Commentary on the Code of Medical Ethics and Deontology
Table of contents
Chapter V: Quality of health care
The physician is obliged to provide his patient with quality service. One of the clauses of the Hippocratic Oath was: "I will apply my treatments for the good of my patients according to my ability and good judgement" ("to the best of my knowledge and ability", others translate). This demand for quality is stronger today because medicine has entered the field of forces (legal, social and economic) that, in our society, have been promoting the control of the quality of products and services. People are no longer satisfied with just any subject medical care: they want it to be of the highest possible quality.
For doctors, however, it is not just a matter of satisfying the demands of users and consumers. The quality of the medical work is an intrinsic deontological requirement. In this Chapter, the Code aims to define the subjective and objective requirements of the professional skill ; it confers on physicians a wide freedom of prescription so that their work is competent and manager; it imposes on them the duty to study, to base their actions on the data of science, and not to put their patients at undue risk. The deontological prohibition of misleading or deceptive practices is included in this Chapter.
article 21.1. All patients have the right to medical care of a scientific and humane quality. The physician has the responsibility to provide this care, regardless of the modality of his or her professional internship , by undertaking to use the resources of medical science in a manner appropriate to his or her patient, according to the medical art of the time and the possibilities available to him or her.
Patients expect - indeed, they have a right - to be treated with respect and efficiency. When they feel that their expectations have been disappointed, they are not always content to protest vigorously: they take the doctor to court in order to be compensated for the damage caused by the doctor's intervention. If medicine loses its human and scientific quality, it not only sours doctor-patient relations, but also risks falling into the absurdity of defensive medicine.
The article states that patients have the right to be treated, not in just any way, but with scientific skill and human appreciation, and that the physician must respond to this right with quality care, which is good medical care internship . According to the text of article, this is specified, given the circumstances, in the notion of the medical art of the moment. This notion has a legal and a deontological aspect. The latter includes, on the one hand, the mastery of the commonly accepted and duly updated scientific instructions and technical skills of medicine, and, on the other hand, diligence and prudence in medical practice. To ensure that the notion of the state of the art does not become an ethically unattainable ideal, it is necessary to refer its elements to real situations, as embodied in the figure of the good, honest, committed and dedicated doctor, manager, working in specific circumstances and with real and finite resources at his or her disposal.
The obligation of quality and skill is universal: it is incumbent on physicians regardless of the modality of their practice. Some of its components are developed in the following articles. It is worth commenting here on an aspect that is sometimes somewhat neglected: the quality of the instruments, apparatus and reagents used by the physician.
In medicine, the material means largely determine the quality of care. The commitment to care for the patient within the physician's means has a twofold significance. On the one hand, it limits the doctor's capacity to act, here and now: impossible demands cannot be made of the doctor, since his efficiency ceiling is often determined by the diagnostic and therapeutic means immediately available. On the other hand, this commitment imposes on the doctor the moral obligation to have sufficient means available in advance in order to provide the level of efficiency that his patients legitimately expect.
Leaving aside the civil liability that a doctor may incur for damage caused to his patients as a result of the poor condition of the equipment or reagents he uses in his professional activity, it is clear that the doctor has a duty of care to ensure their good condition and quality, otherwise more or less serious damage could be caused to patients. Because of the complexity of the mechanical and electronic components of modern medical instruments, technical support from specialised after-sales maintenance services will always be necessary, since it is virtually impossible for the physician to carry out the necessary preventive checks or repairs himself. If the physician is employed by others, he/she must demand that these precautions be observed.
There are two areas in which the physician must be particularly diligent. The first is to avoid physical injury (burns, electrocution, brain damage) to patients or significant delays in diagnosis or treatment due to equipment malfunctions. The second is to avoid maladjustments in the calibration or operation of the instruments that could lead to errors in diagnosis or the amount of therapeutic doses applied.
article 21.2. Except in status emergencies, the physician shall refrain from acting beyond his or her capacity. In such a case, he/she shall propose the use of another competent colleague at subject.
The notion that, by virtue of his academic degree scroll and the registration at high school, the doctor is authorised to perform all medical acts subject is still valid among us. This article reminds the physician, however, of his duty not to recklessly overstep the limits of his competence. It points out that it is only in emergency situations that the physician may take risks that would be inappropriate in normal situations.
1. The "universality" of degree scroll of graduate in Medicine and Surgery.
The registration in an Official Medical Association ( high school ) is an indispensable requirement for the practice of the medical profession. The mere fact of being a member limits professional practice: the member may only practise within the territorial scope of the corresponding high school (articles 35 and 36 of the EGOMC). However, membership of the high school authorises, in principle, the practice of any medical, preventive, diagnostic or therapeutic act. However, this omnivalent and diffuse authorisation to practise all medicine is not deontological in nature, but legal: it means that any professional act undertaken by a duly registered doctor graduate is included in the legal practice and that, therefore, a correctly registered doctor can never be accused of illegal practice of the profession.
But deontology imposes serious ethical restrictions on this unlimited legal authorisation. Indeed, from an ethical point of view, degree scroll is not omnivalent. No one can nowadays dominate the whole of medicine and perform any medical act with skill . The article 21.2 obliges the physician to refrain from initiating medical actions that are beyond his level of skill. And it is precisely an essential element of the physician's skill to know the limits of his or her capabilities, so as not to overstep them unwisely. The doctor must refrain from making irreversible mistakes. This is a matter of serious appeal to the professional conscience. Before applying new diagnostic or therapeutic techniques, physicians must ask themselves in all conscience whether they are sufficiently familiar with them to undertake their implementation responsibly. Such a mandate cannot be taken as a brake on the expansion of the physician's technical skills. On the contrary, it means that such a legitimate and desirable aspiration implies the obligation to achieve, through training and study, the necessary skill to improve the quality and extent of service to patients.
2. The status of extreme urgency.
According to article 4.5, in circumstances of extreme urgency, the doctor is obliged to provide financial aid: the prohibition of article 21.1 therefore lapses. When faced with an exceptionally serious and urgent status , the doctor is obliged to apply remedies that he would not consider himself authorised to undertake under ordinary conditions, because he lacks the necessary skill and experience. These are, for example, life-saving interventions (tracheotomy, cranial trepanation) that cannot be postponed to the scene of the accident or to enquiry, because the urgent need to intervene life and death on a patient in extremis does not permit recourse to a more qualified colleague or evacuation to a hospital. It is then the physician's ethical responsibility to judge on two circumstances: the extreme seriousness of the case and the fact that his or her intervention means that there is a chance, however slight, of overcoming the patient's desperate status .
3. The obligation to have recourse to a competent colleague.
This traditional rule of medical ethics is found in virtually all modern Codes. The London International Code of Medical Ethics states it in these words: "A physician owes his patient all his loyalty and the resources of his science. Whenever an examination or treatment is beyond the physician's capacity, he should call in another qualified colleague at subject".
The decision to suggest that another colleague be called in is sometimes difficult, as the physician may suspect that this could damage his or her prestige, since it is tantamount to acknowledging his or her own limitations to the patient. For the good of the patient, the physician must sacrifice his or her 'honour' and apply for the partnership of the competent colleague. rule An elementary prudent approach is to obtain the patient's or the patient's family's consent: the physician should make clear to them the need to use a more qualified colleague, without ignoring the financial or technical aspects of the case. He/she will respect the patient's decision. Further details are given at article 34.2 of the Code.
article 22.1. The doctor must have professional freedom and the technical conditions that allow him to act independently and with quality assurance. If these conditions are not met, he/she must inform the managing body of attendance and the patient.
1. Professional freedom to act responsibly
Without freedom there can be no responsibility staff. This article enshrines professional freedom and independence more as an ethical duty than as a right. Such freedom constitutes the moral framework , required by the Nuremberg Declaration (article 57-3 of the Treaty of Rome) for the doctor's work in the countries of the European Community. Paragraph I of this basic document states: "Everyone must be assured that the doctor they consult enjoys complete independence in both moral and technical matters and that they are free in their choice of treatment".
A doctor's professional freedom is not a capricious whim: it is the ability to choose, with science and conscience, what he judges best to serve his patient. This professional freedom consists, to begin with, in the so-called freedom to prescribe. In whatever circumstances in which he works, the physician cannot alienate his freedom to make the diagnosis and apply the treatment that, in his judgement, is in the best interests of the patient. He must be free to establish both the frequency and quality of the services to be provided to his patients and the time to be devoted to them; to decide what diagnostic tests are necessary to consolidate the diagnosis and what curative, rehabilitative and preventive treatments should be applied. He cannot sign contracts which, while they are in force, would limit his professional freedom (compulsory application of certain techniques or products) or which, once terminated, would prohibit him from exercising a certain specialization program, seeing certain patients or applying certain treatments.
The Code of Ethics zealously defends members' freedom to prescribe (see purpose articles 22.1, 27.1, 27.2, 35.2, 35.3, 35.4 and 42.2). Freedom is also a right of members enshrined in the EGOMC, which includes, in its article 42, the right "not to be restricted in their professional practice, unless it is not carried out in accordance with professional ethics...".
2. The technical conditions for quality assurance.
What are the technical conditions that the doctor needs to guarantee the good quality of his work? In part these are those mentioned in the commentary on article 21.1, since they fall within the ethical notion of the 'medical art of the moment'. The physician must judge in conscience what these minimum requirements are: at schedule, facilities, instruments, staff ancillary, etc. Some argue that such a judgement in conscience is tantamount to relativising the problem, since one can then judge status as one pleases. The freedom to prescribe is, first of all, an inamissible right, because there can be no professional responsibility without professional freedom. It is contradictory to think that a doctor can work ethically and responsibly while at the same time being deprived of part of his or her freedom. To follow orders blindly or under duress is a moral abdication that cannot be justified either ethically or legally. Professional independence is not a whim or a demonstration of arrogance, but a grave duty imposed by a physician's loyalty to his or her patient. A physician who does not enjoy freedom of prescription cannot guarantee professional confidentiality, quality and continuity of care for his patients.
3. The defence of professional independence vis-à-vis the organisers of medical services and vis-à-vis the patient.
Physicians must protect their freedom to prescribe against the many factors that tend to limit or destroy it: economic measures that seek to limit expense health care, exaggerated demands from patients or their families, mistakes by physicians themselves when they succumb to technological temptations or monetary incentives.
External threats often end up demoralising the doctor, for restrictions below a tolerable limit deprive the patient of the treatment he is entitled to and force the doctor to practise bad medicine. The doctor who overprescribes is already demoralised, for he is either abusing the trust of his patients or practising his profession as if it were a trade.
No member of the profession may ethically work in the service of institutions that do not respect the rules of professional ethics or that prevent a competent and free work for the benefit of the patient. internship The Declaration of Nuremberg (article 57-3 of the Treaty of Rome), which deals with the fundamental principles governing the profession within the Community, stipulates in paragraph I: "Every person must be assured that the doctor to whom he has recourse enjoys complete independence in moral and technical matters, and that he enjoys the freedom to choose his treatment".
The scarcity or deprivation of technical resources is a factor of iatrogenic harm, which the doctor cannot tolerate. Education The expropriation of moral resources (freedom to prescribe, non-discrimination vis-à-vis other colleagues, guaranteed stability at work, the right to continued medical care, etc.) is just as pernicious, for it dispossesses the physician of his or her conscience and turns him or her into a plaything of the employer, be it the State, the insurance company or the private clinic. Certain conditions at work degrade the doctor, such as disproportionately low salaries, deprivation of rest due to excessive on-call duty, or the denial of labour rights, which tend to induce a psychological or real "proletarianisation" of doctors.
The article points to the physician's obligation to inform patients and healthcare providers and to foster a dialogue between them, from which many practical benefits could be derived. After all, good hospitals are characterised by a good information and complaints system at the service of patients. The article provides a basis for the College to protect a physician who was persecuted because of his or her just complaints (see article below).
article 22.2. Physicians, individually or through professional organisations, should draw the attention of the community to deficiencies that impede proper professional practice.
This article, a logical continuation of the previous one, imposes on doctors the duty to denounce to the community situations that entail an unacceptable impairment of their freedom to prescribe, their independence or the means necessary for their work in the service of the patient. The complaint may be made by the physician, at degree scroll staff , or collectively, by the high school, the WTO, trade unions or professional associations.
According to article 3.4 of the EGOMC, it is the proper function of the Colleges to collaborate "with the public authorities in achieving ...the most efficient, fair and equitable regulation of the health attendance ...". This partnership which, ideally, should be synergetic and collaborative, sometimes takes on a strong and vindictive tone. Shortcomings in the functioning of health care institutions, public or private, caused by lack of foresight, structural failures, economic crises or chronic neglect, can cause the quality of services to fall below tolerable levels. It is very important that physicians always maintain equanimity and make a responsible judgement as to whether deficiencies are in fact a morally intolerable deterioration of medical services, rather than merely inconveniences that are annoying and irritating but do not substantially impair the quality of care provided to the sick. The physician should separate this judgement from any other dispute, staff, trade union or corporate, that he or she has pending with the management of the institution. The complaint referred to in this article has a strictly professional basis and has nothing to do with political or ideological antagonism.
The insured person in public or private insurance companies is entitled to receive, in fair return for the contributions he has paid, services of proportionate quality, which the physician has to assess. If he judges that the restrictions imposed on him do not meet the fair expectations of his patients, he is obliged to intervene. Once the internal means referred to in article have been exhausted without obtaining a sufficient response from the managers of the services, the physician, whose primary interest is the service of the patient, must assume the role of public defender of the rights of the sick and explain to the social community, with objectivity and restraint, what the status is. In this way, patients and their relatives will decide how to express their protest and the means they will use to normalise status. Today, patients have more powerful social and political resources at their disposal than doctors to make health service institutions of any subject improve the level of quality of the services they are obliged to provide.
article 23. The practice of medicine is a service based on the scientific knowledge , whose maintenance and update is an individual deontological duty of the physician; and an ethical commitment of all organisations and authorities involved in the regulation of the profession.
1. The duty staff to study.
This article enshrines a perennial duty of the physician, already present in the Hippocratic Oath ("I will do what I know and what I can for the benefit of my patients"), and reiterated in the International Code of Medical Ethics ("The physician owes to his patient... all the resources of his science"). It has already been pointed out (article 21.1) how the lex artis includes, in addition to the correctness of the work performed, prudence and diligence, an element of knowledge: the due science, what the science of the moment considers adequate. This is the updated knowledge , which every honest and intellectually capable doctor must have, not the science of the gifted or that of the researcher in the front line of scientific progress.
Only by having this proper science will the doctor be able to diagnose and treat his patients with acceptable skill , and avoid making serious and irreversible mistakes. Efforts are now being made to give this somewhat vague and undefined notion a precise, quantifiable formulation. Some professional associations have expressed precisely what minimum training is necessary to have sufficient professional skill : they do not simply say that three or five years of residency program are necessary, but how many patients and with what diversity the doctor must have seen, or how many interventions the candidate must have carried out, to have access to such a degree scroll or diploma. This assures the public that doctors who receive such a degree scroll have the essential knowledge, skills and attitudes to provide accredited quality care.
The physician must be a lifelong student. The accelerated progress of medicine renders the best training obsolete in the space of a few years. Keeping up with progress requires a great deal of work and initiative to plan study and permanent Education , as professional obligations, family and social duties and the necessary rest compete fiercely to take up the hours that could have been devoted to study.
Lack of study leads to professional stagnation and routine and turns the doctor into a practitioner. A lack of intellectual curiosity and a lack of commitment to doing things to the best of one's ability are undoubtedly the main cause of the internship poor quality of many doctors. Study is a serious obligation. The sick have a right to be cared for by competent physicians, because they expect to receive care based on the knowledge that is current today, not on notions that were valid years ago.
The article leaves the physician free to decide how to fulfil this duty. A few suggestions, however, are in order. While it is good to have an open curiosity, it is better to limit oneself to serious study of what is most necessary. The physician must be able to determine his or her areas of ignorance and to classify them, for some of them are tolerable (and even beneficial: those that concern rare or exotic matters), while others, because they concern ordinary matters, cannot be excused. A general practitioner, for example, must have a thorough knowledge of the diseases prevalent in the population he or she treats, must know a great deal and be very competent in, for example, the diagnosis and treatment of hypertension or chronic respiratory diseases, in the home care of geriatric patients, in the judicious management of antibiotics and psychotropic drugs, and in preventive measures of general use. In short: he/she must be an expert in the clinical entities he/she routinely encounters.
Each doctor should discover the most favourable place, time and circumstances for the study. He or she should have a Library Services staff that, although small in size, is lively and functional. Each year he/she should buy a few books and maintain a subscription to a quality journal.
He/she should also attend selected courses at update and hospital refresher programmes. He/she will also make use of audio-visual materials from Education and contacts with colleagues.
One aspect of the doctor's continuous training is the improvement of his human training . This is not to be understood as encyclopaedic and refined culture, but rather as the profound knowledge of man, in order to show towards him, whoever he may be, an ever more understanding attitude and respect for his dignity. The sick themselves are the best treatise on humanity, where one can learn about the greatness and weaknesses of our race. The humanism of the physician consists in knowing and respecting his patients as persons: this is the essence of his human training .
2. The Education continued, an institutional duty.
The WTO is obliged to promote by all means at its disposal to constantly improve the scientific level of its members (article 3.3 of the EGOMC). The Code also assigns this duty to other professional organisations (scientific societies, hospitals, Schools of Medicine) and to the bodies and authorities that regulate the profession. A wide variety of means can be offered: congresses and short courses; study materials and audio-visual programmes; bibliographic sessions or attendance to programmes on update. The Luxembourg Declaration of the committee Permanent of Doctors of the European Community stipulates, in order to guarantee the professional skill of the contracted doctor, that he/she should be allowed "to improve technically and update his/her knowledge, during the time of work remunerated". The directors of health institutions must provide the necessary leave, outside of the statutory holidays, to provide for the professional improvement of doctors.
It should be borne in mind that, even in financial terms, the Education continuous improves healthcare performance. Educating doctors in diagnostic strategies, clinical pharmacology, outpatient surgery, for example, is much more effective than harassing them with a policy of cost rationing or administrative threats.
article 24.1. As long as the so-called non-conventional medicines have not achieved an acceptable scientific basis, the doctors who apply them are obliged to objectively record their observations in order to make possible the assessment of the efficacy of their methods.
1. The general attitude towards alternative medicines.
In medicine today, we are witnessing unprecedented scientific progress, progress that consists both in conquering new knowledge and techniques, and in discarding false ideas and inoperative or harmful remedies. issue At the same time, however, and paradoxically, no small number of doctors practice certain varieties of exotic medicines, and no small section of the public is attracted to exotic or naturopathic medicines. One thing is clear: the internship of unorthodox medicines raises complex ethical issues.
Firstly, the relativity of the limits separating these medicines from orthodox medicine. Scientific medicine is, by essence, open to progress, which means that it will always have within it pathogenetic or therapeutic ideas destined to be discarded and replaced by other more valid ones: what is accepted as valid and even advanced by "official" medicine at any given time will later be discarded and even ridiculed, just as procedures that enjoyed respectability in the past are today. But not everything is relative in this field. As we have seen, there is a moral obligation to treat according to the medical art of the moment. It will never be ethical to use irrational therapies, based on illusory systems or distortions of science. Esoteric practices will never be ethical simply because they refuse to reveal their "secrets".
Secondly, that of the inability of many of today's orthodox physicians to offer a remedy to many patients who present with "undifferentiated diseases", chronic and troublesome disorders, for which neither objective pathophysiological instructions can be discovered nor can they be treated effectively and sustainably. Unfortunately, orthodox doctors do not usually show much interest in such difficult patients. It is precisely these patients who turn to alternative medicines and find in them the relief and comfort that scientific doctors have failed to give them. This is a status that orthodox medicine has to accept with humility.
Thirdly, the tolerance of Ministries of Health towards parallel medicines. Parallel medicines, which have not been absorbed by national health systems, attract many patients who are disenchanted with official medicine. This relieves the burden of care and the financial burden on the public attendance . issue As a result, fewer and fewer governments are cracking down on the legally forbidden internship quackery, and the number of countries that tolerate alternative forms of healing under the complacent gaze of the World Health Organisation is growing.
2. The obligation to provide a scientific basis for non-conventional medicines.
According to article 21.1, all members of the medical profession must base their internship practice on the data of science. It follows from this that every physician is obliged to critically review his or her practice in order to keep it in line with current scientific criteria. The Code is sample tolerant of physicians who have incorporated unvalidated or heterodox diagnostic or therapeutic procedures, but imposes a condition on them: they may not abdicate their obligation to critically evaluate the procedures they use. To this end, they are required to record their observations honestly and truthfully. For only in this way, by keeping and critically analysing the medical records of the patients they have treated, is it possible to audit these practices, to determine whether and to what extent they are effective Degree. Orthodox medicine demands the same of every new diagnostic and therapeutic procedure that wants to make its way to the official internship . If a doctor who follows some form of non-orthodox medicine were to neglect this obligation, it would be very difficult for him to prove that his behaviour is that of a true doctor, as he would hardly differ from the behaviour of quacks and witchdoctors.
article 24.2. Practices inspired by charlatanism, those lacking a scientific basis or those promising patients or their relatives impossible cures, illusory or insufficiently proven procedures, the application of simulated treatments or fictitious surgical interventions, or the practice of medicine by means of consultations exclusively by letter, telephone, radio or press are unethical.
This article is a list of deontological offences against the quality of medical care, some of which also appear in the EGOMC: among the prohibitions set out in article 44, or the offences set out in 64.
Firstly, different forms of charlatanism are condemned, which have the common feature of inducing in the patient the conviction that the charlatan doctor is in some way superior to his colleagues, and that, in some way, his personal talents or remedies are also superior (article 64,2,b of the EGOMC). The internship of promising cures or guaranteeing the achievement of certain results (even offering to return the money if the treatment is unsatisfactory for the patient) is condemned: such conduct is a radical adulteration of the practice of medicine, which consists of providing services, not guaranteeing results (article 44,a,i, of the EGOMC). The ethical unworthiness of deceiving the good faith of patients by offering them remedies of unknown efficacy or toxicity, by subjecting them to sham surgical operations, by applying magical, fictitious or illusory procedures is obvious.
staffThe substitution of the ordinary, direct and non-delegable enquiry , with its interrogation and physical examination, by remote consultations by letter and telephone, is also condemned. Also condemned is the recommendation of treatment, which is often made in so-called health clinics, broadcast on radio stations or published in certain magazines. This prohibition does not, of course, refer to the telephone call made by the patient to the attending physician or the letter written to him or her in order to ask a question or report an incident, but to the enquiry which is done entirely by means of letters or telephone conversations, and in which there is no immediate face-to-face relationship between physician and patient.
article 24.3. It is unethical to facilitate the use of the practice, or to cover up in any way, for those who, without possessing the degree scroll doctor's licence, engage in the illegal practice of the profession.
In addition to what is prescribed by the legislation on the crime of intrusiveness and illegal practice of the profession, the ethical misconduct of covering up for or being an accomplice of someone who is not authorised to practise medicine is condemned here.
It is logical for the Code to prohibit, for professional practice purposes, association or cooperation by physicians with non-physicians. The EGOMC also does so, in paragraphs (d) and (g) of its article 44, when it prohibits physicians, respectively, from "entering into agreement with any other person or entity for utilitarian purposes that are unlawful or in violation of professional propriety" and "lending their name to appear as director or advisor of healing centres..., which are not in accordance with the laws in force and the Code of Ethics".
The association, with the purpose to attend to patients, between doctors and quacks, including those who hold diplomas of no legal value, lends itself to the deception of the public, as it would lead many to think that the care offered by a group of which a registered doctor is a member has the guarantee of the WTO. Moreover, it is practically inevitable that a doctor who establishes a subject of association with quacks will be guilty of misrepresenting someone who, without being legally qualified, appears to the public to be practising medicine (Articles 44, b of the EGOMC). For his part, the quack doctor who associates with a doctor is in fact committing the crime of intrusion, typified in article 321 of the Spanish Penal Code, which establishes that "Anyone who carries out acts proper to a profession without possessing the corresponding official degree scroll , or recognised by law or by international provision or agreement , shall be sentenced to a minor prison term. If the offender publicly claims to be a professional, he/she shall also be liable to a fine of 30,000 to 300,000 pesetas".