Ethical aspects of the patient-doctor relationship - public health institutions
Gonzalo Herranz, department de Humanities Biomedicas, University of Navarra.
lecture Delivered in Ferrara, 2002.
The relationships of the characters
The patient as patient-citizen
The rights of patients and third-party payers
Patients' rights in Europe and the USA
Comiogenesis, rights and collective responsibility
Doctors-citizens/patients-citizens: the new synthesis
It is a matter of great interest to analyse the mutation, or rather the progressive replacement of the old, peaceful and paternalistic binomial relationship between patient and doctor by the modern, conflictive and egalitarian relationship between doctor, patient and public institutions.
The classical relationship, whether in the patient's home or in the hospital, is remembered, in a perhaps idealised vision, as a connection staff, if not permanent, at least with a tendency to last. It involved, on the one hand, the patient and his or her relatives, who formed a solid unit, and, on the other hand, the individual doctor. It included, or simply accepted, the asymmetrical character that was considered connatural to the peculiar, knotted between singular persons, one of whom, often in a lower economic and cultural position, was diminished or damaged by the illness.
Today, such a relationship tends to be more anonymous and complex, less so staff. On the one hand, the doctor, like the secondary figures in a play, is simply a doctor, no longer in need of a name. The role staff, nominated, of the doctor of yesteryear can be played by any member of a functional group or of a health care system. Today it is more common for the patient to say, in the impersonal plural: I am going to be seen at the outpatient clinic or the hospital. He no longer says: I am going to be seen by Doctor Tal.
The old relationship, which the French deontologists had characterised as the meeting of a trust with a conscience, which was like a vertical exchange of information and prescriptions, is on its way to extinction. We are moving more and more towards a horizontal relationship, between equals who keep their distance, each with their own conscience, but who are no longer just two: the modern relationship develops under the watchful eye of programmers and managers, under the control of the public administrator or the insurance company inspector.
The two characters from before are now more. This numerical growth multiplies the reciprocal relations. They are now multilateral and modify each other. But this circumstance does not weaken but, on the contrary, reinforces their ethical character. Because they are always interpersonal, these relationships are always intrinsically moral.
It seems appropriate, before considering our main issue of the patient/doctor/public institutions relationship, to make a brief presentation of the characters, a very sketchy outline of the actors.
The characters 
The patient who comes into contact with a doctor, the classic patient, becomes in the new context and depending on the circumstances, a Username, or a customer, a consumer, who examines the market, compares, bargains and contracts. The patient comes to the doctor in poor health, but armed with autonomy, demanding efficiency and, more and more often, displaying detailed and precise knowledge of his or her ailments and rights.
The doctor has gone from being the master of the status to becoming a salaried and replaceable worker. He is now a subordinate, a mere service provider who, if he wants to survive and prosper in the new status , must compete in a degree program for which he has not been trained: that of always giving more for less.
The third-party payer, whether it is the public health system or private insurance companies, holds the purse strings and tends, through money, to dominate status. National health systems compete mimetically with private health systems for prestige, money, clients; they compete to hire the services of star doctors, to offer state-of-the-art technologies, to gain media pre-eminence. Through a more or less intense re-privatisation, public medicine wants to achieve the dynamism of free business. For their part, private health care organisations, the so-called medical industrial complex, apply criteria of economic efficiency in their management which inevitably lead to the commercialisation of medicine. The old-fashioned, solidarity-based, mutual and charitable insurances have had to transform themselves into health care financiers, into openly profit-seeking entities. They merge with each other, create health multinationals, weave networks of hospitals and services. They even produce hybrids - the first hybrids have already appeared - resulting from crossing medical empires with pharmaceutical industries.
Third-party payers, in the public or private sector, all alike, must apply the actions dictated at all times by the science of business, to constantly improve their productivity, verify the quality of their services, audit the performance of human groups and technologies, programme efficiency. Everyone, in the public and private sectors, is obliged to apply austerity policies, to ration with dissimulation, to contain at all costs the expansion of expense.
The relationships of the characters
The relationship between patients, doctors and third-party payers can be considered from many angles and using different optics. As a matter of courtesy and, above all, because I am very interested in the comments and criticisms that my intervention may provoke, I will use in my considerations a very original and fascinating guide : what the Italian rules and regulations prescribes on the doctor/patient/third-party payer relationship, in particular the current Codice di Deontologia Medica, promulgated by the Federazione degli Ordini dei Medici in October 1998. The ethical aspects that concern us today will be reviewed in the light of the Codice.
The patient as patient-citizen
The Codice assigns to the individual who enters into a relationship with the doctor the status of citizen, of patient-citizen. This innovative, almost revolutionary idea is formulated as follows in article 17: The doctor in his relationship with the citizen must imprint his professional activity with respect for the fundamental rights of the person.
The expression citizen or patient-citizen is used profusely in the Codice: it appears, with its natural variations, in every fourth article of the Codice. It is not, apparently, simply to proclaim that the medical internship is to be carried out with respect for individual human rights, as enshrined in the Italian Constitution. The official exegesis of the Federazione degli Ordini itself affirms that we are facing a profound change of mentality: the traditional terminology of the previous editions of the Codice, although not completely eliminated, has been largely replaced and deliberately innovated to consolidate this mutation.
The ordinal commentary points out that "it is clearly decided to use the term 'citizen' instead, where the intention is to underline a universality of fundamental principles". And, although these principles have not been listed, it is clear that the terminological change is obviously aimed at two objectives: one macro-social, defining the collective ethos of medicine as a public service; the other, micro-social and private, establishing the typical features of the doctor-patient relationship in the context of the national health system. Indeed, the commentary on the Federazione's website states, with regard to the first, that the new terminology will serve as a "key to identify the current prospects for the medical profession in society"; and, with regard to the second, it makes it clear that "the patient-patient, from a passive position, moves to another, active one, of protection and respect of his own fundamental rights, giving a clear sign of a different proportion of the doctor-patient relationship".
We are thus faced with an important sociological and ethical evolution. The patient's dignity is no longer protected, as was the case in the previous deontological order, by the prohibition on doctors using their implicit psychological and social superiority to their own advantage. This passive and provided protection disappears in the new circumstances. As a citizen, the patient now enjoys an equal position, with his own intrinsic personal rights, with which he can protect himself. The elimination of the asymmetry of the past is result not only due to a rise in the cultural and economic level of the population, but above all to a strongly felt awareness of subjective, individual rights.
The Federazione's official commentary highlights the fundamental legal and deontological background of the change. It states that the basic rights of the patient-citizen derive from the fundamental principles of the Constitutional Charter, and that, by being transferred to the Codice, they are transformed from rule juridical to rule deontological. Moreover, thanks to this transfer, medical deontology takes on a new dimension and a new social contribution. Perhaps to allay the fears of those nostalgic for the old relationship, the ordinal commentary points out that the new deontological order does not annihilate professional deontology, but gives it greater prestige and dignity. It states that "the change in the doctor-patient relationship, also in the social and legal sphere, highlights the true meaning of medical ethics".
The interpretation that the Codice's drafters offer us of the new status is very open and optimistic. In it, the patient acquires a more effective autonomy, with a broad discretionary capacity to choose and decide. This new power cannot correspond to the libertarian and radical variant of the "patient's power", but to the considered authority of the patient-citizen.
But this new power has had to be acquired on behalf of others. We cannot forget that power is finite and inextensible. When power is distributed or redistributed within a closed system, its total sum remains constant: the gain of some implies the loss of others. It is therefore necessary to ask at whose expense has the patient gained his new power? The doctor's? The third party payer's?
The doctor
The doctor has always been a protean figure, irreducible to a unitary outline . But in today's pluralistic world, his human complexion, his moral stature, his relationships, have become more changeable, because they are closely dependent on a multitude of different environmental factors. The ethical, social and economic circumstances of doctors' work exert very strong effects on their professional way of being and acting.
In order to simplify such a complex issue, I will take the liberty of offering licence only two images of doctors, opposing, polar, and yet intercommunicating and potentially converging. One is that of the salaried doctor, which is delineated in the Codice di Deontologia of 1998. The other corresponds to the doctor-entrepreneur of American medicine.
The doctor employee
How does the Italian Codice characterise the doctor of today, the subject doctor who is the most frequent doctor among us today, the salaried doctor?
In its article 69, the Codice recalls that the doctor, in all circumstances, including that of hiring out his services on the basis of employment or agreement, remains subject to the deontological precepts and to the disciplinary authority of the Medical Order. He adds that, should there ever be a conflict of duties between the ethical rules and those imposed by the public or private entities for which he works, the physician must be guided by a well-defined criterion: he will request the intervention of the Order so that the physician's own rights and those of the citizens are safeguarded. article 69 ends with a precept that is both strong and prudent: the physician should remain at work while awaiting the settlement of "tolerable" differences: but he should leave it when there have been serious violations of human rights and values against persons entrusted to his care, or against the dignity, freedom or independence of his own professional activity.
The article 69 invites doctors and patient-citizens to make a common front, to align themselves, under the ordinal guardianship, in defence, above all, of the human rights and ethical values of the patient. This is what the Federation's official Commentary states: "not only of the autonomy and dignity of the profession, but also and, above all, of the rights of citizens".
The profession is taking sides. And it does so doubly, of course. With a serious sense of justice, it points out to the doctor that his work on behalf of others creates a status of double loyalty, since, on the one hand, it includes him in an organisation management assistant which he must serve with rectitude and honesty; and on the other, it assigns him the duty to protect the just rights of the patient-citizen. And, with a strong sense of its community responsibility, the medical profession, through the Order that represents it, undertakes to mediate with all its social influence in defence of doctors and patients to restore their rights and freedoms, not only in the event of conflict with high legal standards emanating from the State, but also when doctors and patients are harassed by the orders and circulars of local administrators.
In theory, in the new status designed by the Codice, the position of the doctor is well supported, as it is based on his skill, on the high social esteem of the health good he administers, on the long tradition of his friendship with the patient, and, finally, on the more recent tradition of respect and protection of patients' rights.
This power of the doctor, benign and temperate, is not always peacefully enjoyed. It is threatened by periodic evils: periods of economic recession, deterioration of human relations, disruption of medical demographics with the risk of proletarianisation of a more or less large sector of the profession. These ills are well known to us, as they are relatively typical of certain Western European countries.
Suffice it to say this, for the moment, about the doctor employee. Let us move on to consider what is happening on the other side of the Atlantic, to see if salvation can come from America.
The entrepreneurial doctor
In the United States, the main modulating factor of the professional ethos has not been, as in Europe, the development and implementation of national health systems, but the decisive role that economists and administrators have played in the conversion of medicine into a major industry. This ethos has been incubated in hospitals and, in particular, in the relationship between doctors and administrators.
In the years immediately following the Second World War, hospitals were Structures relatively simple to administer. But in the mid-1960s, the management of hospitals began to take on unusual economic, organisational and labour-related dimensions. It then became necessary to apply management models and techniques that went beyond the amateurism of benefactors and physicians. In contrast to Europe, where a large contingent of hospital and national health service administrators was recruited from the ranks of physicians, in the United States it was necessary to recruit business professionals. Things went well at first: the new managers saw themselves as qualified servants of physicians, and they followed the ethical standards of the medical profession well Degree .
But this harmony began to crack as competition between hospitals grew. Hospitals were transformed into profit-making enterprises and medicine became an industrial complex of large economic dimensions. Administrators imposed the need for advanced and aggressive financial management criteria, which often clashed with the professional traditions of physicians. Tension between administrators and physicians grew. The new morality management assistant demanded cutting costs, optimising profits, rationing and rationalising services, serving two masters. For many doctors, this was too strong an attack on the tradition of unlimited service to the patient, so characteristic of the Hippocratic doctor, faithful to the injunction "I will do all I know and can for my patient".
The ethical divorce of the two guilds of administrators and physicians became inevitable and eventually led to the separation of codes of ethics. The administrators' code recognises that the primary function of hospital governance is to provide patients with quality health care, but it establishes mainly economic imperatives. The enormous size of the medical expense has increased the roles and responsibilities of administrators, while at the same time dwarfing the managerial responsibility of physicians. The formerly prevailing relative balance of power has been reversed: today managers and economists are at the helm of the hospital, setting the plans for development, allocating resources, assessing standards of care, judging doctors by their economic performance, governing people.
The pragmatic priority of the financial and organisational has resulted in the pre-eminence of economic values over ethical values in the governance and mission statement of hospitals. The traditional charitable orientation of the hospital institution, public and private alike, has succumbed to the imperatives of economic survival and induced a change in the notion of professionalism of most American physicians. It has also changed the thinking of patients, as evidenced by the rights contained in patients' charters, which we will examine later.
And, strangely enough, these profound changes happen smoothly, almost unnoticed. They take on an initially harmless appearance, as they are about optimising yields, eliminating superfluous expenditure of time and money, adopting well-tested clinical protocols, acting according to diagnostic groups, following the dictates of evidence-based medicine. Doctors tend to accept these interventions without resistance, as they are dictated by the need to rationalise work and expense. But their economic motivation ends up having a heavy influence on patient relations.
The pre-eminence of the financial translates into ways of thinking and acting that end up eroding the human and scientific profile of the physician and reduce his or her field of vision to economic factors and parameters. Administrators prefer and reward physicians who see more patients per unit of time; they give incentives to surgeons and obstetricians with minimal postoperative morbidity and mortality; they reward clinicians Departments who manage to reduce the average length of hospitalisation of their patients; they favour outpatient interventions taken to the maximum permissible risk. The ethical consequences of such policies can be dire. A surgeon who wants to please his managers, who loves the extra money that his high efficiency Degree can bring, starts to discriminate between his patients: in order to surpass his colleagues and to remain at the top of the League table, he needs to select the patients he operates on: he needs to refuse patients with considerable surgical risk, who are no longer operated on, at least not by him. This phenomenon of dumping patients with moderate or high surgical risk also extends to patients whose insurance does not cover the full risk. In the new context, the patient's interests no longer come first. The same applies to obtaining good grade in quality audits: patients are not treated according to the specific needs of each individual, but according to the standard set by each clinical protocol . This destroys the ethical integrity of the doctor, who sacrifices the interests of the patient in order to please the auditors and to advance in the professional degree program .
When the traditional values of medicine come into conflict with the values of the medical market, when the field is dominated by multinational health care companies, it is all too easy for doctors to succumb to the temptation to become entrepreneurs in the medical industry themselves.
Indeed, there has been no shortage of doctors who have rebelled against the exploitation and plundering of which they feel they are victims. In recent years, many have decided to become their own capitalists and to organise quasi-commercial companies dedicated to diagnosis or treatment, joint ventures with colleagues or financiers to exploit medical consumerism. This leads to a final phase in which the doctor regains both control of management and the dividends from his work. The internship of this medicine-business involves considerable financial risks. But above all, it entails serious ethical risks, leading to the conception of medicine as a commercial activity, inseparable from strong, constant conflicts of interest. Ethically scandalous actions have already begun to manifest themselves: new and aggressive forms of advertising favouring medical consumerism; the creation of sophisticated and exclusive health units for wealthy patients, with immediate care services, at home or in hospital, including all kinds of whims and luxuries. The dignity, freedom and prudence of the doctor's prescription are taken captive, sacrificed to the profitability of the business.
The internal morality of medicine is altruistic and rational. It is not the physician's purpose to satisfy people's whims, to maximise their choices or to favour risky lifestyles. One goes to the doctor to maintain and restore health, to alleviate suffering, not to satisfy whims, as when one goes shopping.
In the face of this evolution of American medicine, European medicine, basically non-profit, mostly salaried, presents itself as an ethical blessing. I don't think we can ever be grateful enough for the creation of social medicine in Europe and development .
It is high time to pay attention to a basic aspect of the third-party payer's relationship with patients and physicians: patients' rights.
The rights of patients and third-party payers
Nothing reveals the strengths and weaknesses of the third-party payer, in Europe as well as in America, better than a comparative examination of the patients' rights charters that exist on both sides of the Atlantic.
In order to understand the commonalities and differences between these documents, it is useful first to briefly refer to some characteristics common to most of them.
Although historically some of these rights have their roots in the remote Christian past, it was certain social circumstances that forced their birth in the United States as a relatively late product of the movements to vindicate discriminated minorities. This time and place of birth has left an indelible mark on the character of these rights, compatible with the diversification brought about by their subsequent complex development by many different actors: hospital administrators, consumer groups, patients' associations, civic rights organisations and, of course, ministries of health and their corresponding national health services.
Patients' Bills of Rights refer almost exclusively to in-patients. Very little thought has been given, outside the UK, to the alleged rights of the outpatient and even less to the home patient.
All charters contain a common core of so-called fundamental rights of the sick. They are the translation of fundamental and constitutional human rights into the hospital context. For this reason, they hardly differ from country to country, are legally sound and tend to be preserved over time. These include, for example, the right to receive a respectful attention and congruent with the dignity of the person; to manage one's own autonomy through the granting or withdrawal of informed consent; to the custody of confidentiality; to the protection of health; to respect for privacy and intimacy.
We are more interested in non-fundamental rights, also called special rights, which are those that give diversity to charters. They often seem more like moral rights than legal rights.
Undoubtedly, it has been the institutions that have enacted them that have left the strong imprint of their personality on these rights. The user and consumer movements have enhanced the role of the patient as a purchaser of health care, who controls costs, authorises interventions, and is a very active part of a service contract. In contrast to this contractualist and legal mentality, the professionalist genius of the rights recognised by medical associations: this is the case of the Declaration of Lisbon of the World Medical Association association , in its rich version of 1995, not the very poor version of 1981, which focuses on the rights of the patient to humane quality care in line with scientific advances, to free choice of doctor, to the doctor's advocacy in protecting the patient before third parties, to palliative care. availability Finally, there is a certain typicality in the special rights granted by the national health services: they often bear the insecure mark of the welfare state, as they are conditional on the necessary financial and human resources being available at the moment. Not only are these rights not enforceable in times of economic recession, but they are in fact dependent on the response of the official bureaucratic machine. Thus, for example, rights to complain or to participate in the health management are not always adjudicated by courts or independent bodies, but have to be exercised through the hospital management itself; the right to receive medicines and health products is left to the mercy of availability of resources; rationing is imposed without discussion or warning; the right to receive medicines and health products is left to the mercy of of resources; rationing is imposed without or warning.
Patients' rights in Europe and the USA
Let us now turn to a comparison of secondary rights in Europe and the United States. Let us take as material for analysis the Patient's Bill of Rights of the association American Hospitals (hereinafter PBR) and the Carta dei Diritti del Malato of the Comune di Ferrara (hereinafter CDM). These are two very different documents, which makes their comparison highly illustrative.
The American Hospital association , which acutely perceived the great political and professional significance of patients' rights, promulgated its PBR in 1973 to address patients' conflicting relationships with hospitals. For 19 years, the document remained unchanged, but in 1992 a new, updated version was published, which is still valid today and will serve as a point of comparison with the MCC. The latter was born within the framework of what Bompiani has called the risposta volontaristica, a spontaneous and operational movement B , which, encouraged by the Tribunale per i Diritti del Malato, swept through Italy some twenty years ago. Although the CDM dates back to 1984, it is still in force and retains much of its initial freshness.
What rights does the PBR contain? report Almost exclusively, it contains some sui generis rights, such as the right of the patient to obtain a response to his requests for services; to examine the account of the costs incurred; to receive explanations about them; to know the financial implications of the different treatment options in the medium and long term deadline ; to be transferred at his own request to another facility; to be informed about the hospital's possible financial links and conflicts of interest, as well as about the cost of the interventions and the available payment methods; to know the hospital's internal rules of procedure. These rights reveal, on the one hand, the individualistic and untrusting ideology of the client, which is expressed in the strong control of the economic element, in the demand for promptness of services, in the autonomous approach to what is to be done. They also express the concern to get the most out of the large amount of money that medical care costs: it is a consumer who has to actively control the cost and duration of his stay in hospital, which, at least in economic terms, is a hostile and potentially dangerous habitat, requiring a vigilant attitude.
In contrast to these rights, those granted by the MCC have, to begin with, a clear political-social intention, which enshrines and demands the equality of all before the attendance sanitary , and condemns any form of favouritism, clientelism or corruption. It is worth bearing in mind that all the clauses of the MHC begin with the expression "Ogni malato ha il dirito di" (except the first, which reads "Ogni cittadino malato ha il dirito di"), while the PBR, without aspiring to the universality and equality of these rights, begins each of its clauses with "The patient has the right to". What is most striking, however, in the MCC is the domestic, familiar tone of many of the rights it confers, which seek, at least intentionally, to create a friendly, humanised habitat in the hospital. MCC recognises rights that may seem minor, but which manifest the dignity of the person and the body. These are the rights to be called by name, not by nicknames or diminutives, not to be addressed by name, not to be objectified by references to one's illness or to the issue of one's room; to dress with dignity, without being humiliated by the obligatory use of clothing that violates bodily privacy; to have decent sanitary facilities, and a friendly ecology, with spaces for relaxation in which to have conversations with family and friends. The CDM recovers rights that were already present in the regulations of some medieval hospitals: that of a hot and varied meal, the frequent change of sheets, the right to receive visitors, to call the doctor of one's confidence.
The text of the MLC does not specifically establish before whom these rights are legally enforceable. A precedent grade of La Sezione Ferrarese del Tribunale per i Diritti del Malato states that "I diritti elencati nella nostra 'Carta' possono essere garantiti, spesso, senza grandi impegni finanziari da parte delle Unità sanitarie locali: sometimes it may be enough to make some changes in the organisation of the work in the distribution or in the service; in some cases it is sufficient to change some of the abbreviations or certain behaviours that lead to ignoring or offending our dignity as men and citizens". The same call to civic responsibility is present in the words that the Sindaco di Ferrara prefixes to the MCC: "The self-responsibility of individuals and the participation of the community [...] are principles and objectives that are ever more important and that can be more easily pursued if the instruments of citizen participation are disseminated and strengthened".
Comiogenesis, rights and collective responsibility
The MCC is full of cordiality and goodwill. This might lead one to believe that relations between doctors, patients and administrators in hospitals should reach a high level of human and professional quality. However, the reality all too often belies the effectiveness of these often truncated claims of rights. Nothing causes doctors more moral fatigue than the deterioration of relations with their patients when they see their expectations frustrated to a greater or lesser extent; nor does anything provoke their ethical pessimism more intensely than to watch helplessly as their just claims on behalf of their patients go unheeded.
There is a serious risk of demoralisation in the hospital where physician-patient-administrator relationships are degraded. The new term "comiogenic harm", as opposed to "iatrogenic" harm, has been coined to specifically designate harm due not to individual interventions by doctors or nurses, but to institutional failures. Patients may suffer harm that is directly or indirectly attributable to the inadequacy of the hospital's general operating system, to cracks in the organisational model , to ways of circulating information, to broken links in the chain of command. Comiogenic damage is not distributed randomly: it has been shown that certain hospitals have fees ten or more times higher rates than others. This seems to lend strong support to the view that the system, rather than the individual, may be the main cause of many hospital losses, which can be attributed to factors such as the hospital's poor collective self-image, lack of corporate moral energy, poor speech among its members, lack of clarity about institutional goals, recurring periods of crisis triggered by chronic problems, which are not solved. There are hospitals with very low morale leave, demoralised.
In search of solutions
Dysfunctions or errors in hospitals are not a trivial matter, nor are disruptions in the relationship between doctors, patients and public administration or the private sector.
As far as the individual patient is concerned, these dysfunctions, errors and disorders can create a great deal of additional suffering for those who are going through the crisis of humanity that is any serious illness. At the community level, they cause serious economic damage, while at the same time damaging a highly valued asset: the social solidarity of financial aid . Conflicts in the health sector, if they become chronic, if they are not resolved quickly, tend to harden the heart of society, and end up by brutalising sensitivity towards the weak. It is therefore crucial to seek and test solutions that reduce the frequency and intensity of these conflicts, since it is an illusion to expect that these dysfunctions will disappear spontaneously.
Undoubtedly, the simplification of the relationships will be linked to the reduction of the heterogeneity of the characters, since it is not possible to reduce their issue. We must accept that the system will always be made up of doctors, patients and administrators, who are linked by basic, bilateral relationships (doctors/patients and patients/doctors, doctors/administrators and administrators/doctors, patients/administrators and administrators/patients). In theory, therefore, it is possible to seek to simplify the system by converging or merging the elements most susceptible to remodelling. Leaving aside the relationships between patients and administrators, which are highly politicised and, in my opinion, resistant to a sincere ethical remodelling, there remains the possibility of trying to act on those that can be influenced by the principles of medical ethics: those between doctors and administrators and between doctors and patients.
There is a well-founded belief that some of the ills of health care systems, and more especially the ills of hospitals resulting from unsatisfactory relations between administrators and physicians, could be prevented or alleviated if hospitals were managed by physicians. This claim is based on the idea that if one and the same person were to perform the managerial function at framework with respect for the professional ethics of medicine, many situations of conflict could be avoided or resolved. In this way, misunderstandings between doctors and managers would be avoided: the current noisy and pugnacious field of tensions would be transferred to the silent realm of the conscience of a single individual. If he or she were competent in both the art of management and the art of medicine, the prospects would be brighter, effective solutions would be reached at a much lower moral cost and inter-organisational clashes would be avoided.
Others think that the solution could come from the alliance between doctors and patients who, by assuming the role of citizens, could carry out the responsibilities of the administration and make themselves position responsible for the management health care. It is a solution that does not restrict, as the Italian Codice di Deontologia does, the status of citizen to patients alone, but extends it to doctors. This would create a new system made up of citizen-doctors and citizen-patients, in which administrators would no longer play a leading role.
The doctor-administrator
The figure of the doctor-administrator and his ethical profile are the subject of deontological consideration in the current Codice di Deontologia. The Codice says in its article 70, when describing the specific deontology of the function of health management: "The doctor who carries out health management functions in public or private structures must guarantee, in the performance of his activity, respect for the rules of the Code of Medical Ethics and the defence of the autonomy and professional dignity within the structure in which he operates. Egli has the duty to collaborate with the professional Order, competent for the territory, in the monitoring competitions on the collegiality in the relations with and between doctors for the correctness of the professional services in the interest of the citizens. Egli, altresì, deve vigilare sulla correttezza del materiale informativo attinente alla organizzazione e alle prestazioni erogate dalla struttura".
The official Commentary of the Federazione degli Ordini does not limit itself to pointing out that the managing physician can never exempt himself from the fulfilment of deontological duties. It authoritatively warns that certain special duties apply to him: he is particularly obliged to act in defence of the independence of the medical profession, he must take care of the correctness and collegiality of the relationships of the doctors working in his institution and, above all, he must promote the implementation of the new deontological relationship between doctors and patients-citizens.
The same Codice also claims for the Ordini the function of fixing the ethical limits of the different modalities and forms of the salaried practice of medicine: as a preventive measure against the weakening of corporate ethics, it requires, in article 67, that contracts and agreements for the provision of services be approved by the Orders, after having ascertained their conformity with ordinal deontology and being well convinced that the legitimate freedom and responsibility, independence and autonomy of the doctor are safeguarded in the work context in which the doctors registered in the Order are going to rent their professional services. This is, according to agreement with the official Commentary to the Codice, a decisive issue "for the very future of the medical profession which, in the view of the Ordine professionale, can never be reduced to print, subject only to the automatic mechanism of the cost-profit scheme".
The integration of the vocation of physician and manager in one person is in line with the norms of many documents of medical organisations. And it is also in line with actual experience, which has shown that medical managers, properly trained in business management, have specific advantages over non-medical managers, including, for example, greater credibility, deeper knowledge understanding of how health care works, greater freedom of expression, greater tolerance for thoughtful and evidence-based whistleblowing. It has also been shown that, because they know how to put patient care before the bureaucratic and automated imperatives of savings and management by diagnostic groups, they not only achieve better clinical outcomes, but do so at lower costs. The UK National Health System, together with the British Medical association , has had the audacity to accept the idea of the superiority of doctor-managers, has promoted their training and has seen that, with them at the helm of hospitals, problems become easier. Among other things, because they are better accepted by their colleagues in the hospital, because they are better able to understand clinical problems; because they act according to the imperatives of medical ethics, not just business ethics; because they have a more sympathetic and informed ability to critique the system internally; because they can implement innovative strategies, without the fear of failure that paralyses their non-clinical counterparts, because they know that, should they fail as managers, they always have the possibility of returning to their clinical work . This is difficult or impossible for non-clinical managers, who, as a consequence and in order to remain in their positions, docilely submit to the mandates of their political superiors, however inappropriate or counterproductive they may be for doctors and patients.
It should be noted that the official document doctor-General Manager is not an entertainment for incompetent, disillusioned or bored doctors. It is official document for vocationally motivated doctors who have come to the conclusion that, already today and increasingly in the future, the management of health care is a core element of professional practice.
It should also be an integral part of the Education of future doctors, who will need to be experts both in clinical problem solving and in analysing and deciding on economic and organisational issues. New generations of doctors need to be spared the pain of past misunderstandings and rivalries, and educated in the idea that patients, doctors and managers share the same goals and must be driven by shared ideals. To create such an ethos of cooperation and mutual understanding, it is necessary that some competent physicians of high intellectual and human quality respond to the vocational imperative to devote at least a few years of their professional lives to management .
Doctors-citizens/patients-citizens: the new synthesis
source A continuing problem in Western Europe, where the population is predominantly served by national health care systems, is the failure to develop a specific medical ethics for socialised medicine. In contrast, European biomedical ethics institutions appear to be saturated with ideas and decision-making procedures modelled on the principlist model imported from the United States.
But this only exacerbates the problems and misunderstandings among European doctors and patients. Indeed, principlism is a methodology of ethical analysis and decision-making, designed to be applied to the commercialised medicine practised in the United States. There, patients are consumers who present their demands to physicians and pay for them with money; physicians are providers who dispense medical services to the extent that they are paid for by clients. There, patient self-determination is not only about the dignity, rights and freedoms of the individual: it also has a strong economic component by virtue of the free trade maxim that he who pays, calls the shots. In the bioethics of principles, there is no proper place for the duties, responsibilities and obligations of the patient. This is prevented by the permanently fluid, reversible nature of the consent given by the patient-client, which he can always and at any time withdraw without any change in his relationship with the doctor or the hospital.
In Europe, on the other hand, we believe with firm faith in the possibility of providing medical care to everyone who needs it, even if they cannot pay for it. But in order that this solidarity application for the rest of the sick does not run the opposing risks of ruining the Economics of countries through excessive expense or wastefulness, nor of ruining the health of patients through stinginess and discriminatory rationing, it is necessary for doctors and patients to adopt a position of shared responsibility which corresponds, by its very nature, to an active role of good citizenship. It is therefore entirely correct to speak of doctor-citizen and patient-citizen relationships.
Because the patient-citizen, in stark contrast to the patient as such, not only has rights: his or her membership in a national health system imposes certain well-defined duties on him or her, and points to concrete and serious responsibilities. The idea of a patients' charter of duties, though not recent, has remained until recently in a larval state, due to the massive influence of the principlist ideology of patients' self-determination, and of their legal capacity to choose and to retract any of their previous decisions. Many patients' bills of rights do not even allude to the possibility of patients having duties and responsibilities. And when they do, they refer to the duty to inform about their illness, to participate in making decisions that affect them, to make judicious use of health services, to cooperate in genere with the system, to care for their health, or to recognise the impact that their lifestyle may have on their wellbeing staff.
It was probably the Spanish legislation, with the General Health Law 14/1986, which was the first to introduce in its articles prescriptions on patients' duties towards society. The PBR, in its revised version of 1992, includes a list of patients' responsibilities, dealing with purely individualistic matters, without a single reference letter on the existence of duties towards society. In Italy, a Decree of the President of the committee of Ministers, the Schema generale di riferimento della Carta dei servizi pubblici sanitari, published in the Gazzetta Ufficiale, 1995, includes a model regulating the obligations of the patient Username of the National Health Service, which contains a heterogeneous list of 14 duties. It is important to note the warning in the heading of this list that "the participation in the fulfilment of some duties is the basis for fully enjoying one's own rights. The personal commitment to rights is a respect for the social community and the health services used by all citizens".
Tom Sorell of the University of Essex has recently published article graduate Citizen-Patient/Citizen-Doctor (Health care Analysis 2001;9:25-39), in which he develops a very interesting outline of the dominant role that citizenship should play in the actions of patients and doctors in the context of a national health system. Sorell states, between the lines, that being a citizen precedes the condition of being sick or being a doctor, and that the obligations towards the community in relation to the measured use and manager of health services are strong. The author alludes to the deterioration that postmodernism has brought about in the heart of doctor-patient relations in the sense of being almost exclusively concerned with the particular and individualistic, and of having relegated the social and universal dimensions of human rights to obscurity.
There is no doubt that it is a complex and long-term task deadline to educate society and doctors to be sensitive to social and community values. But it is business worthwhile. And one on which I would like to hear criticisms and comments in the colloquium that follows. That is the sole purpose of my intervention.
I conclude by recalling an idea that I have repeated many times: John Paul II's moral wisdom about human life and medicine is not only contained in the Encyclical Evangelium vitae, in his speeches to doctors and nurses or in his words to the sick. It is also and radically contained in his social encyclical Centessimus annus, whose medical-ethical message we must discover and practise.
Thank you very much.
gradeThe Author wishes to thank Prof. Francesco M. Avato, Sezione di Medicina Legale e delle Assicurazioni, Università degli Studi di Ferrara, for providing him with the text of some of the Charters of Rights of the Sick in force in Italy.