Health care institutions and physicians: ethical tensions
Gonzalo Herranz
department from Humanities Biomedical, University of Navarra
Intervention on Patients, health institutions and physicians: ethical tensions. Health information
In: I conference Jurídico-sanitarias de Navarra
2nd roundtable: The relationship between Health Institutions and the patient: current status and perspectives.
Pamplona, November 14, 2002
Relationships between characters
The rights of patients and third-party payers
Patients' rights in Europe and the USA
Comiogenesis, rights and collective responsibility
Doctors-citizens/patients-citizens: the new synthesis
We all know the story of how the old, simple relationship between patient and physician has been changing into a modern and complex one that today intertwines patients, physicians and healthcare institutions. The peaceful and paternalistic status of yesteryear, as we are well aware, has become conflictive and egalitarian. Bilateral relations between physicians and patients are practically non-existent: encapsulating and infiltrating them, this third institutional element, which may be public or private, but which is always powerful and dominant, has become present.
That classic relationship, whether it developed in the outpatient clinic, in the patient's home or in the hospital, is remembered, in idealized colors, as a connection staff, if not permanent, at least with a tendency to last; it involved, on the one hand, the solid unit formed by the patient and his relatives, and, on the other hand, the individual physician. It included, or simply accepted, the asymmetrical character that was considered connatural to the peculiar relationship between people, one of whom, often in a lower economic and cultural position, was diminished or damaged by the disease.
Today, this relationship has become more anonymous and complex, less staff. On the one hand, the physician, as with the secondary figures in a play, no longer has a name: he or she does not need one, since he or she is simply a physician, anonymous, replaceable. The old role, nominal and staff, of the physician can be played by any member of a functional group . Today it is more frequent for the patient to refer to the physician in an impersonal plural: I am going to be seen at the outpatient clinic, at the hospital, at the clinic. He no longer says: I am going to be seen by Mr. So-and-so or Dr. So-and-so.
The old vertical relationship, described as the meeting of a trust with a conscience, is on its way to extinction, and we are getting used to the new horizontal relationship, between equals, who keep their distance, each with their own rights and their own vision of life. But what is truly new about the new relationship is, above all, that there are no longer only two, because the patient/physician relationship now develops under the watchful eye of managers, programmers, quality analysts, administrators, inspectors, actuaries.
There are now many more people on the scene. Such numerical growth of actors not only multiplies reciprocal relationships, but often puts them in tension. This is decisive from the point of view of ethics, because this complexity and tension does not weaken, but, on the contrary, reinforces their ethical character. Because they are always interpersonal, the relationships between physicians, patients and institutions are always intrinsically moral.
It seems appropriate, before considering our main issue of the patient/physician/institutions relationship, to offer a very sketchy outline of the actors.
The classic patient becomes, in the new context and depending on the circumstances, Username, a client, a consumer. They come to the doctor in poor health, but armed with autonomy, demanding efficacy. And, often, with very precise knowledge of their ailments and their rights. It has even been said that the new patient does not go to the doctor, but "goes doctor shopping". They often take out private health care insurance in addition to that provided by the national health service, and they do so after having examined the market, compared offers and haggled over bargains.
The physician has gone from being the patron saint to becoming a salaried and replaceable worker. He sees himself in the role of a subordinate, a mere service provider, who, in order to survive or prosper in the new status , must compete in a degree program for which he has not been trained: that of always giving more for less.
The third-party payer, whether it is the public health system or the private insurance companies, holds the purse strings and tends, through money, to dominate the status, but needs to keep the patients-electors happy, even to flatter them. In the European Union, national health systems compete with private insurance for prestige, money and clients. They need, to justify their immense cost, to offer the most advanced technologies, to gain social preeminence, to fill more newspaper pages or more minutes on the 9 o'clock news and average. It even wishes to achieve, through a more or less intense re-privatization, the competitive dynamism of the free business. All, public and private, in the so-called medical industrial complex, apply in their management criteria of economic efficiency that lead unfailingly to "commercialize" medicine. The old-fashioned, solidarity-based, mutual and modestly charitable insurance companies have been transformed into health maintenance finance companies and openly seek to make a profit or, at least, to close the year without going into the red. Health multinationals are being created, networks of hospitals and services are being woven. The first hybrids are already appearing, the result of crossing medical emporiums with pharmaceutical industries.
Third-party payers, in the public or private sector, all alike, must apply the actions dictated at all times by the science of business, in order to constantly improve their productivity, verify the quality of their services, audit the performance of human resources and technologies, and program efficiency. And also necessarily, everyone, in the private sector as well as in the public sector, in order to contain at all costs the expansion of expense health care, must apply saving policies, must ration with dissimulation.
Relationships between characters
Relationships between patients, physicians and institutional third parties can be considered from many angles and using different optics. It is useful to follow our story on the project of the Basic Law regulating patient autonomy and the rights and obligations in subject of clinical information and documentation.
In recent times, it has been increasingly affirmed that the patient who enters into a relationship with the physician and healthcare institutions does so in his or her dual capacity as citizen and Username.
Designating the patient as a patient-citizen is not a simple terminological change, result of the obsessive search for originality imposed by modern marketing. It is an action that seeks to make clear a truth that has been kept in the shadows for too long: that the patient must assume an important role in the achievement of two objectives. One, collective, of health policy: that of defining the macro-social ethos of medicine as a public service. The other, private and micro-social: that of establishing the typical features of the doctor-patient relationship in the context of the national healthcare system. In essence, as the Federation of Medical Orders of Italy says in its Commentary on the Code of Ethics, it is a matter of the patient, as a patient-citizen, moving from the passive attitude hitherto in force, to an active stance in which he himself exercises guardianship and demands respect for his own basic rights, and gives a clear sign that he is assuming a new attitude in his relationship with the doctor who treats him and the health system that has assumed the constitutional mandate to protect his health.
An important sociological and ethical evolution can be perceived in this. The patient's dignity is no longer protected, as it was in the previous deontological order, by the prohibition made to the physician to instrumentalize his implicit psychological and social superiority to his own advantage. This protection, passive and provided, disappears in the new circumstances. The patient now enjoys, as a citizen, an equal position: he enjoys his own intrinsic personal rights, with which he protects himself. The elimination of the asymmetry of the past is result of the conjunction of two forces: one partner-economic, the elevation of the cultural and economic level of the population; the other, juridical and political: the conscience, more and more explicit and strongly felt among the general public, of the subjective, individual rights.
It is important to highlight the fundamental legal and deontological background of the change. The basic rights of the patient-citizen, derived from the Constitution and health laws, must be assumed in the professional internship by transforming the legal rule into a deontological rule . In this way, medical deontology will acquire a new dimension and a new social contribution. In it, the patient must become aware of a more effective autonomy, of a discretionary capacity to choose and decide. But the connection to the condition of citizen frees this new autonomy from being dominated by purely libertarian ideas or from falling into the radical dynamic of "patient's power". The new autonomy is qualified by an ethic of specific responsibility when administered by the considered authority of the patient-citizen.
But this new power has had to be acquired on behalf of others. We cannot forget that power is finite and inextensible. When power is distributed or redistributed within a closed system, its total sum remains constant: the gain of some implies the loss of others. It is therefore necessary to ask at whose expense has the patient gained his new power? The physician's? The third party payer's?
The doctor has always been a protean figure, irreducible to a unitary outline . But in today's pluralistic world, his human complexion, his moral stature, his relationships, have become more changeable, because they are closely dependent on a multitude of different environmental factors. The ethical, social and economic circumstances of doctors' work exert very strong effects on their professional way of being and acting.
In order to simplify such a complex issue, I will take the liberty of offering licence only two images of doctors, opposing, polar, and yet intercommunicating and potentially converging. One is that of the salaried doctor, which is delineated in the Codice di Deontologia of 1998. The other corresponds to the doctor-entrepreneur of American medicine.
How does the Italian Codice characterise the doctor of today, the subject doctor who is the most frequent doctor among us today, the salaried doctor?
In its article 69, the Codice recalls that the physician, in all circumstances, including that of renting his services under the regime of employment or agreement, remains subject to the deontological precepts and to the disciplinary power of the Medical Order.1. The duties deriving from the contractual relationship do not escape ordinary jurisdiction. He adds that, should there ever be a conflict of duties between the deontological rules and those imposed by the public or private entities for which he works, the physician must be guided by a well-defined criterion: he will request the intervention of the Order so that the physician's own rights and those of the citizens are safeguarded. He concludes article 69 with a precept, at once strong and prudent: the physician should remain at his work while awaiting the settlement of "tolerable" differences: but he should leave it when there have been serious violations of human rights and values against persons entrusted to his care, or against the dignity, freedom or independence of his own professional activity.
The article 69 invites physicians and patient-citizens to make a common front, to align themselves, under the ordinal guardianship, in defense, above all, of the human rights and ethical values of the patient. This is what the Federation's official Commentary states: "not only of the autonomy and dignity of the profession, but also and, above all, of the rights of citizens".2.
The profession is taking sides. And it does so doubly, of course. With a serious sense of justice, it points out to the doctor that his work on behalf of others creates a status of double loyalty, since, on the one hand, it includes him in an organisation management assistant which he must serve with rectitude and honesty; and on the other, it assigns him the duty to protect the just rights of the patient-citizen. And, with a strong sense of its community responsibility, the medical profession, through the Order that represents it, undertakes to mediate with all its social influence in defence of doctors and patients to restore their rights and freedoms, not only in the event of conflict with high legal standards emanating from the State, but also when doctors and patients are harassed by the orders and circulars of local administrators.
In theory, in the new status designed by the Codice, the position of the doctor is well supported, as it is based on his skill, on the high social esteem of the health good he administers, on the long tradition of his friendship with the patient, and, finally, on the more recent tradition of respect and protection of patients' rights.
This power of the doctor, benign and temperate, is not always peacefully enjoyed. It is threatened by periodic evils: periods of economic recession, deterioration of human relations, disruption of medical demographics with the risk of proletarianisation of a more or less large sector of the profession. These ills are well known to us, as they are relatively typical of certain Western European countries.
Suffice it to say this, for the moment, about the doctor employee. Let us move on to consider what is happening on the other side of the Atlantic, to see if salvation can come from America.
In the United States, the main modulating factor of the professional ethos has not been, as in Europe, the development and implementation of national health systems, but the decisive role that economists and administrators have played in the conversion of medicine into a first-rate industry. That ethos has been incubated in hospitals and, in particular, in the relationships between physicians and administrators.
In the years immediately following the Second World War, hospitals were Structures relatively simple to administer. But in the mid-1960s, the management of hospitals began to take on unusual economic, organisational and labour-related dimensions. It then became necessary to apply management models and techniques that went beyond the amateurism of benefactors and physicians. In contrast to Europe, where a large contingent of hospital and national health service administrators was recruited from the ranks of physicians, in the United States it was necessary to recruit business professionals. Things went well at first: the new managers saw themselves as qualified servants of physicians, and they followed the ethical standards of the medical profession well Degree .
But this harmony began to crack as competition between hospitals grew. Hospitals were transformed into profit-making enterprises and medicine became an industrial complex of large economic dimensions. Administrators imposed the need for advanced and aggressive financial management criteria, which often clashed with the professional traditions of physicians. Tension between administrators and physicians grew. The new morality management assistant demanded cutting costs, optimising profits, rationing and rationalising services, serving two masters. For many doctors, this was too strong an attack on the tradition of unlimited service to the patient, so characteristic of the Hippocratic doctor, faithful to the injunction "I will do all I know and can for my patient".
The ethical divorce of the two guilds of administrators and physicians became inevitable and eventually led to the separation of codes of ethics. The administrators' code recognises that the primary function of hospital governance is to provide patients with quality health care, but it establishes mainly economic imperatives. The enormous size of the medical expense has increased the roles and responsibilities of administrators, while at the same time dwarfing the managerial responsibility of physicians. The formerly prevailing relative balance of power has been reversed: today managers and economists are at the helm of the hospital, setting the plans for development, allocating resources, assessing standards of care, judging doctors by their economic performance, governing people.
The pragmatic priority of the financial and organisational has resulted in the pre-eminence of economic values over ethical values in the governance and mission statement of hospitals. The traditional charitable orientation of the hospital institution, public and private alike, has succumbed to the imperatives of economic survival and induced a change in the notion of professionalism of most American physicians. It has also changed the thinking of patients, as evidenced by the rights contained in patients' charters, which we will examine later.
And, strangely enough, these profound changes happen smoothly, almost unnoticed. They take on an initially harmless appearance, as they are about optimising yields, eliminating superfluous expenditure of time and money, adopting well-tested clinical protocols, acting according to diagnostic groups, following the dictates of evidence-based medicine. Doctors tend to accept these interventions without resistance, as they are dictated by the need to rationalise work and expense. But their economic motivation ends up having a heavy influence on patient relations.
The preeminence of the financial aspect translates into ways of thinking and acting that end up eroding the physician's human and scientific profile and reduce his or her field of vision to economic factors and parameters. Departments Administrators prefer and reward physicians who see more patients per unit of time; they grant incentives to surgeons and obstetricians with minimal postoperative morbimortality; they reward clinicians who manage to reduce the average length of hospitalization of their patients; they favor ambulatory interventions carried out at the maximum permissible risk. The ethical consequences of such policies can be dire. A surgeon who wants to please his managers, who loves the extra money that his high efficiency Degree can bring him, starts to discriminate among his patients: in order to outdo his colleagues and remain at the top of the league table, he needs to select the patients he operates on: he needs to reject patients with considerable surgical risk, who are no longer operated on, at least by him. This phenomenon of dumping patients at moderate or high surgical risk also extends to patients whose insurance does not cover all the risks. In the new context, the patient's interests no longer come first. Something similar is happening to obtain good grade in quality audits: patients are not treated according to the specific needs of each individual, but according to the standard set by each clinical protocol . This destroys the ethical integrity of the physician, who sacrifices the interests of the patient in order to please the auditors and advance in the professional degree program .
When the traditional values of medicine come into conflict with the values of the medical market, when the field is dominated by multinational health care companies, it is all too easy for doctors to succumb to the temptation to become entrepreneurs in the medical industry themselves.
Indeed, there has been no shortage of physicians who have rebelled against the exploitation and plundering of which they feel they are victims. In recent years, many have decided to become their own capitalists and to organize quasi-commercial companies dedicated to diagnosis or treatment, joint ventures with colleagues or financiers to exploit medical consumerism. This leads to a final phase in which the physician regains both control of management and the dividends from his work. The internship of this medicine-business involves no small financial risk. But, above all, it entails serious ethical risks, leading to the conception of medicine as a commercial activity, inseparable from strong, constant conflicts of interest. Ethically scandalous actions have already begun to manifest themselves: new and aggressive forms of advertising that favor medical consumerism; the creation of sophisticated and exclusive health units for wealthy patients, with immediate care services, at home or in the hospital, including all kinds of whims and luxuries. The dignity, freedom and prudence of the doctor's prescription become captive, sacrificed to the profitability of the business.
The internal morality of medicine is altruistic and rational. It is not the physician's purpose to satisfy people's whims, to maximise their choices or to favour risky lifestyles. One goes to the doctor to maintain and restore health, to alleviate suffering, not to satisfy whims, as when one goes shopping.
In the face of this evolution of American medicine, European medicine, basically non-profit, mostly salaried, presents itself as an ethical blessing. I don't think we can ever be grateful enough for the creation of social medicine in Europe and development .
It is high time to pay attention to a basic aspect of the third-party payer's relationship with patients and physicians: patients' rights.
The rights of patients and third-party payers
Nothing reveals the strengths and weaknesses of the third-party payer, in Europe as well as in America, better than a comparative examination of the patients' rights charters that exist on both sides of the Atlantic.
In order to understand the commonalities and differences between these documents, it is useful first to briefly refer to some characteristics common to most of them.
Although historically some of these rights have their roots in the remote Christian past, it was certain social circumstances that forced their birth in the United States as a relatively late product of the movements to vindicate discriminated minorities. This time and place of birth has left an indelible mark on the character of these rights, compatible with the diversification brought about by their subsequent complex development by many different actors: hospital administrators, consumer groups, patients' associations, civic rights organisations and, of course, ministries of health and their corresponding national health services.
Patients' Bills of Rights refer almost exclusively to in-patients. Very little thought has been given, outside the UK, to the alleged rights of the outpatient and even less to the home patient.
All charters contain a common core of so-called fundamental rights of the sick. They are the translation of fundamental and constitutional human rights into the hospital context. For this reason, they hardly differ from country to country, are legally sound and tend to be preserved over time. These include, for example, the right to receive a respectful attention and congruent with the dignity of the person; to manage one's own autonomy through the granting or withdrawal of informed consent; to the custody of confidentiality; to the protection of health; to respect for privacy and intimacy.
We are more interested in non-fundamental rights, also called special rights, which are those that give diversity to charters. They often seem more like moral rights than legal rights.
Undoubtedly, it has been the institutions that have enacted them that have left the strong imprint of their personality on these rights. The user and consumer movements have enhanced the role of the patient as a purchaser of health care, who controls costs, authorises interventions, and is a very active part of a service contract. In contrast to this contractualist and legal mentality, the professionalist genius of the rights recognised by medical associations: this is the case of the Declaration of Lisbon of the World Medical Association association , in its rich version of 1995, not the very poor version of 1981, which focuses on the rights of the patient to humane quality care in line with scientific advances, to free choice of doctor, to the doctor's advocacy in protecting the patient before third parties, to palliative care. availability Finally, there is a certain typicality in the special rights granted by the national health services: they often bear the insecure mark of the welfare state, as they are conditional on the necessary financial and human resources being available at the moment. Not only are these rights not enforceable in times of economic recession, but they are in fact dependent on the response of the official bureaucratic machine. Thus, for example, rights to complain or to participate in the health management are not always adjudicated by courts or independent bodies, but have to be exercised through the hospital management itself; the right to receive medicines and health products is left to the mercy of availability of resources; rationing is imposed without discussion or warning; the right to receive medicines and health products is left to the mercy of of resources; rationing is imposed without or warning.
Patients' rights in Europe and the USA
Let us now turn to a comparison of secondary rights in Europe and the United States. Let us take as material for analysis the Patient's Bill of Rights of the association American Hospitals (hereinafter PBR) and the Carta dei Diritti del Malato of the Comune di Ferrara (hereinafter CDM). These are two very different documents, which makes their comparison highly illustrative.
The American Hospital association , which keenly perceived the great political and professional significance of patients' rights, promulgated its PBR in 1973 to address patients' conflicting relationships with hospitals. For 19 years, the document remained unchanged, but in 1992 a new updated version was published, now in force, which will serve as a point of comparison with the MCC. The latter was born within the framework of what Bompiani called the risposta volontaristica, a spontaneous movement with B operability, which, encouraged by the Tribunale per i Diritti del Malato, swept through Italy some twenty years ago. Although the CDM dates back to 1984, it is still in force and retains much of its initial freshness.
What rights does the PBR contain? Almost exclusively, it contains some sui generis rights, such as the right of the patient to obtain a response to his requests for services; to examine the account of the expenses incurred; to receive explanations about them; to know the immediate and long-term financial implications deadline of the different treatment options; to be transferred at his own request to another center; to be informed report of the hospital's possible financial links and conflicts of interest, as well as of the cost of the interventions and the available payment methods; to know the hospital's internal rules and regulations. These rights reveal, on the one hand, the individualistic and untrusting ideology of the client, which is expressed in the strong control of the economic element, in the demand for promptness in services, in the autonomous approach to what is to be done. They also express the concern to get the most out of the large amount of money that medical care costs: it is a consumer who has to actively control the cost and duration of his stay in the hospital, which, at least in the economic aspect, is a hostile and potentially dangerous habitat, requiring a vigilant attitude.
In contrast to these rights, those granted by the MCC have, to begin with, a clear political-social intention, which enshrines and demands the equality of all before the health attendance , and condemns any form of favoritism, clientelism or corruption. It should be noted that all the clauses of the MCC begin with the expression "Ogni malato ha il dirito di" (Everyone has the right to).3 (except for the first clause, which reads "Ogni cittadino malato ha il dirito di").4), while the PBR, without aspiring to the universality and equality of these rights, begins each of its clauses with "The patient has the right to". What is most striking, however, in the MCC is the domestic, familiar tone of many of the rights it confers, which seek, at least intentionally, to create a friendly, humanized habitat in the hospital. MCC recognizes rights that may seem minor, but which manifest the dignity of the person and the body. These are the rights to be called by name, not by nicknames or diminutives, not to be addressed by name, not to be objectified by references to their illness or to the issue of their room; to dress with dignity, without being humiliated by the obligatory use of clothing that violates their bodily privacy; to have decent sanitary services, and a friendly ecology, with spaces for relaxation in which to have conversations with family and friends. The MCC recovers rights that were already present in the regulations of some medieval hospitals: that of a hot and varied meal, frequent change of linen, the right to receive visitors, to call the doctor of one's choice.
The text of the MLC does not specifically establish before whom these rights are legally enforceable. A precedent grade of La Sezione Ferrarese del Tribunale per i Diritti del Malato states that "I diritti elencati nella nostra 'Carta' possono essere garantiti, spesso, senza grandi impegni finanziari da parte delle Unità sanitarie locali: sometimes it may be enough to modify the organization of the work in the distribution or in the service; in some cases it is sufficient to change some of the abbreviations or certain behaviors that lead to ignore or offend our dignity as men and citizens".5. The same call to civic responsibility is present in the words that the Sindaco di Ferrara prefixes to the MCC: "The self-responsibility of individuals and the participation of the community [...] are principles and objectives that are ever more important and that can be more easily pursued if the instruments of citizen participation are disseminated and strengthened".6.
Comiogenesis, rights and collective responsibility
The MCC exudes cordiality and goodwill. This might lead one to think that the relations between physicians, patients and administrators should reach a high level of human and professional quality in hospitals. However, the reality all too often belies the effectiveness of these claims of rights that have so often been truncated. Nothing causes the physician more moral fatigue than the deterioration of relations with his patients, when they see their expectations frustrated to a greater or lesser extent; nor does anything provoke his ethical pessimism more intensely than to observe helplessly that his just claims on behalf of his patients go unheeded.
There is a serious risk of demoralization in the hospital where relationships between physicians, patients and administrators are degraded. The new term "comiogenic harm," as opposed to "iatrogenic" harm, has been coined to specifically designate harm due not to individual physician or nurse interventions, but to institutional failures. Patients may suffer harm that is directly or indirectly attributable to the inadequacy of the hospital's general operating system, to cracks in the model organization, to the way information is circulated, to broken links in the chain of command. Comiogenic damage is not distributed randomly: it has been shown that certain hospitals have fees ten or more times higher than others. This seems to lend strong support to the view that it may be the system, rather than the individual, that is the main cause of many hospital casualties, which can be attributed to factors such as the hospital's poor collective self-image, lack of corporate moral energy, poor communication among its members, lack of clarity about institutional goals, recurrent periods of crisis triggered by chronic problems, to which no solution is found. There are hospitals with a very low morale leave, demoralized.
Dysfunctions or errors in hospitals are not a trivial matter, nor are disruptions in the relationship between doctors, patients and public administration or the private sector.
As far as the individual patient is concerned, these dysfunctions, errors and disorders can create a great deal of additional suffering for those who are going through the crisis of humanity that is any serious illness. At the community level, they cause serious economic damage, while at the same time damaging a highly valued asset: the social solidarity of financial aid . Conflicts in the health sector, if they become chronic, if they are not resolved quickly, tend to harden the heart of society, and end up by brutalising sensitivity towards the weak. It is therefore crucial to seek and test solutions that reduce the frequency and intensity of these conflicts, since it is an illusion to expect that these dysfunctions will disappear spontaneously.
Undoubtedly, the simplification of the relationships will be linked to the reduction of the heterogeneity of the characters, since it is not possible to reduce their issue. We must accept that the system will always be made up of doctors, patients and administrators, who are linked by basic, bilateral relationships (doctors/patients and patients/doctors, doctors/administrators and administrators/doctors, patients/administrators and administrators/patients). In theory, therefore, it is possible to seek to simplify the system by converging or merging the elements most susceptible to remodelling. Leaving aside the relationships between patients and administrators, which are highly politicised and, in my opinion, resistant to a sincere ethical remodelling, there remains the possibility of trying to act on those that can be influenced by the principles of medical ethics: those between doctors and administrators and between doctors and patients.
There is a well-founded belief that some of the ills of health care systems and, more especially, the ills of hospitals resulting from unsatisfactory relations between administrators and physicians could be prevented or alleviated if hospitals were managed by physicians. This claim is based on the idea that, if one and the same person were to perform the managerial function at framework with respect for the professional ethics of medicine, many situations of conflict could be avoided or resolved. In this way, misunderstandings between physicians and managers would be avoided: the current field of tensions, noisy and pugnacious, would be transferred to the silent realm of the conscience of a single individual. If he or she were competent in both the art of management and the medical art, the prospects would be brighter, effective solutions would be reached at a much lower moral cost, and inter-organizational confrontations would be avoided.
Others think that the solution could come from the alliance between physicians and patients who, by assuming the role of citizens, could carry out the responsibilities of the administration and make themselves position responsible for the management healthcare. It is a solution that does not restrict, as the Italian Codice di Deontologia does, the status of citizen to patients alone, but extends it to physicians. This would create a new system made up of citizen-doctors and citizen-patients, in which administrators would no longer play a leading role.
The figure of the physician-administrator and his ethical profile are the object of deontological consideration in the current Codice di Deontologia. The Code says in its article 70, when describing the specific deontology of the function of health management: "The physician who performs management or health management functions in public or private structures must guarantee, in the performance of his activity, the respect of the rules of the Code of Medical Deontology and the defense of the autonomy and professional dignity within the structure in which he operates. Egli has the duty to collaborate with the Professional Order, competent for the territory, in the vigilance competitions on the collegiality in the relationships with and between doctors for the correctness of the professional performances in the interest of the citizens. Egli, altresì, deve vigilare sulla correttezza del materiale informativo attinente alla organizzazione e alle prestazioni erogate dalla struttura".7.
The official Commentary of the Federazione degli Ordini does not limit itself to pointing out that the managing physician can never exempt himself from the fulfilment of deontological duties. It authoritatively warns that certain special duties apply to him: he is particularly obliged to act in defence of the independence of the medical profession, he must take care of the correctness and collegiality of the relationships of the doctors working in his institution and, above all, he must promote the implementation of the new deontological relationship between doctors and patients-citizens.
The same Codice also claims for the Ordini the function of fixing the ethical limits of the different modalities and forms of the salaried practice of medicine: as a preventive measure against the weakening of corporate ethics, it demands, in article 67, that contracts and service agreements be approved by the Orders, after having ascertained their conformity with ordinal deontology and after being well convinced that the legitimate freedom and responsibility, independence and autonomy of the physician are safeguarded in the work context in which the physicians enrolled in the Order are going to lease their professional services. This is, according to agreement with the official Commentary to the Codice, a decisive issue "for the very future of the medical profession which, in view of the professional Order, can never be reduced to print, subject only to the automatic mechanism of the cost-profit scheme".8.
The integration in a single person of the vocation of physician with that of manager is in line with the standards of many documents of medical organizations. And it is also in line with real experiences, which have shown that medical managers, properly trained in business management, have specific advantages over non-medical managers, including, for example, greater credibility, deeper knowledge of how health care works, greater freedom of expression, more extensive tolerance for thoughtful and evidence-based whistleblowing. It has also been proven that, because they know how to put patient care before the bureaucratic and automated imperatives of savings and management by diagnostic groups, they not only achieve better clinical outcomes, but do so at lower costs. The UK National Health System, along with the British Medical association , has had the audacity to accept the idea of the superiority of physician-managers, has promoted their training and has seen that, with them at the helm of hospitals, problems become easier. Among other things, because they are better accepted by their colleagues in the hospital, since they are better able to understand clinical problems; because their actions are in line with the imperatives of medical ethics, and not just those of business ethics; because they have a more comprehensive and more informed capacity to criticize the system internally; because they can apply innovative strategies, without the fear of failure that paralyzes their non-clinical counterparts, since 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, no matter how inadequate or counterproductive they may be for physicians and patients.
It should be noted that the official document doctor-General Manager is not an entertainment for incompetent, disillusioned or bored doctors. It is official document for vocationally motivated doctors who have come to the conclusion that, already today and increasingly in the future, the management of health care is a core element of professional practice.
It should also be an integral part of the Education of future doctors, who will need to be experts both in clinical problem solving and in analysing and deciding on economic and organisational issues. New generations of doctors need to be spared the pain of past misunderstandings and rivalries, and educated in the idea that patients, doctors and managers share the same goals and must be driven by shared ideals. To create such an ethos of cooperation and mutual understanding, it is necessary that some competent physicians of high intellectual and human quality respond to the vocational imperative to devote at least a few years of their professional lives to management .
Doctors-citizens/patients-citizens: the new synthesis
source A continuing problem in Western Europe, where the population is predominantly served by national health care systems, is the failure to develop a specific medical ethics for socialised medicine. In contrast, European biomedical ethics institutions appear to be saturated with ideas and decision-making procedures modelled on the principlist model imported from the United States.
But this only aggravates the problems and misunderstandings among European physicians and patients. Indeed, principlism is a methodology of ethical analysis and decision-making, designed to be applied to the commercialized medicine practiced in the United States. There, patients are consumers who present their demands to the physician and pay for them with their own money, either by medical act or by pre-paying for items on a list of services to one of the health maintenance organizations; physicians are providers who dispense medical services to the extent that they are paid for by the clients, either directly or through those organizations.
There, patient self-determination has to do not only with the dignity, rights and freedoms of the person: it also has a strong economic component by virtue of the maxim of free trade that says that he who pays, rules. In the bioethics of principles, there is no proper place for the duties, responsibilities and obligations of the patient. This is prevented by the permanently fluid, reversible nature of the consent given by the patient-client, a consent which he can always and at any time withdraw, without this entailing any change in his relationship with the physician or the hospital.
In Europe, on the contrary, we believe with firm faith in the possibility of providing medical care to all those who need it, even if they cannot pay for it. But in order that this solidarity application for the sick does not run the opposing risks of ruining the Economics of countries by excessive expense or wastefulness, nor of ruining the health of patients by stinginess and discriminatory rationing, it is necessary for physicians and patients to adopt a position of shared responsibility that corresponds, by its very nature, to an active role of good citizenship. It is therefore entirely correct to speak of physician-citizen and patient-citizen relationships.
Because the patient-citizen, in marked contrast to the patient as such, not only has rights: his membership of a national health care system imposes certain well-defined duties on him, and points out 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 inform about their disease, to participate in making decisions that affect them, to make judicious use of healthcare services, to cooperate in genere with the system, to take care of their health, or to recognize the impact that their lifestyle can have on their wellbeing staff.
It was probably the Spanish legislation, with Law 14/1986, General Health Law, which was the first to introduce in its articles prescriptions on the duties of patients towards society. The PBR, in its revised version of 1992, includes a list of patients' responsibilities, dealing with purely individualistic matters, without a single reference letter to the existence of obligations towards society. In Italy, a Decree of the President of the committee of Ministers, the Schema generale di riferimento della Carta dei servizi pubblici sanitari9published in the Gazzetta Ufficiale in 1995, includes a model regulating the obligations of the patient Username of the National Health Service, which contains a heterogeneous list of 14 duties. It is important to note the warning at the top of this list that "participation in the performance of some duties is the basis for fully enjoying one's own rights. The personal commitment to rights is a respect for the social community and the health services used by all citizens".10.
Tom Sorell of the University of Essex has recently published article graduate Citizen-Patient/Citizen-Doctor (Health care Analysis 2001;9:25-39), in which he develops a very interesting outline of the dominant role that citizenship should play in the actions of patients and doctors in the context of a national health system. Sorell states, between the lines, that being a citizen precedes the condition of being sick or being a doctor, and that the obligations towards the community in relation to the measured use and manager of health services are strong. The author alludes to the deterioration that postmodernism has brought about in the heart of doctor-patient relations in the sense of being almost exclusively concerned with the particular and individualistic, and of having relegated the social and universal dimensions of human rights to obscurity.
There is no doubt that it is a complex and long-term task deadline to educate society and doctors to be sensitive to social and community values. But it is business worthwhile. And one on which I would like to hear criticisms and comments in the colloquium that follows. That is the sole purpose of my intervention.
I conclude by recalling an idea that I have repeated many times: the moral wisdom of John Paul II about human life and medicine is not contained only in his Encyclical Evangelium vitae, in his speeches to doctors and nurses or in his words to the sick. It is also and radically contained in his social encyclical Centessimus annus, whose medical-ethical message we must discover and practice.
Thank you very much.
gradeThe Author wishes to thank Prof. Francesco M. Avato, Sezione di Medicina Legale e delle Assicurazioni, Università degli Studi di Ferrara, for providing him with the text of some of the Charters of Rights of the Sick in force in Italy.
[1] Equivalent to the Spanish high school de Médicos.
[2] Not only of the autonomy and dignity of the profession, but also, and above all, of the rights of citizens.
[3] Every sick person has the right to.
[4] Every sick citizen has the right to.
[5] The rights listed in our 'Charter' can often be guaranteed without major financial commitments on the part of local health units: sometimes it is enough with some changes in the organization of work at department or service; sometimes it is enough to change some bad habits or certain behaviors that lead to ignore or offend our dignity as men and citizens.
[6] The self-responsibility of individuals and community participation [...] are principles and objectives that are becoming more and more established and can be pursued more easily if the instruments of citizen participation are disseminated and strengthened.
[7] The physician who exercises the functions of management or health management in public or private centers must ensure, in the exercise of his activity, compliance with the rules of the Code of Medical Ethics and the defense of professional autonomy and dignity within the center in which he works. It has the duty to cooperate with the Professional Order, competent by reason of the territory, in the tasks of supervision of the collegiality in the relations with and among physicians for the correctness of professional services in the interest of the citizens. It must also supervise the correctness of the informative material concerning the organization and the services provided by the center.
[8] For the very future of the medical profession which, in the opinion of the professional association , can never be reduced to a business, subject only to the automatic cost-benefit mechanism.
[9] outline general reference letter of the Public Health Services Charter.
[10] Participation in the fulfillment of certain duties is the basis for the plenary session of the Executive Council enjoyment of one's rights. The commitment staff to duties is a respect for the social community and health services enjoyed by all citizens.