means of the usual formula "And for the record for this or that purpose". In addition, the physician should warn the applicant of the possible adverse consequences of any of the information contained in the certificate.

submit A logical consequence of the duty of confidentiality is that certificate should only be sent to the person who has legitimately requested it. If it is to be sent by post or courier, the doctor must ensure that submission the corresponding sheet is sent to the person concerned in his own hand. Trusting in the inviolability of postal communications, he may use the mail certificate with acknowledgement. If the person who requested certificate is unable to collect it, the physician may, prudently considering the circumstances, deliver it to a relative or friend whom he or she considers sufficiently qualified.

Article 13. teamwork shall not prevent the patient from knowing which doctor is responsible for his or her care.

Modern medical care, both outpatient and inpatient, requires the participation of several physicians who are dispersed or form a team. One of them must assume the role of responsible physician to the patient. This is both to coordinate care and to resolve conflicts that may arise within the care team, and to ensure that the inpatient enjoys the personal nature of medical care. In his relations with patients, the physician must avoid anonymity. For him, every patient has a name of his own. The teamwork cannot dilute the personal responsibility of any physician, but neither can it replace the figure of the responsible physician who is responsible for directing and coordinating the care of the patient.

Those who run hospital services must ensure that this deontological duty, which is also a legal obligation, is fulfilled. agreement Indeed, all users of the Public Health Services, according to article 10, 7, of the General Health Law 14/1986, have the right "to be assigned a doctor, whose name will be made known to them, who will be their main interlocutor with the healthcare team. In case of absence, another doctor from the team will assume this responsibility".

Article 14. The consulting room shall be in accordance with the respect due to the patient and shall have the means adequate for the purposes to be fulfilled.

This article sets out the basic features of the place where patients go for medical care: decorum, technical equipment and location.

1. The practice of medicine requires a decent and dignified facility. The place where the doctor interviews and examines his patients, as well as the waiting room conference room and the attached hygienic facilities, must be clean and comfortable. Unfortunately, details are often neglected which, in the eyes of the patients, are of great importance: waiting rooms in consulting rooms or outpatient clinics with insufficient and uncomfortable seating, poor quality and poorly maintained entertainment publications, toilets that are not commensurate with a minimum of human dignity.

It is reprehensible the behaviour of doctors who summon patients, very often on an empty stomach, only to condemn them to an interminable wait: they seem to have forgotten that an important part of the dignity of the practice is the punctuality with which the patients summoned are seen. If ever it is not possible to see them on time, apologies are due.

2. Depending on the type of specialization program practised, clinics or outpatient clinics vary considerably. However, they must all be equipped with the necessary instruments and medicines to provide two orders of service: to provide an ordinary, high-quality and up-to-date attendance and to deal with incidents and accidents occurring in the course of the diagnostic or therapeutic interventions carried out there (see comments on Articles 21.1 and 22.1).

A physician may be guilty of professional misconduct or culpable negligence if he or she does not have the necessary equipment at hand in the office to intervene in emergencies. A physician may not recklessly place his patients in situations of serious risk because his office is poorly equipped or because he lacks competent staff at financial aid . Except in cases of exceptional urgency, the physician may not perform outpatient interventions if he does not have sufficient technical means to carry them out and to maintain appropriate supervision afterwards.

3. From a deontological point of view, the location of the practice is not irrelevant. Whether it is located in a private home, in an outpatient clinic or in a hospital, the practice is, as a matter of principle, a permanent facility with a fixed address and a well-defined schedule . Itinerant practices should therefore be discouraged. It is no longer acceptable today to receive patients in places such as hotel rooms, pharmacies, rooms rented for a few days, etc.

The physician's office should not be in close proximity to or coincide with the place where certain activities are carried out. It is an ethical tradition to prohibit the location of a physician's office in the immediate vicinity of commercial premises dealing in products that are prescribed or advised by the physician. Such commercial premises include pharmacies, optical and hearing aid shops, orthopaedic shops Materials , dietary food shops, but also beauty and physiotherapy institutes, or any other establishment engaged in the production or sale of substances to which preventive or curative effects are attributed (cf. Article 44.4).

Doctors may not take advantage of the opportunity to move their practice to make themselves advertising: they shall simply inform their colleagues and patients by means of a circular letter, indicating the new address and schedule for consultations. They may also, with the authorisation of the Ethics Committee of the Order, place an advertisement to this effect in the local press advertisement .

Article 15.1. The medical act shall be recorded in a medical record. The doctor has the duty, as well as the right, to draw it up.

This first article on the medical record establishes, on the one hand, the need for the physician to record his medical acts in the corresponding clinical document. On the other hand, it states that keeping a medical record is not only a duty but also a right of the physician. The physician is free to decide on the format (history or record) and content of this important document.

The seriousness of their encounters with patients would be reason enough to oblige doctors to open and keep their medical records up to date. No circumstance exempts them from this duty, all the more so since the Code authorises doctors to give their clinical protocols the simple structure of a medical record. The medical record is one of the most reliable indicators of a doctor's professionalism and of skill , since it enables him to review, at a glance, the nature and course of his patient's illnesses and, for any other doctor, to make position and clinical judgement of a case even before examining him personally. This is very important now that many patients are seen by different doctors in hospital or outpatient clinics.

The medical record also has a legal value: converted into material test by order of the judge, it can be the best protection for the doctor against malpractice claims or litigation or, on the contrary, the most efficient piece of evidence that can be used against the doctor, as it is the most important witness goal of the quality, or lack of quality, of the doctor's work. The judge may order the seizure of a medical record or of a file when so required by the judicial procedure . It should be noted in this regard that tampering with or falsifying medical records, as documents of potential probative value, constitutes professional misconduct. A recent decision of the Ethics Commission of the British Medical Association states: "A physician who knowingly makes an entry in a patient's medical record that is false or misleading, or modifies a previous entry by adding to it, or substituting false information for it, or deletes true information with intent to deceive, is guilty of deliberate falsification of the medical record. This is an unethical action and a physician who so acts shall, if the matter is reported to the Commission, be subject to a disciplinary transcript .".

It is therefore the physician's right to keep an up-to-date medical record, i.e. he/she has the right to obtain it personally and to have the time and means necessary to compile it. The medical record is a tangible sample of the professional skill of its author. It is also a reliable indicator of the respect he/she has for his/her patients, a respect that is materially manifested in the format of the clinical protocol , in its legibility and in the care with which it is preserved. Many medical records, both in hospitals and surgeries, are incomplete, untidy, difficult to read or illegible. They are, from a medico-legal point of view, potentially disastrous.

To be useful, the history needs to be: (a) complete, with sufficient and synthetic data on the current illness and remote anamnesis, with the findings of the physical examination and of laboratory, and with the reasons justifying the diagnosis and treatment; b) orderly, i.e., that the notes appear in successive order and duly dated, without irrelevant data or papers; c) intelligible, i.e., written in legible handwriting, in concise and understandable sentences; and d) respectful, without statements that are hurtful to the patient himself, to other colleagues, or to the institution or its directors.

Article 15.2. The doctor is obliged to keep the clinical protocols and the elements Materials of the diagnosis. In the event of not continuing with their conservation due to the passage of time, he/she may, subject to the patient's prior consent knowledge , destroy the aforementioned material, without prejudice to the provisions of special legislation.

1. The first part of this article deals with the obligation to keep medical records. The doctor's file tends to take up more and more space, which creates problems not only in terms of space but also in terms of handling. A conflict then arises between the interest in preservation for health care, scientific, medical-historical or legal reasons, and the need to dispose of material that is of little interest or that has become obsolete or useless. There is an obligation to preserve. The physician must, either personally or through the institution in which he or she works, take care of the physical security of his or her file, protecting it against the risks of theft, fire, deterioration or violation of confidentiality.

One point that the article does not determine is the length of time for which clinical protocols must be retained. A minimum of five years is usually specified, but it is left to the prudence of the physician to determine this period. Today, in large hospitals and outpatient clinics, but also on the doctor's enquiry , data storage procedures are increasingly being used which enable a large amount of written and even graphic information to be stored in a small volume and to be accessed quickly, such as file on optical (microfilm) or computer media (floppy disks or magnetic tapes). The rules laid down by the World Medical Association in its Postulates on the Use of Computers in Medicine are applicable here, in which it imposes the duty to take scrupulous care of the secrecy and security of the information stored, and to oppose legislation which could jeopardise medical confidentiality; the Postulates state that confidentiality is not breached in the course of scientific research, administrative audits or similar studies, provided that the information used does not directly or indirectly identify patients, and finally that medical databases may not be linked to other databases.

2. In its second part, the article deals with the fate of the records and their elements Materials when, due to the death of the patient or when the information becomes obsolete, it is no longer of interest. The problem can be acute when there is a lack of space to keep complete clinical records. A similar situation may arise when a physician ceases to work for any reason (incapacity or death, voluntary retirement or prolonged disciplinary suspension): this eventuality is dealt with in Article 20.

Article 15.3. Medical records shall be drawn up and kept for the purpose of facilitating the patient's attendance . Any other purpose is prohibited, unless the rules of medical confidentiality are complied with and the authorisation of the doctor and the patient is obtained.

The prevailing purpose of the medical record is to provide care: it is a compendium of the patient's clinical biography and the doctor's interventions. The doctor cannot retain all the data he needs to assess each situation on his report and would lose precious time if he had to question the patient in order to reconstruct precisely any aspect of his illness.

Any use of the records other than the strict attendance to the patient (e.g.management assistant, for labour control, for auditing practices) must meet two conditions: confidentiality must not be breached and the free and informed consent of the physician and the patient must be obtained. In the following Chapter, on the professional confidentiality of the doctor, reference is made to the need to maintain complete independence and separation between clinical information and administrative and control data (Article 17.2) and to the rule that, as medical records belong to the field of health care, they must be under the control of a doctor (Article 19.2).

The patient's right, already established by law in some countries, to retain possession of the medical record or to obtain a copy of it upon request is becoming more widespread. This can lead to some complications for the physician arising from comments made in the record that might be considered offensive by the patient. Some physicians have chosen, in such circumstances, to keep two medical records: one containing the objective data and the elements of the diagnosis, Materials , which can be easily communicated to the patient; another containing the physician's considerations and comments, which are his intellectual property, and which need not be given to the patient.

Article 15.4. The scientific and statistical analysis of the data contained in the records and the presentation of individual cases may provide valuable information, and their publication is therefore permissible from a deontological point of view, provided that the patients' right to privacy is respected.

Much biomedical research, though not the most efficient, is based on retrospective (epidemiological, clinical or medical-historical) analysis of a large number of records or on the presentation of cases of great medical interest. This article deals specifically with the deontological conditions for using medical records for research or publication purposes.

Recognising the ethical dignity of biomedical research, the article establishes the specific rule obligation to respect the privacy of patients, with physicians taking care to ensure that patients are not personally identifiable in their publication. When analysing clinical records, researchers should limit their research to the specific aspects of their work. It is also highly desirable to "anonymise" the records by removing patient identifiers and replacing them with numerical or other codes subject. When publishing such research, any data that could contribute to patient identification should be removed: they should not include in their case descriptions the name, initials or the number of the corresponding medical records; they should disclose only scientifically relevant data; photographs of patients should not allow their identification or, otherwise, should only be published if the patient has freely given his or her consent. These rules are among those laid down by the International Committee of Medical Journal Editors in their requirements guidelines for manuscripts submitted for publication.

Article 15.5. The doctor is obliged, at the request and for the benefit of the patient, to provide another colleague with the data necessary for fill in the diagnosis, as well as to facilitate the examination of the tests carried out.

The physician's responsibility for his or her file is full. It is up to the physician to decide whether to allow the patient access to the records (although modern legislation recognises the patient's right to examine his or her records and to force the physician to remove data that the patient considers inappropriate). It is up to the physician to determine what data and what elements of the diagnosis Materials he or she passes on to the colleague who is now treating the patient.

Sometimes the patient asks the doctor for the records, which he or she keeps at file , because he or she needs them to obtain certain benefits or financial compensation. At other times, inspectors, judges or other physicians may request them for specific purposes, such as for the control of benefits, administration of justice, attendance to the patient. The physician will consider each individual case and act according to the circumstances. He or she may never obstruct legal action or cause hardship or harm to his or her patient, for in all circumstances he or she is bound by the precept that he or she must not cause harm to the patient. The physician's ethical disposition is to be open to any cooperation that is in the health interests of his patients.

The doctor may sometimes be confronted with conflicts regarding the submission of elements Materials considered valuable (from a scientific, documentary, professor or legal point of view) that are claimed by the patient. The physician's aspiration to retain them is legitimate, but his or her interest can never prevail over the interest and well-being of the patient. The doctor may retain the original, if a copy of the analytical or exploratory results or a reproduction (photograph, xerox copy) of a graphic document is sufficient. Otherwise, he/she must lend the material needed by the patient. A pathologist, for example, cannot refuse to lend histological sections representative of a biopsy for evaluation by a colleague, as refusal to lend them would require a new tissue collection. Once the material has been studied, it must be returned to him.

According to deontological tradition, a physician must submit the results of diagnostic tests even if the patient is unable to pay the costs and fees involved, because failure to do so could cause harm to the patient. A physician may never harm any patient under any circumstances. A physician knows that there is no shortage of unscrupulous patients who, when they are able to do so, refuse to pay their fees. It is better to be cheated by a scoundrel than to harm an honest man. Although, thanks to the socialisation of medicine and private insurance systems, the situation referred to here is becoming less and less frequent, this behaviour clearly shows that the practice of medicine is not a commercial business, but a service.