Teaching medical ethics
Gonzalo Herranz, department de Humanities Biomedicas, University of Navarra.
lecture Delivered at the Social committee of the University of Alicante, 2002.
Cycle "Ethics, University and Civil Society".
Ethics in university programs of study : Educating doctors ethically in order to educate society.
To begin with, it is worth clarifying one point: just as it is not difficult to think about the numerous and concrete problems of medical ethics and its many disputed questions, it is a much more difficult matter to deal with how to teach it. It is within the reach of anyone with the right official document, to confront, after the always necessary study and the required reflection, any of the bioethical problems that arise from the real advances of research or from the sensationalist news of the media speech. It is always an attractive experience to discuss in an orderly and peaceful manner the rights of patients, the limits of the doctor's freedom to prescribe, the ethical complexities of cloning or the fate of abandoned human embryos.
For me it is more difficult to deal with the topic that has been entrusted to me: how and for what purpose to teach medical ethics, in what social context to do so. It is a matter of great responsibility. I am comforted to know that this concern does not affect me alone.
Jordan Cohen, the current President of the association American College of Medicine, says that Mark Twain once said: "To be a good person is a noble thing; to teach others to be good people is an even nobler thing. And, by the way, much less complicated". But, Cohen rightly observes, the venerable Mr Twain may have said that because he never taught at a medical school School . The opposite is true of us medical teachers. We can, it is true, with effort, come to fulfil exemplary professional commitments, and be good teachers and good doctors, even good people. But teaching medical ethics to students is a complicated business, which never leaves one satisfied.
Throughout my twenty years of teaching Medical Ethics, I have always dedicated a moment, after each class or each seminar, to do the math. And I always came to the same rejuvenating and stimulating conclusion: "next year I will have to do better, much better, in this and in that". I don't think that this talk now will be spared neither of the deficiencies nor of the good resolutions.
I will develop it in the form of three proposals:
1st proposal. That today, educating physicians ethically is a function that the Schools of Medicine cannot avoid.
2ND proposal. That this teaching has a main goal : to be an instrument for integrating future doctors into a profession that is, above all, a moral community.
3RD proposal. That an essential element of the teaching of medical ethics is to educate in social responsibility.
Let's start with the
proposal 1st: Educating physicians ethically is nowadays a function that the Schools of Medicine cannot avoid. 
a. A bit of recent history
But first, an aside. reference letter It is impossible to deal with this point realistically without referring to the status of absence and denial in which the teaching of medical ethics is found in Spain: in short, it can be said that it is a wound that is a blemish on the face of many Schools, a wound that has not been attended to or healed.
Many years ago, in 1976, an unfortunate decision was taken, the consequences of which have been detrimental to many generations of doctors. At that singular juncture of the transition, and as one of the first expressions of the long-awaited autonomy of the Universities, the Deans of Medicine were invited to design different curricula for each School. An important reason for doing so was to make it more difficult, at that time of student plethora, for students to transfer from one Schools to another. The innovation of programmes or teaching methods achieved at the time was neither audacious nor spectacular: everything was reduced to a timid readjustment of Study program, which, perhaps to make room for some new knowledge, implied the elimination from the curriculum of teaching of Medical Ethics.
In defence of those Deans, it should be noted that the academic reality of Deontology at that time was very poor and declining. But for this very reason, what was needed was to resuscitate that moribund subject, to christen it Medical Ethics, to update the contents of the syllabus. But instead, they destroyed it. They did so, curiously, at the time of the most rapid growth of the discipline, when the major medical journals were blaring the message that medical ethics, previously taken for granted, was an essential part of the medical Education as an explicit and ubiquitous subject . They did so at a time when leading universities, in the midst of an economic crisis, were creating or developing vigorous and well-endowed Departments bioethics or biomedical Humanities .
With the passage of time, some Spanish Schools have tried to remedy the educationally deficient per diem expenses that their students were receiving and have offered short courses or optional seminars in medical ethics. This is a testimonial effort and worthy of commendation and imitation. But, after a quarter of a century, there are still a majority of Schools who seem to have reached the pessimistic conclusion that information - I do not say training which is a word that does not sound good in these post-modern times of ours - in medical ethics does not deserve a few hours of teaching, a few square metres of floor space, a modest budget for books and journals or a place headline on the staff of academic staff.
Nearly thirty promotions of doctors have graduated under the implicit assumption that professional ethics are of no interest to them. It is to these generations of doctors that many of those who are now under 55 years of age belong, i.e. many of those who run the Departments of the major hospitals, those who plan health policy, those who run the Medical Associations, the scientific societies, the national commissions of specialization program.
The conclusion is evident, tangible. With a few honourable and exemplary exceptions, the teaching of medical ethics in Spain is at a low ebb. And that has to change.
I hope that this lecture series will be the stimulus, sufficient and effective, that will set in motion policies of healthy rebellion and reform in the face of a shortage that has gone on for far too long.
b. Teaching medical ethics, an unavoidable duty
Having said that, let us move on to our first argument: why should medical ethics be taught at university? I do not know of any serious and rational arguments against it, although I will address them later on reference letter . There is no shortage of arguments in favour. Here are a few.
The practice of medicine is linked to far-reaching ethical issues, which doctors cannot ignore and which they must confront out of respect for the moral structure of medicine. These are questions that very rarely directly affect his work or his patients, but which belong to the territory of bioethics, which is more extensive than that of medical ethics, but close to it. The media on speech publicise them and turn them into topic of social discussion, subject of discussion political . These are issues that doctors are supposed to understand something about, because they have to do with health, health policy and law, the limits of biomedical research , the various applications of Genetics, the anthropology of sexuality, the medicine of the future. The doctor must study medical ethics and bioethics in order to fulfil the role of expert that the people have assigned to him/her, and thus fulfil the role of health educator that the Code of Medical Ethics and Deontology assigns to him/her.
The practice of medicine is also linked to ethical obligations, prescribed by the professional code, everyday and minor, if you will, but potentially conflicting, which the doctor must be aware of, since ignoring them exposes him to potentially serious risks. It is not a question here of technical errors, of iatrogenic events that the physician may commit, nor of accidents that may befall him. It is a matter of infringements of what is mandated or prohibited by the Code of Medical Ethics and Deontology, of conduct that clashes with the statutory rules of medicine and medical law.
It should not be forgotten that ignorance of the ethical rule does not excuse compliance with it. In my long experience in subject deontology I have been able to observe, with pain, how very prominent people in professional practice and in the academic degree program , have violated, without deliberation, with a kind of innocence, benign in intention but culpably ignorant, the most elementary precepts of the ethics of confidentiality, of medical certification, of the attention respectful of the freedom of their patients, of distributive justice, of due respect for the rights of patients, colleagues or third parties.
But the most fundamental reasons for including a robust teaching of medical ethics in our Schools of Medicine are not, however, to prepare the doctor to answer the questions that people may ask him or her, or to avoid mistakes arising from benign ignorance of subject. I am convinced that, in our times, teaching Ethics is a serious duty of the University, because the proper role of the University is to train men and women, not puppets. Not to teach ethics at the University is to let the students down. Ferdinand Hoff, the great German physiopathologist, said it very well at purpose from his experience as a young medical student. Referring to the Gospel saying: Which of you is so wicked that if a son asks for a loaf of bread, he gives him a stone? In his memoirs, he recounts that his professors gave him only a stone of science instead of the bread of wisdom to his questions about the meaning of the human and staff in medicine.
Students want to be taught medical ethics. Not only because they need to be informed of the standards that should guide and inspire them work. But because they have a right to the joy of doing things well, to mature through the effort of doing their duty. In this time of ours when young people tend to be seen as a morally unconcerned generation, I have found in my students a massively favourable attitude towards a strong professional ethic. The reaction of the students parallels, in a way, the reaction André Gide experienced on reading Antoine de Saint-Exupéry's Vol de nuit, which he expresses in the foreword he wrote for the book, when it was revealed to him "this paradoxical truth, for me of considerable psychological importance: that the happiness of man is not in freedom, but in the acceptance of duty [...], in the obscure feeling of duty, greater than that of loving".
In the leading countries, the conviction has been forged over the last thirty years that it is no longer possible to teach medicine seriously without teaching medical ethics. The teaching of medical ethics has Degrees of establishment and maturity that varies from one place to another. In some, it is a consolidated, influential and expanding discipline ; in others, it is still trying to assert itself and to overcome the logical difficulties and resistance that the new tends to encounter. In any case, it can be affirmed that teaching medical ethics is not a passing fad, but an irreversible conquest, which will remain permanently in the curricula of programs of study doctors. This is demanded both by the problematic realities of present-day medicine and by the promising, but at the same time worrying, promises of the medicine of the future. Ethics is as necessary as science on the doctor's Education .
c. The question of programmes, means and their effectiveness
However, apart from the certainty, now shared by almost everyone, that medical ethics must be taught, everything that refers to how to do it is the subject of constant study, experimentation and controversy.
To begin with, it is debated whether it should be included in Study program as a mandatory subject or only elective subject.
For the half-hearted, teaching medical ethics is a difficult pedagogical business and of dubious efficacy. They believe that, in a pluralistic world, the moral opinions of individuals differ and are ultimately an intimate matter and staff; that medical students arrive at university with their moral character already forged, and that teaching them medical ethics will not change their basic moral attitudes; to attempt to do so would be to catechise them. They adduce evidence that, ultimately, knowing ethics does not seem to make doctors better people. They add other secondary reasons, such as the shortage of time due to oversaturation of Study program, the more or less benign refusal among teachers and students to awaken the conscience bug, or the serious lack of prior philosophical training on the part of students. For all these reasons, medical ethics should be a secondary discipline , elective subject.
Among those in favour of teaching medical ethics to medical students and young doctors, many questions are also discussed. For example, at what point should medical ethics be taught: whether at the beginning, among the basic disciplines, or as a genuinely clinical subject at second cycle; or scattered throughout the years of licentiate degree; to whom should the task of teaching be entrusted? which subject matter should be included in a core medical ethics programme, and from which metaethical perspective it should be elaborated and presented; which teaching method, or which combination of them, should be chosen as the most effective: whether the structured lecture method, the informal method of small group case discussion, or the commentary on selected texts. There is strong disagreement as to which epistemological approach is more accurate and has a more lasting influence: the theoretical method of analysing bioethical principles, the practical method of acquiring decision-making skills in the resolution of cases and problems, or the more experiential method of commenting on narratives or personal experiences.
It is discussed whether and how students should be assessed at the end of the course: by means of a formal exam, a essay to be prepared on an assigned topic , or whether it is sufficient to have attended classes and seminars regularly.
One thing seems quite clear: taking a course in medical ethics has consequences, it influences, it changes student. This is what some students tell me, whose knowledge of medical ethics has helped them to resolve serious and complex professional conflicts.
However, little, if any, research has been done on the effects on the collective ethos of the profession and on the behaviour of the individual physician of following some structured medical ethics programs of study during the period of the licentiate degree and in the course of the postgraduate training .
Some authors who have studied the relationship between Education formal medical ethics and skill ethics have come to the general conclusion that teaching and learning medical ethics increases the capacity for moral reasoning, builds confidence, prepares for better ethical decisions in the daily internship , enables to serve on hospital ethics committees, and invites to review the ethical values and decision-making processes in place in the hospital. It is even claimed that it contributes to changing the environment of hospitals and professional associations for the better.
There is also very little empirical programs of study on the consequences of not teaching medical ethics to medical students. It certainly does not seem ethically acceptable to design and carry out a randomised essay comparing the ethics skill of two groups of students who differed only in having received or not received an ethics course. But it is possible to reflect on the consequences of not teaching ethics in medical schools: in my opinion, this leads to a deficiency, which has many serious manifestations.
Indeed, if, in their university years, students receive messages that only talk about Biochemistry , cytology and Genetics, physiopathological and pharmacological mechanisms, diagnostic algorithms and clinical guidelines, and nobody teaches them what the dignity of the patient is and how to treat their body and soul, or how to understand suffering; how to treat colleagues and what are the rules that should govern the relations between doctor-researcher and patient-subject of research; if this happens, it is not difficult to imagine the final result . The final result is a doctor whose capacity for ethical analysis, respect for people and human interaction is merely intuitive, emotional, lacking intellectual incentive, undiscriminating, hypoplastic, perhaps malformed. Such a doctor may know pathology in infinite detail, may be able to interpret diseases in core topic of biological-molecular and genetic disorders, but runs the risk of not knowing the patient as a suffering human being, as much in need of medicine as of respect, information, and perhaps hope.
To a certain extent, the Study program without medical ethics programmes the doctor with a selective blindness to the human side of medicine. This can be seen in the clinical practice of some young doctors. As soon as the patient begins to talk about his illness, the young doctor, blind to ethics, responds in the only way for which he has been trained: he wonders with impatience and curiosity where, in terms of organs or systems, functions and regulations, the data revealed by the patient or those he obtains with his questions aimed at clarifying the pathophysiological. He is not interested in the existential crisis of the illness for the patient, nor is he concerned about the impact it has on the patient's life staff or family life.
In the absence of medical ethics from Study program, the student may finish his degree program without anyone having spoken to him or invited him to reflect on the human and social purposes of medicine, or helped him to acquire a warm and welcoming vision of the dignity and rights of patients.
It is logical, then, that in hospitals staffed by doctors who, in their formative years, have received an exclusively scientistic per diem expenses and have grown up in indifference to the human side of medicine, ethics plays a rudimentary, second-rate role. In such hospitals, law and the legal rule tend, by omission, to take the vacant place of ethics.
Acting in accordance with the legal minimum makes it possible to survive in society, but turns doctor and patient into moral strangers. Compliance with the legal ethical minimum leads to frequent faults of omission. Everything that is not strictly obligatory is neglected. Patients expect more from the doctor. The doctor, without the financial aid of ethics, leaves a trail of small but not painless frustrations in his patients: neglect of respect for the patient's privacy staff and body, inadvertently hurt feelings, gratuitous humiliations by leaving unanswered questions that, although irrelevant to the doctor, may be of fundamental importance to the patient. Today, patients often leave the hospital cured of their illness, but wounded by the inhumane attention received.
From the above, a clear idea can be deduced. Medical Ethics is not only taught at classroom and seminar. The university hospital is the privileged place to teach Medical Ethics. It is the great laboratory of medical ethics practices for students. Clinical professors are professional role models for students, just when they are trying to acquire and consolidate their professional style. If Education ethics is neglected or abandoned, the university hospital runs the risk of becoming a place of diseducation.
Let us now turn to the
2ND proposal. That this teaching has one main goal : to be an instrument for the sincere and critical integration of future doctors into a profession that is, above all, a moral community.
In order to understand this second proposal, we cannot ignore two things data. The first is this: medical ethics connects with society through the Medical Colleges, which are assigned by law the fundamental function of safeguarding and enforcing the deontological and social-ethical principles of the medical profession. The second fact is this: the great window through which the Schools of medicine looks out onto society is the teaching hospitals.
This means that the connection between medical ethics and society depends on the smooth speech between Medical Colleges, Schools of Medicine and University Hospitals.
a. The speech between schools and Schools: Problems and Promises
discussion Not long ago, in March 2000, the committee Permanent European Doctors' Organisation, an organisation that brings together the medical organisations of the 15 countries of the European Union and those of many other countries that have the status of acceding or observer countries, adopted, not without much ado and many postponements, a document of "Recommendations on the teaching of medical ethics". I had presented this initiative in March 1998. The document, which attempts to fill in the previous resolutions of the Permanent committee on subject, contains three recommendations, which are worth commenting on.
The first reads: "The rules and precepts contained in the codes of ethics and deontology of the Member Organisations of the committee Permanent subject shall be the specific taught to students at the Schools medical schools in Europe".
Three reasons are offered in favour of the recommendation. The first reason, which is strongly pragmatic, is based on the fact that medical students tend to become members of national medical associations. As soon as they are registered as doctors, their professional conduct must be adapted to the criteria defined in the respective code of professional conduct and in the guidelines supplementing it. The requirements required by the society to work as a physician includes the knowledge of the professional code of conduct itself.
The second reason is one of moral psychology. It is unreasonable to expect each graduate to be able to invent or improvise his or her own rule of professional conduct. Adjusting one's actions to the rules of professional ethics is not a matter of intuition, imitation or emotion, but result of study, moral analysis and deliberation staff.
The third reason states that if young physicians were to enter the practice of medicine without a clear understanding of the specific ethics of the profession they would expose themselves to serious disciplinary risks, especially in those countries where registration in the medical organisation requires an oath affirming that they know the standards of the code and promise to abide by them. Without a proper knowledge of such ethical commitments, such an oath would be an empty promise or a travesty.
The second recommendation recognises the legitimate freedom of teaching. The introduction of codes of ethics and deontology in medical ethics curricula does not infringe on the freedom of Chair of teachers, who may maintain their ethical convictions or didactic approaches. It is required that the rules and regulations of the Code constitutes a significant, not necessarily exclusive, part of the subject professor . This does not mean that it can be made a superficial exhibition . On the contrary, it requires dealing with the necessary depth of the basic ethical principles underpinning the rules of the code, in order to reveal the professional values and rationality behind them. Finally, it has to instil in students the conviction that Education ethics is a lifelong task, as important as the ongoing Education in the scientific aspects.
The third recommendation points to the need for national, regional or local medical organisations to establish or strengthen their friendly and cooperative relations with the ministries of Education and health, with medical Schools and teaching hospitals with the purpose concrete aim of making the teaching ethics of the profession a reality.
This is a goal that is very appropriate for mature societies that are motivated by friendly cooperation and not by the closed defence of strongholds of power or the perpetuation of personal or institutional rivalries. There is much to be hoped for from this partnership of Schools and Colleges.
Let us look at it. First of all, it would change the attitude that new doctors tend to have towards the Colleges. They do not feel morally identified with an unfamiliar professional body, nor do they perceive it as an ethical community. It is crucial that the university does not disregard the social Structures in which its graduates will live and work. Students need to have, at the end of their programs of study, an operational knowledge of the rules of professional conduct in force in their profession.
guide Secondly, the use of the codes of medical ethics as a source of inspiration for the teaching will, as is proper to university work, lead to their critical analysis. The research of the contents of the codes through serious and critical analysis in seminars or in doctoral thesis could contribute to improving their structure and content in the future.
Thirdly, making codified medical ethics a university subject would broaden the horizon of its study, would lead to the comparative analysis of the various national regulations, would favour the transnational traffic of ideas and, which would be an important fringe benefit, could raise the development of a common European professional ethics, emancipated from the bioethics of North American origin and temperament.
Finally, codified professional ethics is a living product, born of everyday reality, grounded in a human context, not a fictitious one. In fact, a good code is the result of translating into a written text the carefully distilled, debated experience, conservative of the intangible and innovative of the contingent.
Having said the above about the relationship between the Colleges and Schools, I will briefly touch on
b. University hospitals, social observatories
Throughout almost twenty years of teaching medical ethics, I have become increasingly convinced that this task cannot be assigned to one department, to a small group of professors at subject. It is necessary that all doctors who teach, at all levels, in the hospital, are committed to the collective, institutional endeavour of being active ethical agents for students, and also for patients and their relatives. It is often said, and with truth, that medical ethics has always been taught by example and committee, as if by osmosis, by the contagious influence of character on character, by the atmosphere in the hospital.
The hospital is or must be a living moral organism. It must therefore have its own character, its own particular ethical style. It must cultivate a distinct way of being, have an identity as a moral institution, develop an ethical personality, just as it has acquired a legal personality and an economic structure. This opens up the possibility of formulating ideals and sharing them; of developing a unitary, small, minimal but strong moral core, which includes the protection of legitimate diversity. And then, to be careful not to dissociate what is taught and what is practised.
All of us who teach medicine must remember the negative and destructive effect that counter-examples have on students and patients. There is an anthology of counter-examples, collected by medical students in the UK and California, showing the profound crises of moral pain in patients, and of professional vocation in students, that can be provoked by teachers simply by a cynical remark, a derisive word, the unabashed cheek with which a patient or colleague is talked about behind their back, or the shameless confession of having been "smeared" in a conflict of interest. Many students are unable to overcome the rejection of an ethics that is taught but not practised.
It should therefore not be forgotten that the entire teaching staff of the School of Medicine and its university hospital are attached to a permanent Chair, open to the open air of society, where medical ethics is taught in classes and seminars, but also, in a diffuse but decisive way, in the patients' rooms and operating theatres, in the offices, the ward stations, the corridors, the lifts. Much has been said about this environmental teaching of medical ethics, about this "hiddendiary ", which is, for better and for worse, of extraordinary educational effectiveness.
I would like the Code of Medical Ethics and Deontology to be at people's fingertips in all these places, as a moral reference letter term. Much would change if patients and their families were aware of the dignity that the Code confers on them and demanded that it be respected in its many manifestations. I have always maintained that the Code is the best charter of patients' rights.
It is a social responsibility of doctors and patients alike to care for the ethical environment of the hospital. It is a collective moral heritage. Teachers and patients must take an affirmative attitude towards professional ethics and reinforce by their example, their advice and their observations what students learn in their medical ethics course. This is a mark of the quality of a good teacher. The time will come when the objective assessment of candidate as an active ethical agent will be counted among the conditions required to climb the academic staff ladder. And this is a mark of quality in the patient who can never abdicate his or her human dignity and must demand with temperance and fortitude the credit respect due to him or her.
Let us turn finally to the
3RD proposal. The Education in social responsibility is an essential element of the teaching of medical ethics.
Among the moral imperatives that should guide us in practising and teaching medicine is social responsibility. We are not very strong on this, despite the obvious fact that most doctors have leased all or a good part of their work to the National Health System. work For their part, the vast majority of medical students aspire to obtain a place for their postgraduate training programme at spanish medical residency program, in the hope of finding a stable place as soon as possible in medicine managed by the Autonomous Communities or other public bodies or in private institutions. Today, hardly anyone aspires to be self-employed.
But, curiously enough, the Schools are oblivious to this determining circumstance, which alone should provoke in students and teachers a lively and active interest in the ethical values and professional standards of work in social medicine. Hardly anyone feels the commitment to provide students with the information they need on the professional degree program , the hierarchical structure, the statutory rules and regulations , the exercise of increasing responsibilities, or the specific discipline of their work, first as resident doctors, then as assistants or heads of department.
a. Is it possible to perform a social function without acquiring the ethical training , the mentality, that such a official document requires?
An essential aspect of the mindset required to perform this role is to be sensitive to the social, and not just individual, aspects of the rights and duties of patients and third-party payers, be they the National Health System, private insurers and the many entities that perform similar functions.
Patients' Bills of Rights are documents of enormous value educational and ethical value. Nothing reveals the diversity of styles and conceptions of medical ethics better than a comparative examination of patients' charters. To understand the commonalities and differences between these documents, it is useful first to pause very briefly to consider some general characteristics of these charters.
Patients' Bills of Rights are almost exclusively concerned with 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.
These documents usually contain a common core of so-called fundamental rights of patients. They are like the translation of fundamental and constitutional human rights into the hospital context. For this reason, the charters enacted in politically advanced countries hardly differ in this respect. Such basic rights are legally very strong and tend to be preserved over time. These include, for example, the right to receive a respectful and dignified attention ; the right to manage one's own autonomy by granting or withholding informed consent; the right to confidentiality; the right to health protection; and the right to privacy and intimacy.
But it is perhaps more interesting to look at the other, non-fundamental rights, also known as special rights, which are what give the charters their diversity.
They often seem more like moral rights than legal rights. And they bear the strong imprint of the partner-cultural environment or the moral character of the institutions that have promoted or enforced them. Thus, it is noticeable that user and consumer movements have emphasised 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" mood of the rights recognised by medical associations, such as 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 a humane quality of 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. Finally, there is a certain typicality in the special rights granted by the National Health Services, which often bear the arbitrary and condescending mark of the state-providence, by making many rights conditional on availability the necessary economic and human resources. Not only are these rights not enforceable in times of economic recession, but, in fact, they depend at all times on the unappealable response of the official bureaucratic machine.
deadline In the United States, some sui generis rights are enshrined, such as the right of the patient to obtain a prompt response to requests for services; to examine and receive explanations of the costs incurred; to know the immediate and long-term financial implications of different treatment options; to be transferred at one's own request to another facility; to be informed of possible financial links and conflicts of interest of the hospital, as well as of the cost of interventions and available modes of payment; report to be transferred on request to another facility; to be informed about possible financial links and conflicts of interest in the hospital, as well as about the cost of interventions and payment methods available in the admitting hospital and in geographically close hospitals; to be informed about the hospital's rules of procedure. These rights reveal, on the one hand, the ideology of the client, individualistic and untrusting, which is expressed in the strong control of the economic element, in the demand for promptness in services, in the autonomous approach to what is to be done. They also express a concern to get the most out of the large amount of money that medical care usually costs there. Ultimately, the patient is a consumer who has to actively control the cost and duration of his or her stay in hospital, for the hospital is, at least in economic terms, a hostile and potentially dangerous habitat, which demands a vigilant attitude on the part of the patient.
In contrast to these rights, those granted by the European charters have, to begin with, a clear social-political intention, which enshrines and demands the equality of all in the recognised right to health attendance . There is, however, much room for diversity in the European Charters. The Italian Charters, in order to emphasise the communitarian, almost collectivist, character of the rights, always say "Every patient has the right", instead of the American individualist "The patient has the right to". In the same egalitarian line, the Italian charters condemn any form of favouritism, clientelism or corruption. In contrast to the rights, almost all of which are administrative in nature, conferred on the hospital patient by article 10 of the Spanish General Health Law, the Italian charters try to create a friendly, humanised, almost domestic atmosphere in the hospital. Thus, the Italian patient has the right to be called by his name and surname, not by nicknames or diminutives; he cannot be addressed by nicknames; he cannot be objectified by references to the illness he suffers or to the issue of the room he occupies; he cannot be humiliated by the obligatory use of clothing that, in his opinion, violates his dignity as an adult; he has access to clean and well-equipped toilets; he has access to relaxation areas where he can have conversations with relatives and friends. The Italian Charters recover rights that were already present in the regulations of some medieval hospitals: to a warm and varied meal, to a frequent change of linen, to receive visitors, to call the doctor of one's choice.
To make these truly human rights a reality is a worthwhile business . I think it would not be a bad idea to send to the Health Care Ethics Committees of our hospitals a Charter of the Rights of the Sick from any of the Italian public hospitals in order to open new horizons to the concerns of these committees, which are almost exclusively absorbed in legal rather than ethical issues, such as the formalities of informed consent forms or the processes of validation of end-of-life decisions, whether or not they are documented.
b. Seeking connections with society
Social medicine and the mentality of social responsibility it has introduced is a wonderful, irreversible achievement for which we can never be too grateful. But this cannot leave in oblivion the dysfunctions that the socialisation of medicine has caused in the governance of hospitals, in the life of doctors, and in the relationship between doctors and patients. There is a long history of conflicts that have been perpetuated without solution and have had the perverse effect of disillusioning all, desensitising many, and hardening the hearts of a few.
It is therefore crucial to seek, test and teach solutions that reduce the frequency and intensity of these conflicts, as it is illusory to expect these dysfunctions to disappear spontaneously.
It is thought 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 administered by physicians. In order for a physician to acquire the status of physician-administrator, he or she needs to be an expert in the science of health care administration and also in medical ethics. As a doctor and a member of the medical profession, the managing physician can never exempt himself from the fulfilment of his deontological duties or govern the hospital with his back turned to them. He is particularly obliged to act in defence of the independence of the medical profession, he must ensure the correctness and collegiality of the relations of the doctors working in his institution and, above all, he must encourage the establishment of the new relationship between doctors and patients, which is both deontological and social.
It would have to be very careful not to impose conditions on work that would undermine the professional dignity and independence of judgement of doctors. Our legal system, in assigning to the Medical Association the function of setting the ethical limits of the various forms of salaried practice of medicine, provides as a preventive measure against the weakening of professional ethics that contracts and service agreements be approved by the medical associations after they have verified that such contracts are in accordance with corporate ethics and that the legitimate freedom and responsibility, independence and autonomy of the physician are safeguarded in the employment context in which he or she will be hiring out his or her services.
This is not celestial music, but a legal precept, contained in a Royal Decree, whose fulfilment, for various reasons, has never become a reality. I recognise this, but I twist the argument: if it has never become reality, it is because this statutory rules and regulations has never been taken seriously, because it has been continuously admitted, with painful consequences, the custom against the law, of disinterestedness of the Associations in the ethical and social conditions of the work of their salaried members. This is a painful consequence of this widespread benign ignorance of ethics and medical law. In this matter, the influence of legal aid, with its instinctive reluctance to advise against the tide, has been far more influential than deontological opinion.
But let us look to the future with confidence. The integration of the vocation of doctor and manager in one person is in line with the standards of many documents of medical organisations. And it is also in line with real experiences. It is a proven fact, in the UK, in Scandinavia, in Germany, that doctors, once properly trained in business management, have specific advantages over non-medical managers, including, for example, greater credibility, the knowledge deeper understanding of how health care works, greater freedom of expression, more ability to weigh up complaints, more optimism in the rehabilitation of dysfunctions. It has also been shown that because they know how to put patient care before bureaucratic and automated cost-cutting imperatives, they not only achieve better clinical outcomes, but do so at lower costs.
The UK National Health System and the British Medical association have had the audacity to accept the idea of the superiority of physician-managers, have promoted their training and have 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.
A social sense of medical ethics is a necessary prerequisite for a doctor's vocation as a manager. But it is also necessary for all future doctors, who will need to know a great deal about how to analyse and resolve economic and organisational issues. Teaching medical ethics with social intent would spare new generations of physicians the pain of past misunderstandings and educate them to the idea that patients, physicians and managers share the same goals. To create such an ethos of mutual cooperation and understanding requires that some competent physicians of high intellectual and human quality respond to the social responsibility and vocational imperative to dedicate their professional lives to health care management .
c. Physician-citizens/patient-citizens: the new synthesis for social responsibility
I suspect that one source of the problems, in countries where the population has access to national health systems, is the failure to develop a specific medical ethic for socialised medicine.
In fact, the European biomedical ethics institutions appear to be saturated with ideas and decision-making procedures that are modelled on the principlist model imported from the United States. But this does not seem to help much to solve the problems and misunderstandings between doctors and patients in Europe. Indeed, principlism is a methodology of ethical analysis and decision-making, designed to be applied to commercialised medicine in the United States. There, as I noted earlier, patients are consumers who present their demands to physicians and pay them with their 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 principled bioethics, there is no 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, his or her ability to withdraw it at any time and at any moment, without any change in his or her 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, thanks to an equitable and egalitarian redistribution of national income. But in order that this solidarity-based application for the sick does not run the opposing risks of ruining the national Economics through excessive expense or wastefulness, nor of ruining the health of patients through stinginess or 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 marked contrast to the patient-consumer, not only has rights: his or her membership in a national health system imposes certain well-defined ethical duties on him or her, and points to concrete and serious responsibilities. The idea of a patients' charter of duties, although 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 exercise rights, such as the right to be informed about their illness, to participate in making decisions that affect them, to cooperate in genere with the system in the care of their health, to make judicious use of health services, benefits and property.
It was probably the Spanish legislation, with the General Health Law 14/1986, which was the first to introduce in its articles prescriptions on the duties of patients towards health institutions and society. But they have hardly been heard of. The Patients' Bill of Rights of the American Hospitals' association , in its revised version of 1992, includes a list of patients' responsibilities, which deal with purely individualistic matters, without a single reference letter to the existence of duties towards society. In Italy, a Decree of the President of the committee of Ministers, the general outline of reference letter for the Charter of Public Health Services, of 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 at the top of this list that "the fulfilment of these duties is a prerequisite for the enjoyment of one's rights. The commitment to fulfil them is a manifestation of respect for the social community and for the health services that other citizens have to use".
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 preponderant role that the condition of being a citizen should have in the ethical performance of patients and doctors in the context of a National Health System. Sorell states, between the lines, that being a citizen is something that precedes the condition of being sick or being a doctor, and that the obligations towards the community related to the measured use and manager of health services are strong obligations. The author alludes to the deterioration that postmodern ethics has caused in doctor-patient relations, in the sense that they have been reduced almost exclusively to private and individualistic matters, and that the social and universal dimensions of human rights have been relegated to obscurity. There is much room for reflection and experimentation with innovations and reforms.
There is no doubt that it is a complex and long-term task deadline to infiltrate society and doctors with the necessary sensitivity to social and community values. But it is business worthwhile and begins, as the degree scroll of the lecture that I have been entrusted with says, by "ethically educating doctors in order to educate society".
I would like to hear criticisms and comments on what I have just said. What matters is to restore medical ethics to its rightful place in the teaching of students, in the life of hospitals, in the busy care of outpatient clinics. We have, to begin with, the obviously improvable treasure of corporate ethics and deontology. Society, which has charged us with ensuring medical care of scientific quality and ethical dignity, will hold us accountable for what we do and what we fail to do in this area.
Thank you very much.