In defense of professional deontology: a rationale for non-philosophers
Gonzalo Herranz, department of Bioethics, University of Navarra
Intervention in workshop of Bioethics: Trends in moral foundations
Pamplona, September 21, 1996
Difficult to define: Semantic and decisional Babel.
But isn't this a bit of an exaggeration?
Profound conflicts: Deontologism and bioethicism
The difficulty of independence
The slow pace of change in institutional deontology
The excesses of autonomy or, rather, autonomism
Professional ethics, as a doctrine or ethical praxis, has a very bad press. In part, as we shall have occasion to see, it is well deserved: those who propose or administer it have mistreated it; often, they have not hesitated to forget it. At other times, they have brought it up according to their own interests, that is to say, they have instrumentalized it and made opportunistic use of it. Deontology has not had very faithful servants. However, it has not lacked those who have taken care of it and, thus, it has resisted the mistreatment of others. And it continues to present itself as a source of good moral criteria and salt that preserves corporations from corruption.
But much of this discredit comes from outside. It has academic roots: at best it is viewed with disdain. Deontology is seen as a poor sister of ethics, good-natured but dim-witted, lacking intellectual breath, alien to deep ethical reflection, lacking the systematic character of metaethical constructions. It is a kind of hybrid, with a little bit of each.
Between Ethics or, for that matter, Bioethics and Deontology there is the distance average between a treatise and a guide, between a Summa theologica and a popular catechism. Ethics, which defines itself as a science, a rational knowledge, is Philosophy moral, and is sociologically situated between academic disciplines. Some see Deontology as an entertainment for dilettantes, for professionals who are philosophers, who do not go beyond periodically producing a guide of instructions, or a compendium of recipes, to solve small, common problems.
But the worst thing, what makes deontology unpopular or downright unpopular, is not that it has remained lowly in comparison with its sisters. What causes lack of sympathy, even what predisposes to hostility, is that, on the threshold of the 21st century - or to give it more emphasis, of the third millennium - deontology continues to speak of duties, when people only want to hear about freedoms. It is still linked to authority, when the atmosphere is saturated with a general desire to challenge authority and to make fun of the traditions linked to it. Autonomy is in vogue everywhere. Deontology and the codes in which it is usually expressed are no longer in vogue, for it is not to the taste of the times to be commanded.
Ours is a time in which many people do not like respect: it is a sophistic age, in which the idea that nothing and no one is worthy of respect is spreading: everything can be laughed at, there is no room for veneration.
Finally, there is an ideological confrontation, according to which Deontology and Ethics or Bioethics mean not only different things or different ways of behaving, but rival conceptions of the world and of man. There are frontier struggles of domination and control: in the face of public opinion, in the control of the health management , within hospital ethics committees.
Citing the Code in Committee sessions: a very strange thing to do, since it is infrequent and causes surprise.
Deontology and Medical Ethics try to define their specific fields, but without seeking to understand each other.
When representatives of professional bodies and philosophers meet on a committee of essay of standards or statements. Much in common, but also much friction. The long, interminable discussion of the successive drafts of the Convention on Bioethics of the committee of Europe. Biojurists, bioethicists, physicians of different convictions. The fight around the embryo expresses the existence of conflicts between Deontology and Medical Ethics. A typical problem to confront the analytical and the global, those who prefer the big perspectives or those who are happy to dissect subunits.
Difficult to define: Semantic and decisional 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.
Deontology has a bad press, because it is not considered as a distillate of wisdom internship, an elaborated answer, long discussed, consensual, but in solidarity with a very firm professional tradition, with a specific vocation, with a history deeply rooted in what is truly human, with centuries of Christian impregnation. Deontology is not deontology, but it contains much ethics in its structure.
I believe that the phenomenon of the self-regulating corporate organization that produces a professional Code of Conduct will last forever. A Code is a compendium of ethics for the physician's use, which is there to inspire, enrich and develop his or her ethical breath. To philosophers it may seem somewhat inconsistent, eclectic, minor, a regulation rather than a treatise, but a regulation with a lot of ethics in it.
But medical ethics is not easy to define either. Bioethics also gets a bad press. The ideas that circulate around are that it is an offshoot of ethics, a construct created for the demolition of the usual medical-ethical values, a hotbed of those who have never been in a doctor's office, never worked in an NHS, never lived in a hospital, never touched a sick person.
A business that has brought confusion, that has made people lethargic, that fills the heads of the sick with the smoke of unbridled autonomy, that is capable of justifying the medical financial aid to suicide, euthanasia, the most feverish reproductive combinatorics. Some have already said that Ethics or Bioethics has been sold to the highest bidder of capitalism, to the interests of the medical industrial complex, to the health maintenance organizations.
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 real picture is, as we can see, extremely complex. Because neither deontology is a hundred inherited rules, nor medical ethics is a product of armchair philosophers. It seems to me that they are things that, to a greater or lesser degree, must coexist in tension in the soul of the good physician. It is no longer possible to be simply knowledgeable about the Code. It is a lot, but it is not enough: each one must give a reason for his convictions, he must be able to dialectically sustain his fidelity to the codified traditions. Just as in these times it is not enough to survive to be content with having the faith of a charcoal burner, since it is carried away by a few television programs; neither is it enough to be content with mere deontological fidelity, since it is carried away by a few permissive laws or the harsh status labor market, in which to compete for a work space one sometimes has to sell one's soul.
But isn't this a bit of an exaggeration?
The first thing in professional ethics is to produce codes. Without a code there is no profession, because without a code there is no promise to society of skill, service, integrity, unity and prestige of professionals. The social pact means a exchange of the right of exclusivity and prestige for the commitment to guarantee science, skill, dedication: integrity.
Because a Code is a guide that financial aid professionals to direct their work, to know the terms of reference letter, to set the minimum requirements. It is also a regulation that indicates responsibilities, standards of conduct, values to be respected in order to comply with the required requirements . A Code plays a disciplinary role, since it indicates which behaviors mean a transgression of what is established and allows the authority to govern with reference letter to a law, in order to correct those who deviate from the agreed behaviors. A Code is a protective barrier for the patient, who can never be the object of injustice, mistreatment or contempt. If the Codes of Ethics were well known to the public, with the intensity and detail with which the rules of soccer or the Highway Code are known, people would know in advance what to expect from the doctor or the health professional, which would result in a healthy promotion of criticism and trust. The code is thus an open proclamation of moral commitments. In some countries it has the status of law (France, several Latin American republics) and thus serves as a basis for publicly justifying the privileges of the physician. The Code is a source of concord: it regulates interprofessional relations.
Much can be expected from the codes, which should never be a dead letter, but an intensely lived and life-giving spirit.
All this is ethics in action, not just in theory. Therefore, it is important to recognize that good ethics is good ethics. In the professional tradition, there does not seem to be many headaches about the relationship between ethics and deontology. 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. In America: Costa Rica, Guatemala, Venezuela. Code of Deontology: Portugal. Rules of Deontology: Honduras
Code of Medical Ethics: Slovakia, Finland, Greece, Iceland, Norway, Poland. In America, Canada, Argentina, Bolivia, Brazil, Chile, Paraguay, Uruguay, USA. guide of Ethical Conduct: Ireland. guide of Medical Ethics, UK. Ethical Rules. Denmark, Holland. Principles of Medical Ethics, Cuba.
Professional Code: Germany
Professional Standards for Physicians: Sweden
Norms on Medical Ethics and Morals: Colombia. Code of Medical Ethics, Costa Rica. Permanent Professional Standards, Switzerland FMS, German Cantons. More Codes of Ethics, French-speaking Cantons.
Spain dissociates itself from the problem: Code of Medical Ethics and Deontology, decreed at the time a clever Galician, Alberto Berguer, who presided over the WTO in 1990. Peru had done the same in 1970, twenty years earlier. Austria and Mexico have no problems, because they are countries that lack 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 dissolve the problem: there are no limits or specific contents: Medical Ethics and Medical Deontology are understood as one and the same thing, they are one and the same reality that is designated indistinctly in one way or the other, or both, according to geographical areas and local cultural or semantic traditions: Ethics is spoken of more in Northern Europe and in the Anglo-Saxon world. Deontology is spoken of in Southern Europe. But Ethics is spoken of in many Central and South American republics. There are no fixed rules. There seems to be no problem.
Profound conflicts: Deontologism and bioethicism
But we are well aware that, beneath this peaceful appearance, beneath this calm sea, very strong currents are intertwined, very antagonistic conceptions of life and of man are confronting each other. The physician's conduct is one more element of the social, political and ethical pluralism of our time and of our world. It is result and its cause, since it is a very important element of this 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 copy from a article of 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 academic staff of the Kennedy Institute of Ethics at Georgetown University. Through its graduates, some 200 each year, this program has exerted a very strong influence on health professionals and on ethicists who teach in medical schools or serve on committees in clinical entities. A large issue of young physicians and nurses have had Kennedy Institute graduates as ethics teachers who are now directors of bioethics centers. The tradition of the four principles is now so widely accepted that some of its critics have branded it with the label mantra, to imply 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 Patol Lab Med 1994;118:1065-1069.
The difficulty 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.
The fight is on: agnostics and believers, traditionalists and iconoclasts, substantive and procedural, North and South, Common Law and Napoleonic heritage, ethicists and moralists, autonomists and paternalists, legislation and social rules and regulations versus autonomy and professional 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 been radically transformed over time, in health care relations the patient has remained a child, a physical, mental and moral handicapped person, until practically the day before yesterday [...] It was not until well into the 20th century that this status began to be questioned. The emancipation of the patient took place in the United States, the oldest republican democracy on earth, thanks to the implementation of the Principles of Bioethics. And from there, bioethical principles have been spreading throughout the world [...]" (work by S. Aguirre).
This is what deprives. Supporters of one of the poles. Few equanimous who try to distill the wisdom and foolishness of each position.
I think I know quite a bit about medical ethics. And it seems to me that I have not been lazy to read and evaluate everything I could about medical ethics today. And after more than a few years of avoiding being a dilettante, of living the problems with professional seriousness, of being at the birth of some initiatives, of peeping into the international panorama, at least in the European organizations, and of traveling and chatting a lot, I can offer for discussion, some provisional conclusions about the relations between professional Deontology as written request rules and regulations and Medical Ethics as source of reflection and thought.
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.
Nor can we forget the force of professional factors: the introduction of specialization, national health systems, institutional democratization, changes in professional demographics, and the increase in international relations. But, of all the factors, perhaps the most influential has been the reanalysis of the deontological tradition in the light of the moral Philosophy .
Since there is a danger of getting lost in an abstract consideration of things, let's look at a couple of examples. They are two issues that I have studied recently.
The slow pace of change in institutional deontology
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 the official doctrine, Nuremberg was unknown, or worse, ignored. The news was broken, months later, by JAMA in an obscure section of letters from foreign correspondents. The other opinion-forming journals did not even hear about it.
Years of oblivion. In 1948, the Geneva Declaration of Geneva meant the new wine of the new professional ethics in the new wineskin of the declaration for one's own honor that came to replace the old wine of Hippocratic ethics and its old skin of oath before God. The new secular and irenist era opens. Not a word about free and informed consent. In 1949, the London Code, the same thing. In 1964, timidly, Helsinki I introduces the notion of free and informed consent of the subject for experimental intervention.
But the idea enters very slowly in the Codes: 1964, USA, Costa Rica and Peru, 1970. Costa Rica and Peru, 1970. Switzerland and Venezuela, 1971. Belgium, 1975. Canada, Italy and United Kingdom, 1978. Spain, France, 1979. Ireland, 1984. Germany and Portugal, 1985. Chile, 1986. There are no deontological norms on clinical experimentation in the Codes of Argentina, Bolivia, Colombia, Cuba and Colombia.
It is B the resistance to change. I believe that corporate medicine was gripped by a paralysis that lasted almost 20 years, from 1957 to 1977. In that period, in Europe, professional codes of conduct were promulgated in only five countries: Belgium, Germany, Norway, Sweden and Switzerland. And the WMA weathered the storm by publishing predominantly documents from its section partner-economics: the 12 Principles on the Provision of Health Care in National Health Systems (1963), the Recommendations Concerning Health Care in Rural Areas, the Postulate on Family Planning (1969), the Postulate on Pollution (1976). During these 20 years, the Section of Medical Ethics proposed the first and second Declaration of Helsinki (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 Declaration of Tokyo (1975) together 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.
It is a story that remains to be told. One day we will have to study in detail the deep motivations for so much resistance to incorporating what was justly demanded from outside the profession. Probably, the explanation does not come so much from an entrenchment in the conservatism typical of corporations, archetypal of Medicine as a social institution, but from the internal problems that corporate Medicine itself was experiencing. There were certainly social changes, with very different intensity and extent from one country to another. The 1960s were the years of the French May, the Vietnam War, Vatican II and the immediate post-conciliar period, in the Church, the civil rights movements, feminism, consumer activism, the ridiculing of traditional social values, especially moral authority, contempt for the institutions of order (army, religious confessionalism), the expansion of drug addiction, sexual liberation. These were years of economic expansion and flattery of young people, of the revolution, sentimental and ideological, of the singer-songwriters.
In the meantime, medicine was going through a very strong crisis: more than of specialization, of fragmentation into barely intercommunicating subunits; of construction and technical equipment of gigantic hospitals; of depersonalization by development plenary session of the Executive Council of socialized medicine; these are the years of transplants, of the terrible accusations of Beecher and Pappworth against medical abuses in the field of biomedical experimentation, of the ICUs, of the first concerns, in those years of abundance, about medical rationing, of the tolerant legislation of abortion, of hedonistic contraception, of the first protests against the abuse of medical technologies, of science for the people, of so many other things: Humanae vitae, Helsinki I, etc.
Medical corporations were not lacking in problems, so numerous and of such massive dimensions that instead of being solved, they inhibited institutional response capacity.
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 obviously have its flaws and limitations as a term of reference letter ethical. But that is not its main limitation, not even a serious one: what, in my opinion, has rendered it useless or tremendously diminished its effectiveness has been the delay in accepting the challenge of time, the passivity in not teaching it, in not dignifying it, in forgetting it, in depriving it, sometimes cynically, of its educational force. Let us not forget that discipline and disciple come from discere, to teach. The discipline, more than in punishing, is for me in teaching, in educating. This gives it a first-rate ethical value.
This first example almost drove deontology to the wall. It is a story that teaches us that we must be more active, more courageous, more sensitive.
My second example, is a critique of an emblematic aspect of the medical ethics of the four principles.
The excesses of autonomy or, rather, 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 biased relationship, with all the trumps - knowledge and power - in the doctor's hands, has been humanized. Today, in principle, doctor and patient can treat each other on a plane of ethical equality, they can hold a face-to-face dialogue, not in the sense of a trusting tuteo, but in the sense of an interpersonal relationship, of 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 demonstrative test that informed consent is becoming a mere legal disguise than what happened with the informed consent that, from agreement with the Declaration of Helsinki, grants the subject for experimentation. In this rational and free agreement of two moral subjects, the researcher and the proband, instead of being a noble and sincere process of information and consent, it becomes a matter emptied of responsibility.
It is worth recalling the historical process.
August 1947. Back to Nuremberg. Judgment against the Nazi doctors for the atrocities committed in the concentration camps on the occasion of their horrendous experiments. The judicial sentence is justified in the common doctrine of crimes against humanity, in the application of cruel and degrading treatment, and, this is the novelty that interests us, in 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.
In the United States, in 1978, the Belmont Report and, after it, all federal regulations include among the requirements of informed consent that of informing the subject "that he/she may fail his/her participation at any time without penalty or loss of benefits to which the subject is otherwise entitled degree scroll ". In the United Kingdom, the Medical Research Council guidelines state that subjects must be advised that "they will be free to withdraw at any time without giving any reason and without in any way neglecting 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 a seriously obtained and granted consent, from conscious and responsible people. The second is something light, superficial, from individuals who do not respect themselves or others. I sincerely believe that in the genesis of the consent subject Helsinki has intervened a haughty, almost libertarian, notion of the autonomy of the experimental subject, so typical of postmodernity.
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.