Commentary on the Code of Medical Ethics and Deontology

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Chapter VIII: Relations with other health professions

Although physicians play a decisive role in the care of patients, they are not the exclusive caregivers of patients. In order to provide a competent and comprehensive service to them, the physician needs the support of members of the other health professions at partnership . In the status thus created, the physician, who retains ultimate responsibility for his or her patient, is obliged to coordinate the work of all, indicating to himself or herself and to others the goals and limits of this cooperation. An essential feature of this cooperation is respect for the technical and ethical autonomy of all those involved in the common work .

There are many ethical problems that can arise on a daily basis on work at partnership: in order to prevent and solve them, the Code offers in this Chapter some general guidelines.

article 36.1. Physicians must maintain good relations with other health care professionals. They shall be respectful of the auxiliary staff and shall listen to their opinions about the care of the sick, even if they differ from their own.

This article describes the features that professional relationships between physicians and members of other health professions must possess in order to be good, ethically sound: (1) they must be respectful, (2) they must also include recognition of the technical skill , and (3) they must accept the moral autonomy of these collaborators.

1. Professional respect.

It should be borne in mind here, as in any other circumstance in which deontological respect is involved, that it is not limited to the set of gestures imposed by good practice Education, but includes something more profound: the recognition that collaborators are true professionals, who have the right to be treated as responsible and understood persons in the subject that is proper to them; in other words, that they are morally adult persons, whose convictions and dignity are as valid and must be taken into account as those of the doctor himself or herself.

This respect must be applied concretely and directly to the immediate collaborators, as this is required for the best service to the patients, for whom it is good to be cared for by professionals who work together in good harmony and who treat each other with consideration. In contrast, it would be a source of unease for the patients to observe that misunderstandings are aired between doctors and collaborators and that they hide neither their hostility nor their mutual contempt. It is inevitable that the patients will then suspect that their subordinates will neither report to the doctor with the necessary confidence, nor carry out the orders they receive from him with enthusiasm and punctuality.

The same respect excludes from the sphere of professional relations any manifestation of levity or frivolity. Such relations must be correct, without falling into an icy or unhuman formalism, but far removed from all trusting camaraderie. Decorum and dignity must be present in relations between doctors and nurses and assistants, since they constitute, beyond the requirements of a correct working relationship, an important barrier to irresponsibility and to the relaxation of the quality of work.

2. Recognition of the skill technical.

A physician must take into account and respect the views of his or her colleagues on how they believe patients should be treated, even if those views differ from his or her own. Each of the health professions has its own traditions of professional quality and its own particular standards of ethics. agreement It is desirable that doctors and their assistants, before or at the beginning of their partnership, negotiate and agree on the criteria (work content, technical procedures, human style) by which they are to be guided in their work and thus achieve the necessary harmony. But they will not forget, doctors and collaborators, that a good cooperative work requires a certain amount of tolerance for differences and trust in the honesty and skill professionalism of others.

Physicians should communicate their orders clearly and with restraint. He/she should avoid issuing orders in a blunt manner, or making changes in the usual way of proceeding without explaining the reasons for them, or trivialising his/her authority by giving too detailed instructions. True trust in co-workers manifests itself in giving only those orders that are strictly necessary and then doing so with humanity, precision and clarity. It is in the patient's interest to eliminate any ambiguity or vagueness in the physician's orders. Thus, it is important that the physician write in legible handwriting the instructions he or she gives to his or her staff.

3. Moral autonomy of health professionals.

Problems in the execution of the physician's orders do not normally arise. If there is ever a disagreement about the moral or technical content of the order they receive, the staff members should inform the physician of the reasons for the order. The physician must listen to them and, after calm consideration of the data problem raised, modify or maintain the order, giving appropriate reasons in the latter case. A physician may never force one of his staff to act against his conscience or even to do something that seems unreasonable to him. Employees who, a priori, decide to accept any order given to them by their boss as a gift, who reduce their responsibility staff to a morality of blind and uncritical submission, are devoid of ethical dignity. Medicine today demands to be lived with a keen sense of responsibility staff. Physicians should carefully avoid imposing slavish obedience on their assistants. No one in a position of dependence can justify his or her behaviour by claiming that at work he or she is merely following orders. Such an attitude is ethically and professionally indefensible. It is also legally indefensible, as was established, for example, in the judgement of the Nuremberg Trial against the doctors and their assistants who, in carrying out orders, made ignominious use of medicine.

article 36.2. The physician shall respect the scope of the special competence of the staff collaborating with him/her, but shall not allow the latter to invade the area of his/her responsibility, when his/her actions could be harmful to the patient.

It has already been said that it is very important that the specific competencies of the physician's staff be well documented in their contracts or in the institution's rules and regulations. Whether they are individual or collective, the negotiation of these documents should always be done with the best interests of the patients in mind. The boundaries of each individual's responsibilities are also negotiable and may be subject to occasional or permanent shifts.

This raises the problem of delegation of functions. The physician may delegate certain functions to his non-physician collaborators, but he does so with restrictive criteria and a strong sense of responsibility. He is accountable for the conduct of all, especially for the consequences of having entrusted non-physicians to carry out certain procedures that are normally the responsibility of the physician. He shall never delegate functions to collaborators, including physicians, if they are not suitably qualified to perform them, if they do not have the necessary training. If he needs to delegate functions to non-physicians, he shall do so, under his own supervision, to persons whose skill and judgement are clear to him, and he shall then remain available to intervene in case of need.

No physician may co-operate with a system of care that, more or less stably, entrusts non-physicians with the performance of typically medical acts. This is strongly forbidden in the final lines of this article , in parallel to what is stated in article 44, b of the EGOMC. For example, medical acts per se are per se non-delegable which are immediately connected with the diagnosis (taking a medical history, physical examination of the patient), with the determination of the initial therapy and its subsequent modifications, as well as the examinations and enquiries which must precede the issuing of a medical certificate .

Some considerations should be added here on the specific relationships between doctors and pharmacists, since conflicts may arise in these relationships that are potentially dangerous for the patient. In order to avoid and resolve such conflicts, doctors and pharmacists must have a clear idea of their mutual rights and duties, in order to respect and fulfil them.

The physician should refrain from recommending that patients visit a particular pharmacy in preference to others, nor should he/she make directly or indirectly derogatory comments about the quality and price of the services provided by a particular pharmacist. On the contrary, he/she will be strictly impartial towards all pharmacists working in his/her environment. If he/she suspects that a product (specific or magistral formula) served by a pharmacist is not in good condition or does not correspond to the one he/she has prescribed, he/she will deal with the matter directly with the pharmacist manager, never through the patient.

Just as the physician must respect the pharmacist's interventions, the pharmacist shall refrain from criticising to his customers the content of prescriptions written by the physician, nor shall he undermine the physician's reputation with patients. The pharmacist may advise his customers informally on the treatment of minor ailments and dispense advertising medicines, which need not be prescribed by the physician. But he shall refrain from substituting for the doctor in his diagnostic and therapeutic function or from performing, except in emergencies, minor operations or cures.

In advanced countries, the professional responsibilities of pharmacists are expanding. For some years now, pharmacists have been taking on the role of drug experts, especially in the field of side effects and drug-drug interactions. They are also legally authorised, in the absence of a medicine prescribed by a doctor, to replace it with an identical or equivalent medicine. However, in all cases of generic substitution, and in particular in cases of therapeutic substitution, or when they recommend the withdrawal of a medicinal product because of its alleged incompatibility with another, the pharmacist must act prudently, contact the doctor in each case at contact to inform him/her of the relevant points and act in consultation with him/her at agreement .

If conflicts of competence between doctors and pharmacists should ever arise, they should be settled amicably and never in the presence of the patient-client.