Medical Ethics and Professional Conduct
Gonzalo Herranz. department on Bioethics, University of Navarra
Session at the 1st Intensive Course on Bioethics at training
At the workshop on Bioethics, Deontology, and Medical Ethics: Limits and Specific Fields
group of the Galician research on Bioethics and the Spanish association of Bioethics
Santiago, September 17, 1996
b. Difficulty in defining: Babel
d. Deep-Seated Conflicts: Deontology and Bioethics
e. The Challenge of Independence
a. The slow pace of change in institutional ethics
b. The excesses of autonomy—or, rather, of autonomism
Greetings and thanks
In a session on Bioethics, Deontology, and Medical Ethics: Boundaries and Specific Scopes, it seems I will have to discuss the boundaries between Deontology and Medical Ethics and attempt to define their specific scopes.
topic Not very pleasant. Arbitrating border disputes is a complex matter. The Beagle Channel, the Serbo-Bosnians.
Yet another instance of the never-ending border disputes. We in the medical profession are living in an era of balkanization: the Central Ethics Commission is constantly receiving complaints about boundary violations or demands to set limits on the scope of practice of general practitioners and specialists, regionalists and proceduralists, and orthodox and unconventional practitioners.
Everything is very unclear: some of us are advocates of skill, while others support degree program. It’s a never-ending battle, but one that—in times of an unbalanced medical workforce—is intensifying and spreading. A group who is constantly work is collecting data and trying to make his way through the tangled jungle of personal conflicts, group , and legislative ambiguity.
There are also conflicts between deontology and medical ethics. This is a typical problem faced by those with an analytical mindset and those with a holistic one—those who prefer broad perspectives and those who are content to dissect subunits.
b. Difficulty in defining: Babel
Because it is not easy to define what is Deontology and what is Medical Ethics. There is a tendency to confuse medical deontology with deontologism, the rule of codified conduct with a cookbook, with a childish way of dominating behavior, with criteria dictated by corporate gurus to maintain professional status and the privileges of yesteryear.
Medical ethics has gotten a bad rap, as it is not viewed as a distillation of wisdom internship — a well-thought-out, debated, and consensus-based response from the medical profession to a social demand, a compendium for the medical community to use to inspire, enrich, and foster their ethical spirit. To philosophers, it may seem somewhat inconsistent, eclectic, and of lesser importance.
But medical ethics isn’t easy to define either. The ideas floating around are that it’s an offshoot of bioethics—a construct created to tear down traditional medical-ethical values—a figment of the imagination of those who have never set foot in a doctor’s office, worked in the public health system, lived in a hospital, or touched a patient. business —which has sown confusion, stirred up the public, and filled patients’ minds with the smoke of unchecked autonomy—is capable of justifying medical “ financial aid ” toward suicide, euthanasia, and the most reckless reproductive practices.
They do not want to see the transcendental contributions he has made, in rationalizing and formalizing respect for the patient, the analysis of the purposes of medicine, his role as an awakener of dormant consciences, and his role as a vector of patients' rights.
The reality is extremely complex. Because neither professional ethics is a patchwork of inherited rules, nor is medical ethics the product of armchair philosophers. It seems to me that these are things that coexist—with varying degrees of tension—in the soul of a good doctor.
Let's look at an example.
For a work, I have been collecting Codes of Medical Professional Conduct from Europe and America. Judging by their titles, there is something for everyone:
In Europe and the English-speaking world
Code of Medical Ethics: Belgium, France, Italy, Luxembourg. Code of Ethics: Portugal. In the Americas: Costa Rica, Guatemala, Venezuela
Code of Ethics: Honduras
Code of Medical Ethics: Slovakia, Finland, Greece, Iceland, Norway, Poland. In the Americas: Canada, Argentina, Bolivia, Brazil, Chile, Paraguay, Uruguay, and the United States.
guide Code of Ethical Conduct: Ireland
guide Department of Medical Ethics, UK.
Ethical Guidelines. Denmark, the Netherlands
Principles of Medical Ethics, Cuba.
Professional Code: Germany
Professional Standards for Physicians: Sweden
Standards on Medical Ethics and Morality: Colombia
Code of Medical Ethics, Costa Rica
Permanent Professional Standards, Switzerland (FMS), German-speaking cantons. + Codes of Ethics in the French-speaking cantons.
Spain distances itself from the problem: “Code of Medical Ethics and Professional Conduct,” as a shrewd Galician, Alberto Berguer—who chaired the OMC in 1990—once decreed. Peru had done the same in 1970, twenty years earlier.
Austria has no problems, because it is the only country in the Western Hemisphere that lacks a code of professional conduct.
As can be seen, the intermingling, the equivalence of the syntagms is patent. Each national Medical association designates its standards of behavior by combining four or five terms: Code, Norms, or Regulation, with Ethics, Deontology, Morals. Thus, all possible combinations are possible.
This seems to resolve the issue raised by the degree scroll: there are no limits or specific content; Medical Ethics and Medical Deontology are understood as one and the same thing—a single reality that is referred to interchangeably by one term or the other, or both, depending on geographic regions and local cultural or semantic traditions: The term “Ethics” is used more frequently in Northern Europe and the Anglo-Saxon world, while “Deontology” is used more in Southern Europe. However, many countries in Central and South America also use the term “Ethics.” There are no fixed rules. This does not seem to pose a problem.
d. Deep-Seated Conflicts: Deontology and Bioethics
But we know full well that, beneath that peaceful appearance, beneath that calm sea, very strong currents intertwine, and deeply conflicting conceptions of life and humanity clash. The physician’s conduct is yet another element of the social, political, and ethical pluralism of our time and our world. It is both a result —and a cause of it—since it is a fundamental element of that pluralism.
The truth is that there are contrasts between Bioethics and Deontology, at the theoretical level, and between bioethicists and deontologists, or rather between bioethicists and deontologists, everywhere: in publications and discussions, within committees and commissions, and, logically, in the debates in the media.
Although it is repeated ad nauseam that society is pluralistic, we all, inevitably, have, by virtue of our intellectual honesty, a tendency to show the advantages, the superiority, of our own opinion. And although everyone proclaims that no one can violently impose his or her convictions on others, there is - we have witnessed it here and abroad, as a universal phenomenon - an opportunistic search for power, a policy of occupying the positions of training, of economic support for certain educational programs that tend to implant dominant modes of thought.
I am quoting from an article by an American author of undisputed prestige: “The doctrine of the four principles has been taught to hundreds of health professionals through a bioethics course taught every year for the past 18 years by the faculty at the Kennedy Institute of Ethics at Georgetown University. Through its graduates—about 200 each year—this program has exerted a very strong influence on health care professionals and on ethicists who teach at medical schools or serve on committees at clinical institutions. A large issue of young doctors and nurses have had Kennedy Institute graduates—who are now directors of bioethics centers—as their ethics instructors. The tradition of the four principles is now so widely accepted that some of its critics have labeled it a “ label ,” implying that it is often applied automatically and without a solid intellectual and moral foundation.” Pellegrino, DE. The Metamorphosis of Medical Ethics. A 30-Year Retrospective. Arch Pathol Lab Med 1994;118:1065–1069).
e. The Challenge of Independence
It is difficult, in such a context, as in any other, to be truly independent, not to be dragged along by what is fashionable, not to adhere to what is in vogue. Because what is in vogue is to prohibit the adduction of transcendent arguments or references, to cite moral authorities, to allude to the magisterium, to confess a faith. Orthodoxy is to move within the ideas and principles of minimal civil ethics.
It would be very interesting to try to understand, in order to go deeper, the significance internship and the theoretical basis of the minimum civil ethics advocated in the Preamble of the Assisted Reproduction Law, which is declared as the official ethics of the state.
agnostics and believers,
traditionalists and iconoclasts,
substantive and procedural.
North and South
Common Law and the Napoleonic Legacy
ethicists and moralists
autonomists and paternalists
legislation and social rules and regulations versus professional autonomy and self-regulation
Some think that, just as humanity had been asleep until the Enlightenment, the medical internship woke up with the new principle. That, after a slow maturation, Kant gave birth to the idea that persons are autonomous moral subjects. That then begins the long road that brings us, with the progressive implementation of democratic rights, the awakening of tolerance in society, the autonomy of the individual. Absolutisms are questioned and democracies are born.
“What is astonishing is that, even though partner-political relations have undergone radical changes over time, in healthcare relations the patient has remained a child—physically, mentally, and morally disabled—until just the day before yesterday” (work by S. Aguirre). It was not until well into the 20th century that this began to be called into question. This took place in the United States, the oldest republican democracy on earth.
This is what deprives. Supporters of one of the poles. Few equanimous who try to distill the wisdom and foolishness of each position.
I believe I have a fairly thorough understanding of medical ethics. And I don’t think I’ve been lazy about reading and evaluating everything I’ve been able to on contemporary medical ethics. And after quite a few years of striving to avoid being a dilettante, of approaching issues with professional seriousness, of being involved in the inception of certain initiatives, of gaining insight into the international landscape—at least within European organizations—and of traveling and engaging in extensive discussions, I can offer for discussion some provisional conclusions regarding the relationship between professional ethics—as found at written request rules and regulations —and medical ethics—as a field of reflection and thought— source .
Just as it is often said that bioethics came to save philosophical ethics from a near death, it can also be said that the ethical-philosophical consideration of the problems of medicine has brought new life to professional ethics.
Just compare the Codes of thirty years ago with those of today. A Copernican revolution. Clamorous, as in the case of Canada. Progressive, in most other countries. With an inexplicable pachorra, in some cases.
2. This has been result of having subjected the entire deontological system to a serious revision, in the light of the new emphasis on human and civil rights, under the impulse of the new currents of academic ethics, of the new situations created by scientific and technological progress.
3. Nor should we overlook the impact of professional factors: the emergence of medical specialization, national health care systems, institutional democratization, demographic changes, and the growth of international relations. But of all these factors, perhaps the most influential has been the reexamination of the deontological tradition in light of moral philosophy.
Since there is a risk of getting lost in an abstract discussion of these matters, let's look at a couple of examples.
These are two topics I've been studying recently.
a. The slow pace of change in institutional ethics
1997: Fiftieth anniversary of the Nuremberg Code. Mythologization: Nuremberg is the birthplace of modern medical ethics. In a way, history is told in years before and after Nuremberg. Is this true?
Despite official doctrine, Nuremberg was unknown—or worse, ignored. The news was reported months later by the JAMA in an obscure section of letters from foreign correspondents. The other magazines that shape public opinion didn't even hear about it.
Years of neglect. In 1948, the Geneva Declaration—the new wine of the new professional ethics in the new wineskin of the declaration of one’s own honor—came to replace the old wine of the Hippocratic ethics and its old wineskin of the oath before God. A new secular and irenic era dawned. Not a word about free and informed consent. In 1949, the London Code—the same thing. In 1964, tentatively, Helsinki I introduced the notion of the subject’s free and informed consent for experimental intervention.
But the idea was incorporated into the codes very slowly: 1964, U.S.A. Costa Rica and Peru, 1970. Switzerland and Venezuela, 1971. Belgium, 1975. Canada, Italy, and the United Kingdom, 1978. Spain and France, 1979. Ireland, 1984. Germany and Portugal, 1985; Chile, 1986. There are no ethical guidelines on clinical trials in the codes of Argentina, Bolivia, Colombia, and Cuba.
B , there is a resistance to change. I believe that corporate medicine found itself in a state of paralysis that lasted nearly 20 years, from 1957 to 1977. During that period, in Europe, codes of professional conduct were enacted in only five countries: Germany, Belgium, Norway, Sweden, and Switzerland. And the WMA weathered the storm by publishing primarily documents from its economic section— partner: the 12 Principles on the Provision of Medical Care in National Health Systems (1963), the Recommendations Concerning Medical Care in Rural Areas, the Postulate on Family Planning (1969), and the Postulate on Pollution (1976). Over the course of those 20 years, the medical ethics section proposed: the First and Second Helsinki Declarations (1964 and 1975), the Postulate on Death (1968), the Postulate on Therapeutic Abortion (1970), the Postulate on the Use of Computers in Medicine (1973), and the Tokyo Declaration (1975), along with the Postulate on the Use and Misuse of Psychotropic Drugs.
The Lisbon Declaration on the Rights of the Patient did not arrive until 1981.
This is a story yet to be told. Someday we will have to take a close look at the underlying reasons for such resistance to incorporating what was justly demanded from outside the profession. The explanation likely lies not so much in an entrenchment in the conservatism typical of professional organizations—archetypal of medicine as a social institution—but rather in the internal problems that institutional medicine itself was facing. There were certainly social changes, though their intensity and scope varied greatly from one country to another. The 1960s were the years of May 1968 in France, the Vietnam War, Vatican II and the immediate post-conciliar period in the Church, the civil rights movements, feminism, consumer activism, the ridicule of traditional social values, especially moral authority; the contempt for institutions of order (the military, religious denominations); the spread of drug addiction; and sexual liberation. These were years of economic expansion and the glorification of youth, of the sentimental and ideological revolution led by singer-songwriters.
Meanwhile, medicine was undergoing a severe crisis: one characterized not so much by specialization as by fragmentation into subunits with little communication among them; by the construction and technical equipping of giant hospitals; and by the depersonalization caused by development plenary session of the Executive Council of socialized medicine. These were the years of transplants, of Beecher and Pappworth’s terrible accusations against medical abuses in the field of biomedical experimentation, of ICUs, and of the first concerns, in those years of abundance, about medical rationing; of lenient abortion laws; of hedonistic contraception; of the first protests against the abuse of medical technologies; of science for the people; of so many other things: of *Humanae vitae*, of the Helsinki I Declaration, …
Medical organizations had no shortage of problems—so numerous and of such massive proportions that, rather than being resolved, they hindered the institutions’ ability to respond.
But the fact remains: the ethical response was slow, late, lazy. A malignant precedent was set: in the face of problems, it is possible to ignore and marginalize oneself. Deontology has not yet recovered from this attitude: slow to react, slow to promulgate norms or to make recommendations, passive in the face of many ethical infractions. A strong loss of authority: I sometimes think that there was an initial Withdrawal to moral authority. I do not know if Thomas Sterne Eliot's lines can be applied here: In a moment of weakness, we capitulated unconditionally. We surrendered in surrender things that had taken centuries to conquer and will take centuries to regain.
Professional ethics may, of course, have its flaws and limitations as a term of ethical reference letter . But that is not its main limitation—nor is it even a serious one: what, in my view, has rendered it useless or drastically diminished its effectiveness has been the delay in accepting the challenge of the times, the passivity in failing to teach it, to dignify it, to let it fall into oblivion, and to deprive it—sometimes cynically—of its educational power. Let us not forget that “ discipline ” and “disciple” come from “discere,” to teach. “ discipline,” rather than punishing, is, for me, about teaching, about educating. That gives it a paramount ethical value.
This first example almost puts professional ethics up against the wall. It's a story that teaches us that we need to be more active, braver, and more sensitive.
My second example, is a critique of an emblematic aspect of the medical ethics of the four principles.
b. The excesses of autonomy—or, rather, of autonomism
I maintain - as I have written many years ago - that all of us, physicians and non-physicians alike, owe an unpayable debt to contemporary medical ethics for having balanced the physician-patient relationship in the sense of having turned it into a relationship of two equally worthy, equally valuable human beings.
The old, ethically skewed relationship—in which all the advantages—knowledge and power—were in the hands of the doctor—has become more humane. Today, in principle, doctor and patient can interact on an equal ethical footing; they can engage in a dialogue as equals—not in the sense of a familiar, overly casual exchange, but as part of an interpersonal relationship between mature moral agents.
This should always have been present in the doctor-patient relationship, but only in recent years has it been made explicit. We are beginning to adapt to the new status, unfortunately more out of fear of court rulings or rising liability insurance premiums than out of ethical conviction.
Curiously enough, and because of these same legal constraints, rather than medical ones, this ethical equalization between the physician and his patient is expressed in the process of obtaining and documenting informed consent. God willing, the opportunity for ethical growth will not be stifled by mere legal precaution. That could be the death of medical ethics, drowned by law, which is happening in the USA.
For me, there is no more demonstr test tion that informed consent is becoming a mere legal façade for what actually happened with the informed consent that— agreement ly with the Declaration of Helsinki—the subject grants for experimentation. That rational and free agreement between two moral agents—the researcher and the subject—instead of being a noble and sincere process of information and consent, becomes a matter stripped of responsibility.
It is worth recalling the historical process.
August 1947. We return to Nuremberg. The verdict against the Nazi doctors for the atrocities committed in the concentration camps during their horrific experiments. The court’s ruling is based on the established doctrine of crimes against humanity, the infliction of cruel and degrading treatment, and—this is the new development that interests us—what we call the Nuremberg Code.
The Nuremberg Code has ten clauses, of which two, the first and the ninth, deal with the consent of the subject.
The first solemnly states that the voluntary consent of the experimental subject is absolutely necessary. The first clause goes into detail about the information to be given to the candidate experimental subject and the freedom to be granted to him to ensure the voluntary nature of his consent. But the most important thing, in my opinion, that the first clause of Nuremberg says is that the consent to experimentation is not a matter for the subject alone, but that it is up to the experimenter to decide in conscience whether such consent is ethically worthy and correct, whether it has been obtained with sincerity and honesty. For the experimenter is morally obliged to reject as invalid or weakened the consent of whose human dignity he cannot be the guarantor.
The ninth clause adds the conditions for withdrawal of consent: During the course of the experiment, the subject shall be free to terminate his participation in the experiment if he reaches a point status, mental or physical, in which he considers it impossible to continue.
Before we continue, let us ask ourselves what is this Nuremberg mandate: deontology or extra quality ethics? It seems to me that it is medical ethics of a higher quality. And as such, because of its exigency and excellence, it had no future. When 28 years later, in 1975, the Declaration of Helsinki was reformed in Tokyo (Helsinki I had said nothing about the withdrawal of the subject in the course of the experiment), it says the following in point # I.9: In any research on human beings, every potential subject shall be informed that he may withdraw his consent at any time.
This issue becomes more pronounced over time: In the United States, in 1978, the Belmont Report—and, following it, all federal regulations—included among the requirements of informed consent the requirement to inform the subject “that he or she may fail withdraw from the study at any time without penalty or loss of any benefits to which the subject is entitled under any other degree scroll .” In the United Kingdom, the Medical Research Council’s guidelines state that subjects must be informed that “they will be free to withdraw at any time without giving any reason and without this in any way affecting their medical care.”
Logically, it would be macabre to take revenge on the subject who withdraws from the experiment, but is the authorized conduct of abandoning the French woman, after having given her serious, free, conscious consent, ethical?
The consequence of the implementation of "light" consent is the B number of experiments that lose statistical power due to the frivolous or irresponsible behavior of the subjects who abandon them. Or perhaps also because of the lightness with which informed consent is obtained. For this reason, I have proposed to distinguish, from the point of view of both the experimenter and the experimental subject, a subject Nuremberg consent and a subject Helsinki consent.
The first is consent that has been earnestly sought and granted by conscious and responsible individuals. The second is something frivolous and superficial, coming from individuals who respect neither themselves nor others. I sincerely believe that a haughty, almost libertarian notion of the autonomy of the research subject—so characteristic of postmodernity—played a role in the genesis of the Helsinki subject consent.
The first example, that of the stubborn resistance of medical corporations to grasp and incorporate the messages of ethical reflection, sample the excesses of corporate deontology. The second example, sample , shows how human relationships can be degraded in terms of dignity and moral breath when the reflections of ethicists go off track and dilute responsibility to the point of leaving the very human process of free and informed consent invertebrate, but for this very reason manager and solid. When autonomy is flattered, disobedience to the experimental plan and the withdrawal of the clinical essay arise. To compensate, the calculation of the size of the sample has to be done loosely, to compensate for the unsupportive behavior of those who say yes, but do not assume responsibility. This makes research much more expensive. No one is obliged to accept the invitation to be the subject of experimentation. But here, as in everything else, including the electoral promises of politicians, the ethical rule is: be it your yes, yes; and your no, no.
I have proposed to the WMA that the Helsinki declaration be reformed in the sense that the potential subjects of the experiment be report about the consequences, scientific and economic, that derive from the frivolous behavior of those who withdraw without reason, of those who neglect to comply with the experimental plan.
Deontology and medical ethics cannot be opposed to each other. Ethics reduced to reflection remains in philosophical cenacles, in the chatter of committees, in articles that hardly anyone reads.
Deontology remains, when it works, a disciplinary regime, a system for the preservation of corporate privileges, in norms that become intellectually fossilized if it is not enlivened with the sensitivity and vitality that comes from ethical reflection.